RESECTION OF CECUM AND ASCENDING COLON (Right hemicolectomy)
Right hemicolectomy should be undertaken when the tumour is localized in the cecum, the ascending colon, or on its hepatic flexure, as well as in cases with tuberculous lesion of the cecum and, occasionally, with Crohn’s disease.
The patient is placed on his back, the table being tilted to the left in the course of the operation. Endotracheal anesthesia with ether and oxygen or with azeotropic mixture is employed.
Technically, this operation consists in the resection of the distal portion (6—8 cm long) of th ilcum, of the ascending colon, and of a small right segment of the transverse colon with a side-to-side anastomosis between the ileum and transverse colon.
A median incision of the abdominal wall is used. In some cases (in muscular males and in very obese patients) the incision is turned to the right (Fig. 180.1).
After opening the abdominal cavity, the tumour is inspected visually and by palpation for metastases to regional lymph nodes, especially the liver.
The operating table is now slightly tilted to the left around its longitudinal axis, and the small guts are moved to the left half of the abdomen to be held there by moist gauze squares.
The assistant now strongly pulls the abdominal wound edge outwards with a retractor, the bowel is taken to the midline, and the surgeon makes a longitudinal incision of the peritoneum along the lower margin of the cecum and the external margin of the entire ascending colon as far as the hepatic flexure (Fig. 180,2).
The surgeon then cautiously dissects (mainly with a swab) the cecum and ascending colon free toward the midline, together with the internal peritoneal leaf along which run the left colic and ileocolic arteries, so that the quadratus lumborum and, further, the psoas major muscles are exposed posteriorly (Fig. 180,3). All these muscles are covered with fascia; contours of the right kidney and of the lower bend of the duodenum and, closer to the midline, of the ureter, are visualized.
The peritoneal attachments of the hepatocolic ligament that connect the hepatic flexure with the liver and diaphragm, are divided between clamps (Fig. 180.4) and the peritoneumfree tissues of the posterior abdominal wall are covered with a large gauze square to secure hemostasis.
The right quarter of transverse colon is then detached from the omentum by scissors dissection in an avascular area (cf. Fig. 179.1], and the separated part of omentum is transected between clamps and cut across in the area of gastrocolic ligament.
The partially freed cecum and acending colon are now pulled out to the wound and, starting from the cecum, the surgeon cautiously dissects by bit the ileac mesentery between clamps freeing it for a distance of 8— 10 cm from the Bauhiris valve. The ileum is next dissected between two pairs of straight clamps (Fig. 180.5), its proximal stump is carefully closed in two rows with fine silk (Fig. 180,6), and the distal stump is wrapped with gauze without removing the clamp. The surgeon now ligates between clamps and divides the medial peritoneal leaf along with all the vessels supplying the cecum and ascending colon (Fig. 180,7). During this li-gation the ileocolic artery need not be mobilized separately. The peritoneal leaf has to be divided, provided there is no metastases to the lymph nodes, at a distance of 3—4 cm from the ascending colon so that, following resection of the latter, peritonealization of the posterior abdominal wall is possible.
The next step is ligation and cautious division of the transverse mesocolon between two clamps at the border of its first quarter on the right. During this ligation the surgeon should take care to do the least possible damage to the stem of the middle colic artery. The assistant then pulls the ascending colon upwards, while the surgeon applies two clamps to it: a stiff clamp in the direction of hepatic flexure, and a fort clamp — to the right
of the first one. The bowel is then divided between these clamps and the entire mobilized right half of the colon is removed (Fig. 180.8). The distal open stump of the transverse colon is carefully closed with interrupted silk in two layers.
Our preference is for a side-to-side anastomosis between the ileum and transverse colon, as being more reliable. The ileac stump is compressed with a soft clamp 4 cm apart from its closed end, and this clamp is then used to bring the stump close to the transverse colon stump which is also compressed with a soft clamp at its end (Fig. 180.9).
The surgeon now applies the first row of interrupted fine silk sutures of the anastomosis to include the seromuscular coats of both stumps. The sutures should be spaced not less than 0.6—0,8 cm apart. This row of sutures is laid on the transverse colon along the line of its free taenia.
The surgeon then opens the ileac lumen longitudinally for a distance of 4—5 cm, and the edges of the resulting wound are grasped with 3 clamps applied laterally and to the wound ends. The ileac contents are swabbed dry, and the ileac mucosa is painted with iodine tincture.
An identical longitudinal incision is then made to lay open the lumen of the transverse colon. Next the surgeon inserts, from the mucosal side, a second row of anasto-motic sutures of continuous fine silk to embrace all layers of intestinal walls (Fig. 180.10). Having thus sutured both the posteror and anterior semicircumferences of the anastomosis, the surgeon proceeds to lay the anterior row of seromuscular sutures of interrupted fine silk (Fig. 180.11).
Finally, the omental edges are slightly pulled to the right, and the omentum is sutured to the anastomotic line with 3—4 fine silk threads.
Having completed the anastomosis, the surgeon secures a most careful hemostasis of tissues of the bed of cecum and ascending colon, and then peritonealizes the posterior abdominal wall with closely placed sutures by uniting the peritoneal edges along a vertical line and including the underlying fascia. The peritoneal defect is filled with omentum in its upper corner.
Fig. 180. Resection of cecum and ascending colon (Right hemicolectomy):
1. A median incision, which in some cases is curved to the right.
2. Using scissors, the surgeon makes a longitudinal incision of the peritoneum along the under surface of the cecum and external edge of the ascending colon.
3. Moving the ascending colon towards the midline, the surgeon defines the posterior surface of abdominal wall. Seen in this figure are the transverse abdominal muscle and, posteriorly, the quadratus lumborum muscle, psoas muscle, the external edge of kidney, urether, and the lower edge of duodenum.
4. Dissection of the hepatocolic ligament under forceps control.
5. Part of the omentum has been removed; the small gut is doubly divided between 4 clamps; its segment 5–7 cm long is resected.
6. The proximal stump of small gut has been closed in two layers; the distal stump and the clamps are wrapped with gauze.
7. The surgeon divides between clamps and ligates the medial peritoneal leaf along with the vessels supplying the cecum and ascending colon.
8. The assistant pulls by hand the ascending colon outwards, while the surgeon cuts off the transverse colon between clamps near the hepatic flexure.
9. The ileac stump is brought in contact with the transverse colon stump, and the first row of anastomotic sutures is applied.
30. Insertion of a second row of anastomotic sutures of continuous silk following opening the intestinal lumen.
11. The anterior row of seromuscular sutures of fine silk has been inserted