Right Hemicolectomy
What the Examiner Expects
Resection of the cecum, ascending colon, and hepatic flexure with an ileocolic anastomosis, performed primarily for right-sided colon cancer. The examiner expects you to describe the preoperative workup for colon cancer (colonoscopy with biopsy, CT chest/abdomen/pelvis, CEA level), the key vascular anatomy (ileocolic, right colic, and right branch of middle colic arteries — all branches of the SMA), and the creation of a well-vascularized, tension-free ileocolic anastomosis. For cancer, a minimum of 12 lymph nodes must be harvested for adequate staging. The medial-to-lateral laparoscopic approach begins with identification and ligation of the ileocolic pedicle, followed by mobilization along the retroperitoneal plane.
Key Examiner Focus Points
- Indications: cecal/ascending/hepatic flexure cancer, complicated appendicitis, cecal volvulus
- Ligate ileocolic, right colic, and right branch of middle colic vessels
- Ileocolic anastomosis: stapled side-to-side (functional end-to-end) preferred
- Medial-to-lateral approach for laparoscopic technique
- Minimum 12 lymph nodes for adequate cancer staging
Common Curveballs
Intraoperatively, you find a liver lesion suspicious for metastasis
Biopsy the liver lesion (or send for frozen section). If confirmed metastatic, proceed with the right hemicolectomy to prevent obstruction/bleeding, but the treatment plan now requires multidisciplinary discussion for potential hepatic resection. Synchronous liver metastases do not preclude colon resection.
The tumor is invading the duodenum
If the tumor is adherent to the duodenum, perform an en bloc resection — do NOT try to peel it off (tumor spillage risk). This may require a partial duodenal wall resection with primary repair, or in extreme cases, a pancreaticoduodenectomy.
Pathology returns with 8 lymph nodes — inadequate staging
Fewer than 12 nodes represents inadequate lymph node harvest. This affects staging accuracy and may result in understaging. The patient should be discussed at tumor board and may benefit from adjuvant chemotherapy even without proven nodal disease due to staging uncertainty.
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