Open Right Colectomy (Right Hemicolectomy) 

Updated: Feb 16, 2021
Author: Ashwin Pai, MBBS, MS (GenSurg), MRCS; Chief Editor: Kurt E Roberts, MD 

Overview

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 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

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]  

Contraindications

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.

Technical Considerations

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]

Outcomes

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.

 

Periprocedural Care

Preprocedural Planning

Thorough preparation of the bowel is necessary before the operation. Standard bowel preparation may be conducted over a 24-hour period and is usually performed after admission. The patient is allowed to drink only clear liquids for 24 hours, and about 4 L of polyethylene glycol solution is given to the patient to be taken over 2-3 hours in the afternoon of the day before the procedure. A sodium phosphate enema is given on the night before the operation.[1]

Two doses of metronidazole and neomycin sulfate are given after the lavage preparation on the day before surgery. An intravenous (IV) second-generation cephalosporin is administered within 1 hour before incision. Electrolyte levels are obtained again on the night before surgery after the lavage.

Equipment

Open right hemicolectomy is performed with a standard laparotomy set, as follows:

  • Scalpel with No. 11 and No. 15 blades
  • Curved and straight artery forceps
  • A pair of toothed thumb forceps
  • A pair of nontoothed forceps
  • Allis forceps
  • Noncrushing intestinal clamps
  • Surgical cautery
  • Hemostatic clips or ligatures
  • Handheld ultrasonic dissector (if available)
  • Abdominal wall retractors/self-retaining retractors
  • Atraumatic visceral retractors
  • Suture material (absorbable and nonabsorbable)
  • Anastomotic staplers

Patient Preparation

Anesthesia

General anesthesia is preferred for an open right hemicolectomy. An additional epidural block can be placed for postoperative pain management. After induction of anesthesia, a 16-French or 18-French Ryle tube is passed and kept on continuous drainage. The patient is then catheterized with a 14-French Foley catheter for monitoring of intraoperative and postoperative urine output.[4]

Positioning

The standard position for an open right hemicolectomy is supine with strapping of the ankle and wrists to allow intraoperative changes to other positions, such as the Trendelenburg position. The surgeon stands on the patient's left, and the first assistant stands across from the surgeon on the patient's right. The scrub nurse stands beside the surgeon. If a second assistant is needed, he or she usually stands across from the surgeon to the left of the first assistant.

 

Technique

Approach Considerations

Clinicians should adhere to the following basic principles in colon resection:

  • Prepare the patient properly before the operation
  • Perform thorough bowel preparation preoperatively
  • Plan the incisions so as to yield optimal exposure
  • Use Turnbull's no-touch technique when possible
  • Completely mobilize the segment to be resected so that the surgeon can obtain good clearance as well as accomplish a tension-free anastomosis
  • Achieve adequate cancer clearance both in the resected margins and in the lymphatic fields
  • Ensure an adequate blood supply to the segments involved in the anastomosis
  • An end-to-end anastomosis is preferred to a side-to-side or end-to-side anastomosis; the surgeon may use interrupted fine silk sutures in one or two layers or may use anastomotic staplers
  • Achieve good and secure abdominal closure to facilitate early ambulation

Open Right Hemicolectomy

Choice of incision

The choice of incision varies according to the circumstances of the case (eg, the underlying pathology, the extent of the disease, and previous operations). A midline incision is advantageous because it is easily extended to expose any area. This incision is preferred for patients with inflammatory bowel disease because such patients may need frequent operations. A right paramedian incision (see the image below) provides good exposure and is suitable for planned right hemicolectomies.[1]

Right paramedian incision. Right paramedian incision.

Determination of extent of resection

The location of the tumor determines the line of resection. If the tumor is in the cecum, a 10-cm margin of terminal ileum must be resected; however, if the tumor is in the ascending colon, only a few centimeters of ileum is required as a margin. The line of resection should extend to the right side of the transverse colon at the level of the right branch of the middle colic vessels (see the images below).

Extent of right hemicolectomy. Extent of right hemicolectomy.
Part of distal ileum and part of transverse colon Part of distal ileum and part of transverse colon adjacent to hepatic flexure removed with specimen.
Right hemicolectomy specimen. Right hemicolectomy specimen.

Care must be taken to preserve the main branch of the middle colic vessels. To ensure proper lymph node harvesting, the right colic and ileocolic vessels are taken at their origins. Omental attachments to the right colon are generally removed with the specimen.

Various researchers have explored the use of complete mesocolic excision (CME), both open and laparoscopic, in right hemicolectomy.[9]  

Mobilization of colon

The right colon is mobilized (see the image below) by separating the terminal ileum and cecum from the retroperitoneal structures. The ureter and the gonadal vessels are the most important of these. Separation is accomplished by incising the peritoneal attachments to these structures laterally and rotating the cecum anteriorly and medially.

Incision along avascular line to mobilize right co Incision along avascular line to mobilize right colon.

When this mobilization is completed, the attachments to the cecum and terminal small bowel are incised in an inferior-to-superior direction toward the junction of the third and fourth portions of the duodenum. A sponge is often helpful in gently separating the filmy adhesions to the retroperitoneum posteriorly as mobilization continues superiorly.

During this dissection, proper care must be taken to identify and posteriorly displace the gonadal vessels and ureter. Mobilization of the ileocolic vessels is complete once the middle colic artery is identified where it crosses the duodenum.

The lateral dissection is continued upward and around the hepatic flexure with the surgeon's index finger; this provides the plane of dissection for cauterization by the first assistant. The exposure of the hepatic flexure is completed with the midtransverse colon retracted inferiorly. The thin plane between the mesocolon and the gastrocolic ligament can be developed bluntly and dissected to complete the flexure mobilization (see the image below). During the mobilization of the gastrocolic ligament, a few vessels may have to be ligated.

Entire right colon mobilized up to hepatic flexure Entire right colon mobilized up to hepatic flexure.

Apply gentle traction to the transverse mesocolon to mobilize the proximal part of the transverse colon. Perform this maneuver with a gentle touch to avoid avulsing a branch of the middle colic vein from its origin. Next, retract the right colon superiorly and medially to expose the anterior edge of the duodenum and the head of the pancreas (see the image below). Release of these filmy attachments is the last remaining step in the dissection.

Duodenum and major vessels seen after full mobiliz Duodenum and major vessels seen after full mobilization of right colon.

Incise the avascular area between the ileocolic artery and right branch of the middle colic artery to the base of the ileocolic vessels at about the level where it crosses the lateral or inferior edge of the duodenum. Incise the peritoneum overlying the ileocolic vessel, and doubly ligate and divide the vessels.

Next, divide the marginal branches to the ileum, thus preparing the proximal line of resection. Divide the right colic artery, if necessary, and the right branch of the middle colic artery. Finally, clear the distal bowel margin of fat and prepare it for an anastomosis.[4]

Creation of anastomosis

The anastomosis may be created either with a stapler or by means of a handsewn technique.

Stapled anastomosis

A conventional stapled functional end-to-end anastomosis is accomplished with one or two firings of a linear cutting stapler and the use of a linear noncutting stapler. However, the current standard technique is a simplified procedure that uses only two firings of a disposable linear cutting stapler.

Clear away mesenteric fat around the colon and the terminal ileum for approximately 1.5 cm. Make transverse incisions about 1.5 cm long on the specimen sides of these cleared areas on the antimesenteric borders of the ileum and the colon. One of the two sides of the linear cutting stapler is placed into each of the two holes, first in the small bowel and then in the colon. Gently close the stapler, approximating the small bowel and the colon along the antimesenteric border. Once the stapler is in a good position, fire it and remove it.

When the stapler is fired, the previously separate ileal and colonic enterotomies are joined into a single enterotomy. Use a pair of Babcock clamps to grasp opposite borders of this enterotomy at the anterior and posterior staple lines. A long (75-100 mm) linear cutting stapler is then reloaded and placed across the ileum and transverse colon at a right angle to the previous staple line. With retraction of the previous enterotomy, the stapler is fired, completing the surgical resection and anastomosis.

The mesenteric defect can be closed or left open, depending on the surgeon's preference. It has been suggested that routine closure of the mesenteric defect may not be beneficial.[10]

If available, the omentum can be placed over the anastomosis to provide further protection against postoperative anastomotic leakage.[1]

Handsewn anastomosis

The handsewn anastomosis most often performed begins by placing crushing bowel clamps across the colon a few centimeters distal to the area to be divided on the ileum and a few centimeters proximal to the line of transection on the colon. Place noncrushing clamps straight across the colon and ileum. At this point, the ileum and colon are divided, and the specimen is sent for pathologic evaluation. If the diameter of the transected ileum is small, it can be enlarged by dividing it longitudinally along its antimesenteric border.

Three types of anastomosis can be created, as follows:

  • End-to-end
  • Side-to-side
  • End-to-side

First, the two ends of the bowel are approximated, with care taken to ensure that no twists exist. To aid in approximation, place 3-0 stay sutures in the corners of the bowel. Place a posterior row of Lembert sutures first. Place these sutures deep enough to incorporate most of the muscle layer. If the suture can be seen through the serosa, the stitch has been placed too superficially, and a deep needle passage is required. The sutures are tied so as to approximate tissues, not strangle them.

Next, an inner layer of continuous 3-0 suture is used to approximate the mucosal and submucosal layers. The corner of the bowel is secured first, and the continuous suture is then advanced along the posterior aspect of the anastomosis. This suture is tied to itself at the corner.

The occluding bowel clamps are removed from the bowel to allow blood flow to return to the ends of the bowel. The final step includes the anterior second layer of 3-0 Lembert sutures, which approximate the serosal layer and thus bolster the anastomotic line (see the images below).[4]

Ileotransverse anastomosis. Ileotransverse anastomosis.
Ileum anchored to lateral abdominal wall. Ileum anchored to lateral abdominal wall.

Completion and closure

Before closure, check the abdomen for adequate hemostasis, and thoroughly irrigate it with saline. Drains are used only for infection or abscess. Use interrupted or continuous sutures to close the fascial layer, and a continuous subcuticular suture or skin staples are used to approximate the skin.

Postoperative Care

Postoperatively, nasogastric aspiration is maintained until ileus resolves. Clear liquids are started when the patient has a soft abdomen with normal bowel sounds and expels flatus without nausea, vomiting, or abdominal distention. If the patient tolerates liquids well, normal intake can be started after 2 days. IV fluids should be continued until the patient can tolerate normal oral intake. The urinary catheter may be removed 2-3 days after the operation.

Patients who recover sufficiently may be discharged on day 8, and sutures or staples may be removed on day 10.[1]

Complications

Complications of open right hemicolectomy include the following:

  • Postoperative ileus
  • Anastomotic leakage
  • Wound infection [1]
 

Questions & Answers

Overview

What is open right hemicolectomy (open right colectomy)?

What are the types of open right hemicolectomy (open right colectomy)?

What are the indications for open right hemicolectomy (open right colectomy)?

When is open right hemicolectomy (open right colectomy) contraindicated?

What is the anatomy of the colon relevant to performing open right hemicolectomy (open right colectomy)?

What is included in the procedural planning for open right hemicolectomy (open right colectomy)?

What are the reported outcomes for open right hemicolectomy (open right colectomy)?

Periprocedural Care

What is included in the preprocedural patient prep for open right hemicolectomy (open right colectomy)?

What equipment is needed to perform open right hemicolectomy (open right colectomy)?

What is the role of anesthesia in the performance of open right hemicolectomy (open right colectomy)?

How is the patient positioned for open right hemicolectomy (open right colectomy)?

Technique

What are the basic principles of colon resection?

How is the incision chosen in open right hemicolectomy (open right colectomy)?

How is the extent of resection determined in open right hemicolectomy (open right colectomy)?

How is the colon mobilized during open right hemicolectomy (open right colectomy)?

How is anastomosis created in open right hemicolectomy (open right colectomy)?

How is open right hemicolectomy (open right colectomy) closed?

What is included in postoperative care following open right hemicolectomy (open right colectomy)?

What are the possible complications of open right hemicolectomy (open right colectomy)?