Overview
Definition:
Open left hemicolectomy is a surgical procedure involving the removal of the left half of the colon, typically from the splenic flexure to the rectosigmoid junction
This procedure is indicated for various colonic pathologies affecting this segment
It is performed through a traditional open abdominal incision, as opposed to laparoscopic techniques
The surgery involves resecting the involved bowel segment along with its associated mesentery and lymph nodes, followed by an anastomosis (reconnection) of the remaining bowel ends
The specific extent of resection depends on the underlying pathology, often including the descending colon, sigmoid colon, and portions of the transverse colon
It is a major abdominal surgery with significant implications for patient recovery and long-term outcomes
Surgical approach is typically midline or a left paramedian incision.
Epidemiology:
Left-sided colonic resections, including hemicolectomies, constitute a significant proportion of all colectomies performed globally
The incidence varies based on the prevalence of conditions like colorectal cancer, diverticular disease, and inflammatory bowel disease affecting the left colon
In India, with a rising incidence of colorectal cancers and increasing awareness of gastrointestinal diseases, the number of such procedures is substantial
Patient demographics typically include middle-aged to elderly individuals, although younger patients may also require this surgery for specific conditions
The choice between open and laparoscopic approaches is influenced by patient factors, surgeon preference, and institutional resources.
Clinical Significance:
Open left hemicolectomy is crucial for definitive management of potentially life-threatening conditions of the left colon
It offers a radical approach for treating malignancies, providing oncological control through lymphadenectomy
For acute conditions like complicated diverticulitis or ischemic colitis, it can be life-saving by removing necrotic or perforated bowel and preventing sepsis
The procedure also plays a role in managing inflammatory bowel disease exacerbations and benign but symptomatic lesions
Understanding its indications, surgical technique, potential complications, and postoperative care is essential for surgical residents preparing for DNB and NEET SS examinations, as these are frequently tested topics in both theoretical and practical aspects of surgery.
Indications
Malignancy:
Colorectal cancer (adenocarcinoma) of the descending colon, sigmoid colon, or rectosigmoid junction
This is the most common indication for elective left hemicolectomy
The goal is adequate margin clearance and oncologic lymphadenectomy.
Diverticular Disease:
Complicated diverticulitis, including recurrent or severe episodes unresponsive to medical management, diverticular abscess, perforation, or fistula formation
Resection is typically performed after resolution of acute inflammation, but emergent resection may be necessary for peritonitis.
Ischemia:
Ischemic colitis affecting the left colon, which may result from vascular compromise
Resection is indicated if conservative management fails or if there is evidence of transmural necrosis or perforation.
Inflammatory Bowel Disease:
Severe or refractory ulcerative colitis or Crohn's disease involving the left colon where medical therapy is inadequate or complications arise
Segmental resection may be considered for localized disease or strictures.
Benign Tumors:
Large or symptomatic benign tumors (e.g., leiomyomas, adenomatous polyps with high-grade dysplasia) that cannot be removed endoscopically or pose a risk of obstruction or bleeding.
Obstruction:
Colonic obstruction due to any of the above conditions that cannot be relieved by less invasive means
In acute obstruction, an emergent hemicolectomy may be required.
Preoperative Preparation
Patient Assessment:
Thorough medical evaluation to assess fitness for major surgery, including cardiovascular, respiratory, and renal function
Optimization of comorbidities such as diabetes and hypertension
Assessment of nutritional status and anemia.
Bowel Preparation:
Mechanical bowel preparation with oral laxatives and clear liquid diet for 24-48 hours prior to surgery to reduce fecal load and bacterial count
Antibiotic prophylaxis with broad-spectrum agents covering gram-negative and anaerobic bacteria is administered intravenously within an hour of incision.
Imaging:
Preoperative imaging, typically CT scan of the abdomen and pelvis with contrast, to assess the extent of disease, evaluate for metastatic spread (for malignancy), and identify associated complications
Colonoscopy may have been performed for diagnosis and to ensure no synchronous lesions are missed.
Consent And Discussion:
Detailed discussion with the patient and family regarding the procedure, risks, benefits, alternatives, and potential for stoma formation
Obtaining informed consent is mandatory
Planning for pain management, including epidural or patient-controlled analgesia (PCA).
Anesthesia Considerations:
General anesthesia with endotracheal intubation is typically employed
Anesthetic management includes careful fluid resuscitation and monitoring of vital signs throughout the procedure
Epidural anesthesia may be used for postoperative pain control.
Procedure Steps
Incision And Exploration:
A midline or left paramedian incision is made, extending from the xiphoid process to the pubis, depending on the extent of resection required
The abdominal cavity is explored to confirm the diagnosis, assess the extent of disease, and evaluate for any unexpected findings or metastatic disease
Intraoperative palpation of the entire colon is performed to rule out synchronous lesions.
Mobilization Of Colon:
The left colon is mobilized by dividing its peritoneal attachments
This involves incising the white line of Toldt along the left paracolic gutter to free the descending colon
The splenic flexure is mobilized by dividing the lienocolic ligament, often requiring careful dissection to protect the spleen and pancreatic tail
The sigmoid colon is mobilized by dividing the sigmoid mesentery and the superior rectal artery if necessary.
Vascular Ligation:
The blood supply to the resected segment is ligated
This typically involves ligating the inferior mesenteric artery (IMA) at its origin from the aorta for a high sigmoid resection, or ligating the left colic artery and sigmoid arteries
Ligation is performed proximal to the tumor or diseased segment, ensuring adequate margins and lymphatic drainage
The ligation should be done between vascular clips or ties to prevent bleeding.
Resection Of Bowel:
The colon is resected at appropriate points, typically 10-15 cm proximal to the tumor or diseased segment in the transverse colon and 5-10 cm distal to the lesion in the sigmoid colon or rectum
The mesentery is divided along with the bowel to ensure adequate lymphatic and vascular supply removal
Specimen is oriented for pathological examination.
Anastomosis:
Following resection, the remaining ends of the colon (usually the transverse colon and the rectosigmoid) are reconnected
This can be performed as an end-to-end, end-to-side, or side-to-side anastomosis
Most commonly, a stapled anastomosis (circular stapler) is performed for a tension-free connection, or it can be hand-sewn
The integrity of the anastomosis is assessed intraoperatively, often with saline or air insufflation.
Closure:
The abdominal wall is closed in layers, with the peritoneum and fascia approximated with sutures
The skin is closed with sutures, staples, or adhesive strips
A drain may be placed in the peritoneal cavity if indicated, especially in cases of gross contamination or uncertainty about anastomosis integrity.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, urine output, and abdominal distension
Regular assessment for signs of complications such as bleeding, infection, ileus, or anastomotic leak
Pain management is critical.
Fluid And Electrolyte Balance:
Intravenous fluid therapy is continued until the patient can tolerate oral intake
Electrolyte levels are monitored and corrected as needed
Nasogastric tube may be used to decompress the stomach in cases of prolonged ileus or significant nausea/vomiting.
Early Ambulation:
Encourage early mobilization and ambulation as soon as tolerated to prevent deep vein thrombosis (DVT), pulmonary complications, and promote bowel function
Physiotherapy may be involved.
Dietary Advancement:
Gradual advancement of diet from clear liquids to low-residue diet as bowel function returns (e.g., passage of flatus, bowel sounds)
Patients are encouraged to resume a normal diet as tolerated
Nutritional support may be provided if prolonged oral intake is not possible.
Wound Care:
Routine wound care to prevent infection
Incision site is monitored for signs of inflammation, discharge, or dehiscence
Drain management if a drain was placed.
Complications
Early Complications:
Anastomotic leak: leakage of intestinal contents from the reconnected bowel, leading to peritonitis and sepsis
This is a serious complication requiring prompt recognition and management, often surgical re-exploration
Ileus: prolonged functional obstruction of the intestines, leading to abdominal distension, nausea, and vomiting
Wound infection: superficial or deep infection of the surgical incision
Hemorrhage: bleeding from the surgical site or anastomosis
Intra-abdominal abscess: collection of pus within the abdominal cavity
Injury to adjacent organs: spleen, ureter, or bladder injury during mobilization
Deep vein thrombosis (DVT) and pulmonary embolism (PE).
Late Complications:
Stricture formation at the anastomosis: narrowing of the reconnected bowel, leading to symptoms of obstruction
Incisional hernia: protrusion of abdominal contents through a weak spot in the abdominal wall closure
Adhesions: fibrous bands that can cause bowel obstruction
Chronic pain
Sexual dysfunction or bladder dysfunction if pelvic nerves are involved during sigmoid resection.
Prevention Strategies:
Meticulous surgical technique to ensure adequate blood supply to the bowel ends and tension-free anastomosis
Appropriate bowel preparation and antibiotic prophylaxis
Careful handling of tissues and gentle mobilization to avoid injury
Prophylaxis for DVT
Early recognition and prompt management of any signs of complications
Careful assessment of anastomotic integrity intraoperatively
Adequate postoperative care and monitoring.
Prognosis
Factors Affecting Prognosis:
Stage of malignancy (if applicable) is the most significant factor
Patient's overall health status, presence of comorbidities, and occurrence of complications also impact prognosis
The adequacy of surgical resection (R0 resection) and lymph node status are critical for oncologic outcomes
For benign conditions, prognosis is generally excellent once the underlying problem is resolved.
Outcomes:
For benign conditions like diverticulitis, prognosis is good with low recurrence rates after resection
For colorectal cancer, the 5-year survival rate is highly dependent on the stage at diagnosis and treatment response, ranging from over 90% for stage I to less than 15% for stage IV
Patients may experience changes in bowel habits post-surgery, often resolving over time.
Follow Up:
Regular follow-up is essential, especially for patients treated for malignancy
This includes physical examinations, blood tests (CEA levels), and surveillance colonoscopies or CT scans at intervals determined by oncologic guidelines
Patients should be advised to report any new or worsening symptoms immediately
For benign conditions, follow-up is primarily for monitoring recovery and addressing any late complications.
Key Points
Exam Focus:
Indications for open vs
laparoscopic left hemicolectomy
Management of complicated diverticulitis
Oncologic principles of colon cancer resection (margins, lymphadenectomy)
Complications of colonic anastomosis (leak, stricture)
Management of intra-abdominal sepsis
DVT prophylaxis in surgical patients.
Clinical Pearls:
Always perform a thorough abdominal exploration to rule out synchronous lesions in elective cases
Ligate the IMA high to ensure adequate lymphatic drainage when resecting distal sigmoid
Consider the spleen and pancreas when mobilizing the splenic flexure
Ensure a tension-free anastomosis, whether stapled or hand-sewn
Promptly investigate any suspicion of anastomotic leak with imaging and clinical assessment.
Common Mistakes:
Inadequate bowel preparation leading to increased risk of infection
Insufficient oncologic margins or inadequate lymphadenectomy in cancer cases
Injury to adjacent organs during mobilization
Failure to recognize or manage anastomotic leak promptly
Over-reliance on routine drains without specific indications
Inadequate postoperative fluid management leading to dehydration or fluid overload.