Hemicolectomy left, open, curative - general and visceral surgery

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

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.

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.

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.

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.

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.

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

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.

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.

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.