78 Steps Health Journal

Gastrocolic Trunk Of Henle

The patient is placed in the modified lithotomy position to allow the surgeon to stand between the patient's legs for one portion of the operation. After establishing the pneumoperitoneum through an umbilical port, an additional four ports are placed in the left and right lower quadrant, left upper abdomen, and suprapubic area. The operating table is tilted into the slight Trendelenburg position with the left side down to move the small intestine toward the left upper quadrant. The omentum and transverse colon are moved toward the upper abdomen, the ventral side of the right mesocolon is well visualized, and the optimal operative field can be achieved (Figure 8.3.3). Before starting the dissection, the ileocolic pedicle must be definitively identified by retracting the right mesocolon (Figure 8.3.4).

Various approaches, such as lateral-to-medial (lateral approach),1 medial-to-lateral (medial approach),2 and retroperitoneal approach,3

Figure 8.3.3. Good visualization of the right mesocolon is achieved by proper positioning of the patient and by placement of the omentum above the colon.

have been reported in laparoscopic colon surgery, as shown in Figure 8.3.5. The medial approach is quite effective for complete lymphade-nectomy with early proximal ligation, minimal manipulation of the tumor-bearing segment, and ideal entry to proper retroperitoneal

Figure 8.3.4. Definitive identification of the ileocolic pedicle is achieved by retraction at the ileocecal junction.

Figure 8.3.5. Various approaches to the right colon mobilization have been described. A: Lateral to medial ("classic" open approach); B: Medial to lateral (authors' preferred approach); C: Retroperitoneal approach.

plane.4 We believe that the medial approach is optimal in order to maintain conventional oncologic principles.

First, the mesocolon near the ileocecal junction is lifted to confirm the ileocolic pedicle (Figure 8.3.4). The root of ileocolic pedicle is usually located at the lower border of duodenum. The independent right colic vessels, if present, are located at the upper border at duodenum. However, the majority of patients do not have the independent right colic vessels (vessels originating directly from the superior mesenteric artery and vein). The surgeon, first, should stand on the patient's left side to confidently know the ileocolic pedicle from the superior mesenteric vessels, and to mark the lower border of ileocolic pedicle (Figure 8.3.6).

Next, the surgeon moves between the patient's legs and the scope is inserted through the suprapubic port. The medial side of the right mesocolon is first incised starting from the previously marked region below the ileocolic pedicle, followed by the incision of the peritoneum over to the superior mesenteric vessels. This is done before mobilization of the right colon (Figure 8.3.7). With adequate traction of mesocolon toward the right upper quadrant, the ileocolic vessels are easily mobilized from the subperitoneal fascia leading onto the duodenum. Their origins are identified from the superior mesenteric vessels at the lower border of the duodenum and divided (Figure 8.3.8). We classify the

Figure 8.3.6. The surgeon's first step in the dissection is to mark the inferior border of the ileocolic pedicle.

Figure 8.3.7. From between the legs, the surgeon dissects the peritoneum overlying the ileocolic vascular pedicle over to the superior mesenteric vessels.

Figure 8.3.8. The origins of the ileocolic artery and vein are identified, clipped, and divided.

vascular anatomy of this area into two types (type A and type B: Figure 8.3.9A and B). Because a complete lymphadenectomy around the origin of ileocolic vessels is necessary for advanced right colon cancer, this classification is very useful to safely and effectively achieve it. In type A, the ileocolic artery is running in front of the superior mesenteric vein. After mobilization of the ileocolic pedicle from the duodenum, the dissection of the ventral side of the superior mesenteric vein leads to the dissection of the origin of ileocolic artery. In type B, the ileocolic artery is running behind the superior mesenteric vein. After mobilization and division of the ileocolic pedicle from the duodenum, the dissection of the ventral side of the superior mesenteric vein leads to a complete dissection of the root of the middle colic artery and vein (Figure 8.3.10).

Careful dissection onto the duodenum and the caudal portion of the pancreas must be exercised in the exposure of the middle colic vessels. Dissection around Henle's trunk (the truck of mesenteric veins consisting of the gastroepiploic vein fusing with the right branch of the middle colic vein or the main middle colic vein) may lead to the exposure of an accessory right colic vein. Accessory right colic vein and right branches of middle colic vessels are clipped and divided (Figure 8.3.11). However, if an accessory right colic vein is difficult to confirm in this situation, this vein may be easily detected later at the take-down of right flexure. Next, the operating table is tilted into the steep Trendelenburg position with the right side down to move the small intestine toward the right upper quadrant. After confirming the right ureter and gonadal vessels through the subperitoneal fascia at the right pelvic

Figure 8.3.9. Anatomic variations of the origin of the ileocolic vessels. A The ileo-colic artery runs in front of the superior mesenteric vein. B The ileocolic artery runs behind the superior mesenteric vein.

Figure 8.3.10. Dissection of the ventral side of the superior mesenteric vein permits a complete dissection of the root of the middle colic artery and vein.

Figure 8.3.11. Accessory middle colic or right colic veins are clipped and divided. These are common.

Figure 8.3.12. The peritoneum is incised along the base of the ileal mesentery upward to the duodenum.

brim, the peritoneum is incised along the base of the ileal mesentery upward to the duodenum, and the ileocecal region is mobilized medial to lateral (Figure 8.3.12).

Next, the surgeon moves back to the patient's left side and the scope is inserted through the umbilical port. The right mesocolon is mobilized from medial to lateral (Figure 8.3.13). Again, this approach allows dissection into the proper retroperitoneal plane. The right gonadal vessels and ureter are safe from injury in this plane, so exposing them is not necessary. This approach also allows the surgeon to work in a straight path from medial to lateral, without tissue to obstruct the vision that can occur working from lateral to medial. This plane connects the previous dissection plane from the caudal side.

The anatomy around the right flexure is very important to avoid inadvertent bleeding especially from around Henle's (gastrocolic) trunk (Figure 8.3.14). However, if the previous mesenteric dissection is fully performed from the caudal side and the accessory right colic vein is divided, the right flexure is easily taken down only by dividing the hepatocolic ligament (Figure 8.3.15). If the accessory right colic vein is difficult to detect at the previous dissection, it can be easily confirmed from Henle's trunk at this situation and should be divided before extracting the right colon to avoid its injury. Up to this point, the primary tumor has been minimally manipulated using medial to lateral approach. Finally, the right flexure and right colon including the tumor-bearing segment are detached laterally, which completes the mobilization of the entire right colon (Figure 8.3.16).

Once the entire right colon is freed, it is withdrawn through an enlargement of port site at the umbilicus. The wound must be covered with wound protector. The resection of ileum and transverse colon, and

Figure 8.3.13. The right mesocolon is dissected away from the retroperitoneal structures from medial to lateral.

Figure 8.3.14. The venous anatomy between the hepatic flexure and the middle colic vessels has many variations, including Henle's trunk, the fusion between the gastroepiploic vein, and a branch of the right or middle colic vein.

Figure 8.3.15. With earlier steps accomplished, the hepatocolic ligament is easily divided, freeing up the proximal transverse and hepatic flexure of the right colon.

the anastomosis are accomplished extracorporeally by functional end to end anastomotic method using conventional staplers or by a hand-sewn method (Figure 8.3.17). The anastomotic site is returned to the peritoneal cavity. Wounds and peritoneal cavity are copiously irrigated. All wounds are closed and operation is completed (Figure 8.3.18).

Figure 8.3.16. Finally, the tumor-bearing segment of the right colon, with its lateral attachments, are freed up, completing the right colon mobilization.

Figure 8.3.17. After drawing out the right colon using a wound protector, an anastomosis is accomplished extracorporeally. A A functional end-to-end anastomosis is created with a linear-cutter stapler. Note that the colon is occluded using a large Kocher clamp. B The anastomosis is completed with a right-angled firing of the linear-cutter stapler, completely sealing off the bowel. C The completed anastomosis before returning it to the abdomen.

Figure 8.3.17. After drawing out the right colon using a wound protector, an anastomosis is accomplished extracorporeally. A A functional end-to-end anastomosis is created with a linear-cutter stapler. Note that the colon is occluded using a large Kocher clamp. B The anastomosis is completed with a right-angled firing of the linear-cutter stapler, completely sealing off the bowel. C The completed anastomosis before returning it to the abdomen.

Figure 8.3.18. Appearance of the abdomen after the completion of the operation, showing the incision used to extract the specimen and perform the anastomosis (dotted line).

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