Overview
Definition:
Laparoscopic left hemicolectomy is a minimally invasive surgical procedure to remove the left side of the colon, typically including the splenic flexure, descending colon, sigmoid colon, and rectum
It is performed using a laparoscope and specialized instruments inserted through small incisions, offering advantages over open surgery such as reduced pain, shorter hospital stays, and faster recovery.
Epidemiology:
Left hemicolectomy is performed for a variety of colonic pathologies, including malignant tumors, inflammatory bowel disease (Crohn's disease, ulcerative colitis), diverticulitis, and ischemic colitis
The incidence varies based on the prevalence of these conditions in specific populations.
Clinical Significance:
This procedure is a cornerstone in the surgical management of diseases affecting the left colon
Proficiency in laparoscopic techniques for this procedure is crucial for colorectal surgeons to offer patients less invasive treatment options with improved outcomes
Understanding its indications, technical nuances, and potential complications is vital for surgical residents preparing for DNB and NEET SS examinations.
Indications
Malignancy:
Colon cancer involving the splenic flexure, descending colon, sigmoid colon, or rectum
Early-stage cancers are ideal candidates for laparoscopic resection.
Inflammatory Bowel Disease:
Severe, refractory Crohn's disease or ulcerative colitis affecting the left colon, where medical management has failed
Segmental resection is preferred when possible.
Diverticulitis:
Complicated diverticulitis, such as recurrent episodes unresponsive to medical treatment, or complications like abscess formation, fistula, or perforation that cannot be managed conservatively
Often indicated for sigmoid diverticulitis.
Ischemia:
Ischemic colitis affecting a significant portion of the left colon, unresponsive to medical management, or leading to complications like gangrene or perforation.
Other:
Benign polyps that are too large or numerous for endoscopic removal
Volvulus of the sigmoid colon
Intestinal obstruction due to adhesions or strictures in the left colon.
Preoperative Preparation
Patient Assessment:
Thorough medical history, physical examination, and assessment of comorbidities
Evaluation of cardiopulmonary status is essential for laparoscopic surgery.
Imaging:
Preoperative imaging such as CT scan of the abdomen and pelvis with contrast to delineate the extent of disease, assess involvement of adjacent structures, and identify potential surgical planes or anatomical variations
Colonoscopy may be performed to assess the entire colon for synchronous lesions.
Bowel Preparation:
Mechanical bowel preparation with clear fluids and oral laxatives the day before surgery is standard practice to reduce fecal load and facilitate visualization
Antibiotic prophylaxis is also administered.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is required
Careful attention to fluid management and intra-abdominal pressure is crucial
Epidural analgesia may be considered for postoperative pain control.
Informed Consent:
Detailed discussion with the patient regarding the procedure, its benefits, risks, alternatives, and the possibility of conversion to open surgery.
Procedure Steps
Trocar Placement:
Typically, 4-5 ports are used: one umbilical port for the camera, and several 5-12 mm ports placed strategically in the left upper, left lower, and suprapubic regions for instrument manipulation.
Mobilization:
The sigmoid and descending colon are mobilized by dividing the left colic artery and vein, and by dissecting along the white line of Toldt to free the mesocolon and colon from the retroperitoneum.
Division Of Vessels:
Careful identification and ligation of the inferior mesenteric artery (IMA) and vein (IMV) proximally, and the marginal artery and vein distally, depending on the planned resection margin.
Anastomosis:
The colon is divided proximally and distally, and the ends are prepared for anastomosis
Various techniques, including stapled or hand-sewn anastomosis, are employed
A common approach is a side-to-side or end-to-side stapled anastomosis.
Specimen Extraction:
The resected specimen is typically removed through a slightly enlarged incision, usually the umbilical or a supra-pubic port site, after being placed in a specimen bag to prevent contamination.
Postoperative Care
Pain Management:
Multimodal analgesia including IV opioids, NSAIDs, and potentially epidural analgesia
Early mobilization is encouraged.
Monitoring:
Close monitoring for vital signs, urine output, bowel function, and signs of complications such as ileus, infection, bleeding, or anastomotic leak
Nasogastric tube may be used initially for decompression.
Dietary Advancement:
Gradual advancement of diet from clear liquids to solids as bowel function returns, typically within 24-48 hours postoperatively.
Ambulation:
Early ambulation to prevent deep vein thrombosis (DVT), pneumonia, and promote gastrointestinal motility.
Discharge Criteria:
Discharge is usually considered when the patient can tolerate a regular diet, is ambulant, has adequate pain control, and has no signs of complications.
Complications
Early Complications:
Anastomotic leak: Can be devastating, leading to peritonitis and sepsis
Requires prompt diagnosis and management, often surgical re-exploration
Bleeding: From staple lines, vascular pedicles, or surgical site
Intra-abdominal abscess: May require percutaneous drainage or surgical intervention
Ileus: Prolonged bowel dysfunction
Injury to adjacent organs: Such as ureter, bladder, or spleen.
Late Complications:
Stenosis at the anastomosis: Can lead to obstructive symptoms
Bowel obstruction due to adhesions
Incisional hernia: At port sites
Recurrence of malignancy: If the initial resection was for cancer
Chronic pain syndromes.
Prevention Strategies:
Meticulous surgical technique, adequate bowel preparation, judicious use of staplers, ensuring good blood supply to the bowel ends for anastomosis, prompt recognition and management of complications, and adherence to postoperative care protocols.
Key Points
Exam Focus:
Indications for elective vs
emergency left hemicolectomy
Management of sigmoid volvulus
Laparoscopic technique variations
Recognition and management of anastomotic leak
Differentiating Crohn's vs
Ulcerative Colitis indications for resection.
Clinical Pearls:
The white line of Toldt is key for safe medial mobilization
Always confirm the origin of the IMA/IMV
Be vigilant for the ureter during mobilization
A specimen retrieval bag is essential
Consider conversion to open surgery early if technical difficulties arise or patient stability is compromised.
Common Mistakes:
Inadequate bowel preparation leading to poor visualization
Incomplete mobilization of the colon
Insufficient blood supply to the bowel edges for anastomosis
Over-tightening of staple devices causing tissue damage
Failure to identify and protect vital structures like the ureter.