Right Hemicolectomy

Definition and Extent of Resection

Indications

• Invasive carcinoma of the cecum, ascending colon, hepatic flexure, or proximal transverse colon (most common)
• Malignant polyp with positive/unclear margins after polypectomy, or features predicting nodal metastasis (poor differentiation, vascular/lymphatic invasion, high tumor budding, deep submucosal invasion)
• Extended right hemicolectomy for proximal-to-mid transverse colon tumors, synchronous tumors, or multiple adenomas - the middle colic pedicle is ligated at its origin and the anastomosis is between terminal ileum and descending colon
• Crohn's disease involving the terminal ileum/cecum with ileocecal disease
• Cecal volvulus
• Appendiceal carcinoid >2 cm or with positive margins after appendectomy
• Right-sided colitis (ileocolic Crohn's disease)

Key Vascular Anatomy

• Ileocolic artery - always ligated at its origin from the SMA ("high tie")
• Right colic artery - ligated at its origin (variable anatomy; absent in ~15%)
• Right branch of the middle colic artery - included in standard right hemicolectomy; the entire middle colic pedicle is taken in extended right hemicolectomy

Preoperative Preparation

• Full colonoscopy and CT chest/abdomen/pelvis with IV contrast for staging
• Mechanical bowel preparation (polyethylene glycol) + oral antibiotics the day prior - reduces SSI, anastomotic leak, and postoperative ileus
• VTE prophylaxis: subcutaneous heparin, sequential compression devices, LMWH postoperatively, early ambulation
• IV antibiotics before incision, redosed during the case, discontinued postoperatively
• Enhanced recovery pathway (ERAS): carbohydrate loading 4 h preop, alvimopan preoperatively, transverse abdominis plane (TAP) blocks for MIS
• Goal-directed fluid therapy intraoperatively - Fischer's Mastery of Surgery, 8th ed.

Surgical Technique

Open Right Hemicolectomy

1. Position: Supine, arms out. Midline incision with wound protector. Surgeon on the right, assistant on the left.
2. Lateral mobilization: Assistant retracts the right colon medially; surgeon incises the lateral peritoneal reflection (white line of Toldt) with cautery along the right paracolic gutter.

1. Retroperitoneal mobilization: The right colon is swept off Gerota's fascia, the duodenum, and the head of the pancreas. Care is taken around the small veins of the pancreatic head (suture ligation may be needed). The cecum and terminal ileum are dissected anteromedially, identifying and protecting the right gonadal vessels and right ureter (which stay in the retroperitoneum). Dissection extends to the third part of the duodenum.
2. Hepatic flexure takedown: Cautery dissection continuing superiorly.
3. Vascular ligation: The ileocolic artery (and right colic artery if present) are ligated at their origins from the SMA.
4. Bowel division: Mesentery of the distal 10 cm of ileum and the mesocolon to the proximal transverse colon are divided. The greater omentum is divided to the transverse colon transection point.
5. Anastomosis: An ileocolic anastomosis (side-to-side, functional end-to-end stapled, or hand-sewn) is performed once adequate blood supply at both margins is confirmed.

Laparoscopic Right Hemicolectomy

• Patient supine, both arms tucked, padded, strapped with anti-slip pad. Both surgeons stand on the patient's left side.
• Access via Veress needle at Palmer's point (3 cm below left subcostal border, midclavicular line) or Hasson cut-down.
• Port placement: 5-mm supraumbilical port (planned extraction site), three additional 5-mm ports in suprapubic, left upper, and left lower quadrants lateral to rectus.
• Table tilted: Trendelenburg, right side up - to expose ileocolic pedicle.
• A medial-to-lateral approach is standard: ileocolic pedicle identified first, peritoneum incised below it, retroperitoneal dissection plane developed before lateral mobilization.
• Specimen extracted via supraumbilical port site extension or Pfannenstiel incision.
• Anastomosis can be extracorporeal (most common) or intracorporeal.

Robotic Right Hemicolectomy

• Robot docked from patient's right side. Five-port approach (4 robotic + 1 accessory).
• Medial-to-lateral approach as with laparoscopic surgery.
• Advantages: enhanced 3D visualization, greater dexterity for CME dissection near SMA/SMV, particularly useful in obese patients and bulky lymphadenopathy. Trends toward lower conversion rate and higher rates of intracorporeal anastomosis.
• Limitation: Higher cost, longer OR time. In the only RCT comparing laparoscopic vs robotic right hemicolectomy, surgical and oncologic outcomes were equivalent.

Structures at Risk

Anastomosis

• Ileocolic anastomosis: Between terminal ileum and transverse colon
• Can be hand-sewn (single or two-layer) or stapled (side-to-side functional end-to-end)
• Both are oncologically equivalent; technique selected based on surgeon preference, tissue quality, and blood supply
• Extended right hemicolectomy: Anastomosis is between terminal ileum and distal transverse colon or descending colon, depending on vascular supply
• In elderly patients: note that loss of the ileocecal valve can increase daily bowel frequency significantly

Oncologic Principles (CME)

• Sharp dissection between parietal and visceral mesofascial layers (embryological planes)
• Flush ligation of vessels at SMA origin
• Retrieval of ≥12 lymph nodes mandatory for accurate staging
• CME may improve survival in node-positive disease (Hohenberger data) - Bailey and Love's, 28th ed.

Complications

Outcomes Comparison: Open vs Laparoscopic vs Robotic

• Fischer's Mastery of Surgery, 8th edition - Chapter 144 (Open Right Hemicolectomy, Laparoscopic Right Hemicolectomy, Robotic Right Hemicolectomy)
• Bailey and Love's Short Practice of Surgery, 28th edition - Chapter 77 (Operations: Right Hemicolectomy)
• Schwartz's Principles of Surgery, 11th edition - Figure 29-10 (Terminology of colorectal resections)
• Maingot's Abdominal Operations - Table 36-14 (Standard resections of the colon)