Perioperative management - Right hemicolectomy

• Carcinomas of the cecum and ascending colon
• Neuroendocrine tumor (NET) of the appendix, if an appendectomy is not oncologically sufficient.

With the aim of standardizing and optimizing the surgical treatment of colon cancer, a treatment principle was described in 2009 under the term complete mesocolic excision (CME), which is intended to meet the oncological requirements of surgical cancer treatment in all sections of the colon.

This concept is based on the strict preservation of the integrity of the mesocolic fascia on both sides by dissection in the embryonically predetermined slit-shaped space between the visceral and parietal fascia. By preserving both fascial layers, the mesocolon remains intact, avoiding tumor cell dissemination analogous to an intact mesorectum in TME.

Through central vascular ligation at the vessel origin ("high tie"), in right hemicolectomy from the superior mesenteric artery, the complete excision of the regional lymphatic drainage area is achieved. This technique aims to achieve maximum lymph node yield and thereby avoid the main cause of local recurrences.

In conventional resection, the arterial trunk vessels supplying the tumor are not necessarily ligated centrally ("low tie"), which means that complete dissection of the main lymph nodes is not ensured.

The current S3 guideline requires a lymph node yield of at least 12 lymph nodes, noting that the number of lymph nodes present in the area of the right hemicolon is highly variable between individuals and also age-dependent.

Both the higher number of resected lymph nodes and the CME itself likely contribute to improved survival rates according to current evidence.

Lymphatic drainage of the colon

The regional lymphatic drainage area of the colon consists of four lymph node groups. Epi- and paracolic lymph nodes are grouped with the pericolic lymph nodes, with the epicolic lymph nodes running directly along the intestinal wall and the paracolic lymph nodes along the marginal arteries. The intermediate lymph nodes are located along the respective arterial trunk vessels. The main lymph nodes surround the trunk vessels near their origin from the superior mesenteric artery or inferior mesenteric artery in the left colon.

Since the lymphogenic metastasis of colorectal carcinoma follows fixed rules, the supplying arteries with the potentially affected lymph nodes determine the extent of resection and not the primary tumor.

An adequate safety margin ultimately results from the respective arterial supply of the tumor-affected section, with numerous vascular variants. All arteries running centrally within a distance of 10 cm on both sides of the tumor, as well as the colon affected by this arterial supply, are resected. This also applies to the terminal ileum.

• Adenocarcinoma of the right colonic flexure (extended right hemicolectomy)
• Familial adenomatous polyposis (restorative proctocolectomy with ileoanal pouch anastomosis)
• Cancers on the basis of ulcerative colitis (restorative proctocolectomy with ileoanal pouch anastomosis)
• Primary tumor that does not cause symptoms in the presence of unresectable metastasis. Here, the initiation of systemic therapy is recommended.

• Clinical symptoms: Change in bowel habits, anemia, abdominal pain
• Complete colonoscopy with biopsies for histological confirmation. Note: If a colonoscopy is not possible preoperatively due to an impassable stenosis, it should be performed 3-6 months postoperatively.
• Laboratory: CBC, CRP, coagulation, creatinine, electrolytes, blood type, antibody screening test, CEA
• Abdominal ultrasound
• CT thorax/abdomen
• Possibly MRI liver, contrast-enhanced ultrasound liver

Management of Anticoagulants:

• Perioperative therapy with aspirin can be continued. Clopidogrel (ADP inhibitor) should be paused at least 5 days prior.
• Vitamin K antagonists should be paused 7 days, NOACs (new oral anticoagulants) at least 3 days preoperatively, with bridging using short-acting heparins.

For carcinomas with an increased risk of recurrence, a recommendation for neoadjuvant systemic therapy is emerging.

In the case of distant metastases, an interdisciplinary tumor board decides on further therapy.

Preoperative bowel preparation: Current data supports anterograde bowel irrigation with the addition of topical antibiotics.

Perioperative antibiotic prophylaxis, e.g., with a second or third-generation cephalosporin combined with metronidazole (effective against anaerobes)

In case of suspected infiltration of the ureter by the tumor or involvement due to the peritumoral inflammatory reaction, placement of a right-sided ureteral stent!

General Risks:

• Bleeding
• Rebleeding
• Thrombosis
• Embolism
• Wound infection
• Abscess
• Pneumonia
• Cardiac complications
• Urinary tract infection
• Stroke

Specific Risks:

• Injury to the right ureter
• Injury to the duodenum
• Postoperative anastomotic insufficiency
• Spleen injury
• Pancreatic injury
• Bowel injury
• Postoperative passage disorder
• Dehiscence
• Scar and trocar hernia
• Anastomotic stenosis

• Intubation anesthesia and – if possible
• thoracic epidural catheter
• Normothermia (warming patients)

• Supine positioning
• right arm adducted
• left arm extended

• Surgeon to the right of the patient
• 1st assistant to the left of the patient
• 2nd assistant to the right, towards the head of the surgeon
• instrumenting OR nurse to the left, towards the feet of the 1st assistant
• if necessary, 3rd assistant to the left, towards the head of the 1st assistant

The laparotomy is performed with a scalpel, and further incision of the abdominal wall is done using monopolar diathermy. The abdomen is kept open with a retractor system (ring and blades). Additionally, both costal arches are elevated cranially/ventrally with hook systems. Dissection is carried out with monopolar diathermy and scissors, with vessel transections between ligatures using absorbable sutures of 3/0 braided strength. Intestinal anastomosis end-to-end is also performed with absorbable suture material 3/0, either continuously extramucosal or in single button suture technique.

Postoperative Analgesia:
Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management)
Follow the link here to the current guideline Treatment of acute perioperative and post-traumatic pain.

Medical Follow-up:
Early removal of intraoperatively placed drains. Regular wound checks, if non-absorbable – removal of skin sutures around the 12th postoperative day. 

In case of recurrent vomiting, insertion of a gastric tube for decompression of the gastrointestinal tract and aspiration prophylaxis.

7 days after inadequate food intake, parenteral caloric nutrition with 25-30 kcal/kg body weight (Protein:Fat:Carbohydrates – 20:30:50) should be started.

Follow-up: In stages II and III, regular follow-up examinations are indicated. In UICC Stage I, colonoscopies are sufficient as follow-up to detect secondary tumors.
Thrombosis Prophylaxis:
In the absence of contraindications, due to the high risk of thromboembolism, low molecular weight heparin should be administered in a prophylactic, possibly disposition risk-adapted dosage for at least 2, possibly up to 6 weeks, in addition to physical measures. Note: Kidney function, HIT II (history, platelet control). Follow the link here to the current guideline Prophylaxis of venous thromboembolism (VTE).

Mobilization:
Immediate mobilization is aimed for, on the evening of the day of surgery, at the latest on the morning of the following day.

Physical Therapy:
No specific physical therapy required, possibly support for patients with, for example, pulmonary impairment.

Dietary Progression:
From the evening of the day of surgery, tea is possible, early removal of any inserted gastric tube is aimed for. From the 2nd postoperative day, gradual oral dietary progression starting with tea and rusks, then yogurt and pureed food.

Bowel Regulation:
From the 3rd-4th postoperative day, if no spontaneous bowel movement has occurred by then. Here, administration of an oral laxative. In case of intestinal paralysis, 3×1 mg Neostigmine (slowly over about 2 hours; CAVE off-label use) and 3 x 10 mg Metoclopramide each as KI i.v..
Incapacity for Work:
Individually depending on the surgical indication (underlying disease) and the profession practiced, between 3 and 6 weeks; unforeseeable in advanced tumors.