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This article outlines and reviews hemicolectomy, the operative procedure, and the role of the interprofessional team in improving care for patients who undergo this operation. This article covers the relevant anatomy involved in the operation, the steps of the procedure, and important complications to understand regarding the aftercare of these patients. It further highlights the role of the interprofessional team in the workup and postoperative care of these patients. Objectives: Identify the anatomical structures involved in right and left hemicolectomy. Describe the technique of left and right hemicolectomy procedures. Outline the appropriate evaluation of the potential complications of right and left hemicolectomy procedures. Review interprofessional team strategies for improving care coordination and communication to advance operative care in patients undergoing major bowel resection and improve outcomes. Access free multiple choice questions on this topic.

Hemicolectomy is a commonly performed operation for cancer of the colon. The first successful right hemicolectomy was performed in 1832 by Reybard.[1] Since then the technique was subsequently refined by renowned surgeons including Kohler and Mikulicz. In the modern-day, it has become a mainstay to operate laparoscopically, where conditions allow. Robotic techniques are in development and represent the future of minimally invasive surgery for colon cancer.[2][3] This article will discuss the anatomy, indications, contraindications equipment, personnel, procedure, and interprofessional strategy towards the operation.

Overall complication rates from laparoscopic surgery for colorectal surgery are similar to open surgery.[18] Meta-analysis evidence suggests laparoscopic favors quicker recovery while oncological outcomes are non-inferior. The main troubling complications specific to laparoscopic hemicolectomy will be discussed below, including anastomotic leak, ureteric injury, and conversion to open. Other complications general to surgical procedures will be discussed in less detail. Anastomotic Leak Leak rates from laparoscopic right hemicolectomy are around 4% and represent the major risk to morbidity in patients undergoing this operation.[19] Risk factors for a leak can be grouped into local and generalized. General causes include poor nutritional state, anemia, uremia, diabetes, steroid administration, age, smoking status, and sepsis.[20] Local causes include poor blood supply, inappropriate tension, or infection of the anastomosis. Timing and onset of symptoms from a leak can vary and may occur at any time in the first 2 to 3 weeks following the operation. Warning signs include pyrexia, tachycardia, ileus, and hypoxemia, as well as failure to progress post-operatively.[21] If the leak develops further, then local or generalized peritonitis can occur if rapid fecal contamination occurs; the onset of these features is quicker. An anastomotic leak has not been shown to increase the risk of local recurrence or impact disease-free survival.[21] An investigation by CT with water-soluble (oral in right hemicolectomy, rectal in left hemicolectomy) contrast is the gold standard investigation.[22] Results of which must be interpreted within patient context to avoid over-treating a radiological leak. In the patient with systemic deterioration and generalized peritonitis, a return to theatre for laparotomy is essential for source control. In a major disruption, the anastomosis should be taken down and formed into an end ileostomy and mucous fistula. A thorough peritoneal washout should be performed with warm saline. In the systemically well patient, conservative management with bowel rest and antibiotics may be appropriate. Repair of small defects, intra-peritoneal drain, and defunctioning of the anastomosis with a proximal loop ileostomy/colostomy in systemically well patients without generalized peritonitis is another management strategy.[23] Ureteric Injury

Leak rates from laparoscopic right hemicolectomy are around 4% and represent the major risk to morbidity in patients undergoing this operation.[19] Risk factors for a leak can be grouped into local and generalized. General causes include poor nutritional state, anemia, uremia, diabetes, steroid administration, age, smoking status, and sepsis.[20] Local causes include poor blood supply, inappropriate tension, or infection of the anastomosis. Timing and onset of symptoms from a leak can vary and may occur at any time in the first 2 to 3 weeks following the operation. Warning signs include pyrexia, tachycardia, ileus, and hypoxemia, as well as failure to progress post-operatively.[21] If the leak develops further, then local or generalized peritonitis can occur if rapid fecal contamination occurs; the onset of these features is quicker. An anastomotic leak has not been shown to increase the risk of local recurrence or impact disease-free survival.[21] An investigation by CT with water-soluble (oral in right hemicolectomy, rectal in left hemicolectomy) contrast is the gold standard investigation.[22] Results of which must be interpreted within patient context to avoid over-treating a radiological leak. In the patient with systemic deterioration and generalized peritonitis, a return to theatre for laparotomy is essential for source control. In a major disruption, the anastomosis should be taken down and formed into an end ileostomy and mucous fistula. A thorough peritoneal washout should be performed with warm saline. In the systemically well patient, conservative management with bowel rest and antibiotics may be appropriate. Repair of small defects, intra-peritoneal drain, and defunctioning of the anastomosis with a proximal loop ileostomy/colostomy in systemically well patients without generalized peritonitis is another management strategy.[23] Ureteric Injury The ureters become difficult to identify in patients with obesity, diverticular disease, inflammatory bowel disease, and those with previous abdominal surgery/resection in close proximity. Preoperative placement of ureteric stents can aid the identification of ureteral injury.[24] Overall ureteric injury remains a rare occurrence. Conversion to Open

The ureters become difficult to identify in patients with obesity, diverticular disease, inflammatory bowel disease, and those with previous abdominal surgery/resection in close proximity. Preoperative placement of ureteric stents can aid the identification of ureteral injury.[24] Overall ureteric injury remains a rare occurrence. Conversion to Open Indications for open surgery include extensive adhesions, T4 tumors with surrounding invasion, hemorrhage. Conversion to open is associated with worse overall survival in curable resections.[25] Bleeding Laparoscopic surgery reduces blood loss.[26] Wound Infection Wound infection is reduced in laparoscopic surgery.[26]

As discussed above, preoperative assessment is crucial to the identification of patients unsuitable for anesthesia and those who are considered high-risk patients so that a thorough postoperative plan can be put in place preoperatively. The identification of those patients with cardiorespiratory issues requiring high care or intensive care beds is a prime example. The interprofessional team approach in the workup for colorectal cancer has been shown to improve patient outcomes.[27] A discussion and consensus opinion on the best management strategy is considered vital to modern practice and facilitates communication between all specialties involved in patient care simultaneously. Enhance recovery programs are well established in recovery from colorectal resections.[28] The setting of recovery aims for each day regarding factors including nutrition, mobility, analgesia, drains, antibiotics, venous thromboembolism prophylaxis and removal of indwelling lines have been shown to decrease time in hospital and associated costs, reduce nursing workload, and is non-inferior in terms of complications, readmission or mortality.

Cancer nurse specialists provide patient support throughout the patient journey, involved in breaking bad news, providing detailed information regarding the operation and recovery, and many centers now familiarise patients with the intensive care unit/ward environment before the procedure.[29] Specialized stoma care nurses provide advice and reassurance for patients and monitor stoma function if one is formed during the operation. They play an important role pre-operatively in assessing the patient, familiarizing them with the bag, and marking the stoma site. Following discharge, the stoma care nurse holistically provides ongoing support covering psychological, spiritual, and social needs.[30][31]

The role of the nurse is crucial in facilitating inpatient recovery and monitoring for deterioration post-operatively. Hourly observations in recovery until the patient is considered stable allow an assessment of how the patient is recovering post-op with escalation to anesthetic colleagues if required. Nursing monitoring includes regular four hourly vital signs and the use of major early warning scores is key to the escalation of deteriorating patients. Monitoring and accurate charting of patient urine output, drain output, bowel function and nutritional intake are also key elements of inpatient care.