Chapter 24 Left Colectomy: Open and Laparoscopic
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
INDICATIONS
OPERATIVE STEPS
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).
• Consequence
• Repair
• Prevention
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