Hemicolectomy left, open, curative

  1. Surgically relevant anatomy
  2. Transverse colon
  3. Descending colon
  4. Sigmoid colon

  • Prof. Dr. med. Gebhard Reiss

    Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Surgically relevant anatomy

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    • Left lateral transverse colon up to the splenic flexure
    • Descending colon
    • Sigmoid colon
      Rectum

  • Transverse colon

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    • Location: Intraperitoneal; mobile fixation via its own mesentery - transverse mesocolon.
    • Identification: By the so-called
      taeniae = taeniae coli = condensations of longitudinal muscle fibers named according to their anatomical relations as
    • taenia libera (inferior)
    • taenia omentalis (greater omentum)
    • taenia mesocolica (transverse mesocolon)
    • omental appendices = fat-filled tunica serosa
    • Haustra of colon = haustrae coli = visible sacculations in the wall of the colon wall by the arrangement of the circular muscle fibers (plicae semilunares; evident on endoscopy) which are discernible on the outer wall as crescentic folds

  • Descending colon

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    • Definition: That segment of the colon between the splenic flexure (flexura coli sinistra) and the sigmoid colon.
    • Synonym: Colon descendens
    • Location: Secondarily retroperitoneal; connective tissue attachment of posterior wall with the left kidney as well as with the muscular aponeuroses of the quadratus lumborum and transversus abdominis.
    • Identification: As in transverse colon, but : Cross section of the descending colon smaller than that of the ascending colon!

  • Sigmoid colon

    • Synonym: Colon sigmoideum
    • Location: Between the descending colon and rectum, where it is fixed by connective tissue to the retroperitoneum and left ilium; strictly intraperitoneal; differs in course and length, usually 40cm long.
    • Identification: By the taeniae (see above) which gently peter out superior to the rectum.
  1. Indications
  2. Contraindications
  3. Preoperative diagnostic work-up
  4. Special preparation
  5. Informed consent
  6. Anesthesia
  7. Positioning
  8. Operating room setup
  9. Special instruments and fixation systems
  10. Postoperative management

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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  1. Laparotomy
  2. Exploration
  3. Determining the proximal resection margin
  4. Mobilizing the descending colon and sigmoid
  5. Entering the omental bursa
  6. Dividing the greater omentum off the stomach
  7. Transecting the greater omentum
  8. Freeing the splenic flexure
  9. Dividing the left colic vein
  10. Dividing the left colic artery
  11. Dividing the mesocolon
  12. Transecting the colon
  13. Anastomosing the colon
  14. Drainage and wound closure
date of publication: 06.02.2012

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  • Laparotomy

    86-6

    Median laparotomy with the incision passing the umbilicus on the left. Transect the subcutaneous tissue and fascia with diathermy.

  • Exploration

    86-7

    Insert a circular wound edge protector followed by a retractor. Assess tumor size and location. The tumor is palpable just inferior to the splenic flexure. Explore the abdomen to rule out metastases.

  • Determining the proximal resection margin

    86-8

    The upstream resection margin depends on the size and location of the tumor. After identifying the medial colic artery encircle the transverse colon slightly downstream of the artery. Because of the advanced age and distant tumor in the present case, this structure will not be included in the resection.

  • Mobilizing the descending colon and sigmoid

    86-9

    The small intestine is retractedto the right and the descending colon and sigmoid freed from their lateral attachments. The plane of dissection must leave the peritoneal reflection at the level of the tumor, since the tumor appears to break through the serosa.

  • Entering the omental bursa

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    Open the lesser peritoneal sac by dividing the greater omentum off the transverse colon to the left of the planned margin of resection. In order to mobilize the splenic flexure, divide the splenocolic ligament between clamps.

    Note: The omental bursa may also be opened by dividing the gastrocolic ligament superior to the colon to the left of the proximal resection margin.

  • Dividing the greater omentum off the stomach

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    Take down the greater omentum and gastroepiploic arcade off the stomach.

    Note: It is not mandatory to take down the gastroepiploic arcade in left hemicolectomy, but here it is done for reasons of radicality.

  • Transecting the greater omentum

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    Split the greater omentum between Overholt forceps from its free margin toward the proximal resection margin.

  • Freeing the splenic flexure

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    After first dividing the adhesions with the spleen, the attachment of the splenic flexure may usually be divided without any more ligatures. Continue this incision mediad to the lower aspect of the pancreas.

  • Dividing the left colic vein

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    Identify the primary vessels. Since it is not planned to divide the inferior mesenteric artery and vein close to their origin, thereby sparing the blood supply of the sigmoid colon, free the duodenum from the mesocolon and expose the inferior mesenteric vein. Then expose and divide the left colic vein close to its origin.

  • Dividing the left colic artery

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    Expose the left colic artery Determine the distal resection margin in the middle of the sigmoid.. Divide the mesentery step by step while including in the resection as much of the lymphatics as possible. First dissect and and divide the lymph nodes down to the trunk of the left colic artery. Divide the left colic artery while sparing the superior rectal artery.

  • Dividing the mesocolon

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  • Transecting the colon

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  • Anastomosing the colon

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  • Drainage and wound closure

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  1. Intraoperative complications
  2. Postoperative complications

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  • Intraoperative complications

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  • Postoperative complications

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  1. Literature summary
  2. Ongoing trials on this topic
  3. References on this topic
  4. Reviews
  5. Guidelines
  6. literature search

  • Edith Leisten

    MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Reviews

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  • Guidelines

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  • literature search

    Literature search under: http://www.pubmed.com