Left colectomy: Open technique
- Anthony MacLean, MD, FRCSC, FACS
Anthony MacLean, MD, FRCSC, FACS
- Clinical Associate Professor, Department of Surgery
- University of Calgary
- W Donald Buie, MD
W Donald Buie, MD
- Associate Professor of Surgery, Department of Surgery and Oncology
- University of Calgary
A left hemicolectomy includes resection of the transverse colon left of the middle colic vessels to the level of the upper rectum. A segmental left colectomy is performed when lesser resections are indicated (eg, trauma, polyp), provided the anastomosis is performed in well vascularized bowel.
The techniques used to perform left colectomy are reviewed here. Right and extended right colectomy are presented separately. (See "Right and extended right colectomy: Open technique".)
The colon and rectum occupy the retroperitoneal and intraperitoneal spaces, in close approximation to solid organs (figure 1). The ascending and descending colon are retroperitoneal, while the transverse colon, which extends from the hepatic flexure to the splenic flexure, is intraperitoneal. The sigmoid colon continues from the descending colon, ending where the teniae converge to form the rectum.
Arterial supply — The arterial supply of the left colon has few profuse anastomoses and collateral circulations. The middle colic artery (MCA) and the inferior mesenteric artery (IMA) provide the principle blood supply to the left colon (figure 2). The marginal artery of Drummond and the arc of Riolan provide collateral blood vessels. Typically, the blood supply of the transverse colon is excellent provided the marginal artery is not damaged. Variability in the arterial anastomoses occurs, which is an important point when performing a segmental resection. The two most tenuous sites and the corresponding arterial supplies are the splenic flexure (Griffith’s point) and distal descending colon (Sudeck’s point). (See "Overview of intestinal ischemia in adults", section on 'Intestinal vascular anatomy'.)
Venous and lymphatic drainage — The venous drainage of the left colon is through the inferior mesenteric vein (figure 3). The lymphatic drainage flows along the left colic artery and the sigmoid vessels to the inferior mesenteric vessels (figure 4).
- Sonoda T, Milsom JW. Section 5: Gastrointestinal tract and abdomen. Chapter 34: Segmental colon resection.ACS Surgery: Principles and Practice http://www.acssurgery.com/acs/chapters/ch0534.htm (Accessed on November 07, 2011).
- Neutzling CB, Lustosa SA, Proenca IM, et al. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2012; :CD003144.
- Everett WG. A comparison of one layer and two layer techniques for colorectal anastomosis. Br J Surg 1975; 62:135.
- Goligher JC, Lee PW, Simpkins KC, Lintott DJ. A controlled comparison one- and two-layer techniques of suture for high and low colorectal anastomoses. Br J Surg 1977; 64:609.
- Burch JM, Franciose RJ, Moore EE, et al. Single-layer continuous versus two-layer interrupted intestinal anastomosis: a prospective randomized trial. Ann Surg 2000; 231:832.
- Outlaw KK, Vela AR, O'Leary JP. Breaking strength and diameter of absorbable sutures after in vivo exposure in the rat. Am Surg 1998; 64:348.
- Delaney CP, Fazio VW, Senagore AJ, et al. 'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 2001; 88:1533.
- Basse L, Hjort Jakobsen D, Billesbølle P, et al. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000; 232:51.
- Basse L, Thorbøl JE, Løssl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004; 47:271.
- Behrns KE, Kircher AP, Galanko JA, et al. Prospective randomized trial of early initiation and hospital discharge on a liquid diet following elective intestinal surgery. J Gastrointest Surg 2000; 4:217.
- Di Fronzo LA, Cymerman J, O'Connell TX. Factors affecting early postoperative feeding following elective open colon resection. Arch Surg 1999; 134:941.
- DiFronzo LA, Yamin N, Patel K, O'Connell TX. Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection. J Am Coll Surg 2003; 197:747.
- Delaney CP, Zutshi M, Senagore AJ, et al. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 2003; 46:851.
- Khoo CK, Vickery CJ, Forsyth N, et al. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 2007; 245:867.
- COLON ANATOMY
- Arterial supply
- Venous and lymphatic drainage
- PREOPERATIVE EVALUATION AND PREPARATION
- ABDOMINAL EXPLORATION
- EXTENT OF RESECTION
- MOBILIZING THE LEFT COLON
- Lateral-to-medial approach
- Medial to lateral approach
- COLOCOLONIC ANASTOMOSIS
- Hand-sewn anastomosis
- Stapled anastomosis
- - End-to-end
- - Side-to-end
- - Functional end-to-end
- Leak testing
- Preventing complications
- POSTOPERATIVE CARE AND FOLLOW-UP
- SUMMARY AND RECOMMENDATIONS