Open Right Colectomy (Right Hemicolectomy)

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 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 are the main types of open right 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)

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]}

Open right hemicolectomy is also performed as a conversion from initial laparoscopic right hemicolectomy; as many as 20% of laparoscopic colectomies for cancer may require conversion to the equivalent open procedures. ^[3]  

The main contraindication for right hemicolectomy in patients with malignancies is acute obstruction, for 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, a right hemicolectomy is performed.

Other contraindications include significant cardiopulmonary impairment and coagulopathy.

Anatomy

The colon is a 5- to 6-ft-long part of the large intestine (lower gastrointestinal tract) that is shaped like a U. Embryologically, it 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. ^[4]

Tong et al compared laparoscopic (n = 77) and open (n = 105) right hemicolectomy in terms of several variables, including time taken for surgery and duration of hospital stay. ^[5]  Mean operating time was shorter for the open procedure (115.4 min). Seven laparoscopic cases (9%) required conversion to an open procedure. There was no difference in complications. Normal diet was started in the laparoscopic patients a day earlier than the open procedure. Median hospital stay was longer for open (7 days) than for laparoscopic surgery (6 days) and was significantly longer (9 days) in the converted-to-open group.

Siani et al compared laparoscopic with open right hemicolectomy for oncologic clearance over 5 years. ^[6]  Twenty patients with nonmetastatic, noninfiltrating right colonic cancer who were treated with laparoscopic right hemicolectomy were compared with a well-matched group who underwent open right hemicolectomy. There was no statistically significant difference in the cumulative results other than the duration of surgery, which was longer in laparoscopic surgery. The authors concluded that laparoscopic right hemicolectomy was safe and oncologically adequate as compared with open right hemicolectomy.

Kang et al compared early perioperative results and oncologic outcomes for open, laparoscopic, and robotic surgical management of right-side colon cancer. ^[7]  They found that no difference among the three groups with regard to total retrieved lymph node numbers. The robotic and laparoscopic approaches yielded better short-term outcomes in terms of reducing hospital stay compared with the OS. The cost of robotic surgery was relatively high. The benefits of the robotic approach for right hemicolectomy remain unclear.

A descriptive nonrandomized study using data from a Dutch national database evaluated 12,006 patients who underwent elective open (n = 6683) or laparoscopic (n = 5323) right hemicolectomy for right-side colorectal cancer. ^[8]  The 30-day complication rate was 26.1% in the laparoscopic group in 26.1% and 32.1% in the open group. The 30-day mortality was 2.2% in the laparoscopic group and 3.6% in the open group. Open right colectomy appeared to carry a higher risk of complications and mortality even after correction for confounding factors.