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POSTOPERATIVEMANAGEMENT
Atourinstitution,patientsundergoinguncomplicatedleftorsigmoid colectomyrecuperateunderastandardizedprotocoldesignedto acceleraterecovery.Ofcourse,eachpatientisassessedforsuitability beforeinitiatingthisprotocol,andchangesaremadeasindicated throughoutthepostoperativecourse.Thegeneralcomponentsofour earlyrecoveryprotocolarelistedhere.Thetypicalhospitalstayis3–4 days.
Dietandintravenousfluids:Onpostoperativeday0,patients commenceaclearliquiddietandIVfluidsarelimitedto2Lofdextrose
withhalfnormalsaline.Thereafter,IVfluidreplacementisadministered onlyasnecessaryasweallowpermissiveoliguria.Solidfoodisgivenon postoperativeday1andoralfluidreplacementisencouraged. Nasogastricdecompressionisnottypicallyrequired.
Paincontrol:Patient-controlledanalgesiadevicesarestarted immediatelyaftersurgeryalongwithscheduledoralacetaminophenand
gabapentin.Epiduralanalgesiawithbupivacaineisalsoinitiated immediately.IVketorolacisscheduledfrompostoperativeday1fora totalof3days.Typically,transitiontooralnarcoticsoccursonthe secondpostoperativeday,andtheepiduralcatheterisremovedby postoperativeday3.
Ileusprophylaxis:Patientsareambulatedassoonaspostoperative day1.Theyarealsomaintainedonoralalvimopanuntilfirststool.
Venousthromboembolusandinfectionprophylaxis: Subcutaneousenoxaparinisstartedimmediatelyontheeveningof
surgeryandcontinued,evenafterdischarge,foratotalcourseof21days. Nofurtherantibioticsareadministeredaftertheinitialdoseof perioperativeertapenem.Ifciprofloxacinandmetronidazoleareinstead given,thisistypicallycontinuedforatotalof24hoursonly.

COMPLICATIONS

Ileus,surgicalsiteinfections,respiratoryinsufficiency,andanastomotic leakarethemostcommonpostoperativecomplicationsassociatedwith openleftorsigmoidcolectomy.Bothintraoperativemeasuresand alterationsinourstandardizedpostoperativemanagementregimehave significantlyreducedtheratesoftheseproblemsamongourpatient cohort.
Anastomoticleakisthemostfearedcomplicationofanycolectomy. Theanticipatedleakrateforaroutineleftandsigmoidcolectomywith
colorectalanastomosisislessthan4%.Thesecomplicationscanbe conservativelymanagedwithpercutaneousdrainageoffluidcollection andbowelrestiftheleakiscontained.Re-explorationandtakedownof thecolorectalanastomosiswithendcolostomycreationshouldbe performedonlyinthesettingoffrankperitonitisanddiffusefecal contamination.
Deepvenousthrombosisandpulmonaryembolusratesforthose patientsreceivingchemoandmechanicalprophylaxisperioperatively
shouldbelessthan1%.Thus,weadvocateearlyprophylaxiswith enoxaparin(orotheranti-Xacompounds)foreverycolectomypatient unlessotherwisecontraindicated.Inferiorvenacavafiltersarenecessary onlyifthepatientembolizesmultipletimesorcannottolerate anticoagulation.
Surgicalsiteinfection(SSI)isoneofthemostcommon complicationsofcolectomy.Becausetheprocedureisatbestclean-
contaminatedinnature,woundinfectionshavebeenreportedinexcess of20%ofpatients.Strictpreventionofsuccusspillage,woundprotection withincisionbarriers,andadoptionofclean-closuretechniques intraoperativelyhaveresultedindrasticreductionofourownSSIrates towellbelow10%.Ifdeepsubcutaneouswoundinfectiondoesoccur, localmanagementofthewound—openingandpackingorplacementof vacuum-assistedtherapy—alongwithantibioticsareessential.
Postoperativeileusisnotuncommonafteranopenoperation.Even so,thepatientshouldtrialclearliquidsshortlyaftersurgery,and
nasogastrictubesshouldbeavoided.Alvimopan,aperipherallyactingμ­receptorantagonist,mayalsobeusedintheimmediatepostoperative periodtofacilitatebowelfunction.However,ifthepatientdevelops persistentnauseaandradiographicileus,bowelrestandnasogastric tubedrainageshouldbeconsidered.Ileuscanbeexpectedin10–25%of
patients. Urinarytractinfectionsareoftenasideeffectoflong-term
indwellingbladdercatheters.Forthisreason,earlyremovalofthe cathetershouldbeperformedexceptincasesofsuspectedbladderinjury orextensivepelvicdissection.Recognitionofureteralinjurymaybe facilitatedbyobservationofadrainleftinthepelvis.Shouldthedrain volumeincreaserapidly,acreatininelevelcanbeobtainedonthe drainage.Afluidcreatininelevelthatishigherthantheserumcreatinine levelwouldindicatealeakfromtheurinarytractitselfintotheabdomen. Forthestandardleftcolectomy,cathetersareremovedonpostoperative day1.
In-hospitalpneumoniaafterabdominalsurgerycanalmostentirely beavoidedbyencouragingroutineincentivespirometeruseandearly
ambulation.Ofcourse,atelectasisiscommon,althoughinfrequently significantfollowingcolectomy.

RESULTS

Theopenlateral-to-medialleftcolectomyisanexcellentoptionfor anatomicresectionoftheleftandsigmoidcolon.Thisapproachmakes wedgeresectionorsmallsegmentalresectionunnecessarybecausethe anatomicrelationshipsareeasilyvisualized,avascularplanesare exploited,andacolorectalanastomosiscanbeaccomplishedwithout compromisingqualityofoncologicresection.Inaddition,wideresection oflymphaticandadherentretroperitonealorabdominalwalltissues drasticallyreduceslocalrecurrenceratesofstagesIthroughIIIcolon cancerstolessthan1%.Followingsucharesection,themostcommon causeoflocalrecurrenceisperiaorticlymphnodeinvolvement.

CONCLUSIONS

Theuseofanopenlateral-to-medialleftcolectomyshouldbethebasic approachtoleft-sidedcolonicdisease.Thisapproachcapitalizeson knownavascularanatomicplanesandaccesstovesselsattheiroriginto allowforsafe,oncologicallysuperiorresection.Alowrateof complicationsandgoodlong-termoutcomesisexpectedinthesepatients.
RECOMMENDEDREFERENCESAND READINGS
BotomanVA,MPietroM,ThirlbyRC.Localizationofcoloniclesionswithendoscopictattoo.Dis
ColonRectum1994;37:775–6.
ChinCC,YehCY,TangR,ChangchienCR,HuangWS,WangJY.Theoncologicbenefitofhigh
ligationoftheinferiormesentericarteryinthesurgicaltreatmentofrectalorsigmoidcolon
cancer.IntJColorectalDis2008;23(8):783–8. FearonKC,LjunggvistO,VonMayanfeldtM,etal.Enhancedrecoveryaftersurgery:aconsensus
reviewofclinicalcareforpatientsundergoingcolonicresection.ClinNutr2005;24(3):466–77. KanemitsuY,HiraiT,KomoriK,KatoT.Survivalbenefitofhighligationoftheinferior
mesentericarteryinsigmoidcolonorrectalcancersurgery.BrJSurg2006;93(5):609–15. KimE,SheetzK,BonnJ,etal.Astatewidecolectomyexperience:theroleoffullbowel
preparationinpreventingsurgicalsiteinfection.AnnSurg2014;259(2):310–4. LipsettP.Preoperativebowelpreparation.In:CameronJ,CameronA,eds.CurrentSurgical
Therapy.11thed.Philadelphia,PA:Saunders,2014:147–8. SpanjersbergWR,ReuringsJ,KeusF,vanLaarhovenCJ.Fasttracksurgeryversusconventional
recoverystrategiesforcolorectalsurgery.CochraneDatabaseSystRev2013;1–49. ScarboroughJ,MantyhC,SunZ,MigalyJ.Combinedmechanicalandoralantibioticbowel
preparationreducesincisionalsurgicalsiteinfectionandanastomoticleakratesafterelective
colorectalresection:ananalysisofcolectomy-targetedACSNSQIP.AnnSurg2015;262:331–7. WeiserM.Lefthemicolectomyfortreatmentofmalignancy.In:FischerJE,KirbyI,eds.Mastery
ofSurgery.Philadelphia,PA:LippincottWilliams&Wilkins,2007:1533–41.
Chapter9
LaparoscopicMedial-to­LateralColectomy
AzahA.AlthumairiandJonathanE.Efron

INDICATIONS/CONTRAINDICATIONS

Indications
Theindicationsforlaparoscopicleftcolectomyperformedeitherbya medial-to-lateralapproachoralateral-to-medialdissectionarediverse, includingbothmalignantandbenignconditions.Earlyinthehistoryof laparoscopiccolectomy,controversyexistedastothesafetyand feasibilityoflaparoscopiccolectomyforcancer.Thisdebatewas secondarytoearlyrecurrencerates,primarilyportsiterecurrences, whichsurgeonsfearedmaybesecondarytothetechnicalaspectsof laparoscopiccolectomy,suchasthepneumoperitoneum.Several prospective,randomizedtrials,however,havedemonstratedequivalent recurrenceandlong-termsurvivalratesbetweenlaparoscopicandopen colectomiesperformedforcancer.Currently,malignancyisconsideredan optimalindicationforlaparoscopiccolectomies.
Mostbenignconditionsalsolendthemselvestolaparoscopicresection byamedial-to-lateralapproach.Theseconditionsincludediverticulitis, inflammatoryboweldisease,andpolyps.Incomplicateddiverticulitisor Crohn’sdiseasewithanassociatedpericolonicabscess,themedial approachmayallowearlyidentificationoftheureterandiliacvessels, allowingforasaferlateraldissectionintheinflamedtissue.Conversely,if theintestinalmesenteryissignificantlythickenedfromCrohn’sdisease, approachingthedissectionlaterallymayavoidinjuringthemesentery andpreventingexcessbleedingortheformationofamesenteric hematoma.DividingthickenedCrohn’smesenteryisdifficultwitheither vessel-sealingdevicesorintracorporealstaplersandthismaylimitthe abilityofthesurgeontoperformamedial-to-lateraldissectionbecause
divisionofmesentericvesselsmaynotbepossible.
Contraindications
Somerelativecontraindicationsforperformingalaparoscopiccolectomy forcancermaypossiblyincludeT4cancerswithextensiveinvolvementof otherabdominalorgans,ortumorsthataregreaterthan8cmin diameter.Similarly,conditionssuchassigmoidvolvulusandrectal prolapsegenerallyrequireminimalsigmoidmobilizationandtherefore arenotwellservedbyamedial-to-lateralapproachwithhighligationof theinferiormesentericvessels.
PREOPERATIVEPLANNING
Preoperativepreparationbeforelaparoscopiccolectomyincludes ensuringthatthepatient’smedicalcomorbiditiesarewellcontrolledand thatheorsheisanacceptablecandidateforsurgery.Preoperative teachingofthepatientandfamilyshouldincludeinstructionsonthe patient’spostoperativeresponsibilities.Theseinstructionsincludeearly eatingandambulation,useofincentivespirometers,andexpectationsfor earlydischarge.Implementinganenhancedrecoveryaftersurgery (ERAS)pathway,whichisoftentimesutilizedonpatientshaving minimallyinvasivesurgery,reduceshospitallengthofstaywith morbidityandlowreadmissionratessimilartothoseofpatientstreated offprotocol.
Bowelpreparationisacontroversialpracticeforleftcolectomy. Multipleprospectiverandomizedstudieshavebeenperformedexamining theoutcomeofelectivecolonicresectionswithandwithoutbowel preparation.Reportshaveshownnodifferenceincomplicationrates, includinganastomoticleaks,whereasothershavedemonstratedahigher rateofwoundinfectionsinthepatientswhohavereceivedabowel preparation.Reducedsurgicalsiteinfectionsoccurinpatientswho receivedmechanicalandoralantibioticbowelpreparation.Intraoperative colonoscopyforlocalizationofpolypsortumorsduringthesurgerywill requiremechanicalbowelpreparation.Itisthepracticeoftheauthorsto preparethepatientswithamechanicalandoralantibioticbowel preparationforallcolorectalresections.Ifnomechanicaloral preparationisusedforalaparoscopicleftcolectomy,thepatientshould performtwodisposablephosphateenemasbeforeenteringtheoperating roomtoallowunimpededtransanalpassageofacircularstapler.
Finalpreoperativepreparationincludesinstillationofintravenous antibiotics,applicationofawarmingpreoperativewarmingblanket, administrationofsubcutaneousheparin,andapplicationofsequential compressionstockings.Placementofanepiduralcatheterisadvocatedby somesurgeonsforpostoperativepainmanagementtolimitpostoperative narcoticintakeandtoenhancerecovery;however,forlaparoscopic resections,placementofatransversusabdominalplane(TAP)blockis preferredbytheauthors.Adequateintravenousaccessisobtainedbefore positioningthepatientintheoperatingroombecausebotharmswillbe tuckedatthepatient’ssideduringtheoperation.Afoammatt,ornon-slip pad,isplacedbetweenthebedandthepatientandaftertuckingboth armsandplacingthepatientinthemodifiedlithotomyposition(or splittingthelegsonasplittable),thepatientissecuredtothetable. Thesestepsarenecessarytopreventthepatientfrommovingduringthe
operation,becauseoftensteepTrendelenburgwiththepatient’sleftside elevatedarerequiredtokeepthesmallintestineoutoftheoperativefield.
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