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Colon Resection


Medical editor Stein G. Larsen MD
Gastroenterological Surgeon
Oslo University Hospital
Norway

General

The most common resections for colon cancer are:

  • Sigmoid resection
  • Right hemicolectomy
  • Left hemicolectomy

Principles of an open colon resection are shown in the film.

All kinds of colon resections can be performed by laparoscopy when the surgeon is experienced with this technique. Sigmoid resection is the least technically demanding of the procedures.

Sigmoid resection

The sigmoideum is the most common localization for cancer in the colon. Genetically, sigmoideum cancer appears to be similar to cancer on the left side of the colon. Lymphatic spreading occurs along the sigmoideum veins. To remove these, a sigmoideum resection is performed.

The sigmoid, with its mobile mesentery, is usually easy to mobilize. A sigmoideum resection is therefore appropriate as a laparascopic procedure.

Right hemicolectomy

Right-sided colon cancer occurs with half the frequency as cancer in the sigmoid, and is the second most common location for cancer in the colon.

Genetic changes of the cancer cells in the form of microsatellite instability occur relatively frequently. These tumors often have a somewhat better prognosis than cancer without these changes. Lymphatic spreading occurs along the ileocolic veins. To remove the relevant lymphatics, a right-sided hemicolectomy is performed.

Left hemicolectomy

Cancer in the left colon occurs much less frequently than right-sided colon cancer.

Genetically, left-sided colon cancer appears to have more frequent chromosome instability. Lymphatic spreading occurs along the left colica vessels. To remove these, a left-sided hemicolectomy is performed.

Indications

  • Operable colon cancer
  • Palliation of bleeding, colon stenosis or fistulas

Goal

  • Curation
  • Palliation if the patient has relatively long expected survival despite distant metastases

Equipment

  • Laparotomy tray
  • Bookwalters self-retaining retractor
  • Staple instruments: cross-stapling / closing-deviding

Preparation

  • Preoperative bowel emptying is not done, as this does not reduce the frequency of anastomosis leakage or infection.
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis
  • Epidural catheter is inserted for postoperative pain treatment.
  • The patient lies in the supine position on the operation table.
  • The operation is carried out while the patient is under general anesthesia.

Implementation

Sigmoid resection

  • A midline incision is usually made and curves to the right of the navel.
  • The sigmoid vessels are isolated and divided peripheral to the left colic artery.
  • The peritoneum is incised lateral to the descending colon and the bowel is mobilized from the left colon flexure if necessary.
  • The division is made preferably with a stapler (cutting/dividing) which reduces spill of bowel contents.
  • Anastomosis between the descending colon and upper rectum is performed by hand or stapled.
  • The abdomen is rinsed with a cytotoxic solution if there is a possibility for peritoneal surface growth, or there has been peroperative spillage of bowel content.
  • The abdomen is closed.
  • A drain is installed only if there is danger for anastomosis leakage or bleeding

Right hemicolectomy

  • A midline incision is usually made and curves to the right of the navel. Alternatively, a transverse section cranial to the navel through the rectal abdominal muscle is made.
  • The vessels are identified and divided at the base of the transverse mesocolon.
  • The peritoneum is incised laterally to the cecum and ascending colon and the bowel is mobilized from the duodenum.
  • The ileum is divided about 10 cm from the cecum and the transverse colon is divided to the right of the medial colica artery. The division is performed with a closing/dividing stapler which reduces spill of bowel content.
  • Anastomosis between the ileum and transverse colon is made and either sewn by hand or with a stapling instrument.
  • The abdomen is rinsed with a cytotoxic solution if there is a possibility of peritoneal growth or if there is peroperative spillage of bowel content. 
  • The abdomen is closed.
  • A drain is installed only if there is a danger of anastomosis leakage or bleeding.

Left hemicolectomy

  • A midline incision is usually curving to the right of the navel.
  • The base of the mesenterial inferior artery is identified and the left colic and sigmoid arteries are divided.
  • The peritoneum is incised laterally to the descending colon and the bowel is mobilized from the left colic flexure and the omentum is separated form the transverse colon to the median colic artery.
  • The sigmoid colon is mobilized laterally. The division is preferably performed with a closing/dividing stapler which reduces spill of bowel contents.
  • Anastomosis between the transverse colon and sigmoid colon is performed by hand or with a stapling instrument.
  • The abdomen is washed with a cytotoxic solution if there is a possibility of peritoneal growth or if there is peroperative spillage of bowel content. 
  • The abdomen is closed.
  • A drain is installed only if there is a danger of anastomosis leakage or bleeding.

Follow-up

  • The patient is mobilized the evening of the day of the operation, or as soon as possible.
  • The patient can start to drink and eat on the first postoperative day
  • The drain is removed when there is no longer fresh blood, usually on the 2nd-3rd day
  • A bladder catheter is removed on the first postoperative day or when the patient is mobilized.
  • The epidural catheter is removed usually on the 2nd-3rd day and the patient obtains an oral analgesic
  • The patient is discharged after about one week.

Complications

Early

  • In a colon resection, postoperative mortality is rare.
  • Cardiopulmonary complications depend on the patient general health status, operation length and extensiveness. Anastomosis leakage can occur.
  • Postoperative ileus occurs in about 5%.

Delayed

  • Ventral hernias in the abdominal incision can occur.
  • Postoperative ileus is reported in about 5%.
  • For right-sided hemicolectomy, bowel movements are more frequent and the stools at softer. This seldom has clinical significance.

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