What is a hemicolectomy and what are the indications, risks, and management strategies for a middle-aged or older adult patient with a history of gastrointestinal symptoms or a diagnosis of colon cancer, diverticulitis, or inflammatory bowel disease?

Hemicolectomy: Comprehensive Overview

What is a Hemicolectomy?

A hemicolectomy is a surgical procedure that removes approximately half of the colon (large intestine). Right hemicolectomy removes the cecum, ascending colon, hepatic flexure, and proximal transverse colon, while left hemicolectomy removes the distal transverse colon, splenic flexure, descending colon, and sigmoid colon. 1 The remaining bowel segments are reconnected through an anastomosis to restore intestinal continuity.

Primary Indications

Colon Cancer

• Hemicolectomy is the definitive surgical treatment for localized colon cancer, with curative intent achieved through adequate resection margins and lymph node harvest. 2
• Right-sided tumors (cecum, ascending colon, hepatic flexure) require right hemicolectomy 2
• Left-sided tumors (splenic flexure, descending colon, sigmoid) require left hemicolectomy 3
• For tumors located between the distal transverse and proximal descending colon, both extended right hemicolectomy and left hemicolectomy are acceptable options with similar outcomes 1

Inflammatory Bowel Disease (IBD)

• Surgery should be advised for disease not responding to intensive medical therapy, with the decision made jointly by gastroenterologist and colorectal surgeon. 4
• In Crohn's disease, resections should be limited to macroscopic disease only and performed conservatively 4
• For ulcerative colitis with extensive disease, subtotal colectomy is the procedure of choice in acute fulminant cases 4
• Segmental colectomy in Crohn's disease is favored when feasible, particularly in the era of biologics, without increasing recurrence risk when risk factors (multiple affected sites, perianal disease) are absent 4

Lynch Syndrome

• Colectomy with ileorectal anastomosis is the primary treatment for Lynch syndrome patients with colon cancer or non-removable neoplasia. 4
• Consideration for less extensive surgery (hemicolectomy) should be given in patients older than 60-65 years, as life expectancy gained decreases with age (2.3 years at age 27,1 year at age 47,0.3 years at age 67) 4
• After partial colectomy in Lynch syndrome, the 10-year cumulative risk of metachronous colorectal cancer is 16-19%, substantially reduced to 3.4% with subtotal colectomy 4

Diverticulitis

• Elective sigmoid resection in elderly patients should be reserved for very symptomatic disease, stenosis, fistulae, or recurrent bleeding that compromises quality of life, given the high postoperative mortality (0.56% in ages 65-69 to 6.5% in ages >85) and low recurrence risk after conservative management. 4
• Immunocompromised patients (organ transplant, corticosteroid users) require elective sigmoid resection after conservatively treated acute left colonic diverticulitis due to increased risk of complicated disease requiring emergency surgery 4

Surgical Approach: Laparoscopic vs Open

Laparoscopic right hemicolectomy is recommended as the method of choice for colon cancer, with comparable complications, recurrence rates, and 5-year survival (75% in curative intent cases) to open procedures. 2 The laparoscopic approach offers:

• Mean operating time of 119 minutes 2
• Adequate oncologic resection with mean colon length of 27.8 cm and clear margins of 6.8 cm 2
• Conversion rates vary (0% in experienced centers to 16.6% with single-incision techniques) 2, 5

For left hemicolectomy, laparoscopic techniques are increasingly utilized, though the evidence base is still evolving 3. Both extended right hemicolectomy and left hemicolectomy can be performed laparoscopically with similar outcomes 1.

Oncologic Adequacy

Margin Requirements

• All patients should achieve clear surgical margins (achieved in 98.4% of cases in experienced centers) 1
• Mean distal margin width of 6.8 cm is standard 2

Lymph Node Harvest

• Adequate nodal evaluation for staging requires sufficient lymph node harvest 1
• Extended right hemicolectomy achieves adequate nodal evaluation in 78.1% of cases compared to 58.8% for left hemicolectomy 1

Survival Outcomes

• 5-year survival rate for curative intent surgery is 75% 2
• Overall 5-year mortality-free fraction is 63% 2
• Mortality prognostic factors include tumor stage, length of resected colon, and positive lymph nodes 2

Special Considerations in Elderly Patients

Surgical Decision-Making

• The decision about timing and type of surgery should incorporate disease severity, functional status, independence, risks of medical therapy, candidacy for surgery, and risk of postoperative complications rather than chronologic age alone. 4
• Biologics with lower infection or malignancy risk (vedolizumab, ustekinumab) may be preferred in older patients before considering surgery 4

IBD-Specific Considerations

• Elderly patients with IBD are more likely to have left-sided ulcerative colitis (40%) and isolated colonic Crohn's disease (44%) 4
• Care should be multidisciplinary, engaging gastroenterologists, surgeons, geriatricians, nutritionists, and pharmacists 4

Diverticulitis in Elderly

• After a first episode of diverticulitis in elderly patients, recurrence risk is significantly lower than in younger patients 4
• If disease is asymptomatic or mildly symptomatic after medical resolution, elective sigmoid resection is not recommended 4

Postoperative Complications and Management

Anastomotic Leak

• Leak rates are similar between extended right hemicolectomy (6.3%) and left hemicolectomy (5.9%) 1
• Primary anastomosis should not be performed in the presence of sepsis and malnutrition 4

Mortality

• Postoperative mortality ranges from 1.6% for right hemicolectomy to 2.9% for left hemicolectomy 1
• In elderly patients, mortality increases with age, particularly after elective surgery 4

Functional Outcomes

• In Lynch syndrome patients, no difference in global quality of life was noted between partial and subtotal colectomy, though functional outcomes (stool frequency, social impact) were worse after subtotal colectomy 4

Postoperative Surveillance

Colorectal Cancer Screening

• Early colonic evaluation (colonoscopy or CT colonography) should be planned in elderly patients after conservatively treated acute left colonic diverticulitis, as they are twice as likely to be diagnosed with colorectal cancer within one year. 4
• For IBD patients with long-standing colitis, the decision to continue surveillance should incorporate age, comorbidity, life expectancy, and candidacy for surgery 4

IBD Monitoring

• Never rely on symptoms alone; always use objective inflammatory markers (fecal calprotectin, CRP, endoscopy) to guide treatment decisions 6
• Point-of-care calprotectin testing can guide treatment decisions more objectively 7

Critical Pitfalls to Avoid

• Do not perform laparoscopic lavage as the preferred surgical approach in elderly patients with acute diverticulitis and peritonitis due to higher risk of failure to control sepsis. 4
• Do not proceed with elective sigmoid resection in elderly diverticulitis patients without carefully balancing risks and benefits on a case-by-case basis 4
• In Lynch syndrome, do not perform partial colectomy in younger patients (<60 years) without discussing the substantially higher risk of metachronous cancer (16-19% at 10 years) 4
• For Crohn's disease, avoid extensive resections; limit surgery to macroscopic disease only 4
• Do not perform primary anastomosis in the presence of sepsis, malnutrition, or significant contamination 4