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.

Patient instructions

Before surgery, the patient undergoes mechanical bowel preparation under the surgeon’s care, despite the controversy as to whether mechanical cleansing of the intestine is beneficial, necessary, or potentially detrimental.

Elements of informed consent

A thorough discussion of all risks of surgery should at least be mentioned to the patient and recorded on the consent form. The possible need for a diverting stoma should always be mentioned, as should the possible need for open surgery. Thorough informed consents pose no threat to the surgeon or patient; however, incomplete consents foster a breakdown in communication and possible legal problems for the surgeon.

The choice of instruments is largely in response to the particular laparoscopic technique being used.

Although numerous laparoscopic graspers and retractors are available, some of them purportedly atraumatic, it is necessary to remember that unlike open manual bowel retractors, laparoscopic graspers focus their point of contact over a small area of the intestinal wall. Therefore, all manipulation of the small or large intestine during laparoscopy creates a higher risk of bowel injury and should be avoided as much as possible by using patient positioning and techniques of dissection that minimize laparoscopic grasping of the bowel wall.

The author uses laparoscopic Babcock graspers, both because they are less expensive than other, more elaborate graspers that are no less traumatic and because they are readily available in any operating room (OR). With any laparoscopic grasper, the surgeon should fill the jaw of the grasper with the tissue to be grasped rather than pinch the bowel; the former displaces the force applied by the grasper jaw over a larger surface area and thus prevents maximal force of closure over a smaller segment of tissue, which is then more likely to be lacerated or crushed.

Energy devices have evolved to use advanced bipolar technology that reliably transects and seals vessels up to 7 mm in diameter, which includes all of the named major nutrient vessels encountered during a left colectomy. The use of these energy devices provides the advantage of less collateral thermal spread as compared with monopolar cautery. These devices can also perform double duty; they can dissect tissue without necessarily grasping tissue in their jaws, thus replacing other laparoscopic dissectors.

Although endoscopic staplers can also be used to ligate major vessels, the use of energy devices not only is more cost-effective but also prevents the extra time and risk of organ injury from additional instrument exchanges that are required to alternate between dissecting tools and staplers.

Laparoscopes come in rigid and flexible forms. With rigid laparoscopes, an angled view is almost a requirement for a procedure such as a left colectomy, in which the dissection involves the entire left abdomen at a minimum rather than a fixed local point. Flexible laparoscopes offer high-definition images with excellent lighting through a trocar as small as 5 mm, and they offer the advantage of a camera tip that can be flexed 90° in four directions.

Especially for single-site surgery, the flexible laparoscope is quite necessary, allowing the camera shaft to be moved away from the operating surgeon while keeping the region of interest centered on the viewing screen. These cameras impose a learning curve on the camera operator, as seen in the example of how rotating the camera results in rotation of the image on the screen. Although this is often a greater than expected challenge for younger surgical residents, it is not an insurmountable one.

Anesthesia

Patients should be sent to the anesthesia preoperative clinic, if one is available, to allow a thorough preoperative assessment focusing on tolerance of anesthesia. This also ensures that different views regarding the patient’s ability to tolerate surgery do not arise in the preoperative area, after the patient has already consumed the bowel preparation. In addition, it theoretically may reduce delays in the OR if, for example, the patient is found to be difficult to intubate. Some of these factors can be identified and planned for before the date of the procedure.

Positioning

The patient should be placed in a modified lithotomy position (see the image below). The obvious advantage of this positioning is that it allows access to the anorectum for deployment of an end-to-end anastomosis (EEA) stapler. However, another advantage is that this positioning affords the surgeon or an assistant the option of standing between the patient’s legs, which can be helpful during mobilization of the splenic flexure. For the latter reason, the author uses a modified lithotomy position for all laparoscopic operations on the small or large intestine.

Having the patient firmly secured to the operating room table allows maximal Trendelenburg or reverse Trendelenburg positioning, as well as maximal left and right decubitus tilt. Especially in the absence of intra-abdominal adhesions, these extremes of body positioning improve exposure and limit the degree of tissue handling by the surgeon, serving as additional protection against iatrogenic organ injuries.

To prevent patient movement on the OR table, the author uses a beanbag to which the patient is secured (see the first image below). Silk tape (2 in. [5 cm]) is also used to secure the patient to the bean bag and the OR table. To prevent soft-tissue injury, padding is also applied over the olecranon processes and the dorsal aspects of the hands (see the second image below).

Ngu et al reported that robotic surgery, as compared with conventional laparoscopic surgery, leads to superior visualization and more dynamic assistance in hemicolectomies.[16] This conclusion was based on the operative video assessment of 40 procedures that were stratified according the method of surgery, the type of hemicolectomy, and the seniority of the assistant.

The patient is positioned as previously described (see Patient Preparation). Whether a lateral-to-medial (LTM) or a medial-to-lateral (MTL) approach is used is a matter of preference. The most important feature of colon mobilization is identification of the interface between the colonic mesentery and the retroperitoneum. This tissue interface is not the white line of Toldt, though the Toldt line must be incised to expose the mesocolon-retroperitoneum interface.

The author prefers an MTL approach (see the video below), for several reasons. This approach brings the inferior mesenteric artery (IMA) immediately into view, as well as two avascular mesenteric windows, which are always present immediately cephalad and caudal to the IMA. In addition, it requires only one retracting instrument, which facilitates single-site surgery, and it does not require looking "over" the colon from the patient’s right side, thereby allowing less vigorous retraction of the colon and creating less of an opportunity for injury to the specimen.

The mesentery can be easily scored along its medial aspect either mechanically or with a cautery, and the sigmoid mesentery can be retracted away from the retroperitoneum while an energy device is used to perform a blunt and bloodless tissue distraction that involves elevating the mesentery en bloc away from the retroperitoneum.

This technique can also minimize the extent to which tissue is grasped and exposed to electrical energy, until such time as the left ureter is exposed. The retracting instrument can be inserted into the plane between the mesentery and the retroperitoneum, lifting the mesentery toward the anterior abdominal wall without grasping and tearing tissue.

The IMA is circumferentially isolated to ensure that the left ureter is not inadvertently transected or thermally injured. The left ureter and IMA are, in the native anatomy, immediately adjacent, with the vessel lying over the ureter. For this reason, as well as both to allow a complete mobilization of the sigmoid colon and to achieve an adequate lymph node yield in cases of cancer, the sigmoid colon is completely mobilized to the midline of the peritoneal cavity.

With the IMA skeletonized and with the colon mobilized so that the colon can be retracted straight toward the anterior abdominal wall, the left ureter can easily be located from both a medial and a lateral view. These points should be documented in the operative report, describing the care taken to identify and protect the left ureter. If these steps cannot be achieved, the IMA should not be blindly ligated, and the procedure should be preemptively converted to laparotomy for the patient’s safety.

For colonic malignancies, the IMA should be ligated proximal to its bifurcation to remove the entire lymph node cache by transecting the artery near its junction with the aorta. Conversely, for benign diseases, the IMA may be ligated more distally so as to reduce the risk of urinary and sexual dysfunction from damage to the autonomic nerves in the para-aortic region.

Even in the setting of benign disease, by ligating the IMA at the level of its bifurcation and using a more proximal level of mesenteric transection, fewer second- and third-order arterial vessels are encountered, which reduces the risk of pesky bleeding because a more proximal mesocolic dissection involves bloodless planes between named vessels.

This technique also removes diseased and thickened mesentery that must be maneuvered over or around in constructing a tension-free colorectal anastomosis. Furthermore, mobilizing the colon in this manner, where the mesentery is freed from the retroperitoneum at the midline peritoneal cavity, allows full exposure and isolation of the left ureter and kidney, prevents devascularization of the colon through distal transection of its mesentery, and provides maximal colonic length for a proper anastomosis.

The descending colon can be easily mobilized as far proximally as the splenic flexure by continuing the same method of mobilization as discussed for the sigmoid colon. (See the video below.)

The descending colon is retracted toward the anterior abdominal wall and the midline of the peritoneal cavity. The line of fusion between the posterior aspect of the colon mesentery and the retroperitoneum marks the line of dissection, allowing mobilization of the remaining left colon to the midline. The colon is retracted, and the line of fusion either is scored with electrical energy or is mechanically separated through tissue distraction. With proper retraction, this is a quick, bloodless process that does not require electrical energy to perform safely.

Although mobilization of the splenic flexure (see the videos below) is not always necessary, it is sometimes mandated for a tension-free anastomosis. This is a more complex maneuver because of the close proximity of the stomach, spleen, and pancreas, as well as the need to avoid inadvertently transecting the transverse mesocolon, which potentially devascularizes the large intestine to be used for the anastomosis.

Splenic flexure mobilization may not be rigorously defined, and the term may be used in various ways by different surgeons. As a rule, however, the term splenic flexure mobilization should not be used to refer to incising the line of Toldt to the level of the splenic flexure but should be reserved for some degree of transection of the distal transverse mesocolon for the purpose of relocating the splenic flexure away from the spleen.

The MTL approach preferred by the author involves placing the patient in maximal reverse Trendelenburg positioning with continued right lateral decubitus tilt. The midpoint of the gastrocolic ligament is transected, allowing entry into the lesser sac. The remaining gastrocolic ligament is transected to the level of the inferior pole of the spleen, and this point of view allows the surgeon to avoid getting lost and ending up near the splenic hilum—an easy mistake to make in a patient with more visceral obesity.

The stomach is then reflected cephalad so as to expose the posterior gastric wall, which can be easily and inadvertently injured during splenic flexure mobilization. This also exposes the pancreas, which is important in that the level of mesenteric transection is several centimeters caudal to the inferior border of the pancreas. This is to preserve collateral arterial blood flow, as well as to maximize colonic length.

By this time, avascular mesenteric windows on either side of the left branch of the middle colic vessel have been further developed and exposed through the previous descending colon mobilization. These windows can then be easily identified and opened, allowing proximal transection of the left branch of the middle colic artery near the inferior border of the pancreas.

The splenic flexure proper can then be transected in an MTL direction, with the inferior pole of the spleen, the pancreas, and the transverse mesocolon clearly delineated. With the patient in reverse Trendelenburg, the colon naturally moves away from the spleen, allowing further exposure of the spleen without retraction. The previous transection of the gastrocolic and splenocolic ligaments prior to the mesenteric resection allows the colon to be safely retracted caudally without tearing of the splenic capsule; the spleen and colon are no longer attached.

The transverse colon can be mobilized to the midline of the peritoneal cavity, and the main branch of the middle colic artery and the marginal artery are preserved, with the latter now serving as the main tributary to nourish the descending colon. This places the distal half of the transverse colon and the descending colon in the midline of the peritoneal cavity, in a straight line toward the pelvis, and provides adequate length for virtually every colorectal anastomosis.

Splenic flexure mobilization is arguably the most dangerous maneuver that colorectal surgeons perform. With a proximal transection of the transverse mesocolon, a bleeding vessel can potentially retract into a retropancreatic position, continuing to bleed but not visible without pancreatic mobilization.

Application of an endostapler to the proximal and distal resection margins, followed by specimen exteriorization and creation of an anastomosis, is self-explanatory (see the videos below).

Every effort should be made to transect as much mesentery as possible toward the bowel wall before stapler application in an effort to prevent bleeding after stapling. The endostaplers must be placed straight across the bowel, not at an angle; angled placement creates zones of ischemia, as well as a higher risk of inadequate margins of resection for cancers. If postcolectomy bleeding occurs, it may be treatable by means of endoscopy.[29]

A study assessing the effect of the site used for speciment extraction on the incidence of wound infection after laparoscopic colon resection found that infection rates were higher when midline or Pfannenstiel incisions were used for specimen extraction and lower when right-lower-quadrant or left-lower-quadrant incisions were used.[30]

With regard to the typical course of patients undergoing a laparoscopic left colectomy, their bladder catheter is removed within 24 hours after the procedure, and a solid food diet is started immediately after surgery. The patient is provided with low-dose patient-controlled analgesia, and every effort is made to use nonsteroidal anti-inflammatory drugs (NSAIDs) and other nonopioid medications to control surgical-site discomfort.

The patient may be safely discharged home once the passage of flatus resumes, which is usually on postoperative day 2 or 3. Given that most patients undergo mechanical bowel preparation, awaiting a bowel movement would seem to introduce an unnecessary delay in hospital discharge.

A study by Pardo Aranda et al suggested that fast-track recovery protocols could be applied to single-port laparoscopic surgical procedures on the colon as safely and effectively as they could to multiport laparoscopic surgical procedures.[31]

A prospective study of patients undergoing elective colorectal resections found that those treated with a standardized enhanced recovery program (ERP; n = 100), as compared with those treated before the introduction of the ERP (n = 100), had significantly shorter hospital stays, imposed lower nursing worloads, and showed no increase in postoperative complications, 30-day readmission, or mortality.[32] In addition, total mean direct costs per patient were significantly higher for patients in whom the ERP was not implemented.

A study (N = 23) by Zarzavadjian le Bian et al addressed the safety and feasibility of repeat laparoscopic colorectal resection (LCRR; right side, n = 11; left side, n = 8; proctectomy, n = 4) in patients with colorectal cancer (CRC) or benign conditions.[33] Indications for repeat LCRR included CRC, dysplasia, anastomotic stricture, and inflammatory bowel disease (IBD). Thirteen (57%) patients required conversion to laparotomy (12 for intense adhesions). Conversion rate, operating time, and intraoperative blood loss were greater for repeat LCRR than for primary LCRR; however, oncologic outcomes were not compromised with repeat LCRR, which was found to be a safe and feasible procedure for CRC.

Preoperative testing should include, at a minimum, a complete blood count (CBC), a comprehensive metabolic panel, and a blood type and screen. Prothrombin time (PT) and partial thromboplastin time (PTT) are not routinely necessary. A carcinoembryonic antigen (CEA) level should be obtained prior to resections of colon adenocarcinomas.