Open right hemicolectomy/ step by step/ operative surgery

OPEN RIGHT HEMICOLECTOMY- STEP BY STEP OPERATIVE SURGERY
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Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• In this video today, I have discussed Open Right Hemicolectomy .
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch all my teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.

1. OPEN RIGHT HEMICOLECTOMY DR.B.Selvaraj MS; Mch ; FICS; “ Surgical Educator” Malaysia OPERATIVE SURGERY

2. OPEN RIGHT HEMICOLECTOMY INDICATIONS: Malignant tumors in Ileocecal region, ascending colon and hepatic flexure Adenomatous polyps in Rt Colon Ileocecal TB, IBD, Cecal diverticulosis, bleeding Vascular ectasia & Cecal volvulus ANESTHESIA: GA/ETT POSITION: Supine Diagnosis Confirmed by colonoscopic biopsy Staging by CECT Informed consent- risks of surgery: Anastomotic leak- 2% Hemorrhage- 1% Bowel obstruction- 2% Wound infection- 2 to 10% Injury to ureter and duodenum- 1% Pre-op preparation Adequate mechanical bowel preparation the day before surgery with orthograde enema Prophylactic IV broad spectrum antibiotics VTE prophylaxis with LMWH and pneumatic stockings

3. SURGICAL ANATOMY

4. Incision: Access Midline extending above and below umbilicus Right para-median Exposure Abdominal pack over small intestine and retract to left side Table may be tilted to left side Surgeon may stand on left side OPEN RIGHT HEMICOLECTOMY

5. Mobilisation of Right Colon Incise the whiteline of Toldt upto hepatic flexure Mobilise Rt Colon from retroperitoneal structures Mobilisation of Right Colon Avoid injury to Duodenum, Rt Ureter and Rt Gonadal vessels This mobilisation is Cattell- Braasch Maneuver OPEN RIGHT HEMICOLECTOMY

6. Mobilisation of hepatic flexure Divide the hepatico -colic ligament Mobilisation of greater omentum with Transverse Colon For simple Rt hemicolectomy  Divide omentum close to Transverse colon For Radical hemicolectomy Divide omentum just below the gastro-epiploic arcade OPEN RIGHT HEMICOLECTOMY

7. Ligation of the blood vessels C ome to right side of table Lift the terminal ileum and right colon Transilluminate the mesentery Ligation of blood vessels Clamp, divide and ligate the ileo-colic and right colic vessels at their origin from the superior mesenteric artery Clamp, divide, and ligate the right branch of the middle colic artery. OPEN RIGHT HEMICOLECTOMY

8. Transaction of Ileum Clear the bowel wall at the sites of transection and apply crushing clamps. Apply occlusion clamps on the proximal small bowel and distal large bowel. Transaction of Transverse Colon Divide the bowel on the crushing clamps leaving them on the specimen You can also transact them using GIA stapler OPEN RIGHT HEMICOLECTOMY

9. Anastomosis of Ileum to Transverse Colon- Hand-sewn Anastomosis End-to-end anastomosis: anastomosis either using a single layer of interrupted sero -muscular 3/0 Vicryl or PDS sutures or alternatively as a two-layer suturing technique. Cheatel’s manuver Anastomosis of Ileum to Transverse colon- Stapler Anastomosis End to End anastomosis Using GIA stapler OPEN RIGHT HEMICOLECTOMY

10. Anastomosis of Ileum to Transverse Colon- Stapler Anastomosis End to side using EEA Stapler Surgery for Hepatic flexure Carcinoma Right Radical Extended hemi-colectomy OPEN RIGHT HEMICOLECTOMY

11. Closure of mesenteric defect Close the defect without including the blood vessels Keep a drain close to anastomosis Closure of Laparotomy By mass closure with 1-0 prolene or PDS OPEN RIGHT HEMICOLECTOMY

12. Post-op Care No need to continue antibiotics postoperatively unless there is intraabdominal infection. Nasogastric tube is not routinely placed. Begin ambulating on postoperative day 1. Foley catheter can usually be removed on postoperative day 1 or 2 unless an epidural remains in place. The patient can be started on a liquid diet. The diet can be advanced based on clinical progress. DVT prophylaxis should be continued until the time of discharge and can be considered as an outpatient in certain subsets of patients. Patient should be counseled about the initial changes in bowel habits including more frequent, loose stools and the possible appearance of blood clots in the first few bowel movements. OPEN RIGHT HEMICOLECTOMY

13. Pearls & Pitfalls Colon mobilization: The plane between the mesocolon and the retroperitoneum is an avascular embryologic plane that should be dissected sharply. Excess blood loss during this dissection alerts the surgeon that the incorrect plane was entered. Vascular dissection: - During dissection of the middle colic vessels, avulsion of the large collateral branch that connects the inferior pancreaticoduodenal vein with the middle colic vein and superior mesenteric vein can result in bleeding that is difficult to control because the vein retracts and cannot be isolated easily. - Avoiding excess upward and medial traction of the right colon while mobilizing the hepatic flexure best prevents this. - Transillumination of the mesocolon and the mesentery of the terminal ileum can help to identify vascular arcades to minimize iatrogenic injury in patients with thick mesentery and can assure good blood supply to the anastomosis Anastomosis: A well-vascularized, tension-free anastomosis minimizes the risk of anastomotic breakdown - If there is any doubt regarding the integrity of the anastomosis, the bowel segments should be further resected to healthy, vascularized bowel. - Blood supply to the anastomosis can also be further assessed with Doppler ultrasound if necessary. OPEN RIGHT HEMICOLECTOMY

14. OPEN RIGHT HEMICOLECTOMY MINDMAP

15. THANK YOU