What is a Right Hemicolectomy
A right hemicolectomy is a surgical procedure that removes the right side of the colon, including the cecum, ascending colon, hepatic flexure, and typically the proximal transverse colon, along with the associated mesentery containing blood vessels and lymph nodes, followed by reconnection of the small bowel (terminal ileum) to the remaining colon (ileo-colic anastomosis). 1, 2
Anatomical Extent of Resection
The procedure involves removal of specific colonic segments and their vascular supply:
- Bowel segments removed: Cecum, ascending colon, hepatic flexure, and proximal transverse colon 1, 2
- Vascular structures ligated: Ileocolic vessels, right colic vessels (when present), and right branches of middle colic vessels 3, 4
- Mesenteric excision: Complete mesocolic excision (CME) with removal of associated lymphatic channels and lymph nodes 3, 2
- Typical resection length: Approximately 27-28 cm of colon 5
Reconstruction Method
After resection, bowel continuity is restored:
- Primary anastomosis: The terminal ileum is connected to the transverse colon (ileo-colic anastomosis), which is the preferred approach due to excellent blood supply and mobility of the small bowel 1
- Alternative in high-risk situations: Terminal ileostomy with colonic fistula when primary anastomosis is considered unsafe 1, 2
Key Surgical Principles
The procedure follows oncologic principles to optimize cancer outcomes:
- High ligation: Blood vessels are ligated close to their origin from the superior mesenteric vessels to maximize lymph node harvest 3, 2
- Adequate margins: Safe surgical margins around the tumor (typically 6-7 cm) 5
- Lymph node harvest: Minimum of 12 lymph nodes should be examined for optimal staging, though 6 nodes is the minimum acceptable 2, 1
Clinical Context and Indications
Right hemicolectomy is performed for:
- Malignant disease: Right-sided colon cancer (cecum, ascending colon, hepatic flexure) 1, 2
- Emergency presentations: Obstructing or perforated right colon cancer 1
- Lynch syndrome: Patients with hereditary colon cancer syndromes requiring prophylactic or therapeutic resection 1
- Unresectable polyps: Premalignant lesions that cannot be removed endoscopically 1
Surgical Approach Options
The procedure can be performed through different techniques:
- Open surgery: Traditional approach via laparotomy 6
- Laparoscopic approach: Minimally invasive technique with comparable oncologic outcomes and similar 5-year survival rates (75%) to open surgery 5, 7
Extended Right Hemicolectomy
When tumors are located at the distal transverse colon or hepatic flexure:
- Additional resection: Extends further into the transverse colon with ligation of the middle colic vessels 6, 2
- Comparable outcomes: Similar postoperative morbidity, mortality, and survival to standard right hemicolectomy 6
Anatomical Advantages
Right hemicolectomy has favorable technical characteristics compared to left-sided resections:
- Easier mobilization: The hepatic flexure is technically simpler to mobilize than the splenic flexure 1
- Superior blood supply: The ileo-colic anastomosis benefits from excellent vascularization, unlike critical zones in the left colon dependent on marginal arcade patency 1
- Small bowel mobility: Allows anastomosis without additional surgical maneuvers 1
- Lower leak rates: Anastomotic leak rates range from 0.5-4.6% in emergency cases, compared to 3.5-30% for left-sided resections 1
Common Pitfall to Avoid
Inadequate lymph node sampling: Failure to harvest at least 12 lymph nodes results in suboptimal staging and may incorrectly classify patients as stage II when they actually have stage III disease, leading to undertreatment 2, 1