A right hemicolectomy is usually performed for cancer of the cecum and ascending colon, and

for some hepatic flexure cancers (figure 3). The general principles for performing the operative
procedure are described elsewhere. (See "Overview of colon resection" and "Right and
extended right colectomy: Open technique".)

COLON RESECTION

Types of colon resection Types of colon resection are described below. Resections are
based anatomically on the location of the lesion, blood supply (figure 1 and figure 2), and for
malignant lesions, the lymphatic drainage of the colon (figure 3) [34]. Resection margins must
be chosen to ensure adequate blood supply in the remaining colon. (See "Left colectomy: Open
technique" and "Right and extended right colectomy: Open technique".)

Segmental colectomy Segmental resection, which removes only an affected portion of

bowel, can be performed when a lesser resection is indicated (eg, trauma, polyp), provided
the anastomosis will be performed in well vascularized bowel (figure 4).

Ileocecectomy Ileocecectomy resects a portion of the distal ileum and the cecum (figure
5).

Right hemicolectomy Right hemicolectomy removes a portion of the distal ileum, the
cecum, ascending colon, and the transverse colon to the right of the middle colic artery
(figure 6A-B).
 Extended right hemicolectomy Extended right hemicolectomy expands right
hemicolectomy to include the transverse colon over to the splenic flexure (figure 7).

Transverse colectomy Transverse colectomy removes the transverse colon (figure 8).
Transverse colectomy is uncommonly performed for malignancy, as cancers are generally
to the right or left of the midline, and thus, a right extended or left hemicolectomy should be
performed to achieve an adequate lymphadenectomy.

Left hemicolectomy Left hemicolectomy removes the transverse colon to the left of the
middle colic artery, left colon and sigmoid colon to the level of the upper rectum (figure 9A-
C).

Sigmoidectomy Sigmoidectomy removes the sigmoid colon (figure 10).

Subtotal colectomy Subtotal colectomy removes the entire intraperitoneal colon (figure
11).

Benign versus malignant disease

The extent of colon resection depends upon the disease process being treated. (See 'Types of
colon resection' above.)

Benign lesions are generally removed using a segmental resection or hemicolectomy

(right or left). For localized benign conditions of the colon (eg, trauma, diverticular disease,
inflammatory bowel disease), a segmental resection with a primary anastomosis in well-
vascularized colon and a limited mesenteric resection can be performed. Diverticular
disease, typically treated with a sigmoidectomy, may require a left hemicolectomy if the
descending colon is unsuitable for an anastomosis. Extended resection (extended right or
left colectomy) or subtotal colectomy may be needed for more extensive benign disease of
the colon (eg, inflammatory bowel disease, diverticular disease, fulminant Clostridium
difficile colitis). For large polyps that require resection because of a possible malignancy,
the authors perform a formal cancer operation.

Malignant lesions located in the appendix, cecum, and ascending colon can be resected
by a right hemicolectomy. Malignant lesions located in the hepatic flexure or proximal to the
midtransverse colon are resected with an extended right colectomy. Malignant lesions of
the left colon are typically resected with a left hemicolectomy. For malignant lesions of the
splenic flexure, a limited resection extending from the transverse to the sigmoid colon can
be performed, but the pedicle of the left colic artery and the first sigmoid branch should be
included in the specimen. A small number of transverse tumors may be amenable to
transverse colectomy. The surgical margins for a curative resection for colon cancer should
be at least 5 cm from the tumor on both sides [35].
The extent of the mesenteric resection also varies according to whether the resection is being
performed for benign conditions or malignancy. Figures that show these differences are given in
the section above. (See 'Types of colon resection' above.)

For benign disease including trauma, mesenteric vessels can generally be divided close
to the mesenteric border of the colon since it is unnecessary to resect draining lymph
nodes. However, in settings of severe mesenteric inflammation (eg, diverticulitis,
inflammatory bowel disease) and thickening of the mesentery near the bowel wall, a more
extensive mesenteric dissection may be necessary [34].

For malignancy, a complete mesocolic resection ligates the mesenteric vessels close to
their root to optimally resect the lymphovascular tissue. As an example, for left colectomy
the inferior mesenteric artery is ligated at its origin from the aorta, the inferior mesenteric
vein is ligated at the level of the pancreas; the mesentery and draining lymphatics are
removed with the vascular pedicle.

Complete mesocolic excision has been reported to improve oncologic outcomes, but could
result in higher morbidity. In one study, complete mesocolic excision was associated with more
intraoperative injuries to other organs (9.1 versus 3.6 percent), postoperative sepsis (6.6 versus
3.2 percent), and respiratory failure (8.1 versus 3.4 percent) compared with conventional
surgery [36]. In the same study, the 30-day (OR 1.07, 95% CI 0.62-1.80) and 90-day mortality
(OR 1.25, 95% CI 0.77-1.94) associated with complete mesocolic excision were higher, but not
statistically different from those of conventional surgery. The two techniques have not been
directly compared in prospective trials.