Sharon L. Stein

Introduction

A right colectomy is performed to treat a number of pathologies. Common indications include an unresectable polyp, colon cancer, Crohn disease of the terminal ileum, and right-sided diverticular disease. Ischemia and volvulus may also be indications. Resection of the terminal ileum and cecum is common to all these procedures. The distal extent of the right hemicolectomy will vary depending on the indication, oncologic principles, and adequacy of perfusion to the right or transverse colon.

Superficial Anatomy and Topographic Landmarks

Before making an incision, either laparoscopic or open, it is important to understand the relationship between surface anatomy and the abdominal anatomy (Fig. 21-1, A). Understanding the location of the most difficult part of the anatomy or most tethered portion of the colon will assist in appropriately placing an incision. Also, in the morbidly obese patient, surface anatomy, such as the location of the umbilicus, may be greatly altered. The umbilicus may reach down to the pubis and overlie a large pannus, which may distort normal relationships with internal anatomy.

Although the right colon is typically tethered by the ileocolic artery, lateral attachments, and the middle colic artery, the inferior portion of the right colon and ileum will be very mobile after the surgery is performed. Attachments to the middle colic and lesser sac are typically the most tethered portion of the operation. In addition, appropriate isolation and evaluation of adequate blood flow of the middle colic vessels is often the most difficult part of the case (Fig. 21-1, B). For this reason, laparoscopic extraction incisions are usually made over the middle colic arteries.

The middle colic arteries typically lie approximately midway between the xiphoid process and the umbilicus in a nonobese patient. The inferior extent of the procedure (inferior dissection of terminal ileum and cecum) is typically only centimeters below the umbilicus and medial to the anterior superior iliac spine. Therefore, an open right colectomy can often be performed through a relatively small periumbilical midline or right-sided transverse incision in a thin patient.

Anatomic Approach to Right Colectomy

Different surgical approaches to the right colon have been described and include medial to lateral, lateral to medial, inferior to superior, and superior to inferior. Varying the approach can allow for a safe, oncologically appropriate operation, depending on body habitus and pathology. Although anatomic relationships are constant, the surgeon’s awareness of proximity of structures must change.