Ileocecal Resection
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Ileocecal resection is the surgical removal of the cecum along with the most distal portion of the small bowel—specifically, the terminal ileum (TI). This is the most common operation performed for Crohn disease, though other indications also exist (see below). Ileoceal resection may be accomplished via either an open or a laparoscopic approach (see Technique). [1, 2, 3, 4, 5] Laparoscopic ileocecal resection appears to be an acceptably safe alternative to the equivalent open procedure, [6, 7] provided that sufficient laparoscopic expertise is available.
Ileocecal resection is indicated for the following:
Ileocecectomy, along with other major operations, is contraindicated in patients with severe medical comorbidities who are critically ill and unable to survive a laparotomy or general anesthesia.
Formal right hemicolectomy, rather than just ileocecal resection, is the treatment of choice for cecal volvulus (with or without ischemia) and right-side colon cancers for which surgery is appropriate (eg, colonic adenocarcinoma, appendiceal malignancy, or a T1 polyp of the cecum that is endoscopically unresectable).
As in all surgery, understanding the anatomy is key for safe and successful ileocecal resection. [8] The TI empties into the saclike cecum through the ileocecal valve, a mucosal invagination. The appendix originates from the cecum on the posteromedial surface at the convergence of the taeniae coli. The cecum is suspended by a short mesocecum and generally has limited mobility.
The vascular supply of the TI and the cecum is derived from the ileocolic artery, which is a branch of the superior mesenteric artery (SMA). If the right colic artery is present, it can branch off the ileocolic artery. Communication with adjacent vessels in the colon exists via the marginal artery of Drummond. The venous drainage follows the arterial supply and drains into the superior mesenteric vein (SMV), which joins with the splenic vein to form the portal system.
The lymphatic drainage, also following the arterial anatomy, goes to the superior mesenteric lymph nodes. Sympathetic innervation and parasympathetic innervation of the right colon originate from the lower thoracic spinal cord and the right vagus nerve, respectively.
During mobilization of the cecum and right colon, the surgeon must be mindful of the duodenum, kidney, and ureter deep to the colon. (See the image below.)
Novell R et al. Colon. Novell R, Baker DM, Goddard N, eds. Kirk’s General Surgical Operations. 6th ed. Edinburgh: Elsevier; 2013. 219-20.
Hunt SR. Open right colectomy. Fleshman JW, Birnbaum EH, Hunt SR, eds. Atlas of Surgical Techniques for Colon, Rectum and Anus. Philadelphia: Elsevier Saunders; 2013. 2-11.
Dietz DW. Part 1: right colon, open medial to lateral. Wexner SD, Fleshman JW, Fischer JE, eds. Colon and Rectal Surgery: Abdominal Operations. Philadelphia: Lippincott Williams & Wilkins; 2012. 1-7.
Husain F, Kodner I, Lin E. Part 1: right colon, open lateral to medial. Wexner SD, Fleshman JW, Fischer JE, eds. Colon and Rectal Surgery: Abdominal Operations. Philadelphia: Lippincott Williams & Wilkins; 2012. 9-16.
Franklin ME, Russek K. Laparoscopic right hemicolectomy. Fischer JE, Jones DB, Pomposelli FB. Fischer’s Mastery of Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. Chap 155.
Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Is laparoscopic ileocecal resection a safe option for Crohn’s disease? Best evidence topic. Int J Surg. 2014. 12 (5):22-5. [Medline]. [Full Text].
Cocorullo G, Tutino R, Falco N, Salamone G, Fontana T, Licari L, et al. Laparoscopic ileocecal resection in acute and chronic presentations of Crohn’s disease. A single center experience. G Chir. 2017 Sep-Oct. 37 (5):220-223. [Medline]. [Full Text].
Wick EC. Colonic and rectal anatomy and physiology. Mulholland MW, Lillemoe KD, Doherty GM, eds. Greenfield’s Surgery: Scientific Principles and Practice. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2011. 1017-21.
Billingham RP, Rossi DC. Preoperative bowel preparation: is it necessary?. Cameron JL, Cameron AM, eds. Current Surgical Therapy. 10th ed. Philadelphia: Elsevier Saunders; 2011. 131-2.
Gardenbroek TJ, Verlaan T, Tanis PJ, Ponsioen CY, D’Haens GR, Buskens CJ, et al. Single-port versus multiport laparoscopic ileocecal resection for Crohn’s disease. J Crohns Colitis. 2013 Nov. 7 (10):e443-8. [Medline].
de Groof EJ, Buskens CJ, Bemelman WA. Single-Port Surgery in Inflammatory Bowel Disease: A Review of Current Evidence. World J Surg. 2016 Sep. 40 (9):2276-82. [Medline]. [Full Text].
Juan L Poggio, MD, MS, FACS, FASCRS Associate Professor of Surgery, Chief, Division of Colorectal Surgery, Department of Surgery, Drexel University College of Medicine
Juan L Poggio, MD, MS, FACS, FASCRS is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons
Disclosure: Nothing to disclose.
Andrew C Raissis, MD Fellow, Department of Colon and Rectal Surgery, MedStar Washington Hospital Center
Andrew C Raissis, MD is a member of the following medical societies: American Society of Colon and Rectal Surgeons
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Keith D Gray, MD, FACS Chief, Division of Surgical Oncology, Assistant Professor, Department of Surgery, University of Tennessee Graduate School of Medicine; Medical Director, Gastrointestinal Tumor Service (GITS), The University of Tennessee Medical Center Cancer Institute; Clinical Specialist, Department of Surgery, The University of Tennessee Medical Center
Keith D Gray, MD, FACS, is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, National Medical Association, Society of Surgical Oncology, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.
Khanjan H Nagarsheth, MD Chief Resident in General Surgery, Department of Surgery, University of Tennessee Health Science Center College of Medicine
Khanjan H Nagarsheth, MD, is a member of the following medical societies: American College of Surgeons and Tennessee Medical Association
Disclosure: Nothing to disclose.
Ileocecal Resection
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