Laparoscopic-Assisted Right Hemicolectomy

The patient-centered environment of the operating room often precludes extensive intraoperative discussions or detailed explanations between a resident and the attending surgeon. This constraint in real-time feedback poses a challenge for surgical residents to refine their surgical skills. Implementation of a structured case review between attendings and senior residents at interval timepoints of their rotations could support addressing this gap. In this case, we present a laparoscopic right hemicolectomy. This procedure removes a portion of the colon and is commonly indicated for colon cancer. In this video article, a senior general surgery resident participates in the procedure and then engages in a structured case review with their attending, analyzing the fundamental steps of the procedure as well as identifying opportunities for technical improvement and enhancement of intraoperative decision-making.

A right hemicolectomy is a procedure that involves removing a portion of the colon and is most often performed for colon cancer, but several other indications may necessitate this procedure. These include inflammatory bowel disease, perforation, obstruction, large colonic polyps with a high potential for malignancy, cecal volvulus, right-sided diverticular disease, complicated appendicitis, ischemic colitis, and non-iatrogenic or iatrogenic trauma.³ Removal of the colon can be completed via an open, laparoscopic, or robotic approach. The chosen modality is left to a surgeon’s discretion, maximizing patient safety and optimal outcomes. 

A 70-year-old female presented for surgical evaluation of a large polyp at the appendiceal orifice of the cecum. The patient previously had a positive fecal immunochemical test (FIT), which prompted a colonoscopy that revealed a 4-cm polypoid partially obstructing mass at the appendiceal orifice with a biopsy result of tubulovillous adenoma (TVA). A planned endoscopic mucosal resection (EMR) resulted in incomplete resection of the lesion, after which the patient was referred for surgical evaluation. Previous history is notable for hypertension, hyperlipidemia, BMI of 21.8 Kg/m², and a herniated lumbar disc. 

The physical exam was largely unremarkable. 

A colonoscopy revealed a 4-cm large polypoid, partially obstructing mass at the appendiceal orifice, which was biopsied and identified as a tubulovillous adenoma (TVA). Additionally, a 3-mm polyp in the transverse colon was removed and identified as a tubular adenoma (TA). In the pathology report, it was noted that the superficial nature of the biopsy specimen at the appendiceal orifice could not allow for complete excision and leaves the risk of an unsampled invasive component of the polyp. 

An extensive discussion occurred with the patient. In that discussion, it was shared that due to the size of the polyp and incomplete EMR a concern remained for potential malignant transformation within the tubulovillous adenoma. As such, it was recommended to the patient that she consider undergoing a right hemicolectomy. The operation was described to the patient in extensive detail. Risks were presented, which included, but were not limited to, bleeding, infection, anastomotic leak, and injury to abdominal organs and structures. The patient verbalized understanding and consent was obtained for a laparoscopic right hemicolectomy. 

The rationale for a right hemicolectomy in this case centers on both the risk of malignant transformation and the importance of accurate staging to direct treatment for adjuvant therapy and surveillance. Tubulovillous adenomas represent 10–15% of colon polyps and have a 20–25% chance of harboring malignancy. Additionally, polyps larger than 2 cm have a greater than 40% chance of malignancy. Due to the size and type of the polyp, rather than proceed with an appendectomy, which could have shown malignant transformation in such a large polyp, we elected to proceed with a formal right hemicolecomy.⁴ A right hemicolectomy allows for complete resection of the lesion and surrounding lymph nodes, which promotes a thorough histopathological evaluation of the mass. This allows for accurate cancer staging, which is useful for assessing the need for postoperative management, ultimately aiming to improve patient outcomes, reduce recurrence, and inform prognosis. 

Laparoscopic right hemicolectomy is relatively contraindicated in patients with a number of comorbidities including obesity, cardiovascular issues, prior abdominal surgery, and respiratory issues. Additionally, this procedure in the setting of malignancy requires a nuanced approach and an experienced operator. Thus, effective surgical coaching of residents is essential for the development of residents’ technical and operative decision-making skills. By receiving effective feedback on these skills, residents can refine their abilities and provide the benefits of laparoscopic surgery.

The patient is brought to the operating theater, placed in the supine position, and secured to the operating table. Both arms are left out (abducted) at 90 degrees and secured. Of note, many surgeons prefer to tuck the left arm or both arms for ease of movement of the surgical team. Preoperative antibiotics and deep venous thromboembolism chemoprophylaxis are administered. A surgical timeout is taken. 

A supraumbilical incision is made and the abdominal cavity is entered under direct visualization via the Hasson technique. A 12-mm port is placed, and the abdomen is insufflated. Under direct laparoscopic visualization, 3 additional 5-mm ports are placed. One in the left lower quadrant, one in the left upper quadrant, and one in the right lower quadrant. The patient is then placed in slight Trendelenburg position, and the right side of the table is elevated providing optimal exposure of the right colon.

The omentum is swept over the liver to expose the root of the mesentery. Of note, some surgeons begin the operation by dividing the falciform ligament of the liver to allow space for the transverse colon and great omentum to be accommodated more freely over the liver, to aid in exposure of the transverse colon, mesocolon and its vessels, the duodenum, and the right colon itself. Next, the medial-to-lateral dissection of the right colon begins. The duodenum is safely identified within the retroperitoneum to avoid injury. Next, the ileocolic pedicle is placed on tension and a plane is developed posterior to this pedicle. This plane is developed to the level of the paracolic gutter and caudally towards the cecum. The duodenum is then identified again and preserved while next ligating the ileocolic pedicle. The ileocolic pedicle, wherein the vasculature that supplies the right colon lies, is taken as proximally as possible to ensure an adequate number of lymph nodes are obtained for pathologic staging. Within this case, the ileocolic pedicle is divided only with an energy device due to surgeon comfort and experience. Securing the ileocolic pedicle with a ligature or clip in addition to division via an energy device is common practice. 

The patient is then placed steeper in Trendelenburg position and the lateral attachments of the terminal ileum, cecum, and right ascending colon are divided joining the previously described dissection plane that was created in the medial-to-lateral fashion. 

The patient is now placed in steeper Trendelenburg position, and the hepatocolic ligament and part of the gastrocolic ligament are released while visualizing and preserving the duodenum. 

The initial periumbilical incision is enlarged and the mobilized colon delivered through this incision. The terminal ileum is identified and transected 5 cm proximal to the ileocecal valve. The mesentery is then divided toward the previous dissection plane made via the medial-to-lateral colon mobilization. The colon is then transected at the proximal transverse colon. The remaining colonic mesentery is divided. Please note, the mesocolon and small bowel mesentery can be divided laparoscopically to limit the necessary extension of the periumbilical incision for delivery of the bowel. An ileocolonic anastomosis is then performed and the bowel returned to the abdomen. The fascia and skin are then closed. 

The dynamic environment of the OR can make it challenging to provide in-depth intraoperative teaching; however, general surgery residents have consistently indicated the need for these discussions. Providing consistent and structured opportunities for residents to review procedures external to the intraoperative period is critical for the development of their technical skills. After the case, the resident and attending surgeon discussed the resident’s knowledge of advanced anatomy, ergonomics, tissue handling, awareness of critical steps in the procedure, anticipation, and operative decision-making.^3,4 Following this film review session, the resident and attending surgeon attested marked improvement and comfort when the same case was performed later in the month.

We present a case of a right hemicolectomy performed for a large polypoid mass at the appendiceal orifice in a 70-year-old female patient. In this case, we highlight the surgical approach for a right hemicolectomy and the importance of effective surgical coaching for residents in mastering this technique.

As residency programs continue to advance surgical education, effective coaching ensures that residents receive adequate and timely feedback, comprehend critical aspects of cases, and demonstrate substantial growth during clinical rotations. In the setting of increasing demands for minimally-invasive procedures, effective coaching can enhance the delivery of high-quality patient care and increase residents’ confidence in their ability to perform these complex procedures.

None.

The patient involved in this video article gave their informed consent to be filmed and is aware that the images will be published online for the medical community.