Right Hemi Colectomy (open)
General remarks
- Indications for an open right hemi colectomy include previous surgery, suspected adhesions, large tumor in lean patients
- Incision can be made as a midline (usualy in IBD patients)or oblique. The latter tends to have a reduced incidence for an incisional hernia. Also with an oblique incision, mobilisation of the hepatic flecture is more easy
- Pre-operative bowel preparation is not necessary
- Anastomoses can be made handsewn, or by using a stapler device. There is still controversy on which technique has the lowest leak rate
Step by step
- Oblique incision from umbilicus towards the 12th rib
- Opening the anterior fascia
- Divide muscle fibers and beware of the superficial epigastric vessels
- Opening the posterior fascia
- Opening the peritoneum make sure not to damage the bowel underneath. It is advised to use sciccors instead of the electrocautery
- Identify the tumor (mostly marked distal to the tumor)
- Mobilize the ascending colon by incising the white line of Toldt, stay anterior to Gerotas fascia
- Open the lesser sac (bursa omentalis) by dividing the ometum from the transverse colon. If the tumor is not invaded into the omentum, then try to save the omentum, since that can be used to drape it on top of the future anastomoses
- Work towrds the hepatic flecture and avoid any damage to the gallbladder
- Mobilize the mesocolon and be very careful not to damage the duodenum
- Indentify de ileocolic artery and the right branche of the middel colic artery
- Divide the meseterium in a V-shape and the ligate the main vessels at its base
- Align both the small and large bowel and make an opening at the antimeseteric side, for the small bowel distal to the transsection position, for the large bowel proximal to the transsection position
- Introduce the liniar stapler and create the side to side anti-peristaltic connection
- Make a cross stapling and therby release the specimen
- A tension relasing suture can be placed in the corner of the side stapler
- Reposition the anastomosis and position the ometum on top of it
- Closure of the fascia in 2 layers
- Skin closure with staplers (woundinfection is more likely to occur with sutures as compared to skinstaplers)
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