Right and extended right colectomy: Open technique

INTRODUCTION — Right colectomy refers to the resection of a portion of the distal ileum, cecum, ascending colon, and proximal to mid-transverse colon. Extended right hemicolectomy refers to extension of the distal resection margin to include the distal transverse colon up to the splenic flexure.

The techniques used to perform right and extended right colectomy are reviewed here. Left colectomy is presented separately. (See "Left colectomy: Open technique".)

COLON ANATOMY — The colon and rectum occupy the retroperitoneal and intraperitoneal spaces, in close approximation to solid organs (figure 1). The ascending and descending colon are retroperitoneal, while the transverse colon, which extends from the hepatic flexure to the splenic flexure, is intraperitoneal. The sigmoid colon continues from the descending colon, ending where the teniae converge to form the rectum.

Arterial supply — The right colic artery and the ileocolic artery provide the principal blood supply to the right colon (figure 2). The marginal artery of Drummond and the arc of Riolan provide collateral blood vessels. Typically, the blood supply of the transverse colon is excellent provided the marginal artery is not damaged. Variability in the arterial anastomoses occurs, which is an important point when performing a segmental resection. Two sites of tenuous perfusion are the splenic flexure (Griffith's point) and distal descending colon (Sudeck's point). (See "Overview of intestinal ischemia in adults", section on 'Intestinal vascular anatomy'.)

Venous and lymphatic drainage — The venous drainage of the right colon is through the superior mesenteric vein (figure 3). The lymphatics drain via the corresponding arterial supply (figure 4).

INDICATIONS FOR COLON RESECTION — Malignant, premalignant, and benign diseases are indications for a right colectomy and include a right colon cancer (eg, cecum, ascending colon), appendiceal cancer, large adenomas, right-sided diverticulitis, inflammatory bowel disease, ischemia/infarction, infection, trauma, and cecal volvulus. The indications for an extended right colectomy include a cancer located between the hepatic flexure and mid-transverse colon, synchronous ascending and transverse colon cancers, and multiple adenomas, which may or may not be part of a genetic syndrome. (See "Overview of colon resection", section on 'Indications for colon resection'.)

PREOPERATIVE EVALUATION AND PREPARATION — General issues regarding the medical preparation of patients, including antibiotic prophylaxis, bowel preparation, and other considerations prior to colon resection, are reviewed separately. (See "Overview of colon resection", section on 'Preoperative evaluation'.)

It can be helpful to have a flexible colonoscope available in the operating room as it may be needed to identify a cancer or other mucosal lesion that cannot be palpated.

ABDOMINAL EXPLORATION — Prior to proceeding with colon resection, the abdomen should be systematically explored. The anatomy of the colon and its blood supply should be verified, noting any anatomic variations or possibly any congenital anomalies (eg, malrotation).

For patients with abdominal trauma, the abdomen is packed and systematically examined, removing the packs in turn. Bleeding is controlled first, followed by control of gastrointestinal leakage. (See "Traumatic gastrointestinal injury in the adult patient", section on 'Abdominal exploration'.)

For patients with cancer, this evaluation includes an assessment of local, regional, and distant disease.

●The abdomen is explored for evidence of anomalies and/or metastatic disease, including peritoneal implants, hepatic metastases, and distant nodal metastases.

●The primary tumor is palpated to confirm its location. Local and regional resectability is determined by assessing tumor invasion into the abdominal wall, gallbladder, liver, stomach, vena cava, duodenum, pancreas, and/or superior mesenteric vessels. The entire colon is palpated to identify synchronous colonic lesions.

EXTENT OF RESECTION — The selection of the operative procedure (eg, right or extended right colectomy) is based upon the location of the lesion, malignant or benign indication, blood supply, and venous and lymphatic drainage of the colon. The blood supply, venous return, and lymphatic drainage of the colon are shown in the figures linked above and are critical in planning a colectomy. (See 'Colon anatomy' above.)

Right colectomy — Neoplastic lesions located in the appendix, cecum, and ascending colon and benign lesions (eg, cecal diverticulum, inflammatory bowel disease) limited to the right colon can be resected by a standard right colectomy. The resection extends from the distal ileum and can extend to the mid-transverse colon; this involves isolating and dividing the ileocolic, right colic, and either the right or hepatic branch of the middle colic artery and vein (figure 5).

Right extended colectomy — Malignant lesions located in the hepatic flexure or proximal to the mid-transverse colon and benign inflammatory conditions extending to the mid-transverse colon may be resected with an extended right colectomy (figure 6). An extended right colectomy includes the resection of the distal transverse colon and sometimes the splenic flexure and involves ligating the ileocolic, right colic, and middle colic vessels. An anastomosis is avoided in areas of unreliable blood supply (eg, mid-ascending colon or splenic flexure). An option for the extended right colectomy for proximal to mid-transverse colon cancers is a transverse colectomy (figure 7). The caveat of this procedure is that the distal and proximal ends of the resected bowel need to be well mobilized and assessed carefully to ensure a tension-free and well-vascularized anastomosis; hence, the extended right colectomy may be preferred in these settings.

Mesenteric resection — The extent of the mesenteric resection also varies according to the indication for surgery. For example, when performing a colectomy for non-neoplastic disease, mesenteric vessels may be divided closer to the mesenteric border of the colon as it is unnecessary to resect draining lymph nodes (figure 8 and figure 9). However, for settings of severe mesenteric inflammation (eg, diverticulitis, inflammatory bowel disease) and thickening of the mesentery near the bowel wall, a more radical mesenteric dissection may be warranted. When colectomies are performed for malignancy, the mesenteric vessels are ligated close to their root for optimal resection of lymphovascular tissue (figure 10).

Omental resection — The omentum is dissected off the transverse colon (figure 11) or divided at the distal bowel resection margin and the proximal portion removed for ascending colon, hepatic flexure, and transverse colon cancers.

MOBILIZING THE RIGHT COLON — There are two approaches to resecting the right colon; one begins laterally by mobilizing the colon and progresses medially, while the other begins medially by identifying the lymphovascular bundle and progresses laterally. The approach is at the discretion of the surgeon.

In the lateral-to-medial approach, the mesentery is thoroughly mobilized prior to vascular division. This allows for accurate identification of the root of the mesentery, the retroperitoneal duodenum, and the right ureter prior to dissection in the mesenteric root and division of the vessels. The medial-to-lateral technique has been used primarily in laparoscopic surgery where vascular ligation prior to mobilization is necessary in order to maintain necessary traction and exposure of the mesenteric structures; however, this approach is also easily applied in the open setting.

Lateral-to-medial approach — The lateral-to-medial approach begins by mobilizing the right colon by first dividing the lateral attachments of the colon and developing the retromesenteric plane in a lateral-to-medial fashion. This approach is performed for both malignant and benign right colon diseases.

The general principles for performing a right or extended right colectomy, beginning with the mobilization of the colon, include:

●Retract the colon medially and divide the lateral peritoneal attachments of the cecum and ascending colon along the white line of Toldt. The peritoneum and the colon are gently separated from the loose areolar tissue by finger dissection (figure 12).

●Avoid injury to the duodenum, right ureter, and gonadal vessels. These structures should remain posterior and lateral to the right colon, underneath an intact retroperitoneal fascia (figure 13). Dissection is carried out between the posterior aspect of the right colon mesentery and Gerota's fascia, taking care to avoid excessive traction on the duodenum. Injury to the duodenum can occur during hepatic flexure mobilization. This usually results from excessive caudal and medial retraction of the colon during attempts to bring the superior aspect of the hepatic flexure into view or from overly aggressive blunt dissection of the retroperitoneal structures, including the duodenum, off the posterior aspect of the transverse colon mesentery (figure 14). Some degree of fusion may exist between Toldt's retroperitoneal fascia and the mesentery, making dissection precarious, particularly around Gerota's fascia.

●Divide the right renocolic ligament using electrocautery.

●Dissect distally along the colon until the gastrocolic ligament is encountered. The gastrocolic ligament is a portion of the greater omentum, extends from the greater curvature of the stomach to the transverse colon, and forms the anterior portion of the lesser sac (omental bursa). It is inferior and parallel to the stomach and is the left continuation of the transverse mesocolon (figure 11). Once the lesser sac is opened, the gastrocolic ligament is divided from left to right, completing mobilization of the hepatic flexure. The duodenum and head of the pancreas are now exposed (figure 15). Any remaining attachments between the right colon mesentery and anterolateral portion of the second and third part of the duodenum are divided.

●Release the terminal ileum by dividing the fold of Treves on its antimesenteric border.

●Ligate the lymphovascular pedicle and resect the bowel. (See 'Medial-to-lateral approach' below.)

Medial-to-lateral approach — The medial-to-lateral approach is ideal for resection of inflamed bowel and adjacent mesentery and for performing the "no-touch" approach to colon cancer resection by ligating the lymphovascular pedicle prior to mobilizing the colon.

The advantages of this approach include maximal time for sharp demarcation between ischemic and well-perfused bowel, ligation of the lymphovascular pedicle prior to risk of injury by torsion during colon mobilization, and more efficient identification of the resection plane in the setting of severe mesenteric inflammation (eg, diverticulitis, inflammatory bowel disease).

The general principles for performing a right or extended right colectomy, beginning with ligation of the mesenteric lymphovascular pedicle, include:

●Identify the lymphovascular pedicles by retracting the small bowel to the left side of the abdominal cavity and elevating the right colon to expose the root of the mesentery.

•The ileocolic vessels are located at the caudal portion of the root of the mesentery and supply/drain the terminal ileum and cecum. The proximal ileocolic artery is just inferior to the duodenum.

•The right colic vessels are variable; they are predominantly a branch of the ileocolic artery but in some circumstances are located at the middle of the root of the mesentery and supply/drain the distal ascending colon and hepatic flexure.

•The middle colic vessels exit the root of the mesentery close to the third portion of the duodenum and supply/drain the transverse colon.

●Identify the superior mesenteric artery to prevent injury or inadvertent ligation.

●Incise the peritoneum overlying the vascular pedicle and ligate the vessels in close proximity to their origins. One may doubly ligate the larger vessels with a nonabsorbable (ie, silk) or a slowly dissolving (ie, polyglycolic acid) suture. Single ligatures are used for small- to medium-size vessels (figure 16). Energy and stapling devices may also be used to ligate and divide appropriately sized vessels.

●Resect the mesentery by sequentially clamping and tying or with the use of energy devices (eg, LigaSure, Enseal) (figure 16 and figure 17). In cases of right colectomy for Crohn disease where the mesentery is thick and friable, we often find the clamp and tie technique superior.

ILEOCOLONIC ANASTOMOSIS — Options for restoring bowel continuity include side-to-side, end-to-side, and end-to-end configurations, which are performed with stapling devices or hand-sewn. Stapling the anastomosis requires less time to perform and offers the potential for reduced fecal contamination.

Data regarding outcomes following stapled versus hand-sewn ileocolonic anastomosis are conflicting. In a Cochrane review of seven randomized trials that included 1125 patients, stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (odds ratio 0.48, 95% CI 0.24-0.95) [1]. However, a subsequent nationwide retrospective cohort study of 1414 right-sided colon cancer patients demonstrated a twofold increase in anastomotic leak after stapled versus handsewn ileocolic anastomosis [2]. Given these inconsistencies and the equivalence of the two approaches for most outcomes evaluated, we feel that the anastomotic technique should depend on the surgeon's preference, experience, and availability of equipment. (See "Bowel resection techniques", section on 'Type of anastomosis'.)

In patients with Crohn disease, the risk of recurrence of disease is not influenced by the approach used for bowel anastomosis. A randomized trial of 139 patients with Crohn disease found no difference in symptomatic or endoscopic recurrence rates at 12 months for patients undergoing a stapled side-to-side ileocolic anastomosis compared with a hand-sewn end-to-end ileocolic anastomosis (22.7 versus 21.9 percent and 37.9 versus 42.5 percent, respectively) [3]. Small bowel resection for Crohn disease is different from ileocolic resection and is discussed in another topic. (See "Surgical management of Crohn disease", section on 'Small bowel or ileocecal resection'.)

Stapled side-to-side functional end-to-end anastomosis — When the bowel is very thick, hand-sewn techniques are preferred. The anastomotic suture depth can be adjusted according to bowel thickness, unlike staple heights, which are preset.

The technical steps for a stapled side-to-side functional end-to-end anastomosis include:

●The ileum and colon are transected using a linear cutting stapler in an area cleared of mesentery for 2 cm (figure 18).

●The ileum and colon are lined up side by side such that their mesenteries are not twisted and the antimesenteric and mesenteric borders of the two bowel loops approximate each other.

●The antimesenteric staple line corners are removed using either heavy scissors or electrocautery.

●The arms of a linear cutting stapler are inserted into the bowel lumens (figure 19). The staple line is cleared of the mesenteries, the ileum and colon are placed at the inside corner of the instrument, and the stapler is fired.

●The remaining enterotomy is closed using a linear stapler (picture 1), including the serosa circumferentially. Care is taken to offset the two staple lines from each other.

●A single nonabsorbable seromuscular suture should be placed at the apex of the anastomosis to prevent "unzipping" (figure 20).

●Any excessive bleeding from the staple lines is controlled with electrocautery or with figure-of-eight absorbable sutures (figure 20).

●The mesenteric defect may be closed by suturing together the peritoneum overlying the two cut mesenteries with a running absorbable suture. Some surgeons do not close the mesenteric defect, as the risk of internal herniation is low and closing the defect has not been shown to reduce the risk of a subsequent internal hernia.

An alternative, based on surgeon preference, to transecting the ileum and colon as the initial step is to create transverse enterotomies in preparation for placement of the linear cutting stapler (figure 21) [4]. The specimen is divided after the ileum and colon are stapled together to form the anastomosis.

Stapled end-to-side anastomosis — An ileocolic anastomosis can also be performed with the use of a circular stapler. These technical steps are followed when performing a stapled end-to-side anastomosis:

●The distal ileum is prepared for the anastomosis by clearing the mesentery and sharply dividing the bowel against a distal clamp (figure 22). Electrocautery can also be used to divide the bowel.

●The anvil of a circular stapler is placed into the bowel lumen and secured with a manually or stapler-placed purse-string suture (figure 23).

●A longitudinal colotomy is made on the specimen side of the colon at least 10 cm proximal to the site chosen for transection and the circular stapler inserted (figure 24).

●The spike of the stapler is brought through the antimesenteric side of the colon 1 cm distal to the transection site, preferably through a taenia coli (figure 25).

●The anvil and spike are connected and the circular stapler closed and fired, creating an anastomosis between the end of the ileum and the side of colon (figure 25).

●A linear stapler is used to transect the colon from the specimen (figure 26). Any bleeding points can be oversewn with a silk suture.

Hand-sewn end-to-end anastomosis — Single-layer and double-layer techniques using absorbable and nonabsorbable suture can be used to perform a hand-sewn end-to-end anastomosis. A meta-analysis of seven randomized trials including 842 patients identified no significant difference between single-layer and double-layer anastomosis closure for anastomotic dehiscence, perioperative complications, or mortality [5]. We perform a two-layer anastomosis using an inner running absorbable suture and outer interrupted nonabsorbable sutures.

The technical steps when performing a hand-sewn end-to-end anastomosis include:

●The ileum and transverse colon are divided using a scalpel, scissors, or monopolar electrocautery (figure 22).

●A Cheatle slit is made in the antimesenteric border of the ileum to accommodate any size discrepancy between the ileum and colon (figure 27).

●The ileum and colon are aligned end to end, ensuring that their mesenteries are not twisted, and stay sutures are placed in the antimesenteric and mesenteric borders of these bowel loops in preparation for suturing (figure 28).

●The outer, posterior layer is approximated by placing interrupted Lembert seromuscular nonabsorbable sutures approximately 3 to 4 mm apart.

●The inner, posterior layer is performed using a full-thickness, running, absorbable suture starting from the middle of the anastomosis and proceeding outward in either direction (figure 28).

●Connell-type sutures are utilized to transition to and complete the superficial inner layer (figure 29).

●The anterior outer layer is approximated using interrupted Lembert seromuscular nonabsorbable sutures (figure 30).

ABDOMINAL CLOSURE — After completion of the ileocolic anastomosis and closure of the mesenteric defect, the abdominal cavity may be irrigated with sterile saline and suctioned dry. Hemostasis is confirmed and omentum is positioned over the anastomosis and under the incision. The fascia and skin are closed in standard fashion. It is not necessary to place drainage catheters following a right colectomy. (See "Principles of abdominal wall closure".)

COMPLICATIONS — Complications of right colectomy include anastomotic leak, abdominopelvic abscess, fistula, hemorrhage, bowel obstruction, and wound infection, as well as complications of general anesthesia. (See "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery".)

Preventing complications — There are several critical structures that must not be damaged during the colectomy.

●Injury to the right ureter or gonadal vessels – When incising the lateral peritoneal attachments of the cecum and ascending colon, the operating surgeon must be keenly aware of the location of the right ureter and right gonadal vessels. Injury to these structures is avoided by dissecting anteromedial to them within the areolar plane along the white line of Toldt (figure 13). (See 'Lateral-to-medial approach' above.)

●Injury to the duodenum – Injury to the duodenum can occur during hepatic flexure mobilization. This usually results from excessive caudal and medial retraction of the colon during attempts to bring the superior aspect of the hepatic flexure into view or from overly aggressive blunt dissection of the retroperitoneal structures, including the duodenum, off the posterior aspect of the transverse colon mesentery (figure 14). (See 'Lateral-to-medial approach' above.)

●Venous bleeding – When ligating the middle colic vessels, the surgeon must avoid excessive upward traction as this may cause avulsion of a large collateral branch between the middle colic vein and inferior pancreaticoduodenal vein (figure 3). The most effective method of obtaining hemostasis if bleeding occurs in this area is to hold pressure for a period to allow the anesthesia team time to prepare for significant blood loss. If pressure alone is insufficient, one may carefully place figure-of-eight sutures incorporating the point of injury. Attempting to clamp and tie the injured vessel can cause further avulsion and hemorrhage. (See 'Medial-to-lateral approach' above.)

●Inadvertent ligation of the superior mesenteric artery – The superior mesenteric artery (SMA) must not be mistaken for the right colic artery (figure 2). The surgeon should lift the right and transverse colon in a cephalad direction and visualize and palpate the ileocolic vessels arising from the root of the mesentery, traversing to the terminal ileum and cecum. The superior mesenteric vessels are located medial to the ileocolic trunk. Ligation of the SMA will result in bowel infarction. (See 'Medial-to-lateral approach' above.)

●Excessive tension on the anastomosis – Failure to divide a sufficient amount of the gastrocolic ligament distally can lead to suboptimal mobility of the transverse colon and, consequently, undue tension on the ileocolic anastomosis.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colorectal cancer" and "Society guideline links: Colorectal surgery for cancer".)

SUMMARY AND RECOMMENDATIONS

●Right colectomy – Neoplastic lesions located in the appendix, cecum, and ascending colon and benign lesions (eg, cecal diverticulum, inflammatory bowel disease) limited to the right colon can be resected by a standard right colectomy. The resection extends from the distal ileum to a point between the distal ascending colon and the mid-transverse colon and involves isolating and dividing the ileocolic artery and possibly the right colic artery and either the right or hepatic branch of the middle colic artery and vein. (See 'Extent of resection' above.)

●Extended right colectomy – Neoplastic lesions located in the hepatic flexure or in the proximal to mid-transverse colon and benign inflammatory conditions extending to the mid-transverse colon may be resected with an extended right colectomy (figure 6). An extended right colectomy includes the resection of the distal transverse colon and sometimes the splenic flexure and involves ligating the ileocolic and middle colic vessels. (See 'Extent of resection' above.)

●Ileocolonic anastomosis – The continuity of the bowel is restored by an ileocolic anastomosis, which is performed by a stapled or hand-sewn technique, depending on the preference of the surgeon. There is insufficient evidence to demonstrate superiority of stapled over hand-sewn anastomosis. In the setting of thickened bowel and inflammation, we suggest a hand-sewn rather than stapled anastomosis (Grade 2C). (See 'Ileocolonic anastomosis' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Randolph Steinhagen, MD, who contributed to earlier versions of this topic review.