With the wide acceptance of laparoscopic surgery for colon cancer, most patients with right colon pathology, both benign and malignant, are being treated by the “minimally invasive” approach. Within our department, the number of open right colectomies has dropped precipitously over the past 10 years. However, due to our department’s reputation as a national referral center for complex colorectal problems, approximately 50% of right colectomies are still performed using an open technique. The principle indications in these cases are locally advanced colon cancer and recurrent inflammatory bowel disease.

In most centers, open right colectomy is most commonly performed using a “lateral-to-medial” approach where the tumor is manipulated prior to ligation of the venous drainage. In the 1950s, however, seminal work by Barnes (1) and Turnbull (2) led to the development of a “no touch” isolation approach to segmental colectomies in patients with cancer. The principles of the “no touch” technique were based on the observations by several investigators that cancer cells were actively shed into the bloodstream during tumor manipulation. This concept was first introduced by Tyzzer (3) in 1913 who found that the vigorous manipulation of implanted chest wall tumors in mice resulted in the development of extensive liver metastases. In 1954, Cole et al. (4) reported the finding of shed cancer cells in the portal venous blood of a perfused resected cancer-bearing segment of human colon. One year later, Fisher and Turnbull (5) reported cancer cells in the portal venous blood of 8 of 25 resected colectomy specimens.

In 1952, Barnes (1) described a technique for right colectomy whereby the vascular pedicles and adjacent lymphatic channels were ligated prior to mobilization of the colon and manipulation of the tumor. The procedure began with division of the mid-transverse colon. Beginning with the middle colic vessels, the mesenteric dissection proceeded toward the terminal ileum, dividing and ligating the right branch of the middle colic artery and vein, right colic vessels, and ileocolic pedicle. The terminal ileum was then divided. Only at this point, with the vascular and lymphatic drainage of the right colon controlled, was the tumor manipulated to allow division of the lateral attachments of the right colon and completion of the operation. Barnes noted that this technique was proposed in order to “prevent forcing, by such manipulation, malignant cells into the areas beyond the site of surgery via the blood and lymph channels.”
The author also stated that a literature search, as well as personal visits to some of the largest surgical clinics of the time, led him to believe that these principles were being ignored by surgeons of the day and most right colectomies were being performed in nononcologic fashion; similar to the lateral-to-medial approach taught to most residents and fellows today! Barnes concluded that “the procedure now seems so reasonable and based on such good surgical principles that I cannot believe it to be a new departure, but merely the dusting off of a very old (albeit long forgotten) technique.”

In 1953, Turnbull (2) (Fig. 1.1), who was then the chairman of the Department of Colon and Rectal Surgery at the Cleveland Clinic, devised a similar operation that followed these basic oncologic principles. Termed the “no-touch isolation technique,” it involved a unique medial-to-lateral approach to vascular ligation prior to tumor manipulation. His initial report on the results of the technique, presented to the American Surgical Association in 1967, was hailed by discussants as “the most important advance in the surgical treatment in carcinoma of the colon in the (preceding) thirty years” (2). Turnbull compared 664 patients operated upon using his “no touch” technique with 232 patients undergoing “conventional” colectomy and found a marked improvement in 5-year survival rates (50.8% vs. 34.8%). This overall survival rate of 50% was unheard of at the time, as the usual rate for colon cancer was between 25% and 35%. Further examination of the data revealed that the greatest advantage for the “no touch” technique was in patients with stage C (lymph node positive) tumors (58% vs. 28%).

Subsequent studies, however, have failed to firmly demonstrate this advantage for Turnbull’s “no touch” technique. Despite this, a “no touch” segmental colectomy is still performed by many of the colorectal surgeons in our department.