Laparoscopic Left Colectomy (Left Hemicolectomy)

Most gastrointestinal (GI) surgeons now accept that laparoscopic surgery for both benign and malignant diseases of the colon is within the mainstream of patient care and that it results in superior clinical outcomes (eg, shorter hospital stay, less surgical-site discomfort, and quicker return to normal activity) as compared with open surgery (OS). ^{[1, 2, 3]} Laparoscopy has been associated with a lower incidence of both surgical-site infections (SSIs) ^{[4, 5]} and hernias ^[6] and with greater patient satisfaction as compared with laparotomy. ^{[7, 8]}

Although concerns regarding recurrence and survival rates associated with laparoscopic colon cancer resections initially dampened enthusiasm for minimally invasive surgery (MIS) in this setting, subsequent clinical studies established that properly performed laparoscopies produce comparable colon cancer outcomes comparable to those of OS, as well as improved clinical results. ^{[9, 10]}

The prolonged operating time was one of the concerns with minimally invasive left colectomy. In a study aimed at addressing this concern, Sweigert et al examined overall morbidity, SSI rate, and length of hospital stay in patients undergoing laparoscopic left colectomy compared with those undergoing open left colectomy. ^[11] Despite the longer operating time, laparoscopic left colectomy was associated with lower risk-adjusted rates of overall morbidity and SSI and shorter hospital stays. The laparoscopic left colectomy group also had lower rates of composite 30-day death or serious morbidity.

A “division of labor” has occurred within the field of MIS techniques, which has shaped a number of innovations that include robotic assistance, ^{[12, 13, 14, 15, 16]} more reliable energy devices, endostaplers, and a motivation to reduce the number of access sites (even to the point of limiting surgical access to a single port).

The optimal procedure for transverse colon cancer remains controversial, in that there is uncertainty over radical lymph node dissection. In a study of 252 patients who underwent laparoscopic surgery for transverse colon cancer, Fukuoka et al found that laparoscopic surgery led to an optimum radical lymph node dissection for transverse colon cancer. ^[17] ​ Lymph nodal metastasis was reported to be an independent risk factor for relapse-free survival.

Splenic flexure colon cancer, though a rare disease that accounts for only 2-8% of colorectal cancers, can have a good outcome following segmental resection. ^[18] Laparoscopic segmental left colectomy can be an option for such tumors, in addition to conventional anterior resection.

In the United States, despite the advantages afforded to patients by laparoscopy, the adoption of these techniques in the general population is still limited to a minority, though the proportion has been growing. ^[19] Much of the reluctance to implement laparoscopic techniques has been related to the technical challenge posed by complex laparoscopic procedures such as colon resections. The following article describes the fundamental aspects involved in approaching a laparoscopic left hemicolectomy (left colectomy).

The indications for a laparoscopic left hemicolectomy are identical to those for an open left hemicolectomy and include, but are not limited to, the following:

• Malignancy
• Endoscopically unresectable adenomatous polyps
• Diverticulitis
• Infectious colitides (eg, left-side Clostridioides [Clostridium] difficile colitis)
• Inflammatory bowel disease (IBD)
• Ischemic colitis
• Colonic volvulus
• GI bleeding

The list of contraindications for laparoscopy is more difficult to define than the list of indications because contraindications often depend on the surgeon’s level of expertise with less straightforward patients and diseases. Certainly, hemodynamic instability or cardiopulmonary disease that is severe enough to make peritoneal insufflation and Trendelenburg positioning dangerous represents a physiologic derangement that precludes the safe application of laparoscopy.

The author believes that these two states represent the only firm, absolute contraindications for laparoscopy. Whereas it is true that what constitutes instability or heart and lung disease too severe for laparoscopy may fall along a spectrum, it is also true that these clinical indices are more readily identified and are more consistently acknowledged between surgeons than other factors are.

In terms of relative contraindications, morbid obesity obscures major mesenteric vessels from view, inhibits effective tissue retraction, and can make tissue dissection more difficult because of the thicker visceral fat; all of these effects can conduce to the easier commission of technical errors.

Locally advanced cancers that may be amenable to an R0 resection should be carefully considered for a preemptive conversion when discovered unexpectedly during laparoscopy; however, more experienced oncologic surgeons have demonstrated that en-bloc resections of organs such as kidneys and the small intestine are possible, with cancer-related outcomes similar to those of open surgery.

Phlegmonous tissue, such as would be encountered in severe, complicated Crohn disease or in diverticulitis, may not be resectable via laparoscopy, because of tissue friability, bleeding, and a distortion of the patient’s anatomy that necessitates open exposure; however, laparoscopic treatment has also been reported to be successful in this scenario when carried out by an experienced surgeon.

Large intestinal obstructions can be quite challenging to address laparoscopically, depending on the degree of proximal intestinal dilatation present; the more limited volume of unencumbered working space, coupled with the higher risk of iatrogenic intestinal perforation from retracting instruments, may warrant an open approach.

Carcinomatosis may or may not represent an indication for open surgery; whereas biopsies of peritoneal implants are easily accomplished laparoscopically, extensive resections, especially of the parietal peritoneum, should be approached via laparotomy.

Adhesions pose a technical challenge to the minimally invasive surgeon, especially when their location is between two segments of small intestine. In this situation, both small-intestine segments may be mobile enough to prevent adequate tissue distraction and delineation of each segment, with the two limbs of bowel moving as a single entity during retraction.

Furthermore, adhesions to the anterior abdominal wall may promote bowel injuries upon trocar placement or during adhesiolysis. Laparoscopic adhesiolysis requires advanced technical skill both with the use of laparoscopic scissors and with intracorporeal suturing to address the lacerations that will inevitably be encountered at some point.

Best practices

No single best approach or series of individual steps is recommended for safely performing a laparoscopic left colectomy; however, for pedagogic purposes, the following may be considered to be the key milestones of the surgical procedure:

• Sigmoid colon mobilization - Identification of the left ureter; ligation of the inferior mesenteric artery (IMA)
• Mobilization of the descending colon
• Mobilization of the splenic flexure
• Proximal and distal transection of the colon with an endoscopic stapler
• Exteriorization of the specimen
• Construction of the anastomosis

The order in which these steps are taken should not be viewed as set in stone. The order listed above is the one preferred by the author because it identifies the left ureter earlier in the course of the operation.

Procedural planning

Mechanical bowel preparation

The issues of whether mechanical bowel preparation should be offered to the patient undergoing a left colectomy and under what circumstances this should occur if it is offered will not be addressed in this article. The author uses an osmotic laxative in addition to poorly absorbed oral antibiotics on the day before the procedure. Rectal irrigation performed in the operating room for the purposes of cleansing the rectum or removing exfoliated tumor cells is not routinely used by the author.

Trocar placement

For multiple-site laparoscopy, the surgeon can limit the number of ports to three. The 12-mm trocar can be used to exteriorize the specimen and to place the anvil for the end-to-end anastomosis (EEA) stapler; however, it is usually easier to create a small, suprapubic incision for these purposes because partially closing an enlarged trocar site never regains the airtight seal initially present upon port placement.

For single-site laparoscopy, which is the author’s preferred approach to laparoscopic colorectal surgery, the trocar is placed through the umbilicus, unless doing so represents a higher chance of requiring a stoma, in which case the trocar is positioned at that location.

Complication prevention

The keys to prevention of complications include the following:

• Skeletonizing the IMA, largely mechanically, with a minimum of electrical energy until exposure and isolation of the left ureter before vessel ligation
• Using body positioning and medial-to-lateral (MTL) mobilization of the sigmoid colon to avoid grasping the colon as much as possible
• MTL mobilization of the splenic flexure to avoid a splenic capsular injury
• Using an advanced bipolar device for potentially less thermal injury with pelvic dissection 

A retrospective analysis of 777 patients who underwent laparoscopic left-side colon resections showed that the use of an intraoperative air leak test (ALT) to assess the colorectal anastomosis reduced the rate of postoperative anastomotic leakage. ^[20] ALT was performed in 398 patients and not performed in the remaining 379. The overall postoperative colorectal anastomosis leakage rate was 4.1%; in the ALT group it was 2.5%, compared with 5.8% in the non-ALT group.

Studies have generally found that the outcomes of laparoscopic colon resection are at least comparable to those of open resection. ^{[21, 22, 23]}

In a retrospective study using a population-based database of patients undergoing elective colectomy over a period of 7 years, Wei et al compared the outcomes of MIS and OS and evaluated trends in MIS (laparoscopic or robotic). ^[24] The authors noted a rising trend in MIS rates and a tenfold increase in robotic surgery. Although the operating time was longer in the MIS group, the rates of complications (eg, anastomotic leakage, bleeding, and infection) were lower, the length of stay was shorter, and total hospital costs were reduced in comparison with OS.

The safety and feasibility of repeat laparoscopic colorectal resection (LCRR) were assessed in a study by Zarzavadjian le Bian et al, ^[25] which included 23 patients who had colorectal cancer (CRC; n = 11) or benign conditions (dysplasia [n = 5], anastomotic stricture [n = 4], or IBD [n = 3]) and underwent right-side resection, left-side resection, or proctectomy. Thirteen (57%) patients required conversion to laparotomy (12 for intense adhesions). Although repeat LCRR had a higher conversion rate, a longer operating time, and greater intraoperative blood loss than primary LCRR, postoperative outcomes were not compromised.

Although single-port laparoscopic approaches have garnered considerable interest, concern has been expressed about whether they yield outcomes comparable to those of multiport approaches. A case-match study by Marks et al concluded that single-port colorectal surgery is a safe alternative to multiport surgery across the full array of procedures (including left colectomy) in equivalent patients. ^[26]  A double-blind randomized controlled trial by Maggiori et al concluded that single-port laparoscopic colectomy conferred no additional benefit other than cosmetic result as compared with multiport laparoscopic colectomy. ^[27]

In a propensity score matching analysis that included 494 patients who underwent elective laparoscopic colectomy with a 1:1 ratio of right colectomy (RC) to left colectomy (LC), Lin et al showed that time to first flatus, time to first semiliquid, and length of stay were shorter in LC patients than in RC patients (p< 0.05). ^[28] They noted that laparoscopic RC was associated with prolonged postoperative ileus and suggested that caution be exercised during the early feeding of patients undergoing this procedure.