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INDICATIONS

Resection of the right colon is commonly indicated for carcinoma, inflamatory bowel disease,

and more rarely for tuberculosis or volvulus of the cecum, ascending colon, or hepatic flexure.

PREOPERATIVE PREPARATION

Some tumors of the right colon present as an obstruction and may require relatively urgent

operation for excessive cecal distention ( 15 cm) in the presence of a competent ileal

cecal valve. Such a patient is resuscitated with correction of fluid and electrolyte imbalances.

The proximal bowel is decompressed with a nasogastric tube. Once the patient's physiologic

status is optimized, he or she will proceed to urgent operation, wherein a right colectomy can

be performed in an unprepared bowel. The left side of the colon should be decompressed

with enemas and the prudent surgeon should verify that there is not a second or

matachronous colorectal lesion. If the right colectomy is being done in an elective setting, the

entire colon should be evaluated with either colonoscopy or barium enema. Blood transfusion

may be advisable, especially in older patients with cardiovascular disease, when a silent and

unrecognized iron deficiency anemia has been created by a silent neoplasm of the right

colon. Preexisting steroid therapy is continued with intravenous replacement as the patient

prepares for surgery. Perioperative systemic antibiotics are given.

ANESTHESIA

Either general inhalation or spinal anesthesia is satisfactory.

POSITION

The patient is placed in a comfortable supine position. The surgeon stands on the patient's

right side.

OPERATIVE PREPARATION

The skin is prepared in the routine manner and a sterile plastic drape applied.

INCISION AND EXPOSURE

A liberal midline incision centered about the umbilicus is made. A transverse incision just

above the level of the umbilicus also provides an excellent exposure. The lesion of the right

colon is inspected and palpated to determine whether removal is possible. In the presence of

malignancy, the liver is also palpated for evidence of metastasis. If the lesion is inoperable, a

lateral anastomosis may be performed between the terminal ileum and the transverse colon.

After resection has been decided upon, the small intestines are walled off with gauze or

replaced partially in a plastic bag, and the cecum is exposed.

DETAILS OF PROCEDURE

An incision is made in the peritoneal reflection close to the lateral wall of the bowel from the

tip of the cecum upward to the region of the hepatic flexure (Figure 1). A liberal margin should

be assured in the region of the tumor. Occasionally, the full thickness of the adjacent

abdominal wall may require excision to include the local spread of tumor. Since the entire


hepatic flexure is usually removed as part of a right collectomy, the hepatocolic ligament,

which contains some small blood vessels, must be divided and ligated, but there will be no

blood vessels of importance in the peritoneal attachments along the right gutter. With the

lateral peritoneal attachment divided, the large bowel may be lifted mesially with the left hand,

while the loose areolar tissue lying under it is dissected off with a moist gauze sponge over

the right index finger (Figure 2). In elevating the right colon toward the midline, the surgeon

must positively identify the right ureter and be certain that it is not injured. Care is taken also

toward the top of the ascending colon and near the hepatic flexure to avoid injury to the third

portion of the duodenum, which underlies the large bowel (Figure 3). The raw surface

remaining after the intestine has been freed and brought outside the peritoneal cavity is

covered with warm, moist gauze pads. The middle colic vessels are identified, along with the

right-hand branches heading toward the hepatic flexure and the planned zone of transection.

The mesentery of the large bowel is clamped and divided just distal to the hepatic flexure or

wherever the bowel is to be resected. The right branches or all of the middle colic vessels are

divided and doubly ligated. The bowel at the selected level for division is freed of all

mesentery, omentum, and fat on both sides. All vessels must be carefully ligated. The right

half of the greater omentum is divided near the greater curvature of the stomach and excised

along with the right colon.

The terminal ileum is prepared for resection some distance away from the ileocecal valve,

depending upon the amount of blood supply that must be sacrificed to ensure excision of the

lymph node drainage area of the right colon. After the small intestine has been prepared at its

mesenteric border, a fan-shaped excision of the mesentery to the right colon is carried out.

This usually includes part of the right branches of the middle colic vessels. In the presence of

malignancy, the lymph node dissection should descend as far as possible along the course of

the right colic and ileocolic vessels without compromising either the middle colic vessels or

the superior mesenteric vascular supply of the remaining small bowel (Figure 4). The blood

vessels of the mesentery are doubly tied (see Pyloromyotomy—Intussusception).

A straight vascular clamp, or some other type of straight clamp, is applied obliquely to the

small intestine about 1 cm from the mesenteric border to ensure a serosal surface for the

placement of sutures for the subsequent anastomosis. Stone, Kocher, or Pace-Potts clamps

are next applied across the large intestine, which is then divided between the clamps. The

intervening section of bowel, with its fan-shaped section of mesentery and nodes, is excised.

The divided proximal end of the small intestine is covered with gauze moistened with saline,

and closure of the stump of the large bowel is started unless an end-to-end or end-to-side

anastomosis is planned. Some surgeons prefer to use stapling devices in which case the

colon and terminal small bowel are resected using the GIA60 device. The ileum and

transverse colon may then be anastomosed in an antimesenteric side-to-side manner using

the technique shown in Resection of Small Intestine, Stapled (Alternative Methods). As

staples may not be universally available, the techniques for hand-sewn anastomoses are

shown in the next sections.


The end of the colon is closed by a continuous absorbable suture on an atraumatic needle

and whipped loosely over a Pace-Potts or similar noncrushing clamp (Figure 5). Interrupted

000 silk sutures placed beneath the clamp may be used. The clamp is then opened and

removed. If a continuous suture is used, it is pulled up snugly and tied. A single layer of 000

silk Halsted mattress sutures is placed about 2 or 3 cm from the original suture line, care

being taken that no fat is included. As these sutures are tied, the original suture line is

invaginated so that serosa meets serosa (Figure 6). The surgeon must determine before

closing the ends of the colon whether an end-to-end, end-to-side, side-to-end, or lateral

anastomosis is to be carried out (Figures 14, 16, 17 and 18).

The end-to-side approximation is physiologic, simple, and safe to perform. The small

intestine, still held in its clamp, is brought up adjacent to the anterior taenia of the colon

(Figure 7). The small intestine should retain a good color and give evidence of adequate

blood supply before the anastomosis is attempted. If its color indicates an inadequate blood

supply, the surgeon should not hesitate to resect a sufficient length until its viability is

unquestionable. Next, the omentum, if not previously excised, is retracted upward, and the

anterior taenia of the transverse colon is grasped with Babcock forceps at the site chosen for

anastomosis (Figure 7). Following this, the edge of the mesentery of the small intestine

should be approximated to the edge of that of the large intestine, so that herniation of the

small intestine cannot occur beneath the anastomosis into the right gutter (Figure 14). This

opening is closed before the anastomosis is started, since on rare occasions the blood supply

may be injured by the procedure and the viability of the anastomosis jeopardized. A small,

straight crushing clamp is applied to the anterior taenia, including a small bite of the bowel

wall (Figure 8). Following this, the clamps on the terminal ileum, as well as on the anterior

taenia of the transverse colon, are so arranged that a serosal layer of interrupted 000

mattress or nonabsorbable synthetic sutures can be placed, anchoring the terminal ileum to

the transverse colon (Figure 9). The two angle sutures are not cut and serve as traction

sutures (Figure 9). An opening is made into the large intestine by excising the protruding

contents of the crushing clamp that has been applied to the anterior taenia (Figure 10). An

enterostomy clamp is then applied behind each of the crushing clamps. The crushing clamps

are removed, and the terminal ileum is opened; likewise, the crushed contents of the

transverse colon are separated. Sometimes it is necessary to enlarge the opening in the

mucosa of the colon, since the previous excision of the contents of the crushing clamp did not

provide a sufficiently large stoma for satisfactory anastomosis. The mucosa is then

approximated with a continuous locked nonabsorbable suture on atraumatic needles, which is

started in the midline posteriorly. The sutures, A and B, are continued as a Connell inverting

suture around the angles and anteriorly to ensure inversion of the mucosa (Figures 11 and

12). Interrupted fine 000 silk sutures are preferred by some for closing the mucosal layer. An

anterior row of mattress sutures completes the anastomosis. Several additional mattress

sutures may be placed to reinforce the angles (Figure 13). The patency of the stoma is

tested. It should permit introduction of the index finger. If the tension is not too great, the raw


surface over the iliopsoas muscle may be covered by approximating the peritoneum of the

lateral abdominal wall to the mesentery.

The second method shown is a direct end-to-end anastomosis (Figures 15 and 16). The

discrepancy in the size of the terminal ileum and the transverse colon can be overcome safely

by attending to certain technical details. Added luminal circumference can be provided by

exaggerating the oblique division of the terminal ileum. During the anastomosis, slightly larger

bites are taken in the colonic side to compensate for the discrepancy between the two sides

of the anastomosis. Following completion of the anastomosis, any remaining gap between the

mesenteries is approximated. The patency of the lumen is determined by palpation.

If a side-to-end anastomosis is preferred by the surgeon, the stump of the small intestine is

closed as previously described for the large intestine. The small intestine is then brought up

to the open end of the large intestine (Figure 17), the posterior row of serosal sutures is

placed, the small intestine is opened, and the continuous mucosal suture or the inverting

sutures are placed as well as, finally, the anterior serosal sutures of interrupted 000 silk or

nonabsorbable synthetic material. Whenever this type of procedure is carried out, care should

be taken that only a very small portion of small intestine protrudes beyond the suture line,

since blind ends of bowel that are in the peristaltic line form a stagnant pouch against which

peristalsis tends to work, increasing the chance of eventual breakdown.

In the fourth method, the ends of the large and small intestines are closed, and a lateral

anastomosis is carried out. Only a small portion of small intestine should protrude beyond the

suture line. The small intestine should be anchored to the colon with interrupted sutures of

silk or nonabsorbable synthetic material, including both angles of the stoma as well as the

closed end of small bowel (Figure 18). The stapled equivalent of each of the variations can be

found in earlier chapters illustrating the use of various stapling instruments in small bowel

anastomoses.

CLOSURE

Drains are undersirable unless gross infection has been encountered. The site of

anastomosis is covered with omentum. The abdominal wall is closed in routine fashion, and a

sterile dressing is applied.

POSTOPERATIVE CARE The patient should be in a comfortable position. Diarrhea or frequent bowel movements may

be satisfactorily controlled by medication and diet. The need for continued steroid therapy,

particularly in patients with regional ileitis, should not be overlooked in the immediate

postoperative period.

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