Left Colectomy: Open and Laparoscopic

Chapter 24 Left Colectomy: Open and Laparoscopic



Edward C. Lee, MD, Kelly Garrett, MD



INTRODUCTION


A left colectomy is indicated for pathologic processes involving the distal third of the transverse colon, the descending colon, and the sigmoid colon. In general, this encompasses diseases such as diverticulitis, ischemic colitis, segmental Crohn’s colitis, and neoplasms, both benign and malignant. In resection of malignant diseases, lymphatic drainage and blood supply generally control the extent of dissection. A minimum of 5 cm on either side of the lesion is considered an adequate margin. Bowel margins are also important when resection is undertaken for benign diseases.1 For instance, in the treatment of diverticular disease, the entire distal sigmoid colon should be removed and anastomosed to the rectum. It has been shown that retaining a distal sigmoid cuff may contribute to recurrent diverticulitis.2,3 In comparison, conservative resection margins are recommended in the treatment of inflammatory bowel disease. The presence of residual microscopic disease at resection margins has not been shown to reduce recurrence rates. Therefore, resection margins should be determined by gross inspection only.4 As a final point, in benign diseases, dissection of the mesentery can be carried out at any level; however, it is most often carried out at the same level as it is for malignant disease for the sake of convenience in ligation of vessels and lymphatics.1


Open left colectomy has traditionally been the operation of choice. Some literature has demonstrated laparoscopic colon resection to be a safe and practical approach for resecting both benign and malignant diseases.5–8 Both surgical procedures generally involve the same concept. In the open procedure, however, dissection starts at the white line of Toldt, whereas laparoscopically, it is often done using a medial to lateral approach. Overall, a steep learning curve, approaching between 30 to 70 cases, is associated with the laparoscopic technique.9 However, laparoscopic colectomies are gradually becoming the standard of care at major institutions. Patients undergoing laparoscopic colectomy have been shown to resume a diet quicker, to need less narcotic analgesia, to have a quicker return of bowel function and a shorter hospital stay.6


This chapter reviews both the open and the laparoscopic procedures, along with their respective complications and outcomes. Although each technique may differ with regard to operative steps, the risks and pitfalls are similar.



INDICATIONS



• Neoplasms involving the distal transverse colon, splenic flexure, descending colon, and sigmoid colon

• Segmental Crohn’s colitis

• Diverticulitis

• Ischemic colitis


OPERATIVE STEPS



Open Procedure



Step 1 Incision of lateral peritoneal reflection and mobilization of sigmoid colon

Step 2 Identification of left iliac artery and ureter

Step 3 Mobilization along left pericolic gutter

Step 4 Takedown of gastrocolic ligament and enter lesser sac

Step 5 Mobilization of splenic flexure

Step 6 Division of proximal colon with gastrointestinal anastomosis (GIA) stapler

Step 7 Ligation of mesenteric vessels

Step 8 Ligation of superior rectal artery

Step 9 Division of mesorectum

Step 10 Division of rectosigmoid colon with TA stapler

Step 11 Anastomosis with end-to-end anastomosis (EEA) stapler or hand-sewing

Step 12 Test anastomosis with rigid sigmoidoscope by filling with air while occluding lumen proximally


Laparoscopic Procedure



Step 1 Trocar placement

Step 2 Retract sigmoid colon laterally and score medial peritoneal attachment

Step 3 Identify superior rectal artery and left ureter from medial to lateral

Step 4 Ligate superior rectal artery with GIA stapler (vascular load)

Step 5 Develop plane between rectosigmoid and mesorectum

Step 6 Division of rectosigmoid colon with GIA stapler

Step 7 Division of mesorectum with harmonic scalpel or GIA stapler (vascular load)

Step 8 Takedown of lateral peritoneal attachment proceeding cephalad toward splenic flexure with harmonic scalpel

Step 9 Takedown gastrocolic ligament and enter lesser sac

Step 10 Mobilization of splenic flexure

Step 11 Extraction of left colon through umbilical port after extension of port site incision

Step 12 Division of mesocolon

Step 13 Division of proximal colon extracorporally

Step 14 Pursestring suture and insertion of EEA anvil into proximal colon

Step 15 Partial closure of umbilical incision, reinsertion of trocar, and reestablishment of pneumoperitoneum

Step 16 Insertion of EEA through anus and intracorporeal anastomosis

Step 17 Test anastomosis with rigid sigmoidoscope

Step 18 Removal of trocars


OPERATIVE PROCEDURE



Incision of the Lateral Peritoneal Reflection and Mobilization of the Sigmoid Colon with Ligation of the Superior Rectal Artery



Ureter Injury


The left ureter is in close proximity to the rectosigmoid colon in the region where it crosses over the left common iliac artery. Injuries to the ureter most commonly occur while taking down the lateral peritoneal reflection at the white line of Toldt and during identification and ligation of the superior rectal artery. When the colon is retracted medially, the left ureter may be elevated with the sigmoid mesocolon and mistaken for the superior rectal artery or another mesenteric vessel10 (Fig. 24-1).


image

Figure 24-1 In medial to lateral dissection, the left ureter is swept lateral to medial to expose the superior rectal artery, as seen here.



• Consequence



Iatrogenic injury is most often to the left ureter. Injury can occur in several ways during this step of the procedure. Most common injuries consist of complete transection, excision of an entire segment or portion of the ureteral wall, suture ligation, heat damage from electrocautery, devascularization, or accidental crush with a surgical clamp.10,11 Awareness of these injuries allows for immediate repair. However, 50% to 70% of the time iatrogenic ureteral injuries go unnoticed until symptoms become apparent postoperatively.10

Grade 2/3 complication


• Repair



When injury to the ureter is recognized intraoperatively, urologic consultation should be obtained. The plan for repair is based on the length and location of the injury as well as the patient’s overall condition. One third of iatrogenic injuries will involve the distal ureter. These are primarily repaired with ureteroneocystostomy and stent placement. Vesicopsoas hitch can be done with greater loss of distal ureter length. Although rare during left colectomy, upper and midureteral injuries are generally repaired by ureteroureterostomy over an internal stent. Transureteroureterostomy or a Boari tabularized bladder flap is indicated with more significant loss of length. Other options include autotransplantation and ileal transposition; however, these are rarely indicated.10

Injuries identified during the postoperative course present more of a challenge. Flank pain and fevers are the most common presenting signs and symptoms. Other manifestations include ureterovaginal and ureterocutaneous fistulas. Diagnosis is generally made by cystoscopy, and the level of injury can be confirmed by retrograde pyelogram.12,13 If these injuries present within the immediate postoperative period, operative intervention and repair are warranted. When injury recognition is delayed further, endourologic management with percutaneous nephro-stomy can be carried out prior to definitive surgical repair.


• Prevention



When the sigmoid colon is mobilized, the left ureter should be identified as it crosses anterior to the common iliac artery (Fig. 24-2). Before ligation of the superior rectal artery and stapling through the rectosigmoid junction, care should be taken to keep the location of the ureter in mind (Fig. 24-3A). Sometimes, it is useful to identify the pulsation of the iliac artery and then look for the ureter crossing over5 (see Fig. 24-3B). In the open procedure, the ureter is generally mobilized laterally, whereas it is mobilized medially in the laparoscopic procedure away from the superior rectal artery. Gentle palpation is useful for identification; however, the ureter should not be snapped or pulled. More so, extensive skeletonization should not be performed because of the risk of compromising the local blood supply. This can result in ischemic necrosis.11 If there is suspicion of a ureteral injury intraoperatively, 12.5 g of mannitol can be injected intravenously followed by 5 ml of indigo carmine dye or methylene blue. The diagnosis is made if blue dye infiltrates the operative field.14 Some patients are considered at risk preoperatively secondary to a history of previous pelvic surgery, radiation therapy, or large pelvic masses. In these cases, the anatomy can be defined with a preoperative excretory urogram and placement of ureteral stents prior to incision.11 Stents do not absolutely protect against injury but may help to clearly identify damage if and when it occurs.

image

Figure 24-2 In lateral to medial dissection, the left ureter is swept medial to lateral to make the sigmoid colon into a midline structure. In this dissection, stay as close to the sigmoid colon as possible because all the critical structures—left ureter, left iliac vessels, and left gonadal vessels—need to be exposed laterally.

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Left Colectomy: Open and Laparoscopic

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