How is laparoscopic left colon resection (colectomy) performed?

Updated: Apr 05, 2021
  • Author: David E Stein, MD, MHCM; Chief Editor: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed)  more...
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Answer

After patient positioning and rectal irrigation, a Foley catheter is placed with sterile technique.

After preparing and draping, the abdomen is entered with a 12-mm umbilical incision; once the peritoneum is opened, sutures are placed, and a 12-mm port is secured. This is known as the Hasson technique. After insufflation to 15 mm Hg with CO2, the authors place a right-upper-quadrant 5-mm port and a right-lower-quadrant 12-mm port. The patient is placed in Trendelenburg position and tilted to the right. The small bowel is placed in the right upper quadrant.

The authors use a medial-to-lateral approach. The inferior mesenteric vessels are identified at their takeoff from the aorta. The peritoneum is incised in this plane and the ureter identified. Once this is completed, the vessels are ligated. Whereas the authors commonly use an endoscopic stapler, other surgeons often use energy devices, clips, and Endoloops. Once the vessels are ligated, the plane under the mesocolon is developed laterally and superiorly. With the transected vascular pedicle retracted, dissection then proceeds down into the pelvis.

For cancer operations, the authors dissect at least 5 cm distal to a cancer. If the tumor is in the very distal rectum, a lower midline or Pfannenstiel incision is often required to facilitate exposure and transection of the rectum at the level of the anorectal ring. A total mesorectal excision (TME) is performed for all low rectal cancers, and sphincter preservation is possible if there is a 2-cm mucosal margin above the dentate line.

For diverticular operations, the authors dissect to the upper rectum where the taeniae coli coalesce. Once the distal margin is identified, the bowel is transected with an endoscopic stapler. The authors then divide the distal mesocolon or mesorectum with an energy device and proceed up the patient's left side, dividing the white line of Toldt. The authors routinely mobilize the splenic flexure to obtain adequate length for performing an anastomosis. Often, an additional port must be placed on the patient's left flank.

For left colon cancers, the authors divide the inferior mesenteric vein (IMV) at the level of the splenic flexure; these cases require extensive mobilization of the transverse colon and its mesentery. It is imperative to divide the mesocolon as close to its origin as possible, leaving extensive collateral blood supply to the proximal colon that will be anastomosed.

Once the colon is completely mobilized, the specimen is extracted. A wound protractor, GelPort, Dextrus, or other device may be used to facilitate extraction. The authors require a 4- to 5-cm incision for extraction. Graspers are placed on the distal end of the specimen. The CO2 is exsufflated through the ports, and the incision is made and the wound protector placed. Extraction may be done in the left flank or umbilical area or via a Pfannenstiel incision. For a coloanal anastomosis, the authors extract transanally.

After extraction, the specimen is transected on the proximal end. For diverticular cases, the authors transect where the bowel becomes soft and supple. For cancers, transection corresponds to the area of mesocolon and the segment of colon being removed.

Routinely, the authors perform colorectal anastomoses using a 29-mm circular stapler. The specimen is sharply transected, allowing visualization of the lumen and colonic-wall bleeding, confirming an adequate blood supply. A 2-0 polypropylene purse-string suture is then placed. The anvil is placed into the colon lumen, and the purse-string suture is tied. This area is inspected for any imperfections in the closure or in the distal edge of the colon wall.

The colon is then placed back into the abdomen, and the extraction site is closed. Subsequently, the authors reinsufflate and perform a stapled anastomosis, taking care to ensure that the colon is rotated appropriately. Air insufflation via the rectum with saline irrigation is performed to look for bubbles, indicating a defect in the anastomosis. The stapler donuts are also inspected to ensure that a complete circular rim of tissue has been obtained.

If bubbles emerge from the anastomosis, the authors laparoscopically oversew the anastomosis and perform the leak test again. If there is any concern with the anastomosis, proximal diversion with a loop ileostomy is performed.

Gloves, gowns, and instruments are then changed. Irrigation with 3 L of saline is performed. The small bowel is inspected to ensure that no internal hernias are present. Gas is exsufflated via the ports, and the incisions are closed.

For a coloanal anastomoses, the dentate line is mobilized at the anal verge. After the specimen is extracted, a handsewn transanal anastomosis is performed. Here, exposure is facilitated by the Lone-Star retractor.

For an abdominoperineal resection (APR), the authors perform the case as above, with the following exceptions.

The splenic flexure is not mobilized, and dissection is performed distal to the rectosacral fascia (Waldeyer fascia) circumferentially. Once dissection is complete, the authors transect proximally in the sigmoid colon and create the colostomy. The incisions are then closed, the colostomy is matured, and the patient is flipped into the prone jackknife position.

After preparation and draping, the authors mark an incision 1 cm from the coccyx and ischial tuberosities and then make the incision and dissect circumferentially to the level of the levators. The true pelvis is entered anterior to the coccyx in such a way as to “connect” with the previous posterior dissection. Once this plane is opened, the levators are pulled caudally with a finger and transected circumferentially.

The specimen is then exteriorized with only the anterior attachments still in place. Once this is done, careful dissection in this plane is performed under direct vision to avoid injury to the prostate or vagina. If the tumor is invading these structures, a posterior vaginectomy can be performed, or a portion of the prostate can be dissected with the specimen.

The specimen is extracted through the perineum, and the incision is closed in multiple layers.

For additional information, see Laparoscopic Left Colectomy (Left Hemicolectomy).


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