Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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Dissecting from the left aspect of the omentum, mobilize the gastrocolic ligament off the transverse colon and splenic flexure (Figure 60-6).

The least traumatic way of taking down the splenic flexure involves dividing these avascular ligaments from either side of the splenic flexure (see Figure 60-5) rather than pulling on the flexure with downward traction.

Gastrocolic ligament incised

FIGURE 60–6

The blood supply to the left colon originates from the inferior mesenteric artery and mainly involves the left colic artery. The points of transection of the proximal and distal large bowel are decided upon based on the mesenteric blood supply. The colon is then divided with

the gastrointestinal anastomosis (GIA) stapler at the proximal and distal resection margins (Figure 60-7). The left colic artery and proximal sigmoid arteries are ligated at their origins. Careful attention must be paid to the bowel ends to ensure a healthy blood supply and that the ends would reapproximate without tension.

Bowel divided with GIA stapler

FIGURE 60–7

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The sigmoid colon may be resected if the tumor is located in the distal descending colon or sigmoid colon. As the retroperitoneum is exposed, the left ureter should be identified, typically anterior to the external iliac vessels. The limits of resection are determined: proximal sigmoid tumors will involve sacrifice of branches of the left colic artery, and distal sigmoid tumors will involve sacrifice of branches of the superior rectal artery and transecting the colon to the level of the sacral promontory. The splenic flexure may have to be mobilized to create a tension-free anastomosis.

Hand-sewn end-to-end (see Figures 60-8 through 60-11) anastomosis: After noncrushing bowel clamps are applied proximal to the bowel ends, the staple lines are cut using electrocautery or Metzenbaum scissors. In a standard two-layer anastomosis, the posterior (outer) layer of the transverse colon and proximal rectum are reapproximated with 3-0 silk interrupted (Lembert) sutures. Two continuous absorbable sutures are used in the posterior inner row (see Figure 60-9), and each is brought anteriorly, where the transition to Connell sutures is made (see Figure 60-10).

Finally, the anterior (outer) layer is completed with interrupted Lembert sutures (see Figure 60-11). The mesenteric defect can be reapproximated with a continuous absorbable stitch, with care to ensure that the underlying vessels supplying the bowel are not compromised.

3. CLOSING

The abdominal cavity is irrigated with copious warm saline. The omentum can be overlaid on top of the newly formed anastomosis. After ensuring hemostasis, sponge counts, and instrument counts, close the abdomen using a no. 1 polydioxanone (PDS) suture. The subcutaneous tissue is irrigated again, and the skin is closed with skin clips.

STEP 4: POSTOPERATIVE CARE

Ambulation and incentive spirometry on postoperative day 1 is important for the prevention of postoperative atelectasis. Oral intake of clear liquids can begin after removal of the nasogastric tube. The Foley catheter is left in place for a few days because of the high incidence of urinary retention in male patients.

STEP 5: PEARLS AND PITFALLS

Injury to the spleen: Omental adhesions between the omentum and splenic capsule can cause inadvertent avulsion or injury to the splenic capsule if traction on the omentum is applied.

Injury to the left ureter: After division of the renocolic ligament, the left ureter is visualized in the left retroperitoneum. The entire length of the ureter can be traced down to the pelvis if necessary.

SELECTED REFERENCES

1. Wille-Jørgensen P, Rasmussen MS, Andersen BR, Borly L: Heparins and mechanical methods for thromboprophylaxis in colorectal surgery. Cochrane Database Syst Rev 2004(4):CD001217.

2. Stahl TJ, Gregorcyk SG, Hyman NH, et al: Practice parameters for the prevention of venous thrombosis. Dis Colon Rectum 2006;49:1477-1483.

pedicle. Care should be taken to avoid division of nerve fibers during high IMA division, which results in retrograde ejaculation in male patients.

STEP 2: PREOPERATIVE CONSIDERATIONS

Preoperative considerations for laparoscopic left and sigmoid colectomy are similar to those outlined in Chapter 59.

Bowel continuity may or may not be restored depending on the clinical circumstances.

If an ostomy is planned, the patient should be marked preoperatively for either an end sigmoid colostomy or loop ileostomy and educated concerning the new ostomy.

Indications for laparoscopic left and sigmoid colectomy include:

Benign polyps or lesions not amenable to endoscopic resection

Malignant lesions located in the splenic flexure, descending colon, and sigmoid colon

Diverticulitis of the sigmoid colon

Complicated as defined by history of perforation and abscess formation, stricture, and fistula

In immunocompromised patients (steroid-dependent and transplant patients)

In select few who had multiple episodes of recurrent simple disease

Crohn’s disease

Sigmoid volvulus

The hand-assisted technique is particularly beneficial in difficult cases, such as complicated diverticulitis and Crohn’s disease, allowing for improved ease of dissection under operative conditions that are normally challenging even in the open setting.

Informed consent addresses complications as outlined in Chapter 59, but should include possibility of damage to nerves, creating sexual dysfunction such as retrograde ejaculation.

STEP 3: OPERATIVE STEPS

1.POSITIONING

The patient is placed supine on the operating table on a deflated bean bag covered with two hospital sheets.

After general endotracheal anesthesia is administered, a Foley catheter is placed along with sequential compression devices on the lower extremities.

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During the setup, the surgeon confirms with the anesthesia team that the proper preoperative prophylactic antibiotic is being administered before initiating the procedure based on measures defined by the Physician Quality Reporting Initiative.

The patient is placed in low lithotomy position using Allen stirrups. A soft roll is placed under the pelvis to elevate and pad the hips.

The arms are padded and tucked so that the top sheet comes over and underneath the bottom sheet. Care is taken to ensure that all intravenous (IV) lines are padded away from the skin to prevent pressure necrosis. The hands are placed in slightly flexed position with circular roll to prevent intraoperative movement.

The bean bag is inflated with the sides and top corners turned up. Padding is placed between the patient’s head and the walls of the bean bag. A blue towel is placed across the patient’s chest on which heavy tape is used to encircle the patient on the operating table. Attention is paid to ensure that the tape is not restricting to respiration.

Abdominal and pubic hair is clipped off as needed.

A warmer is placed appropriately to ensure normothermia during the procedure.

An orogastric tube is placed by the anesthesia team for the duration of the procedure, to be removed upon completion of the procedure.

The surgeon stands to the right of the patient, with the assistant between the patient’s legs or next to the surgeon on the right.

Monitors are placed on the upper and lower left side of the patient.

Digital rectal examination is performed, followed by rigid proctoscopy. This confirms a clean rectal vault and absence of unappreciated rectal pathologic findings.

The abdomen is prepped and draped in standard fashion according to the surgeon’s preference.