Laparoscopic redo ileocolic anastomosis for anastomotic leakage after right hemicolectomy: A case report

Abstract

BACKGROUND

Anastomotic leakage (AL) after right hemicolectomy is less common than after rectal surgery, yet it often necessitates prompt surgical intervention once it occurs. Reoperation is typically performed via an open approach, and reports of laparoscopic redo anastomosis are scarce. Owing to the rarity of this complication, practical surgical decision-making and technical details are insufficiently described. This case report presents step-by-step techniques and key considerations for laparoscopic redo ileocolic anastomosis in a carefully selected patient.

CASE SUMMARY

A 77-year-old man with multiple comorbidities presented with hematochezia and was diagnosed with ascending colon cancer. He underwent laparoscopic right hemicolectomy with D3 complete mesocolic excision and central vascular ligation. On postoperative day 6, AL was suspected following colonoscopy performed for recurrent bleeding. Emergency reoperation revealed localized peritonitis without generalized contamination. Laparoscopic redo ileocolic anastomosis was performed after careful assessment of retroperitoneal adhesions, followed by selective protective ileostomy. The postoperative course was uneventful, and the patient was discharged on postoperative day 8.

CONCLUSION

Laparoscopic redo ileocolic anastomosis is feasible for AL after right hemicolectomy in carefully selected patients.

Key Words: Right hemicolectomy; Anastomotic leakage; Laparoscopic reoperation; Redo anastomosis; Case report

Core Tip: Anastomotic leakage after right hemicolectomy is uncommon but usually requires surgical reintervention once diagnosed. Laparoscopic redo anastomosis remains rarely reported, and practical guidance for real-world decision-making is limited. This case report demonstrates a stepwise approach to laparoscopic redo ileocolic anastomosis, emphasizing early assessment of peritonitis, careful evaluation of retroperitoneal adhesions near the duodenum and pancreas, and key technical strategies to avoid major complications. This report provides practical insights for surgeons considering a minimally invasive approach in carefully selected patients.

INTRODUCTION

Anastomotic leakage (AL) remains one of the most serious complications following colorectal cancer surgery and is associated with significant morbidity, prolonged hospitalization, and increased mortality[1,2]. The incidence of AL varies according to tumor location. While AL occurs more frequently after rectal cancer surgery, reported in up to 8%-15% of cases, the incidence after right hemicolectomy is generally lower, ranging from approximately 3% to 5%[3].

With advances in minimally invasive techniques, laparoscopic and robotic right colectomy with complete mesocolic excision and D3 lymphadenectomy have demonstrated favorable short- and long-term oncologic outcomes[4-7]. However, despite its relatively low incidence, AL after right hemicolectomy almost always requires active intervention once diagnosed[8]. Unlike rectal AL, which may sometimes be managed with fecal diversion alone, leakage after right-sided colectomy frequently necessitates resection and redo anastomosis because of intraperitoneal contamination and the absence of a distal reservoir[8,9].

Although laparoscopic reintervention for AL after right hemicolectomy has been reported, the available evidence is limited to small retrospective series from highly selected centers[8]. In particular, previous studies have primarily focused on feasibility and short-term outcomes, while detailed descriptions of intraoperative decision-making and step-by-step surgical techniques are scarce, and video-based reports remain extremely limited[8-10]. Therefore, we present a case of AL after laparoscopic right hemicolectomy successfully managed with laparoscopic redo ileocolic anastomosis. This report aims to share practical technical tips and decision-making strategies that may assist surgeons facing similar situations.

CASE PRESENTATION

Chief complaints

A 77-year-old man presented to the Department of Emergency with acute hematochezia.

History of present illness

Despite two days of conservative management and temporary discontinuation of clopidogrel, bleeding persisted. Colonoscopy revealed an ascending colon tumor with active luminal bleeding. Emergency surgery was planned on hospital day 5.

History of past illness

The patient had a history of hypertension, diabetes mellitus, atrial fibrillation, chronic kidney disease on maintenance hemodialysis, and non-ST-elevation myocardial infarction treated with drug-eluting stents in the left anterior descending and left circumflex arteries five years earlier. He had been receiving long-term clopidogrel therapy.

Personal and family history

There was no remarkable personal or family history related to gastrointestinal malignancy.

Physical examination

On admission, the patient was hemodynamically stable. Abdominal examination revealed no tenderness, guarding, or palpable mass.

Laboratory examinations

Initial laboratory investigations demonstrated anemia consistent with acute gastrointestinal bleeding. No laboratory findings suggestive of systemic infection or organ dysfunction were identified.

Imaging examinations

Initial colonoscopy demonstrated an ascending colon cancer with active luminal bleeding (Figure 1A). On postoperative day 6, the patient developed recurrent hematochezia, with more than 800 g of bloody output within six hours. Colonoscopy revealed no active bleeding. A blood clot was identified at the anastomotic site (Figure 1B) and was removed by irrigation, with the post-irrigation endoscopic appearance of the anastomotic site (Figure 1C). Postoperative computed tomography revealed perianastomotic inflammation and free air consistent with AL (Figure 2).

Figure 1 Intraoperative and postoperative colonoscopic findings of the ileocolic anastomosis. A: Preoperative colonoscopic findings demonstrating an ulcerofungating mass in the ascending colon with active luminal bleeding; B: Colonoscopic view of the ileocolic anastomosis showing an adherent blood clot without active bleeding; C: Post-irrigation colonoscopic view of the ileocolic anastomosis after removal of the blood clot.

Figure 2 Contrast-enhanced computed tomography demonstrating increased perianastomotic inflammatory changes with extraluminal free air, consistent with anastomotic leakage.

FINAL DIAGNOSIS

Bleeding ascending colon adenocarcinoma with invasion into the subserosa, moderately differentiated, with all 21 harvested lymph nodes negative, no lymphovascular or perineural invasion, and clear resection margins for a tumor measuring 8.0 cm × 5.5 cm, complicated by AL after laparoscopic right hemicolectomy.

TREATMENT

Initial operation

Laparoscopic right hemicolectomy was performed under general anesthesia using a five-port technique, following oncologic principles of D3 complete mesocolic excision with central vascular ligation. The right colon was mobilized using an inferior-to-superior approach with careful preservation of the ureter and retroperitoneal structures. Central vascular ligation was achieved at the origin of the ileocolic vessels, and the right branch of the middle colic artery was divided while preserving the left branch. Specimen extraction was performed through a 4-cm mini-laparotomy. A side-to-side functional ileocolic anastomosis was created using linear staplers with reinforcement sutures. The anastomosis was covered with omentum, and a drain was placed. Operative time was 100 minutes with an estimated blood loss of 20 mL. R0 resection was achieved.

Diagnosis of AL

On postoperative day 6, the patient developed recurrent hematochezia with more than 800 g of bloody output within six hours. Colonoscopy revealed a blood clot at the anastomotic site without active bleeding (Figure 1B and C). Shortly thereafter, drain output abruptly increased and resembled intraluminal bloody material. Computed tomography demonstrated perianastomotic inflammation and free air, leading to the diagnosis of AL (Figure 2).

Reoperation and technical considerations

Reoperation was performed laparoscopically under general anesthesia. An 11-mm camera port was inserted through the previous infraumbilical incision, and the abdominal cavity was explored. Localized peritonitis without generalized contamination or severe ileus was observed, and laparoscopic reintervention was deemed feasible. Three additional ports were placed through the previous trocar sites. The anastomotic site was found to be covered by omentum, with surrounding inflammatory changes and bloody material. Careful dissection revealed a pinpoint defect at the functional anastomosis, through which bloody material was discharged.

Key technical steps

Key technical steps including: First, the feasibility of laparoscopic redo surgery was assessed by gently lifting the anastomosis with laparoscopic instruments to evaluate adhesion to the retroperitoneum, particularly near the duodenum and pancreas. Excessive traction or aggressive use of energy devices was avoided, as injury to retroperitoneal organs can be catastrophic. Second, the omentum covering the anastomosis was carefully separated using primarily mechanical force. Energy devices were minimized, especially near the duodenum and pancreas. Third, approximately 5 cm distal to the anastomosis, the transverse colon was transected using a linear stapler. This early distal transection provided effective traction and facilitated safer dissection of the anastomosis from the retroperitoneum.

After sufficient mobilization, the specimen was retrieved through the previous mini-laparotomy. Approximately 5 cm proximal to the anastomosis, the ileum was transected. A redo functional ileocolic anastomosis was constructed extracorporeally using linear staplers, and reinforcement sutures were applied. Given the patient’s prolonged fasting period and the need for early resumption of antiplatelet therapy, a protective loop ileostomy was created in the right lower quadrant. The omentum was repositioned to cover the new anastomosis. The key steps of the procedure are demonstrated in Video.

OUTCOME AND FOLLOW-UP

The patient was managed in the intensive care unit for two days because of his cardiac comorbidities. Oral intake was resumed on postoperative day 2. He recovered without further complications and was discharged on postoperative day 8. The overall clinical course is summarized in Table 1.

Table 1 Timeline of clinical events.

Time point	Event	Details
Hospital day 1	Emergency department visit	77-year-old man presented with hematochezia; multiple comorbidities (HTN, DM, AF, CKD on hemodialysis, prior NSTEMI)
Hospital day 1-2	Initial conservative management	Temporary discontinuation of clopidogrel; persistent hematochezia despite 2 days of conservative treatment
Hospital day 3	Diagnostic colonoscopy	Ascending colon cancer with active luminal bleeding
Hospital day 5	Initial surgery	Laparoscopic right hemicolectomy with D3 complete mesocolic excision and central vascular ligation; extracorporeal side-to-side ileocolic anastomosis; omental coverage
Postoperative day 1-5	Early postoperative course	Initially stable; minimal drain output (2-3 mL/day)
Postoperative day 6	Clinical deterioration	Recurrent hematochezia (> 800 g within 6 hours); colonoscopy showed blood clot at anastomosis without active bleeding
Postoperative day 6	Diagnostic confirmation	Sudden increase in drain output (approximately 50 mL/30 minutes); CT showed perianastomotic inflammation and free air to anastomotic leakage diagnosed
Postoperative day 6	Emergency reoperation	Laparoscopic redo ileocolic anastomosis performed; careful retroperitoneal assessment; extracorporeal reconstruction; selective protective loop ileostomy
Postoperative day 1-2 after reoperation	Post-reoperation recovery	Intensive care unit care for 2 days due to cardiac history; oral intake resumed on postoperative day 2 after redo surgery
Postoperative day 8 after reoperation	Discharge	Uneventful recovery; discharged without further complications

HTN: Hypertension; DM: Diabetes mellitus; AF: Atrial fibrillation; CKD: Chronic kidney disease; NSTEMI: Non-ST elevation myocardial infarction; CT: Computed tomography.

DISCUSSION

AL after right hemicolectomy is less frequent than after rectal cancer surgery, with reported rates of approximately 3%-5%, but it remains a clinically significant complication once it occurs[3]. Unlike rectal AL, which may sometimes be managed conservatively with fecal diversion alone, leakage after right-sided colectomy usually necessitates surgical intervention due to intraperitoneal contamination and the absence of a distal reservoir[8,9]. Consequently, prompt reoperation is often required.

Despite the increasing adoption of minimally invasive techniques in colorectal surgery, open surgery remains a common approach for reoperation in cases of AL after right hemicolectomy[8,9]. Previous studies have shown that laparoscopic reintervention is feasible in carefully selected patients; however, available evidence is limited to small retrospective series from highly specialized centers, and most reports focus primarily on feasibility and short-term outcomes rather than on detailed intraoperative strategies. As a result, practical guidance regarding intraoperative decision-making and step-by-step technical considerations for laparoscopic redo anastomosis remains limited.

This case report therefore focuses on case-specific intraoperative decision-making and technical lessons demonstrated during laparoscopic redo ileocolic anastomosis. Rather than attempting to expand existing outcome data, the present report aims to illustrate how laparoscopic reintervention can be safely approached in a real-world emergency setting. Several key factors contributed to the successful outcome in this case.

First, careful patient selection and early intraoperative feasibility assessment were essential. Laparoscopic reintervention was considered after careful assessment of the extent of peritonitis and bowel distension at the beginning of reoperation. Equally important was early evaluation of adhesions between the anastomosis and retroperitoneal structures, particularly the duodenum and pancreas. Dense adhesion in this area carries a substantial risk of iatrogenic injury if aggressive laparoscopic dissection is attempted. Therefore, this relationship should be assessed at an early stage of laparoscopy, and failure to achieve safe mobilization with gentle traction alone should prompt consideration of conversion to open surgery.

Second, meticulous dissection techniques were critical. In redo surgery following D3 complete mesocolic excision, the anastomosis is often adherent to the retroperitoneum, especially near the duodenum and pancreas. Aggressive traction or liberal use of energy devices in this region may result in serious complications. As demonstrated in the accompanying video, mechanical dissection using laparoscopic instruments was prioritized, and energy devices were used sparingly and only when clearly safe.

Third, early distal transection of the transverse colon proved to be a useful technical maneuver. Transecting the bowel distal to the anastomosis provided effective traction and improved exposure, facilitating safer mobilization of the anastomosis from surrounding structures. This approach may be particularly helpful when inflammatory adhesions limit visualization and should be considered as part of a standardized strategy for laparoscopic redo surgery.

The role of omental coverage at the initial operation also deserves consideration. In this patient, the anastomosis was well covered by omentum, and contamination remained localized at the time of reoperation. Although definitive evidence is lacking, omental coverage may help delay progression from localized to generalized peritonitis, thereby providing a critical window for early diagnosis and minimally invasive reintervention.

Protective ileostomy was selectively performed in this case due to the patient’s prolonged fasting period and the need for early resumption of antiplatelet therapy following myocardial infarction. This highlights that fecal diversion should be individualized rather than routinely applied, taking into account both surgical and medical risk factors.

This report has several limitations. It represents a single case, and the findings cannot be generalized to all patients with AL after right hemicolectomy. Moreover, laparoscopic redo anastomosis should be attempted only by surgeons experienced in advanced minimally invasive colorectal surgery. Nevertheless, by providing a concise surgical video and focused technical discussion, this report offers practical insights that may assist surgeons when managing carefully selected cases.

CONCLUSION

Laparoscopic redo ileocolic anastomosis can be a feasible and safe option for AL after right hemicolectomy in carefully selected patients. The accompanying surgical video provides practical technical insights that may assist surgeons considering a minimally invasive approach for this challenging condition.