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260
S. Saad
32
. Fig. 32.13 Transvaginal extraction. The wound
protector is introduced through posterior colpotomy
approach is very similar to the open right hemicolectomy. Another advantage of this approach with
extracorporeal anastomosis is lower costs, if hand
suture is done, and it will also allow teaching of
hand-sutured anastomosis to surgical residents.
As an alternative to Pfannenstiel incision
(. Fig.32.13), the extraction of the colon specimens can be done with minilaparotomy in the
right upper quadrant of the abdomen or a small
median incision near the umbilicus. ese two
locations of the extraction side allow extracorporeal anastomosis.
In selected female patients with small tumors
below 4 cm diameter, a transvaginal extraction of
Classication of intraoperative diculties in right hemicolectomy
I Ideal patient
Technical easy to operate. Every operating
technique is unproblematic
II Not ideal patient
Moderate technical diculties
Some operating techniques are more dicult than
others
III Problematic patients. Dicult to operate. Some
operating methods are much more dicult than
others
IV Very problematic patient. Every operative technique
is very dicult
. Fig. 32.14 Wounds after laparoscopic right
hemicolectomy
the colon specimen can be done (
. Fig.32.14). Aer
intracorporeal ileotransversostomy, a small incision
is done as a posterior colpotomy. We use the Alexis
wound protector to deliver the specimen through
the vagina. e colpotomy can be closed by single
stitches with 1-0 Vicryl. is suture line can also be
checked by laparoscopic view. e advantage of
transvaginal specimen extraction is the avoidance
of a minilaparotomy. e wound morbidity of a
minilaparotomy like postoperative pain, wound
infection, and hernia formation is avoided.
Here we classify the intraoperative diculties
in patients undergoing laparoscopic right hemicolectomy.
Laparoscopic technique with or without
minilaparotomy
Intracorporeal anastomosis
Laparoscopic with or without minilaparotomy
Intra- or extracorporeal anastomosis
Laparoscopic-assisted hemicolectomy with
minilaparotomy
Intra- or extracorporeal anastomosis or
laparoscopic hand-assisted or open surgery
Laparoscopic, hand assisted with minilaparotomy
Extracorporeal anastomosis or open colectomy
261
Individual Surgery for Left Hemicolectomy
Contents
Chapter 33 Introduction – 263
MichaelKorenkov, Christoph-omasGermer,
andHaukeLang
Chapter 34 Surgical Technique and Dicult
Situations from Joerg C. Kal
(Conventional) – 267
JörgC.Kal, DimitriosPantelis,
andBurkhardStoels
VIII
Chapter 35 Surgical Technique and Dicult
Situations from Amjad Parvaiz: Splenic
Flexure Tumors (Laparoscopic) – 273
AmjadParvaiz andManfredOdermatt
Chapter 36 Surgical Technique and Dicult
Situations from Thomas Schiedeck
(Laparoscopic) – 281
omasH.K.Schiedeck andMartenSchmerer
263
Introduction
MichaelKorenkov, Christoph-omasGermer, andHaukeLang
33.1 Open Left Hemicolectomy forColon Cancer – 264
33.2 Laparoscopic Left Hemicolectomy
forColon Cancer – 264
33.3 Classication ofIntraoperative Diculties – 265
33
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_33
264
M. Korenkov et al.
33
A le hemicolectomy is not a common surgical
procedure. Many of the technical steps are similar
to those of a sigmoid or rectal resection, but there
are surgery-related features. e surgery can be
performed via an open technique or laparoscopically; however, most surgeons prefer an open
technique.
33.1 Open Left Hemicolectomy
forColon Cancer
Midline laparotomy, le paramedian laparotomy,
and middle abdomen transverse laparotomy are
the most common approaches. All of these incisions permit an adequate exploration of the area.
For an adequate approach, both colon exures
and the rectosigmoid junction should be reachable without any diculty. Some surgeons distinguish between a vertical and a horizontal type of
incision depending on the location of the tumor.
A middle abdomen transverse laparotomy has
been favored by surgeons for tumors of the le
colonic exure. A vertical incision has been used
for tumors of the descending colon.
e extent of resection depends on the location of the tumor. e “classic” le hemicolectomy with high ligation of the inferior mesenteric
artery and vein and transection of the transverse
colon aboral from the middle colic pedicle along
with the distal bowel transection at the upper rectal level should be performed on tumors of the
descending colon.
For colonic tumors located at the splenic exure, the extent of resection consists of transection
of le colic artery, proximal transverse colonic
transection oral or aboral from middle colic pedicle, as well as distal bowel transection at the colosigmoid junction. In the case of transverse colon
transection on the oral side from the middle colic
pedicle, a middle colic artery should be centrally
transected. e technical diculties of le colon
mobilization are similar to those of the le colon
mobilization during rectal cancer surgery.
Most oen, dicult decision situations occur
during anastomosis creation. In case of distal
bowel transection in proximal rectum, most surgeons favor a transversorectal end-to-end anastomosis created with a circular stapler. By preserving
the sigmoid colon, both a handsewn (end-to-end)
and stapled anastomosis are possible. A stapled
anastomosis can be created with a linear (side-toside) or circular stapler (end-to-end or end-toside), whereas an anvil should be placed in the
sigmoid colon, and the stapler stab should be
introduced via colostomy in the transverse colon.
For the creation of a tension-free transversosigmoid or transversorectal anastomosis, it is
sometimes necessary to perform a complete division of the gastrocolic ligament and mobilization
of the right colic exure. In some cases, it can lead
to circus vicious. An extend bowel mobilization
can cause a peripheral blood ow disorder and
requires a new bowel resection that can lead to
anastomosis tension, which requires a new mobilization. To avoid such situations, it is sometimes
necessary to perform a partial colectomy with
creation of an ileosigmoid anastomosis or transversorectal anastomosis with protective loop ileost omy.
33.2 Laparoscopic Left
Hemicolectomy forColon
Cancer
A laparoscopic le hemicolectomy is more sophisticated than an open hemicolectomy. Given that a
tumor localization on the descending colon and
splenic exure occurs only seldomly, this is relatively dicult for many surgeons because this
requires a large number of patients to complete
the learning curve.
e laparoscopic mobilization of the le colon
for the le hemicolectomy is not distinguishable
from the mobilization for the low anterior rectal
resection. e most technical diculties can
occur during the transection of the mesocolon.
Contrary to laparoscopic preparation in the
pelvic area, sometimes an adequate exploration of
preparation plain in the middle le abdomen is
much more dicult. Periodically, despite the
maximal right overturning of the operating table
and 30° le site elevating is not possible to see an
operating plain. Additionally, the steps of the surgery have dierent grades of diculty. e lateral
mobilization of the le colon and transection of
the inferior mesenteric artery are mostly technical
rather than problematic. e transection of the
descending and transverse mesocolon is more
Introduction
265
33
dicult, particularly in severely obese patients. In
dicult situations, it is helpful to perform proximal and distal colon transection to improve the
traction options. e distal colon transection is
typically uneventful. e identication of the
proximal transection plain related to the middle
colic pedicle is oen dicult in obese patients. An
In the event of using an intracorporeal stapler, it is
more favorable to use a side-to-side linear stapler
for an anastomotic technique. Preoperative bowel
cleansing is necessary prior to the technique.
Alternatively, a “technical” sigmoid resection with
creation of transversorectal anastomosis with a
circular stapler can be performed.
always gut identied landmark is a ligament of
Treitz. e middle colic vessels located oral side
from the projection of the ligament of Treitz on
the mesocolon. Aer completion of the proximal
33.3 Classication ofIntraoperative
Diculties
and the distal colon transection, the identication
of the medial preparation plain easier.
Removal of the sigmoid bowel is not abso-
lutely necessary for tumors of the splenic exure.
. Table 33.1 Grading of operative diculties for oncological left hemicolectomy
Grading Case type
I (ideal cases)
It is a simple surgery; every surgical technique is
technically unproblematic
II (not quite ideal)
Some minor technical diculties may occur;
some surgical techniques can be more dicult
than others
III (problematic)
Dicult to operate, some surgical techniques are
considerably more dicult than others
IV (very problematic)
Every surgical step is dicult
e surgical diculty for oncological le hemico-
lectomy can be classied as summarized in
. Table33.1.
Slender or normal-weight patient
No previous abdominal surgery
Moderate obese patient (BMI approximately 30kg/m
Otherwise, similar to grade I
Overweight patient (BMI > 35kg/m
Previous extended upper abdomen surgery (gastric
resection, pancreatic surgery, splenectomy,
transabdominal left nephrectomy)
Patients with large bowel ileus from tumor obstruction
Patients with dicult small bowel shifting on the right side
Extreme form of grade III factors
2
)
2
)
Surgical Technique
andDicult Situations
byJoerg C.Kal
(Conventional)
JoergC.Kal, DimitriosPantelis, andBurkhardStoels
34.1 Introduction – 268
34.2 Preparation – 268
34.3 Surgical Technique – 268
34.4 Postoperative Management – 269
267
34
34.5 Dicult Situations – 269
34.5.1 Splenic Injury – 269
34.5.2 Ureteral Injury – 269
34.5.3 Poor Circulation oftheResection Margins – 270
34.5.4 Left Hemicolectomy UnderEmergency
Conditions – 270
34.5.5 Intraoperative Challenges inUnexpected
Advanced Oncological Findings – 270
34.5.6 Classication ofIntraoperative Diculties – 271
References – 271
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_34
268
J.C. Kalff et al.
34
34.1 Introduction
e le hemicolectomy involves the resection of
the le aboral transverse colon, the middle colic
vessels, and the entire le hemicolon down to the
upper rectum.
e most common indication for this surgical
procedure is a malignant tumor in the splenic
exure or descending colon. Even with sigmoid
carcinomas, an extension of the resection and
thus performing a le hemicolectomy can become
necessary (e.g., tumor location in the proximal
sigmoid, poorly perfused oral resection margins,
or due to descending colon unsuitable for anastomosis with extensive diverticulitis).
We prefer the minimally invasive approach for
resections on the le hemicolon. However, the
conventional open surgical technique in the radical le hemicolectomy remains the standard procedure and must be mastered by every colorectal
surgeon.
34.2 Preparation
5 All patients with histologically conrmed
colon cancer and suspected presence of an
inltrative growth found during preopera-
tive diagnosis are discussed in our oncology
tumor board.
5 Preoperative vaccination of patients occurs
only in carcinoma of the splenic exure with
inltration of the spleen and thus possibly
required splenectomy.
5 Based on the results of numerous random-
ized clinical trials before colonic resections,
an orthograde colonic lavage can be omit-
ted. In our clinic, we usually carry out a
double enema to clean the rectum and distal
sigmoid colon as the only action prior to
operations on the le hemicolon on the day
before surgery.
5 In our clinic, a perioperative antibiotic pro-
phylaxis is given 30min before skin incision
with ampicillin 2g/1g sulbactam (Unacid
3g) iv or in the presence of penicillin allergy
alternatively with clindamycin 600mg/metro-
nidazole 500mg (Sobelin 600 mg/Clont 500
mg) iv. is is repeated aer 4 h intraopera-
tive, if necessary.
5 Patient positioning is done on a rotated
table with legs spread and using pneumatic
alternating pressure cus on both lower legs.
is positioning allows the intraoperative
access to the perineum, thereby making a
stapler anastomosis possible.
5 e surgeon wears a head lamp. Surgery is
carried out usually with two assistants and
using a special abdominal retractor system.
34.3 Surgical Technique
e standards of oncological tumor surgery must
be respected (exploration of the abdominal cavity,
sucient safety margins oral and aboral, central
lymph node dissection, R0 resection of the tumor
while avoiding tumor initiation, multivisceral
resection in a situation with T4 inltrative
growth). During an emergency surgery, a primary
resection of the tumor and the avoidance of a twostage procedure with a proximal protective stoma
should also be sought [1].
e exact extent of resection is denitely
decided in the context of the exploration of the
abdomen and possibly also aer complete mobilization of the le hemicolon.
5 Access is via a median laparotomy le side
to the umbilicus. e abdomen is explored,
and the local resectability and the presence
of metastases (especially lymphatic, perito-
neal, or hepatic) are evaluated.
5 In open surgery, we usually prefer (in contrast
to the minimally invasive approach) during
le hemicolectomy the approach from lateral.
e peritoneal adhesions are dissected with
gentle retraction of the colon medially by the
rst assistant in the avascular layer. Bleeding
indicates preparation in the wrong layer.
5 e le ureter is identied just proximal
to its crossing with the le common iliac
artery, dissected and looped.
5 e splenic exure is completely mobilized.
5 e omentum is cut to about the middle of
the transverse colon. From here, the omen-
tal bursa is entered and the splenic exure
completely freed from the pancreatic lower
margin. Especially at high le exures, access
is facilitated by maximum mobilization of the
mesocolon of the Gerota’s fascia.
5 e middle colic artery is identied. e
oral surgical margin at the transverse colon
is marked preserving the artery and the
intestine is looped.
Surgical Technique andDifficult Situations byJoerg C.Kalff (Conventional)
269
34
Due to the central lymph node dissection and transection of the main trunk of the inferior mesenteric
artery with consecutive inevitable hypoperfusion
in the area of the entire sigmoid colon, transsection is carried out at the level of the upper third
of the rectum (approximately 1–2 cm below the
promontory).
5 Approximately at the level of the promon-
tory, the peritoneum is incised medially, and
from here toward the duodenum, the origin
of the inferior mesenteric artery from the
aorta is depicted. To avoid injury to the inferior mesenteric plexus running directly next
to the aorta, we transect the artery approximately 0.5–1cm distal to its origin between
two Overholt clamps.
5 Centrally the artery is sutured and ligated.
e ligature on the mesentery of the prepared specimen is le long for the pathologist to identify the boundary nodes.
5 e lymph node dissection is completed by
transection of the inferior mesenteric vein
on the pancreatic lower margin at the specied oral surgical margins and under the
protection of the middle colic artery.
In our clinic, we prefer performing rectal anastomoses with a so-called double-stapling technique
(transection of the rectum with a curved cutter stapler and anastomosis using a circular stapIer).
Alternatively, the anastomosis can be sewn manually in the upper rectum aer le hemicolectomy. In
most cases, a continuous, single-row suture with
monolament thread is used.
5 Sucient blood circulation at the level of
transsection in colon (palpation of the pulse
in the marginal artery, bleeding from the
resection margins) and rectum must be
checked before nishing the anastomosis.
e anastomosis itself must be tension free.
5 Anastomotic tightness is tested by perianal
air insuation.
5 Regularly capillary drains (draining anasto-
motic area) can be omitted.
34.4 Postoperative Management
Seventeen years aer the rst publication of a
fast-track rehabilitation program in elective
colon resections by Kehlet et al. and 11 years
aer such a program was rst established in a
German clinic, it is proved that the fast-track
rehabilitation for elective colonic resections
compared to “traditional” treatment lowers the
complication rate and reduces length of hospital
stay [2]. Key points of the fast-track concept,
such as the thoracic epidural anesthesia, early
enteral nutrition, and early mobilization of the
patient, are among the standards of perioperative care to our patients in oncological open le
hemicolectomy.
34.5 Dicult Situations
34.5.1 Splenic Injury
It is a rare complication associated with a high
morbidity. An injury to the spleen can occur during mobilization of the splenic exure and especially in the transsection of the splenocolic
ligament. In such a situation, one should take special care that tearing the colon or the major
omentum while setting of situs can indirectly lead
to a laceration of the splenic capsule. e incidence of splenic injuries is indicated with 0.42 %
in a major review (13897 colectomies, Mayo
Clinic, Rochester, USA) [3]. e risk is signicantly increased in previously operated patients
with adhesions in this area and in very obese
patients. Splenectomy should be performed only
as an ultima ratio if other surgical actions fail to
control bleeding.
Smaller capsule injuries can be stopped by
electrocoagulation and compression. Trying to
reach hemostasis by hemostyptics, especially
through the use of collagen matrix-bound coagulation factors, is always justied. For heavy bleedings and patients in unstable condition, the
indication for splenectomy should not be delayed
too long.
34.5.2 Ureteral Injury
e incidence of this rare complication is indicated with 0.3–1.5 % in the literature [4]. e key
to avoiding an injury during a le hemicolectomy is the early identication of the le ureter
[5]. Under dicult local circumstances (e.g.,
multiple previous surgeries, radiation, retroperitoneal brosis), a preoperative ureteral stenting
is advisable.
270
J.C. Kalff et al.
34
Intraoperatively identied ureteral injuries
need to be repaired directly. Postoperatively diagnosed ureteral injuries require surgical revision.
e repair and supply of the ureter with a stent
should be performed by a urologist if no appropriate expertise of the surgeon exists.
If the ureter is accidentally ligated, the ligature
is removed and the ureter observed. If substantial
injury results, resection of the aected section
with end-to-end anastomosis is advisable. For
long-segment defects, reconstruction should be
performed by a “psoas-hitch procedure.”
34.5.3 Poor Circulation
oftheResection Margins
e blood perfusion of the resection margins
must be controlled to reduce the risk of anastomotic leakage before suturing the anastomosis.
Unfortunately, a reliable quantitative method
does not exist, and therefore the judgment is
highly dependent on the experience of the surgeon. On suspicion of hypoperfusion, a further
resection should be performed. An extended le
hemicolectomy with transection of the middle
colic artery and an ascendo-rectostomy to achieve
a tension-free situation may be required.
34.5.4 Left Hemicolectomy
UnderEmergency Conditions
Sometimes the rst symptoms of a tumor require
emergency laparotomy. In general, this is the case
if the tumor perforates due to tumor-related intestinal obstruction. A mechanical ileus with
impending decompensation may also require
emergency surgery.
Standards of septic abdominal surgery apply
in perforation with peritonitis. We always strive
for a primary oncological resection with anastomosis in the same session, if necessary, under the
protection of the anastomosis by a protective loop
ileostomy. Only in bloodstream-compromised,
high-septic patients or in highly complicated local
ndings resection according to Hartmann is indicated. A three-stage procedure with primary
stoma leaving the tumor-bearing segment remains
rare to individual cases.
34.5.5 Intraoperative Challenges
inUnexpected Advanced
Oncological Findings
Other Colon Tumors
In the case of intraoperative diagnosis of a second
cancer in the ascending colon or transverse colon,
we regularly carry out a subtotal colectomy with
an ileorectostomy.
Inltrative Tumor Growth
(T4 Situation)
In case of intraoperative diagnosis of tumor
growth into adjacent organs (stomach, pancreatic tail, spleen, le kidney), an en bloc resection is performed removing the entire
tumor-bearing region. Hereby, extensive upper
abdominal surgery (gastrectomy, distal pancreatectomy, splenectomy) might become necessary. In any case, le hemicolectomy is
performed with oncological central lymph node
dissection.
PeritoneaI Carcinomatosis
In case of intraoperative diagnosis of peritoneal
carcinomatosis and in the absence of distant
metastases, an oncological le hemicolectomy is
done. In the further course, cytoreductive surgery
with hyperthermic intraoperative peritoneal chemotherapy (HIPEC) is evaluated.
Liver Metastases
In the case of intraoperative diagnosis of
liver metastases, a primary histological confirmation is mandatory. If an option of an R0
resection by atypical liver resection or segmentectomy is given, this is done in the same session followed by an oncological left
hemicolectomy. Advanced liver resections (e.g.,
hemihepatectomy) are usually carried out by a
two-stage approach.
Liver Cirrhosis, Portal Hypertension
The presence of liver cirrhosis CHILD B and C
is a challenge with respect to the occurrence of
intraoperative and specifically postoperative
complications. Preoperatively, the possibility of
improving a patient should be investigated
by a specialized hepatologist (e.g., by TIPS).
Surgical Technique andDifficult Situations byJoerg C.Kalff (Conventional)
. Table 34.1 Degree of intraoperative diculties in conventional left hemicolectomy
271
34
Grade I:
Ideal patient
Grade II:
Not quite ideal patient
Grade III:
More problematic patient
Grade IV:
Very problematic patient
Technically easy to operate, any surgical
method is unproblematic feasible
Moderate technical diculties, some
surgical methods can be more dicult
than others
Dicult to operate, some surgical
methods are more dicult than others
Any surgical action is very dicult Former laparostoma
Apronounced portal hypertension in the upper
abdomen and retroperitoneum may make it
impossible to carry out an oncological left
hemicolectomy. Here a limited resection with
a Hartmann procedure makes sense in some
cases.
34.5.6 Classication of
Intraoperative Diculties
We classify intraoperative diculties in patients
who have to undergo a le hemicolectomy, as
shown in . Table34.1.
Patients with normal BMI
No previous abdominal surgery
Small tumor
Obesity
Previous abdominal surgery
Slight adhesions
Large tumor
Scarred abdomen
Previous colon resection
Advanced inltrative tumor growth
Emergency surgery (ileus, perforation)
Advanced liver cirrhosis (portal
hypertension, ascites)
Dense adhesions
References
1. Keller R, Bruch HP, Czymek R. Kolonkarzinom. Allgemein- und Viszeralchirurgie up2date. 2008;6:407–430.
2. Schwenk W. Fast-Track: Evaluation eines neuen Konzeptes. Chirurg. 2012;83:351–355.
3. Holubar SD, Wang JK, Wol BG, Nagorney DM, Dozois
EJ, Cima RR, O’Byrne MM, Qin R, Larson DW. Splenic
salvage after intraoperative splenic injury during colectomy. Arch Surg. 2009;144:1040–1045.
4. Palaniappa NC, Telem DA, Ranasinghe NE. Incidence of
iatrogenic ureteral injury after laparoscopic colectomy. Arch Surg. 2012;147:267–271.
5. McLean A, Buie WD. Left colectomy: Open technique.
2012. http://www.uptodate.com/contents/left-colectomy-
open-technique.