How is open 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

In open versions of these procedures, the same preoperative preparation and patient positioning is used, and the authors follow similar technique. A vertical midline incision is used routinely. For right and transverse colectomies, two thirds of the incision should be above the umbilicus and one third of the incision below. The reverse is true for left-side, sigmoid, and rectal surgery. For coloanal anastomosis or APR, the incision should be carried down to the symphysis pubis to facilitate pelvic exposure.

After patient positioning and rectal irrigation, a Foley catheter is placed with sterile technique. The patient is prepared and draped, and the midline incision is made. Once the incision is open, a wound drape is placed to protect the wound. The authors prefer a Balfour retractor with a bladder blade and C-arm attachment. The low profile permits a deeper reach into the pelvis without the need to struggle with the retractor. Others use the Buchwalter.

A wet lap sponge is placed over the small bowel, which is then placed in the right upper quadrant, exposing the takeoff of the inferior mesenteric artery (IMA) at its takeoff from the aorta. Once identified, the IMA is dissected free with long right-angle clamps and clamped. Prior to clamping and transection, the ureter must be identified, after which the mesocolon is divided laterally and up to the colon wall. The colon wall is divided with a stapler. This division is the proximal margin for sigmoid or rectal surgery.

The IMA is then retracted upward, and the plane under it is dissected until the lane between the mesorectum and the pelvic fascia is entered.

Dissection continues caudally until the distal margin of resection is encountered. Transection is performed with a stapler at the distal margin for a cancer or at the coalescing of the taeniae for diverticulitis. For a left colectomy, the initial division of the bowel is a distal transection. The white line is then mobilized proximally and the splenic flexure taken down, when indicated, as mentioned above. The distal transverse colon is transected and the remaining mesorectum divided. Omentum is mobilized off the transverse colon to facilitate obtaining sufficient length.

Both anastomosis and APR are performed exactly as described for the laparoscopic technique. Gowns, gloves, and instruments are changed, and the fascia is closed with running looped suture. The skin is closed with staples.

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


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