Three steps and a join- a simple guide to right- and left-sided medial to lateral laparoscopic colorectal surgery, page 2

In a appropriately consent and anaethatised patients

Entry

Step 1: Medial–lateral dissection under ileocolic vessels and division of the ileocolic artery

Roll left side down)
Ileocolic junction is grasped and extended anteriorly tentingup the ileocolic artery.
Open the peritoneum just under and parallel to the ileocolic artery, close to its origin from the superior mesenteric artery.
Blunt dissection in this plane under the ileocolic artery
The duodenum should be encountered immediately and protected
Dissection then extends cranially and to the right until the colon at the hepatic flexure is visualised.
The ileocolic artery is then divided with either a vascular stapler (switch to 5mm camera) or taken with Hem-o-lok
A Ray-Tec is placed at the supero-lateral margin of the dissection, and this Ray-Tec will be encountered in Step 2

Step 2 Mobilisation of the hepatic flexure

The patient is placed steep head down
The small bowel is delivered out of the pelvis and placed in the left upper quadrant.
The caecum and terminal ileum are retracted cranially and anteriorly.
Dissection is commenced under the mesentery of the terminal ileum, and this dissection should quickly meet the dissection in Steps 1 and 2 leaving only some lateral peritoneum right at the caecum that can be divided to complete the dissection.
The mobilisation of the terminal ileal mesentery should continue medially to the third part of the duodenum (to allow full ileal mobilitiy when the specimen is exteriorised)