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Acs0534 Segmental Colon Resection 2006
1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 1 34 SEGMENTAL COLON RESECTION Toyooki Sonoda, M.D., and Jeffrey W Milsom, M.D., F.A.C.S. . Resections for Benign Disease Segmental (or partial) resections of the colon are commonly per- formed throughout the world to treat both benign and malignant For patients with benign colon disease, removal of the diseased disease. Benign conditions that may be treated with these proce- portion of the bowel in such a way as to leave uninvolved, healthy, dures include polyps, inﬂammatory bowel disease, diverticulitis, and well-vascularized margins should be sufﬁcient treatment. hemorrhage, ischemia, trauma, and redundancy (e.g., volvulus, When indicated, the proximal and distal ends are anastomosed to constipation, or rectal prolapse). However, malignant conditions, restore continuity of the bowel. In these benign cases, dissection of as a group, constitute the most common indication for colon the mesentery should be performed where it is easiest and most resection. Adenocarcinoma is the neoplasm for which segmental convenient. To this end, the major named branches are usually colectomy is most commonly performed in most Western coun- divided in their midportions: if the mesentery is divided within a tries, but there are a number of other neoplasms (e.g., carcinoid few centimeters of the bowel wall, many of the small mesenteric tumor, lymphoma, leiomyoma, and leiomyosarcoma) for which branches will have to be ligated, which is inconvenient and time- such treatment may also be indicated. Detailed knowledge of the consuming [see Figure 1]. relevant surgical anatomy and a systematic approach to colonic Modern electrosurgical devices, such as the LigaSure vessel mobilization are essential to the performance of a safe and onco- sealing system (Valleylab, Boulder, Colorado), can reliably seal logically sound segmental colectomy. mesenteric vessels as large as 7 mm in diameter without the tradi- tional clamping and tying, and they can reduce operating times during more extensive colon resections (whether laparoscopic or Operative Planning open).The LigaSure Atlas and the LigaSure V use bipolar current and have a built-in knife that allows the surgeon to seal and divide BENIGN VERSUS MALIGNANT DISEASE the vessel in a single maneuver. The differences between segmental colon resections done to Certain inﬂammatory conditions (e.g., Crohn disease and di- treat benign disease and those done to treat malignancies are fun- verticulitis) may result in such severe pericolic inﬂammation and damentally important and may have a substantial effect on out- thickening that dissection of the mesentery close to the bowel wall come. Accordingly, before speciﬁc techniques are described, it is may not be possible. In these cases, it may be necessary to perform worthwhile to review these differences, paying particular attention a more radical mesenteric dissection in an area where the mesen- to the basic principles of and justiﬁcations for oncologic resections. tery is softer. Severe inﬂammatory adhesions may cause the bowel a b Figure 1 Illustrated is the difference between (a) malignant and (b) benign resections of the sigmoid colon.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 2 to be stuck to the retroperitoneum, making the usual lateral mobi- Sigmoid Colon lization of the colon nearly impossible. In these cases, early divi- sion of the mesentery (i.e., medial-to-lateral mobilization of the colon) may provide easier access to the proper plane of dissection, where the tissues are soft (i.e., in the retromesenteric plane ante- rior to Toldt’s retroperitoneal fascia [see Figure 2]). This approach may help minimize the risk of injury to retroperitoneal organs (e.g., the ureter). Aorta Resections for Malignant Disease Colon resections for malignancy should include radical en bloc removal of the draining lymphovascular complex, with bowel margins wide enough to limit intraluminal and pericolic (lym- phatic) recurrence.The drainage of the lymphatic system mirrors Gonadal Vessels Ureter that of the vascular system. In the case of colon carcinomas, there are two possible directions for lymphatic drainage: (1) paraintesti- Figure 2 In patients with severe inﬂammatory conditions of the nal (along the intestine) and (2) central (along named mesenteric colon, early division of the mesentery provides access to the vessels). To prevent regional lymphatic recurrence, the major retromesenteric plane medially. draining mesenteric vessel should be divided at the point of ori- gin, together with the accompanying lymphatic network. If the tumor is equidistant from two named mesenteric vessels, both lation during colon cancer operations (though the evidence for vessels should be ligated proximally. this phenomenon is still inconclusive).7-9 Although, in most cases, intramural spreading of cancer should To date, only one randomized, prospective trial has compared not exceed 2 cm,1,2 an oncologic resection of the abdominal colon the no-touch isolation technique with conventional techniques for should aim at achieving proximal and distal margins of at least 5 the curative treatment of colon cancer. In this trial, which involved to 10 cm to ensure adequate procurement of the epicolic and 236 patients, there was no signiﬁcant difference in 5-year survival pericolic lymph nodes.3,4 The two exceptions to this rule are in between the no-touch group and the conventional group, though resection of rectal cancer, where a margin of 1 to 2 cm is accept- there was a trend toward better cancer-related survival in the for- ed as part of a sphincter-saving operation, and in resection of a mer.10 Fewer liver metastases were observed in the no-touch cecal carcinoma, where the ileum can be divided close to the ileo- group, and those that were observed seemed to develop later.This cecal valve without compromising the oncologic outcome, pro- study was criticized on the grounds that the mean numbers of vided that the lymphatic vessels along the ileocolic pedicle are lymph nodes harvested were only 3.8 and 4.8 for conventional removed. The ultimate length of the resected bowel segment is and no-touch operations, respectively, which raised questions dictated by the lymphovascular resection. Large adenomatous about the quality of the oncologic resections. However, the au- polyps may harbor cancer, especially when they are villous, and thors pointed out that the study was designed to analyze only the resections for this indication should also include wide mesenteric effects of early lymphovascular isolation and that extensive lym- clearance. phadenectomies were not performed. Another randomized, prospective trial compared extended Oncologic principles There is increasing evidence that the resections with segmental resections for treatment of carcinoma of quality of the operation done to treat colorectal carcinoma is the left colon. In this trial, 260 patients with cancer between the directly correlated with the quality of the oncologic outcome. To distal transverse colon and the rectosigmoid were randomly date, the bulk of this evidence has come from studies of rectal car- assigned to undergo either left hemicolectomy or segmental colec- cinoma, but the correlation appears to hold true for colon cancer tomy.11 The lymphadenectomy done as part of the left hemicolec- as well. In an excellent study carried out by the German Colon tomy extended to the origin of the inferior mesenteric artery Cancer Study Group, the treating surgeon and the treating (IMA), whereas that done as part of the segmental colectomy was institution were found to be independent variables that affected more limited, extending only to the region of the left colic artery both survival and locoregional recurrence after colon cancer (LCA). There was no difference in survival between the two resections.5 groups, even when Dukes class C (TNM stage III) cancers were The concept that surgical technique may inﬂuence survival was compared. Although a few retrospective studies have suggested ﬁrst popularized in the 1960s. In a classic study (that has nonethe- that a more extensive lymphadenectomy improves survival, there less been criticized for its uncontrolled methodology), Turnbull remains some disagreement regarding whether true high ligation and associates retrospectively compared the outcomes of patients accomplishes this goal.12-14 Intuitively, it would seem that high lig- who underwent resections for malignancy that used the no-touch ation should affect survival only in patients who have malignant isolation technique with the outcomes of patients who underwent lymph node involvement up to—but not past—the origin of the more traditional resections performed by other surgeons.6 The draining vessel. However, an adequate lymphadenectomy is un- patients who underwent no-touch oncologic resections had a bet- doubtedly important for accurate staging, and the current recom- ter 5-year survival. In the no-touch isolation technique, draining mendation is that at least 13 lymph nodes should be harvested to mesenteric vessels are ligated at their origin early in the dissection, ensure a high degree of staging accuracy.15 and the bowel is divided proximal and distal to the lesion before Although the quality of the operation does appear to affect the the tumor is mobilized; as a result, the tumor is effectively isolat- oncologic outcome, routine use of no-touch isolation for curative ed from intraluminal and hematogenous spillage during manipu- treatment of colon cancer is not currently an evidence-based prac- lation.This operative technique makes sense in the light of reports tice. We believe that the risk of locoregional recurrences can be suggesting that malignant cells may be shed into the portal circu- minimized by maintaining the following principles:
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 3 a b c 10 cm A d e f A B B g Figure 3 (a) Shown is oncologic resection of cecal and ascending colon carci- noma. (b) Shown is oncologic resection of hepatic ﬂexure carcinoma, in which the distance between the tumor and the left branch of the middle colic vessels is greater than 10 cm. (c) Shown is oncologic resection of proximal transverse colon carcinoma, in which the distance between the tumor and the left branch of the middle colic vessels is less than 10 cm. (d) Depicted are two options for resection of transverse colon carcinoma: transverse colectomy (A) and extend- ed right hemicolectomy (A plus B). (e) Depicted are two options for resection of splenic ﬂexure carcinoma: splenic ﬂexure resection (A) and left hemicolec- tomy (A plus B). (f) Shown is oncologic resection of descending colon carcino- ma. (g) Shown is oncologic resection of sigmoid colon carcinoma. 1. Wide mesenteric clearance, including high ligation of all drain- colon carcinomas. Recommended resections of the abdominal ing mesenteric vessels. colon for cancer depend on the location of the tumor [see Fig- 2. Minimization of trauma to the tumor during mobilization. ure 3]. 3. Adequate proximal and distal bowel margins. 4. Wide clearance of tumor in cases of contiguous organ invasion. LAPAROSCOPIC VERSUS OPEN RESECTION 5. Complete and accurate intraoperative exploration. Laparoscopic surgical treatment of colorectal disease has been It can be argued that the no-touch isolation technique is an slow to gain acceptance, primarily because the techniques are dif- important component of oncologic surgical principles. Certainly, ﬁcult to master, the operations are longer, and the ileus response this technique adds little to the difﬁculty of the operation and is still not eliminated after the procedure. At present, the over- can be performed without causing additional morbidity. We whelming majority of colon resections in the United States are still continue to employ the no-touch technique in the resection of being performed by conventional means.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 4 to the lateral mobilization employed in most open colectomies. In all, there are four main approaches to mobilizing the colon. With the lateral approach, the lateral attachment of the colon is divided ﬁrst, and the retromesenteric plane is then developed in a lateral- to-medial fashion. With the medial-to-lateral approach, the mes- enteric vessels are isolated ﬁrst, and the retromesenteric plane is then developed in an outward direction, with the lateral attach- ments of the colon left alone to suspend the colon during medial mobilization. With the inferior approach (as in right colectomy), the ileal attachment to the retroperitoneum is dissected initially in 5 mm the direction of the duodenum. With the superior approach, the greater omentum and the transverse colon are dissected ﬁrst. 10 mm It is quite possible—indeed, likely—that during the mobiliza- tion of a given colon segment, several or all of these approaches may be used sequentially. One approach may suit a particular patient better than another one does, and it is not uncommon for 5 mm one approach to be abandoned in favor of another in the middle of the operation. Accordingly, it is important that surgeons achieve 5 mm proﬁciency with all four approaches to mobilization. Provided that 5 mm the proper dissection plane is entered, all four approaches will eventually converge. Figure 4 Laparoscopic right hemicolectomy. Illustrated is rec- Laparoscopic Right Hemicolectomy ommended port placement. A right hemicolectomy is performed to treat neoplasms of the cecum, the ascending colon, or the hepatic ﬂexure. An extended A growing number of reports have described short-term bene- right hemicolectomy is usually performed to treat tumors located ﬁts of laparoscopy in treating benign conditions of the colon (e.g., in the transverse colon, especially those to the right of the midline. diverticulitis, Crohn disease, and ulcerative colitis). Controlled OPERATIVE TECHNIQUE studies performed by experienced surgeons have found laparosco- py to have advantages over open resection in terms of resolution Step 1: Placement of Ports of ileus, duration of hospitalization, level of postoperative pain, recovery of pulmonary function, and complication rates.16-20 Even The patient is placed in a modiﬁed lithotomy position. Four 5 mm some cost analyses favor laparoscopic colectomy over convention- ports and one 10 mm port are placed [see Figure 4].The surgeon can al surgery, ﬁnding that the higher costs of the surgical instruments stand either between the patient’s legs or on the patient’s left. and the potentially longer operating times are outweighed by the Step 2: Isolation of Ileocolic Pedicle shorter duration of hospitalization.21-24 There also appears to be a lower incidence of surgical site complications after laparoscopy The patient is moved into the Trendelenburg position, with the than after open surgery, as well as a lower incidence of postopera- right side tilted up.The greater omentum is raised above the trans- tive adhesions (and thus, possibly, of subsequent small bowel verse colon, and the transverse colon is retracted superiorly. The obstruction).25,26 terminal ileum is allowed to drop inferiorly toward the pelvis, and Fear of port-site recurrences initially kept laparoscopy from the proximal small bowel loops are swept to the patient’s left. The being widely accepted in the treatment of colorectal carcinoma, but several randomized, controlled studies reported that the wound recurrence rates with laparoscopic resections were no dif- Ileocolic Artery and Vein ferent from those with open resections.27-31 Particularly signiﬁcant were the long-awaited results of the randomized, prospective trial carried out by the Clinical Outcomes of Surgical Therapy (COST) Study Group, which found the oncologic outcomes of open and laparoscopic surgery to be similar after a median follow-up period of 4.4 years.31 Also noteworthy was a randomized, prospective trial from Barcelona, which reported that cancer-related survival was actually better after laparoscopic surgery for colon cancer than after open surgery.29 Further randomized trials are under way in Europe and Australia. These studies have helped lift the virtual moratorium on laparoscopic treatment of colorectal cancer, but surgeons must be reminded that they must ﬁrst gain adequate laparoscopic experience with benign conditions of the colon before attempting laparoscopy for malignant disease. APPROACHES TO MOBILIZATION OF COLON The development of laparoscopy has given prominence to the Figure 5 Laparoscopic right hemicolectomy. The ileocolic pedi- concept of medial-to-lateral mobilization of the colon, as opposed cle is dissected in the direction of its origin and isolated.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 5 90% of cases, the right colic artery (RCA) branches off from the ICA, not from the superior mesenteric artery (SMA). A window is made in the mesentery inferior and superior to the ileocolic pedi- cle, and the pedicle is dissected in the direction of its origin and lig- ated [see Figure 5]. Ligation can be accomplished by means of clips, vascular staplers, or the LigaSure Atlas; unless clips are used, the ICA and the ileocolic vein (ICV) can be ligated together. Step 3: Dissection of Middle Colic Vessels Next, the thin cut edge of the transverse mesocolon overlying the duodenum is grasped, and the duodenum is carefully swept down in a posterior direction.This measure initiates the medial-to- lateral mobilization of the transverse colon. The head of the pan- creas is bluntly dissected, with care taken not to avulse the right colic vein or a branch of the inferior pancreaticoduodenal vein. A plane is gently developed to the right of the middle colic vessels. If this dissection proves difﬁcult, the planned medial-to-lateral mobi- lization approach should be abandoned in favor of superior mobi- lization, and the omentum should be dissected off the transverse colon. In this way, access behind the middle colic artery (MCA) is facilitated. The ﬁrst vessel encountered to the right of the middle colic ves- sels is a venous branch to the right colic ﬂexure. This branch con- verges with the right gastroepiploic vein (GEV) to form Henle’s gastrocolic trunk, which empties into the superior mesenteric vein (SMV). The right colic vein (RCV) should be divided proximally Figure 6 Laparoscopic right hemicolectomy. The right colic vein so as to spare the right GEV. In some cases, an artery accompa- and the artery accompanying it to the hepatic ﬂexure are isolated nies the RCV to the hepatic ﬂexure; if present, this artery should and divided. be divided proximally, together with the vein [see Figure 6]. The peritoneum overlying the middle colic vasculature is then opened duodenum is initially identiﬁed through the mesentery, just to the from right to left, and the right branch of the MCA is isolated and right of the superior mesenteric vessels at the angle between the divided at its origin, with care taken to preserve the left branch. transverse mesocolon and the right colonic mesentery. With The anatomy of the MCA is quite variable, and the classic pattern anterolateral traction placed on the ileocecal junction, the ileocol- of a single trunk that bifurcates into right and left branches occurs ic pedicle can be seen “bowstringing” through the mesentery, just in only 46% of cases. Instead, one, two, or even three vessels may inferior to the duodenum. Studies of arterial anatomy show that arise from the SMA to supply the transverse colon. the ileocolic artery (ICA) is a constant structure and that, in almost In the case of an extended right hemicolectomy, the main trunk of the MCA should be divided at its takeoff from the SMA at the base of the pancreas.To this end, the peritoneum overlying the base of the middle colic vessels is opened from right to left, and a dis- section plane is created to the left of the MCA [see Figure 7]. Access behind the middle colic vessels is best gained by proceeding from left to right, with the surgeon operating from the patient’s left side. The middle colic vessels are isolated and divided at the appropriate level. After ligation of the middle colic vessels, an area of the trans- verse colon is chosen as the distal transection line, and the trans- verse mesocolon is divided in the direction of the bowel wall. Step 4: Medial-to-Lateral Mobilization of Right Colon The transverse mesocolon is then lifted anteriorly, and blunt medial-to-lateral dissection of the colon is performed, extending the previous dissection plane above the duodenum to the patient’s right [see Figure 8]. Care should be taken to ensure that the dis- section plane remains anterior to Toldt’s retroperitoneal fascia (the white line of Toldt). The dissection is extended underneath the hepatic ﬂexure, then underneath the right colon and the cecum. The right ureter should remain safely underneath an intact retro- peritoneal fascia. Step 5: Inferior Mobilization of Ileum and Lateral Mobilization of Right Colon Figure 7 Laparoscopic right hemicolectomy. The main trunk of the middle colic artery is most easily accessed via a plane creat- Next, the terminal ileum is retracted out of the pelvis. With ed to the left of the vessel. strong traction applied anteriorly and cephalad, the ileal attach-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 6 mesentery is dissected from the divided ileum toward the cut edge of the ileocolic pedicle, and the ileal and accessory ileal branches are ligated. The marginal artery of the transverse colon is ligated, and the transverse colon is divided with a linear stapler 5 to 10 cm distal to the tumor to liberate the specimen. As in the equivalent open procedure, the anastomosis is then created extracorporeally with either handsewn stitches or staples. The bowel is replaced into the abdomen, and the minilaparotomy is closed. TROUBLESHOOTING Injury to Superior Mesenteric Vessels The SMV is fragile and is susceptible to sharp injury, as well as to avulsion injury at the origin of the ICV caused by aggressive blunt dissection. Accordingly, the area around this vessel must be dissected with particular care. To prevent sharp injury to the SMV, the peritoneum overlying the origin of the ileocolic pedicle should be dissected ﬁrst; this measure should help clarify the vas- cular anatomy. During ligation of the ileocolic pedicle, a small stump should be left to prevent encroachment into the superior mesenteric vessels. If bleeding develops from the cut pedicle, an absorbable 2-0 tie can be placed around the stump with an Endoloop applicator (Ethicon Endo-Surgery, Somerville, New Jersey). Injury to Inferior Pancreaticoduodenal Vein or Right Gastroepiploic Vein The head of the pancreas is susceptible to signiﬁcant venous bleeding, especially when a branch of the inferior pancreaticoduo- denal vein is torn during aggressive blunt mobilization. The right GEV is also at risk for division or injury with proximal ligation of the RVC. Any blunt dissection at the pancreatic head must be per- Figure 8 Laparoscopic right hemicolectomy. The right colon undergoes medial-to-lateral retromesenteric dissection, with the formed gently. It should be kept in mind that the RCV converges lateral attachments remaining untouched. with the right GEV at the head of the pancreas. To prevent injury to the right GEV, the transverse colon should be lifted anteriorly, and only the vein or veins traveling to the colon should be divid- ment to the retroperitoneum is exposed and the peritoneum ed; any veins traveling underneath the colon toward the stomach incised. If the medial dissection was adequate, this attachment should be spared. will be thin; if not, the retroperitoneum may remain adherent to the cecum, in which case it will be necessary to identify the right ureter as it crosses over the right iliac vessels to ensure that it is not injured during mobilization. After the dissection has met the previous medial dissection plane, it is continued around the appendix and the cecum, and the lateral attachments of the right colon are taken down [see Figure 9]. Dissection of the hepatic ﬂexure will become difﬁcult with this approach. To resolve the difﬁculty, the patient is taken out of the Trendelenburg position, and the surgeon moves to the patient’s left.The omentum is fur- ther dissected off the proximal transverse colon from left to right, and the takedown of the hepatic ﬂexure is completed via this approach. Step 6: Exteriorization, Resection, and Anastomosis The appendix is grasped with a bowel clamp. A minilaparoto- my is made, either as a midline extension of the umbilical port incision or in the epigastrium, depending on the transverse colon reach. It is usually about 5 cm long, but the size may be adjusted, depending on the size of the tumor. A wound protector is insert- ed to keep the surgical site from being contaminated by tumor. The mobilized right colon is then exteriorized. Extracorporeally, the terminal ileum is cleaned and divided Figure 9 Laparoscopic right hemicolectomy. The right colon is proximal to the ileocecal valve with a linear stapler. The ileal mobilized laterally.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 7 Injury to Duodenal Sweep incision. Superiorly, the incision should extend about two thirds of Because the origin of the ileocolic pedicle is always in close the distance between the umbilicus and the xiphoid; inferiorly, it proximity to the duodenal sweep, the latter structure is at risk for should extend about one third of the distance between the umbili- injury during dissection of the former. Accordingly, during the cus and the pubic symphysis. The abdomen is explored for mobilization and division of the ileocolic pedicle, the duodenum metastatic disease, and an abdominal retractor is inserted. A sim- should be identiﬁed and bluntly swept away to ensure that it is not ple retractor, such as a Balfour or Alexis wound retractor, will usu- subjected to sharp injury or accidental cauterization. ally sufﬁce, though some additional manual retraction may be nec- essary. Some surgeons prefer to use a Thompson or Omni retrac- Injury to Right Ureter tor, either of which will be more cumbersome to set up than a As a rule, in a properly performed laparoscopic right hemi- Balfour or Alexis retractor but will allow a wider ﬁeld of retraction. colectomy, the ureter should remain underneath Toldt’s retroperi- Step 2: Division of Ileocolic Pedicle toneal fascia, and thus, the surgeon should be able to complete the operation without seeing a skeletonized right ureter. However, The tumor is identiﬁed but is not extensively manipulated.The injury to the right ureter remains a risk. If Toldt’s fascia cannot be omentum and the transverse colon are retracted superiorly, and clearly visualized via a medial approach and the dissection plane any obvious lymph node enlargement is addressed along the ileo- is unclear during the isolation of the ileocolic pedicle, it is advis- colic and middle colic vessels, the right gastroepiploic vessels, and able to switch to an inferior approach and mobilize the ileum off the superior mesenteric vessels. If malignant involvement is sus- the retroperitoneum, identifying the right ureter and tracing it pected, a central lymph node may be sampled and evaluated by toward the duodenum before dividing the pedicle. Right ureter frozen-section examination.The ileocolic pedicle is identiﬁed as in injury most commonly occurs over the right iliac vessels during a laparoscopic right hemicolectomy. A mesenteric window is cecal mobilization; accordingly, care should be taken to make sure made superior and inferior to the ileocolic pedicle, and the pedi- that the dissection plane is not too posterior. cle is isolated between two ﬁngers. Both the artery and the vein are dissected in the direction of their origin from the superior mesen- Mobilization Posterior to Gerota’s Fat teric vessels, and the pedicle is clamped, divided, and tied. In some patients, Gerota’s fat is fused to the posterior aspect of Step 3: Dissection of Middle Colic Vessels the right colon mesentery.When this is the case, there is a risk that Gerota’s fat will be entered during either medial or lateral mobi- Next, the duodenum and the head of the pancreas are gently lization—or, worse, that dissection will take place posterior to the mobilized posteriorly and are bluntly swept away from the poste- kidney during lateral mobilization.To minimize this risk, one must rior aspect of the transverse mesocolon to expose the right side of carefully look for Toldt’s retroperitoneal fascia during both medi- the middle colic vessels. A dissecting clamp is placed underneath al and lateral mobilization, then make sure to push down this fas- the peritoneum at the superior aspect of the divided ileocolic pedi- cia and remain anterior to it. cle, and the peritoneum is incised just to the right of the superior mesenteric vessels in the direction of the trunk of the middle colic Twisting of Ileum during Anastomosis vessels.The peritoneum is then further incised along the right side During anastomosis, the terminal ileum (or, less commonly, the of the middle colic trunk past the bifurcation of the middle colic transverse colon) can be twisted 360º around its mesentery. The vessels. (Delineation of these vessels can be facilitated by transil- twisting tends to occur after division of the ileum, while the sur- lumination of the transverse mesocolon from the superior aspect.) geon is concentrating on the transverse colon; often, it is not visi- The right branches of the middle colic vessels are then carefully ble through a minilaparotomy and consequently goes unnoticed. isolated and divided at their origins; the left branches are spared. To prevent this complication, two seromuscular stay sutures, one The dissection is extended back toward the pancreas, and the RCV proximal and one distal, may be placed into the ileum after the is divided at its origin, with the right GEV spared [see Laparoscopic right colon is exteriorized and the terminal ileum and the mesen- Right Hemicolectomy, above]. The transverse mesocolon is dis- tery are divided. These stay sutures are clamped individually and sected outward toward the transverse colon wall, where the mar- are never crossed. Once the anastomosis has been created, a ﬁnal ginal artery is divided and tied. The omentum is dissected away look through the laparoscope can conﬁrm that the mesenteric ori- from the right half of the transverse colon, and the transverse colon entation is correct. is transected with a linear cutting stapler (for a stapled anastomo- sis) or divided between clamps (for a handsewn anastomosis). If, during any part of this dissection, the anatomy of the middle Open Right Hemicolectomy colic vessels is unclear, it is advisable to switch to a superior The major elements of open right hemicolectomy are essential- approach. In this approach, the omentum is dissected away from ly the same as those of the corresponding laparoscopic procedure the right half of the transverse colon and the mesocolon, and the [see Laparoscopic Right Hemicolectomy, above]: (1) vascular iso- transverse colon is cleaned off and divided at the appropriate level. lation, (2) bowel division, (3) mobilization, and (4) anastomosis. The transverse mesocolon is then dissected in a central direction. The length of the resected specimen should be the same for the The marginal artery is divided, and the mesentery is divided with open version of the operation as for the laparoscopic version. In the electrocautery in the direction of the bifurcation of the middle what follows, we describe the no-touch isolation technique, which colic vessels. At this point, the right branch of the middle colic sys- is our preferred approach. tem should be easily identiﬁable. After the right branch is divided, the RCV is identiﬁed and divided near the head of the pancreas— OPERATIVE TECHNIQUE again, with the right GEV spared. Step 1: Incision Step 4: Division of Ileum and Ileal Mesentery Although the operation is technically feasible through either a Next, the terminal ileum is retracted forcefully out of the pelvis transverse incision or a midline incision, we prefer to use a midline and dissected free of the retroperitoneal structures along Toldt’s
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 8 ureter and the gonadal vessels. Dissection is continued around the cecum, and the right colon is mobilized along the white line of Toldt in the direction of the hepatic ﬂexure. Some degree of fusion may be present between Toldt’s retroperitoneal fascia and the mesentery, causing the mobilization to stray posterior to Gerota’s fascia or even the right kidney; however, the correct dissection plane always remains anterior to the retroperitoneal fascia. A ﬁn- ger is passed underneath the peritoneal layers of the hepatic ﬂex- ure, and the ﬂexure is mobilized with the electrocautery. As the right colon is peeled away from the retroperitoneal fascia, the duodenum is identiﬁed. The duodenal attachments to the mobilized right colon are divided to free the specimen. 5 mm (Optional) 10 mm Step 6: Anastomosis The anastomosis between the ileum and the transverse colon 5 mm 5 mm can be created with any of several handsewn or stapled techniques (e.g., end-to end, end-to-side, side-to-side, or functional end-to- end). Basic anastomotic techniques are discussed in greater detail 10 mm elsewhere [see 5:29 Intestinal Anastomosis]. For present purposes, it is sufﬁcient to note that all of the various approaches to intestinal anastomosis, if constructed well, should yield essentially equal 5 mm results in terms of postoperative function and rate of leakage. Whichever approach is adopted, it is essential that the cut ends of Figure 10 Laparoscopic sigmoid colectomy. Illustrated is rec- the bowel be well perfused. If bowel perfusion is in doubt, one ommended port placement. should check for bleeding from the cut bowel edge or assess the marginal artery for pulses or bleeding. The mesenteric window need not be closed after creation of the anastomosis, because it is retroperitoneal fascia.The terminal ileum is cleaned off and divid- usually large and a mesenteric hernia with incarceration is exceed- ed about 5 cm proximal to the ileocecal valve, either with a linear ingly rare. cutting stapler or between clamps. The ileal mesentery is then divided in the direction of the cut ileocolic pedicle. The marginal Laparoscopic Sigmoid Colectomy artery and the ileal and accessory ileal branches are divided. This step completes the isolation of the tumor before any manipulation Step 1: Placement of Ports of the cancer-bearing segment. The patient is placed in a modiﬁed lithotomy position.Three or Step 5: Mobilization of Right Colon four 5 mm ports, one 10 mm port, and one 12 mm port are placed [see Figure 10]. When addressing the left lower quadrant, the sur- The rest of the bowel mobilization is carried out via the lateral geon stands to the patient’s right, with the assistant standing to the approach. With the ileocecal region retracted cephalad, the peri- patient’s left. When mobilizing the splenic ﬂexure, the surgeon toneum is incised around the cecum along the white line of Toldt. stands between the patient’s legs, with the assistant standing to the A ﬁnger is passed through the peritoneal defect, and the cecum is patient’s right. retracted away from the retroperitoneum to facilitate this dissec- tion. It is important that the dissection remain anterior to the right Step 2: Isolation and Division of Inferior Mesenteric Vessels The patient is moved into a steep Trendelenburg position, with the left side tilted up.With the medial-to-lateral approach to mobi- lization, the IMA is ﬁrst approached medially. The sigmoid colon is retracted strongly out of the pelvis, and the sigmoid mesocolon is placed on anterolateral traction by the assistant. The initial dis- section plane is just posterior to the IMA, where there is a clear avascular space, and the dissection is best begun at the sacral promontory. A wide peritoneal incision is made in the sigmoid mesentery [see Figure 11].The right and left hypogastric nerves are swept away from the inferior mesenteric vessels in a posterior direction. The dissection plane is then extended laterally toward the abdominal wall, staying anterior to Toldt’s retroperitoneal fas- cia. The left ureter must be identiﬁed before the next step is initi- ated; if it cannot be identiﬁed, it should be sought on the superior aspect of the LCA, or the approach should be changed to a later- al one.The IMA is isolated at its takeoff from the aorta and divid- ed. The IMV is then isolated and divided proximally. Figure 11 Laparoscopic sigmoid colectomy. A wide peritoneal Next, Toldt’s retroperitoneal fascia is bluntly swept away from window is created to provide access to the avascular plane poste- the posterior aspect of the left colon mesentery in a medial-to-lat- rior to the inferior mesenteric vessels. eral direction as far as the lateral abdominal wall. If the dissection
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 9 attachments to the transverse mesocolon, and this area should be dissected carefully so as not to injure the pancreatic tail, which sometimes, at ﬁrst viewing, is difﬁcult to distinguish from omen- tal fat. A LigaSure Atlas or an ultrasonic dissector works especial- ly well for limiting blood loss during takedown of the splenic ﬂex- ure. The greater omentum is dissected off the distal transverse colon from right to left, the lesser sac is entered, and mobilization is continued laterally until it meets the previous dissection, at which point the ﬂexure is completely mobilized. Step 4: Distal Division, Exteriorization, and Proximal Division of Sigmoid Colon The mesentery of the rectosigmoid is then mobilized, and the line of distal transection is determined. The hypogastric nerves should be assessed again to conﬁrm that they are not stuck to the mesentery in this area. The upper mesorectum, including the superior hemorrhoidal vessels, is divided until the rectosigmoid wall is cleaned off. A laparoscopic linear stapler is inserted through the 12 mm port in the lower abdomen, and the rectosigmoid is divided. Division may require one or two ﬁrings and is facilitated by the use of an articulated rotating stapler.The cut end of the rec- Figure 12 Laparoscopic sigmoid colectomy. In a medial-to-lat- tosigmoid is grasped with a bowel grasper placed through the right eral retromesenteric dissection, the correct dissection plane is lower quadrant port. anterior to Toldt’s retroperitoneal fascia. A minilaparotomy is then created, either as an extension of the left lower quadrant port incision or as an extension of the umbilical is carried out in the correct plane, Gerota’s fat will remain safely port incision. As in a right hemicolectomy, the length of the minila- underneath Toldt’s retroperitoneal fascia, as will the left ureter and parotomy is tailored to the size of the tumor. A wound protector is the left gonadal vein [see Figure 12]. This retromesenteric dissec- inserted to prevent implantation of tumor cells, and the cut end of tion is then continued toward the upper pole of the kidney until it the specimen is exteriorized through the minilaparotomy [see Figure becomes difﬁcult, at which point it is extended inferiorly toward 14].The sigmoid colon is brought out of the wound until at least 15 the left psoas muscle and the iliac vessels. cm proximal to the tumor has been exteriorized.The colon is then divided so as to leave an adequate proximal margin, and the mar- Step 3: Lateral Mobilization of Left Colon and Takedown of ginal artery is ligated at this level to liberate the specimen. Splenic Flexure The sigmoid colon is retracted medially, and its attachment to the lateral abdominal wall is taken down. If the medial mobiliza- tion was adequately done underneath the sigmoid colon, the lat- eral attachment should be thin [see Figure 13].The lateral ligament is divided cephalad, toward the splenic ﬂexure. The attachments of the splenic ﬂexure are complex; eventually, the splenocolic lig- ament, the so-called renocolic ligament (which is actually more a fusion of tissues than it is a ligament), and the omental attach- ments are mobilized. The inferior border of the pancreas has Figure 13 Laparoscopic sigmoid colectomy. The left colon is Figure 14 Laparoscopic sigmoid colectomy. After distal transec- mobilized laterally. tion, the sigmoid colon is exteriorized.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 10 Step 5: Anastomosis ment and the greater omentum, it is important that the dissection Next, the colon is prepared for anastomosis. A purse-string not wander away from the colonic wall; if it does, the anatomy can suture is placed into the open mouth of the colon, and the center become even more confusing. rod and the anvil of a circular end-to-end anastomosis (EEA) sta- Positive Anastomotic Leak Test pler are inserted. The colon is placed back into the abdomen, and the minilaparotomy is closed. When a leak test yields positive results, the anastomosis must be Pneumoperitoneum is reestablished, and under laparoscopic repaired or revised. If the site of the bubbling from the anastomo- visualization, a stapled circular anastomosis is fashioned between sis can be identiﬁed and is on the anterior aspect of the colon, the proximal cut end and the rectosigmoid stump. A leak test is sutures may be placed laparoscopically for repair, and the leak test performed by instilling normal saline into the pelvis, occluding the should be repeated. If the site of the leak is hard to identify, the rec- bowel proximal to the anastomosis, and injecting air through a tum distal to the anastomosis may be dissected and divided and rigid proctoscope or a ﬂexible sigmoidoscope. A ﬁnal exploration the anastomosis refashioned; however, this can be a difﬁcult pro- is performed to conﬁrm that the small bowel has not migrated cedure. In cases where laparoscopic repair is not feasible, a small underneath the left colon mesentery. laparotomy (either a Pfannenstiel incision or a low midline inci- sion) may be made, and the problem may be addressed by means TROUBLESHOOTING of open techniques. Difﬁculty Identifying IMA Open Sigmoid Colectomy Especially in obese patients, initial identiﬁcation of the IMA can be difﬁcult from the medial approach (with dissection either too The major elements of open sigmoid colectomy, like those of posterior or too anterior), leading to a bloody and confusing mobi- open right hemicolectomy, are similar to those of its laparoscopic lization. The problem can be minimized by ﬁrst retracting the sig- counterpart [see Laparoscopic Sigmoid Colectomy, above]: (1) vas- moid colon strongly out of the pelvis, then retracting it anterolat- cular isolation, (2) bowel division, (3) mobilization, and (4) anas- erally. This action pulls the IMA pedicle anteriorly away from the tomosis. The excellent visualization afforded by the laparoscope surface of the aorta.The next step is to feel for the sacral promon- allows the use of the no-touch isolation technique for laparoscop- tory with laparoscopic instruments and start the dissection there; ic resection of left colon malignancies, but it is difﬁcult to employ this site affords the easiest entry into the avascular plane posterior a true no-touch technique for open left colon resections. Because to the IMA. If the bony promontory cannot be palpated, the colon it is hard to ligate the IMA as the initial step, the sigmoid colon is has not been adequately retracted. If the correct plane still cannot usually mobilized via a lateral approach, which facilitates isolation be identiﬁed, it is advisable to switch to the lateral approach. and ligation of the inferior mesenteric vessels. Injury to Hypogastric Nerve Plexus OPERATIVE TECHNIQUE The right and left hypogastric nerves travel along the anterior surface of the aorta and over the aortic bifurcation, then spread out Step 1: Incision toward the pelvic sidewall. Branches of these nerves—and some- A midline incision is made from a point halfway between the times the main trunks—adhere to the posterior aspect of the infe- xiphoid and the umbilicus down to the level of the pubis. The rior mesenteric pedicle and consequently may be transected when abdomen is explored, and a wound retractor is inserted. the IMA is divided.To keep this from occurring, these nerves must be visualized and swept away in a posterior direction. The initial Step 2: Mobilization of Sigmoid Colon mesenteric window should be made wide enough for adequate The sigmoid colon is strongly retracted in an anteromedial visualization. The surface of the aorta and its bifurcation should direction, and the white line of Toldt is incised to allow the sigmoid not be skeletonized. colon to be mobilized in a medial direction.With care taken not to dissect into the retroperitoneal structures, the dissection proceeds Injury to Left Ureter cephalad toward the splenic ﬂexure along the line of fusion With the medial approach, it is easy to dissect too deeply, between the left colon and Toldt’s retroperitoneal fascia, remaining extending the plane underneath the left ureter and the left gonadal anterior to the fascia at all times. The left gonadal vessels and the vein. Care should therefore be taken to search for Toldt’s retroperi- left ureter are identiﬁed and swept away from the sigmoid mesen- toneal fascia and stay anterior to it. Ideally, the left ureter should tery. Eventually, the undersurface of the IMV is identiﬁed in the be identiﬁed before the IMA is ligated. If this is not possible, it is midline.The left hypogastric nerve ﬁbers are bluntly swept away in advisable to switch to the lateral approach and mobilize the sig- a posterior direction, and a ﬁnger is inserted underneath the infe- moid colon accordingly. rior mesenteric vessels toward the patient’s right. The sigmoid mesentery from the medial side is then opened widely, and the Tearing of Splenic Capsule during Splenic Flexure Mobilization right hypogastric nerve ﬁbers are preserved by sweeping them Avulsion of the splenic capsule is usually caused by traction.The away from the IMA in a posterior direction. capsule is most vulnerable to injury when the colon is in close proximity to the spleen.The risk of splenic injury may be reduced Step 3: Division of Inferior Mesenteric Artery and Vein by either (1) early (posterior) dissection of the renocolic ligament The IMA is dissected in the direction of its takeoff from the before lateral mobilization of the splenic ﬂexure or (2) dissection aorta, isolated, and divided. If the IMA is not fully skeletonized, the of the ﬂexure close to the colonic wall. The early separation of the left ureter should be checked to make sure that it has not been left kidney from the left colonic mesentery (with the dissection inadvertently clamped together with the IMA before transection of plane remaining anterior to the retroperitoneal fascia) causes the the vessel.The IMV, located just lateral to the IMA at this location, ﬂexure to drop down, which widens the distance between the is isolated and divided in the direction of the inferior border of the colon and the spleen. During mobilization of the splenocolic liga- pancreas.The mesenteric dissection is then continued back toward
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 11 the LCA, which is divided at its origin to preserve a secondary quate and that the remaining bowel will be able to reach down to arcade that will perfuse the proximal aspect of the anastomosis. the pelvis without undue tension. The left colon mesentery is divided from the cut edge of the LCA toward the bowel wall, and Step 4: Mobilization of Left Colon and Splenic Flexure the marginal artery is divided. The bowel is transected between The splenic ﬂexure should be mobilized via an inferior rather clamps. than a lateral approach.With the sigmoid colon retracted anterior- Distally, the rectosigmoid colon and the mesentery are mobi- ly and superiorly, a broad white line is apparent, delineating the lized, and the hypogastric nerves are swept away from the specimen. fusion of Toldt’s retroperitoneal fascia with the left colon mesen- The mesentery of the rectosigmoid is dissected, and the superior tery (i.e., the renocolic ligament). The retroperitoneal fascia over- hemorrhoidal vessels are divided. The rectosigmoid wall is then lying the left kidney is bluntly swept away from the posterior aspect cleaned off and divided either between clamps or with a linear sta- of the left colonic mesentery toward the base of the pancreas. pler (for a double-stapled anastomosis) to liberate the specimen. When the upper pole of the left kidney is reached, the colon is returned to its original position, and the splenic ﬂexure is Step 6: Anastomosis approached. A colorectal anastomosis is created between the proximal and Early mobilization of the splenic ﬂexure posteriorly allows the distal cut edges of the bowel. For a double-stapled anastomosis [see ﬂexure to drop down, increasing the distance between it and the 5:29 Intestinal Anastomosis], a purse-string suture is placed into the capsule of the spleen in most cases. A ﬁnger is inserted underneath open mouth of the proximal bowel, the center rod and the anvil of the peritoneum overlying the splenic ﬂexure, staying close to the a circular EEA stapler are inserted, and the purse-string suture is colon wall, and this splenocolic ligament is divided with the elec- tied.The body of the stapler is advanced into the rectal stump, and trocautery. Any omental attachments to the ﬂexure that are present the spike is pushed through the rectal wall. Once the proximal are divided close to the colonic wall until the dissection becomes bowel has been checked to conﬁrm that it is not twisted, the sta- difﬁcult.Takedown of the splenic ﬂexure is easiest when dissection pler is engaged and ﬁred. A leak test of the anastomosis is then per- is done from both the right and the left. The omentum is dissect- formed by instilling saline into the pelvis and gently infusing air ed away from the distal transverse colon in a right-to-left direction into the bowel with a rigid proctoscope or a ﬂexible sigmoidoscope as the colon both distal to and proximal to the ﬂexure is simulta- while occluding the bowel proximally. neously retracted inferiorly (the so-called omega maneuver). The The anastomosis can also be created by means of a handsewn ﬁnal attachments of the splenic ﬂexure are taken down with the technique or a single-stapled technique (in which purse-string electrocautery. sutures are placed in both the proximal bowel and the distal bowel); these alternatives are described in more detail elsewhere [see 5:29 Step 5: Proximal and Distal Division of Bowel Intestinal Anastomosis]. In many cases, handsewn and stapling tech- With the left colon fully mobilized, the proximal resection line is niques may be equally suitable; however, for anastomoses fash- chosen, with care taken to ensure that the proximal margin is ade- ioned lower in the pelvis, staples should be favored over sutures. References 1. Williams NS, Dixon MF, Johnston D: Reappraisal cancer. Dis Colon Rectum 42:1449, 1999 Prospective, randomized trial comparing laparo- of the 5 centimetre rule of distal excision for carci- 9. 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Rouffet F, Hay JM,Vacher B, et al: Curative resec- scopic total colectomy for acute colitis: a case con- bution of metastatic lymph nodes in colorectal tion for left colonic carcinoma: hemicolectomy vs. cancer by the modiﬁed clearing method. Dis trol study. Dis Colon Rectum 44:1441, 2001 segmental colectomy. A prospective, controlled, Colon Rectum 37:219, 1994 multicenter trial. Dis Colon Rectum 37:651, 1994 21. Senagore AJ, Duepree HJ, Delaney CP, et al: Cost 4. Hida JI, Okuno K,Yasutomi M, et al: Optimal lig- structure of laparoscopic and open sigmoid colec- 12. Tagliacozzo S, Tocchi A: Extended mesenteric ation level of the primary feeding artery and bowel tomy for diverticular disease: similarities and dif- excision in right hemicolectomy for carcinoma of resection margin in colon cancer surgery: the inﬂu- ferences. Dis Colon Rectum 45:485, 2002 the colon. Int J Colorect Dis 12:272, 1997 ence of the site of primary feeding artery. Dis 22. 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© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 34 SEGMENTAL COLON RESECTION — 12 26. Gutt CN, Oniu T, Achemmer P, et al: Fewer adhe- cancer surgery: a preliminary report. J Am Coll 31. Clinical Outcomes of Surgical Therapy Study sions induced by laparoscopic surgery? Surg Surg 187:46, 1998 Group: A comparison of laparoscopically assisted Endosc 18:898, 2004 and open colectomy for colon cancer. N Eng J 29. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al: Med 350:2050, 2004 27. Stage JG, Schulze S, Moller P, et al: Prospective Laparoscopy-assisted colectomy versus open randomized study of laparoscopic versus open co- colectomy for treatment of non-metastatic colon lonic resection for adenocarcinoma. Br J Surg 84: 391, 1997 cancer: a randomized trial. Lancet 359:2224, 2002 Acknowledgment 28. Milsom JW, Bohm B, Hammerhofer KA, et al: A 30. Leung KL, Kwok SP, Lam SC, et al: Laparoscopic Figures 1 through 3, 5 through 9, and 11 through 14 prospective, randomized trial comparing laparo- resection of rectosigmoid carcinoma: prospective Alice Y. Chen. scopic versus conventional techniques in colorectal randomized trial. Lancet 363:1187, 2004 Figures 4 and 10 Tom Moore.
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