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Ileocecal Resection

  • Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Jan 12, 2015
 

Overview

Background

Ileocecal resection is the surgical removal of the cecum along with the most distal portion of the small bowel, specifically the terminal ileum. This is the most common operation performed for Crohn disease, though other indications also exist (see below).

Anatomy

As in all surgery, understanding the anatomy is key for safe and successful ileocecal resection.[1] The terminal ileum empties into the saclike cecum through the ileocecal valve, a mucosal invagination. The appendix originates from the cecum on the posteromedial surface at the convergence of the taeniae coli. The cecum is suspended by a short mesocecum and generally has limited mobility.

The vascular supply of the terminal ileum and cecum is derived from the ileocolic artery, which is a branch of the superior mesenteric artery (SMA). If the right colic artery is present, it can branch off the ileocolic artery. Communication with adjacent vessels in the colon exists via the marginal artery of Drummond. The venous drainage follows the arterial supply and drains into the superior mesenteric vein (SMV), which joins with the splenic vein to form the portal system.

The lymphatic drainage, also following the arterial anatomy, goes to the superior mesenteric lymph nodes. Sympathetic innervation and parasympathetic innervation of the right colon originate from the lower thoracic spinal cord and the right vagus nerve, respectively.

During mobilization of the cecum and right colon, the surgeon must be mindful of the duodenum, kidney, and ureter deep to the colon. (See the image below.)

Arterial blood supply to colon. Arterial blood supply to colon.

Indications

Ileocecal resection is indicated for the following:

  • Crohn disease complicated by stricture of the terminal ileum (TI) after failed medical therapy
  • Cecal perforation
  • High-risk premalignant polyps of the cecum that are not amenable to endoscopic polypectomy
  • High-risk benign polyps not amenable to endoscopic polypectomy (eg, large tubulovillous adenoma)
  • Lower gastrointestinal (GI) hemorrhage localized to the cecum
  • Noniatrogenic injury (eg, gunshot wound with cecal perforation)
  • Iatrogenic injury (eg, perforation or hemorrhage after colonoscopy or polypectomy)
  • Palliatiion in specific cases (eg, cecal cancer with metastasis with complications such as bleeding or obstruction)

Contraindications

Ileocecectomy, along with other major operations, is contraindicated in patients with severe medical comorbidities who are critically ill and unable to survive a laparotomy or general anesthesia.

Formal right hemicolectomy, rather than just ileocecal resection, is the treatment of choice for cecal volvulus (with or without ischemia) and right-side colon cancers for which surgery is appropriate (eg, colonic adenocarcinoma, appendiceal malignancy, or a T1 polyp of the cecum that is endoscopically unresectable).

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Preparation

As always, a thorough history and physical is the first step preoperatively. Specifically, one should focus on cardiopulmonary risk factors, inflammatory bowel treatment history, as well as previous surgical history. A complete blood count, chemistry panel, and coagulation panel should be obtained. Computed tomography of the abdomen and pelvis is the best imaging modality for the acute abdomen. Obtain a chest X-ray and EKG when appropriate. Finally, review previous colonoscopies leading to the diagnosis for which the surgery will be performed.

Preoperative mechanical or antibiotic bowel preparation is not necessary; in fact, the randomized controlled trials in the surgical literature (almost all from outside the United States) has not shown bowel preparation to have any benefit to patients undergoing elective colon resection.[2] However, bowel preparation can make perioperative colonoscopy possible, depending on the clinical circumstances, and can also allow easier manipulation of the colon during laparoscopic procedures. On the other hand, it can lead to problematic electrolyte derangements.

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Technique

Ileoceal resection may be accomplished by means of either an open or a laparoscopic approach.[3, 4, 5, 6, 7]

Open resection

The patient is placed in the supine position with arms abducted and supported on arm boards. Antithromboembolism stockings are applied. The surgeon may elect to give oral alvimopam to shorten postoperative ileus. The patient will also be given preoperative enoxaparin or heparin for prophylaxis against venous thromboembolism.

General anesthesia is induced, muscle relaxation is achieved, and the endotracheal tube is placed. Prophylactic antibiotics are administered within one hour of incision to cover colonic and skin flora (eg, piperacillin-tazobactam, ertapenem, or a third-generation cephalosporin and metronidazole.) A Foley catheter is placed to drain the bladder and monitor the quantity and color of urine. An orogastric tube is placed to temporarily decompress the stomach and is removed before extubation.

The abdomen is shaved, widely prepared with an iodine- or alcohol-based formulation, and draped in the usual fashion. The electrocautery, vessel sealer/ultrasonic dissector, and suction tubing are secured to the drapes. The operating surgeon stands at the patient’s left, with the assistant on the right.

A lower midline laparotomy is made from around the epigastrium to the lower abdomen. The colon, liver, and small bowel are inspected and palpated. In Crohn disease patients, small-bowel length should be measured; these patients are susceptible to short-bowel syndrome. Next, a self-retaining retractor (eg, Bookwalter) or a wound protector is placed to allow for proper exposure.

The cecum with its characteristic taeniae is located in the right lower quadrant. Using the left hand, the surgeon can lift the cecum and terminal ileum medially and up off the pelvis and place tension on the white line of Toldt (the avascular plane of loose connective tissue that is formed from the coalescence of the right colon’s posterior serosa and the parietal peritoneum of the abdominal sidewall).

This line is taken down with electrocautery while tension is maintained. The plane is developed up to the hepatic flexure, and the right colon is mobilized bluntly away from the duodenum, located at the base of the colonic mesentery.

At this point, margins of resection are identified. Note that intestinal sparing is a key in Crohn disease patients, and adequate margins are not necessary. Windows in the mesentery are made up to the bowel wall by means of both blunt dissection and division with electrocautery. A gastrointestinal anastomosis (GIA) cutting stapler is used to divide both ends of the bowel transversely, and attention is then directed toward the remaining mesentery.

The mesentery can be divided with traditional clamp-and-tie technique or with a vessel sealer device. The thickened mesentery of Crohn disease patients may have to be ligated with an overlapping clamp technique. Once this is done, the specimen is handed off, and attention is directed toward creation of the anastomosis.

The remaining ends of the small and large bowel are brought into proximity. Either a stapled or a handsewn technique may be used to create the anastomosis. Sewing the bowel may allow more versatility in making up for a size discrepancy. The use of a Cheatle slit in the antimesenteric border of the ileum may be necessary to spatulate and widen it to match the size of the large bowel. The mesentery may then be closed with continuous 3-0 absorbable suture to help prevent an internal hernia.

At this point, the anastomosis is palpated for adequate diameter, and the peritoneum can be irrigated with warm saline. The fascia is closed in the usual fashion. Because there usually is no gross spillage of stool, the skin can be approximated with several surgical staples.

Laparoscopic resection

Laparoscopic ileocecal resection can be performed for the same indications stated above, with some exceptions. Obviously, the surgeon must be comfortable and proficient with laparoscopic surgical technique, and there must be no contraindications to performing a laparoscopic procedure.

Preoperative preparation is as described above for open resection, with some modifications for laparoscopy. The patient’s arms should be tucked to the sides. A modified lithotomy position, with hips and knees flexed slightly, may facilitate intraoperative colonoscopy (if indicated). Pressure points should be noted and appropriately addressed before positioning is complete.

The patient should be well secured to the operating room table to allow safe rotation and tilting of the table. This will allow for proper visualization during the dissection. Video monitors should be placed on either side of the patient so the entire surgical team has an unobstructed view.

Pneumoperitoneum is established by means of the surgeon’s preferred method (eg, open Hasson or Veress needle). Various layouts for port placement exist. The goal is to triangulate toward the cecum so as to enable the safest and most efficient laparoscopic technique.

The camera port is placed first at the umbilicus. A 5 mm working port is placed in the left lower quadrant. Any adhesions present are lysed in a stepwise manner to allow safe placement of the remaining ports. Usually, a diamond pattern works best, with ports at the umbilicus, left lower quadrant, suprapubic area, and right lower quadrant. The surgeon’s preference and experience will dictate any deviation from this placement scheme. The surgeon stands on the patient’s left along with the camera operator; an assistant can stand on the patient’s right.

The abdominal organs are examined for any unexpected pathology that might change the planned procedure. The dissection is then carried out in a fashion similar to that described above. Trendelenburg and left-side-down positioning of the table will help keep the small bowel from obstructing the surgeon’s view.

For dividing the mesentery and vessels, including the ileocolic vessels, several options are available to the surgeon, including an endoscopic stapler, surgical clips, an ultrasonic dissector, and an electrothermal vessel-sealing device. The bowel itself is divided with an endoscopic stapler.

An endoscopic specimen retrieval bag is used to hold the specimen and store it above the liver until it is time for removal. A minilaparotomy is created as an extension of either the right lower quadrant port site or the umbilical port site. This allows removal of the specimen as well as creation of the anastomosis by delivering the bowel through the laparotomy. The anastomosis is carried out in the preferred fashion, the bowel is returned to the abdomen, and the incision is closed.

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Post-Procedure

Postoperative care

Postoperatively, the patient is extubated and moved to the recovery area before transfer to the surgical floor. He or she is kept on NPO (nil per os) status except for oral medications for postoperative day 0. Patient-controlled analgesia (PCA) is a common choice for postoperative pain control. Maintenance intravenous fluids are continued until the patient has adequate oral intake, and a clear liquid diet is started on postoperative day 1.

Perioperative antibiotics are continued for 24 hours, and the Foley catheter is removed on the morning of postoperative day 1. Chemoprophylaxis for venous thromboembolism (eg, heparin or enoxaparin) is continued until discharge, and alvimopam (if started preoperatively) is continued until the first bowel movement. The diet is advanced when there is return of bowel function. The patient is encouraged to ambulate as early as the night of surgery and perform incentive spirometry to help prevent pulmonary complications.

Daily surveillance laboratory tests, including a complete blood count and basic metabolic panel, are obtained until the values have normalized and the patient has tolerated a diet. The patient is medically fit for discharge only after he or she has passed the first bowel movement, has tolerated at least a full liquid diet, has adequate pain control with oral medication, and has ambulated. Follow-up in the surgeon’s office 10-14 days after the procedure is ideal for removing staples and assessing the patient’s recovery.

Complications

Early complications of ileocecal resection include the following:

  • Excessive bleeding
  • Wound infection, including superficial and deep
  • Deep vein thrombosis and/or pulmonary embolism
  • Prolonged ileus
  • Urinary tract infection
  • Pulmonary complications (ex, pneumonia)
  • Cardiac complications (ex, myocardial infarction)
  • Wound dehiscence
  • Anastomotic leak (signs of which may be tachycardia, fever, leukocytosis, ileus, sepsis, or feculent material from the incision); in a study of Crohn patients undergoing ileocecal or ileocolic resection, steroid usage and presence of abscess preoperatively were independent risk factors for anastomotic complication at a rate of 14% (40% when both factors were present)

Late complications of ileocecal resection include the following:

  • Anastomotic stricture
  • Bowel obstruction secondary to adhesions
  • Fistula
  • Incisional hernia
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Contributor Information and Disclosures
Author

Juan L Poggio, MD, MS, FACS, FASCRS Associate Professor of Surgery, Director of Robotic Colon and Rectal Surgery, Division of Colorectal Surgery, Department of Surgery, Drexel University College of Medicine

Juan L Poggio, MD, MS, FACS, FASCRS is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew Raissis, MD Resident Physician, Department of Surgery, Drexel University College of Medicine

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.

Acknowledgements

Keith D Gray, MD, FACS Chief, Division of Surgical Oncology, Assistant Professor, Department of Surgery, University of Tennessee Graduate School of Medicine; Medical Director, Gastrointestinal Tumor Service (GITS), The University of Tennessee Medical Center Cancer Institute; Clinical Specialist, Department of Surgery, The University of Tennessee Medical Center

Keith D Gray, MD, FACS, is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, National Medical Association, Society of Surgical Oncology, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Khanjan H Nagarsheth, MD Chief Resident in General Surgery, Department of Surgery, University of Tennessee Health Science Center College of Medicine

Khanjan H Nagarsheth, MD, is a member of the following medical societies: American College of Surgeons and Tennessee Medical Association

Disclosure: Nothing to disclose.

References
  1. Wick EC. Colonic and Rectal Anatomy and Physiology. Mulholland MW, Lillemoe KD, Doherty GM. Greenfield’s Surgery: Scientific Principles and Practice. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2011. 1017-1021.

  2. Billingham RP, Rossi DC. Preoperative Bowel Preparation: Is It Necessary?. Cameron JL, Cameron AM. Current Surgical Therapy. 10th ed. Philadelphia, PA: Elsevier Saunders; 2011. 131-132.

  3. Novell R et al. Colon. Novell R, Baker DM, Goddard N, eds. Kirk’s General Surgical Operations. 6th ed. Edinburgh: Elsevier; 2013. 219-220.

  4. Hunt SR. Open Right Colectomy. Fleshman JW, Birnbaum EH, Hunt SR, eds. Atlas of Surgical Techniques for Colon, Rectum and Anus. Philadelphia, PA: Elsevier Saunders; 2013. 2-11.

  5. Dietz DW. Part 1: Right Colon, Open Medial to Lateral. Wexner SD, Fleshman JW, Fischer JE. Colon and Rectal Surgery; Abdominal Operations. Philadelphia, PA: Lippincott Williams & Wilkins; 2012. 1-7.

  6. Husain F, Kodner I, Lin E. Part 1: Right Colon, Open Lateral to Medial. Wexner SD, Fleshman JW, Fischer JE, eds. Colon and Rectal Surgery; Abdominal Operations. Philadelphia, PA: Lippincott Williams & Wilkins; 2012. 9-16.

  7. Franklin ME, Russek K. Laparoscopic Right Hemicolectomy. Fischer JE, Jones DB, Pomposelli FB. Fischer’s Mastery of Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012. Ch 155.

 
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