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Open Right Colectomy (Right Hemicolectomy)

  • Author: Ashwin Pai, MBBS; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Oct 02, 2015
 

Background

Open right hemicolectomy (open right colectomy) is a procedure that involves removing the cecum, the ascending colon, the hepatic flexure (where the ascending colon joins the transverse colon), the first one-third of the transverse colon, and part of the terminal ileum, along with fat and lymph nodes.[1] It is the standard surgical treatment for malignant neoplasms of the right colon; the effectiveness of other techniques are measured by the effectiveness of this technique.

In 1832, Reybord, who had recorded his experiences with treatment of cancers of the colon, reported the first successful resection and anastomosis of the bowel for carcinoma. Kohler performed the second successful resection and anastomosis. Paul and Mikulicz performed exteriorization-resection of carcinoma of the colon.

The following is a list of the main types of right open hemicolectomy:

  • Right hemicolectomy in one stage, with end-to-end anastomosis by the open and closed techniques
  • Modified Mikulicz procedure for carcinoma of the right colon
  • Two-stage right hemicolectomy - First stage, lateral or end-to-side ileocolostomy; second stage, right hemicolectomy
  • Turnbull method (no-touch isolation technique)
  • Barnes method (physiologic resection of the right colon)
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Indications

Indications for open right hemicolectomy include numerous benign and malignant conditions. The most common malignant condition is adenocarcinoma of the right colon; other malignant indications are malignant tumors of the appendix and cecum.

The benign conditions include adenomatous polyps of the colon that cannot be removed endoscopically, carcinoids, inflammatory bowel disease (Crohn disease and sometimes ulcerative colitis), cecal volvulus, severe appendicitis with involvement of the cecum in the inflammatory process, and isolated right-side colonic diverticular disease (rare).[2, 1]

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Contraindications

The main contraindication for right hemicolectomy in patients with malignancies is acute obstruction, in which a two-stage right hemicolectomy is advisable. The authors believe that in cases of large intestinal obstruction with altered parameters and vital signs, a bypass procedure is initially a better choice than radical resection, which the patient is less likely to tolerate. Therefore, in the first stage, an ileotransverse anastomosis is performed, and in the second, right hemicolectomy is performed.

Other contraindications include significant cardiopulmonary impairment and coagulopathy.

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Technical Considerations

Anatomic considerations

The colon is a 5- to 6-ft-long part of the large intestine (lower gastrointestinal tract) that is shaped like a U. Embryologically, the colon develops partly from the midgut (ascending colon to proximal transverse colon) and partly from the hindgut (distal transverse colon to sigmoid colon). The ascending (right) colon lies vertically in the most lateral right part of the abdominal cavity. The cecum is at the proximal blind end (pouch) of the ascending colon. The ascending colon takes a right-angle turn just below the liver (right colic or hepatic flexure) and becomes the transverse colon, which has a horizontal course from right to left.

For more information about the relevant anatomy, see Colon Anatomy, Large Intestine Anatomy, Lower GI Tract Anatomy, and Liver Anatomy.

Procedural planning

In order to plan an operation for a patient with colon cancer, the surgeon must have a thorough understanding of the tumor's location in the bowel, the stage of the cancer, and the patient's physiologic status. The location of the tumor and the histopathology are important data elements that allow preoperative selection of an operative plan and determination of the optimal resection margins.

The presence of a lesion at watershed areas of vascular supply, such as the hepatic and splenic flexures, may necessitate more extensive resection of colonic length for a safe and complete oncologic procedure. An extended right or left colectomy may be indicated to remove all contributing vascular supplies.

In addition, information consistent with hereditary nonpolyposis colon cancer supports the resection of the entire diseased colon rather than a simple segmental resection. This diagnosis may also be supported by special stains of the biopsy specimen that demonstrate microsatellite instability, the hallmark of the disease, which develops from mutations in the DNA mismatch repair system.[3]

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Contributor Information and Disclosures
Author

Ashwin Pai, MBBS MS (GenSurg), MRCS, Honorary Assistant Medical Officer, Department of Surgery, Kasturba Medical College, India

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

References
  1. BG Wolff, DW Larson. Right hemicolectomy for treatment of cancer: open technique. Fischer JE. Mastery of Surgery. 5th ed. Lippincott, Williams & Wilkins; 2006. 138.

  2. Fornaro R, Frascio M, Sticchi C, De Salvo L, Stabilini C, Mandolfino F. Appendectomy or right hemicolectomy in the treatment of appendiceal carcinoid tumors?. Tumori. 2007 Nov-Dec. 93(6):587-90. [Medline].

  3. Rothenberger DA. Conventional Colectomy. LP Fielding, SM Goldberg. Rob and Smith's Operative Surgery - Surgery of the Colon, Rectum, and Anus. 5th ed. UK: Hodder Arnold; 1993. 347.

  4. Tong DK, Law WL. Laparoscopic versus open right hemicolectomy for carcinoma of the colon. JSLS. 2007 Jan-Mar. 11(1):76-80. [Medline].

  5. Siani LM, Ferranti F, Marzano M, De Carlo A, Quintiliani A. [Laparoscopic versus open right hemicolectomy: 5-year oncology results]. Chir Ital. 2009 Sep-Dec. 61(5-6):573-7. [Medline].

  6. Fry RD, Mahmoud N, Maron DJ, Ross HM, Rombeau J. Colon and rectum. Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 18th ed. Saunders Elsevier; 2007. chap 50.

  7. Kelly MD, Bunni J, Pullyblank AM. Laparoscopic assisted right hemicolectomy for caecal volvulus. World J Emerg Surg. 2008. 3:4. [Medline].

  8. Turnbull RB Jr, Kyle K, Watson FR, Spratt J. Cancer of the colon: the influence of the no-touch isolation technic on survival rates. Ann Surg. 1967 Sep. 166(3):420-7. [Medline]. [Full Text].

 
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Right paramedian incision.
Extent of right hemicolectomy.
Incision along avascular line to mobilize right colon.
Entire right colon mobilized up to hepatic flexure.
Duodenum and major vessels seen after full mobilization of right colon.
Part of distal ileum and part of transverse colon adjacent to hepatic flexure removed with specimen.
Ileotransverse anastomosis.
Ileum anchored to lateral abdominal wall.
Right hemicolectomy specimen.
Intraoperative picture showing the ileocolic junction with loop of small intestine.
Specimen of right hemicolectomy for malignancy of ascending colon.
Specimen opened showing the tumor.
 
 
 
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