Open Left Colectomy (Left Hemicolectomy) Technique

Updated: Mar 21, 2016
  • Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Technique

Open Left Hemicolectomy

After the patient is intubated under general anesthesia, a good muscle relaxant is administered and an endotracheal tube placed. A Foley catheter is inserted into the bladder for accurate measurement of urine output during the procedure and for at least 24 hours after surgery. An orogastric tube is placed to decompress the stomach during the operation; this tube is removed at the end of the procedure.

The entire abdomen is prepared with either povidone-iodine or chlorhexidine antiseptic solution. Sterile draping is applied, ensuring adequate exposure of the abdomen and allowing easy access to the rectal area, if necessary. An electrocautery device (Bovie), a LigaSure 10-mm coagulator, or an ultrasonic dissector device and suction tubing are set up. The operating surgeon stands on the right of the patient, with the assistant on the left of the patient. If available, a second assistant could stand between the legs of the patient.

The left colon is accessed via a generous midline laparotomy. (Some surgeons have suggested that a left transverse laparotomy may be associated with lower rates of respiratory complications and incisional hernias. [5] ) A thorough exploration of the abdominal cavity is performed. The entire colon is examined for palpable lesions. The surface of the liver is examined for any metastatic lesions.

Moist laparotomy pads are used to tuck the transverse colon and the small bowel loops cephalad and to the right, away from the operative field, for adequate exposure of the left colon and the mesenteric vessels. Self-retaining retractors such as the Bookwalter or Thompson retractor can be used for this. A St Mark retractor should be available if access to the pelvis is necessary.

The length of the colon to be resected is determined in part by the location of the lesion; this, in turn, determines the extent of intestinal devascularization that will ensue from proper lymphadenectomy and obtaining a longitudinal margin (along the length of colon) of at least 5 cm from the lesion proximally and distally. A minimum of 12 lymph nodes within the mesentery is considered an adequate resection when a left hemicolectomy or sigmoidectomy is performed for cancer.

Lateral approach

The lateral approach is preferred by most surgeons for open colectomies. The assistant holds the sigmoid colon and retracts it medially and upwards. The surgeon then starts dissecting along the white line of Toldt, which is the line of attachment to the parietal peritoneum on the lateral side. This is extended superiorly up to the splenic flexure and inferiorly down to the level of the pelvic brim.

At this point, the left ureter is identified in order to prevent inadvertent injury. The ureter is seen crossing the gonadal vessels at the level of the pelvic brim and has a characteristic peristaltic movement (akin to the movement of an earthworm).

The medial border of the mesentery is then easily lifted off the retroperitoneal attachments, which helps identify the inferior mesenteric artery (IMA) and other vascular branches. The IMA and the inferior mesenteric vein (IMV) are ligated and divided. The mesenteric attachments are then divided towards the colon, which is dictated by the length of the colonic segment to be removed. Sometimes, it may be necessary to divide the left branch of the middle colic artery, if the lesion is located in the splenic flexure.

To take down the splenic flexure, the patient is placed in a reverse Trendelenburg position. The retractors are adjusted in such a way that the transverse colon is released and the small bowel is packed towards the right lower quadrant. The transverse colon is mobilized by dividing the greater omentum and entering the lesser sac.

The colonic mesenteric attachment is then dissected off the retroperitoneum and extended laterally toward the splenic flexure, with care taken not to injure to the splenic vessels. A combination of blunt dissection and electrocoagulation is necessary to enter the right plane and avoid bleeding complications.

Once the colonic segment is mobilized, the ends of the colon are then divided with a gastrointestinal anastomosis (GIA) stapler. The resected specimen is sent to the pathology department for histologic analysis.

After the colon resection, the two ends of the colon are anastomosed to each other either by using the stapling device or by using the handsewn technique. The anastomosis can be performed in an end-to-end, end-to-side, or side-to-side manner.

If the entire sigmoid colon is removed, the colon-to-rectum anastomosis is usually performed with a circular stapling device such as the end-to-end anastomosis (EEA) stapler. The anvil of the EEA stapler is sutured to the distal end of the proximal portion of the colon. The surgeon then stands between the patients’ legs and passes the stapling device through the anal canal into the rectum until it reaches the proximal end of the rectal stump.

Once in place, the EEA stapler is opened, exposing the probe, which is then attached to the anvil at the other end of the colon. Finally, the EEA stapler is closed and fired to complete the anastomosis. The donuts obtained after stapling are checked for complete rings.

The anastomosis is tested for any leaks by placing the patient in the reverse Trendelenburg position and filling the pelvis with warm saline. The surgeon then passes a rigid sigmoidoscope through the anal canal and directly visualizes the anastomosis.

After clamping the colon proximal to the anastomosis, the surgeon insufflates the rectum with air via the sigmoidoscope. The colon is checked for adequate distention with air and for any bubbling of air in the pool of saline in the pelvis. The presence of a stream of bubbles indicates a positive leak test, and every measure must be taken to ensure that the leak is fixed. This may require placing sutures across the gap or, in some cases, complete revision of the anastomosis.

The entire peritoneal cavity is then irrigated with copious amounts of warm saline solution. The wound is closed in layers. The fasciomuscular layer is closed either in a continuous or an interrupted fashion. No. 1 polydioxanone or polypropylene suture material is ideal for this layer. The subcutaneous layer is not usually sutured. The skin is closed using skin staples or interrupted vertical mattress sutures using 4/0 nylon or polypropylene sutures.

Medial approach

In the medial approach, the origin of the IMA is exposed first; this is located just below the third portion of the duodenum. The root of the mesentery is incised to further reach the vessels. In the high-ligation technique, the IMA is then ligated and divided proximal to the origin of the left colic artery.

Next, the IMV is ligated and divided. The ureter is identified at this stage, usually crossing the gonadal vessels at the pelvic brim. This is done in order to prevent inadvertent injury to the ureter.

The mesentery is then elevated off the retroperitoneum, and the line of mesenteric division is delineated. The rest of the left colon is mobilized by dividing the mesenteric attachments. The lateral attachments of the colon are then divided along the white line of Toldt. This frees up the entire segment of the colon. From this point forward, the procedure is much the same as in the lateral approach.

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Postoperative Care

Postoperatively, the patient is extubated and transferred to the recovery room for appropriate monitoring before transfer to the floor. The patient is kept on nil per os (NPO) status, except for oral medications with a sip of water for up to 24 hours. Intravenous (IV) fluids and antibiotics are continued for up to 24 hours. Antiembolic stockings are continued, and deep vein thrombosis chemoprophylactic drugs (eg, low molecular weight heparin) are started on postoperative day 0.

After 24 hours, the patient is allowed to have clear liquids as tolerated, with IV fluids still running until the patient tolerates oral intake. The Foley catheter is removed on postoperative day 1. The patient is encouraged to ambulate and perform incentive spirometry to prevent atelectasis.

Daily laboratory tests, including at least a complete blood count with differential and basic metabolic panel, are performed until the patient has tolerated a clear-liquid diet, depending on clinical progress and recovery. The diet is slowly advanced after the patient has had return of bowel function, which is evidenced by passing either flatus or feces. Only after the patient has had a bowel movement, has tolerated at least a full-liquid diet, and has ambulated is he or she deemed medically fit for discharge. Although earlier studies suggested that gum chewing in the postoperative period is beneficial for reducing the duration of ileus, [6] a randomized trial from 2015 did not find this measure to be advantageous. [7]

Follow-up in the office 10-14 days postoperatively is ideal for removal of staples and sutures and for discussing the results of the pathologic analysis of the specimen. Depending on the pathologic stage, the patient may require systemic therapy in the form of chemotherapy. [1, 2, 3, 8]

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Complications

Early complications of open left colectomy are as follows:

  • Excessive bleeding
  • Ureteral injury
  • Wound infection, both superficial and deep
  • Deep vein thrombosis and pulmonary embolism
  • Urinary tract infection
  • Pulmonary complications (eg, atelectasis/pneumonia)
  • Cardiac complications (eg, myocardial infarction, congestive heart failure)
  • Prolonged ileus
  • Wound dehiscence and evisceration
  • Anastomotic leak

Late complications are as follows:

  • Anastomotic stricture
  • Tumor recurrence
  • Bowel obstruction secondary to adhesions
  • Incisional hernia
  • Sexual/urinary dysfunction (due to autonomic nerve injury)
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