Left Colectomy
Michael A. Valente
Left Colectomy
Surgical excision of the left and/or sigmoid colon is most often performed for malignant disease and also for benign conditions, such as diverticulitis. Inflammatory bowel disease and ischemic colitis are other less common indication for a left colectomy.
The location and extent of the disease dictates the amount of colon to be removed.
Benign conditions such as diverticulitis or sigmoid colon malignancies usually only require a sigmoid colectomy with a descending colon to rectum anastomosis (Fig. 21-1).
FIGURE 21-1 ▪ Sigmoid colon carcinoma. High ligation of the inferior mesenteric artery. Descending colon to rectum anastomosis may be performed for these lesions. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
Malignancies of the left colon require complete mesocolic excision; thus, the left and sigmoid colon must be removed, secondary to high ligation of the inferior mesenteric artery (IMA) and the entire mesocolic fascia is kept intact on the anterior and posterior surfaces (Fig. 21-2).
 FIGURE 21-2 ▪ Left colon carcinoma. High ligation of the inferior mesenteric artery and inferior mesenteric vein will mandate both the left and sigmoid colon to be removed. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.) |
Perioperative Consideration
Formal preoperative assessment, including cardiopulmonary evaluation, basic blood work, and appropriate imaging tests, should be performed to prepare the patient for the operating room.
For cases of carcinoma, complete staging is compulsory, including computed tomography scans of the chest, abdomen, and pelvis, as well as obtaining a carcinoembryonic antigen level.
Nutritional parameters are checked, including albumin and prealbumin.
All patients (unless contraindicated) should receive preoperative oral antibiotics (eg, metronidazole and neomycin), along with a full mechanical bowel preparation, and are provided a chlorhexidine body wash for the night prior to surgery.
In patients who have a diagnosis of neoplasia (adenomatous lesion or invasive cancer), accurate preoperative localization of the lesion is imperative.
If the lesion has not been endoscopically marked (ie, tattoo), a repeat colonoscopy by the surgeon should be performed before the patient is taken to the operating room for accurate localization.
Patient Positioning
Patients are placed in the modified lithotomy position with Yellowfins stirrups or alternatively placed in a split-leg table (Fig. 21-3).
Careful attention is paid to protect bony prominences so as to prevent nerve damage, especially the peroneal and ulnar/radial nerves.
It is our preference to tuck both arms at the patient’s sides for all abdominopelvic cases (open or laparoscopic) for easy access and ergonomic comfort for the surgeons performing the operation.
In general, for laparoscopic cases, the patient is secured to the table over the chest, either with 3-in tape or a Velcro strap.
An inflatable bean bag or foam is also an option.
Guidelines for appropriate antibiotic use are strictly followed in all patients, including 2 g of intravenous ceftriaxone and 500 mg intravenous metronidazole within 60 minutes of incision; penicillin allergic patients will receive 400 mg intravenous ciprofloxacin and 500 mg metronidazole.
Bladder catheter and orogastric tube are routinely placed.
FIGURE 21-3 ▪ Modified lithotomy position. Notice both arms tucked to the patient side for either open or laparoscopic procedures. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
Ureteral stents are very selectively placed to aid in identification of the ureters.
At our institution, ureteral stents are generally reserved for complex reoperative cases with extensive fibrosis or inflammatory changes of the pelvis.
Operative Approach
The vast majority of left colectomies are now performed laparoscopically (Fig. 21-4).
Robotic surgery may also be utilized, although this chapter focuses on the laparoscopic approach.
FIGURE 21-4 ▪ Room setup for laparoscopic left colectomy. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
There is still a role for the open surgical approach as well, especially in cases of previous abdominopelvic surgery or in cases where tumor-specific indications are present, such as a large or T4 neoplasms with invasion into adjacent structures or in some patients who are super morbidly obese.
Equipment
Laparoscopic
Open
Self-retaining retractor
Lighted St. Mark retractor
30-60 mm linear stapler
Atraumatic bowel clamps
Both Approaches
0-Prolene suture
Absorbable 0-ties
Suture of ligature 1- or 0- absorbable suture
End-to-end stapler
Wound protector
Flexible sigmoidoscopy for air leak test
Technique
Basic Operative Steps in Left Colectomy (Regardless of Approach)
Abdominal exploration and lesion identification
High ligation of IMA and inferior mesenteric vein (IMV)
Sigmoid and left colon mobilization
Mobilization of splenic flexure
Proximal colon transection
Distal margin transection (usually at the upper rectum)
Colorectal anastomosis
Creation of diverting loop ileostomy based on multiple factors and not routine.
Abdominal Exploration
Periumbilical access is obtained via cut-down technique and insufflation to 12-15 mm Hg of carbon dioxide ensues.
A 12-mm port is placed in the right lower quadrant, one 5-mm port in the right upper quadrant, and an optional 5-mm port can be placed on the left lower/left lateral quadrant (Fig. 21-5).
If open, the incision is made via the midline from the above the umbilicus down to the level above the pubic symphysis.
Upon entering the abdomen, a thorough exploration is performed to exclude metastatic disease. The peritoneum is inspected for tumor implantation, and the liver is examined.
Adnexal structures are examined in the pelvis for any signs of metastatic spread.
Assessment of any lateral extension of the tumor or potential invasion into any adjacent structures is also addressed at this time.
High Ligation of the Inferior Mesenteric Artery and Vein
A medial-to-lateral approach is typically preferred and undertaken for all cancer operations by the author (for both open and laparoscopic approaches).
In open cases, the peritoneum on both sides of the rectum is incised at the level of the sacrum promontory, with care to avoid the ureters and the sympathetic nerves.
The dissection is carried underneath the superior rectal artery and is continued medially to the origin of the IMA off of the aorta.Related posts:
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