Left Colectomy 

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Left Colectomy

 

Description

  • left colectomy is removal of part of the descending colon (left side of colon), also known as left hemicolectomy
  • extended left colectomy is removal of at least the splenic flexure, descending colon, and sigmoid colon (Colorectal Dis 2013 Jun;15(6):747)

Anatomy

  • large intestine is composed of 6 sections including
    • cecum
      •  proximal portion of ascending colon attached to end of small intestine (a blind pouch at level of the ileocecal junction)
      •  ileocecal valve separates ileum from cecum
      •  appendix attaches to posteromedial wall of cecum just below ileocecal junction
    • ascending colon
      •  courses superiorly on right side of abdomen from right iliac fossa to right lobe of liver
      •  turns in a left direction at right colic flexure to become transverse colon
    • transverse colon
      •  most mobile and longest portion of colon
      •  attached to a mesentery (transverse mesocolon)
      •  located between right and left colic flexures
      •  left colic flexure is attached to diaphragm through phrenicocolic ligament
    • descending colon
      •  located between left colic flexure superiorly and left iliac fossa inferiorly
      •  terminates at sigmoid colon
    • sigmoid colon
      •  S-shaped intestinal loop with variable length
      •  connects descending colon to rectum
    • rectum
      •  rectum starts at level of the third sacral segment
      •  located within sacrococcygeal concavity
      •  becomes anal canal at puborectal sling
      • anterior to rectum are
        •  rectovesical pouch, prostate, bladder, urethra, and seminal vesicles in men
        •  rectouterine pouch, cervix, uterus, and vagina in women
  • location of structures are considered retroperitoneal or intraperitoneal
    • retroperitoneal structures include
      •  ascending colon
      •  descending colon
      •  rectum
      •  anal canal
    • intraperitoneal structures include
      •  cecum
      •  appendix
      •  transverse colon
      •  sigmoid colon
  • blood supply
    •  cecum – supplied by ileocolic artery (terminal branch of superior mesenteric artery); appendix is supplied by branch of ileocolic artery
    •  ascending colon – supplied by ileocolic and right colic arteries (both branches of superior mesenteric artery)
    •  transverse colon – supplied mostly by middle colic artery (branch of superior mesenteric artery), but may receive blood from right and left colic arteries
    •  descending and sigmoid colon – supplied by left colic and sigmoid arteries (branches of inferior mesenteric artery)
    •  rectum and anal canal – supplied by superior rectal artery (branch of inferior mesenteric artery) and branches of internal iliac arteries
  • nerve supply
    •  ascending colon and proximal two-thirds of transverse colon are innervated by superior mesenteric plexus (including sympathetic, parasympathetic, and sensory input)
    •  transverse colon (distal one-third), descending colon, and sigmoid colon are innervated by inferior mesenteric plexus (including sympathetic, parasympathetic, and sensory input)
  •  Reference – StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2022 Jan

Indications

  • colorectal cancer
    • nonmetastatic colorectal cancer
      • extent of colonic resection is determined by blood supply and distribution of regional lymph nodes(1)
        •  resection should include ≥ 5 cm of colon on either side of tumor, but wider margins often needed to match ligation of arterial blood supply (ESMO Grade B, Level IV)
        •  ≥ 12 lymph nodes should be resected to define stage II vs. stage III, and to identify and remove any possible lymph node metastases (ESMO Grade B, Level IV)
      • indications for open or laparoscopic colectomy in patients with nonmetastatic colorectal cancer
        • open approach usually indicated for patients with locally advanced cancer (such as T4), acute bowel obstruction, or perforation
        • consider laparoscopic-assisted colectomy for patients with any of the following, assuming the surgeon is experienced in performing laparoscopically assisted colorectal surgery
          •  no locally advanced disease
          •  no acute bowel obstruction or perforation due to cancer
          •  no previous abdominal surgeries and/or low risk of abdominal adhesions
          •  no obesity
        •  thorough abdominal exploration is required before laparoscopic resection, and consider preoperative marking of small lesions
        •  patients with abdominal adhesions found in exploration should have open procedures
        • Reference – National Comprehensive Cancer Network (NCCN) clinical practice guideline on colon cancer can be found at NCCN website (free registration required)
    • metastatic colorectal cancer in patients for whom resection of liver or lung metastases is also possible
  • segmental Crohn disease
  • severe ischemic colitis
  • left colectomy may be indicated in patients with ischemia in left colon and > 3 of the following
    • peritoneal signs
    • massive bleeding
    • universal fulminant colitis with or without toxic megacolon
    • portal venous gas and/or pneumatosis intestinalis on imaging
    • failure of acute segmental ischemic colitis to respond to treatment within 2-3 weeks with continued symptoms or a protein-losing colopathy
    • apparent healing but with recurrent episodes sepsis
    • symptomatic colon stricture
    • symptomatic segmental ischemic colitis
    • Reference – Crit Care Med 2015 Apr;43(4):801
  • sigmoid or cecal volvulus, often to prevent recurrence or if bowel is perforated
  • diverticulitis, in select patients
    • generally, for patients with diffuse peritonitis or for those in whom nonoperative management of acute diverticulitis fails, urgent sigmoid colectomy is advised (ASCRS Grade 1C)(2)
    • nonurgent resection can be performed to manage active diverticulitis

Preoperative Considerations

Preoperative Enhanced Recovery After Surgery (ERAS) Protocols

  • follow ERAS protocols
  • ERAS protocols (also called fast-track protocols or enhanced recovery protocols) refer to combinations of perioperative procedures and practices intended to improve outcomes in patients having surgery such as avoiding nausea and pain, early return of normal bowel function, improved wound healing with reduced infection rate, and shortening length of hospital stay
    •  ERAS protocols may reduce length of hospital stay, risk of postoperative complications, and time to return of gastrointestinal function in patients having gastrointestinal or colorectal surgery (level 2 [mid-level] evidence)
    •  ERAS or fast-track surgery protocols may reduce risk of healthcare-associated infections in patients having abdominal or pelvic surgery (level 2 [mid-level] evidence)
  • American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommendations for components of ERAS protocol after colon and rectal surgery
    • preoperative interventions
      • preadmission counseling
      • nutrition and bowel preparation
        • continue clear liquid diet up to 2 hours before general anesthesia (ASCRS/SAGES Grade 1, Level A)
        • consider encouraging carbohydrate loading in patients without diabetes before surgery (ASCRS/SAGES Grade 2, Level B)
        • consider oral nutritional supplementation in malnourished patients before elective colorectal surgery (ASCRS/SAGES Grade 2, Level B)
        • use of mechanical bowel preparation plus oral antibiotic bowel preparation before elective colorectal surgery is generally recommended (ASCRS/SAGES Grade 1, Level B)
          • multiple oral antibiotic bowel preparation regimens have been proposed, with metronidazole, neomycin, kanamycin, erythromycin, and ciprofloxacin being commonly used in various protocols on review, but there is controversy concerning the overall benefit of oral antibiotics as a means of preventing both surgical site and anastomotic infections balanced with a potential risk for Clostridioides difficile suprainfection or adverse drug reactions, and there is no clear guidance as to one regimen vs. another (Ann Surg 2019 Jul;270(1):43full-text)
      • preadmission optimization and orders
        •  consider multimodal prehabilitation (enhancement of preoperative condition) before elective colorectal surgery in patients with multiple comorbidities or significant deconditioning (ASCRS/SAGES Grade 2, Level B)
        •  consider use of standardized order sets as part of the enhanced recovery pathway (ASCRS/SAGES Grade 2, Level C)
      • American Society of Health-System Pharmacists/Infectious Diseases Society of America/Surgical Infection Society/Society for Healthcare Epidemiology of America (ASHP/IDSA/SIS/SHEA) recommendations for antimicrobial prophylaxis for colorectal surgery (ASHP Category A)
        • recommended regimen in colorectal surgery is usually combination of a cephalosporin IV and mechanical bowel prep with another antibiotic given orally
          • IV regimens
            • cefazolin IV plus metronidazole IV
              • cefazolin 2 g IV 60 minutes before surgical incision
                • 30 mg/kg in children, 3 g in patients ≥ 120 kg (265 lbs)
                • redosing interval 4 hours if still in surgery
              • metronidazole 500 mg (15 mg/kg in children) IV 60 minutes before surgical incision
            •  cefoxitin 2 g IV, 40 mg/kg in children, redosing interval 2 hours
            •  cefotetan 2 g IV, 40 mg/kg in children, redosing interval 6 hours
            • ceftriaxone IV plus metronidazole IV if resistance to first- or second-generation cephalosporins likely
              •  ceftriaxone 2 g IV, 50-75 mg/kg in children
              •  metronidazole 500 mg (15 mg/kg in children) IV 60 minutes before surgical incision
          • alternatives
            • ampicillin-sulbactam 3 g (ampicillin 2 g /sulbactam 1 g) IV, 50 mg/kg of ampicillin component in children, redosing interval 2 hours
            •  ertapenem 1 g IV, 15 mg/kg in children
          • oral antibiotics given in 3 doses over approximately 10 hours (the afternoon and evening before the operation and after the mechanical bowel prep)
            • a standard regimen is at 19, 18, and then 9 hours before surgery
            • neomycin sulfate 1 g plus erythromycin base 1 g orally for adult, neomycin sulfate 15 mg/kg plus erythromycin base 20 mg/kg orally for children, or
            • neomycin sulfate 1 g for adult plus metronidazole 1 g for adult orally, 15 mg/kg neomycin sulfate plus metronidazole 15 mg/kg orally for children
        • Reference – Am J Health Syst Pharm 2013 Feb 1;70(3):195, Surg Infect (Larchmt) 2013 Feb;14(1):73
    • other interventions typically included in ERAS protocols prior to surgery
      •  preoperative cardiac evaluation includes evaluation of clinical risk factors, use of risk calculators (such as the Perioperative Cardiac Risk Calculator, Revised Cardiac Risk Index, and NSQIP Surgical Risk Calculator), and brain natriuretic peptide (BNP) testing; see Preoperative Evaluation and Management for Adults for more information
      •  venous thromboembolism prophylaxis with American College of Chest Physicians (ACCP) 2012 recommendations for thromboprophylaxis for general and abdominal-pelvic surgery
      • use preemptive, multimodal anti-emetic prophylaxis to reduce perioperative nausea and vomiting (ASCRS/SAGES Grade 1, Level A)
      • use alvimopan with open colorectal surgery to hasten recovery (ASCRS/SAGES Grade 1, Level B), but its benefit after minimally invasive surgery is not clear
        • alvimopan is a peripherally acting mu opioid receptor antagonist which is FDA approved to accelerate restoration of normal bowel function in patients ≥ 18 years old having partial large or small bowel resection surgery
          • for use in hospitalized patients only
          • recommended dose 12 mg orally prior to surgery, then 12 mg orally twice daily for up to 7 days (but ≤ 15 doses maximum)
          • Reference – FDA Press Release 2008 May 20 (updated 2013 Apr 15)

Procedural Considerations

Perioperative Enhanced Recovery After Surgery (ERAS) Protocols

  • perioperative interventions
    • use surgical site infection prevention bundles (small sets of evidence-based practices to decrease surgical site infections) to reduce surgical site infection (ASCRS/SAGES Grade 1, Level B)
    • pain control
      • implement multimodal, opioid-sparing, pain management plan before anesthesia induction (ASCRS/SAGES Grade 1, Level B)
      • use thoracic epidural analgesia for open colorectal surgery, but routine use in laparoscopic colorectal surgery is not recommended (ASCRS/SAGES Grade 1, Level B)
    • perioperative nausea and vomiting
    • intraoperative fluid management
      • tailor fluid infusion to avoid excess fluid administration and volume overload, or undue fluid restrictions and hypovolemia (ASCRS/SAGES Grade 1, Level A)
      • use balanced chloride-restricted crystalloid solutions for maintenance infusions and fluid boluses in patients having colorectal surgery; colloid solutions provide no benefit when routinely used for fluid boluses (ASCRS/SAGES Grade 1, Level B)
      • avoid intraoperative hypotension; adverse outcomes including myocardial and acute kidney injuries are associated with even short duration of mean arterial pressure < 65 mm Hg (ASCRS/SAGES Grade 1, Level B)
      • in high-risk patients and patients undergoing colorectal surgery with anticipated significant intravascular losses, use goal-directed hemodynamic therapy (ASCRS/SAGES Grade 1, Level B); definition of “high-risk patients” typically includes those with
        • history of severe cardiorespiratory illness, such as acute myocardial infarction, chronic obstructive pulmonary disease, or stroke
        • planned surgery duration > 8 hours
        • age > 70 years plus evidence of limited physiological reserve of ≥ 1 vital organ
        • respiratory failure
        • aortic vascular disease
    • surgical approach
    • discontinue IV fluids in early postoperative period if no surgical complications or hemodynamic instability (ASCRS/SAGES Grade 1, Level B)
    • Reference – Surg Endosc 2023 Jan;37(1):5full-text

Technique

  • anatomical landmarks to identify during the operative procedure(3)
    • spleen – the splenic flexure and inferior pole of the spleen
    • border of pancreas
    • ligaments
      • gastrocolic ligament
      • spleno-omental ligament, also known as criminal fold of Morgenstern, is a constant peritoneal fold attached to the lower pole of the spleen near to splenic flexure but is distinct from the splenocolic ligament
    • fasci
      • Toldt fascia
      • Gerota fascia
    • vasculature
      • inferior mesenteric vein
      • inferior mesenteric artery
    • border between colonic mesentery and retroperitoneum
  • guidelines agree that colorectal surgery, including left colectomy, should be performed using a laparoscopic technique whenever laparoscopic surgical expertise is available
    • American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommends a minimally invasive surgical approach when appropriate and whenever expertise is available (ASCRS/SAGES Grade 1, Level A)(Surg Endosc 2023 Jan;37(1):5full-text)
    • open approach usually indicated for patients with locally advanced cancer (such as T4), acute bowel obstruction, or perforation
    • consider laparoscopic-assisted colectomy for patients with any of the following
      •  no locally advanced disease
      •  no acute bowel obstruction or perforation due to cancer
      •  no previous abdominal surgeries and/or low risk of abdominal adhesions
      •  no obesity
    •  thorough abdominal exploration is required before laparoscopic resection, with identification of any preoperative markings of small lesions
    •  patients with extrensive intraabdominal adhesions identified during exploration should have open procedures
    • Reference – National Comprehensive Cancer Network (NCCN) clinical practice guideline on colon cancer can be found at NCCN website (free registration required)
    • European Association for Endoscopic Surgery (EAES) recommendations for laparoscopic colectomy
      • access to organs through laparoscopic colectomy may be by single port or multiple ports
      • in patients with tumors stage < T4 or < 5 cm, with body mass index (BMI) < 35, and no previous abdominal surgery, single incision laparoscopic colectomy could be offered to patients as an equally safe and effective alternative compared to multi-port colonic surgery with comparable histological surrogate outcome (EAES Weak recommendation, Level 2)
      • authors note recommendation is based on 3 randomized trials that measured histologic outcomes and included patients with left or right colectomies, sigmoid resections, and low anterior resections with the largest trial not yet able to report results on 5-year disease free survival
      • Reference – Surg Endosc 2019 Apr;33(4):996full-text
  • mobilization of splenic flexure to prepare for colonic anastomosis allows access to colon; surgeon mobilizes splenic flexure by some degree of distal transverse mesocolon transection to mobilize splenic flexure away from spleen(3)
    • transection of ligaments
      • using a medial-to-lateral approach, the patient is placed in maximal reverse Trendelenburg (head up) positioning with right lateral decubitus tilt
      • gastrocolic ligament is transected at Bouchet area and at area level with inferior pole of spleen
      • stomach is reflected cephalad to expose posterior gastric wall and the pancreas
      • mesenteric transection is 1 cm caudal to inferior border of pancreas in order to preserve arterial blood flow and maximize colonic length
      • splenic flexure is transected in medial-to-lateral direction to divide splenocolic ligament and spleno-omental ligament (also called criminal fold of Morgenstern)
      • transection of spleno-omental ligament is important because peritoneal fold is most commonly responsible area for iatrogenic injuries to the splenic lower pole during operation on the left upper quadrant
    • vasculature is ligated prior to mobilization of transverse mesocolon
      • transverse mesocolon is proximally transected along avascular plane between Toldt fasci and Gerota fascia; this creates a meso-colonic window
      • transverse colon can be mobilized to the midline of the peritoneal cavity, and the main branch of the middle colic artery and the marginal artery are preserved
      • first vascular step is division of inferior mesenteric vein (patient’s positioning is shifted to supine position with slight head-down tilt, maintaining rightward rotation); after dissection of the ligament of Treitz and peritoneal leaf overlying the left mesocolon, the exposed inferior mesenteric vein is dissected free, lifted, and divided below the inferior margin of the pancreas
    • second vascular step is division of inferior mesenteric artery
      • patient is placed in extreme Trendelenburg position with rotation to right to expose the sigmoid mesentery root
      • mesenteric-mesocolic ligament of Gruber (a peritoneal fold stretched from the root of the mesentery to the angle of insertion of the sigmoid mesocolon) is typically grasped to create tension on the peritoneum, followed by incision from and over the right iliac vessels to allow access to the intersigmoid recess
      • mesentery is typically scored along its medial aspect either mechanically or with an energy device, and the sigmoid mesentery retracted away from the retroperitoneum
      • in patients with colon cancer, the inferior mesenteric artery is ligated proximal to its origin to remove the entire lymph node cache by transecting the artery flush the aorta
      • in patients with benign diseases, the inferior mesenteric artery may be ligated more distally, which reduces risk of damage to autonomic nerves in area that may lead to urinary and sexual dysfunction
  • colon is mobilized and elevated from peritoneum prior to excision
    • interface between the colonic mesentery and the retroperitoneum should be clearly identified before mobilizing sigmoid colon(3)
    • patient is placed in extreme Trendelenburg position and right sigmoid colon is rotated as colon is slowly mobilized(3)
    • approach for colon mobilization is completed either lateral-to-medial or medial-to-lateral
      • in medial-to-lateral approach surgeon explores, identifies, and divides mesenteric blood vessels proximally before dividing lateral peritoneal attachments
      • in lateral-to-medial approach, surgeon divides lateral peritoneal attachments first, as in open surgery, then explores the medial mesentery and divides identified blood vessels proximally
      • Reference – Int J Colorectal Dis 2019 May;34(5):787
  • diseased part of colon is excised as dissection planes of descending colon and medial-to lateral sigmoid colon are joined(3)
  •  any thickened or diseased mesentery is removed to prepare area for tension-free colonic anastomosis and to prevent devascularization of the colon through distal transection of its mesentery, and provides maximal colonic length for a proper anastomosis
  • colonic anastomosis is generally performed, though in some patients Hartmann procedure may be required
  • intraperitoneal rectal dissection and rectal transection is performed similarly(3)
  • suprapubic or a right lower quadrant mini-laparotomy close to the groin is created by extending the laparoscopic incision(3)
  • left colectomy is completed outside the abdominal cavity including the vascular pedicle(3)
  • vasculature anastomosis is made between superior mesenteric artery and marginal artery brand of inferior mesenteric artery, usually at Griffith point(3)

Hartmann Technique

  • in Hartmann technique, sigmoid colon is resected, rectal stump is closed, and an end colostomy rather than a colonic anastomosis is created (J Visc Surg 2016 Feb;153(1):31full text, Ann R Coll Surg Engl 2018 Apr;100(4):301full-text)
  • loop colostomy, which involves diversion of the colonic contents through a sideways incision in a loop of bowel that is then in a loop outside the colon, is not technically a colon resection and will not be discussed here as it is not routinely used in adult colorectal surgery, although it is sometimes performed after trauma, in low-resource settings, in children for anal atresia, and in situations where a patient is too unstable to tolerate the Hartmann procedure (J Visc Surg 2016 Feb;153(1):31full text, Ethiop J Health Sci 2016 Mar;26(2):117, World J Emerg Surg 2018;13:36, World J Surg 2019 Jan;43(1):169, J Pediatr Surg 2017 May;52(5):783)
  • indications for Hartmann procedure
    • colon or upper rectal cancer
      • patients with stricture or preocclusion in patients without signs of complications such as perforation, parietal guarding, or small bowel incarceration
      • palliative management of patients with serious comorbidities or preexisting anal incontinence
    • diverticular disease, particularly with peritonitis (Hinchey stage IV or Hinchey stage III patients with severe life-threatening sepsis or severe comorbidities, and possibly patients with Hinchey stage II patients for whom drainage is not appropriate)
    • postoperative anastomotic leak
    • ischemic colitis (emergency management) for Favier Class 3 or Class 2 with unfavorable progression
    • sigmoid volvulus in very rare cases
    • abdominal trauma in very rare cases
    • Reference – J Visc Surg 2016 Feb;153(1):31full text, Ann R Coll Surg Engl 2018 Apr;100(4):301full-text
  • lack of combined oral antibiotic and mechanical bowel prep, younger age, and other factors may predict risk of anastomotic leak following colectomy (level 2 [mid-level] evidence)
    •  based on diagnostic cohort without independent validation
    • 38,475 patients who had anastomosis without diversion were evaluated for risk factors to determine risk of anastomotic leak within 30 days of surgery
    • risk factors assessed included age, sex, tobacco use, hematocrit < 30%, diagnosis, bowel prep with and without antibiotic, ASA class, type of surgical approach, operation time, and wound class
    • younger age, male sex, tobacco use, anemia, receipt of neoadjuvant chemotherapy, a diagnostic indication of cancer, bowel preparation other than combined, ASA class III and IV, wound class of III/IV, an open operative approach, and increasing operative time were independent risk factors for anastomotic leak
    •  risk score was constructed so that the greater the number of points on a scale from -10 to +34, the greater the risk of anastomotic leak
    • overall risk of anastomotic leak 3.3% (range 0-25.64%)
    • point system was applied to 3,960 patients who had not had ostomy to identify percentage of patients with an elevated risk of leakage if they had had anastomosis or who might have been at lower risk and could have had an anastomosis rather than diversion
      •  35% (21) of patients with predicted risk of anastomotic leak > 18% had temporary ostomy
      • estimated 56% of patients who had diversion were at lower risk of anastomotic leak than overall patient population
    • authors suggest higher scores may be used to identify patients who would benefit from temporary diversion ostomy
    • Reference – J Gastrointest Surg 2020 Jan;24(1):132full-text

Evidence for Different Techniques

  • laparoscopic left hemicolectomy appears to have lower risk of postsurgical morbidity but may have similar postoperative mortality and overall 5-year survival rate compared to open approach (level 2 [mid-level] evidence)
    • based on retrospective cohort study
    • 564 adults having left hemicolectomy for colorectal cancer were evaluated and matched by propensity score analysis
    • patients had either laparoscopic or open approach based on physician and patient choice
    • all patients with laparoscopic approach had multi-port incisions and all procedures had medial-to-lateral transection
    • patients who had open approach were more likely to have had a prior colorectal surgery (13.7% vs. 5.3%)
    • 1 patient initially receiving laparoscopic approach was converted to open approach due to seeding of tumor in omentum
    • comparing laparoscopic approach vs. open approach
      • postoperative 30-day mortality in 0.6% vs. 0% (not significant)
      • surgical site infection in 2.4% vs. 6.7% (p < 0.001)
      • postoperative morbidity in 9.2% vs. 16.5% (p < 0.001)
      • median postoperative hospital stay 7 days vs. 10 days (p < 0.001)
      • 5-year overall survival 82% vs. 80.3% (not significant)
      • 5-year disease-free survival 72.9% vs. 72.7% (not significant)
    • Reference – Surg Laparosc Endosc Percutan Tech 2020 Dec 4;31(2):196full-text
  • multiport and single-incision laparoscopic colectomy appear to have similar 5-year overall survival and 5-year recurrence-free survival in adults with colon cancer (level 2 [mid-level] evidence)
    • based on follow-up of randomized trial with wide confidence interval
    • 200 adults aged 20-80 years (mean age 67 years) with colon cancer in Japan who were randomized to multiport laparoscopic colectomy vs. single-incision laparoscopic colectomy were followed for 5 years
      • all patients had tumor length ≥ 4 cm
      • tumor location included sigmoid (51.5%), ascending (21%), cecum (12.5%), or rectosigmoid colon (15%)
      • patients who had preoperative treatment (including chemotherapy, radiation therapy, hormone therapy) for colorectal cancer were excluded
    • adjuvant chemotherapy in 18% of patients in multiport laparoscopic colectomy group and in 21% of single-incision laparoscopic colectomy group
    • conversion to open surgery in 2 patients in multiport laparoscopic colectomy and 1 patient in single-incision laparoscopic colectomy
    • median follow-up 61 months
    • 1 patient in multiport laparoscopic colectomy was lost to follow-up
    • comparing multiport laparoscopic colectomy vs. single-incision laparoscopic colectomy
      • 5-year overall survival 95% vs. 93% (hazard ratio for death 1.39, 95% CI 0.44-4.39), not significant but CI includes possibility of benefit or harm
      • 5-year recurrence-free survival 91% vs. 88% (hazard ratio for death 1.37, 95% CI 0.58-3.24), not significant but CI includes possibility of benefit or harm
    • Reference – Ann Surg 2021 Jun 1;273(6):1060
    • postoperative complication rates at 30 days (primary outcome in original trial) can be found in Br J Surg 2016 Sep;103(10):1276 full text
  • approach to surgery may be either medial-to-lateral or lateral-to-medial
    • in medial-to-lateral approach surgeon explores, identifies, and divides mesenteric blood vessels proximally before dividing lateral peritoneal attachments
    • in lateral-to-medial approach, surgeon divides lateral peritoneal attachments first, as in open surgery, then explores the medial mesentery and divides identified blood vessels proximally
    • Reference – Int J Colorectal Dis 2019 May;34(5):787
  • laparoscopic medial-to-lateral approach appears associated with reduced risk of conversion to open surgery and shorter operative time than lateral-to-medial approach for colectomy (level 2 [mid-level] evidence)
    •  based on systematic review of mostly retrospective cohort studies
    • systematic review and meta-analysis of 8 studies (6 retrospective cohort studies and 2 randomized trials) comparing outcomes with laparoscopic medial-to-lateral approach vs. laparoscopic lateral-to-medial approach in 1,477 patients receiving colectomy
    • compared to lateral-to-medial approach, medial-to-lateral approach had
      • lower rate of conversion to open approach in analysis of 8 studies with 1,477 patients (odds ratio [OR] 0.43, 95% CI 0.26-0.72)
      •  shorter procedure time in analysis of 4 studies with 772 patients (mean difference [MD] – 32.25 minutes, 95% CI -53.16 to -11.33 minutes), results limited by significant heterogeneity
      • shorter hospital stay in analysis of 5 studies with 898 patients (MD – 1.54 days, 95% CI -2.79 to -0.29 days), results limited by significant heterogeneity
    • no significant difference in perioperative mortality, overall complications, wound infection, anastomotic leak, bleeding, or number of harvested lymph nodes
    • in subgroup analysis of 192 patients receiving left colectomy in 2 studies (12 patients had left hemicolectomy), medial-to-lateral approach associated with borderline significant reduction in conversion to open surgery (OR 0.25, 95% CI 0.06-1.01)
    • no significant difference in overall complications, anastomotic leak, bleeding, wound infection, or length of stay
    • Reference – Int J Colorectal Dis 2019 May;34(5):787
  • anastomosis
    • intracorporeal technique for anastomosis appears associated with better outcomes than extracorporeal technique for anastomosis in patients receiving left colectomy (level 2 [mid-level] evidence)
      • based on systematic review without meta-analysis
      • systematic review of 5 studies with 459 adults comparing intracorporeal colonic anastomosis with extracorporeal colonic anastomosis included in analysis; 1 of the studies with 114 patients evaluated robotic surgery, 4 studies assessed laparoscopic incision
      • compared to extracorporeal anastomosis, intracorporeal anastomosis associated with
        • reduced risk of conversion to open surgery in 2 of 3 studies for which it was assessed
          • 2% vs. 21% (p < 0.01) in case control study including 181 adults
          • 5.3% vs. 19.3 % (p = 0.03) in retrospective propensity-matched comparison including 114 patients treated with robotic minimally invasive surgery
        • lower risk of complications in 2 of 4 studies for which it was assessed
          • 9.8% vs. 28.1% (p < 0.01) in case-control study of 184 adults
          • 0% vs. 13.9% (p = 0.04) in retrospective cohort with propensity score matching with 72 adults
      • reported complications included surgical site infections, anastomotic leak, and incisional hernia; reporting of specific complications varied across studies, but when reported intracorporeal anastomosis associated with lower rate with exception of anastomotic leak
      • anastomotic leak reportedly higher in 3 of 5 studies reporting result, but difference did not reach statistical significance in any study
      • Reference – J Gastrointest Oncol 2020 Jun;11(3):500full-text
    • stapler and hand-sewn colorectal anastomosis may have similar rates of anastomotic dehiscence, wound infection, and hospital stay, though stapled anastomosis may increase risk of stricture (level 2 [mid-level] evidence)
      •  based on Cochrane review of trials without blinding of outcome assessors
      •  systematic review of 9 randomized trials comparing stapler and hand-sewn colorectal anastomosis in elective surgery in 1,233 adults
      • compared to hand-sewn anastomosis, stapled anastomosis associated with
        • no significant differences in
          •  mortality in analysis of 7 trials with 901 patients
          •  overall dehiscence in analysis of 9 studies with 1,233 patients
          •  clinical anastomotic dehiscence in analysis of 9 studies with 1,233 patients
          •  radiological anastomotic dehiscence in analysis of 6 trials with 825 patients
          •  anastomotic hemorrhage in analysis of 4 trials with 662 patients
          •  wound infection in analysis of 6 trials with 567 patients
          •  hospital stay in 1 trial with 159 patients
        •  increased risk for stricture (odds ratio [OR] 3.59, 95% CI 2.02-6.35) in analysis of 7 trials with 1,042 patients
        •  nonsignificant increase in need for reoperation (OR 1.94, 95% CI 0.95-3.98) in analysis of 3 trials with 544 patients
      •  Reference – Cochrane Database Syst Rev 2012 Feb 15;(2):CD003144
    • right colonic transposition and complete intestinal derotation post extended left colectomy appear to have similar rates of anastomotic leak (level 2 [mid-level] evidence)
      • based on retrospective cohort study
      • 39 patients in a single institution had extended left colectomy including splenic flexure, descending colon, and sigmoid colon
      • 51% of patients had prior left colectomy
      • colonic mobilization at time of anastomosis was right colonic transposition in 29 patients and complete intestinal derotation in 10 patients
        • in right colonic transposition, right colon and right hepatic flexure mobilized to base of right mesocolon and right colon is rotated 180 degrees in sagittal plan and around ileocecal pedicle axis
        • in complete intestinal rotation, transverse colon is detached from viscera so that it can be rotated 180 degrees in a frontal plane and around superior mesenteric vessel axis so that right colon is on left side of abdomen while jejunoileum is on right side
      • choice of procedure was at surgeon’s discretion
      • anastomotic complications in 6.9% of patients receiving right colonic transposition compared to 20% (2 patients) receiving complete intestinal rotation (not significant)
      • 0 patients reported chronic intestinal pain or had rehospitalization for intestinal obstruction at mean follow-up 20 months
      • Reference – Colorectal Dis 2013 Jun;15(6):747
  • see also
    • Colorectal Surgery Considerations
    • Anastomotic Leak
    • Ureteral Injury

Postoperative Considerations

Enhanced Recovery After Surgery (ERAS) Protocols

  • American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommendations for components of ERAS protocol after colon and rectal surgery
    • postoperative interventions
      • early, progressive patient mobilization is associated with shorter length of hospital stay (ASCRS/SAGES Grade 1, Level C)
      • discontinue IV fluids in early postoperative period if no surgical complications or hemodynamic instability (ASCRS/SAGES Grade 1, Level B)
      • ileus prevention
        • offer a regular diet within 24 hours after elective colorectal surgery (ASCRS/SAGES Grade 1, Level B)
        • sham feeding via chewing sugar-free gum for ≥ 10 minutes 3-4 times daily after colorectal surgery is safe, results in small improvements in gastrointestinal recovery, and may be associated with reduced length of hospital stay (ASCRS/SAGES Grade 1, Level B)
        • use alvimopan with open colorectal surgery to hasten recovery (ASCRS/SAGES Grade 1, Level B), but its benefit after minimally invasive surgery is not clear
      • remove urinary catheters, typically,
    • discharge criteria
      • consider discharge from hospital before return of bowel function in select patients (ASCRS/SAGES Grade 2, Level B); consider in patients that have
        • adequate home support
        • close outpatient surveillance
        • ability to tolerate clear liquids in postoperative recovery unit
    • Reference – Surg Endosc 2023 Jan;37(1):5full-text
  • alvimopan is a peripherally acting mu opioid receptor antagonist
    • alvimopan (Entereg) is a peripherally acting mu opioid receptor antagonist which is FDA approved to accelerate restoration of normal bowel function in patients ≥ 18 years old having partial large or small bowel resection surgery
      • for use in hospitalized patients only
      • recommended dose 12 mg orally prior to surgery, then 12 mg orally twice daily for up to 7 days (but ≤ 15 doses maximum)
      • Reference – FDA Press Release 2008 May 20 (updated 2013 Apr 15)

Common Complications

  • colectomy carries risks associated with most colorectal surgeries
    • bowel injury
    • surgical site infection
    • major vessel injury
    • splenic injury
    • urinary dysfunction
    • ureteral injury
    • urinary bladder injury
    • urethral injury
    • sexual dysfunction
    • impaired female sexual fertility
  • see also for additional information
    • Complications in Colorectal Surgery Considerations
    • Prevention and Management of Postoperative Ileus
    • Suspected Surgical Site Infection – Approach to the Patient

Guidelines and Resources

Guidelines

International Guidelines

  • Enhanced Recovery After Surgery/International Association for Surgical Metabolism and Nutrition/European Society for Clinical Nutrition and Metabolism (ERAS/IASMEN/ESPEN) guideline on perioperative care in elective colonic surgery can be found in World J Surg 2013 Feb;37(2):259
  • World Society of Emergency Surgery (WSES) guideline on management of acute colonic diverticulitis in the emergency setting can be found in World J Emerg Surg 2020 May 7;15(1):32full-text

United States Guidelines

United Kingdom Guidelines

  • National Institute for Health and Care Excellence (NICE) guidance on laparoscopic surgery for colorectal cancer can be found at NICE 2006 Aug 23:TA105PDF, evidence reviewed 2010 Feb

European Guidelines

Asian Guidelines

Review Articles

Patient Information

References

General References Used

The references listed below are used in this DynaMed topic primarily to support background information and for guidance where evidence summaries are not felt to be necessary. Most references are incorporated within the text along with the evidence summaries.

  1. Labianca R, Nordlinger B, Beretta GD, et al; ESMO Guidelines Working Group. Early colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013 Oct;24 Suppl 6:vi64-72full-text.
  2. Hall J, Hardiman K, Lee S, et al; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum. 2020 Jun;63(6):728-747, commentary can be found in Dis Colon Rectum 2021 Feb 1;64(2):e41.
  3. Hüscher CGS, Lirici MM, Marks JH, Dapri G, Ancona E. Laparoscopic left colectomy: modern technique based on key anatomical landmarks reported by giants of the past. Minim Invasive Ther Allied Technol. 2021 Feb;30(1):1-11.

Recommendation Grading Systems Used

  • European Society for Medical Oncology (ESMO) grading system for recommendations
    • levels of evidence
      • Level I – evidence obtained from ≥ 1 randomized trial of good methodological quality with low potential for bias or meta-analyses of multiple, well-designed, controlled studies without heterogeneity
      • Level II – evidence obtained from small or large randomized trials with suspicion of bias (lower methodological quality) or meta-analyses of lower quality trials or trials with heterogeneity
      • Level III – evidence obtained from prospective cohort studies
      • Level IV – evidence obtained from retrospective cohort studies or case-control studies
      • Level V – evidence obtained from studies without control group, case reports, or expert opinions
    • grades of recommendation
      • Grade A – strong evidence for efficacy with substantial clinical benefit (strongly recommended)
      • Grade B – strong or moderate evidence for efficacy but with limited clinical benefit (generally recommended)
      • Grade C – insufficient evidence for efficacy or benefit which does not outweigh risk or disadvantages (recommended as optional)
      • Grade D – moderate evidence against efficacy or for adverse outcome (generally not recommended)
      • Grade E – strong evidence against efficacy or for adverse outcome (never recommended)
    •  Reference – ESMO clinical practice guideline on diagnosis, adjuvant treatment, and follow-up for early colon cancer (Ann Oncol 2013 Oct;24 Suppl 6:vi64full-text)
  • World Society of Emergency Surgery (WSES) uses Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system
    • strength of recommendation
      • Strong – desirable effects of an intervention clearly outweigh the undesirable effects, or clearly do not
      • Weak – trade-offs are less certain, either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced
    • quality of evidence
      •  High – further research very unlikely to change confidence in estimate of effect
      •  Moderate – further research likely to have important impact on confidence in estimate of effect and may change estimate
      •  Low – further research very likely to have important impact on confidence in estimate of effect and likely to change estimate
      •  Very low – any estimate of effect is very uncertain
    • Reference – WSES guideline on management of acute colonic diverticulitis in the emergency setting (World J Emerg Surg 2020 May 7;15(1):32full-text)
  • American Society of Colon and Rectal Surgeons (ASCRS) uses Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system
    • strength of recommendation
      • 1 (Strong recommendation) – benefits clearly outweigh risk and burdens or vice versa
      • 2 (Weak recommendation) – benefits closely balanced with risks and burdens
    • quality of evidence
      • Level A – high-quality evidence – randomized controlled trials (RCTs) without important limitations or overwhelming evidence from observational studies
      • Level B – moderate-quality evidence – RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies
      • Level C – low- or very low-quality evidence – observational studies or case series
    • Reference – ASCRS guideline on treatment of left-sided colonic diverticulitis (Dis Colon Rectum 2020 Jun;63(6):728), commentary can be found in Dis Colon Rectum 2021 Feb 1;64(2):e41
  • European Society of Coloproctology (ESCP) uses modified Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 system
    • levels of evidence
      • Level 1 – systematic review of randomized trials or n-of-1 trials
      • Level 2 – randomized trial or observational study with dramatic effect
      • Level 3 – nonrandomized controlled cohort/follow-up study (level may be downgraded based on study quality, imprecision, and indirectness; level may be upgraded if there a large or very large effect size)
      • Level 4 – case series, case-control studies, or historically controlled studies
      • Level 5 – mechanism-based reasoning
    • Reference – ESCP guideline on management of diverticular disease of the colon (Colorectal Dis 2020 Sep;22 Suppl 2:5full-text), explanation of levels of evidence can be found at 2011 OCEBM Levels of Evidence PDF
  • American Society of Colon and Rectal Surgeons/Society of American Gastrointestinal and Endoscopic Surgeons (ASCRS/SAGES) grading system for recommendations
    • strength of recommendation
      •  Grade 1 – strong recommendation – benefits clearly outweigh risks and burdens (or vice versa) for most, if not all, patients
      •  Grade 2 – weak recommendation – benefits and risks closely balanced and/or uncertain
    • quality of evidence
      •  Level A – high-quality evidence – randomized trials without factors that reduce quality of evidence, or well-done observational studies with very large magnitude of effect
      •  Level B – moderate-quality evidence – downgraded randomized trials or upgraded observational studies
      •  Level C – low- or very low-quality evidence – observational studies or case series
    • References
  • European Association for Endoscopic Surgery (EAES) grading system for recommendations
    • strength of recommendation
      • Strong recommendation – desirable effects of intervention clearly outweigh undesirable effects, or clearly do not
      • Weak recommendation – desirable and undesirable effects are closely balanced
      • No recommendation – further research required before any recommendation can be made
    • levels of evidence
      • Level 1
        •  treatment benefits – systematic review of randomized trials or n-of-1 trials
        •  common treatment harms – systematic review of randomized trials, systematic review of nested case-control studies, n-of-1 trial with patient the question is raised about, or observational study with dramatic effect
        •  rare treatment harms – systematic review of randomized trials or n-of-1 trial
      • Level 2
        •  treatment benefits – randomized trial or observational study with dramatic effect
        •  common treatment harms – individual randomized trial or observational study with exceptionally dramatic effect
        •  rare treatment harms – randomized trial
      • Level 3
        •  treatment benefits – nonrandomized controlled cohort/follow-up study
        •  common and rare treatment harms – nonrandomized controlled cohort/follow-up study (postmarketing surveillance) provided there are sufficient numbers to rule out a common harm (for long-term harms the duration of follow-up must be sufficient)
      •  Level 4 – case series, case-control studies, or historically controlled studies
      •  Level 5 – mechanism-based reasoning
    • Reference – EAES consensus statement on single-incision endoscopic surgery (Surg Endosc 2019 Apr;33(4):996full-text)
  • American Society of Health-System Pharmacists/Infectious Disease Society of America/Surgical Infection Society/Society for Healthcare Epidemiology of America (ASHP/IDSA/SIS/SHEA) grading system for recommendations
    • categories of recommendation
      • Category A – based on levels I-III
      • Category B – based on levels IV-VI
      • Category C – based on level VII
    • levels of evidence
      • Level I – evidence from large, well-conducted, randomized controlled clinical trials, or a meta-analysis
      • Level II – evidence from small, well-conducted, randomized controlled clinical trials
      • Level III – evidence from well-conducted cohort studies
      • Level IV – evidence from well-conducted case-control studies
      • Level V – evidence from uncontrolled studies that were not well conducted
      • Level VI – conflicting evidence that tends to favor the recommendation
      • Level VII – expert opinion or data extrapolated from evidence for general principles and other procedures
    •  Reference – ASHP/IDSA/SIS/SHEA clinical practice guideline on antimicrobial prophylaxis in surgery (Am J Health Syst Pharm 2013 Feb 1;70(3):195)

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