Ileocecal Resection

Updated: Feb 08, 2017
  • Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Kurt E Roberts, MD  more...
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Overview

Background

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.

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Indications

Ileocecal resection is indicated for the following:

  • Crohn disease complicated by stricture of the TI after failed medical therapy
  • Cecal perforation
  • High-risk premalignant polyps of the cecum that are not amenable to endoscopic polypectomy
  • High-risk benign polyps not amenable to endoscopic polypectomy (eg, large tubulovillous adenoma)
  • Lower gastrointestinal (GI) hemorrhage localized to the cecum
  • Noniatrogenic injury (eg, gunshot wound with cecal perforation)
  • Iatrogenic injury (eg, perforation or hemorrhage after colonoscopy or polypectomy)
  • Palliatiion in specific cases (eg, cecal cancer with metastasis with complications such as bleeding or obstruction)
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Contraindications

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).

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Technical Considerations

Anatomy

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.)

Arterial blood supply to colon. Arterial blood supply to colon.
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