Overview
Definition:
Open right hemicolectomy is a surgical procedure involving the removal of the ascending colon and the terminal ileum, along with the associated mesentery and regional lymph nodes
It is typically performed for benign or malignant conditions affecting the right side of the colon
The remaining segments of the colon and ileum are then reconnected, usually via an ileocolic anastomosis.
Epidemiology:
Right hemicolectomy is one of the most common colonic resections performed worldwide
Indications vary by geographic region and disease prevalence, with appendicular abscess, Crohn's disease, and right-sided colon cancer being frequent causes in India
The incidence of colon cancer is rising, contributing to the demand for hemicolectomies.
Clinical Significance:
This procedure is crucial for managing a spectrum of diseases impacting the cecum, ascending colon, and hepatic flexure, ranging from appendicular abscesses and inflammatory bowel disease to colorectal cancer
Proficiency in open right hemicolectomy is fundamental for surgical residents preparing for DNB and NEET SS examinations, requiring a thorough understanding of its indications, technical nuances, and potential complications to ensure optimal patient outcomes.
Indications
Malignancy:
Colorectal cancer involving the cecum, ascending colon, or hepatic flexure
Staging and lymph node dissection are critical components
Lymph node yield is paramount for accurate staging and prognosis.
Benign Conditions:
Inflammatory conditions such as Crohn's disease affecting the terminal ileum or cecum
Complicated appendicitis with abscess or perforation that cannot be managed non-operatively
Intestinal obstruction due to adhesions or malignancy
Diverticular disease rarely necessitates right hemicolectomy but can be an indication if complicated.
Other Indications:
Ischemic colitis affecting the right colon
Trauma to the right colon
Benign tumors like polyps that are too large or invasive for endoscopic removal
Familial adenomatous polyposis (FAP) or hereditary non-polyposis colorectal cancer (HNPCC) with involvement of the right colon.
Preoperative Preparation
Patient Evaluation:
Thorough history, physical examination, and assessment of comorbidities
Evaluation of nutritional status and performance status (ECOG/KPS score).
Bowel Preparation:
Mechanical bowel preparation with polyethylene glycol or sodium phosphate solution the day before surgery
Oral antibiotics may be administered in select cases, particularly for elective oncologic resections.
Anesthesia Considerations:
General anesthesia with endotracheal intubation
Epidural anesthesia for postoperative pain management can be considered
Fluid management and hemodynamic monitoring are essential.
Imaging And Staging:
CT scan of the abdomen and pelvis for staging of malignancy and assessment of spread
Colonoscopy to rule out synchronous lesions in the remaining colon
Blood work including complete blood count, electrolytes, renal and liver function tests, coagulation profile, and tumor markers (CEA for malignancy).
Procedure Steps
Incision And Exposure:
A midline or right paramedian incision is typically used
The abdomen is explored to confirm resectability and rule out metastatic disease
Mobilization of the right colon involves division of the white line of Toldt, freeing the ascending colon and hepatic flexure from the retroperitoneum.
Vascular Control And Mesenteric Division:
Identification and ligation of the ileocolic artery and vein, and the right colic artery and vein if present
Division of the mesentery is performed from the root to the bowel, ensuring adequate margins for lymph node dissection in oncologic cases.
Bowel Transection And Anastomosis:
Transection of the terminal ileum approximately 5-10 cm from the ileocecal valve and transection of the transverse colon at or distal to the hepatic flexure
The specimen is removed
An end-to-end or side-to-side ileocolic anastomosis is fashioned using staplers or sutures
The mesenteric defect is repaired.
Closure:
Inspection for hemostasis and watertight anastomosis
The abdominal wall is closed in layers
Drains are typically not required unless there is gross contamination or concern for anastomotic leak.
Postoperative Care
Pain Management:
Multimodal analgesia including IV opioids, NSAIDs, and epidural anesthesia if used
Patient-controlled analgesia (PCA) can be beneficial
Early mobilization is encouraged.
Fluid And Electrolyte Balance:
Intravenous fluids are administered to maintain hydration and electrolyte balance
Monitoring of urine output and serum electrolytes is crucial
Nasogastric decompression may be used if paralytic ileus is present, though usually not routinely required.
Dietary Advancement:
Gradual advancement of diet as tolerated, starting with clear liquids and progressing to solids
Patients are encouraged to resume normal bowel function
Monitoring for return of bowel sounds and flatus.
Monitoring For Complications:
Close monitoring for signs of infection, anastomotic leak (fever, tachycardia, abdominal pain, peritonitis), ileus, bleeding, and deep vein thrombosis (DVT)
Prophylactic antibiotics are continued for a short duration
DVT prophylaxis with subcutaneous heparin and compression stockings is standard.
Complications
Early Complications:
Anastomotic leak: the most feared complication, leading to peritonitis and sepsis
Wound infection and dehiscence
Intra-abdominal abscess formation
Postoperative ileus
Hemorrhage from surgical site or staple line
Injury to adjacent organs (e.g., ureter, duodenum).
Late Complications:
Bowel obstruction due to adhesions
Incisional hernia at the site of abdominal closure
Stricture formation at the anastomosis
Chronic pain
Altered bowel habits
Recurrence of disease if malignancy was the indication.
Prevention Strategies:
Meticulous surgical technique with adequate blood supply to the bowel ends
Careful handling of tissues to minimize trauma
Secure and watertight anastomosis
Optimal bowel preparation and perioperative antibiotics
Prompt recognition and management of any signs of complications
DVT prophylaxis and early mobilization.
Key Points
Exam Focus:
Indications for right hemicolectomy, including oncologic vs
benign
Key steps in mobilization and vascular control
Principles of ileocolic anastomosis (stapled vs
hand-sewn)
Common causes and signs of anastomotic leak
Lymph node yield in oncologic resections is critical for staging.
Clinical Pearls:
Always confirm resectability with a thorough abdominal exploration
Ensure adequate vascular supply to both ends before anastomosis
Meticulous repair of the mesenteric defect prevents internal hernias
Consider the use of indocyanine green (ICG) fluorescence angiography to assess bowel perfusion before anastomosis
Early ambulation is key for reducing postoperative complications.
Common Mistakes:
Inadequate lymphadenectomy in oncologic cases
Insufficient bowel margins
Compromised blood supply to the anastomotic ends
Failure to repair the mesenteric defect
Delay in recognizing and managing anastomotic leak
Inadequate bowel preparation leading to increased infection risk.