Colon Resection Technique

Colectomies can be performed either laparoscopically or via an open abdominal incision.

The advantages of laparoscopic surgery are as follows:

• Shorter hospital stay (which does not appear to be associated with an increased risk of readmission ^[37] ) 
• Faster return to activities of daily living
• Lower rate of perioperative complications
• Decreased formation of adhesions, and thus reduced occurrence of intestinal obstruction

In a retrospective cohort evaluation of 716 consecutive patients who underwent bowel resection at the Cleveland Clinic, laparoscopic access significantly reduced the incidence of small-bowel obstruction as compared with the open procedure. ^[38]

After patient positioning and rectal irrigation, a Foley catheter is placed with sterile technique.

After preparing and draping, the abdomen is entered with a 12-mm umbilical incision; once the peritoneum is opened, sutures are placed, and a 12-mm port is secured. This is known as the Hasson technique. After insufflation to 15 mm Hg with CO₂, the authors place a right-upper-quadrant 5-mm port and a right-lower-quadrant 12-mm port. The patient is placed in Trendelenburg position and tilted to the right. The small bowel is placed in the right upper quadrant.

The authors use a medial-to-lateral approach. The inferior mesenteric vessels are identified at their takeoff from the aorta. The peritoneum is incised in this plane and the ureter identified. Once this is completed, the vessels are ligated. Whereas the authors commonly use an endoscopic stapler, other surgeons often use energy devices, clips, and Endoloops. Once the vessels are ligated, the plane under the mesocolon is developed laterally and superiorly. With the transected vascular pedicle retracted, dissection then proceeds down into the pelvis.

For cancer operations, the authors dissect at least 5 cm distal to a cancer. If the tumor is in the very distal rectum, a lower midline or Pfannenstiel incision is often required to facilitate exposure and transection of the rectum at the level of the anorectal ring. A total mesorectal excision (TME) is performed for all low rectal cancers, and sphincter preservation is possible if there is a 2-cm mucosal margin above the dentate line.

For diverticular operations, the authors dissect to the upper rectum where the taeniae coli coalesce. Once the distal margin is identified, the bowel is transected with an endoscopic stapler. The authors then divide the distal mesocolon or mesorectum with an energy device and proceed up the patient's left side, dividing the white line of Toldt. The authors routinely mobilize the splenic flexure to obtain adequate length for performing an anastomosis. Often, an additional port must be placed on the patient's left flank.

For left colon cancers, the authors divide the inferior mesenteric vein (IMV) at the level of the splenic flexure; these cases require extensive mobilization of the transverse colon and its mesentery. It is imperative to divide the mesocolon as close to its origin as possible, leaving extensive collateral blood supply to the proximal colon that will be anastomosed.

Once the colon is completely mobilized, the specimen is extracted. A wound protractor, GelPort, Dextrus, or other device may be used to facilitate extraction. The authors require a 4- to 5-cm incision for extraction. Graspers are placed on the distal end of the specimen. The CO₂ is exsufflated through the ports, and the incision is made and the wound protector placed. Extraction may be done in the left flank or umbilical area or via a Pfannenstiel incision. For a coloanal anastomosis, the authors extract transanally.

After extraction, the specimen is transected on the proximal end. For diverticular cases, the authors transect where the bowel becomes soft and supple. For cancers, transection corresponds to the area of mesocolon and the segment of colon being removed.

Routinely, the authors perform colorectal anastomoses using a 29-mm circular stapler. The specimen is sharply transected, allowing visualization of the lumen and colonic-wall bleeding, confirming an adequate blood supply. A 2-0 polypropylene purse-string suture is then placed. The anvil is placed into the colon lumen, and the purse-string suture is tied. This area is inspected for any imperfections in the closure or in the distal edge of the colon wall.

The colon is then placed back into the abdomen, and the extraction site is closed. Subsequently, the authors reinsufflate and perform a stapled anastomosis, taking care to ensure that the colon is rotated appropriately. Air insufflation via the rectum with saline irrigation is performed to look for bubbles, indicating a defect in the anastomosis. The stapler donuts are also inspected to ensure that a complete circular rim of tissue has been obtained.

If bubbles emerge from the anastomosis, the authors laparoscopically oversew the anastomosis and perform the leak test again. If there is any concern with the anastomosis, proximal diversion with a loop ileostomy is performed.

Gloves, gowns, and instruments are then changed. Irrigation with 3 L of saline is performed. The small bowel is inspected to ensure that no internal hernias are present. Gas is exsufflated via the ports, and the incisions are closed.

For a coloanal anastomoses, the dentate line is mobilized at the anal verge. After the specimen is extracted, a handsewn transanal anastomosis is performed. Here, exposure is facilitated by the Lone-Star retractor.

For an abdominoperineal resection (APR), the authors perform the case as above, with the following exceptions.

The splenic flexure is not mobilized, and dissection is performed distal to the rectosacral fascia (Waldeyer fascia) circumferentially. Once dissection is complete, the authors transect proximally in the sigmoid colon and create the colostomy. The incisions are then closed, the colostomy is matured, and the patient is flipped into the prone jackknife position.

After preparation and draping, the authors mark an incision 1 cm from the coccyx and ischial tuberosities and then make the incision and dissect circumferentially to the level of the levators. The true pelvis is entered anterior to the coccyx in such a way as to “connect” with the previous posterior dissection. Once this plane is opened, the levators are pulled caudally with a finger and transected circumferentially.

The specimen is then exteriorized with only the anterior attachments still in place. Once this is done, careful dissection in this plane is performed under direct vision to avoid injury to the prostate or vagina. If the tumor is invading these structures, a posterior vaginectomy can be performed, or a portion of the prostate can be dissected with the specimen.

The specimen is extracted through the perineum, and the incision is closed in multiple layers.

For additional information, see Laparoscopic Left Colectomy (Left Hemicolectomy).

In open versions of these procedures, the same preoperative preparation and patient positioning is used, and the authors follow similar technique. A vertical midline incision is used routinely. For right and transverse colectomies, two thirds of the incision should be above the umbilicus and one third of the incision below. The reverse is true for left-side, sigmoid, and rectal surgery. For coloanal anastomosis or APR, the incision should be carried down to the symphysis pubis to facilitate pelvic exposure.

After patient positioning and rectal irrigation, a Foley catheter is placed with sterile technique. The patient is prepared and draped, and the midline incision is made. Once the incision is open, a wound drape is placed to protect the wound. The authors prefer a Balfour retractor with a bladder blade and C-arm attachment. The low profile permits a deeper reach into the pelvis without the need to struggle with the retractor. Others use the Buchwalter.

A wet lap sponge is placed over the small bowel, which is then placed in the right upper quadrant, exposing the takeoff of the inferior mesenteric artery (IMA) at its takeoff from the aorta. Once identified, the IMA is dissected free with long right-angle clamps and clamped. Prior to clamping and transection, the ureter must be identified, after which the mesocolon is divided laterally and up to the colon wall. The colon wall is divided with a stapler. This division is the proximal margin for sigmoid or rectal surgery.

The IMA is then retracted upward, and the plane under it is dissected until the lane between the mesorectum and the pelvic fascia is entered.

Dissection continues caudally until the distal margin of resection is encountered. Transection is performed with a stapler at the distal margin for a cancer or at the coalescing of the taeniae for diverticulitis. For a left colectomy, the initial division of the bowel is a distal transection. The white line is then mobilized proximally and the splenic flexure taken down, when indicated, as mentioned above. The distal transverse colon is transected and the remaining mesorectum divided. Omentum is mobilized off the transverse colon to facilitate obtaining sufficient length.

Both anastomosis and APR are performed exactly as described for the laparoscopic technique. Gowns, gloves, and instruments are changed, and the fascia is closed with running looped suture. The skin is closed with staples.

For additional information, see Open Left Colectomy (Left Hemicolectomy).

The abdomen is entered as above. Ports are placed in the left upper and lower quadrants. The patient is placed in the Trendelenburg position and tilted to the left.

The terminal ileum is identified and the mesocolon traced. By raising the terminal ileum, the mesentery is draped over the ileocolic artery. The takeoff of the ileocolic artery is identified at the level of the inferior margin of the duodenum. The vessels are skeletonized and transected. The plane under the mesentery is developed up to hepatic flexure and distal to the terminal ileum. The ureter should be seen in the retroperitoneum.

The mesocolon is then divided medial to the ileocolic vessel with an energy source. The ileum is transected 5 cm proximal to the cecum with an endoscopic stapler. The white line of Toldt is mobilized up to and including the hepatic flexure until the original plane of dissection at the inferior margin of the duodenum is encountered. The right branch of the middle colic artery is then taken with an energy source. A grasper is placed on the ileum and the appendix/cecum. The gas is exsufflated through the ports, and an extraction site is made at the umbilicus, as described above.

The colon is transected with a linear cutting stapler and the specimen sent to pathology. An anchor stitch is placed to orient the small intestine, and the proximal and distal crotch stitches are placed. A side-to-side functional end-to-end anastomosis is created with 75-mm cutting staplers. The end is closed with a noncutting linear stapler. The staple lines are oversewn, and the mesenteric defect is approximated, if feasible.

The bowel is then replaced into the abdominal cavity. Gowns, gloves, and instruments are changed, and irrigation is performed. The authors do not routinely reinsufflate unless there is very bloody irrigation. Fascial closure followed by skin closure is performed.

If a medial-to-lateral dissection cannot be performed, a lateral-to-medial approach can substituted. This approach is often used because of an inability to visualize the vessels owing to adhesions or redundant bowel. In addition, if the vital structures are difficult to identify, conversion to open surgery should take place. Prior to this, it is acceptable to use a hand-assist device.

In a review of the evolution of right colon resection, Gachabayov et al described techniques such as the medial-to-lateral mobilization used in minimal access surgery and the lateral-to-medial mobilization used in open surgery and D2 and D3 lymphadenectomy. ^[39] They also described various anastomotic configurations (eg, isoperistaltic and antiperistaltic anastomoses) and methods of anastomosis which are used in minimal access surgery (eg, intracorporeal, extracorporeal, totally stapled, and stapled-handsewn techniques). The review also covered laparoscopic and robotic suturing, mucosal eversion and inversion, and specimen extraction sites.

For additional information, see Laparoscopic Right Colectomy (Right Hemicolectomy).

Performing an open right colectomy requires a midline incision, after which the small bowel is retracted to the left side and covered with a wet sponge. The ileocolic vessel is dissected free at the inferior edge of the duodenum. The white line of Toldt is mobilized from the terminal ileum up to and including the hepatic flexure. The right branch of the middle colic artery is divided, and the ileum and transverse colon are brought out of the wound. The anastomosis is performed as described above.

For additional information, see Open Right Colectomy (Right Hemicolectomy).

Total/subtotal colectomy and total proctocolectomy

The authors approach these cases, whether laparoscopic or open, by ligating the vasculature and then mobilizing from the cecum to the distal transverse colon and down the left side. For an ileorectal anastomosis, the authors use a 29-mm stapler but always perform a side-to-end anastomosis. It is imperative to leave at least 4 cm of distal bowel to ensure collateral blood supply. The ileorectal anastomosis is anchored to avoid rotation and a "maypole effect."

End-to-end anastomosis vs side-to-end anastomosis (Baker)

Although the authors routinely perform an end-to-end anastomosis, a side-to-end anastomosis can also be performed. When using a stapler, it should be placed through the distal end and brought out 4 cm proximally at the antimesenteric border. The distal end is then stapled closed and oversewn. In low pelvic anastomoses, there may be a functional benefit for side-to-end anastomosis. In addition, a colonic pouch may be created to allow better function postoperatively.

Ostomy creation

Preoperative marking is imperative. An ostomy site should be placed through the rectus abdominis rather than through the external oblique muscles. In addition, the patient should be marked while lying flat and while sitting to permit identification of folds of skin that may interfere with ostomy pouching. Avoid beltlines when placing the ostomy, and ensure that an obese patient can see where the ostomy will be.

The authors’ technique is to excise a disk of skin and divide the subcutaneous tissues and anterior rectus sheath vertically. The muscle is bluntly split and the posterior sheath incised. The authors perform Brook ileostomies to facilitate pouching. Colostomies need not be raised above skin level.