Resection of the right colon is commonly indicated for carcinoma, inflammatory bowel disease, and, more rarely, tuberculosis or volvulus of the cecum, ascending colon, or hepatic flexure.
Some tumors of the right colon present as an obstruction and may require relatively urgent operation for excessive cecal distension (≥15 cm) in the presence of a competent ileal cecal valve. Such a patient is resuscitated with correction of fluid and electrolyte imbalances. The proximal bowel is decompressed with a nasogastric tube. Once the patient's physiologic status is optimized, he or she will proceed to urgent operation, wherein a right colectomy can be performed in an unprepared bowel. The prudent surgeon should verify that there is not a second or metachronous colorectal lesion. If the right colectomy is being done in an elective setting, the entire colon should be evaluated with either colonoscopy or barium enema. Blood transfusion may be advisable, especially in older patients with cardiovascular disease, when a silent and unrecognized iron-deficiency anemia has been created by a silent, long-standing neoplasm of the right colon. Any preexisting steroid therapy is continued with intravenous replacement as the patient prepares for surgery. Perioperative systemic antibiotics are given.
Either general inhalation or spinal anesthesia is satisfactory.
The patient is placed in a comfortable supine position. The surgeon stands on the patient's right side.
The skin is prepared in routine manner. Sterile drapes are applied according to the surgeon's specifications. Then a time-out is performed.
A liberal midline incision centered about the umbilicus is made. A transverse incision just above the level of the umbilicus also provides excellent exposure. The lesion of the right colon is inspected and palpated to determine whether removal is possible. In the presence of malignancy, the liver is also palpated for evidence of metastasis. If the lesion is inoperable, a side-to-side anastomosis may be performed between the terminal ileum and the transverse colon without any resection (see Chapter 50). After resection has been decided on, the small intestines are walled off with packs, and the cecum is exposed.
An incision is made in the peritoneal reflection close to the lateral wall of the bowel from the tip of the cecum upward to the region of the hepatic flexure (FIGURE 1). A liberal margin should be ensured in the region of the tumor. Occasionally, the full thickness of the adjacent abdominal wall may require excision to include the local spread of tumor. Because the entire hepatic flexure is usually removed as part of a right colectomy, the hepatocolic ligament, which contains some small blood vessels, must be divided ...