Right Hemicolectomy Open Technique
Malignancy (most often the cancer is an adenocarcinoma)
Longitudinal midline – this is the most common incision in right hemicolectomy and runs up and down usually from just above the symphysis pubis (pubic bone) to above the umbilicus (belly button).
Transverse lower right quadrant – this incision is used less commonly but gives good exposure at the ileocecal region (where the small bowel turns into the large bowel).
Surgical Details of Right Hemicolectomy
1. An incision is made in the skin with a #10 blade
2. Bovie cautery is used to dissect the subcutaneous fascia
3. The scalpel is used to incise the fascia in the midline (usually above the umbilicus) between the rectus muscles.
4. The peritoneum is grasped between two forceps and palpated to insure that bowel is not present
5. The peritoneum is incised with a Metzenbaum scissors.
6. If purulent or bloody peritoneal fluid is returned, a culturette swab is obtained times two.
7. The balance of the incision is opened.
8. Bookwalter, Balfour, or Thompson retractors are used to provide exposure
9. In right hemicolectomy, an incision is made at the peritoneal reflection lateral to the cecum.
10. Dissection upwards towards the hepatic flexure (area of the colon next to the liver) from this initial incision is performed, usually with the Bovie Cautery.
11. The hepatic flexure of the colon is “taken down” or released from its retroperitoneal attachments.
12. Care must be taken in ligating the small blood vessels in the hepatic-colic ligament (connective tissue between the colon and the liver).
13. Care must be taken whne doing a right hemicolectomy to not injure the 2nd and 3rd part of the duodenum, which is directly deep to the hepatic flexure of the colon.
14. Once the retroperitoneal attachments are freed the right colon can be lifted toward the midline.
15. The right ureter may be visualized running under the elevated right colon.
16. The area of transection in the transverse colon is selected by palpating for the middle colic vessels and its right branches.
17. The omentum is freed off the area of resection of the colon by using hemostats or Kelly clamps to cross-clamp and then ligate with 2-0 silk ties
18. A hemostat or Kelly clamp is used to open a window in the mesentery just beneath the edge of the bowel on the mesenteric side at the planned area of transection.
19. A one half of a GIA bowel stapler is placed through the just formed mesenteric window and one half is placed over the bowel wall.
20. The GIA stapler is closed and fired transecting the bowel wall.
21. The transection area of the terminal ileum is selected and a hemostat or Kelly clamp is used to open a small window in the mesentery.