Lt hemicolectomy - Surgical Approach, Complications.

This is a detailed Presentation of the surgical procedure - Left Hemicolectomy. It deals with the Surgical anatomy, Indications, Surgical Steps, Complications of the Procedure

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Left Hemicolectomy
-Dr. Vikas V

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Anatomy of the Large Intestine

Diameter: 7.5-2.5cm

Length: 150 cm

Anatomic landmark:

Haustra

Epiploic appendages

Taeniae coli

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Indications

Malignancies of
transverse colon,
cancers of the distal transverse colon,
splenic flexure,
descending colon, and
sigmoid are treated by left hemicolectomy

High-risk premalignant polyps of the left colon that are not amenable to
endoscopic polypectomy

High-risk benign polyps that are not amenable to endoscopic polypectomy

Carcinoid of the left colon

Chronic diverticular disease

Ischemic colitis

Volvulus

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Incidence of Carcinoma In Large Bowel

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Key Points

Marginal artery should be retained in all these patients especially in
malignancies to maintain the blood supply retained to colon and
anastomotic site.

Left branch of the middle colic artery when retained is adequate
enough to maintain the blood supply.

Inferior mesenteric artery is ligated and divided at its origin from the
aorta and inferior mesenteric vein is divided at lower border of the
pancreas.

In benign diseases vessels are not ligated at their origin but close to
the colonic wall as lymphovascular clearance is not needed

The length of intestine resection is determined by the extent of
intestinal devascularization required for proper lymphadenectomy

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Procedure

Optimal exposure is initially obtained by retracting the small
bowel cephalad and, to the right, in a moist laparotomy pad,
using a self-retaining retractor such as a Bookwalter or
Thompson retractor

The Sigmoid colon is first mobilized off the lateral sidewall
and retroperitoneum by retracting the sigmoid colon medially,
and the lateral attachment of the colon is meticulously
dissected .

This maneuver exposes the peritoneal reflection, which often
extends onto the sigmoid mesentery.

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To ensure easy approximation of the open ends of
the large bowel, especially if the lesion is located
near the splenic flexure, it is necessary to free the
intestine from adjacent structures
The splenocolic ligament is
divided between curved
clamps, and the contents
are ligated to avoid
possible injury to the
spleen, with troublesome
hemorrhage

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In some instances, a true
phrenocolic ligament can be
developed, which mustbe
divided to free the splenic
flexure

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To free a portion of the
transverse colon, the
omentum may be freed
from the bowel by incising
its avascular attachments
adjacent to the colon

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The splenic flexure is reflected
medially following the division of
its attachments, and care is
taken to avoid the kidney and
the underlying ureter.
It is usually necessary to divide
a portion of the transverse
mesocolon
The bowel is freed of all fatty
attachments at the site selected
for anastomosis

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With the bowel at the
point of the lesion
held in the left hand,
lateral peritoneal
reflection of the
mesocolon is incised
close to the bowel
except in the region of
the tumor over as
wide an area as
seems essential for
its free mobilization

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A fan-shaped
incision of
sufficient size is
made so that the
entire left colic
artery and vein
down to their
origins can be
removed in order
to maximize
removal of
regional lymph
nodes

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The mesenteric border of
the bowel at the proposed
site of resection is cleared
of mesenteric fat in
preparation for the
anastomosis

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Margins of resection

The extent of colon resection is then determined by the
remaining vascular supply, provided that a minimum of 5 cm
of normal intestine proximal and distal to the lesion is included in
the specimen.

The length of intestine resection is determined by the extent of
intestinal devascularization required for proper
lymphadenectomy

After resection, restoration of intestinal continuity can be
performed by suturing or stapling in an end-to-side, side-to-side,
or end-to-end manner.

A minimum of 12 lymph nodes within the mesentery is
considered an adequate resection

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Paired crushing
clamps of the
Stone or similar
type are placed
obliquely across
the bowel above
the lesion within
1 cm of the limits
of the prepared
mesentery .

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The sutures at the angles are
not cut and are utilized for
traction
Enterostomy clamps are
placed several centimeters
from the crushing clamps,
and the crushing clamps are
removed
Clamps are approximated
and manipulated so that the
posterior serosal surface of
the intestine is presented, to
facilitate placement of a layer
of interrupted mattress 000
silk sutures

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The mucosa is approximated
with a continuous lock suture
on an atraumatic needle
starting in the middle of the
posterior layer
At the angle, the lock suture
is changed to one of the
Connell type to ensure
inversion of the angle and
the anterior mucosa

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A second continuous suture is
started adjacent to the first
one and is carried out in a
similar fashion
After the mucosa has been
accurately approximated, the
two continuous sutures, A and
B, are tied with the knot on the
inside

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The anastomosis is further
reinforced by ananterior
serosal layer of interrupted
000 silk sutures.
It is sometimes advisable to
reinforce the mesenteric
angle with one or two
additional mattress sutures.
Any remaining opening of the
mesentery is then closed with
interrupted sutures of fine silk.

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Adequacy of the blood supply to
the site of the anastomosis
should be inspected.
Active, pulsating vessels should
be present adjacent to the
anastomosis on both sides
If the blood supply appears to
be interfered with and the color
of the bowel is altered, it is
better to resect the anastomosis
rather than risk leakage and
potentially fatal peritonitis

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The patency of the stoma
is carefully tested by
compression between
the thumb and index
finger

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Post Operative Care

The nasogastric tube provides decompression until bowel activity
returns, usually on the first or second day aft er surgery.

Oral intake of clear liquids is begun and advanced as tolerated,
whereupon intravenous hydration and electrolytes are discontinued.

Antithrombosis measures should be continued from preoperative
period and are currently recommended for 28 days postoperatively

Wound infections are relatively common after colonic surgery

Any patient not progressing as expected or with unexplained cardiac
abnormalities, fever or worsening abdominal pain.
Early investigation with contrast enhanced CT scan is appropriate

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Enhanced Recovery Programme

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Complications
Intraoperative –

Injury to left ureter;

Injury to spleen, Splenic injury can occur while mobilizing
the splenic fl exure; alternatively spleen may get infiltrated
by the splenic flexure growth which needs splenectomy

Haemorrhage—adequate exposure and careful dissection
of vessels will prevent this.

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Postoperative Complications—

Anastomotic leak :
it is usually partial leak and subsides gradually.
If significant high fistula persists then covering diversion proximal colostomy
or ileostomy should be done.
Often peritonitis may develop in such situation, anastomotic site is detached
and proximal colonic part of anastomosis is brought out as colostomy;
distal rectal stump is closed (Hartmann’s) which is sutured to sacral
promontory by 2-3 silk sutures to prevent it from getting retracted;
once patient recovers from sepsis, only after 3 months resurgery should be
done to maintain the continuity.

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
Pelvic abscess, left sided subphrenic abscess are other
complications which can occur.

DVT and pulmonary embolism (PE)

Urinary tract infection

Pulmonary complications (eg, atelectasis/pneumonia)

Cardiac complications (eg, myocardial infarction,
congestive heart failure)

Paralytic Ileus

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
Paralytic Ileus
Postoperative ileus requires observation if the patient
is clinically stable.
Reduction of narcotics, increased ambulation, and
correction of electrolytes are advocated.
In rare cases, parenteral nutrition is initiated if an ileus
is prolonged for more than 14 days

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Late complications

Anastomotic stricture

Tumor recurrence - There is some evidence to suggest
that adenomas are more likely to recur after left
hemicolectomy than after right hemicolectomy [13, 14]

Bowel obstruction secondary to adhesions

Incisional hernia

Sexual/urinary dysfunction (due to autonomic nerve injury

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Conclusion

Extent of resection based on Indication

Sometimes may require Ileostomy for bowel rest

The length of intestine resection is determined by the
extent of intestinal devascularization required for proper
lymphadenectomy

A minimum of 12 lymph nodes within the mesentery is
considered an adequate resection

Post operative & Intra Operative Complications need to be
handled carefully.

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References

Surgical Anatomy and Technique , Lee J., Skandalakis

Bailey & Love's Short Practice of Surgery, 27th Edition

Zollinger's Atlas of Surgical Operations, Tenth Edition by Robert M.
Zollinger Jr

Shwartz’s Principles of Surgery, 10e. F. Charles Brunicardi, Dana K.
Andersen

Shackelford’s Surgery of the Alimentary tract 8
th Edition

Chassin’s Operative Strategy in General Surgery

Fischer’s Mastery of Surgery 6
th edition

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Thank You