Plate 62

Resection of the right colon is commonly indicated for carcinoma, inflammatory bowel disease, and more rarely for 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 distention (≥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 neoplasm of the right colon. 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 the routine manner and a sterile drape applied.

A liberal midline incision centered about the umbilicus is made. A transverse incision just above the level of the umbilicus also provides an 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 lateral anastomosis may be performed between the terminal ileum and the transverse colon. After resection has been decided upon, 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. Since 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 and ligated, but there will be no blood vessels of importance in the peritoneal attachments along the right gutter. With the lateral peritoneal attachment divided, the large bowel may be lifted mesially with the left hand, while the loose areolar tissue lying under it is dissected off with a moist gauze sponge over the right index finger (Figure 2). In elevating the right colon toward the midline, the surgeon must positively identify the right ureter and be certain that it is not injured. Care is taken also toward the top of the ascending colon and near the hepatic flexure to avoid injury to the third portion of the duodenum, which underlies the large bowel (Figure 3). The raw surface remaining after the intestine has been freed and brought outside the peritoneal cavity is covered with warm, moist gauze pads. The middle colic vessels are identified, along with the right-hand branches heading toward the hepatic flexure and the planned zone of transection. The mesentery of the large bowel is clamped and divided just distal to the hepatic flexure or wherever the bowel is to be resected. The right branches or all of the middle colic vessels are divided and doubly ligated. The bowel at the selected level for division is freed of all mesentery, omentum, and fat on both sides. All vessels must be carefully ligated. The right half of the greater omentum is divided near the greater curvature of the stomach and excised along with the right colon.

The terminal ileum is prepared for resection some distance away from the ileocecal valve, depending upon the amount of blood supply that must be sacrificed to ensure excision of the lymph node drainage area of the right colon. After the small intestine has been prepared at its mesenteric border, a fan-shaped excision of the mesentery to the right colon is carried out. This usually includes part of the right branches of the middle colic vessels. In the presence of malignancy, the lymph node dissection should descend as far as possible along the course of the right colic and ileocolic vessels without compromising either the middle colic vessels or the superior mesenteric vascular supply of the remaining small bowel (Figure 4). The blood vessels of the mesentery are doubly tied.

A straight vascular clamp, or some other type of straight clamp, is applied obliquely to the small intestine about 1 cm from the mesenteric border to ensure a serosal surface for the placement of sutures for the subsequent anastomosis. Stone, Kocher, or Pace-Potts clamps are next applied across the large intestine, which is then divided between the clamps. The intervening section of bowel, with its fan-shaped section of mesentery and nodes, is excised. The divided proximal end of the small intestine is covered with gauze moistened with saline, and closure of the stump of the large bowel is started unless an end-to-end or end-to-side anastomosis is planned. Many surgeons prefer to use stapling devices, in which case the colon and terminal small bowel are resected using a linear stapling device. The ileum and transverse colon may then be anastomosed in an antimesenteric side-to-side manner using the technique shown in Plate 48, Resection of Small Intestine, Stapled. As staples may not be universally available, the techniques for hand-sewn anastomoses are shown in the continuing figures of Plate 63.

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