Principle of right hemicolectomy- oncological resection of the right half colon with ligation of the vascular pedicle and corresponding lymphadenectomy.
A) Location. Hospital, operating room.
b) Alternative:
Laparoscopic access.
Extended right hemicolectomy (including both flexures and part of the descending colon).
Hartmann's operation with a long stump and end ileostomy.
V) Indications for right hemicolectomy: cancer of the right colon, diverticular disease, cecal volvulus.
G) Preparation:
Full examination colon in all planned cases, marking (tattooing) of small tumors is desirable.
Mechanical bowel preparation (traditional) or no bowel preparation (an evolving concept).
Installation of ureteral stents in cases of repeated operations or pronounced anatomical changes (for example, inflammation).
Marking the stoma site.
Antibiotic prophylaxis.
d) Stages of right hemicolectomy surgery:
1. Patient position: supine, modified position for perineal stone section (surgeon's preference).
2. Laparotomy: mid-median, right transverse (from the navel), subcostal incision on the right.
3. Installation of an abdominal retractor and hand mirrors for exposure of the right colon.
4. Revision abdominal cavity: local resectability, secondary pathological changes (liver/gallbladder, small/large intestine, female genital organs), other changes.
5. Determination of resection boundaries:
A. Cecum/ascending colon: right branch of the middle colic artery.
b. Hepatic flexure: extended right hemicolectomy.
6. Mobilization of the right half of the colon: starts from the ileocecal junction and continues along the lateral canal to the hepatic flexure. Anatomical landmarks: ureter, duodenum(avoid injury!).
7. Dissection of the omental bursa: oncological principles resections require at least a hemiomentectomy on the tumor side; The division of the gastrocolic ligament is carried out in several stages (in case of a benign disease, the omentum can be preserved by separating it from the transverse colon).
8. Identification of the ileocolic vascular bundle: contoured by traction on the cecum towards the right lower quadrant.
9. Oncological ligation (ligation with suturing) of the vessels of the right half of the colon. Before cutting tissue, it is necessary to ensure the safety of the ureter.
10. Step-by-step ligation in the direction of the right branch of the middle colic artery.
11. Crossing the intestine and forming a side-to-side ileotransverse anastomosis with a stapler.
12. Removal and macroscopic examination of the drug: verification pathological changes and resection boundaries.
13. Strengthening the fastening seam with separate interrupted seams.
14. Suturing the window in the mesentery.
15. Drainage is not indicated (except special occasions). There is no need for (NGZ).
16. Suturing the wound.
e) Anatomical structures at risk of damage: right ureter, duodenum, superior mesenteric vein, middle colon artery.
and) Postoperative period : “fast-track” management of patients: taking fluids on the first postoperative day (in the absence of nausea and vomiting) and rapid expansion diets as tolerated.
h) Complications of right hemicolectomy:
Bleeding (associated with surgical intervention): traction on the superior mesenteric vein, inadequate ligation of the vascular pedicle, middle colon artery.
Anastomotic failure (2%): technical errors, tension, inadequate blood supply.
Damage to the ureter (0.1-0.2%).
The results of treatment of 15 patients were assessed in the long-term period from 7 to 12 years after left-sided hemicolectomy with correction of the ligamentous apparatus of the colon. The operations were performed on patients with constipation resistant to drug therapy due to slow colonic transit. The diagnosis was made after performing polypositional irrigography, studying the colonic transit time with radiopaque markers, and organic pathology of the colon and rectum was excluded. After surgery, all patients report regular independent bowel movements. 3 operated patients sometimes have problems in the form of periodic constipation, but these patients adapt quite easily and achieve regular bowel movements with the help of small doses of laxatives and diet. Postoperative complication in the form of early adhesive small intestinal obstruction was noted in 1 patient; there were no other complications. Left-sided hemicolectomy with correction of the ligamentous apparatus of the colon is an organ-preserving operation aimed at normalizing stool in patients with delayed transit of the colon. Postoperative outcomes largely depend on patient selection. The operation is effective for slow transit constipation. Long-term results were tracked over a period of 7 to 12 years; all patients report satisfaction with the results of our surgery and improved quality of life.
chronic constipation of slow transit
left hemicolectomy
1. Achkasov S.I., Salamov K.N., Kapuller L.L. et al. Constipation due to anomalies in the development and position of the colon in adults. // Ross. magazine gastroenterol, hepatol, coloproctol. 2000. - No. 2. - P. 58-63.
2. Ivashkin V. T., Poluektova E. A. Clinic and diagnosis of functional constipation // Attending physician. - 2001. - 05-06/01.
3. Arhan P, Devroede G, Jehannin B. et al. Segmental colonic transit time. // Dis Colon Rectum. - 1981. - 24(8). - P. 625-629.
4. Chaussade S., Roche H., Khyari A. et al. Measurement of colonic transit time: description and validation of a new method. // Gastroenterol Clin Biol. - 1986. - 10(5). - P. 385-389.
6. Kalbassi M. R., Winter D. C., Deasy J. M. Quality-of-life assessment of patients after ileal pouch-anal anastomosis for slow-transit constipation with rectal inertia. // Dis Colon Rectum. - 2003. - 46(11). - P. 1508-1512.
7. Knowles C. H., Eccersley A. J., Scott S. M. et al. Linear Discriminant Analysis of Symptoms in Patients with Chronic Constipation: Validation of a New Scoring System (KESS). // Dis Colon Rectum. - 2000. - V. 43 (10). - P. 1419-1426.
8. Lane W. A. The results of the operative treatment of chronic constipation. // Br. Med. J. -1908. - V. 1. - P. 1125-1128.
9. Metcalf A.M., Phillips S.F., Zinsmeister A.R. et al. Simplified assessment of segmental colonic transit. // Gastroenterology. - 1987. - 92(1). - P. 40-47.
10. Raahave D., Christensen E., Loud F.B., Knudsen L.L. Correlation of bowel symptoms with colonic transit, length, and faecal load in functional faecal retention. // Dan Med Bull. - 2009. - 56(2). - P. 83-88.
11. Ribas Y., Saldaña E., Martí-Ragué J., Clavé P. Prevalence and pathophysiology of functional constipation among women in Catalonia, Spain. // Dis Colon Rectum. - 2011. - 54(12). - P. 1560-1569.
12. Riss S., Herbst F., Birsan T., Stift A. Postoperative course and long term follow up after colectomy for slow transit constipation - is surgery an appropriate approach? // Colorectal Dis. - 2009. - 11(3). - P. 302-307.
13. Rome Foundation. Guidelines Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders. // J Gastrointestin Liver Dis. - 2006. - 15(3). - P. 307-312.
14. Ware J. E., Kosinski M., Keller S. D. SF-36 Physical and Mental Health Summary Scales: A User`s Manual // The Health Institute, New England Medical Center. Boston. Mass., 1994.
15. Wong S. W., Lubowski D. Z. Slow-transit constipation: evaluation and treatment // ANZ Journal of Surgery. - 2007. - V. 77(5). - P. 320-328.
16. Zhao R. H., Baig M. K., Thaler K. J. et al. Reduced expression of serotonin receptors in the left colon of patients with colonic inertia. // Dis Colon Rectum. - 2003. - V.46(1). - P. 81-86.
IntroductionChronic constipation resistant to conservative methods treatment, represent serious problem gastroenterology, and there remains a group of patients for whom surgical treatment may be indicated.
Constipation can be due to many reasons, one of which is slow transit of colon contents. Slow transit constipation (STC) is much more common in women and can be combined with an elongated type of colon structure, characterized by kinks and impaired fixation of its various parts. In experimental studies and multiple clinical observations, there is evidence indicating a connection between constipation and an elongated type of colon structure.
The purpose of our work was to analyze the results of conservative and surgical treatment using the proposed method and assessing the quality of life of patients with slow transit constipation.
Patients and technique
Between 1999 and 2004, 342 patients were evaluated and treated for chronic constipation in our clinic, of which 195 patients best met the Rome III criteria C3 classification. Age ranged from 17 to 70 years (median 47.3 ± 16.8 years), 173 (88.72%) were women and 22 (11.28%) were men. 144 women gave birth, and 56 of them experienced deterioration in stool rhythm and constipation after childbirth. Of this number, 15 (7.7%) women with VMT aged 17 to 44 years were operated on, average age was 29.9±7.6 years. The examination of patients included colonoscopy to exclude organic pathology. Patients with constipation underwent irrigography, and if signs of colonic elongation (kinks, doublings, impaired fixation, loops, etc.) were detected in combination with persistent chronic constipation, functional studies were performed to assess the segmental colonic transit time (SCT) of radiopaque markers according to A. M. Metcalf. To determine the position of markers on the image, bone landmarks and gas shadows described by P. Arhan were used. As extreme normal values VTKT we took data from the work of S. Chaussade. Transit was regarded as slow if the total VTCT exceeded 85 hours, transit in the right sections - more than 25 hours, in the left sections - more than 35 hours, and in the rectosigmoid section - over 40 hours.
Conducted functional study rectum to exclude a proctogenic cause of constipation - the tone of the sphincters, the volume of expulsion, and the inhibitory reflex were determined.
When surveying patients, we used the KESS assessment system, which allows us to reliably determine both the degree of decompensation of constipation and the effectiveness of conservative and surgical methods treatment.
To assess the quality of life (QoL) of patients before and after surgical treatment we used the SF-36 questionnaire. Scores on each scale ranged between 0 and 100, with 100 representing complete health, and all scales formed two indicators: mental and physical well-being. The results were presented in the form of scores on 8 scales, designed in such a way that a higher score indicates more high level QOL.
All patients with chronic constipation were prescribed conservative therapy. A fractional (up to 5 times a day) diet was used in compliance with drinking regime(up to 1.5 liters per day) with the inclusion of biokefir and juices. The diet included fruits, vegetables, oils, dietary fiber, and bran. Drug therapy included antispasmodics (dicetel, duspatalin, no-spa), prokinetics (motilium, coordinax). Laxatives were used to a limited extent and predominantly of osmotic action (Duphalac). Eubiotics were prescribed (hilak, bifiform, linex, bifidumbacterin).
Most patients after therapy noted an improvement in both the rhythm of intestinal function and general condition, but in a number of patients a lasting effect was not achieved even after 3-4 courses conservative treatment. After treatment, these patients resumed all symptoms of VMT. Surgical treatment was recommended for such patients.
The selection of patients for surgical treatment was carried out with an assessment of initial functional and anatomical parameters (Table 1). Indications for surgical treatment of patients were signs of pronounced lengthening of all parts of the colon, increased colonic transit time (Fig. 1), persistent constipation, and lack of effect from conservative therapy.
Table 1 Signs of an elongated type of colon structure according to irrigography in 15 operated patients before surgery
|
Dolichosigma |
Doubling of the hepatic flexure |
||||||
|
Loops sigmoid colon |
Duplication of the splenic flexure |
||||||
|
Transversoptosis |
Mobile cecum |
||||||
Rice. 1a. Rice. 1b.
Rice. 1. Colonic transit time (CTT) according to Metcalf A. M. After 72 hours (Fig. 1a) and 144 hours (Fig. 1b) from the start of taking markers. Arrows indicate clusters of radiopaque markers in the ascending, transverse, descending departments(Fig. 1a) and in the rectosigmoid colon (Fig. 1b).
Studies in the preoperative period in 15 patients showed a significant increase in colonic transit time compared with normal values, so the average value of VTCT was 106.9 ± 4.5 hours in patients with VMT, with normal indicators 67 hours according to S.Chaussade (P<0,001).
results
After standard bowel preparation, 15 patients underwent surgery using the technique we developed. A midline laparotomy was performed, and the cecum, ascending colon, and hepatic flexure were mobilized by dissecting the parietal peritoneum and fetal ligaments. Mobilization of the transverse colon was carried out by separating it from the gastrocolic ligament while preserving the greater omentum. Then the splenic flexure, descending and sigmoid colon, often represented by a large loop located in the right iliac region, were mobilized. As a result, the colon was completely mobilized to the rectum and, when straightened, was no longer placed in the same place. Next, the mobilized colon was placed along the perimeter of the abdominal cavity so that the transverse colon took the place of the descending and sigmoid colon. The cecum and ascending colon were fixed to the lateral tena from the bottom up with 3-4 sutures to the iliacus muscle. The lateral edge of the dissected parietal peritoneum was sutured to the intestine with separate sutures. The newly formed transverse colon was fixed behind the tena with separate sutures over a distance of 14–15 cm to the root of the mesentery. The redundant portion of the transverse colon, the descending colon and the sigmoid colon, was resected. A transversorectal anastomosis was performed using 2-row sutures. The colon was fixed in the left lateral canal with separate sutures to the parietal peritoneum (Fig. 2).
Fig.2. Patient G., 22 years old. a) irrigogram of the colon before surgical treatment; b) 6 months after surgical correction (horizontal position of the patient); c) 6 months after surgical correction (patient position upright)
On the 4th day of the postoperative period, the patients began to eat and walk. The patient had spontaneous bowel movements on days 5-6 after surgery. On the 10th day of the postoperative period, patients experienced complete restoration of motor-evacuation activity of the gastrointestinal tract. There were no lethal outcomes; one patient had a postoperative complication - early adhesive small intestinal obstruction, which was eliminated with relaparotomy. The average postoperative hospital stay was 12.5±1.6 days.
Long-term results of treatment were monitored in all 15 operated patients over a period of 7 to 12 years. All patients noted improvement after surgery: regular independent bowel movements appeared, all patients refused enemas, 12 patients stopped using laxatives, 3 periodically use herbal laxatives in small doses. The results of conservative and surgical treatment calculated using the KESS system are shown in Fig. 3.
Rice. 3. Dynamics of symptoms of MMT in 15 patients during the stages of treatment (KESS)
1. Duration of constipation. 2. Use of laxatives. 3. Stool frequency (with current treatment). 4. Failed evacuation attempts. 5. Feeling of incomplete emptying after stool. 6. Abdominal pain. 7. Bloating. 8. Enemas/finger aid. 9. Time required for bowel movement (minutes/attempts). 10. Difficulties in evacuation (pain during defecation). 11. Stool consistency (without laxatives)
As can be seen in Fig. 3, after conservative treatment, there was an insignificant improvement in the patients’ condition and a decrease in symptoms of VMT (P>0.05). The patients' condition significantly improved after surgical treatment of patients with VMT (P<0,01).
Quality of life indicators also improved in patients after surgical treatment (Fig. 4).
Rice. 4. Changes in quality of life indicators in 15 patients with CMT after surgical treatment. 1 - physical functioning; 2 - role-playing activity; 3 - bodily pain; 4 - general health; 5 - viability; 6 - social functioning; 7 - emotional state; 8 - mental health
A study of quality of life indicators in operated patients, assessed on the SF-36 scale, revealed that there was a significant improvement in all studied parameters (P<0,01).
Discussion
In 1908, W. A. Lane developed a method of surgery for chronic constipation, which is still a recognized standard in many countries and consists of a total or subtotal colectomy, cecorectal or ileorectal anastomosis. However, the operation is associated with the development of a number of complications, the leading of which are diarrhea and incontinence, ulcerative proctitis, fluid and electrolyte disturbances, etc. Similar conditions, according to various authors, develop in 15-30% of operated patients, and the number of postoperative complications reaches 32.4%, which forces surgeons to resort to repeated operations, an example of which is the creation of a small intestinal reservoir. Subtotal resection of the colon with cecorectal anastomosis also in some cases leads to both diarrhea and relapses of chronic constipation.
There are studies showing that during EMT, the left half of the colon and, in particular, its nervous system suffer the most. Based on literature data and our own experience, we see the advisability of removing the left half and leaving the right half of the colon during surgery for CMT. It should also be noted that there is no ideal operation for slow transit constipation, and excessive “radicality” in attempts to surgically correct this disease can lead to the development of an even more severe condition. Here, in our opinion, a “golden mean” is necessary. The task of surgeons should be to carefully select patients for surgical treatment. Surgery should be performed on patients with CMT who have pronounced signs of lengthening of the colon, kinks, or disturbances in the fixation of the colon. Our operation is aimed at eliminating the elongated type of colon and allows us to create optimal conditions for the functioning of the colon remaining after resection and in most cases leads to normalization of stool.
It should be noted that surgery is not an alternative to conservative treatment. The surgical method for these patients is only a stage of treatment that eliminates the anatomical prerequisites for VMT. In the future, these patients should be observed and treated by gastroenterologists, following recommendations related to the regimen, diet and lifestyle.
Reviewers:
- Uvarov Ivan Borisovich, Doctor of Medical Sciences, Head. Department of Coloproctology No. 5 of the State Budgetary Healthcare Institution Clinical Oncology Dispensary No. 1, Department of Health of the Krasnodar Territory, Krasnodar.
- Aleksey Viktorovich Vinichenko, Doctor of Medical Sciences, oncologist surgeon, Department of Coloproctology No. 5, Clinical Oncology Dispensary No. 1, Department of Health of the Krasnodar Territory, Krasnodar.
Bibliographic link
Gumenyuk S.E., Potemin S.N., Potemin S.N. LEFT-SIDE HEMICOLECTOMY WITH COLON FIXATION IN PATIENTS WITH REFRACTORY SLOW-TRANSIT CONSTIPATION // Modern problems of science and education. – 2012. – No. 4.;URL: http://science-education.ru/ru/article/view?id=6804 (access date: 12/12/2019). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"
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For colon cancer, the extent of resection, depending on the location of the tumor, ranges from distal resection of the sigmoid colon to colectomy, i.e. removal of the entire colon. The most commonly performed are distal resection of the sigmoid colon, segmental resection of the sigmoid colon, left-sided hemicolectomy, resection of the transverse colon, right-sided hemicolectomy (Fig. 1), subtotal resection of the colon. These operations differ from each other in the volume of resection of the colon, the anatomy of the transected vessels and, accordingly, the removed area of lymphogenous metastasis.
Rice. 1. Scheme of resection of the large intestine for cancer of various localizations: a - resection of the sigmoid colon; b - left-sided hemicolectomy; c - right hemicolectomy; d - resection of the transverse colon.
Distal resection of the sigmoid colon consists of resection of the distal two-thirds of the sigmoid colon and the upper third of the rectum with ligation of the sigmoid and upper rectal vessels. Restoration of the colon is carried out by forming a sigmorectal anastomosis.
Segmental resection of the sigmoid colon- resection of the middle part of the sigmoid colon with ligation of the sigmoid vessels and the formation of an anastomosis.
Left hemicolectomy involves removal of the left half of the colon (sigmoid, descending and distal half of the transverse colon) with ligation and intersection of the inferior mesenteric vessels and the formation of a transversorectal anastomosis.
Transverse colon resection involves ligation and intersection of the middle colon artery at its base and the formation of an anastomosis.
Right hemicolectomy consists of removing the cecum with the distal part of the ileum (10-15 cm), the ascending colon and the proximal third of the transverse colon with ligation and intersection of the ileocolic vessels, the right colon artery and the right branch of the middle colic artery. Restoration of intestinal continuity is carried out by forming an ileotransverse anastomosis.
Subtotal colon resection- removal of the entire colon, with the exception of the most distal part of the sigmoid colon, forming an ileosigmoid anastomosis. In this case, all the main vessels supplying the colon are crossed.
If lymph nodes are affected, extended resection volumes should be performed. Thus, for cancer of the sigmoid colon of any location in these cases, left-sided hemicolectomy with ligation of the inferior mesenteric arteries and veins and the formation of a transversorectal anastomosis is indicated. For cancer of the descending section or left flexure, distal subtotal resection of the colon is indicated with ligation of the trunk of not only the inferior mesenteric vessels, but also the middle colon artery with the further formation of an ascendorectal anastomosis.
In the same situation, but with a right-sided localization of the tumor, proximal subtotal resection of the colon with ligation of the ileocolic, right colic and middle colic arteries and the formation of an ileosigmoid anastomosis is indicated. When the tumor is localized in the middle third of the transverse colon and the presence of lymphatic metastases, the extent of resection should range from subtotal resection to colectomy with ileorectal anastomosis. If the tumor is located in the right or left flexure of the colon, a typical right or left hemicolectomy is performed, respectively. If the lymph nodes are affected, proximal or distal subtotal resection of the colon is indicated, respectively.
When a colon tumor grows into neighboring organs (bladder, small intestine, stomach, etc.), combined operations should be used. Modern surgical techniques, features of anesthesia and intensive care allow simultaneous resection of any abdominal organ and retroperitoneal space. The use of intraoperative ultrasound helps to better differentiate true tumor growth from perifocal inflammation of nearby organs.
In recent years, along with intestinal resection, removal of distant metastases has been increasingly used, in particular liver resections of varying volume and technique (the so-called complete cytoreduction). Palliative resections (incomplete cytoreduction) should also be used in the absence of contraindications, trying whenever possible to avoid symptomatic surgery (formation of colostomies or bypass anastomoses).
Colon resections should be completed with the formation of an anastomosis with restoration of natural intestinal passage. This is possible if the following conditions are met: good bowel preparation, good blood supply to the anastomosed sections, absence of bowel tension in the area of the intended anastomosis.
When forming an anastomosis, the most widely used double-row interrupted suture with an atraumatic needle. It is also possible to use other options: mechanical staple suture, mechanical suture made of absorbable material or metal with shape memory, single-row manual suture, etc. If there is no confidence in the reliability of the colonic anastomosis, a proximal colostomy should be formed.
In case of tumor complications during urgent operations on an unprepared intestine, preference should be given to multi-stage treatment. At the first stage, it is advisable not only to eliminate the complications that have arisen, but also to remove the tumor itself; at the second stage, it is advisable to restore natural intestinal passage. Such methods of surgical treatment include the von Mikulich-Radetzky operation with the formation of a double-barreled colostomy and the Hartmann operation - the formation of a single-barrel colostomy and tightly suturing the distal segment of the colon. Restoration of natural intestinal passage is carried out after 2-6 months after the patient’s condition has normalized.
Savelyev V.S.
Surgical diseases
Hemicolectomy is a surgical procedure used to treat various diseases of the colon. Used in abdominal surgery, oncology and proctology. The history of colon resection begins in 1832, when Dr. Raybord reported the first successful operation with intercolon anastomosis. The first laparoscopic hemicolectomy was performed in the United States in 1990 by Dr. Jacobs.
Depending on the part of the colon being removed, a distinction is made between left-sided and right-sided hemicolectomy. Both operations are performed open or laparoscopically. In an open hemicolectomy, half of the intestine is removed through a large incision in the abdominal wall. When using the laparoscopic technique, colon resection is performed through small holes under video camera control using endoscopic equipment. The advantage of the open method is the absence of the need for expensive laparoscopic equipment, better conditions for visual examination, the ability to obtain tactile information about the condition of the abdominal organs, and lower prices. The benefits of laparoscopic hemicolectomy include reduced recovery time, less pain, absence of large scars, reduced risk of infectious complications and incisional hernia, and early recovery of bowel function.
After left hemicolectomy.
After the operation, the patient is taken to the department of the department or the department of anesthesiology and resuscitation, where he is monitored for his condition. Continuation of infusion therapy, administration of antibiotics and analgesics to prevent deep vein thrombosis. Every other day the patient can use clear liquids. When the body picks it up and the intestines begin to function, the diet gradually expands. Otherwise, continue infusion therapy and prescribe parenteral nutrition. Patient activation begins the day after surgery.Sometimes in the postoperative period, patients develop intestinal paresis. To eliminate paresis, sufficient fluid therapy, adequate analgesia, correction of electrolyte imbalance and early activation are necessary. Patients with vomiting and bloating may experience relief from insertion of a nasogastric tube, although this exercise alone does not relieve ileus. Drug administration increases intestinal motility, so it is best to use epidural analgesia for anesthesia. Sometimes, when paresis requires medical stimulation of the intestines, its implementation should begin only with the ineffectiveness of other methods, and not from the first day of the postoperative period. For stimulation, prozerin is used (the use of the drug is limited by side effects), metoclopramide and alvimopan. After a few days, the drainage is removed from the abdominal cavity.
After a laparoscopic hemicolectomy, the sutures are removed for 6-7 days, and after an open procedure - for 9-10 days. The patient then goes home. After the trip, short daily walks with gradually increasing duration are recommended. It is allowed to go up and down the stairs; during the initial recovery period, the patient needs the help of another person. Immediately after unloading, you can raise the weight up to 5 kg; after a month, the weight of the load can be gradually increased.
Showering can be done two days after laparoscopic surgery (if the patient is able to do so). Cuts should be thoroughly cleaned, without soap, and thoroughly dried. With open hemicolectomy, hygiene procedures should be postponed until the sutures are removed. Performance is usually restored within 6-8 weeks. If colon resection was performed for a malignant tumor, the patient may require chemotherapy after receiving histological results.
Left-sided and right-sided hemicolectomy are radical operations to remove part of the large intestine from one side. Such an intervention is considered simple, but it involves a long course of rehabilitation and changes in the patient’s lifestyle, and therefore is prescribed only for vital indications.
Who is hemicolectomy indicated for?
In order for a patient to be prescribed resection of half of the intestine, serious reasons are needed. And usually these are severe pathologies that cannot be treated conservatively. Colon cancer comes first. The part of the intestine affected by cancer is immediately removed to prevent the spread of metastases.
Hemicolectomy is also indicated in the presence of polyps with malignancy in the large intestine and in the advanced stages of certain diseases: Crohn's disease, ulcerative colitis, perforation or diverticulosis of the colon, volvulus of the sigmoid colon.
Curious! In an adult, the length of the large intestine is 1.5-2 meters. It turns out that during a hemicolectomy, approximately a meter of the organ is excised.
There are no absolute contraindications to emergency hemicolectomy, because when a person’s condition is critical, one has to take risks even if there are some associated problems. A planned operation may be postponed if the patient has severe diseases of the cardiovascular system, renal or liver failure, or diabetes mellitus in the decompensated stage.
Preparing the patient for surgery
The preparatory period before hemicolectomy can be divided into two lines. The first is the necessary preoperative examinations (fluorography, ECG), tests (OAM, OAC, biochemistry) and consultations with specialists. The second is the behavior of the patient himself and his compliance with medical prescriptions.
What do doctors do
Among the specific examinations, colonoscopy is prescribed, which allows you to visually assess the condition of the part of the intestine to be removed, as well as take a piece of the mucous membrane for a biopsy to determine the cell type. If the results of the study are insufficient, an additional irrigoscopy is performed. Particularly severe conditions (colon cancer) also require computed tomography.
What does the patient do
The patient needs to start a slag-free diet 3-5 days before surgery. It will allow you to clean the intestines as thoroughly as possible to simplify the work of doctors and minimize the risk of infection during the intervention. We will have to exclude:
- fat;
- roast;
- smoked;
- sauces;
- nuts;
- black tea and coffee;
- baked goods;
- alcohol;
- mushrooms;
- garlic;
- fresh fruits and berries.
It would be ideal to eat a salad called “Broom” or “Brush” 2 days before surgery. It will cleanse the intestinal walls of remaining toxins. The recipe is very simple: coarsely grated carrots, beets and fresh lettuce. The original recipe uses white cabbage, but it causes gas, which is undesirable before a hemicolectomy. The salad is dressed with vegetable oil and lemon juice.
How is the operation performed?
Right or left hemicolectomy can be performed in two ways: open (laparotomy) and closed (laparoscopy). The second one is preferable, because This means minimal blood loss and rapid recovery. But laparoscopy may be contraindicated or impossible if the hospital does not have endoscopic equipment.
Laparotomy
The operation is performed under general mask anesthesia. The patient lies on his back. The incision is made in the area of the anterior peritoneal wall. The affected half of the intestine is isolated and mobilized from neighboring organs and vessels (from the splenic flexure and mesenteric artery, if it is a left-sided hemicolectomy, and from the hepatic flexure and ileocolic artery, if it is a right-sided hemicolectomy).
The mobilized affected part of the intestine is clamped on both sides and cut off. The remaining stumps are stitched together with an anastomosis - a special connection for strength and restoration of patency. In some cases, the lower part of the remaining intestine is sutured, and the second part is removed through the peritoneum to form a temporary colostomy.
Laparoscopy
Laparoscopic hemicolectomy is performed under either general anesthesia or epidural anesthesia. The patient also lies on his back. An endoscope (a tube with a camera for displaying an image on a monitor) and surgical instruments are inserted into the peritoneum through punctures. The technique for intestinal mobilization and excision is approximately the same as for open surgery.
After laparoscopic hemicolectomy, several small sutures (2-3 cm each) remain, which are quickly tightened, reducing the rehabilitation period.
Why is half the intestine removed?
This is a natural question asked by people who have pathology (tumor, polyps, torsion) only in a small area of the intestine. Why not perform a hemicolectomy on the affected area only? There are several explanations for this.
- The right and left halves of the colon are supplied with blood from different large arteries: from the superior and inferior mesenteric arteries, respectively. And when one of the vessels is ligated during the operation, the entire half of the intestine “dies”, and there is no point in leaving necrotic areas.
- The border between the division of the large intestine into right and left parts is the transverse colon. It is mobile and easier to anastomose.
- Removing half of the intestine gives better results for cancer. Because from the time of testing for tumor localization to the day of hemicolectomy, metastases may have time to spread. Therefore, part of the intestine is removed “with a reserve.”
Features of the postoperative period
Patients after laparotomy hemicolectomy are forced to remain in bed for at least 3 days to prevent the sutures from coming apart. If it was a laparoscopy, then you can and even need to get up the very next day after the operation. Both types of hemicolectomies require the installation of a drain, which is removed only after 2-3 days.
By the way! Patients who required hemicolectomy went into surgery in an already weakened or even emaciated state. Therefore, recovery will also be difficult.
After the operation you should not drink or eat. Only the next day a small amount of liquid is allowed. Liquid food is gradually introduced. Due to the reduction in intestinal length, the patient will have to follow a diet for the rest of his life. It excludes foods that require many hours of digestion (pork, lamb, beef, legumes, cabbage, some root vegetables, nuts).
Indigestion will torment the patient for about 3-4 weeks while the body adapts to new conditions. But it is advisable to avoid constipation so that too hard stool does not put pressure on the internal seams. For this purpose, the doctor usually prescribes mild laxatives.
Possible complications of hemicolectomy
Both left-sided and right-sided hemicolectomy can cause the same complications, early ones of which include injury to nearby organs (ureter, duodenum), internal bleeding, suture dehiscence, infection and inflammation of the abdominal cavity. Also, immediately after surgery, intestinal paresis (obstruction) may develop.
Attention! Some complications are dangerous because they can only be eliminated surgically. And performing another operation on the body of a weakened patient is a big risk.
If no force majeure occurred during the operation or immediately after it, and the patient was successfully discharged home, it is important to follow all the doctor’s instructions and prescriptions. Because it takes 4-6 months to fully recover from a right or left hemicolectomy. And during this time, complications may also develop: adhesions, ulcers at the anastomosis, cicatricial stenosis of the intestine, hernia.
Anemia, weight loss, decreased immunity are not complications, but typical consequences that can rarely be avoided. All this is gradually passing. After six months, we can talk about stable adaptation: both physiological and psychological. A person gains weight, gets used to a new diet, and learns to listen to the body’s feedback on changes in diet.
