Open vs totally laparoscopic right colectomy: technique and results

BackgroundRight colectomy is the surgical treatment for malignantpathologies involving the intestinal tract between theileocecal Bahuino valve and the colic hepatic flexure.Laparoscopic resection must respect the same oncologi-cal criteria as the open approach including:‘’no-touchisolation technique’’, isolation and ligation of the vascularpedicles at the origin, oncological lymphadenectomy and‘’distal and radial clearance’’ of the neoplasm from resec-tion margins.Two major procedures have been described for thetreatment of right colon tumors: Open right colectomy(ORC) and Totally Laparoscopic resection (TL) in whichvascular ligations, intestinal resection and anastomosis areperformed by laparoscopy (Figure 1).In ORC technique, there is an abdominal right sidelaparotomy; in TL there is a minilaparotomy used only forendobag colon extraction and it is located in parapubicregion.MethodsFrom May 2004 to march 2013, we performed in HighSpecialistic Surgical Centers (Aosta “Parini” Hospital andNaples “Federico II” University) 132 laparoscopic rightcolectomies and 127 open right colectomies of which wehave selected 75 laparoscopic cases of these 11 for benignpathologies and 64 for neoplastic diseases and 75 OpenCases. The M/F rate was 1/1. The mean age was 64.7 ± 7.2.Colonic preoperative washout was performed to allpatients with 2 L for a day of polyethylene glycol (PEG) inthe two days before the operation, associated with a fiber-free diet. The day before operation, we positioned in allpatient antalgic peridural catheter with 0.5% levobupiva-caine (4 ml/h); on the following day, in the operatingroom, after anesthetic induction, we also positioned naso-gastric tube (NG tube) and urinary catheter (UC) and nodrain according to Kehlet protocols (in the last 23 cases).In the TL colectomy, the sovrapubic minilaparotomy of6 ± 2 cm is necessary only for the specimen extractionfrom the parapubic minilaparotomy performed by a 15-mm Endocatch, preventing the peritoneal spreading ofneoplastic cells.The procedures were considered curative only whenthere was no intraoperative evidence of secondarylocations.NG tube was removed after the operation and UC in themorning after surgery. The patients were allowed to drinkliquids with oral assumption of medicines the evening ofthe operation (Table 1) [1]. All the patients underwent acycle of postoperative physiokinesis therapy. Patients weredischarged when they became autonomous in movementsand walking with a restored bowel function without feverand pain.They were followed-up at least 1 year, starting on the30


Background
Right colectomy is the surgical treatment for malignant pathologies involving the intestinal tract between the ileocecal Bahuino valve and the colic hepatic flexure. Laparoscopic resection must respect the same oncological criteria as the open approach including: ''no-touch isolation technique'', isolation and ligation of the vascular pedicles at the origin, oncological lymphadenectomy and ''distal and radial clearance'' of the neoplasm from resection margins.
Two major procedures have been described for the treatment of right colon tumors: Open right colectomy (ORC) and Totally Laparoscopic resection (TL) in which vascular ligations, intestinal resection and anastomosis are performed by laparoscopy ( Figure 1).
In ORC technique, there is an abdominal right side laparotomy; in TL there is a minilaparotomy used only for endobag colon extraction and it is located in parapubic region.

Methods
From May 2004 to march 2013, we performed in High Specialistic Surgical Centers (Aosta "Parini" Hospital and Naples "Federico II" University) 132 laparoscopic right colectomies and 127 open right colectomies of which we have selected 75 laparoscopic cases of these 11 for benign pathologies and 64 for neoplastic diseases and 75 Open Cases. The M/F rate was 1/1. The mean age was 64.7 ± 7.2.
Colonic preoperative washout was performed to all patients with 2 L for a day of polyethylene glycol (PEG) in the two days before the operation, associated with a fiberfree diet. The day before operation, we positioned in all patient antalgic peridural catheter with 0.5% levobupivacaine (4 ml/h); on the following day, in the operating room, after anesthetic induction, we also positioned nasogastric tube (NG tube) and urinary catheter (UC) and no drain according to Kehlet protocols (in the last 23 cases). In the TL colectomy, the sovrapubic minilaparotomy of 6 ± 2 cm is necessary only for the specimen extraction from the parapubic minilaparotomy performed by a 15mm Endocatch, preventing the peritoneal spreading of neoplastic cells.
The procedures were considered curative only when there was no intraoperative evidence of secondary locations.
NG tube was removed after the operation and UC in the morning after surgery. The patients were allowed to drink liquids with oral assumption of medicines the evening of the operation (Table 1) [1]. All the patients underwent a cycle of postoperative physiokinesis therapy. Patients were discharged when they became autonomous in movements and walking with a restored bowel function without fever and pain.
They were followed-up at least 1 year, starting on the 30 th postoperative day and then at 3, 6 and 12 months from the operation. After the first year the patients were followed-up each 6 months until the 5 th p.o. year.

Results
The results are shown in Table 2: the mean operative time was similar between the two groups whereas the data related to p.o. pain, analgesic consumption and digestive function restoration was better in TL group compared to ORC group. The mean hospital stay was about 5 days in TL vs 7 days in ORC tecnique. There were no post-operative complications and there was no mortality in the TL group. There wasn't recurrence of the neoplastic disease in both groups after five years of follow-up [4]. Technical: the facilitated closure of the mesos by laparoscopy in TL right colectomy avoids internal hernias, and the absence of mesos traction during the laparoscopic anastomosis allows a faster restoration of peristalsis; 3. Anesthetic: thanks to the smaller size of parapubic minilaparotomy. In conclusion according to results of this study TL right colectomy seems to be a feasible and safe tecnique with the same oncological results of the open approach but with an improved post-operative patient's comfort, however it is necessary to conduct further perspective studies to draw definitive conclusion.