Right hemicolectomy explain the procedure in detail

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right hemicolectomy surgical procedure diagram anatomy

This composite image illustrates the surgical anatomy and intraoperative dissection of the ileocolic artery (ICA) during a right hemicolectomy or similar colonic procedure. Image A is an anatomical diagram featuring a schematic 'open book' model of the abdominal vasculature and mesentery. It depicts the superior mesenteric vein (SMV) as a central axis, with the ileocolic artery branching toward the cecum and ascending colon. A dotted line indicates the planned surgical dissection plane along the SMV axis. Image B is a grayscale intraoperative photograph corresponding to the diagram, labeled as 'ileocolic Artery-View'. It shows the surgical field during the dissection of the ileocolic artery. Laparoscopic or open surgical instruments are visible, including a dissection tool positioned beneath the vessel to isolate it from the surrounding fatty mesenteric tissue. The image demonstrates the clinical application of embryologically defined fascial planes to achieve a complete mesocolic excision (CME), emphasizing the vascular relationship between the ICA and the SMV.

Educational figure illustrating surgical anatomy for right-sided hemicolectomy. Figure A is an anatomical diagram representing the 'open book' model of fascial and vascular planes. It shows the stomach, duodenum, and ascending colon in relation to the mesenteric root. Key vascular structures highlighted include the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) trunk, with a specific focus on the V-shaped confluence of the ileocolic vessels. A curved arrow indicates the incision site of the ileocolic mesentery and the division of the ileocolic vein (ICV). Figure B is an intraoperative clinical photograph (monochrome) providing the 'ileocolic vein-view' post-dissection. The image demonstrates the surgical exposure of the ICV separated from the surrounding fatty mesentery, with surgical retractors and instruments visible in the operative field. This content is designed to teach medical professionals the precise anatomical landmarks and vascular dissection steps required for complete mesocolic excision (CME).

This composite educational resource features an intraoperative laparoscopic photograph (left) paired with a corresponding labeled anatomical diagram (right) depicting a right hemicolectomy procedure. The content illustrates the surgical dissection of the mesocolon and vascular control. Key anatomical structures labeled include the transverse colon at the superior margin and the root of the ascending/small intestine mesentery at the inferior aspect. Centrally, the image highlights the right branch of the middle colic vessels being approached for division. The 'divided ascending mesentery' is shown, demonstrating the mobilization of the colon from the retroperitoneum. A laparoscopic surgical instrument, labeled as a Karl Storz tool, is positioned to manipulate the right branch of the middle colic vessels. This visual is designed to teach laparoscopic surgical anatomy, specifically the identification and ligation of colic vasculature and the mobilization of the right colon using a caudal-to-cranial approach.

Anatomical illustration and surgical diagram depicting the right atrial cryoablation procedure, likely for the treatment of atrial fibrillation (Cox-Maze IV variant). The diagram shows a grayscale medical illustration of the right atrium and surrounding cardiac anatomy, including the superior vena cava, inferior vena cava, and tricuspid annulus. Superimposed on the anatomy are specific surgical markers: dashed lines represent surgical incisions, specifically the lateral longitudinal incision extending from the interatrial groove toward the tricuspid annulus. Solid black lines delineate the cryoablation lesion set. These ablation lines are strategically placed at the junction of the incision and tricuspid annulus, as well as along the posterior walls of the venae cavae. The educational focus is the spatial mapping of transmural cryo-lesions designed to interrupt macro-reentrant circuits in the right atrium while maintaining surgical access and anatomical integrity of the conduction system.

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Right Hemicolectomy - Detailed Procedure

Overview and Indications

A right hemicolectomy removes the terminal ileum (typically 10-15 cm), the cecum, the ascending colon, the hepatic flexure, and the proximal transverse colon to approximately its midpoint. Continuity is restored with an ileocolic (ileo-transverse) anastomosis. The procedure is indicated for:

Carcinoma of the cecum, ascending colon, or hepatic flexure
Crohn's disease of the terminal ileum / ileocecal region
Cecal volvulus
Complicated appendiceal pathology (appendiceal neuroendocrine tumors >20 mm, goblet-cell carcinoids, positive margins after appendectomy)
Severe right-sided colitis refractory to medical therapy

An extended right hemicolectomy is performed for tumors of the midtransverse colon; it continues to include the transverse colon down to the splenic flexure, with the terminal ileum anastomosed to the descending colon.

Preoperative Preparation

Mechanical bowel preparation: controversial - most colorectal surgeons still perform it. Key advantages: intraoperative colonoscopy feasibility, absence of a stool load if a diverting stoma becomes necessary.
Antibiotic prophylaxis: given within 1 hour of incision, targeting both aerobic (E. coli, Klebsiella) and anaerobic (Bacteroides fragilis) organisms. Options include: a 2nd/3rd-generation cephalosporin + metronidazole, ertapenem, or piperacillin-tazobactam. Duration limited to <24 hours.
VTE prophylaxis: sequential compression devices and low-molecular-weight heparin.
Stoma marking: stoma nurse marks the right iliac fossa if a stoma is a possibility.
Preoperative imaging (CT abdomen/pelvis with contrast) and colonoscopy for tumor staging.

Open Right Hemicolectomy

Positioning and Access

The patient is placed supine with both arms out. A midline incision is standard - it provides excellent access to the entire right colon and the root of the mesentery. A wound protector is placed. A self-retaining retractor (e.g., Bookwalter or Omni-Tract) is positioned. The surgeon stands on the right and the assistant on the left.

The abdomen is fully explored to assess for metastatic disease (liver, peritoneum, lymph nodes).

Step 1 - Lateral Mobilization (White Line of Toldt)

The assistant retracts the right colon medially to the left. The surgeon incises the lateral peritoneal reflection (white line of Toldt) with electrocautery from the cecum up to the hepatic flexure.

Figure 144.1: Incision of the white line of Toldt during open right hemicolectomy - the assistant retracts the colon medially while the surgeon divides the lateral peritoneal reflection

Step 2 - Retroperitoneal Mobilization

The right colon is swept anteromedially, developing the avascular plane between the mesentery/colonic mesofascia and the retroperitoneum. Structures that must be identified and preserved in the retroperitoneum include:

Right gonadal vessels (right ovarian/testicular vein and artery)
Right ureter - identified crossing the iliac vessels
Gerota's fascia (covering the right kidney)
Second and third portions of the duodenum and the head of the pancreas

Care is taken to avoid traction injury to the small veins around the head of the pancreas; bleeding here often requires suture ligatures.

Figure 144.2: Mobilization of the right colon off the retroperitoneum - showing displacement of the right colon off Gerota's fascia, the duodenum, and the head of the pancreas

The hepatic flexure attachments (hepatocolic and duodenocolic ligaments) are divided similarly with cautery.

Step 3 - Omentum

The right portion of the omentum is resected en bloc (for oncological cases) and divided below the right gastroepiploic arcade. It is dissected off the mid-transverse colon and divided between clamps and ties or with a vessel-sealing device. The lesser sac is entered. This maneuver ensures adequate lymphadenectomy along the transverse mesocolon.

Step 4 - Vascular Control (Ileocolic Pedicle)

The cecum is retracted to the right to place the ileocolic pedicle under tension. The ileocolic vessels are located at the caudal portion of the root of the mesentery. The right colic vessels are anatomically variable - most commonly a branch of the ileocolic pedicle, but occasionally arise as a separate takeoff from the superior mesenteric artery and vein (SMA/SMV).

The ileocolic vessels are cleared at their junction with the SMA/SMV, ligated, and divided between clamps and ties or with a vessel-sealing device - this constitutes high ligation consistent with principles of total mesocolic excision (TME/CME).

Dissection then continues along the SMV superiorly. The middle colic pedicle is identified, and the right branch of the middle colic vessels is ligated and divided. The mesentery is fully divided to the transverse colon, maintaining the integrity of the visceral fascial envelope around the mesocolon (CME principle: no breach of the mesofascial envelope).

Intraoperative dissection of the ileocolic artery showing the CME plane along the SMV axis

Step 5 - Division of the Bowel

Terminal ileum: divided 10-15 cm proximal to the ileocecal valve with a linear stapler (GIA/Endo-GIA).
Transverse colon: divided at the appropriate level (mid-transverse for standard resection, more distal for extended right hemicolectomy) with a linear stapler.

The specimen is removed.

Step 6 - Ileocolic Anastomosis

The anastomosis is fashioned between the terminal ileum and the proximal transverse colon. The main techniques are:

Stapled side-to-side (functional end-to-end) anastomosis - most common:

An enterotomy (in the ileum) and a colostomy (in the transverse colon) are made on the antimesenteric borders.
The GIA-80 stapler is inserted into both lumens and deployed, creating a wide side-to-side anastomosis.
The common opening is then closed by deploying a TA-90 stapler across the remaining enterotomy/colostomy.

Hand-sewn end-to-end or end-to-side anastomosis is also acceptable, typically using a two-layer technique (inner absorbable continuous suture, outer interrupted seromuscular sutures).

The anastomosis is assessed for tension (should lie tension-free), vascularity (mesenteric defect aligned, no twisting), and hemostasis. The mesenteric defect is generally not closed routinely (to avoid internal herniation risk in some practices).

Step 7 - Closure

The abdomen is irrigated. The fascia is closed with a running looped PDS (polydioxanone) suture. Subcutaneous tissue and skin are closed. Wound drains are not routinely placed.

Laparoscopic Right Hemicolectomy

Positioning and Port Placement

The patient is supine with both arms tucked and padded, secured to a nonskid cushioned pad to prevent sliding during positional changes. Both surgeons stand on the left side of the patient.

A Veress needle is placed at Palmer's point (3 cm below the left subcostal border, midclavicular line) for pneumoperitoneum, or a Hasson cut-down technique (open access) is used. A 0-degree laparoscope is used.

Port placement (4 ports, all 5-mm):

Figure 144.5: Port placement for laparoscopic right hemicolectomy - supraumbilical camera port, suprapubic port, left upper quadrant port, and left lower quadrant port (all 5 mm)

Supraumbilical port - camera port (also the planned extraction site)
Suprapubic port - working port
Left upper quadrant port - working port (lateral to rectus)
Left lower quadrant port - working port (lateral to rectus)

Table positioning: Trendelenburg with the right side of the table tilted upward. The omentum is swept cephalad; the small bowel is displaced to the left to expose the ileocolic pedicle and duodenum.

Medial-to-Lateral Approach (Standard Laparoscopic Technique)

This is the preferred laparoscopic technique, opposite to the lateral-to-medial approach used in open surgery.

The terminal ileum and cecum are retracted to the right lower quadrant, placing the ileocolic pedicle under tension.
The peritoneum is incised below the ileocolic pedicle at the level of the duodenum.
Submesenteric dissection proceeds from medial to lateral - the right colon mesentery is lifted off the retroperitoneum, exposing the duodenum, Gerota's fascia, gonadal vessels, and ureter. The visceral fascial layer is kept intact (CME principle).
The ileocolic pedicle is cleared, ligated, and divided at its SMA/SMV origin - using a vessel-sealing device, endoscopic vascular stapler, or clips.
The transverse colon is placed on tension; the transverse mesocolon is scored; the right branch of the middle colic pedicle is ligated and divided. The mesentery is fully divided to the transverse colon.
The omentum is dissected off the distal transverse colon with entry into the lesser sac.
The hepatic flexure attachments are divided medial to lateral - the previous medial-to-lateral dissection has already freed the retroperitoneal plane, keeping the ureter, kidney, and gonadal vessels posteriorly.
The white line of Toldt is divided laterally to complete mobilization.
The terminal ileum mesentery is divided to the bowel wall.

Extraction and Extracorporeal Anastomosis

The umbilical port site is enlarged (typically to 3-4 cm), a wound retractor is placed, and the cecum is delivered through the incision with a laparoscopic bowel grasper. The terminal ileum, right colon, and proximal transverse colon are extracted.

The bowel is divided extracorporeally with a linear stapler at the terminal ileum and transverse colon. The anastomosis is fashioned extracorporeally using a stapled side-to-side (GIA + TA) or hand-sewn technique, identical to the open approach. The bowel is returned to the abdomen, the wound retractor is removed, and the fascia is closed.

For intracorporeal anastomosis (increasingly used), both limbs are divided laparoscopically, the anastomosis is constructed inside the abdomen using an endoscopic GIA stapler, and the specimen is extracted through a small Pfannenstiel or expanded port incision.

Robotic Right Hemicolectomy

The robotic approach uses a medial-to-lateral dissection analogous to laparoscopic technique, but with wristed instrument technology providing superior visualization and maneuverability - particularly useful for dissection around the SMV and the head of the pancreas.

OR configuration: The robotic cart approaches from the patient's right, perpendicular to the table. Both surgeons and the cart are on the right.

Port placement: A supraumbilical port for the robotic 0-degree endoscope; three additional robotic arms with monopolar curved scissors (Arm 1), fenestrated bipolar forceps (Arm 3), and a Cadiere grasper (Arm 4); plus a 5-mm assistant port for suction/irrigator and bowel grasper.

Steps mirror the laparoscopic technique. The ileocolic and middle colic pedicles are ligated and divided using wristed robotic instruments. Intracorporeal anastomosis is particularly well-suited to the robotic platform due to improved dexterity in needle-driving and stapler positioning.

Extent of Resection (Oncological Principles - CME)

Complete Mesocolic Excision (CME) with central vascular ligation is the gold standard for right colon cancer:

Principle	Detail
Plane of dissection	Sharp dissection in the embryological mesocolic plane - intact visceral fascia
High vascular ligation	At the SMA/SMV origin for maximum lymph node yield
Lymph node harvest	Minimum 12 nodes required for adequate staging
Resection margins	Minimum 5 cm proximal and distal to the tumor

Postoperative Care (Enhanced Recovery After Surgery - ERAS)

Diet: Early oral fluids same day of surgery; soft diet by day 1-2
Ambulation: Encouraged from day 0 post-operatively
Nasogastric tube: Not routinely used
Urinary catheter: Removed within 24 hours
Analgesia: Multimodal - non-opioid analgesics (NSAIDs, paracetamol), wound infiltration, epidural or transversus abdominis plane (TAP) block
VTE prophylaxis: Low-molecular-weight heparin continued for 28 days after cancer surgery
Hospital stay: Typically 3-5 days laparoscopic, 5-7 days open

Key Anatomical Hazards

Structure at Risk	Consequence if Injured
Right ureter	Ureteric injury, fistula, stricture
Right gonadal vessels	Bleeding, gonadal ischaemia
Duodenum (2nd/3rd part)	Duodenal fistula - catastrophic
Head of pancreas small veins	Troublesome bleeding requiring suture ligature
SMV/SMA	Major haemorrhage
Right hepatic flexure - bile duct proximity	Bile duct injury (uncommon)

Anastomotic Leak - Key Points

Incidence: approximately 2-4% for right-sided anastomoses (lower than left-sided)
Predisposing factors: tension, poor blood supply, distal obstruction, malnutrition, steroids
The ileocolic anastomosis has a better blood supply and lower intraluminal pressure than left-sided anastomoses, explaining the lower leak rate
In elderly patients, loss of the ileocecal valve after right hemicolectomy may increase stool frequency, and in some cases cause fecal incontinence - important in preoperative counseling

Sources: Fischer's Mastery of Surgery, 8th Edition (Chapter 144); Maingot's Abdominal Operations; Bailey and Love's Short Practice of Surgery, 28th Edition

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