Abstract
Surgical resection remains the foundation for curative treatment of colon cancer. A proper oncologic resection comprises: (1) a complete en bloc removal of the tumor along with any extracolonic involvement, (2) clear proximal, distal, and radial margins, and (3) an adequate clearance of loco-regional lymph nodes. The manner in which the resection is performed may vary, e.g., laparoscopic vs. robotic vs. open, but the principles remain the same.
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References
The ASCRS Textbook of Colon and Rectal Surgery. 2nd ed. New York: Springer; 2011.
Basse L, Werner M, Kehlet H. Is urinary drainage necessary during continuous epidural analgesia after colonic resection? Reg Anesth Pain Med. 2000;25(5):498–501. doi:10.1053/rapm.2000.9537.
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Key Operative Steps
Key Operative Steps
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1.
A midline laparotomy incision is made.
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2.
Begin mobilization by separating the sigmoid colon from the retroperitoneum and left pelvic sidewall. Expose the peritoneal reflection leading to the avascular plane that runs from the sigmoid mesentery up to the splenic flexure.
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3.
Once the gonadal vessels and left ureter are identified, then incise the white line of Toldt to separate the lateral attachments of the left colon.
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The mesentery of the sigmoid and left colon can be dissected anterior to Toldt’s fascia.
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5.
Perform takedown of the splenic flexure and visualize the tail of the pancreas.
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6.
The extent of resection will depend on the location of the tumor. For splenic flexure lesions, ligate the left branch of the middle colic artery and left colic artery. For left colon cancers, the left branch of the middle colic, left colic, and first sigmoidal branch are ligated. For sigmoid lesions, the superior hemorrhoidal artery is ligated distal to the takeoff of the left colic artery.
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Divide the mesentery prior to division of the bowel wall to allow for demarcation.
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Perform stapled anastomosis by dividing the mesentery first. Align the bowel walls and create colotomies along the antimesenteric taeniae of the proximal and distal colon. Use a GIA stapler for the anastomosis. Use a TA stapler to divide and close the colon.
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Perform hand-sewn anastomosis in a 1-layer fashion. Align the ends of the colon with Dennis clamps and use interrupted seromuscular sutures to create the anastomosis.
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10.
For distal tumors consider using a circular stapler for the anastomosis.
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Madoff, R.D., Sun, M.Y. (2015). Open Left Colectomy. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_18
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DOI: https://doi.org/10.1007/978-1-4939-1893-5_18
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