What is involved in a right hemicolectomy procedure for an adult patient with colon cancer?

Right Hemicolectomy for Colon Cancer

For adult patients with right-sided colon cancer, right hemicolectomy with primary ileocolic anastomosis is the procedure of choice, involving resection of the cecum, ascending colon, hepatic flexure, and proximal transverse colon with high ligation of the ileocolic artery and removal of associated mesocolon and lymph nodes. 1

Surgical Technique and Extent of Resection

Standard Oncologic Principles

• Excision of the primary tumor with safe margins (typically 5-10 cm proximal and distal to the tumor) is essential for adequate oncologic clearance 2, 3

• High ligation of the ileocolic artery at its origin from the superior mesenteric artery is mandatory, along with ligation of the right branch of the middle colic artery when performing extended right hemicolectomy 4

• Complete mesocolic excision (CME) with sharp dissection of the mesocolon without preparation tears ensures adequate lymph node harvest and optimal oncologic outcomes 4

• Adequate lymph node harvest requires removal of vessels and associated mesocolon containing lymphatic channels, with a minimum of 12 lymph nodes needed for proper staging 2, 4

• Intraoperative examination of the liver, pelvis, and ovaries (in women) should be performed, with sampling or frozen section of suspicious masses 2

Anatomic Considerations

• The entire bowel should be carefully examined during surgery because multiple synchronous lesions may be present in up to 5% of cases 1

• Assessment of the superior mesenteric artery and vein proximity or involvement should be performed during surgery 1

• The hepatic flexure is easier to mobilize compared to the splenic flexure, and the mobility of the small bowel allows for tension-free ileo-colic anastomosis 1

Anastomotic Technique

Primary Anastomosis Strategy

• Primary ileocolic anastomosis is the preferred option for stable patients with right-sided colon cancer causing acute obstruction 1

• Both stapled and handsewn techniques yield equivalent results in experienced hands, with comparable rates of anastomotic leak (0.5-4.6% in emergency cases, 0.5-1.4% in elective cases) and postoperative bleeding 5, 6

• Stapled end-to-side anastomosis is associated with lower rates of postoperative ileus (6.5%) compared to stapled side-to-side anastomosis (7.2%) 6

• Effective anastomosis requires good bowel vascularization without undue traction and adequate blood supply from the ileocolic vessels 5

Alternative Approaches When Primary Anastomosis is Unsafe

• Terminal ileostomy with colonic fistula represents a valid alternative when primary anastomosis is considered unsafe due to patient instability, poor bowel preparation, or compromised vascular supply 1

• Ileostomy creation should be balanced with the risk of electrolyte imbalance and high-output stoma complications 1

Emergency Presentations

Right-Sided Obstruction

• Right colectomy with primary anastomosis remains the preferred option even in emergency obstruction, as the ileo-colic anastomosis benefits from optimal blood supply 1

• For unstable patients with right-sided obstruction, right colectomy with terminal ileostomy should be considered the procedure of choice 1

• Severely unstable patients should be treated with a loop ileostomy as a damage control measure 1

Right-Sided Perforation

• Right colectomy with terminal ileostomy should be considered the procedure of choice for perforated right colon cancer 1

• Right colectomy with ileo-colic anastomosis could be performed only if no significant increase in operative time is required and good bowel vascularization is present and expected in the perioperative period 1

• If open abdomen is necessary, stoma creation should be delayed until the patient is stabilized 1

Criteria for Unstable Patients

A patient should be considered unstable and amenable for damage control treatment if any of the following are present: 1

• pH < 7.2
• Core temperature < 35°C
• Base excess < -8
• Laboratory/clinical evidence of coagulopathy
• Any signs of sepsis/septic shock, including necessity of inotropic support

Unresectable Disease

• For unresectable right-sided colon cancer, a side-to-side anastomosis between the terminal ileum and the transverse colon (internal bypass) can be performed as the preferred palliative option 1

• Loop ileostomy represents an alternative when internal bypass is not feasible 1

• Decompressive cecostomy should be abandoned due to high rates of malfunction and complications 1

Laparoscopic Approach

Elective Setting

• Laparoscopic right hemicolectomy is the method of choice in experienced centers for elective cases, with 5-year survival rates of 75% and comparable complications and recurrence rates to open procedures 3

• The standardized laparoscopic procedure includes mobilization from vascularized mesenteric bridges with window technique, transection of the ileocolic lymphovascular pedicle, and lateral and proximal mobilization of the ileocecum, ascending colon, right flexure, and proximal transverse colon 3

• Extracorporeal anastomosis is performed after enlargement of one trocar incision and exteriorization of the resected colon 3

Emergency Setting

• Laparoscopy in emergency treatment of obstructing right colon cancer cannot be recommended and should be reserved for selected favorable cases in specialized centers 1

• The limited role in emergency settings is due to technical difficulty, patient instability, and lack of evidence supporting equivalent outcomes 1

Antibiotic Management

Prophylaxis for Obstruction

• Prophylactic antibiotics targeting Gram-negative bacilli and anaerobes are mandatory for all patients with colorectal obstruction, even without systemic signs of infection, due to potential bacterial translocation 1

• Prophylactic antibiotics should be discontinued after 24 hours (or 3 doses) in patients without systemic infection 1

Therapeutic Antibiotics for Perforation

• Antibiotic therapy targeting Gram-negative bacilli and anaerobes is always required in patients with colon perforation 1

• In critically ill patients with sepsis, early use of broader-spectrum antimicrobials is indicated 1, 5

• Refine therapy based on microbiological findings and local resistance patterns once culture results are available 5

Special Considerations

Prophylactic Procedures

• Prophylactic cholecystectomy should be considered if future treatment with octreotide or lanreotide is anticipated, given the association between long-term somatostatin analogue treatment and development of biliary symptoms and gallstones 1

• Prophylactic bilateral oophorectomy should be performed in post-menopausal women with colon cancer 2

• Subtotal colectomy should be considered for patients with Lynch syndrome 2

Postoperative Bowel Function

Expected Changes

• Loose stool, increased bowel frequency, and/or nocturnal defecation occur in approximately one in five patients (20%) following right hemicolectomy 7

• Some symptoms may improve spontaneously with time, but chronic dysfunction can persist 7

Potential Causes of Chronic Dysfunction

• Bile acid malabsorption and/or small bowel bacterial overgrowth may be the cause for chronic bowel dysfunction after right hemicolectomy 7

• Patients should be counseled preoperatively about potential changes in bowel function, and follow-up should be designed to identify and effectively treat significantly altered bowel function 7

Common Pitfalls and Caveats

Technical Errors to Avoid

• Inadequate lymph node harvest can compromise oncologic staging; ensure CME technique with high vessel ligation to achieve adequate nodal staging (minimum 12 nodes) 2, 4

• Preparation tears in the mesocolon compromise oncologic quality; sharp dissection without tears is essential 4

• Low ligation of the ileocolic artery (not at the origin from the superior mesenteric artery) results in inadequate lymph node harvest 4

• Incomplete resection of invaded organs; always perform en bloc resection rather than attempting to separate adherent structures 2

Clinical Decision-Making Errors

• Performing primary anastomosis in unstable patients significantly increases morbidity and mortality; use damage control principles with terminal ileostomy 1

• Inadequate bowel preparation compromises anastomotic integrity; ensure proper preparation in elective cases 2

• Failure to examine the entire colon may miss synchronous lesions present in up to 5% of cases 1