Right and Extended Right Colectomy - Open Technique - UpToDate

7/9/2020 Right and extended right colectomy: Open technique - UpToDate
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Right and extended right colectomy: Open technique

Author: Andrea C Bafford, MD
Section Editor: Martin Weiser, MD
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2020. | This topic last updated: Apr 24, 2019.
INTRODUCTION
Right colectomy refers to the resection of a portion of the distal ileum, cecum, ascending colon,
and proximal to mid-transverse colon. Extended right hemicolectomy refers to extension of the
distal resection margin to include the distal transverse colon up to the splenic flexure.
The techniques used to perform right and extended right colectomy are reviewed here. Left
colectomy is presented separately. (See "Left colectomy: Open technique".)
COLON ANATOMY
The colon and rectum occupy the retroperitoneal and intraperitoneal spaces, in close
approximation to solid organs (figure 1). The ascending and descending colon are retroperitoneal,
while the transverse colon, which extends from the hepatic flexure to the splenic flexure, is
intraperitoneal. The sigmoid colon continues from the descending colon, ending where the teniae
converge to form the rectum.
Arterial supply — The right colic artery and the ileocolic artery provide the principle blood supply
to the right colon (figure 2). The marginal artery of Drummond and the arc of Riolan provide
collateral blood vessels. Typically, the blood supply of the transverse colon is excellent provided
the marginal artery is not damaged. Variability in the arterial anastomoses occurs, which is an
important point when performing a segmental resection. Two sites of tenuous perfusion are the
splenic flexure (Griffith's point) and distal descending colon (Sudeck's point). (See "Overview of
intestinal ischemia in adults", section on 'Intestinal vascular anatomy'.)
Venous and lymphatic drainage — The venous drainage of the right colon is through the
superior mesenteric vein (figure 3). The lymphatics drain via the corresponding arterial supply
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(figure 4).
INDICATIONS FOR COLON RESECTION
Malignant, premalignant, and benign diseases are indications for a right colectomy and include a
right colon cancer (eg, cecum, ascending colon), appendiceal cancer, large adenomas, right-sided
diverticulitis, inflammatory bowel disease, ischemia/infarction, infection, trauma, and cecal
volvulus. The indications for an extended right colectomy include a cancer located between the
hepatic flexure and mid-transverse colon, synchronous ascending and transverse colon cancers,
and multiple adenomas, which may or may not be part of a genetic syndrome. (See "Overview of
colon resection", section on 'Indications for colon resection'.)
PREOPERATIVE EVALUATION AND PREPARATION
General issues regarding the medical preparation of patients, including antibiotic prophylaxis,
bowel preparation, and other considerations prior to colon resection are reviewed separately. (See
"Overview of colon resection", section on 'Preoperative evaluation'.)
It can be helpful to have a flexible colonoscope available in the operating room as it may be
needed to identify a cancer or other mucosal lesion that cannot be palpated.
ABDOMINAL EXPLORATION
Prior to proceeding with colon resection, the abdomen should be systematically explored. The
anatomy of the colon and its blood supply should be verified, noting any anatomic variations or
possibly any congenital anomalies (eg, malrotation).
For patients with abdominal trauma, the abdomen is packed and systematically examined,
removing the packs in turn. Bleeding is controlled first, followed by control of gastrointestinal
leakage. (See "Traumatic gastrointestinal injury in the adult patient", section on 'Abdominal
exploration'.)
For patients with cancer, this evaluation includes an assessment of local, regional, and distant
disease.
● The abdomen is explored for evidence of anomalies and/or metastatic disease, including
peritoneal implants, hepatic metastases, and distant nodal metastases.
● The primary tumor is palpated to confirm its location. Local and regional resectability is
determined by assessing tumor invasion into the abdominal wall, gallbladder, liver, stomach,

vena cava, duodenum, pancreas, and/or superior mesenteric vessels. The entire colon is
palpated to identify synchronous colonic lesions.
EXTENT OF RESECTION
The selection of the operative procedure (eg, right or extended right colectomy) is based upon the
location of the lesion, malignant or benign indication, blood supply, and venous and lymphatic
drainage of the colon. The blood supply, venous return, and lymphatic drainage of the colon are
shown in the above figures and are critical in planning a colectomy. (See 'Colon anatomy' above.)
Right colectomy — Neoplastic lesions located in the appendix, cecum, and ascending colon, and
benign lesions (eg, cecal diverticulum, inflammatory bowel disease) limited to the right colon can
be resected by a standard right colectomy. The resection extends from the distal ileum and can
extend to the mid-transverse colon; this involves isolating and dividing the ileocolic, right colic, and
either the right or hepatic branch of the middle colic artery and vein (figure 5).
Right extended colectomy — Malignant lesions located in the hepatic flexure or proximal to the
mid-transverse colon and benign inflammatory conditions extending to the mid-transverse colon
may be resected with an extended right colectomy (figure 6). An extended right colectomy
includes the resection of the distal transverse colon and sometimes the splenic flexure, and
involves ligating the ileocolic, right colic, and middle colic vessels. An anastomosis is avoided in
areas of unreliable blood supply (eg, mid-ascending colon or splenic flexure). An option to the
extended right colectomy for proximal to mid-transverse colon cancers is a transverse colectomy
(figure 7). The caveat of this procedure is the distal and proximal ends of the resected bowel need
to be well mobilized and assessed carefully to ensure a tension-free and well-vascularized
anastomosis; hence, the extended right colectomy may be preferred in these settings.
Mesenteric resection — The extent of the mesenteric resection also varies according to the
indication for surgery. For example, when performing a colectomy for non-neoplastic disease,
mesenteric vessels may be divided closer to the mesenteric border of the colon as it is
unnecessary to resect draining lymph nodes (figure 8 and figure 9). However, for settings of
severe mesenteric inflammation (eg, diverticulitis, inflammatory bowel disease) and thickening of
the mesentery near the bowel wall, a more radical mesenteric dissection may be warranted [1].
When colectomies are performed for malignancy, the mesenteric vessels are ligated close to their
root for optimal resection of lymphovascular tissue (figure 10).
Omental resection — The omentum is dissected off the transverse colon (figure 11) or divided at
the distal bowel resection margin and the proximal portion removed for ascending colon, hepatic
flexure, and transverse colon cancers.

MOBILIZING THE RIGHT COLON
There are two approaches to resecting the right colon; one begins laterally by mobilizing the colon
and progresses medially, while the other begins medially by identifying the lymphovascular bundle
and progresses laterally. The approach is at the discretion of the surgeon.
In the lateral to medial approach, the mesentery is thoroughly mobilized prior to vascular division.
This allows for accurate identification of the root of the mesentery, the retroperitoneal duodenum,
and the right ureter prior to dissection in the mesenteric root and division of the vessels. The
medial to lateral technique has been used primarily in laparoscopic surgery where vascular
ligation prior to mobilization is necessary in order to maintain necessary traction and exposure of
the mesenteric structures; however, this approach is also easily applied in the open setting.
Lateral to medial approach — The lateral to medial approach begins by mobilizing the right
colon by first dividing the lateral attachments of the colon and developing the retromesenteric
plane in a lateral to medial fashion. This approach is performed for both malignant and benign
right colon diseases.
The general principles for performing a right or extended right colectomy, beginning with the
mobilization of the colon, include [1]:
● Retract the colon medially and divide the lateral peritoneal attachments of the cecum and
ascending colon along the white line of Toldt. The peritoneum and the colon are gently
separated from the loose areolar tissue by finger dissection (figure 12).
● Avoid injury to the duodenum, right ureter, and gonadal vessels. These structures should
remain posterior and lateral to the right colon, underneath an intact retroperitoneal fascia
(figure 13). Dissection is carried out between the posterior aspect of the right colon mesentery
and Gerota's fascia, taking care to avoid excessive traction on the duodenum. Injury to the
duodenum can occur during hepatic flexure mobilization. This usually results from excessive
caudal and medial retraction of the colon during attempts to bring the superior aspect of the
hepatic flexure into view, or from overly aggressive blunt dissection of the retroperitoneal
structures including the duodenum off the posterior aspect of the transverse colon mesentery
(figure 14). Some degree of fusion may exist between Toldt's retroperitoneal fascia and the
mesentery, making dissection precarious, particularly around Gerota's fascia.
● Divide the right renocolic ligament using electrocautery.
● Dissect distally along the colon until the gastrocolic ligament is encountered. The gastrocolic
ligament is a portion of the greater omentum, extends from the greater curvature of the
stomach to the transverse colon, and forms the anterior portion of the lesser sac (omental
bursa). It is inferior and parallel to the stomach and is the left continuation of the transverse

mesocolon (figure 11). Once the lesser sac is opened, the gastrocolic ligament is divided from
left to right, completing mobilization of the hepatic flexure. The duodenum and head of the
pancreas are now exposed (figure 15). Any remaining attachments between the right colon
mesentery and anterolateral portion of the second and third part of the duodenum are divided.
● Release the terminal ileum by dividing the fold of Treves on its antimesenteric border.
● Ligate the lymphovascular pedicle and resect the bowel. (See 'Medial to lateral approach'
below.)
Medial to lateral approach — The medial to lateral approach is ideal for resection of inflamed
bowel and adjacent mesentery, and for performing the "no-touch" approach to colon cancer
resection by ligating the lymphovascular pedicle prior to mobilizing the colon.
The advantages of this approach include maximal time for sharp demarcation between ischemic
and well-perfused bowel, ligation of the lymphovascular pedicle prior to risk of injury by torsion
during colon mobilization, and more efficient identification of the resection plane in the setting of
severe mesenteric inflammation (eg, diverticulitis, inflammatory bowel disease).
The general principles for performing a right or extended right colectomy, beginning with ligation of
the mesenteric lymphovascular pedicle, include [1]:
● Identify the lymphovascular pedicles by retracting the small bowel to the left side of the
abdominal cavity and elevating the right colon to expose the root of the mesentery.
• The ileocolic vessels are located at the caudal portion of the root of the mesentery and
supply/drain the terminal ileum and cecum. The proximal ICA is just inferior to the
duodenum.
• The right colic vessels are variable; they are predominantly a branch of the IC but in
some circumstances are located at the middle of the root of the mesentery and
supply/drain the distal ascending colon and hepatic flexure.
• The middle colic vessels exit the root of the mesentery close to the third portion of the
duodenum and supply/drain the transverse colon.
● Identify the superior mesenteric artery to prevent injury or inadvertent ligation.
● Incise the peritoneum overlying the vascular pedicle and ligate the vessels in close proximity
to their origins. One may doubly ligate the larger vessels with a nonabsorbable (ie, silk) or a
slowly dissolving (ie, polyglycolic acid) suture. Single ligatures are used for small to medium-
size vessels (figure 16). Energy and stapling devices may also be used to ligate and divide
appropriately sized vessels.

● Resect the mesentery by sequentially clamping and tying or with the use of energy devices
(eg, LigaSure, Enseal) (figure 16 and figure 17). In cases of right colectomy for Crohn's
disease where the mesentery is thick and friable, we often find the clamp and tie technique
superior.
ILEOCOLONIC ANASTOMOSIS
Options for restoring bowel continuity include a side-to-side or an end-to-side ileocolic

anastomosis, which is performed with a stapling device or hand-sewn. Experience, surgeon
preference, and availability of equipment dictate the type of anastomosis a surgeon performs in a
given situation. Stapling the anastomosis requires less time to perform and offers the potential for
reduced fecal contamination.
There appears to be no significant advantage of a stapled anastomosis versus a hand-sewn one

for outcomes that include mortality, overall dehiscence, clinical and radiographic leaks,
hemorrhage, and wound infection. A meta-analysis of nine randomized trials that included 1233
adults undergoing elective colorectal surgery found insufficient evidence to demonstrate
superiority of stapled over hand-sewn anastomosis [2]. Stricture rate was, however, significantly
higher for stapled versus hand-sewn anastomosis (40 of 500 patients [8 percent] versus 10 of 496
patients [2 percent]).
These findings cannot be generalized to patients with inflammatory bowel disease, as there were
only 94 patients (9 percent) with Crohn's disease. Limitations of these trials include the lack of
description of the type of hand-sewn anastomosis (one layer versus two layers) and lack of
comparison of sewing materials, which may contribute to the higher leak rates with hand-sewn
anastomoses. The difference in clinical leak rates was small. There were no data on the outcomes
of patients with leaks. Given these limitations and the equivalence of the two approaches for all
other outcomes evaluated, we feel that the anastomotic technique should depend on the
surgeon's preference, experience, and availability of equipment. (See "Management of
anastomotic complications of colorectal surgery", section on 'Dehiscence and leaks'.)
In patients with Crohn's disease, the risk of recurrence of disease is not influenced by the
approach used for bowel anastomosis. A randomized trial of 139 patients with Crohn's disease
found no difference in symptomatic or endoscopic recurrence rates at 12 months for patients
undergoing a stapled side-to-side ileocolic anastomosis compared with a hand-sewn end-to-end
ileocolic anastomosis (22.7 versus 21.9 percent and 37.9 versus 42.5 percent, respectively) [3].
Stapled side-to-side functional end-to-end anastomosis — When the bowel is very thick,
hand-sewn techniques are preferred. The anastomotic suture depth can be adjusted according to
bowel thickness, unlike staple heights, which are preset.
The technical steps for a stapled side-to-side functional end-to-end anastomosis include:
● The ileum and colon are transected using a linear cutting stapler in an area cleared of
mesentery for 2 cm (figure 18).
● The ileum and colon are lined up side by side such that their mesenteries are not twisted and
the antimesenteric and mesenteric borders of the two bowel loops approximate each other.
● The antimesenteric staple line corners are removed using either heavy scissors or
electrocautery.
● The arms of a linear cutting stapler are inserted into the bowel lumens (figure 19). The staple
line is cleared of the mesenteries, the ileum and colon are placed at the inside corner of the
instrument, and the stapler is fired.
● The remaining enterotomy is closed using a linear stapler (picture 1), including the serosa
circumferentially. Care is taken to offset the two staple lines from each other.
● A single nonabsorbable seromuscular suture should be placed at the apex of the anastomosis
to prevent "unzipping" (figure 20).
● Any excessive bleeding from the staple lines is controlled with electrocautery or with figure-of-
eight absorbable sutures (figure 20).
● The mesenteric defect may be closed by suturing together the peritoneum overlying the two
cut mesenteries with a running absorbable suture. Some surgeons do not close the
mesenteric defect as the risk of internal herniation is low and closing the defect has not been
shown to reduce the risk of a subsequent internal hernia.
An alternative, based on surgeon preference, to transecting the ileum and colon as the initial step
is to create transverse enterotomies in preparation for placement of the linear cutting stapler
(figure 21) [4]. The specimen is divided after the ileum and colon are stapled together to form the
anastomosis.
Stapled end-to-side anastomosis — An ileocolic anastomosis can also be performed with the
use of a circular stapler. These technical steps are followed when performing a stapled end-to-side
anastomosis:
● The distal ileum is prepared for the anastomosis by clearing the mesentery and sharply
dividing the bowel against a distal clamp (figure 22). Electrocautery can also be used to divide
the bowel.
● The anvil of a circular stapler is placed into the bowel lumen and secured with a manually or
stapler-placed purse-string suture (figure 23).
● A longitudinal colotomy is made on the specimen side of the colon at least 10 cm proximal to
the site chosen for transection and the circular stapler inserted (figure 24).

● The spike of the stapler is brought through the antimesenteric side of the colon 1 cm distal to
the transection site, preferably through a taenia coli (figure 25).
● The anvil and spike are connected and the circular stapler closed and fired, creating an
anastomosis between the end of the ileum and the side of colon (figure 26).
● A linear stapler is used to transect the colon from the specimen (figure 27). Any bleeding
points can be oversewn with a silk suture.
Hand-sewn end-to-end anastomosis — Single-layer and double-layer techniques using

absorbable and nonabsorbable suture can be used to perform a hand-sewn end-to-end
anastomosis. A meta-analysis of seven randomized trials including 842 patients identified no
significant difference between single-layer and double-layer anastomosis closure for anastomotic
dehiscence, perioperative complications, or mortality [5]. We perform a two-layer anastomosis
using an inner running absorbable suture and outer, interrupted nonabsorbable sutures.
The technical steps when performing a hand-sewn end-to-end anastomosis include:
● The ileum and transverse colon are divided using a scalpel, scissors, or monopolar
electrocautery (figure 22).
● A Cheatle slit is made in the antimesenteric border of the ileum to accommodate any size
discrepancy between the ileum and colon (figure 28).
● The ileum and colon are aligned end-to-end, ensuring that their mesenteries are not twisted,
and stay sutures placed in the antimesenteric and mesenteric borders of these bowel loops in
preparation for suturing (figure 29).
● The outer, posterior layer is approximated by placing interrupted Lembert seromuscular

nonabsorbable sutures approximately 3 to 4 mm apart.
● The inner, posterior layer is performed using a full-thickness, running, absorbable suture
starting from the middle of the anastomosis and proceeding outward in either direction (figure
29).
● Connell-type sutures are utilized to transition to and complete the superficial inner layer
(figure 30).
● The anterior outer layer is approximated using interrupted Lembert seromuscular

nonabsorbable sutures (figure 31).
ABDOMINAL CLOSURE

After completion of the ileocolic anastomosis and closure of the mesenteric defect, the abdominal
cavity may be irrigated with sterile saline and suctioned dry. Hemostasis is confirmed and
omentum is positioned over the anastomosis and under the incision. The fascia and skin are
closed in standard fashion. It is not necessary to place drainage catheters following a right
colectomy. (See "Principles of abdominal wall closure".)
COMPLICATIONS
Complications of right colectomy include anastomotic leak, abdominopelvic abscess, fistula,

hemorrhage, bowel obstruction, and wound infection, as well as complications of general
anesthesia. (See "Management of intra-abdominal, pelvic, and genitourinary complications of
colorectal surgery".)
Preventing complications — There are several critical structures that must not be damaged
during the colectomy.
● Injury to the right ureter or gonadal vessels – When incising the lateral peritoneal attachments
of the cecum and ascending colon, the operating surgeon must be keenly aware of the
location of the right ureter and right gonadal vessels. Injury to these structures is avoided by
dissecting anteromedial to them within the areolar plane along the white line of Toldt (figure
13). (See 'Lateral to medial approach' above.)
● Injury to the duodenum – Injury to the duodenum can occur during hepatic flexure
mobilization. This usually results from excessive caudal and medial retraction of the colon
during attempts to bring the superior aspect of the hepatic flexure into view, or from overly
aggressive blunt dissection of the retroperitoneal structures including the duodenum off the
posterior aspect of the transverse colon mesentery (figure 14). (See 'Lateral to medial
approach' above.)
● Venous bleeding – When ligating the middle colic vessels, the surgeon must avoid excessive
upward traction as this may cause avulsion of a large collateral branch between the middle
colic vein and inferior pancreaticoduodenal vein (figure 3). The most effective method of
obtaining hemostasis if bleeding occurs in this area is to hold pressure for a period to allow
the anesthesia team time to prepare for significant blood loss. If pressure alone is insufficient,
one may carefully place figure-of-eight sutures incorporating the point of injury. Attempting to
clamp and tie the injured vessel can cause further avulsion and hemorrhage. (See 'Medial to
lateral approach' above.)
● Inadvertent ligation of the superior mesenteric artery – The superior mesenteric artery (SMA)
must not be mistaken for the right colic artery (figure 2). The surgeon should lift the right and
transverse colon in a cephalad direction and visualize and palpate the ileocolic vessels arising
from the root of the mesentery, traversing to the terminal ileum and cecum. The superior
mesenteric vessels are located medial to the ileocolic trunk. Ligation of the SMA will result in
bowel infarction. (See 'Medial to lateral approach' above.)
● Excessive tension on the anastomosis – Failure to divide a sufficient amount of the

gastrocolic ligament distally can lead to suboptimal mobility of the transverse colon and,
consequently, undue tension on the ileocolic anastomosis.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Colorectal cancer" and
"Society guideline links: Colorectal surgery for cancer".)
SUMMARY AND RECOMMENDATIONS
● Neoplastic lesions located in the appendix, cecum, and ascending colon, and benign lesions
(eg, cecal diverticulum, inflammatory bowel disease) limited to the right colon can be resected
by a standard right colectomy. The resection extends from the distal ileum to a point
between the distal ascending colon and the mid-transverse colon, and involves isolating and
dividing the ileocolic artery and possibly the right colic artery, and either the right or hepatic
branch of the middle colic artery and vein. (See 'Extent of resection' above.)
● Neoplastic lesions located in the hepatic flexure or in the proximal to mid-transverse colon
and benign inflammatory conditions extending to the mid-transverse colon may be resected
with an extended right colectomy (figure 6). An extended right colectomy includes the
resection of the distal transverse colon and sometimes the splenic flexure, and involves
ligating the ileocolic and middle colic vessels. (See 'Extent of resection' above.)
● The continuity of the bowel is restored by an ileocolic anastomosis, which is performed by a

stapled or hand-sewn technique, depending on the preference of the surgeon. There is
insufficient evidence to demonstrate superiority of stapled over hand-sewn anastomosis. In
the setting of thickened bowel and inflammation, we suggest a hand-sewn rather than stapled
anastomosis (Grade 2C). (See 'Ileocolonic anastomosis' above.)
ACKNOWLEDGMENT
The editorial staff at UpToDate would like to acknowledge Randolph Steinhagen, MD, who
contributed to earlier versions of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.

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REFERENCES
1. Sonoda T, Milsom JW. Section 5: Gastrointestinal tract and abdomen. Chapter 34: Segment
al colon resection.ACS Surgery: Principles and Practice http://www.acssurgery.com/acs/chap
ters/ch0534.htm (Accessed on November 07, 2011).
2. Neutzling CB, Lustosa SA, Proenca IM, et al. Stapled versus handsewn methods for
colorectal anastomosis surgery. Cochrane Database Syst Rev 2012; :CD003144.
3. McLeod RS, Wolff BG, Ross S, et al. Recurrence of Crohn's disease after ileocolic resection
is not affected by anastomotic type: results of a multicenter, randomized, controlled trial. Dis
Colon Rectum 2009; 52:919.
4. Meagher AP, Wolff BG. Right hemicolectomy with a linear cutting stapler. Dis Colon Rectum
1994; 37:1043.
5. Sajid MS, Siddiqui MR, Baig MK. Single layer versus double layer suture anastomosis of the
gastrointestinal tract. Cochrane Database Syst Rev 2012; 1:CD005477.
Topic 15011 Version 23.0

GRAPHICS
Anatomic relationship of colon to surrounding structures
This figure depicts the relationship of the large intestine to the overlying and underlying
organs and vessels.
Graphic 60998 Version 1.0

Blood supply to the colon and rectum
The blood supply to the colon originates from the SMA and the IMA. The SMA arises
approximately 1 cm below the celiac artery and runs inferiorly toward the cecum, terminating
as the ileocolic artery. The SMA gives rise to the inferior pancreaticoduodenal artery, several
jejunal and ileal branches, the middle colic artery, and the right colic artery.
As a general rule, the middle colic artery arises from the proximal SMA and supplies blood to
the proximal to midtransverse colon. However, it occasionally provides the predominant
blood flow to the splenic flexure.
The right colic artery supplies blood to the mid-distal ascending colon. In anatomical studies,
the right colic artery arises independently from the SMA in 28 percent of individuals, which is
depicted in this figure. More frequently, the right colic artery arises with, or as a branch of,
the middle colic, ileocolic, or left colic arteries. The right colic artery is absent in 13 percent of
individuals. [1]
The ileocolic artery supplies blood to the distal ileum, cecum, and proximal ascending colon.
The IMA arises approximately 6 to 7 cm below the SMA. The IMA gives rise to the left colic
artery and sigmoid arteries continuing as the superior rectal (hemorrhoidal) artery. It is
largely responsible for supplying blood distal to the transverse colon.
SMA: superior mesenteric artery; IMA: inferior mesenteric artery.
Reference:
1. Bergman RA, Thompson SA, Afifi AK, Saadeh FA. Compendium of Human Anatomic
Variation: Text, Atlas, and World Literature, Urban & Schwarzenberg, Baltimore, MD 1988.

Venous drainage of the colon and rectum
The mesenteric veins parallel their corresponding arteries. The SMV drains the small intestine,
cecum, and ascending and transverse colon via the jejunal, ileal, ileocolic, right colic, and
middle colic veins. The IMV drains the descending colon through the left colic, the sigmoid
through the sigmoid vein, and the rectum through the superior rectal vein. The IMV fuses with
the splenic vein, which then joins the SMV to form the portal vein.
SMV: superior mesenteric vein; IMV: inferior mesenteric vein.

Lymphatic drainage of the colon and rectum
This figure depicts the lymphatic drainage of the colon and rectum.

Right colectomy for malignancy
This figure illustrates the extent of a right colectomy. For malignant lesions, the
resection involves isolating and dividing the ileocolic vessels, right colic vessels,
and either the right or hepatic branch of the middle colic artery and vein at their
origins.

Extended right colectomy for malignancy
This figure depicts the boundaries of an extended right hemicolectomy, which

includes the resection of the distal transverse colon and sometimes the splenic
flexure, and, for cancer, involves ligating the ileocolic, right colic, and middle
colic vessels at their origin.

Colectomy for mid-transverse colon cancer
This figure depicts the extent of resection for a malignant lesion located in the
mid-transverse colon.

Handling the mesentery during resection of benign colon

disease
Main branches or named vessels should be individually divided and ligated. The
mesenteric tissue can otherwise be divided between clamps and ligated or by
using an energy device.

Resection of right colon for benign disease
For benign disease (eg, diverticulitis, volvulus), it is not necessary to divide the
mesenteric vessels at their origin.

Handling the mesentery during resection of colon cancer
When colectomies are performed for malignancy, the mesenteric vessels are
ligated close to their root for optimal resection of lymphovascular tissue.

Gastrocolic ligament and the lesser sac

Blunt mobilization of the right colon from retroperitoneal

structures
This figure illustrates blunt dissction of the space between the peritoneum of the
ascending colon and the underlying retroperitoneal structures (eg, kidney,
ureter, gonadal vessels).

Relationship between ascending colon and posterior structures
This figure illustrates the relationship of the right, ascending colon and the posterior
structures, including the second portion of the duodenum, kidney, ureter, and gonadal
vessels.

Mobilization of the hepatic flexure
This figure illustrates a mobilized hepatic flexure of the right colon. The second
portion of the duodenum and the head of the pancreas are exposed.

Mobilization of the hepatic flexure for colon cancer

Ligation of mesenteric vessels for right hemicolectomy

Resection of right colon mesentery
This figure depicts the incision of the peritoneal surface of the mesentery and
ligation of the mesenteric vessels.

Ileocolic anastomosis - Transection of ileum and colon

Ileocolic functional end-to-end anastomosis and linear

cutting stapler

TA stapling device
Picture of a DST Series™ TA™ Single Use Reloadable Stapler.
Copyright © 2011 Covidien. All rights reserved. Used with the permission of Covidien.

Ileocolic anastomosis - Stapled anastomosis with

reinforcing sutures

Ileocolic anastomosis - Transverse enterostomies

Right colectomy - transecting the ileum and colon

Insertion of anvil of circular stapler into ileum
The anvil is secured to the ileum with a purse string suture.

Insertion of circular stapler into colon

Ileocolic anastomosis created with a circular stapler

Ileocolic anastomosis - anvil and spike of circular stapler

Ileocolic stapled anastomosis - end to side

Cheatle slit
A Cheatle slit can be cut on the antimesenteric border of the smaller-caliber

bowel (in this case ileum) to match it with a larger-caliber bowel (in this case
colon) if an end-to-end sutured anastomosis is planned. Alternatively, the size-
mismatched bowels can be anastomosed using side-to-end or end-to-end
techniques.

Hand-sewn ileocolic anastomosis - two layer closure

posterior wall

Hand-sewn ileocolic anastomosis - two layer closure

anterior wall
Connell sutures are used on the anterior wall of the anastomosis between the
ileum and colon.

Hand-sewn ileocolic anastomosis - Lembert sutures

Contributor Disclosures
Andrea C Bafford, MD Nothing to disclose Martin Weiser, MD Nothing to disclose Wenliang Chen, MD,
PhD Nothing to disclose
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Right and Extended Right Colectomy - Open Technique - UpToDate

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Right and Extended Right Colectomy - Open Technique - UpToDate

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7/9/2020 Right and extended right colectomy: Open technique - UpToDate

Official reprint from UpToDate®

Right and extended right colectomy: Open technique

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INDICATIONS FOR COLON RESECTION

PREOPERATIVE EVALUATION AND PREPARATION

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MOBILIZING THE RIGHT COLON

● Divide the right renocolic ligament using electrocautery.

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● Identify the superior mesenteric artery to prevent injury or inadvertent ligation.

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Options for restoring bowel continuity include a side-to-side or an end-to-side ileocolic

There appears to be no significant advantage of a stapled anastomosis versus a hand-sewn one

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Hand-sewn end-to-end anastomosis — Single-layer and double-layer techniques using

The technical steps when performing a hand-sewn end-to-end anastomosis include:

● The outer, posterior layer is approximated by placing interrupted Lembert seromuscular

● The anterior outer layer is approximated using interrupted Lembert seromuscular

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Complications of right colectomy include anastomotic leak, abdominopelvic abscess, fistula,

● Excessive tension on the anastomosis – Failure to divide a sufficient amount of the

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● The continuity of the bowel is restored by an ileocolic anastomosis, which is performed by a

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Topic 15011 Version 23.0

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Anatomic relationship of colon to surrounding structures

Graphic 60998 Version 1.0

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Blood supply to the colon and rectum

SMA: superior mesenteric artery; IMA: inferior mesenteric artery.

Graphic 73756 Version 11.0

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Venous drainage of the colon and rectum

SMV: superior mesenteric vein; IMV: inferior mesenteric vein.

Graphic 81960 Version 4.0

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Lymphatic drainage of the colon and rectum

Graphic 58219 Version 1.0

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Right colectomy for malignancy

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Extended right colectomy for malignancy

This figure depicts the boundaries of an extended right hemicolectomy, which

Graphic 51067 Version 2.0

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Colectomy for mid-transverse colon cancer

Graphic 69341 Version 3.0

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Handling the mesentery during resection of benign colon

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Resection of right colon for benign disease

Graphic 98859 Version 1.0

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Handling the mesentery during resection of colon cancer

Graphic 106973 Version 1.0

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Gastrocolic ligament and the lesser sac