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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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Chapter 21
Left Colectomy
MICHAEL A. VALENTE
Left Colectomy
Surgical excision of the left and/or sigmoid colon is most often performed
for malignant disease and also for benign conditions, such as diverticulitis.
Inflammatory bowel disease and ischemic colitis are other less common
indication for a left colectomy.
The location and extent of the disease dictates the amount of colon to be
removed.
Benign conditions such as diverticulitis or sigmoid colon malignancies
usually only require a sigmoid colectomy with a descending colon to
rectum anastomosis (Fig. 21-1).
FIGURE 21-1 Sigmoid colon carcinoma. High ligation of the inferior mesenteric artery.
Descending colon to rectum anastomosis may be performed for these lesions.
Malignancies of the left colon require complete mesocolic excision; thus,
the left and sigmoid colon must be removed, secondary to high ligation of
the inferior mesenteric artery (IMA) and the entire mesocolic fascia is kept
intact on the anterior and posterior surfaces (Fig. 21-2).
FIGURE 21-2 Left colon carcinoma. High ligation of the inferior mesenteric artery and
inferior mesenteric vein will mandate both the left and sigmoid colon to be removed.
Perioperative Consideration
Formal preoperative assessment, including cardiopulmonary evaluation,
basic blood work, and appropriate imaging tests, should be performed to
prepare the patient for the operating room.
For cases of carcinoma, complete staging is compulsory, including
computed tomography scans of the chest, abdomen, and pelvis, as well as
obtaining a carcinoembryonic antigen level.
Nutritional parameters are checked, including albumin and prealbumin.
All patients (unless contraindicated) should receive preoperative oral
antibiotics (eg, metronidazole and neomycin), along with a full
mechanical bowel preparation, and are provided a chlorhexidine body
wash for the night prior to surgery.
In patients who have a diagnosis of neoplasia (adenomatous lesion or
invasive cancer), accurate preoperative localization of the lesion is
imperative.
If the lesion has not been endoscopically marked (ie, tattoo), a repeat
colonoscopy by the surgeon should be performed before the patient is
taken to the operating room for accurate localization.
Patient Positioning
Patients are placed in the modified lithotomy position with Yellowfins
stirrups or alternatively placed in a split-leg table (Fig. 21-3).
Careful attention is paid to protect bony prominences so as to prevent
nerve damage, especially the peroneal and ulnar/radial nerves.
FIGURE 21-3 Modified lithotomy position. Notice both arms tucked to the patient
side for either open or laparoscopic procedures.
It is our preference to tuck both arms at the patient’s sides for all
abdominopelvic cases (open or laparoscopic) for easy access and
ergonomic comfort for the surgeons performing the operation.
In general, for laparoscopic cases, the patient is secured to the table
over the chest, either with 3-in tape or a Velcro strap.
An inflatable bean bag or foam is also an option.
Guidelines for appropriate antibiotic use are strictly followed in all
patients, including 2 g of intravenous ceftriaxone and 500 mg intravenous
metronidazole within 60 minutes of incision; penicillin allergic patients
will receive 400 mg intravenous ciprofloxacin and 500 mg metronidazole.
Bladder catheter and orogastric tube are routinely placed.
Ureteral stents are very selectively placed to aid in identification of the
ureters.
At our institution, ureteral stents are generally reserved for complex
reoperative cases with extensive fibrosis or inflammatory changes of
the pelvis.
Operative Approach
The vast majority of left colectomies are now performed laparoscopically
(Fig. 21-4).
FIGURE 21-4 Room setup for laparoscopic left colectomy.
Robotic surgery may also be utilized, although this chapter focuses on the
laparoscopic approach.
There is still a role for the open surgical approach as well, especially in
cases of previous abdominopelvic surgery or in cases where tumorspecific indications are present, such as a large or T4 neoplasms with
invasion into adjacent structures or in some patients who are super
morbidly obese.
Equipment
Laparoscopic
30-degree, 10- and 5-mm laparoscope
10-mm camera port
Two 5-mm ports, one 12-mm port
Endo-GIA stapler
5-mm bipolar energy device
Two 5-mm atraumatic bowel graspers
Metzenbaum and/or hook cautery tip
5-mm clip applier
Open
Self-retaining retractor
Lighted St. Mark retractor
30-60 mm linear stapler
Atraumatic bowel clamps
Both Approaches
0-Prolene suture
Absorbable 0-ties
Suture of ligature 1- or 0- absorbable suture
End-to-end stapler
Wound protector
Flexible sigmoidoscopy for air leak test
Technique
Basic Operative Steps in Left Colectomy (Regardless of
Approach)
Abdominal exploration and lesion identification
High ligation of IMA and inferior mesenteric vein (IMV)
Sigmoid and left colon mobilization
Mobilization of splenic flexure
Proximal colon transection
Distal margin transection (usually at the upper rectum)
Colorectal anastomosis
Creation of diverting loop ileostomy based on multiple factors and not
routine.
Abdominal Exploration
Periumbilical access is obtained via cut-down technique and insufflation
to 12-15 mm Hg of carbon dioxide ensues.
A 12-mm port is placed in the right lower quadrant, one 5-mm port in
the right upper quadrant, and an optional 5-mm port can be placed on
the left lower/left lateral quadrant (Fig. 21-5).
FIGURE 21-5 Port placement for laparoscopic left colectomy; the left lower
quadrant 5-mm port may not always be necessary, but may be used for an extraction
site as well.
If open, the incision is made via the midline from the above the umbilicus
down to the level above the pubic symphysis.
Upon entering the abdomen, a thorough exploration is performed to
exclude metastatic disease. The peritoneum is inspected for tumor
implantation, and the liver is examined.
Adnexal structures are examined in the pelvis for any signs of metastatic
spread.
Assessment of any lateral extension of the tumor or potential invasion into
any adjacent structures is also addressed at this time.
High Ligation of the Inferior Mesenteric Artery and Vein
A medial-to-lateral approach is typically preferred and undertaken for all
cancer operations by the author (for both open and laparoscopic
approaches).
In open cases, the peritoneum on both sides of the rectum is incised at the
level of the sacrum promontory, with care to avoid the ureters and the
sympathetic nerves.
The dissection is carried underneath the superior rectal artery and is
continued medially to the origin of the IMA off of the aorta.
Branches of the hypogastric nerve plexus are identified and cautiously
swept posteriorly toward the aorta.
The left ureter should be identified at this time before any vessel is ligated.
The IMA should be isolated and skeletonized and doubly clamped (Fig.
21-6).
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