Open Medial-to-Lateral

Jorge A. Lagares-Garcia

Paul R. Sturrock

Indications/Contraindications

Segmental colectomy is performed to treat benign or malignant conditions of the colon. Left sided colectomy is performed as a single procedure or as a step in a complex resection such as total abdominal colectomy. The steps of the colectomy have been determined for over a century of medicine, with the most common description being the lateral-to-medial approach. However, Turnbull championed the medial-to-lateral approach as part of the “no touch” technique. Whether it is performed for benign or malignant disease, the steps are simple. The surgeon can rapidly control the vascular pedicle of the segment to be resected and proceed with the dissection. Full identification of vital structures avoids early injury.

Current indications for colon resection are displayed in Table 7.1. Strong consideration should be given to performing an open colectomy for patients who have a contraindication to laparoscopic surgery.

Debate exists in the literature regarding the optimal approach to left sided colectomy, and the proponents of medial-to-lateral approach describe this technique as more adequate when colonic pathology is lateral or adherent to the abdominal wall. This approach allows an easier access to the lateral structures (iliac vessels, ureter, renal pelvis, inferior mesenteric vein, ligament of Treitz, and splenic pedicle) through the mesenteric window.

Preoperative Evaluation

A thorough history and physical examination should be performed prior to any procedure. Special emphasis must be placed on premorbid cardiac and pulmonary disease. Also, it is important to obtain a history of any prior abdominal surgery and, if available, operative reports should be reviewed to aid in the planning of the procedure. Auxiliary studies that help complete the preoperative assessment vary depending on the underlying pathology. Whenever possible, a colonoscopy should be performed to assist in the
diagnosis and to detect any underlying synchronous processes that may alter the surgical approach. Colonoscopy also allows for tattooing of pathologic lesions to aid in operative identification. Computed tomography scanning of the abdomen and pelvis can be helpful in both benign and malignant conditions, either to identify the extent of disease or to discover the presence of intra-abdominal metastases, which also can affect the operative plan. Baseline biochemical studies should include a complete blood cell count, carcinoembiogenic antigen when malignancy is suspected, liver profile, and coagulation studies.

Table 7.1 Indications for Colon Resection

Colon cancer	Inflammatory bowel disease
Endoscopically unresectable polyp	Gastrointestinal bleeding
Diverticular disease	Diverticular
Ischemic colitis	Arteriovenous malformation
Trauma with perforation	Miscellaneous
Endoscopic iatrogenic colon injury

Preoperative anesthesia consultation should be obtained and a chest X-ray and preoperative electrocardiogram is routinely recommended. Most of the institutions have protocols regarding the performance of these tests based on age and associated risk factors.

If cardiac or respiratory comorbidity needs to be further assessed, preoperative cardiac stress test, cardiac catheterization, and pulmonary function tests may be indicated at the request of the consulting specialist.

Once the patient has been medically cleared, discussion is undertaken regarding the procedure, risks, benefits, and alternatives of the surgery and informed consent is obtained.

Surgery

Patient Preparation

It is routine in the authors’ practices to avoid mechanical and antibiotic oral bowel preparation. The patient must remain NPO for at least 6 hours prior to the procedure; this timeline may vary depending on the preferred practice of the anesthesia staff. In patients with intestinal obstruction, it is normally recommended and preferred by the anesthesia team to have a nasogastric tube inserted with decompression of the upper intestinal tract to minimize the risk of aspiration during induction of anesthesia. The morning of the procedure, the patient is instructed to perform two enemas and a chlorhexidine based soap shower.

Recent studies have shown that the use of intraoperative bispectral index guided general anesthesia on recovery in patients after colon resection resulted in earlier extubation and shorter recovery unit length of stay. This method translated into a reduction by 23% in the cost of anesthetic and also a decrease in intra- and postoperative hypotension.

After consultation with anesthesia, patients may elect for placement of an epidural catheter for postoperative pain control. In the authors’ practice, we have not found significant differences in postoperative recovery in those who have had an epidural compared to patients who have not, so we routinely leave this decision up to the patient. The authors do recommend epidural placement in patients who have a low pain threshold or who have been receiving chronic narcotics, as these patients can be predicted to find it difficult to control pain after a laparotomy.

Within an hour of incision time, a prophylactic dose of antibiotic is given by anesthesia. This could be a second generation cephalosporin in an appropriately weight-based dosage. Alternatively, we have used a combination of ciprofloxacin and metronidazole
if the patient has a penicillin or cephalosporin allergy. Intraoperative re-dosing of antibiotic is done at 4-hour intervals in the event of a long operative case.

Equipment

Adequate review of the equipment needed for open colectomy prior to the procedure is always recommended to avoid intraoperative delays due to the lack of equipment. All surgeons should have a preference list of equipment for each abdominal operation. Exposure during the performance of a colectomy is basic, and routinely employs the principles of triangulation for the dissection. The authors routinely use Bookwalter™ retractor (Raynham, MA, USA) for any abdominal operation. This equipment was originally idealized by Dr. John R. Bookwalter in 1964 after falling asleep during an operation while holding a retractor.

Patients in whom an extended resection of the rectum or pelvic floor is necessary at the performance of the left colectomy, we routinely have available in the operating theater a St. Mark’s pelvic retractor with a 15 degree angle at the tip and a lip at the end of the blade.

To expedite the dissection and vessel ligation, we routinely use the LigaSure 10 mm diameter Impact™ (Valleylab, Boulder, CO, USA) and the electrocautery. However, other dissection devices such as the Harmonic Wave® (Ethicon Endo-Surgery Inc, Cincinnati, OH, USA) may be used for the dissection and the vessel coaptation during the procedure. All of these devices are obviously dependent on hospital availability and cost.

Patient Position and Protective Devices

The patient is routinely positioned in the modified lithotomy position to allow access to the perineum for passing a surgical stapler, and for the operating surgeon or an assistant to stand between the patient’s legs during periods of difficult dissection. The authors’ preference is to use Yellowfin® stirrups (Allen®, Acton, MA, USA) (Fig. 7.1). There are significant advantages of this system in the boot design; it decreases the pressure under the peroneal fossa and the superficial peroneal nerve, allows for a significant lithotomy and abduction range of the hip with a squeeze grip handle. The boot configuration is thus much safer than the traditional Lloyd-Davies stirrups.

The authors advocate about 5–7 cm of the perineum to be below the surgical table after the patient has been placed in the stirrups, with support of a jelly pad underneath the sacroiliac joint.

The arms may be tucked or extended on arm bands. There are some difficulties in tucking the arms in wide patients, and the locking system for the Bookwalter™ arising from the rails of the table may compress the arm. Extended arms may also injure the brachial plexus if there is too much abduction of the shoulder. We routinely position
at 90 degrees or less from the body. All areas of pressure must be padded to avoid pressure necrosis and nerve damage (Fig. 7.1).