Chapter 6: Laparoscopic Right Hemicolectomy

BACKGROUND

Right hemicolectomy involves the removal of 10 cm of the terminal ileum, cecum, ascending colon, and the proximal transverse colon. Right hemicolectomy is indicated for malignant lesions involving the right colon, including the hepatic flexure and the proximal transverse colon. In addition, it is indicated in cases of unresectable polyps, cecal diverticulitis, volvulus, and Crohn’s disease. Right hemicolectomy implies division of the ileocolic, right colic, and right branch of the middle colic vessels. This can be achieved laparoscopically, laparoscopic assisted, through the open approach, or robotically.

Extended right hemicolectomy implies dividing the main trunk of the middle colic artery and extending the distal resection to include the proximal two-thirds of the transverse colon.

PREOPERATIVE CONSIDERATIONS

Ureteral Stents

Placement of ureteral stents should be considered in patients with:

• Severe inflammation or phlegmon involving the right lower quadrant/retroperitoneum

• A hostile abdomen

• Ureteric involvement with primary pathology demonstrated on preoperative imaging

• Morbid obesity

Intraoperative CO₂ Colonoscopy

It is prudent to have the CO₂ colonoscope in the operating room (OR) in the following situations:

• To cross-check/confirm the exact location of a lesion within the colon in the operating room.

• In ileocolic Crohn’s disease where there is an ileo-sigmoid fistula. The CO₂ scope can be used to do an air leak test for the sigmoid repair/anastomosis.

Imaging

Personal review of all imaging by the surgeon is a must. In addition to the usual staging information, a surgeon should glean the following from preop scans and use them for operative planning:

• The exact location of the lesion/pathology.

• The colonic anatomy (high cecum, redundant transverse colon, prior resections, etc.).

• Involvement of adjacent organs (i.e. duodenum, ureter, sigmoid colon, and kidney). This will determine the need for supplementary procedures such as placement of ureteral stents, planning for en bloc resection of involved organs, etc.

Stoma Marking

A diverting ileostomy or creation of an end ileostomy and a mucous fistula (Prasad ostomy) should be considered in patients at a high risk for anastomotic leak, and such patients will need a preoperative stoma nurse visit and stoma marking. In a select subset of patients, one may decide to make an anastomosis and perform a proximal diverting loop ileostomy. Patients who may need diverting ileostomy after right hemicolectomy include the following:

• Patients with malnutrition—albumin <3 g/dL

• Immunocompromised patients (transplant/steroids/biologics/AIDS/uncontrolled diabetes)

• In the presence of a significant size discrepancy between the lumen of the small bowel and large bowel

• In the presence of sepsis and peritonitis

• If the patient is hemodynamically unstable, requiring persistent preoperative/intraoperative vasopressor support

Colonoscopy

If the patient has not had a colonoscopy, then a colonoscopy should ...