Overview
Definition:
Laparoscopic left colectomy with intracorporeal anastomosis is a minimally invasive surgical procedure to remove a portion of the descending and/or sigmoid colon performed entirely within the abdominal cavity, followed by rejoining the remaining bowel ends using stapling devices without externalization
This technique aims to reduce incisional morbidity and hospital stay compared to open surgery.
Epidemiology:
Left colectomies are performed for a variety of colonic pathologies including diverticulitis, colorectal cancer, inflammatory bowel disease (IBD), and adenomas
Laparoscopic approaches are increasingly favored for elective cases, with adoption rates varying based on surgeon expertise and institutional resources
Incidence of colon cancer remains significant across India, driving the need for such procedures.
Clinical Significance:
This procedure represents a cornerstone in the surgical management of left-sided colonic diseases
Proficiency in laparoscopic techniques and intracorporeal anastomosis is crucial for surgeons preparing for DNB and NEET SS examinations, as it reflects current standards in surgical practice and patient outcomes
Understanding its nuances is vital for both operative success and managing potential complications.
Indications
Indications:
Benign diseases: Complicated diverticulitis (abscess, perforation, obstruction, fistula) unresponsive to conservative management
Large colonic polyps or adenomas not amenable to endoscopic removal
Rectal prolapse (sigmoid resection with rectopexy)
Malignant diseases: Colorectal cancer of the descending colon, sigmoid colon, or rectosigmoid junction where a clear margin can be achieved laparoscopically
Benign strictures or neoplasms
Inflammatory bowel disease (Crohn's disease, Ulcerative colitis) affecting the left colon.
Contraindications:
Absolute contraindications: Unstable patient
Irreducible bowel obstruction with suspected ischemia
Extensive adhesions from previous surgeries precluding safe dissection
Relative contraindications: Severe comorbidities affecting anesthetic risk
Significant morbid obesity
Advanced malignancy with extensive local invasion or distant metastasis
Surgeon's inexperience with laparoscopic colorectal surgery for complex cases.
Preoperative Preparation
Patient Assessment:
Thorough medical history and physical examination
Assessment of comorbidities (cardiac, pulmonary, renal)
Nutritional status evaluation
Thorough review of imaging studies (CT scan, MRI, colonoscopy) to define extent of disease and anatomical relationships.
Bowel Preparation:
Mechanical bowel preparation with clear liquids and laxatives is typically performed 24-48 hours prior to surgery
Antibiotic prophylaxis (e.g., Cefoxitin or Cefotetan plus Metronidazole, or Ciprofloxacin plus Metronidazole) is administered intravenously 30-60 minutes before incision to reduce surgical site infection risk.
Anesthesia And Imaging:
General anesthesia with endotracheal intubation
Intraoperative imaging review to confirm surgical targets
Consider preoperative marking of lesions if difficult to palpate or identify laparoscopically.
Procedure Steps
Trocar Placement:
Typically 4-5 ports are used: a camera port (umbilicus), working ports in the left upper, left lower, right lower quadrants, and a potential assistant port
Pneumoperitoneum is established with CO2 insufflation to 12-15 mmHg.
Mobilization Of Colon:
The colon is mobilized from the white line of Toldt laterally
The splenic flexure may need to be mobilized for adequate length
Dissection proceeds along the mesentery, ligating the inferior mesenteric artery (IMA) and its branches, and the inferior mesenteric vein (IMV) proximal to the pancreas
Care is taken to preserve autonomic nerve supply and avoid injury to adjacent structures (spleen, duodenum, ureter, small bowel).
Resection:
The bowel is divided proximally and distally using laparoscopic staplers (linear cutting staplers) or harmonic scalpels, with appropriate stapling devices ensuring safe margins and hemostasis.
Intracorporeal Anastomosis:
After specimen retrieval (often through a slightly enlarged port site), the anvil of a circular stapler is introduced into the proximal end of the colon
The distal end is brought out through a small incision (e.g., suprapubic), the firing head of the circular stapler is inserted, and the purse-string is secured
The stapler is then inserted and fired intracorporeally
The integrity of the anastomosis is checked by insufflating the colon and observing for leaks, and by assessing the staple line for hemostasis
A confirmatory test like methylene blue instillation or intraoperative endoscopy can be considered.
Postoperative Care
Pain Management:
Multimodal analgesia including IV patient-controlled analgesia (PCA), oral opioids, and NSAIDs
Epidural analgesia may be considered for extended procedures.
Fluid And Nutrition:
Intravenous fluids are maintained
Enteral feeding is typically resumed once bowel sounds return and flatus is passed, often within 24-48 hours postoperatively
Clear liquids are advanced as tolerated.
Monitoring And Ambulation:
Close monitoring for vital signs, urine output, and signs of complications (bleeding, infection, anastomotic leak)
Early ambulation is encouraged to reduce risks of DVT and pulmonary complications
Nasogastric tube removal is usually performed once bowel function resumes.
Complications
Early Complications:
Anastomotic leak: The most serious early complication, presenting with peritonitis, sepsis, and potential need for reoperation
Bowel obstruction: Due to ileus or mechanical issues
Bleeding: From staple lines or mesenteric vessels
Injury to adjacent organs: Spleen, ureter, duodenum, bladder, small bowel
Port site hernia.
Late Complications:
Anastomotic stricture: May require endoscopic dilation or reoperation
Adhesions leading to small bowel obstruction
Incisional hernias (though less common with laparoscopic surgery)
Chronic pain
Recurrence of disease.
Prevention Strategies:
Meticulous surgical technique: careful dissection, adequate bowel preparation, appropriate stapler selection, and secure anastomosis
Thorough assessment of anastomotic integrity
Close postoperative monitoring
Early mobilization and appropriate pain control
Prophylaxis against DVT and infection.
Key Points
Exam Focus:
Indications for left colectomy, differences between open and laparoscopic approaches, critical steps of laparoscopic mobilization and intracorporeal anastomosis, management of complications like anastomotic leak, importance of IMA ligation and splenic flexure mobilization.
Clinical Pearls:
Always confirm pneumoperitoneum before starting dissection
Identify the white line of Toldt early for safe medial mobilization
Mobilize the splenic flexure adequately for tension-free anastomosis
Ensure good visualization of the mesentery before stapling or ligating vessels
Palpate the staple line for integrity after firing the stapler.
Common Mistakes:
Inadequate mobilization leading to tension on the anastomosis
Injury to surrounding organs during dissection
Incomplete ligation of mesenteric vessels
Inadequate assessment of anastomotic integrity
Premature discontinuation of antibiotics
Failure to consider reoperation for anastomotic leak.