Laparoscopic Right Hemicolectomy

Description

Laparoscopic Right Hemicolectomy is a minimally invasive surgical procedure involving the removal of the right side of the colon alongside the terminal ileum. It is typically performed in cases of right sided bowel cancer, alongside less common reasons such as inflammatory bowel disease and cecal volvulus.

The surgical procedure is performed under general anaesthetic and recovery takes up to 6 weeks. During the recovery period, the patient is encouraged to keep active and maintain an adequate fluid and fibre intake. Postoperative pain can be managed using over the counter pain medication.

Complications of the procedure range from bleeding and surgical site infections to more severe complications such as anastomotic leaks and damage to either the ureters or superior mesenteric vein.

What is it?

A laparoscopic right hemicolectomy is a minimally invasive surgical procedure involving the removal of the right side of the colon, alongside forming an anastomosis (attachment) of the end of the small intestine with the remaining left portion of the colon (ileocolic anastomosis). The colon is split into a right and left portion, with the right side consisting of the caecum and ascending colon. The transverse colon may/may not be removed in a laparoscopic right hemicolectomy depending on the reason for the surgery (1).

Why is it done?

There are many reasons why a laparoscopic right hemicolectomy needs to be performed. These include:

1. Colon cancer - This is the most common reason necessitating removal of the right colon. The cancer may either be primary and originated within the bowel, or may have spread there from elsewhere in the body (metastasis). If the cancer has spread to the transverse colon, this may also have to be removed via an extended right hemicolectomy (2).
2. Colonic Polyps - The presence of a polyp may also necessitate removal of the right colon if the polyp has a high malignant potential, that is to say it has a high probability of becoming cancerous. Hence this is done as a preventative procedure (3).
3. Cecal volvulus - This is a form of intestinal obstruction where the caecum twists alongside its mesentery and results in obstruction. The terminal ileum and ascending colon may also be affected (4).
4. Appendicitis - The appendix is attached to the caecum, and while appendicitis rarely requires removal of the right colon, it may be necessary if the appendicitis is complicated and perforation/rupture has occurred (5).
5. Ischaemic Colitis - This occurs when blood supply to the colon is restricted, resulting in inflammation and injury. If left untreated it can progress onto bowel ischaemia (6).
6. Inflammatory Bowel Disease - This includes conditions such as Crohn's Disease and Ulcerative Colitis, where the colon becomes inflamed and in severe cases requires removal. In the case of ulcerative colitis, removal of the affected portion of the colon can be a curative treatment (7).

Anaesthesia

The procedure is formed under General Anaesthetic and typically lasts between 3-4 hours. On the day of your operation, you will meet the Anesthetist who will go through the procedure and discuss any concerns or questions you may have. Because general anaesthetic will be used, you will be unconscious throughout the surgery. As a result, an endotracheal tube will need to be placed down your throat to help you breathe (see diagram below).

Will I need to do any preparation?

You will be required to attend a pre-admission clinic with the surgeon and anaesthetist approximately 2 weeks before the operation is scheduled to take place. Here, your vital signs will be measured and you will be given information about the procedure and what to expect. This is also a good opportunity to ask any questions or raise any concerns you may have. It is important that you bring your medications with you as certain medications such as anticoagulants may need to be temporarily stopped in the period before your operation to reduce the risk of complications.

If you haven’t had one already, the doctors may send you off for imaging of your bowel to locate the tumour via a CT-scan. This will help the doctors assess which portion of the bowel needs to be removed and if the transverse colon should be removed alongside the caecum and ascending colon. You may also have blood tests and an ECG conducted to check for any other issues that may need correcting before the surgery occurs and to ensure you are fit enough for the major surgery to proceed.

There are a variety of different preparations that may need to be conducted to help prepare your bowel for the operation. These include:

1. Following a special diet in the few days before your operation, including a balance of fruit and vegetables.
2. Taking laxatives or enemas before your operation to ensure any bowel contents are removed and hence the colon is empty and ready for surgical removal.
3. Taking of supplements to correct vitamin and electrolyte imbalances
4. If you smoke, you will be strongly encouraged to stop smoking before the operation as this will greatly increase the chances of a successful recovery.

In order to prevent the risk of any complications, particularly aspiration, you will be asked to stop eating 6 hours before the surgery is scheduled to take place, and to stop drinking 2 hours before the surgery.

Before the anaesthetic is given, you will likely be administered a course of prophylactic antibiotics to prevent the risk of infection. These include cefuroxime and metronidazole, which have been shown to reduce the risk of sepsis occurring during removals of the colon.

The Procedure

The whole procedure will take between 2-4 hours. The steps of the procedure are as follows:

1. Once the general anaesthetic has been given, you will be placed in the Trendelenburg position (see diagram below). The abdomen will be sterilised using a chlorhexidine preparation to minimise the risk of any infections developing at the incision sites.
2. Incisions will be made in the abdomen for the various different pieces of equipment to enter. These include the laparoscope, which is a thin tube with a camera on the end, allowing the surgeon to visualise and perform the operation. Incisions will typically be made at the following sites:
3. Infra-Umbilically - This is just below your belly-button
4. Suprapubic - Just above your groin
5. Epigastric - In your stomach region
6. Left lumbar - In the left middle region of your abdomen
7. Once the incisions have been made, the operation will begin by first mobilising the right colon by removing any adhesions and attachments it may have. This makes it easier for the surgeon to operate on and remove. Dissection of the mesentery (which attached the intestines to the posterior abdominal wall) is first conducted around the terminal ileum region. Once this is complete, dissection of the mesentery is continued from the caecum to the hepatic flexure along the ascending colon. At this stage of the surgery, the surgeon ensures not to dissect too deep into the posterior abdominal cavity to prevent any damage to the ureters or great vessels such as the aorta.
8. Once the right colon has been mobilised, the bed is tilted to the reverse Trendelenburg position (see diagram below). In this position, the ligament stretching from the greater curvature of the stomach to the transverse colon is dissected. The stomach may be elevated at this point to allow the surgeon to continue dissection towards the hepatic flexure, meeting the end of the original dissection in the previous stage.
9. The mesocolon, which connects the transverse colon to the posterior abdominal wall, is dissected beginning at the hepatic flexure. Any arteries supplying the ileocolic and right colic pedicles are dissected, clipped, and divided.
10. At this stage, once the right colon has been fully mobilised and the blood supply ligated, the right colon is dissected from the terminal ileum until the hepatic flexure. This portion is then removed, and it is now necessary to perform a functional end-to-end ileocolic anastomosis. The terminal ileum and colon are similarly divided using a stapler, and then an anastomosis (attachment) is formed between the two using a special anastomotic stapler. At this stage, the surgeon has to take care not to include any mesentery in the anastomosis, as this can result in ischaemia. The surgeon will carefully inspect the anastomosis, checking for any sites of possible leakage.
11. Before removing the equipment, the surgeon may pump gas into the abdomen to allow inspection and to check the integrity of the anastomosis. They may also place a drain near the anastomosis to collect any excess fluid (10).

Post Procedure

Once the surgery has been completed, you will be taken to a recovery room where you will be woken up and your vital signs monitored. You will be given some intravenous painkillers to help deal with the postoperative pain, and you may have a drainage tube in site where the operations took place to remove any accumulating fluid. After the anesthesia was administered, a urinary catheter would have been inserted to help drain the urine. This will have to remain in place for 1-2 days before it can be removed.

You can expect to stay in hospital between 4-8 days depending on your recovery. The medical team will regularly check up on you and inspect the wound sites to assess whether you are fit for discharge. During this time, you will be given water to drink, and eventually soft food when you feel more comfortable. You will also be encouraged to move and be active, as this helps recovery in the long term and reduces the risk of deep vein thrombosis (blood clot formation in the legs).

Caring for yourself at home

Full recovery may take between 4-6 weeks, and during this time you may feel weak and tired. Hence it is important that you have someone with you at home to help you with daily activities such as shopping and cleaning. For the first 6 weeks post discharge, avoid any heavy lifting and strenuous exercise.

As part of your recovery, it is important that you incorporate gentle exercise in your daily routine, as prolonged bed rest hinders your recovery from surgery and increases the risk of blood clot formation. An example of gentle exercise included walking in the garden. You may have more frequent and loose bowel motions than normal for the first few days after discharge, although this is expected to improve over time.

It is normal to feel pain and unusual sensations around the wound site and in your abdomen, even after several months. In most cases, this is due to healing and hence you can manage this using simple over the counter painkillers such as paracetamol to help you feel better. If the pain is severe and worsening over time, contact your doctor urgently as this may indicate an infection or leak.

Where can I find more information?

NHS Information on Bowel Cancer - https://www.nhs.uk/conditions/bowel-cancer/