Introduction: This case report analyzes the clinical symptoms, comorbidity factors, surgical approach, and postoperative outcomes of a patient with hepatic flexure cancer at UMHATEM “N. I. Pirogov” EAD.

Case presentation: Clinical data for a 65-year-old woman with a colonic neoplasm, operated on in the Department of General, Visceral, and Emergency Surgery at UMHATEM “N. I. Pirogov” EAD on 30 January 2024, were analyzed. Comorbidity factors were idiopathic thrombocytopenic purpura (PLT 77,000) and Hashimoto’s disease. Surgery was performed after 5 days of preparatory therapy with platelet concentrate and methylprednisolone, resulting in PLT 89,000. Operative time was 189 min; blood loss was 70 mL. There were no intraoperative complications.

Conclusion: Laparoscopic right hemicolectomy offers significant advantages, being both safe and effective. This approach yields favorable initial outcomes, including a reduced incidence of complications. Furthermore, it accords with essential oncologic tenets while maintaining comparable surgical durations.

neoplasm, colon, laparoscopic surgery, approach, outcomes, thrombocytopenia

Colorectal cancer poses a major global health threat, with increasing incidence and mortality rates worldwide. According to the International Agency for Research on Cancer’s (IARC) GLOBOCAN 2020 project, age-standardized incidence rates (ASIR) and age-standardized mortality rates (ASMR) per 100,000 individuals were calculated. The association between ASIR, ASMR, and the HDI was analyzed using Pearson correlation, considering a statistical significance threshold of p < 0.05. In 2020, a total of 1,931,590 new colorectal cancer cases were recorded globally, with a male predominance of 55.18%. The global colorectal cancer ASIR was 19.5 per 100,000 (23.4 in males, 16.2 in females). Furthermore, there were 935,173 colorectal cancer-related deaths, with males accounting for 55.13%. The overall colorectal cancer ASMR was 9 (11 in males, 7.2 in females). A strong positive correlation emerged between ASIR and ASMR (0.895, p ≤ 0.001), HDI (0.794, p ≤ 0.001), and life expectancy (0.724, p ≤ 0.001) (Darmadi et al. 2025).

Globally, colorectal cancer (CRC) is the third most frequent neoplasm among men and ranks second in women (Vabi et al. 2021; Viale 2020). Right-sided colon cancers represent roughly 15% of CRC cases, primarily affecting patients in their seventies.

For early-stage CRC, endoscopic treatment, including endoscopic mucosal resection and endoscopic submucosal dissection, has been performed. However, lymph node dissection is an integral part of surgical treatment for advanced-stage cancer because of the high incidence of lymph node metastasis. Conventional open surgery has evolved into laparoscopic and robotic surgery. Furthermore, multidisciplinary treatment is needed to cure CRC completely (Shinji et al. 2022). The goal of surgery is the en bloc removal of the diseased colonic segment with 5-cm margins and lymphadenectomy (mesocolic excision). A minimum of 12 lymph nodes is required for adequate staging (Benson et al. 2021).

Following Jacobs’ groundbreaking work in 1991 (Jacobs et al. 1991), advancements in technology and the standardization of surgical methods have spurred the growth of laparoscopic colorectal surgery (LCS), generating a substantial body of research in this area.

Laparoscopic colorectal surgery has now become widely adopted for the treatment of colorectal neoplasia. Common minimally invasive techniques include multiport laparoscopy, single-incision laparoscopy, and hand-assisted laparoscopy, with the choice of technique depending on several patient and surgeon factors (Parker et al. 2017).

The minimally invasive technique for treating right colon tumors employs laparoscopic-assisted right colectomy (LARC) paired with extracorporeal ileocolic anastomosis (ECA).

Contemporary reviews comparing outcomes of open and laparoscopic right colectomy reveal no statistically significant disparities in complication rates, overall morbidity, or mortality (Zheng et al. 2005).

Performing a laparoscopic right colectomy that also includes intracorporeal anastomosis is considered a more challenging procedure and a frequent subject of debate among surgeons (Bergamaschi et al. 2008).

The benefits of the minimally invasive method in colorectal surgery are clearly established in numerous reviews. It correlates with superior perioperative results compared with traditional open procedures. This includes several advantages, such as reduced reliance on postoperative pain medication, faster return to normal bowel function, and reduced hospital stay duration (Abraham et al. 2007; Hewett et al. 2008).

Different strategies to perform laparoscopic right hemicolectomy (LRC) involve considerations such as total mesocolic excision and variations in dissection (from “cranial” to “caudal,” from “caudal” to “cranial,” from “lateral” to “medial,” or from “medial” to “lateral”), as well as incision location for specimen extraction and the specific anastomosis method utilized (Fabozzi et al. 2016; Li et al. 2016; Lu et al. 2016).

The principle of complete mesocolic excision (CME), incorporating high arterial ligation as advocated by Hohenberger et al., is now regarded by surgical teams as the gold standard in the management of colonic tumors (West et al. 2010). Significant improvements in oncologic outcomes have been documented (West et al. 2008; Chebbi et al. 2015).

This case report aims to analyze the clinical symptoms, comorbidity factors, surgical approach, and postoperative outcomes of a patient with hepatic flexure cancer and thrombocytopenia at UMHATEM “N. I. Pirogov” EAD.

A platelet count below the lower limit of normal (150,000/µL for adults) is defined as thrombocytopenia. Platelets are blood cells that contribute to blood clotting and wound healing – risks associated with thrombocytopenia range from no risk to bleeding and thrombosis. The correlation between the severity of thrombocytopenia and bleeding risk remains uncertain. Spontaneous bleeding can occur with a platelet count under 10,000/µL, and surgical bleeding with counts below 50,000/µL. Thrombocytopenia is also associated with thrombosis in conditions such as heparin-induced thrombocytopenia (HIT), antiphospholipid antibody syndrome (APS), disseminated intravascular coagulation (DIC), thrombotic microangiopathy (TMA), and paroxysmal nocturnal hemoglobinuria (PNH) (Jinna and Khandhar 2023).

Thrombocytopenia is categorized numerically into three stages: mild, 100,000–150,000/µL; moderate, 50,000–100,000/µL; and severe, < 50,000/µL. However, thrombocytopenia is not usually detected clinically until platelet counts fall below 100,000/µL. Severe thrombocytopenia, such as intracerebral or intra-abdominal bleeding, may be life-threatening, and immediate treatment can be lifesaving. Platelet transfusion is not required in all cases of thrombocytopenia (Erkurt et al. 2012).

Preoperative thrombocytopenia is associated with inferior outcomes in surgical patients. In an observational cohort study of adults undergoing elective surgery, results were summarized by Matzek et al. (2021).

Figure 1. 

Options for colorectal cancer treatment.

Figure 2. 

Life-threatening complications of platelet transfusion.

A total of 120,348 patients were included in the analysis: 72.3% (95% CI, 72.1–72.6) had normal preoperative laboratory values, 26.3% (26.1–26.6) had isolated anemia, 0.80% (0.75–0.86) had thrombocytopenia with anemia, and 0.52% (0.48–0.56) had isolated thrombocytopenia (0.38% [0.34–0.41] nonincidental, 0.14% [0.12–0.17] incidental). Thrombocytopenia was associated with longer hospital stays in patients with concurrent anemia (multiplicative increase of the geometric mean 1.05 [1.00, 1.09] days; p = 0.034) but not in those with normal preoperative hemoglobin concentrations (multiplicative increase of the geometric mean 1.02 [0.96, 1.07] days; p = 0.559). Thrombocytopenia was associated with increased odds of intraoperative transfusion regardless of anemia status (nonanemic: 3.39 [2.79, 4.12]; p < 0.001; anemic: 2.60 [2.24, 3.01]; p < 0.001). Thrombocytopenia was associated with increased rates of intensive care unit (ICU) admission in nonanemic patients (1.56 [1.18, 2.05]; p = 0.002) but not in those with preoperative anemia (0.93 [0.73, 1.19]; p = 0.578) (Matzek et al. 2021).

A low platelet count is a relative contraindication to surgery due to the risk of bleeding. Platelet transfusions are used in clinical practice to prevent and treat bleeding in patients with thrombocytopenia. Current practice in many countries is to correct thrombocytopenia with platelet transfusions before surgery, although alternatives are also used (Estcourt et al. 2018).

Platelet transfusion may precipitate complications ranging from benign to life-threatening (Kiefel 2008; Agarwal et al. 2025).

Clinical data for a 65-year-old woman with a colonic neoplasm, operated on in the Department of General, Visceral, and Emergency Surgery at UMHATEM “N. I. Pirogov” on 30 January 2024, were analyzed.

The diagnosis was based on history, physical examination, ultrasound, colonoscopy, and CT. FCS results and histology verification revealed adenocarcinoma in situ in the hepatic flexure. CT showed a hepatic flexure tumor without lymphatic or hematogenous metastasis. Blood test results confirmed thrombocytopenia (PLT 77,000).

In this study, the following parameters were assessed: age, gender distribution, clinical symptoms, mode of treatment, morbidity, and mortality. Comorbidity factors were idiopathic thrombocytopenic purpura (PLT 77,000) and Hashimoto’s disease. The hematologist prescribed 5 E thrombocyte concentrate and urbason 40 mg (2 doses per day) for 5 days before surgical intervention. Endocrinology consultation determined that no additional therapy was needed. ASA score was II; BMI was 26. Previous abdominal surgery: appendectomy during childhood.

A minimally invasive right hemicolectomy involves the ligation of several key arteries: the ileocolic artery, the right colic artery (if present), and the right branch of the middle colic artery. The proximal bowel is divided at the terminal ileum, while the distal division occurs at the transverse colon. The anastomosis is typically constructed either using a side-to-side technique between the terminal ileum and transverse colon or through stapling.

We have a preference for the Delphi procedure, which involves several critical steps. The initial phase encompasses dissecting the gastrocolic ligament. This dissection is carried out along the greater curvature of the stomach, positioned close to the gastroepiploic vessels. The stomach and omentum are then detached from the ventral surface of the transverse mesocolon. Following this, the Toldt fascia is carefully separated, and the right colic flexure is freed from the Gerota fascia, allowing its mobilization towards the midline. Subsequently, dissection continues within the plane of the Toldt fascia, and the right colon, along with its mesocolon, undergoes complete dissection.

The mesocolon is then dissected along the mesenteric root, with the right colic vessels sealed. Removal of the mesocolon proceeds accordingly. The ileocolic anastomosis can be achieved through various methods, including intracorporeal or extracorporeal techniques. A stapled side-to-side anastomosis is frequently employed. A crucial step involves confirming the absence of any twists in the bowel. Once the anastomosis is completed, the specimen is extracted, and the mesentery is closed. Finally, a thorough laparoscopic inspection is conducted after closing the laparotomy.

Histology revealed tubular adenoma with high-grade dysplasia and transition into highly differentiated colonic adenocarcinoma with infiltration into the lamina propria, without infiltration through the muscularis mucosae. The fibrovascular axis and base of the tumor showed no neoplastic infiltration. Resection lines were free of tumor infiltration. Isolated lymph nodes showed no metastases.

The patient provided written informed consent to participate. The study was also authorized by the institutional ethics committee.

Surgery was performed after 5 days of preparatory therapy with thrombocyte concentrate and methylprednisolone, resulting in PLT 87,000. Operative time was 189 min; blood loss was 70 mL. There were no intraoperative complications.

Postoperative flatus recovery occurred on the 3^rd postoperative day. The timing of the first stool was on the 4^th postoperative day, after which the nasogastric tube was removed. Hospital stay, drain removal, and discharge occurred on the 5^th postoperative day.

The postoperative complication was wound infection, present until the 3^rd postoperative day, and treated with antiseptic dressing.

The verified histology result was low-grade adenocarcinoma – pTis N0 M0 R0 L0 V0. The distal margin of resection was 7 cm, and the proximal margin 21 cm. The number of harvested lymph nodes was 14, all negative.

No postoperative chemotherapy was recommended.

The advantages observed with laparoscopy in the immediate aftermath, compared with open surgical approaches, are widely acknowledged. These include reduced pain, improved respiratory function, a decreased incidence of postoperative ileus, and a shorter period of hospitalization (Weeks et al. 2002; Veldkamp et al. 2005). These positive outcomes are directly linked to a lesser degree of surgical trauma, along with a diminished systemic stress response following laparoscopic intervention (Wu et al. 2003).

The clinical benefits of laparoscopic surgery are well established, but evidence for financial benefits is limited. A study that included patients who underwent colorectal surgery between January 2010 and 2015 collected a range of financial data and divided patients into two groups. The primary outcome was total cost, defined by surgery-related costs.

A total of 1,246 patients were included, of which 440 surgeries were performed laparoscopically. The total median cost of laparoscopy was higher compared with open surgery (EUR 4,665 vs EUR 4,268, p = 0.001). Laparoscopy was associated with higher equipment costs (EUR 857 vs EUR 232, p < 0.001), longer operating time (3.2 vs 2.5 hours, p < 0.001), and more readmissions (10.9% vs 8.5%, p < 0.001). However, after adjusting for heterogeneity, no difference was found in total cost. Surgery-related costs were counterbalanced by lower costs associated with shorter median hospital stay (6 vs 9 days, p < 0.001), less morbidity (37.3% vs 55.1%, p < 0.001), and lower mortality (1.8% vs 5.6%, p = 0.013) for laparoscopy (Maassen van den Brink et al. 2021).

Laparoscopic colorectal surgery (LCS) consistently achieves superior oncological results compared with open procedures, notably mitigating critical risks related to port-site metastases. It also addresses doubts regarding the adequacy of oncologic resections.

There is growing evidence that the laparoscopic approach is equivalent or superior to open operation for a broad spectrum of colorectal procedures. Laparoscopic colectomy was accepted later due to its technical complexity, despite its favorable outcomes (Kumar et al. 2023).

Contemporary guidelines for achieving oncologic radicality advocate meticulous techniques, including proximal ligation of the principal arterial supply, establishment of adequate proximal and distal resection margins, careful dissection of lymph nodes, and the implementation of “no-touch isolation” techniques that prevent direct handling or perforation of the tumor. Furthermore, the adoption of a protected specimen retrieval method is highly recommended.

Acknowledging the potential for precise lymph node removal – a direct consequence of vascular ligation – we recognize its necessity intracorporeally, accomplished through Endoclips or staplers, irrespective of the chosen approach, be it LARC or TLRC. The exterior vessel tying of the ileocolic vessels, performed outside the body through a mini-laparotomy, as advocated by Young-Fadok and colleagues, has proven to be more difficult to execute and, from an oncological perspective, less satisfactory.

Currently, we believe that minimally invasive surgery provides the most suitable treatment strategy for such scenarios, since it circumvents the need to remove sizable tissue masses through a large abdominal incision. Externalizing mesenteries that are both heavy and short necessitates more extensive incisions, thereby increasing the likelihood of tearing that could compromise the anastomosis procedure. Patient outcomes, including both morbidity and mortality, align with results documented in worldwide investigations.

A laparoscopic right hemicolectomy offers significant advantages, being both safe and effective. This approach yields favorable initial outcomes, including a reduced incidence of complications. Furthermore, it accords with essential oncologic tenets while maintaining comparable surgical durations.

Conflict of interest

The authors have declared that no competing interests exist.

Ethical statements

The authors declared that no clinical trials were used in the present study.

The authors declared that no experiments on humans or human tissues were performed for the present study.

Informed consent from the humans, donors or donors’ representatives: UMHATEM “Pirogov”.

The authors declared that no experiments on animals were performed for the present study.

The authors declared that no commercially available immortalised human and animal cell lines were used in the present study.

Use of AI

No use of AI was reported.

Funding

No funding was reported.

Author contributions

All authors have contributed to the production of the manuscript.

Author ORCIDs

Konstantin Ivanov Kostov https://orcid.org/0000-0001-8752-8323

Vesselin Marinov Marinov https://orcid.org/0009-0009-5542-1930

Nikolay Zarkov Bashev https://orcid.org/0009-0007-8029-9856

Petar Yordanov Atanasov https://orcid.org/0009-0006-8337-2089

Maria Stamova Vakrilova Becheva https://orcid.org/0000-0002-2734-8280

Angelina Georgieva Kirkova-Bogdanova https://orcid.org/0000-0002-9884-8186

Maria Krasteva Bozhkova https://orcid.org/0000-0002-9115-3437

Data availability

All of the data that support the findings of this study are available in the main text.