Keywords

Anatomy and Indications

The right colon extends from the cecum, which is typically fixed in the right lower quadrant to the hepatic flexure, where it transitions to the transverse colon. The arterial supply to the right colon is derived from the superior mesenteric artery. The ileocolic branch supplies the terminal ileum and cecum. In 32–63 % of the population, the right colic artery supplies the ascending colon, but a substantial proportion of the population derives arterial blood flow to the right colon from the ileocolic artery alone [1, 2]. Branches of the middle colic artery can supply the hepatic flexure. There can be collateral vessels between these branches and those from the right colic artery forming the right portion of the marginal artery. The venous drainage of the right colon mirrors the arterial supply – the ileocolic, right colic, and middle colic veins drain into the superior mesenteric vein. The lymphatic supply to the colon follows the blood supply through the mesentery.

Benign or malignant lesions of the cecum and right colon can be treated by right hemicolectomy. Indications for benign processes involving the right colon are Crohn’s disease, ischemia, trauma, diverticulitis and cecal volvulus. Malignant or premalignant lesions are also appropriately managed with right hemicolectomy, including adenocarcinomas or colonoscopically unresectable adenomas. In addition, appendiceal neoplasms such as adenocarcinoma or carcinoid tumors larger than 2 cm, those not confined to the appendix, or with positive lymph nodes require right hemicolectomy [3].

The extent of resection for malignant lesions located within the cecum or ascending colon is dictated primarily by the blood supply and lymphatic drainage. Where formal oncologic resection is required, the extent of colon removed is based upon the area supplied by the ileocolic and right colic artery. If extended right hemicolectomy is warranted, removal of additional transverse colon supplied by the middle colic artery may be required.

Preoperative Preparation

Individual patient risk factors will determine what additional cardiac and pulmonary work-up is required preoperatively. Pertinent preoperative work-up is determined by the underlying diagnosis requiring right colon resection. Colonoscopy is used to identify, obtain tissue diagnosis, and permanently mark (tattoo) the location of an intra-luminal lesion. This is particularly important when a laparoscopic approach is planned. Using india ink, the endoscopist should tattoo immediately adjacent to the lesion and ideally in at least 2 quadrants, allowing intra-operative identification [4].

In cases where malignancy is proven or suspected, preoperative work-up should also include a chest x-ray and computed tomography of the abdomen and pelvis for complete oncologic staging [5]. Preoperative carcinoembryonic antigen (CEA) is obtained to facilitate postoperative surveillance. Evidence of metastatic disease does not necessarily exclude right hemicolectomy, but may alter the treatment approach and planning. Careful discussion with the patient about goals of therapy, patient preferences, and relative balance of risks and benefits is required prior to performing any operative procedure.

Preoperative patient preparation usually involves full mechanical bowel preparation with oral antibiotics. An updated Cochrane Review concluded that there is no evidence that preoperative mechanical bowel preparation alone decreases rates of anastomotic leak, mortality, peritonitis, need for reoperation, wound infection, or morbidity. Additionally, there is some suggestion that inadequate bowel preparation which leaves liquid stool within the colon may be associated with poorer outcomes [6]. However, a Veteran’s Administration study noted that mechanical bowel preparation with oral antibiotics may decrease rates of surgical site infections [7]. Other preoperative considerations must include appropriate DVT prophylaxis and Surgical Care Improvement Project (SCIP) appropriate IV antibiotics [8].

Anesthesia and Positioning

General anesthesia is utilized for open and laparoscopic right hemicolectomy. In extremely high risk patients, spinal anesthesia can be considered for open procedures [9]. In open cases a thoracic epidural catheter may be utilized and can be placed preoperatively or postoperatively for pain control, and may reduce narcotic requirements and promote earlier return of bowel function [10].

The patient is positioned supine on the operating room table. Arms may be tucked at the patient’s sides for a laparoscopic approach. Deep vein thrombosis prophylaxis is provided with sequential compression devices and subcutaneous unfractionated heparin given prior to beginning the case. Preoperative antibiotics with gram positive and gram negative coverage (SCIP inf-2 guidelines [8]) are given within 60 min of making incision (SCIP inf-1 [8]) and re-dosed as needed throughout the case. An indwelling urinary catheter is placed for monitoring during the procedure.

Operative Descriptions

Open Right Hemicolectomy

The decision to perform an open or laparoscopic right hemicolectomy will depend on patient factors and the surgeon’s familiarity with the laparoscopic approach. We will begin with a description of the open approach.

An incision in made from just above to just below the umbilicus. The subcutaneous tissues and linea alba are divided with either the scalpel or electrocautery until the peritoneum is identified. This is elevated and entered sharply with a scalpel or Metzenbaum scissors. A self-retaining retractor is placed, and the liver, peritoneum and other organs are inspected and palpated for evidence of other pathology.

The peritoneal reflection is incised lateral to the cecum, and this incision is carried superiorly toward the hepatic flexure of the colon. The right ureter must be identified and preserved as it crosses anteriorly over the right common iliac bifurcation. The colon is further mobilized medially lifting the mesentery from the retroperitoneum. As the dissection is carried toward the hepatic flexure, the second and third portions of the duodenum must be identified and protected from injury (Fig. 22.1). The duodenum is kept posteriorly while the colon is brought anteriorly during dissection from the retroperitoneum (Fig. 22.2). The vessels in the hepatocolic ligament are ligated and divided and the lesser sac is entered mobilizing the proximal transverse colon.

Figure 22.1
figure 1

The right colon is retracted medial while dividing the lateral peritoneal attachments, taking care to identify and preserve the right ureter. As the dissection is carried superiorly, the duodenum must be identified and protected

Full size image
Figure 22.2
figure 2

As the right colon is mobilized and rotated medially, the second and third portion of the duodenum should be identified and kept posterior

Full size image

The omentum is dissected free from the transverse colon at the distal resection site and divided using either the clamp and tie technique, or using a vessel sealing device (ultrasonic coagulating shears or electrothermal bipolar vessel sealers). If performing the operation for benign disease, the mesenteric attachments of the right colon can be divided close to the mesenteric border of the colon. If the operation is performed for malignancy, the resection site should be chosen to ensure a luminal margin of at least 5 cm [11]. A window is created in the transverse mesocolon at the site where the colon will be divided, the marginal artery of Drummond is ligated and divided, and the transverse mesocolon is divided down to the base of the mesentery to identify the middle colic vessel bifurcation. The right branch of the middle colic is ligated and divided at its origin while the left branch is preserved. If the lesion is at the hepatic flexure or proximal transverse colon, the specimen can be extended by dividing the middle colic vessels at their base. If the right colic vessels are present, these are also divided at their origin, and the mesentery is divided down to the base of the ileocolic vessels (Fig. 22.3), which are also ligated and divided. The mesentery of the terminal ileum is divided, and the proximal margin of the specimen should include 5–10 cm of small bowel [11, 12], although more can be excised for cecal tumors. The specimen is opened on the back table and inspected to ensure that it contains the lesion of interest and margins are appropriate. It can then be passed off the table and sent to surgical pathology.

Figure 22.3
figure 3

The mesentery of the right colon and, if necessary, the transverse colon is ligated. When malignant disease is resected, the ileocolic and right colic (if present) vessels are identified and divided near their origin to allow for adequate lymph node sampling. The right branch of the middle colic is usually divided at its bifurcation from the left branch

Full size image

The ileocolic anastomosis can be created either in a hand-sewn or stapled fashion. We describe the side-to-side stapled approach. After initially dividing the mesentery as already described, the ileum and transverse colon are aligned side by side and enterotomies are made on the antimesenteric borders of both limbs of bowel. The two halves of a linear stapler (typically 75 or 80 mm) are passed into the lumen of both the large and small bowel (Fig. 22.4). After firing the stapler, the intraluminal staple lines are inspected for bleeding. The anterior and posterior staple lines should be slightly off-set, and a 60-mm transverse non-cutting stapler is used to close the end of the anastomosis distal to the prior enterotomies (Fig. 22.5). The bowel is divided sharply on the stapler. This staple line can be oversewn if desired with interrupted imbricating sutures, and the mesenteric defect can be closed with a running absorbable suture to prevent risk of internal hernia. The abdomen is irrigated, inspected for bleeding, and the fascia is closed with running absorbable suture. The subcutaneous tissue is again irrigated, and the skin is closed.

Figure 22.4
figure 4

The side-to-side stapled anastomosis is constructed after resecting the specimen. Each half of the linear cutting stapler is passed through enterotomies in the terminal ileum (left) and transverse colon (right). Firing the stapler creates a lumen through the antimesenteric borders of the intestine

Full size image
Figure 22.5
figure 5

The common enterotomy from the side-to-side stapled anastomosis is closed using the transverse non-cutting stapler. Care is taken not to narrow the newly created lumen, and the staple line can be oversewn

Full size image

Laparoscopic Assisted Right Hemicolectomy

Laparoscopic assisted right hemicolectomy can be performed under general anesthetic with similar preparation and positioning as described above. Because of the reduction of tactile sensation during the laparoscopic portion of the case, tattooing of the lesion colonoscopically takes on increased importance.

The abdomen can be entered using a Veress needle technique or the Hasson technique [13]. With the Hasson approach a 1–1.5 cm peri-umbilical incision is made and dissection is carried down until the linea alba can be identified and elevated. This is divided, and the peritoneum is sharply incised. Stay sutures are placed at the lateral edges of the fascia, and the 12 mm Hasson trocar is inserted into the abdomen. The stay sutures are used to secure the trocar in place, and the abdomen is insufflated to 15 mmHg with carbon dioxide. The laparoscope is inserted, and the abdomen is inspected for injury during insertion and for other intra-abdominal pathology which may preclude resection. In general, a 30 ° scope is utilized for this procedure. Additional 5 mm ports are placed in the supra-pubic midline and in the left lower quadrant; a third port can be placed in the left upper quadrant or in the right lower quadrant, depending on the need during dissection.

The colon may be mobilized using either a lateral to medial or medial to lateral approach. The lateral to medial approach is as follows: the patient is placed in Trendelenberg with tilt to elevate the right side. The terminal ileum is identified and retracted anteriorly, as is the appendix and cecum to allow incision of the peritoneal attachments. These are divided and dissection continues in a cephalad direction, taking care to identify the gonadal vessels and the right ureter as it passes over the right common iliac vessels and ensure that this remains posterior as the colon is mobilized anteriorly (Fig. 22.6). As the dissection approaches the hepatic flexure, the duodenum must be identified and protected (Fig. 22.7). The hepatocolic ligament and omental attachments are divided after placing the patient in a reverse Trendelenberg position. After completing the mobilization of the specimen, the terminal ileum and ascending colon are elevated to identify the ileocolic vessels at their origin (Fig. 22.8). A window is created on either side, and the vessels are divided using a vessel sealing or stapling device.

Figure 22.6
figure 6

Laparoscopic lateral-to-medial mobilization: the right colon lateral peritoneal attachments are incised and the colon retracted medially, anteriorly, and cephalad to allow dissection from underlying retroperitoneal structures including the right ureter and gonadal vessels. The psoas muscle and right iliac vessels are also seen

Full size image
Figure 22.7
figure 7

As with the open dissection, the right colon is lifted medially and anteriorly, allowing dissection of the third portion of the duodenum, which falls posteriorly as the retroperitoneal attachments to the colon are divided

Full size image
Figure 22.8
figure 8

Lateral-to-medial mobilization: after the right colon has been mobilized laterally, the ileocolic vessels are identified by elevating the terminal ileum and cecum. This allows creation of mesenteric windows on either side of the vessels prior to division at their origin

Full size image

For the medial to lateral approach, after entering the abdomen, the mesentery of the terminal ileum and right colon is elevated, and the ileocolic vascular pedicle is identified (Fig. 22.9). The peritoneum overlying the mesentery is incised, and windows are made on either side of the vessels at the proximal base (Fig. 22.10). The duodenum is visualized and swept posteriorly as the mesentery is elevated from the retroperitoneum. The ileocolic vessels are then divided with a stapler or energy sealing device (Fig. 22.11). Once they are divided, dissection can then continue, mobilizing the lateral peritoneal reflection of the colon. Care is again taken to free the hepatic flexure from the underlying duodenum during dissection. The remainder of the operation is as described above. Advantages of the medial to lateral approach include easier mesenteric dissection as the colon is tethered to the abdominal wall rather than being free to move, earlier identification and preservation of the ureter and gonadal vessels, decreased bleeding from early control of vascular pedicles, and decreased manipulation of the diseased portion of colon [14].

Figure 22.9
figure 9

Laparoscopic medial-to-lateral mobilization: after identifying the terminal ileum and cecum, the vascular pedicle containing the ileocolic vessels is identified and elevated

Full size image
Figure 22.10
figure 10

Medial-to-lateral mobilization: the mesentery is incised around the vessels. Careful dissection is carried out to identify the duodenum and sweep the retroperitoneal structures posterior

Full size image
Figure 22.11
figure 11

Medial-to-lateral mobilization: the ileocolic vascular pedicle is isolated allowing safe division of the vessels at their mesenteric origin. Once divided, mobilization of the lateral peritoneal attachments of the right colon is performed

Full size image

The proximal colon or terminal ileum is secured with laparoscopic graspers and all other ports are removed to desufflate the abdomen. The peri-umbilical port site is extended if necessary to accommodate a small wound protector device (2–6 cm length). The specimen is extracted and the remaining mesentery is divided to the mid-transverse colon and distal ileum. The side to side stapled ileocolic anastomosis is then created as described above. Closure of the large mesenteric defect is usually not possible, and thus is left open. The anastomosis is then replaced back into the abdomen, which is irrigated and inspected for bleeding. The fascial incision is closed with absorbable suture, and the skin and remaining port sites are irrigated and closed.

Further Innovations

Laparoscopic assisted colectomy is well accepted for treatment of benign and malignant disease of the colon [15, 16]. Variations of minimally invasive surgery are also described. This has included a single incision laparoscopic right hemicolectomy. For this technique, a gel port or specially formatted port allowing insertion of multiple instruments is placed in the abdomen at the umbilicus. The case is then performed as described above. The specimen is then retrieved through the umbilicus, with the bowel exteriorized and anastomosis performed. A recent meta-analysis of nine comparative studies revealed no significant difference in postoperative outcomes or oncologic results with single incision laparoscopic right hemicolectomy compared to the standard laparoscopic approach, though prospective randomized studies are lacking [17].

Postoperative Care

Patients are admitted to the general care floor for postoperative monitoring and pain control. A nasogastric tube is not utilized. Early mobilization should be encouraged, and deep vein thrombosis prophylaxis should be continued. In appropriate patients, non-steroidal anti-inflammatory medications and other non-narcotic modalities of analgesia should be included to minimize narcotic requirements. A liquid diet can be started early postoperatively, and the diet advanced upon full return of bowel function. Patients can anticipate a 3–5 day hospital stay and are ready for discharge upon return of bowel function, tolerating oral intake, ambulating, and appropriate pain control. Complications include wound infection, prolonged ileus, and anastomotic leak.