What is the purpose and procedure of a right (r) hemicolectomy?

Right Hemicolectomy: Purpose and Procedure

Right hemicolectomy is a surgical procedure that involves removing the right side of the colon and is primarily performed to treat right-sided colon cancer, complicated acute right colonic diverticulitis, and certain neuroendocrine tumors. 1

Indications

The main indications for right hemicolectomy include:

• Right-sided colon cancer
• Complicated acute right colonic diverticulitis (ARCD)
• Neuroendocrine tumors of the appendix >2cm
• Goblet cell tumors of the appendix (always require right hemicolectomy)
• Obstructing lesions of the right colon

Anatomical Considerations

A right hemicolectomy involves removal of:

• Terminal ileum (last portion of small intestine)
• Cecum
• Ascending colon
• Hepatic flexure
• Proximal portion of transverse colon
• Associated mesentery containing lymphatic channels and nodes

Surgical Procedure

Standard Approach

1. Exposure: Typically performed through a median laparotomy incision or laparoscopically
2. Exploration: Examination of the liver, pelvis, and ovaries (in women) for metastases
3. Vascular Control: Identification and ligation of ileocolic, right colic, and right branch of middle colic vessels
4. Resection: Removal of the right colon with adequate margins and associated lymphadenectomy
5. Reconstruction: Formation of an ileocolic anastomosis (joining the terminal ileum to the remaining colon)

Laparoscopic Approach

• Laparoscopic right hemicolectomy has become well-established with proven benefits including:

  • Reduced postoperative pain
  • Faster return of bowel function
  • Shorter hospital stays
  • Equivalent oncologic outcomes compared to open surgery 2

• Technical variations include:

  • Medial-to-lateral dissection (preferred by many surgeons)
  • Intracorporeal vs. extracorporeal anastomosis

Special Considerations

For Cancer Cases

• Complete mesocolic excision with D3 lymphadenectomy is recommended for optimal oncologic outcomes 3
• Right hemicolectomy with primary anastomosis is the preferred option for right-sided colon cancer causing acute obstruction 1
• For unresectable right-sided cancer, a side-to-side anastomosis between terminal ileum and transverse colon (internal bypass) can be performed 1

For Unstable Patients

• In hemodynamically unstable patients (pH <7.2, core temperature <35°C, BE <-8, coagulopathy, or sepsis/septic shock):
  • Right colectomy with terminal ileostomy should be considered the procedure of choice
  • Severely unstable patients should be treated with a loop ileostomy 1

For Diverticulitis

• Uncomplicated acute right colonic diverticulitis should initially be treated with antibiotic therapy
• For complicated ARCD, surgical treatment with resection and primary anastomosis is recommended whenever possible 1

For Appendiceal Neuroendocrine Tumors

• Appendiceal NETs >2cm require right hemicolectomy
• Smaller tumors (<2cm) may require right hemicolectomy if they:
  • Breach the serosal surface
  • Invade the mesoappendix by >3mm
  • Are located at the base of the appendix 1

Outcomes and Complications

Right hemicolectomy carries significant morbidity and mortality risks, particularly in emergency settings:

• Mortality rates: approximately 9.7%
• Severe complications: 18.8%
• Anastomotic leak: 3.9%
• Wound complications: 4.8% 4

Independent factors associated with worse outcomes include:

• High ASA score
• Need for stoma creation 4

Anastomotic Techniques

Different anastomotic configurations can be used:

• Stapled end-to-side
• Stapled side-to-side
• Handsewn technique

Recent evidence suggests comparable rates of anastomotic leak and post-operative bleeding between these techniques, though stapled end-to-side anastomosis may result in lower rates of prolonged ileus compared to stapled side-to-side anastomoses 5.

Postoperative Care

• Antibiotic therapy duration depends on the indication and patient condition
• For cancer cases, surveillance should include regular follow-up with imaging and laboratory studies
• For complicated diverticulitis, once the infectious state resolves, follow-up colonoscopy should be performed 1

Key Pitfalls to Avoid

• Failure to recognize anatomical variations, especially in venous structures
• Inadequate lymph node harvest in cancer cases
• Compromised blood supply to anastomotic segments
• Excessive tension on the anastomosis