LAP RIGHT HEMICOLECTOMY-STEP BY STEP Operative Surgery.pptx

In this presentation, you will learn how to do a Lap. hemicolectomy in step-by-step manner.

1. LAP RIGHT HEMICOLECTOMY DR.B.Selvaraj MS; Mch ; FICS; “ Surgical Educator” Malaysia OPERATIVE SURGERY

2. LAP RIGHT HEMICOLECTOMY INDICATIONS: Malignant tumors in Ileocecal region, ascending colon and hepatic flexure Adenomatous polyps in Rt Colon Ileocecal TB, IBD, Cecal diverticulosis, bleeding Vascular ectasia & Cecal volvulus ANESTHESIA: GA/ETT POSITION: Supine/modified lithotomy Diagnosis Confirmed by colonoscopic biopsy Staging by CECT Informed consent- risks of surgery: Anastomotic leak- 2% Hemorrhage- 1% Bowel obstruction- 2% Wound infection- 2 to 10% Injury to ureter and duodenum- 1% Pre-op preparation Adequate mechanical bowel preparation the day before surgery with orthograde enema Prophylactic IV broad spectrum antibiotics VTE prophylaxis with LMWH and pneumatic stockings Tattooing of the tumor endoscopically or by localization on a barium enema.

3. SURGICAL ANATOMY

4. Positioning & Port placement Modified lithotomy position Pneumoperitoneum by Veress needle/ Hasson’s canula- 4 ports Dissection & Vascular control Medial to lateral approach- for malignant tumors ; Lateral to medial approach- for benign lesions Skeletonise ileo-colic vessel & continue dissection until seeing duodenum safe guard duodenum, Rt ureter & Rt gonadal vessels LAP RIGHT HEMICOLECTOMY

5. Dissection & Vascular control Divide ileo-colic vessels by vascular stapler Divide peritoneum below ileum and connect this with previous area of dissection Mobilisation of Right Colon Mobilise cecum & ascending colon by incising the lateral peritoneal reflection and pulling it towards the midline This mobilisation is Cattell- Braasch Maneuver LAP RIGHT HEMICOLECTOMY

6. Divide greter omentum from transverse colon upto hepatic flexure For simple Rt hemicolectomy  Divide omentum close to Transverse colon For Radical hemicolectomy  Divide omentum just below the gastro-epiploic arcade Divide Rt colic artery and Rt branch of middle colic artery With vascular stapler LAP RIGHT HEMICOLECTOMY

7. For intra-corporeal ileo-colic anastomosis Divide the terminal ileum and transverse colon with an endoscopic GIA stapler Place the divided bowel over the liver Place divided ileum and transverse colon side by side Make stab incision in transverse colon 8cms from its cut end and in the terminal ileum 2 cms from its cut end Insert the blades of GIA stapler into the colon and ileum and create a stoma between them Close enterotomy with 3-0 vicryl Remove the specimen either by extending umbilical port incision or Lt lateral port after placing Alexis wound protector Close the wound in layers For extra-corporeal ileo-colic anastomosis Extend umbilical incision and open peritoneum Place Alexis wound protector Extract the devascularised and mobilised bowel outside LAP RIGHT HEMICOLECTOMY

8. For extra-corporeal ileo-colic anastomosis- Stapler Divide ileum and colon with GIA stapler Now you can do either stapler anastomosis or hand sewn anastomosis OPEN RIGHT HEMICOLECTOMY

9. For extra-corporeal ileo-colic anastomosis  Hand sewn End-to-end anastomosis: anastomosis either using a single layer of interrupted sero -muscular 3/0 Vicryl or PDS sutures or alternatively as a two-layer suturing technique. Cheatel’s manuver LAP RIGHT HEMICOLECTOMY

10. Post-op Care Adherence to a postoperative colorectal clinical pathway ensures standardization of care and facilitates timely discharge from the hospital. Adequate pain control is achieved using patient-controlled analgesia, Inj Tramadol which can be replaced with oral analgesics on 2 nd post-op day Stress ulcer prophylaxis should be made for patients with symptoms or history of gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD). Prophylaxis for deep venous thrombosis, consisting of sequential compression devices while in bed, and heparin 5000 U subcutaneously every 8 hours or enoxaparin 40 mg subcutaneously every morning, starting within 24 hours after surgery. Adequate IV fluid should be administered with monitoring of urine output. The Foley catheter may be removed on postoperative day 1. Clear liquid diet is started on postoperative day 1 and gradually advanced to normal diet Early ambulation should be started on postoperative day 1. LAP RIGHT HEMICOLECTOMY

11. Pearls & Pitfalls Prophylactic antibiotic for colorectal surgery, ertapenem ( Invanz ) 1 g intravenously, before surgery, requires only a single dose for 24-hour coverage. Furthermore, it lasts for the duration of the procedure and does not require additional dosing The hepatic flexure suspensory ligaments should be divided with caution, because there are often large veins here. Careful dissection and the use of energy ligatures should strongly be considered to avoid uncontrollable bleeding and subsequent conversion to open laparotomy. Smaller lesions in the colon should be marked with tattoo ink for confirmation of location, which will assist in removal of the primary lesion with adequate 5-cm margin and areas of lymphatic drainage. Placement of Seprafilm under the midline incision minimizes adhesions on re-entry for subsequent operations. This should be considered, especially for indications such as Crohn’s disease and colon cancer. LAP RIGHT HEMICOLECTOMY

12. LAP RIGHT HEMICOLECTOMY MINDMAP

13. THANK YOU