Combined Medial and Caudal Approach for Right Hemicolectomy
Condition: Colon Cancer
MeSH terms: Colonic Neoplasms
Study type: Interventional

Summary: 
      Right sided hemicolectomy is the standard type of operation for cancers in the caecum, the
      ascending colon, proximal transverse colon.The aim of this study was to assess the safety and
      feasibility of combined medial and caudal approach in performing right hemicolectomy and to
      compare outcome between laparoscopic and open surgery in right colon cancer.
    

Detailed description: 
      The incidence of colorectal cancer is increasing. Slight shift towards right colon cancer is
      noticed in the last 2 decades in Egypt. This can be attributed to advances in diagnostic
      tools and increased public health awareness as right sided colon cancer was almost presented
      late as most of tumors located in the capacious cecum. Hence, early diagnosis with good
      radical procedure offers better outcome, quality of life and survival. Many approaches for
      right colon resection were described. In this study we adopted the combined medial and caudal
      approach for right colon resection in cases of right colon cancer in both open and
      laparoscopic techniques.

      Traditionally, approach to right colon cancer is through open exploration but this approach
      has more blood loss, prolonged postoperative hospital stay, sever postoperative pain and
      delayed recovery.

      As combined medial and caudal approach is a radical procedure,the purpose of the present
      study was to compare between laparoscopic and open right hemicolectomy both done with
      combined medial and caudal approach in right colon cancer as regards technical feasibility,
      advantages and disadvantages of both procedures.

      This was prospective randomized study and was carried out on 26 participants as number of
      cases with right hemicolon cancer is about 2 per month in our center. Those participants
      diagnosed as operable right sided colon cancer and the participants were divided into two
      groups:

      Group I: Open combined medial and caudal right hemicolectomy included 13 participants Group
      II: Laparoscopic combined medial and caudal right hemicolectomy included 13 participants

      All patients with inclusion criteria were subjected to preoperative assessment in the form
      of:

        -  Full history.

        -  Clinical evaluation.

        -  Laboratory investigation (Complete blood picture, liver function tests, blood sugar,
           blood urea, serum creatinine, prothrombin time, serum albumin and tumour marker CEA).

        -  Imaging (chest X-ray, US abdomen, CT abdomen and pelvis).

        -  Histopathology diagnosis (endoscopic biopsy, tissue diagnosis).

        -  Determined whether participants underwent open or laparoscopic operation is
           multifactorial e.g., patients desire, contraindications for laparoscopy and mass size if
           more than 5 cm preferred to have open surgery.

        -  Informed written consent taken from the patients or the legal guardian.

      operative technique: both groups offered combined medial and caudal approach

        -  Fasting for 6 hours with no oral intake or only clear fluids intake the day before or
           better bowel preparation.

        -  After confirming the availability of blood of matching blood group, general anesthesia
           is inducted and prophylactic antibiotics are given.

        -  Patient positioning:

             1. group I: (Open cases) The standard position for an open right hemicolectomy is
                supine with strapping of the ankle and wrists, such as the Trendelenburg position.
                The surgeon stands on the patient's left, and the first assistant stands across
                from the surgeon on the patient's right. The scrub nurse stands beside the surgeon.
                If a second assistant is needed, he or she usually stands across from the surgeon
                to the left of the first assistant.

             2. group II: laparoscopic cases: The patient should be placed in the supine position
                with his two legs apart and arms tucked beside the body.

      The surgeon should stand between the patient's legs with the assistant standing on the
      patient's left and the camera operator standing on the assistant's left side, and the scrub
      nurse on the patient's right side.

      The video monitor is placed on the patient's upper right.

        -  Abdominal access and trocar placement by open or closed technique using veress needle
           for pneumoperitoneum with an intraperitoneal pressure of 14 mmHg.

        -  The procedure requires 5 trocars.

        -  A 10 mm trocar is placed 3 cm below umbilicus for the 30° angled telescope to get an
           adequate view. The incision would be enlarged to extract the specimen and performing
           anastomosis.

        -  A12 mm trocar is introduced 5 cm below the telescope port for the surgeon right hand
           instrument.

        -  A 5 mm port is inserted at the McBurney's point for the surgeon's left hand instrument.

        -  Additional two 5 mm trocars are placed at the opposite of McBurney's point and the right
           subcostal position respectively for the assistant to retract and display the colon and
           mesocolon.

      Intraoperatively, all patients will be assessed for:

        -  Time of the procedure.

        -  Amount of blood loss.

      post operatively: Postoperative medications given. Monitoring of vital signs and drains. post
      operative assesment of pain is subjective to the participant as he gave it a score from 1 to
      10. minimal pain score(1 to 3), mild (4 to 6) and sever (7 to 10). Ambulation and clear oral
      fluids started when intestinal sounds are audible followed by soft diet. The intraperitoneal
      tube drain removed when there is less than 50cc of fluid per 24h or after performing
      ultrasonography.

      Follow up:

      Participants are reviewed as outpatients weekly for 1 month or more frequent if they develop
      any complications between their visits.

      The postoperative pathological results, number of lymph node dissection, postoperative
      exhaust time, postoperative abdominal drain volume and duration, postoperative short term
      complications, hospital stay and postoperative pathological staging will be recorded.
    

Intervention name(s): combined medial and caudal approach right hemicolectomy open and laparoscopic
Intervention type(s): Procedure
Intervention description(s): resection of right colon cancer by this radical approach
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Intervention model description: all participants underwent right hemicolectomy using combined medial and caudal approach and divided into 2 groups group I had open surgery and group II had laparoscopic surgery
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: right colon; medial and caudal approach; hemicolectomy