Open Right Colectomy (Right Hemicolectomy) Technique

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

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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]

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Complications

Complications of open right hemicolectomy include the following:

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