Open right hemicolectomy

Key principles

• Adherence to oncological resection principles (if for cancer)
• Preservation of colonic vascular supply and length if possible
• Restoration of GI continuity with a well vascularised and tension-free anastomosis

Right hemicolectomy is the resection of the Right colon along with its supplying vascular pedicle and appropriate reconstruction and restoration of GI continuity. This is usually done in the context of malignancy so would also encompass an oncological lymphadenectomy.

Specific preoperative preparation

• Ensure full work up with clinical and pathological staging complete
• No requirement for routine bowel prep
• Always ensure stoma site marked in the acute setting and in all CD patients
• Has tumour been tattooed if likely small/difficult to palpate

Operation Details

• Position supine with arms abducted to 80 degrees in cruciform position
• Prep and square drape from xiphisternum to pubis
• I operate from the L) hand side of the patient
• Midline laparotomy incision and application of appropriate retractor (I use to large Alexis)
• Key steps
  • Examine abdomen and liver surface for evidence of metastatic disease
  • Palpate tumour to accurately locate
  • Pack small bowel towards pelvis/LLQ with moist pack
  • Mobilise
    • Traction R) colon towards midline and mobilisation along lateral peritoneal reflection/line of Toldt
      • Mobilsation proceeds in an caudal to cranial direction and lateral to medial
      • During mobilisation care should be take to identify relevant anatomical structures
        • Duodenum superiorly
        • Ureter, gonadal vessels
    • Mobilise hepatic flexure by continuating my lateral mobilisation with aid of index finger dissection
      • Can facilitate by mobilising from Tx colon end by dissection of anterior leaf of greater omentum off the Tx colon
    • Aim to mobilise R) colon to the midline
  • Identify transection points
    • Identify vascular structures for ligation
      • Usually Ileocolic +/- R) colic or R) branch or Middle colic
        • Middle colic will often need to be taken if extended R) HC
    • Score peritoneum to mark course and make hole in mesentery at transection points
    • Divide along this line with care to adequate vessel ligation
      • Robert’s clamps and 0 vicryl ties to all named colic vessels and 2/0 to smaller.
        • I double ligate the Ileocolic vessels
      • I perform a high ligation of the ileocolic vessel to ensure adequate lymphadenectomy and lymph node harvest
      • Prior to ligation of marginal A/R) branch of middle check for pulsatile retrograde flow
  • Perform anastomosis
    • Ensure adequate orientation, vascularity and tension free
      • Stapled
        • Stapled, side-to-side using a GIA (usually 80) purple load
        • Enterotomies in area of bowel being resected
        • Single firing longitudinal along anti-mesenteric border checking mesentery is well clear and waiting appropriate time after clamp prior to firing
        • Check internal staple line for bleeding and iffset staple lines
        • Transverse firing in similar fashion
        • I oversew the transverse staple line for haemostasis and place 2x crotch sutures 3/0 PDS in the apex of the anastomosis to minimise direct staple line tension
      • Hand-sewn
        • End to end 3-0 PDS
  • Change gloves
  • Close mesenteric defect with continuous 3/0 PDS taking care to avoid underlying vessels
  • Ensure Haemostasis
  • Washout Warm saline and suction all FF o No routine drain
  • Fascial closure with 2x loop 0 PDS
  • 3/0 SC monocryl closure to skin

Intraoperative complications & challenges

• Bleeding from hepatic flexure vessels
  • Pressure and packing, being as specific as possible
  • If significant then inform anaesthetist
  • Avoid diathermy. If pressure fails then suture ligation 3/0 vicryl o Topical Haemostatic agents
• Injury to ureter
  • Call urology for assistance as soon as recognized
  • Principles
    • Avoid aggressive dissection/stripping of ureter as may compromise vascular supply
    • Debride damaged/irregular ends
    • Aim for primary or spatulated closure
    • Use JJ stent
• SB injury
  • Control contamination with direct pressure and swab
  • Avoid clamps and clips as this would further damage SB
  • Debride any thermal injury/ischaemia
  • Primary suture closure usually suffice, if extensive then limited SB resection

Post-operative complications

• Immediate
  • Intra-op
  • Bleeding
  • Iatrogenic injuries
  • Anaesthetic complications
• Early
  • Anastamotic leak (less common than L) sided surgery)
  • Bleeding/Haematoma
  • Wound complications
    • Infection
    • Dehiscence – Deep or superficial o Infection
  • Pulmonary
  • Urinary o MI/DVT/PE/CVA
• Late
  • Stricture
  • Recurrence of pathology