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Chapter 5 • Open Left and Sigmoid Colectomy 65
Figure 5-6 Figure 5-7
Duodenum
Figure 5-8
Splenic flexure
Figure 5-9
66 Chapter 5 • Open Left and Sigmoid Colectomy
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The left colon is lifted from the abdomen and is pulled to the patient’s left, exposing the
medial aspect of the left colon mesentery over the aorta. The IMA is encountered at the level
of the aorta just above the bifurcation of the common iliac artery and vein. The inferior
mesenteric vein (IMV) is identified at the level of the ligament of Treitz at the base of the
mesentery of the left colon above a window of clear peritoneum along the anterior surface
of the aorta (Figures 5-10 and 5-11). The IMA and IMV are isolated at their origins and
divided between ties (Figures 5-12 and 5-13).
Chapter 5 • Open Left and Sigmoid Colectomy 67
Point of
1st branch
transection
Tail of
pancreas
Window
Figure 5-10
IMV
Marginal artery of Drummond
IMA
Duodenum
Window
Aorta
Figure 5-11
of IMV
IMV origin
Ureter
Figure 5-12
Figure 5-13
68 Chapter 5 • Open Left and Sigmoid Colectomy
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The left colon is stretched all the way to the pelvis, bringing the splenic flexure to near the
pelvic brim; this allows the left colon to be evaluated for point of transection, removing
adequate proximal and distal margins for the lesion (Figure 5-14). A purse-string instrument
is used to place a purse-string suture, or a hand-sewn purse-string suture is placed at the site
of transection after dividing the mesenteric vessels. The purse-string suture is placed so that
adequate blood supply is available and there is no tension or twisting (Figures 5-15 and
5-16A and B).
Chapter 5 • Open Left and Sigmoid Colectomy 69
Figure 5-14 Figure 5-15
A
Transverse colon
Splenic
flexure
Sigmoid colon
B
Figure 5-16A-B
Rectum
70 Chapter 5 • Open Left and Sigmoid Colectomy
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For a stapled circular anastomosis, the circular stapler anvil and shaft are secured in the
proximal purse-string suture and reinforced with ties as needed to complete the doughnut
around the base of the shaft of the stapling instrument head (Figure 5-17). The sigmoid or
rectum is transected at the level of the sacral promontory using either a linear cutter stapler
or a transverse linear stapler to create the transverse staple line (Figure 5-18). The circular
stapler itself is introduced through the anal canal to the level of the transverse staple line,
and the post is inserted and extended through the midportion of the rectal stump at the
midportion of the transverse staple line. The left colon is brought into the pelvis without
twisting (Figure 5-19A). The stapler is reconnected and closed under direct vision, maintaining good orientation with the mesentery of the left colon directed posteriorly (Figures 5-19B
and 5-20A-D).
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The anastomosis can be checked by insufflating air through a rigid proctoscope, with the
bowel proximal to the stapled anastomosis occluded and the pelvis filled with saline, to create
an underwater test. Any bubbles seen would indicate a leak at the staple line, and this should
be oversewn with Lembert sutures of 3-0 absorbable suture.
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The abdomen is closed after irrigation, and the small bowel is returned in gentle S-shaped
curves and is covered with adhesion barrier.
Figure 5-17 Figure 5-18
Chapter 5 • Open Left and Sigmoid Colectomy 71
A
Figure 5-19A
B
Figure 5-19B
Division of
rectum
Insertion and assembly
of stapling device
A
B C D
Figure 5-20A-D
Anastomosis
72 Chapter 5 • Open Left and Sigmoid Colectomy
Step 4: Postoperative Care
The abdomen is generally closed with a running No. 1 loop absorbable suture and staples.
Patients are ambulated early. Intravenous fluid replacement is given to maintain a urine output
of greater than 30 mL/hr. Nasogastric decompression is not required unless the patient becomes
nauseated. Most patients tolerate clear liquids within 24 to 48 hours, and the diet can be
advanced as tolerated. Patients should be given prophylactic antibiotics for 24 hours, incentive
spirometry, and deep vein thrombosis prophylaxis and encouraged to ambulate as much as
possible during the early postoperative period. Usual hospital stay after an open left colectomy
is 4 to 5 days; the hospital stay is shorter when the patient is placed on a fast-track postoperative regimen. Postoperative analgesia is usually managed with patient-controlled analgesia
followed by a switch to oral analgesics.
Step 5: Pearls and Pitfalls
The most critical aspect of left colectomy is ensuring an airtight anastomosis with no tension
with good blood supply and no twisting; this can be accomplished with routine attention to
detail. The patient may be best served by placement of a pelvic drain if the dissection is carried
into the pelvis and there is enough oozing from surfaces to justify continued drainage. A pelvic
drain does not eliminate the possibility of a leak, but drainage may be an early indicator of
breach of anastomotic integrity. The patient can be fed on a fast-track basis (early recovery
process). It is important to ensure that the patient can evacuate either gas or stool before discharge to avoid undetected anastomotic leak.
Adequate length for the left colon is guaranteed only if the splenic flexure is mobilized. Some
surgeons hesitate to add this complexity to the case, but, if done routinely, it becomes a straightforward procedure on every patient. Ligation of the IMV and IMA at their origin also adds an
extra dimension of length to the left colon specimen, while adding a degree of radicality. This
maneuver is actually a simplification of the procedure because only two vessels are required for
ligation. The decision regarding vessel division in the proximal left colon mesentery becomes
much simpler because of the easy mobility of the colon and the possibility for using the splenic
flexure itself as the proximal anastomotic segment.
Chapter 5 • Open Left and Sigmoid Colectomy 73
Selected Readings
Adachi Y, Sato K, Kakisako K, et al. Quality of life after laparoscopic or open colonic resection for cancer. Hepatogastroenterology
2003;50:1348–51.
Seitz G, Seitz EM, Kasparek MS, et al. Long-term quality-of-life after open and laparoscopic sigmoid colectomy. Surg Laparosc Endosc
Percutan Tech 2008;18:162–7.
Step 1: Clinical Anatomy
C H A P T E R
6
Laparoscopic Left
Colectomy
Matthew G. Mutch
The left colon lies along the left side of the abdomen suspended from the splenic flexure to the
pelvic brim by lateral peritoneal attachments. The mesentery of the left colon arises from the
midline of the abdomen along the aorta. The sigmoid colon has no lateral peritoneal attachments
other than some congenital adhesions, which fix the apex of the sigmoid to the pelvic brim and
the iliac fossa. Otherwise, the sigmoid colon is attached to the retroperitoneum through a
midline mesentery arising from the inferior mesenteric artery (IMA) and extending down into
the pelvis to the mesorectum. The splenic flexure is attached to the undersurface of the tip of
the spleen, the lower edge of the tail of the pancreas, and the anterior surface of the left kidney
by various levels of suspensory ligaments and peritoneal extensions. The blood supply to the
left colon is based on the IMA, which arises from the anterior surface of the aorta just above
the bifurcation of the common iliac arteries. The IMA extends anteriorly and bifurcates to
produce the superior rectal artery feeding the sigmoid colon and the rectum. The left colic artery
extends cephalad to provide the left colon and distal splenic flexure with blood supply through
the arcade at the mesenteric edge known as the marginal artery of Drummond. The retroperitoneum behind the left colon contains the left ureter and the gonadal vessels lying over the
psoas muscle. The ureter crosses the iliac vessels at the bifurcation of the iliac vessels into the
external and internal iliac branches (Figure 6-1).
Step 2: Preoperative Considerations
74
The indications for laparoscopic left colectomy include colon cancer, diverticulitis, and isolated
inflammatory bowel disease such as Crohn’s disease. The preparation for a left colectomy usually
includes a mechanical bowel preparation. The patient receives preoperative antibiotic prophylaxis and deep vein thrombosis prophylaxis with sequential compression devices and anticoagulation for malignancy. The preferred anastomotic technique for a left colectomy involves a
circular stapled end-to-end anastomosis, which may be made anywhere along the rectum or
sigmoid colon depending on blood supply, indication, and disease limitations.