Open Right Hemicolectomy

ANATOMY
Ileocolic is a constant vessel
Right colic is a direct branch of SMA in only 13% cases. Middle colic forms a vascular arcade with ileocolic constantly.
Middle colic branches 2cm from origin (it is a single vessel from SMA in only 45% cases)the most common variation is 2 middle colics
Usually one branch running between ileocolic and SMA

1.Position the patient supine.
2.Prepare the abdomen and square drape using Ioban
3.Standing on the patients left side make a midline incision centered on the umbilicus. (transverse incision if pulmonary impairment)
4.Place a Balfour self retaining retractor and conduct a laparotomy to determine the extent of peritoneal disease and liver metastases.
5.Start to mobilize the right colon by dividing the peritoneum of the right paracolic gutter from the caecum to the hepatic flexure taking care to avoid the duodenum and overlying veins superiorly.
6.Control the veins superficial to the plane of the duodenum with serial clamping with Fraser forceps and vicryl ties or alone with diathermy if not significant.
7.Divide any adhesions to the gall bladder.
8.Mobilize the greater omentum off the transverse colon (if for a hepatic flexure tumour, resect omentum en bloc) up to the point of intended division of the transverse colon and enter the lesser sac.
9.Complete the mobilization the right colon/terminal ileum by dissecting it off the posterior abdominal wall, aided by retraction. The ureter and gonadal vessels should fall posteriorly.
10.Ligate the right branch of the middle colic artery for a caecal cancer and the main trunk for a cancer at the hepatic flexure (beware of collateral veins from the middle colic to the pancreatico-duodenal).
11.Ligate the ileocolic vessels at their origin.
12.With the colon mobilized, prepare the ends of the ileum and colon for anastomosis by ligating the marginal artery and clearing the colon and ileum of mesentery.
13.Divide the terminal ileum between Kocher forceps and a soft bowel clamp placed proximally. (can do this with GIA/TLC)

Anastomosis is variable

14.Place the anvil of a CEEA circular endo-luminal stapler (size 28) in the stump of the terminal ileum and secure with a 4/0 PDS pursestring.
15.Place a soft bowel clamp quite proximal to the site of intended anastomosis on the colon. Make an enterotomy proximal to the site of anastomosis and insert the head of the CEEA stapler bringing out the spike at the site of the intended anastomosis.
16.Perform the anastomosis and then resect the specimen by dividing the colon proximal to the anastomosis with a linear stapler (Tyco autosuture GIA 60 or 80 or TLC 50, 75, 100 (Ethicon), with 3.8mm staples) incorporating the enterotomy within the specimen.
17.Reinforce the anastomosis and end staple line with inverting Lembert (burying or staple line inversion suture) or Cushing sutures.
18.Lavage with water and close the mesenteric defect with vicryl.
19.Mass abdominal closure and staples or monocryl.