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Tumor in the left colic flexure


Medical editor Arild Nesbakken MD
Gastroenterological Surgeon
Oslo University Hospital
Norway

General

For cancer in the left colic flexure both the middle and left colic arteries have to be divided centrally. 

As a minimum, the intestine on the right side of the transverse colon to the transition descending colon/sigmoid is resected. In emergencies, and possibly in those cases where the transverse/sigmoid anastomosis does not fall nicely, the entire right colon is removed and an ileo/sigmoid anastomosis is performed.


Equipment

  • Laparotomy- or laparascopic equipment

Preparation

Bowel emptying is not necessary.

Patient preparation:

  • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addtition should have oral antibiotics from the day before the surgery.
  • thrombosis prophylaxis with low molecular weight heparin.

During the surgery it is inserted:

  • epidural catheter for pain management.
  • urinary catheter.
  • naso-gastric tube which is removed by the end of the surgery.

Implementation

There are two alternative methods:

  • At emergency surgery of ileus/perforation an extended right-sided hemicolectomy is performed in addition to resection of the intestinal segment  around  the left colic flexure to the lower part of the descending colon.
  • At elective surgery one is dividing distally in the same level, but cecum ascending colon and the right part of transverse colon may be retained if the bowel is released and a good anastomosis without any tensioning is performed.

In both cases a standard lymph node resection is performed.

Colica media is divided centrally and colica sinistra is divided by mesenterica inferior.



Follow-up

    • The patient is mobilized in the evening the day of surgery, or possibly the next day.
    • The patient can carefully start to drink and eat on the first postoperative day.
    • The urinary catheter is removed on the first postoperative day or when the patient is mobilized.
    • The epidural catheter is usually removed on the continues on peroral analgetics.

    Complications

    • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarction and arrythmias and dysrhythmia may occur. Basal atelectasis and/or pleural fluid and possibly pneumonia are more common.
    • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvic infections, diffuse or localized, are rare in the absence of anastomosic leakage.
    • Intraabdominal bleeding, including bleeding from anastomosis is relatively rare.
    • After open surgery wound dehiscence and infection in the abdominal wound occur to varying degrees, from light superficial infection to abdominal wall abscess.
    • Paralytic ileus is common in the presence of another complication, but can also appear without any specific cause.
    • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
    • Port-site hernia occurs after a laparoscopy.
    • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
    • Urinary retention.

    Late complications

    • Ventral hernia in the abdominal wound may occur.
    • Postoperative ileus occurs in about 5%.

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