Open Right Colectomy (Right Hemicolectomy)

Open Right Colectomy (Right Hemicolectomy)

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Open right hemicolectomy (open right colectomy) is a procedure that involves removing the cecum, the ascending colon, the hepatic flexure (where the ascending colon joins the transverse colon), the first third of the transverse colon, and part of the terminal ileum, along with fat and lymph nodes. [1] It is the standard surgical treatment for malignant neoplasms of the right colon; the effectiveness of other techniques are measured by the effectiveness of this technique.

In 1832, Reybord, who had recorded his experiences with treatment of cancers of the colon, reported the first successful resection and anastomosis of the bowel for carcinoma. Kohler performed the second successful resection and anastomosis. Paul and Mikulicz performed exteriorization-resection of carcinoma of the colon.

The following are the main types of open right hemicolectomy:

Indications for open right hemicolectomy include numerous benign and malignant conditions. The most common malignant condition is adenocarcinoma of the right colon; other malignant indications are malignant tumors of the appendix and cecum.

The benign conditions include adenomatous polyps of the colon that cannot be removed endoscopically, carcinoids, inflammatory bowel disease (Crohn disease and sometimes ulcerative colitis), cecal volvulus, severe appendicitis with involvement of the cecum in the inflammatory process, and isolated right-side colonic diverticular disease (rare). [2, 1]

The main contraindication for right hemicolectomy in patients with malignancies is acute obstruction, for which a two-stage right hemicolectomy is advisable. The authors believe that in cases of large intestinal obstruction with altered parameters and vital signs, a bypass procedure is initially a better choice than radical resection, which the patient is less likely to tolerate. Therefore, in the first stage, an ileotransverse anastomosis is performed, and in the second, right hemicolectomy is performed.

Other contraindications include significant cardiopulmonary impairment and coagulopathy.

The colon is a 5- to 6-ft-long part of the large intestine (lower gastrointestinal tract) that is shaped like a U. Embryologically, it develops partly from the midgut (ascending colon to proximal transverse colon) and partly from the hindgut (distal transverse colon to sigmoid colon).

The ascending (right) colon lies vertically in the most lateral right part of the abdominal cavity. The cecum is at the proximal blind end (pouch) of the ascending colon. The ascending colon takes a right-angle turn just below the liver (right colic or hepatic flexure) and becomes the transverse colon, which has a horizontal course from right to left.

For more information about the relevant anatomy, see Colon Anatomy, Large Intestine Anatomy, Lower GI Tract Anatomy, and Liver Anatomy.

In order to plan an operation for a patient with colon cancer, the surgeon must have a thorough understanding of the tumor’s location in the bowel, the stage of the cancer, and the patient’s physiologic status. The location of the tumor and the histopathology are important data elements that allow preoperative selection of an operative plan and determination of the optimal resection margins.

The presence of a lesion at watershed areas of vascular supply, such as the hepatic and splenic flexures, may necessitate more extensive resection of colonic length for a safe and complete oncologic procedure. An extended right or left colectomy may be indicated to remove all contributing vascular supplies.

In addition, information consistent with hereditary nonpolyposis colon cancer supports the resection of the entire diseased colon rather than a simple segmental resection. This diagnosis may also be supported by special stains of the biopsy specimen that demonstrate microsatellite instability, the hallmark of the disease, which develops from mutations in the DNA mismatch repair system. [3]

Tong et al compared laparoscopic (n=77) and open (n=105) right hemicolectomy on the basis of several variables, including time taken for surgery and duration of hospital stay. [4]  Mean operating time was shorter for the open procedure (115.4 min). Seven laparoscopic cases (9%) required conversion to an open procedure. There was no difference in complications. Normal diet was started in the laparoscopic patients a day earlier than the open procedure. Median hospital stay was longer for open (7 days) than for laparoscopic surgery (6 days) and was significantly longer (9 days) in the converted-to-open group.

Siani et al compared laparoscopic with open right hemicolectomy for oncologic clearance over 5 years. [5]  Twenty patients with nonmetastatic, noninfiltrating right colonic cancer who were treated with laparoscopic right hemicolectomy were compared with a well-matched group who underwent open right hemicolectomy. There was no statistically significant difference in the cumulative results other than the duration of surgery, which was longer in laparoscopic surgery. The authors concluded that laparoscopic right hemicolectomy was safe and oncologically adequate as compared with open right hemicolectomy. Further randomized controlled trials are needed to further elucidate its role in right-colon cancer.

Kang et al compared early perioperative results and oncologic outcomes for open, laparoscopic, and robotic surgical management of right-side colon cancer. [6]  They found that no difference among the three groups with regard to total retrieved lymph node numbers. The robotic and laparoscopic approaches yielded better short-term outcomes in terms of reducing hospital stay compared with the OS. The cost of robotic surgery was relatively high. The benefits of the robotic approach for right hemicolectomy remain unclear.

Wolff BG, Wang JY. Right hemicolectomy for treatment of cancer: open technique. Fischer JE, Jones DB, Pomposelli FR, et al, eds. Mastery of Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. Vol 2: Chap 161.

Fornaro R, Frascio M, Sticchi C, De Salvo L, Stabilini C, Mandolfino F, et al. Appendectomy or right hemicolectomy in the treatment of appendiceal carcinoid tumors?. Tumori. 2007 Nov-Dec. 93 (6):587-90. [Medline].

Rothenberger DA. Conventional colectomy. Fielding LP, Goldberg SM, eds. Rob and Smith’s Operative Surgery – Surgery of the Colon, Rectum, and Anus. 5th ed. London: Hodder Arnold; 1993. 347.

Tong DK, Law WL. Laparoscopic versus open right hemicolectomy for carcinoma of the colon. JSLS. 2007 Jan-Mar. 11 (1):76-80. [Medline].

Siani LM, Ferranti F, Marzano M, De Carlo A, Quintiliani A. [Laparoscopic versus open right hemicolectomy: 5-year oncology results]. Chir Ital. 2009 Sep-Dec. 61 (5-6):573-7. [Medline].

Kang J, Park YA, Baik SH, Sohn SK, Lee KY. A Comparison of Open, Laparoscopic, and Robotic Surgery in the Treatment of Right-sided Colon Cancer. Surg Laparosc Endosc Percutan Tech. 2016 Dec. 26 (6):497-502. [Medline].

Sheng QS, Pan Z, Chai J, Cheng XB, Liu FL, Wang JH, et al. Complete mesocolic excision in right hemicolectomy: comparison between hand-assisted laparoscopic and open approaches. Ann Surg Treat Res. 2017 Feb. 92 (2):90-96. [Medline]. [Full Text].

Ashwin Pai, MBBS, MS (GenSurg), MRCS Honorary Assistant Medical Officer, Department of Surgery, Kasturba Medical College, India

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Open Right Colectomy (Right Hemicolectomy)

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