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342 Atlas of Gastrointestinal Surgery: The Colon
Gastrointestinal continuity can be re-established by either a handsewn or stapled anastomosis. In preparation to per-
form a handsewn coloproctostomy, it is important to clear the mesentery from around the ends of the bowel to be anas-
tomosed. At this time, the staple lines should be carefully inspected for any hidden diverticula, which may hinder the per-
formance of the anastomosis. The two ends of the bowel must be brought together without tension. The anastomosis begins
with placing a posterior row of interrupted 3-0 silk Lembert sutures. Gentle traction on the lateral sutures stabilizes the
colon for placement of these stitches (8). The staple lines are then excised with the electrocautery (9), and the sutures
in the posterior row are cut. The posterior inner layer consists of a continuous locking suture using 3-0 synthetic absorbable
material, brought around anteriorly as a Connell stitch (10 and 11).
Posterior
outer row
8
Rectosigmoid
Transverse
colon
9
Staple lines
excised
Posterior
inner row
(locking)
Anterior
inner row
10 11
12
Left Hemicolectomy 343
The outer anterior layer consists of interrupted 3-0
silk Lembert sutures (12).
Anterior
outer row
Upon completion of the anastomosis, the remain-
ing mesenteric defect is closed with interrupted 3-0
silk sutures (13). No drains are necessary for this
procedure. The abdomen is copiously irrigated with
antibiotic-containing solution. The abdominal wound
is closed by approximating the midline fascia with an
interrupted nonabsorbable suture. The skin is closed
with a subcuticular stitch.
Completed
coloproctostomy
Tr. colon
13
Rectum
344 Atlas of Gastrointestinal Surgery: The Colon
Extended Left Hemicolectomy
Operative Indications
When a midtransverse colon cancer is present, an
extended left hemicolectomy can be performed.
However, an extended right hemicolectomy is pre-
ferred because of a better vascular supply to the
small bowel-to-colon anastomosis. An extended
left hemicolectomy results in the removal of the
entire transverse colon, splenic flexure, and
descending colon and anastomosing the ascending
colon to the sigmoid colon (1, line A-B). The
middle colic and left colic arteries are divided. In
older patients with sigmoid diverticular disease or
atherosclerotic disease, an anastomosis in the sig-
moid colon may not heal well; therefore an
anastomosis in the rectosigmoid should be per-
Omentum
Transverse colon
Middle
colic a.
IMA
Left
colon
Left
colic a.
formed (1, line A-C). Preoperative preparation
of the patient includes an optimal mechanical
bowel preparation, intravenous antibiotics, and
prophylaxis for deep vein thrombosis.
Sigmoid
colon
Rectum
1
Extended Left Hemicolectomy 345
Operative Technique
The patient is positioned in the supine or lithotomy position,
with the left arm or both arms tucked. This allows for an addi-
tional assistant to retract the abdominal wall to better expose the
splenic flexure. A midline incision is made in preparation for
removal of the left colon (2). A self-retaining retractor is used
to assist in exposure. The patient’s abdomen is thoroughly
explored for metastatic disease. The liver and periaortic regions
are palpated, and the small intestine and colon are inspected in
a systematic fashion. During exploration, the surgeon should
2
assess for evidence of locally advanced disease involving the
omentum, stomach, small bowel, spleen, or pancreas. If locally
advanced disease is found, every effort is made to remove the
involved structures.
The procedure begins with careful retraction of the small bowel and left colon to the patient’s right side by the assist-
ing surgeon. The operating surgeon then mobilizes the attachments of the left colon along the line of Toldt with the elec-
trocautery. When mobilizing the left colon medially, it is important to recognize the position of the left ureter, which lies
medial to the gonadal vessels and superior to the common iliac artery. Once the ureter is visualized, the sigmoid colon can
be mobilized to the level of the rectosigmoid junction. A right-angle clamp may be placed under the peritoneal attach-
ments by the assistant surgeon to prevent injury to underlying structures.
Electrocautery generally is sufficient to maintain hemostasis when releasing the splenic flexure attachments. However,
care must be taken when applying traction to any attachments to the spleen so that the splenic capsule is not injured.
Often, the omentum can be wrapped around the colon making separation more difficult. Further mobilization of the colon
occurs with the release of the attachments of the omentum from the transverse colon as well as the hepatic flexure. Complete
mobilization will allow the right colon to reach the rectosigmoid when the anastomosis is ready to be performed. If there
is involvement of the omentum, the omentum should be taken with the specimen by entering the lesser sac at the lower
edge of the stomach. The omentum can then be easily divided.
Once the left colon is fully mobilized, ligation of the vascular supply is easily accomplished. First the left colic artery
is identified as it branches from the inferior mesenteric artery toward the descending colon. The left colic vessels are ligat-
ed with either a 2-0 nonabsorbable suture ligature or a second reinforcing tie. The mesentery can then either be divided
to the mid sigmoid colon or to the rectosigmoid junction. A linear stapling device is use to divide the distal bowel.
346 Atlas of Gastrointestinal Surgery: The Colon
Counterclockwise
rotation of right colon
The middle colic artery is identified more readily if the mesentery
to the splenic flexure and distal transverse colon is divided first.
Division of the middle colic artery and vein at their origins
can be accomplished with a 2-0 nonabsorbable suture
ligature or a second reinforcing tie. Division of the
3
Clockwise rotation
of right colon
Right
colon
Rectum
mesentery is completed with preservation of the
remaining ileocolic vessels, and the proximal bowel
is divided with a linear stapling device.
Re-establishing gastrointestinal continuity can be diffi-
cult following an extended left colectomy. To anastomose the
right colon to the rectosigmoid colon, the right colon can be
rotated in a counterclockwise (3) or clockwise (4) fashion to
bring the two ends of the bowel together. A stapled or hand-
sewn anastomosis can then be performed as previously described.
It will not be possible to close the mesenteric defect; howev-
er the remaining colon should be positioned naturally in the
posterior abdomen. The abdomen is copiously irrigated
with an antibiotic-containing solution. The abdominal
wound is closed by approximating the midline fascia
with an interrupted nonabsorbable
suture. The skin is closed with a
Right
colon
4
Rectum
subcuticular stitch.
Laparoscopic Left Hemicolectomy
Operative Indications
The indication for the laparoscopic removal of a left-sided colon cancer is similar to indication for an open left hemicolec-
tomy. Prospective randomized studies have shown the results to be equivalent. For advanced tumors invading into adjacent
structures such as the abdominal wall or bladder, a laparoscopic approach may be contraindicated. Because of the variabil-
ity in reporting the correct location of a left-sided colon tumor endoscopically, it is best to have the tumor tattooed prior
to a laparoscopic approach. Preoperative preparation of the patient includes an optional mechanical bowel preparation,
intravenous antibiotics, and prophylaxis for deep vein thrombosis.
Operative Technique
Essential to the performance of a laparoscopic resection is patient
positioning. The patient is in the low lithotomy position with the
right arm tucked. The abdomen is prepped widely. A nasogas-
tric tube and foley catheter should be placed prior to trocar inser-
tion. The video monitors are placed near the head of the bed,
and the operating surgeon stands at the patient’s right side. A
laparoscopic left hemicolectomy can be performed with four
ports; three 10-mm trocars and one 5-mm trocar. The camera
port is established first in the infraumbilical region using the open
Hasson technique. The remaining ports are positioned. A 5-mm
port is placed in the epigastrium and a 10-mm port is placed
midline, approximately two finger breaths above the pubic
symphysis. The final trocar is placed in the right lower abdomen
along the mid axillary line and at least 2 cm from the iliac crest.
348 Atlas of Gastrointestinal Surgery: The Colon
The position of this port may vary verti-
cally based upon the intracorporeal dis-
2
Left
colon
tance to the splenic flexure. A 30
degree angled camera is used to per-
form the procedure (1).
The procedure begins with
abdominal exploration for evidence
of disseminated disease. The lateral
attachments of the left colon are
then mobilized along the line of
Sigmoid
colon
Toldt. This is facilitated by placing the
operating table in steep Trendelenberg
position, with the left side of the
Lateral
attachments
released
abdomen tilted up, and having both the
assistant and the operating surgeon standing to
the patient’s right. The assistant retracts the colon
with a laparoscopic atraumatic grasper and
electrocautery scissors and releases the lat-
eral attachments of the left colon (2).
Mobilization of the splenic flexure is
facilitated by placing the patient in
steep reverse Trendelenberg and
applying gentle traction on the colon
while the electrocautery scissors are
medially by gently grasping the left colon with an atrau-
matic grasper. The operating surgeon begins the resection
Spleen
3
Stomach
used to free omental attachments to
the spleen (3) and transverse colon
(4). To avoid injury, the position
of the stomach should be identified
frequently during mobilization of the
splenic flexure.
Left
colon
Laparoscopic Left Hemicolectomy 349
Alternatively, if the disease within the colon involves the omentum, it should be taken en bloc with the colon. This
is accomplished by entering the lesser sac through the omentum, away from the tumor (5). While the electrocautery
scissors work well to separate the omentum from the colon, the LigaSure or Harmonic scalpel should be used to divide
the omentum.
Omentum preserved
Stomach
Tr. colon
Tr. colon
4
Omentum resected with specimen
Stomach
Tr. colon
Omentum
5
350 Atlas of Gastrointestinal Surgery: The Colon
Once the bowel has been mobilized, the mesentery is divided. It is important to ligate the left colic and left branch
of the middle colic vessels at their origin to obtain an appropriate lymphadenectomy. The colon is retracted laterally and
the vascular pedicles are identified. Windows are created in the mesentery surrounding the vascular pedicles with the elec-
trocautery scissors. The ureter is identified running laterally. The vascular pedicles are either divided with an endovascular
stapler or endoclips (6). The remaining mesentery can be divided with the LigaSure or Harmonic scalpel.
Left colon
IMA
Left
colic a.
Sigmoid
colon
L. ureter
Aorta
6
Rectosigmoid
divided
Laparoscopic Left Hemicolectomy 351
L. ureter
Sigmoid
colon
7
Once the mesentery is freed, the distal bowel is grasped at the intended resection line and any remaining mesentery is
dissected away from the bowel wall. Failure to do this may allow mesentery to be caught up in the anastomotic staple line
and potentially lead to postoperative anastomotic bleeding. Tension is applied to the colon to lift it out of the pelvis. If
the mesentery has been adequately mobilized, only one or two applications of the laparoscopic linear stapling device will
be required to divide the rectosigmoid colon (7). Once the bowel has been divided, the entire length of the mobilized
colon should be visualized to make certain that all mesenteric attachments have been divided. The specimen is still attached
to the transverse colon proximally.
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