Overview
Definition:
Laparoscopic sigmoid colectomy is a minimally invasive surgical procedure to remove a segment of the sigmoid colon using laparoscopic techniques
It involves making small incisions through which a camera and specialized instruments are inserted to perform the resection and anastomosis.
Epidemiology:
Sigmoid colectomy is frequently performed for various benign and malignant conditions of the sigmoid colon
The increasing adoption of laparoscopic techniques has made it a preferred approach for many patients, with reported rates of laparoscopic sigmoid colectomy varying significantly by institution and surgeon expertise.
Clinical Significance:
This procedure is crucial for managing common colonic pathologies including diverticulitis, colorectal cancer, polyps, and inflammatory bowel disease affecting the sigmoid colon
Understanding its indications, techniques, and potential complications is vital for surgical residents preparing for DNB and NEET SS examinations, as it represents a fundamental component of colorectal surgery.
Indications
Malignant Neoplasms:
Colorectal cancer of the sigmoid colon requiring resection
Staging and lymph node dissection are integral parts of the procedure for malignancy.
Diverticulitis:
Recurrent, complicated (abscess, perforation, fistula), or fulminant sigmoid diverticulitis unresponsive to conservative management
Elective sigmoid colectomy is typically performed after acute episodes resolve.
Benign Strictures:
Benign strictures of the sigmoid colon due to chronic inflammation, ischemia, or radiation injury
Strictures causing significant obstruction or symptoms are indications for resection.
Polyps:
Large or sessile sigmoid polyps that cannot be removed endoscopically, or those with high-grade dysplasia or suspicion of malignancy.
Inflammatory Bowel Disease:
Refractory sigmoid involvement in Crohn's disease or ulcerative colitis, or complications such as toxic megacolon or obstruction.
Preoperative Preparation
Patient Evaluation:
Comprehensive history, physical examination, and assessment of comorbidities
Evaluation of nutritional status and cardiopulmonary reserve.
Bowel Preparation:
Mechanical bowel preparation with clear liquids and laxatives is typically performed 24-48 hours preoperatively
Antibiotic prophylaxis (e.g., cephalosporin and metronidazole) is administered shortly before surgery.
Imaging And Staging:
CT scan of the abdomen and pelvis for staging of malignancies, assessing extent of diverticulitis, and identifying anatomical variations
Colonoscopy may be performed preoperatively to assess the entire colon and rule out synchronous lesions.
Informed Consent:
Detailed discussion with the patient regarding the procedure, its benefits, risks, alternatives, and expected recovery, including potential conversion to open surgery.
Procedure Steps
Patient Positioning And Access:
Patient is placed in the lithotomy or supine position
A pneumoperitoneum is established, and typically 3-5 trocars are inserted in the left upper quadrant, left lower quadrant, and periumbilical region.
Colon Mobilization:
The sigmoid colon is identified and mobilized by dissecting the mesocolon, preserving the inferior mesenteric artery and vein
The sigmoid colon is dissected free from surrounding structures, taking care to identify and protect the ureter and gonadal vessels.
Vascular Ligation:
The inferior mesenteric artery and vein are identified and ligated at an appropriate origin to ensure adequate length for anastomosis and oncologic clearance if for malignancy.
Bowel Transection:
The colon is transected proximally and distally using stapling devices or harmonic scalpels
The specimen is removed through one of the port sites, often enlarged or within an endoscopic retrieval bag.
Anastomosis:
An end-to-end, end-to-side, or side-to-side anastomosis is fashioned using a stapler or hand-sewn technique
The integrity of the anastomosis is confirmed by gentle insufflation or air leak test
The specimen is retrieved, and the port sites are closed.
Postoperative Care
Pain Management:
Adequate analgesia using multimodal approaches, including patient-controlled analgesia (PCA) or epidural anesthesia, is essential
Early ambulation is encouraged.
Dietary Advancement:
Patients are typically kept NPO initially and advanced to clear liquids as tolerated, progressing to a regular diet as bowel function returns and anastomotic integrity is presumed
Diet advancement should be guided by clinical assessment.
Monitoring:
Close monitoring for signs of infection, anastomotic leak (e.g., tachycardia, fever, abdominal pain, elevated white blood cell count), ileus, and bleeding
Vital signs and fluid balance are carefully tracked.
Discharge Criteria:
Discharge is typically considered when the patient is ambulating, tolerating a regular diet, has adequate pain control with oral analgesics, and has no signs of complications
A follow-up appointment is scheduled.
Complications
Early Complications:
Anastomotic leak is the most feared complication and can lead to peritonitis, sepsis, and reoperation
Bleeding from staple lines or mesenteric vessels
Bowel obstruction due to adhesions or retained fecaliths
Injury to adjacent organs such as ureter, bladder, or small intestine
Port site hernia or infection.
Late Complications:
Incisional hernia
Adhesions leading to small bowel obstruction
Chronic pain
Anastomotic stricture or stenosis
Recurrence of disease if malignancy was treated.
Prevention Strategies:
Meticulous surgical technique, careful identification and preservation of vital structures, adequate bowel preparation, appropriate stapler selection, and confirming anastomotic integrity
Postoperative monitoring for early detection of leaks and prompt intervention are crucial.
Key Points
Exam Focus:
Indications for elective vs
emergency sigmoid colectomy
Principles of laparoscopic dissection and mobilization
Techniques for safe vascular ligation and anastomosis
Management of specific complications like anastomotic leak.
Clinical Pearls:
Always identify and protect the ureter during sigmoid mobilization
Ensure adequate length of bowel for tension-free anastomosis
Use an endoscopic retrieval bag for specimen removal to prevent wound contamination
Consider intraoperative imaging if significant bowel edema or inflammation is present.
Common Mistakes:
Inadequate bowel preparation
Insufficient mobilization leading to tension at the anastomosis
Ligation of inappropriate vascular pedicles
Failure to identify and protect adjacent structures
Delayed diagnosis or management of anastomotic leak.