What are the operative steps for an extended right hemicolectomy for colorectal cancer?

From the Guidelines

An extended right hemicolectomy for colon cancer involves several key operative steps, prioritizing a wide resection of the involved segment of bowel together with the removal of its lymphatic drainage, as outlined in the most recent guidelines 1. The procedure begins with appropriate patient positioning, typically supine, followed by abdominal access via midline laparotomy or laparoscopic ports. After exploration of the abdominal cavity to assess for metastatic disease, the surgeon mobilizes the right colon by incising along the white line of Toldt, continuing the dissection to include the hepatic flexure and proximal transverse colon. The surgeon identifies and ligates the ileocolic, right colic, and right branch of middle colic vessels at their origin to ensure adequate lymph node harvesting, with the goal of resecting at least 12 lymph nodes to clearly define stage II versus III and to identify and eradicate potential lymph node metastases 1. The greater omentum is separated from the transverse colon, and the duodenum is carefully identified and protected (Kocher maneuver may be performed if needed). The terminal ileum is divided approximately 10-15 cm proximal to the ileocecal valve, and the transverse colon is divided distal to the tumor with adequate margins, typically near the middle colic vessels, ensuring a segment of colon of at least 5 cm on either side of the tumour is resected 1. After specimen removal, intestinal continuity is restored with an ileocolic anastomosis, either hand-sewn or stapled. The mesenteric defect is closed, hemostasis is ensured, and the abdomen is irrigated before closure. This extensive resection provides adequate oncologic margins and regional lymphadenectomy for right-sided colon cancers, particularly those located near the hepatic flexure or proximal transverse colon, and can be safely carried out using a laparoscopic approach, which has been shown to have similar long-term oncological results to the conventional approach, with advantages including reduced pain, reduced length of hospital stay, and reduced duration of ileus 1. Some key points to consider when performing an extended right hemicolectomy include:

• The importance of technically experienced surgeons when using a laparoscopic approach 1
• The need to avoid serious abdominal adhesion due to prior major abdominal surgery when using a laparoscopic approach 1
• The consideration of a one-stage procedure with either subtotal colectomy and ileorectal anastomosis or segmental resection after intraoperative colonic lavage for obstructive colorectal cancers 1

From the Research

Operative Steps for Extended Right Hemicolectomy

The operative steps for an extended right hemicolectomy for colorectal cancer involve several key procedures:

• Mobilization of the hepatic flexure from the duodenum and exposure of the third part of the duodenum and pancreatic head 2
• Division of the ileocecal vessels at the root using a medial-to-lateral approach, and separation of the cecum from the retroperitoneal space 2
• Opening of the omental bursa and exposure of the inferior border of the pancreas 2
• Division of the right colic vessels at the roots and dissection of the mesenteric fat along the left edge of the superior mesenteric artery to the inferior border of the pancreas 2
• Dissection of the lymph nodes along the superior mesenteric vein (SMV) using a caudal-to-cranial approach 3
• Full mobilization of the mesocolon containing 10 cm of normal colon distal to the lesion, followed by complete mobilization of the lateral attachments of the ascending colon 3

Key Considerations

Some key considerations during the procedure include:

• Identification of the middle colic artery (MCA) trunk and branches, as well as the common origin of the MCA and right colic artery (RCA) 4
• Isolation of the gastrocolic trunk (GCT), which has five origins and can have 2,3, or 4 branches 4
• Thorough dissection of No. 6 group lymph nodes and the omental arcade 10 cm from the pylorus 4
• Use of a medial-to-lateral approach, which is more in line with the principle of no-touch in tumor surgery 4, 5
• Consideration of a caudal-to-cranial approach, which may be a safe alternative to the conventional medial-to-lateral approach, especially for inexperienced surgeons 3

Surgical Approaches

Different surgical approaches can be used for extended right hemicolectomy, including:

• Medial-to-lateral approach 4, 2, 5
• Caudal-to-cranial approach 3
• Open approach 6
• Laparoscopic approach 4, 2, 5, 3