Right hemicolectomy

Overview

The majority of patients who have hemicolectomy surgery have a condition that has caused the right side of the large intestine to become diseased, necessitating its removal. Large right-sided colon polyps, bowel cancer, Crohn's disease, and various appendix anomalies are also common surgical diseases.

 

What is Right Hemicolectomy?

The procedure to remove the diseased portion of your colon is known as a right hemicolectomy. Right hemicolectomies are most usually performed for colon cancer, however they can also be performed for diverticular disease, intestinal ischaemia, or bowel perforation.

Right hemicolectomies can be performed openly or laparoscopically, and as an elective or emergency procedure. During the indexing operation, an anastomosis from the ileum to the transverse colon is created in the vast majority of patients (or to the splenic flexure in an extended right hemicolectomy). A defuncting ileostomy can also arise in rare cases, especially if there are worries about the anastomosis.

 

Anatomy and Physiology

Understanding the anatomy of hemicolectomy necessitates familiarity with structures such as the colon, arterial supply, venous drainage, lymphatic supply, and peritoneal attachments. The anatomy of the right and left hemicolectomy will be reviewed.

 

Anatomy of the Colon

The cecum, appendix, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and sigmoid colon make up the colon. The ileocaecal valve connects the ileum to the cecum. The colon develops embryologically from the midgut (cecum to two-thirds of the way down the transverse colon) and the hindgut (the last one-third of the way along the transverse colon to the sigmoid colon). The colon is made up of incomplete sacculations called haustra and a longitudinal smooth muscle layer called the teniae coli that lies right below the serosa. The appendices epiploicae are fatty extensions that run down the colon.

 

Right Colon

The right colon begins in a seemingly endless pouch called the cecum, which is located in the right iliac fossa of the belly. A layer of peritoneum covers the anterior and lateral sides of the ascending colon. The hepatic flexure is located intraperitoneally in the right hypochondrium, next to the liver. The paracolic gutter, which is located lateral to the ascending and descending colon, serves as a collection point or conduit for free fluid in the peritoneal cavity.

The superior mesenteric artery (SMA), which branches from the abdominal aorta anteriorly near the lower pole of L1, supplies blood to the right colon. The SMA divides into two primary branches that serve the right colon, the right colic and middle colic arteries. The ileocolic artery is another branch that serves the terminal ileum and caecum. The Drummond artery is a branch of the middle colic that connects with a branch of the left colic artery.

The superior mesenteric vein and its tributaries flow into the hepatic portal vein for venous drainage of the right colon. The lymphatic drainage of the colon occurs via lymph nodes located on the colon's surface (epicolic), which drain into the paracolic nodes. The intermediate nodes are located around arterial branches from named arteries (for example, branches of the right colic artery), while the mesocolic lymph nodes are located along the identified vessels themselves. 

 

How can I prepare for right hemicolectomy surgery?

Work Up

Several stages are included in the routine workup for elective hemicolectomy. All patients should be evaluated for surgical readiness from the outset. This includes tests such as a full blood count, urea and electrolytes, group and save, and, if necessary, an electrocardiogram (ECG). If needed, further tests to check cardiovascular and respiratory fitness, such as spirometry, transthoracic echocardiography (TTE), and cardiopulmonary exercise testing, should be performed.

 

Bowel Prep

In the absence of obstructive lesions, bowel preparation is given prior to surgery to mitigate the impact of an early anastomotic leak. Sodium picosulphate and magnesium citrate are routinely used to prepare the bowel. This product increases colonic contraction while decreasing sodium/water reabsorption in the distal small intestine. The literature discusses several alternate bowel preparation strategies. 

 

Prophylactic Antibiotics

Cefuroxime and metronidazole are typically given immediately before anesthesia induction. Metronidazole offers protection against Bacteroides fragilis. Cephalosporin is a broad-spectrum antibiotic that kills anaerobes in the stomach. The use of antibiotics to minimize sepsis rates in colorectal resections is supported by high-level randomized control trial data. If extensive soiling has occurred intraoperatively, antibiotics should be used for an extended period of time.

 

Bladder Catheterization

After anesthesia is administered, bladder catheterization enables for meticulous monitoring of fluid balance in the postoperative phase.

 

What happens during the operation?

Your surgery will be either a 'open' procedure with one long incision (cut) in your belly (tummy) or keyhole surgery with a few minor incisions.

The patient is in the Trendelenburg position, with a little left lateral tilt. Following chlorhexidine preparation of the skin, the whole abdomen should be sterile draped. Using an open cut down method and a Hasson trocar, a 10 mm port should be placed infra-umbilically. Suprapubic, epigastric, and left lumbar positions are common locations for an extra 10-12 mm port. To obtain the appropriate views throughout the procedure, a 30-degree endoscope should be employed.

 

Step 1: Mobilization of the Right Colon

Diathermy or a harmonic device is used to dissect the mesentery of the terminal ileum. The application of medial tension to the right colon enables for the precise dissection of the peritoneum layer covering the right paracolic gutter. To move the right colon from the caecum to the hepatic flexure, the dissection is continued cephalad.

The Gerota fascia enclosing the kidney is exposed, allowing dissection along this avascular plane. Further incision into the retroperitoneum should be avoided to avoid ureter/kidney/great vessels injury. The 2 and 3 parts of the duodenum are evident when the hepatic flexure is approached. Returning the colon to its former place makes surgeon orienting easier.

 

Step 2: Mobilization of the Transverse Colon

The bed has been tilted to the reverse Trendelenburg position. The gastrocolic ligament is dissected, and a Nathanson retractor is used to raise the stomach using the left upper quadrant (LUQ) port, allowing additional dissection and entrance into the smaller sac. The previous plane of dissection is encountered and met as the dissection progresses towards the hepatic flexure.

 

Step 3: Control of Mesentery

The mesocolon is revealed by retracting the right colon laterally and elevating the proximal transverse colon. The mesocolon is initially dissected at the hepatic flexure between the right and center colic pedicles. The mesocolon that covers the ileocolic and right colic pedicles is dissected, and the arteries are cut and separated near to their origin.

 

Step 4: Anastomosis

Extracorporeal anastomosis can be performed with less difficulty than intracorporeal anastomosis and without increasing the size of the incision needed for specimen extraction. It also enables a more precise estimate of margins. The specimen is brought out with terminal ileum after the wound has been stretched and the wound protector has been applied. A functional end-to-end ileocolic anastomosis is commonly done. The terminal ileum is separated with a linear stapler proximal to the Treves ligament.

Using a stapling instrument, the colon is similarly dissected distally to the specimen. To implant the stapling arms, two enterotomies are done at the ends of the colon and ileum. Then, using an anastomotic stapler, a side-to-side anastomosis is created, taking care not to include any mesentery. A linear stapler is used to seal the remaining flaw. Anastomosis integrity must be carefully examined, with any deficiencies necessitating oversewing. The "crotch" of the anastomosis is the most likely location for a leak.

 

Step 5: Closure and Re-inspection

The rectus sheath is closed in one piece, and the abdomen is insufflated to provide laparoscopic view of the anastomosis, hemostasis, and irrigation before trochar removal under vision. Many surgeons leave an intra-peritoneal drain at the anastomotic site; however, the evidence does not support this practice in this kind of surgery. Theoretically, this reduces the impact of contamination in the event of a leak, as well as the collection of fluid that may become contaminated.

 

Keyhole surgery

Three or four tiny (one cm) incisions will be made in your abdomen by your surgeon. They will insert a telescopic camera into one of these small wounds to display a bigger view of the organs in your abdomen (on a television screen). The additional cuts enable the physician to employ specialized surgical instruments. One of the cuts will be made longer (8 to 10 cms) so that your surgeon may remove the bowel section that was operated on.

It is not always possible or safe to complete the operation with laparoscopic surgery. If this is the case, your surgeon will do an 'open' procedure and create a wider incision to deal with it. Many surgeons are increasingly adopting robots to assist with keyhole procedures such as right hemicolectomy.

 

Will I need to have a stoma (bowel bag)?

It is quite rare that you will require a stoma. When it is not feasible to reconnect the bowel, the end of the intestine is taken out onto the abdomen (tummy), forming a hole outside the body known as a stoma. To collect your bowel contents, a stoma bag is subsequently put around this orifice.

A stoma can be either permanent or transient. A stoma nurse will examine you if you require or suspect that you require a stoma. These specialized nurses are experienced in caring for individuals with stomas and can answer any queries you may have.

 

What should I expect after surgery?

Immediately after the operation (within the first 24 to 48 hours), you will need:

• Oxygen through a face mask
• A drip into a vein in one of your arms to give you fluid
• A catheter (tube) in your bladder to drain away urine, and
• Medication to deal with pain from the incision. This may be given as an epidural (where the medicine is given through a fine tube in your back) or through the drip

Later (the following day or so), you will need to:

• Start eating again, starting with liquids and gradually introducing solid foods, and
• Move around as soon as possible

If you have laparoscopic or robotic surgery, you may recover more quickly after surgery and go home sooner.

Your feces will be liquid when you initially start going to the toilet again. It can take many weeks to go back to normal, and you may need to alter your diet on occasion.

 

What is the recovery like for right hemicolectomy surgery?

The time it takes to recuperate after bowel surgery varies. It normally requires a hospital stay of three to 10 days (in simple situations), depending on whether you have open or laparoscopic surgery. The following tubes may be in place immediately after your procedure to assist us in caring for you:

• A drip will be used to control the pain (tube into the veins on your arm). This will allow you to move more freely. As you heal, they will be withdrawn and pain relievers in the form of pills will be administered. The discomfort eventually subsides, especially after you're up and moving around.
• Fluids delivered by a drip in your arm will keep you hydrated until you can drink freely again.
• A catheter (a tube inserted into your bladder) will empty your urine into a collecting bag, allowing us to precisely quantify the volume. Depending on your recuperation, these tubes will be removed as soon as feasible. The nursing team will assist you in getting out of bed as soon as possible following the procedure; being active will help to lessen the risk of problems from the procedure.

 

• Diet

You may be able to eat in the first few days of recuperation, but your appetite will most likely be diminished. It is critical to consume little amounts of readily digestible meals on a regular basis. You will be given precise guidance on what you can eat over the first several days. Soups, snacks, and high-energy beverages can be used to complement meals. During the mending process, the body demands a lot of calories. There is no special diet beyond the first few days, and we advise you to gradually return to your usual diet as soon as you can take it.

• Bowel actions

It may take some time for the bowel to heal. Passing wind indicates that your gut is resuming its function. It is typical for the bowel to be irregular, and drugs to either slow the bowel down or moderate laxatives to assist the bowel to move are occasionally required.

• Exercise

You will be urged to get out of bed the next day and will be seen by a physiotherapist to assist you in doing so. You'll be wearing elastic stockings to lower your chance of a blood clot, but doing some exercise will also help. The physiotherapist will also instruct you on deep breathing techniques for your lungs, which will aid in the prevention of chest infections. Lifting is not advised following abdominal surgery for roughly six weeks.

• Driving

Check with your insurance carrier to see if they have any exclusions. This includes being under the influence of pain relievers. You must be capable of performing an emergency stop and must wear a seat belt.

 

Are there any risks/complications associated with right hemicolectomy surgery?

Any operation carries a risk, the risks of all operations include:

• Chest Infection. This would require antibiotics and physiotherapy.
  
• Blood Clots in the legs (deep vein thrombosis) or in the lung (pulmonary embolism). We decrease this risk by using elastic stockings and blood thinning injections.
• Anaesthetic. This procedure is performed under general anesthesia (you will be asleep). Please request an explanation document on general anesthesia and the hazards linked with it. If you are at higher risk due to other medical issues, your consultant will refer you to an anesthesiologist for a formal examination.
• Bleeding. This can occur with any operation.
• Patients who are very overweight, smoke or have other medical problems are at increased risk of all of these complications.

 

• Compartment Syndrome 

Compartment syndrome is an uncommon but painful and possibly dangerous illness caused by hemorrhage or swelling in a muscular compartment. The pressure within the gap might build up to the point where it interferes with muscle and nerve function. The region most likely impacted by the surgery is your legs, due to the position your legs must be in throughout the procedure, although it can also affect your arms, belly, or bottom cheeks.

The most frequent symptom is pain, which is followed by numbness. A fasciotomy is used to treat the condition. To alleviate the pressure and prevent lasting harm, the surgeon would need to open the skin and muscle of the afflicted region. The wound is treated, but sutures are not applied until 48-72 hours later. You may not be able to get out of bed or bear weight until the wound has healed.

This is a big procedure with significant dangers, and only a tiny proportion of individuals survive. Your consultant will go through your specific risks with you and answer any concerns you may have. Measures are attempted to limit these dangers; nonetheless, it is not feasible to totally eliminate all risks. This surgery also has the following risks:

 

Leakage at the anastomosis (new join in the bowel)

This is a significant difficulty. It is treated with antibiotics and frequently necessitates further surgery, which may end in an ileostomy (bowel brought out onto the skin and a bag worn to collect waste from bowel). If this issue happens, the stoma expert can provide you with further information and will visit you in the hospital.

Increased risk of infection because the bowel is an organ that is full of bacteria. 

This might be a wound infection or an infection within the abdomen in the form of an abscess. Antibiotics are administered to help manage the infection, and sometimes an abscess must be drained.

• Bowel stops working. This is temporary but can cause bloating of the tummy and sickness.
• Damage to other internal organs whilst removing the tumor in particular the bladder and small tubes to the bladder from the kidneys.

 

Conclusion 

A right hemicolectomy involves the removal of the terminal ileum, caecum (containing the appendix), ascending colon, and hepatic flexure. The transverse colon is also removed with an extended right hemicolectomy. Several benign and malignant disorders are indications for open right hemicolectomy.