Ih-Ping Huang, MD; Michael Slavens, MD; C. Daniel Smith, MD; Edward Lin, DO
We present a case of a laparoscopic right hemicolectomy with intracorporeal anastomosis and left lateral segmentectomy. Laparoscopy here provides optimal exposure for both the right hemicolectomy as well as the left lateral segmentectomy for the single metastatic liver lesion.
The patient is a 76 year old female with newly diagnosed anemia. She denies any weight loss or changes in bowel habit. She has diabetes and hypertension and her physical exam of the abdomen is unremarkable. Her work up includes a colonoscopy that reveals a single friable fungating cecal mass measuring approximately 7 cm and biopsies demonstrate a moderately differentiated adenocarcinoma. Furthermore, a CT scan of the abdomen shows a single solitary 2.5 cm left liver lesion while a CT scan of the chest does not reveal any other metastatic lesions. A whole body PET scan also demonstrates a focus of increased FDG uptake in the left lobe of the liver and in the ileocecal region.
The patient is consented for surgery after preoperative work up is completed. In the OR, the patient is placed in supine position with the left arm tucked against the torso and the legs placed on a split-Y table. The camera port is placed at the umbilicus via the open technique and pneumoperitoneum established. Then under direct vision a 10-12 mm port is placed in the upper midline followed by a 5 mm port in the lower midline abdomen.
The right hemicolectomy is initiated by scoring and taking down the right peritoneal reflection from the ileocecal region with the dissection carried out toward the hepatic flexure. Care is taken to identify the duodenum. Then using the harmonic shears the gastrocolic attachments are taken down at the transverse colon. Gray Endo GIA staples are used to divide the right branch of the middle colic artery and the mesentery, while blue Endo GIA staples divide the transverse colon and ileum. The free colon specimen is retrieved at the end of the case. Next, the intracorporeal anastomosis is prepared via a side to side approximation of the proximal ileum to the distal transverse colon with a stay suture. Two enterotomies are created with the harmonic shears. Tension is held on the stay suture to facilitate maneuvering and placement of the white Endo GIA stapler that forms the common enterostomy. Then three stay sutures are placed evenly along the enterotomy and held up while a blue Endo GIA stapler closes the enterotomy.
Finally, for the hepatic resection we place two additional trocars. One 10-12 mm port is placed in the right subcostal margin and a 5 mm port in the left subcostal margin. The harmonic shears are used to take down the falciform ligament as well as start the liver resection. Good hepatic hemostasis is achieved with this method. As the dissection is carried out posteriorly, one has to be cognizant of the approaching hepatic vessels. We first divide the posterior pedicle with a gray Endo GIA stapler. Then the left branch of the middle hepatic vein is divided followed by the left hepatic vein. The raw liver surface is inspected and hemostasis is ascertained with cautery.
A 5-6 cm upper midline incision is made and a wound protector placed to retrieve the colon and liver specimens. A flat #10 blake drain is placed next to the raw liver surface and brought out thru the left 5 mm trochar site. Fascia and skin incisions are then closed.
The patient tolerated the procedure well and had an uneventful postoperative course. Clear liquids are tolerated on POD #3. Her final pathology show an invasive adenocarcinoma of the colon and metastatic colon adenocarcinoma of the liver specimen.