Hepatic Flexure
The hepatic (or right) flexure is the anatomic name for the bend in the colon as it transitions from the ascending colon to the transverse colon. The hepatic flexure usually contains only small, unnamed vessels, although in some patients there are larger vessels that require ligation. Certain disease states, such as portal hypertension with retroperitoneal collateralization, can cause the hepatic flexure to become quite vascular.
The intraoperative photograph demonstrates the hepatic flexure in situ (Fig, 23-1, A). The liver is cephalad and the right kidney is posterior. The ascending colon is mobilized from its lateral attachments at the white line of Toldt. As the ascending colon is mobilized medially, the dissection is complete when the duodenum is identified and preserved posteriorly with the retroperitoneum. Aggressive traction near the end of the mobilization may cause avulsion injury to the middle colic vein, which results in difficult-to-control hemorrhage.
An alternative and more common strategy for mobilization of the hepatic flexure is to begin by dividing the lateral attachments of the ascending colon along the white line of Toldt. The dissection then proceeds distally around the hepatic flexure at the ascending-transverse junction and continues medially.
