Colon Resection


Article Author:
Bettina Lieske


Article Editor:
Hira Ahmad


Editors In Chief:
Anantha Padmanabhan
Aakash Gajjar
Burt Cagir


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
1/12/2019 8:42:38 PM

Introduction

 Colon resection is the removal of part or the entire colon, depending on the underlying etiology of the disease that necessitates the removal.[1][2]

Anatomy

The colon derives embryologically from the midgut and hindgut.

It is divided into the cecum, ascending, transverse, descending and sigmoid colon and rectum.

  • Blood supply to the midgut portion (cecum to splenic flexure) derives from the superior mesenteric artery, namely ileocolic artery, right colic artery (inconsistent) and middle colic artery, which further divides into right and left branch.
  • The blood supply to the hindgut portion (splenic flexure to rectum) derives from the inferior mesenteric artery, namely left colic artery, sigmoid branches and superior rectal artery.
  • Superior mesenteric artery and inferior mesenteric artery connect at the splenic flexure via the marginal artery (of Drummond), thus enabling collateral supply.
  • The distal part of the rectum derives additional supply from the internal iliac artery via the pudendal artery which gives rise to the inferior and middle rectal arteries.

Arteries, veins and lymphatic drainage are located in the mesocolon, which during the oncological surgical resections of total mesorectal excision and complete mesocolic excision gets removed in its entirety corresponding to the part of the colon to be removed.

Indications

The commonest indication for surgical resection of the colon is a colorectal malignancy, and the resection should be carried out according to oncological principles:

  • Resection margin 5 cm proximal and distal to tumor for colonic malignancies
  • Circumferential resection margin for rectum, distal margin of 2 cm adequate
  • Remove vasculature and lymphatic drainage at level of origin of primary feeding vessel
  • Thus allowing resection of locoregional lymph node-bearing mesentery for cure and staging
  • The fashioning of a well vascularized and tension-free anastomosis

Contraindications

Colonic resection is classified as major surgery and should not be undertaken if the patient is physically not fit to sustain a major procedure. Reversible and modifiable risk factors should be addressed before surgery, and postoperatively, a patient may require intensive or high dependency facilities.

Equipment

Colonic resection can be carried out via open (laparotomy) or minimal access (laparoscopic, robotic) approaches.

  • The open approach requires a sterile operating theater, an operating table that allows removal of the end segment and sidebars for mounting the attachments to place the patient's legs in a Lloyd Davies position. All instruments can be found in a major laparotomy set, including bowel clamps.
  • The laparoscopic approach in addition to the above set up requires a gas insufflator, display screens, laparoscopic camera, and instruments.
  • For the robotic approach, the robot is required.
  • Equipment for bowel anastomosis would be suture material for a handsewn anastomosis (absorbable braided or monofilament, strength 3/0).
  • Stapled anastomosis would require linear staplers for a side-to-side anastomosis (75 or 100mm in length), or a circular stapling device for an end-to-end anastomosis (diameter 28 mm to 33 mm, depending on patient size).
  • For rectal surgery, a small extra table needs to be prepared with proctoscope, bladder syringe, and lubricant to facilitate rectal washout and anastomosis.

Personnel

Colonic resection requires a full contingent of operating theater personnel (scrub side, anesthesia side, and assistant to position the patient), an anesthetist, and a team of surgeons (at least one operating surgeon and one assistant).

Preparation

Before surgery, the patient should be thoroughly evaluated.[3]

  • The colonic evaluation consists of colonoscopy to assess the disease is necessitating resection, as well as ensuring that the remainder of the colon is normal (e.g., no synchronous tumors) and imaging modalities such as CT, to assess for the distant spread and stage the disease appropriately.
  • Laparoscopic resection for small tumors requires pre-operative marking of the lesion with an endoscopic tattoo to enable intra-operative identification.
  • Rectal cancers in addition to the above require an MRI scan of the rectum and/or an endorectal ultrasound.
  • Prepare the patient pre-operatively according to local protocol. Most institutions will use bowel preparation and give intravenous peri-operative antibiotic prophylaxis.

Technique

Bowel resection can be carried out as an open or laparoscopic procedure; the surgical principles remain the same.[4][5]

The key to adequate resection is the blood supply to the colon. Resection for benign disease does not need to be as extensive, but resection for malignancy should aim to resect the named colonic vessels supplying the cancer-bearing portion of the colon as close to their origin as possible to yield an adequate number of lymph nodes in the colonic mesentery (> 12).

The bowel proximal and distal to the resection has to be mobilized to allow a tension-free anastomosis, and the anastomosis should have a good blood supply. Depending on expertise and equipment available, a bowel anastomosis can be performed hand-sewn or stapled.

For example, a formal right hemicolectomy entails ligation of the ileocolic, right colic (if present) and right branch of the middle colic artery. Proximal bowel division is carried out at the terminal ileum, and distal bowel division at the transverse colon. The anastomosis is conventionally formed as a side-to-side between the terminal ileum and the transverse colon.

Resection of a sigmoid colon tumor entails ligation of the inferior mesenteric artery and inferior mesenteric vein. Proximal bowel division is carried out at the distal descending colon, and distal bowel division at the upper rectum, above the peritoneal reflection. The anastomosis is conventionally formed as an end-to-end between the descending colon and the upper rectum with the help of a circular stapling device inserted via the anal canal.

Complications

Procedure-related complications can be divided into complications encountered during the surgery and post-operative complications.[6][7][8]

Procedural complications include bleeding, most often venous in nature due to the handling of the mesocolon or during dissection of the greater omentum, and rarely from any of the named vessels.

However, an arterial bleed from the named vessels of the colon can be torrential and requires swift action, especially in laparoscopic procedures, where the bleeding can potentially obscure the view if it hits the camera.

Direct pressure where possible to temporarily arrest the bleeding buys time to strategise, reposition, request additional instruments, site further ports, if necessary, and definitively stop the bleed.

Another intra-operative complication is damage to surrounding structures. The structure most at risk is the left ureter. For left-sided surgery, it should always be identified. If an intra-operative injury (diathermy burn, transection) occurs and is recognised immediately, it can be repaired, and a ureteric stent should be placed to reduce the risk of stricture. If the injury is only diagnosed in the post-operative period, management depends on the extent and location of the injury, the general state of the patient and expertise available. A urological specialist should be consulted if available.

Post-operative complications include infections (wound, chest, urinary tract). Early mobilization, physiotherapy, incentive spirometry and removal of urinary catheters can prevent infections. Wound infection risk in clean-contaminated surgery is greatly reduced by giving prophylactic antibiotics within one hour of skin incision.

Anastomotic leak is a dreaded complication for all surgeons performing colonic resection and primary anastomosis. A high index of suspicion is indicated if postoperatively, a patient does not progress as expected, as signs and symptoms can be subtle to start with, especially if the leak is in the pelvis and the patient has a defunctioning stoma. Patients may have pyrexia, tachycardia, cardiac arrhythmias (new onset atrial fibrillation), complain of abdominal pain and bloating, and have a distended, tender, and potentially peritonitic abdomen. Inflammatory markers will be raised more markedly than expected in the post-operative period. Free air under the diaphragm may not be visible on an erect chest x-ray, but CT will show pneumoperitoneum and fluid around the anastomosis. In patients who have undergone anterior resection, it is advised to perform the scan with rectal contrast.

Depending on the severity of the leak and the patient's general state, the management can include all or parts of the following: 

  • antimicrobial therapy, 
  • drainage of pus collections (percutaneously if patient stable and expertise available), and 
  • consideration for a re-look surgical procedure to wash and drain the abdominal cavity, inspect the anastomosis, and either defunction the patient or take the anastomosis apart and bring out the proximal bowel as an end stoma (akin to a Hartmann's procedure).

Clinical Significance

Prerequisites For Good Anastomosis

  • Adequate blood supply: consider patient factors during surgery (functional like blood pressure or inotropes; organic like peripheral vascular disease, calcified vessels, or thrombosis, plaques)
  • Other colonic pathology (diverticulosis, proximal dilatation in obstructed cases)
  • Tension free (adequate length of the bowel, adequate length of the mesentery)  

Adequate length of the colonic conduit for anterior resection:

  • Divide the IMV as high as possible (landmark is the DJ flexure, divide cephalad to last visible tributary, divide the peritoneum taking care not to injure the marginal artery
  • Full mobilization of the splenic flexure. Check that the conduit reaches to the symphysis pubis – then it will reach the pelvis for a colorectal anastomosis
  • Check that the conduit reaches to the symphysis pubis, then it will reach the pelvis for a colorectal anastomosis

Enhancing Healthcare Team Outcomes

While colon resection is done by the surgeon, the monitoring of the patient and preoperative workup is usually done by the anesthesiologist. Both before and after surgery, the nurse plays a vital role in bowel preparation and postoperative monitoring. The patient must have DVT prophylaxis and must be taught how to use the incentive spirometer. Physical therapy is usually consulted for ambulation of the patient in the post-operative period. [9][10]

Evidence-based Outcomes

Today elective colon resections have excellent outcomes. Most patients have a short stay in hospital of about four days. By paying attention to detail, the risk of wound infection is also minimized. Current data indicate that laparoscopic colectomy is as effective as open colectomy in preventing recurrence of cancer. Further, several clinical trials have shown that the risk of seeding is not increased at the port sites.[11] (Level ll)


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Attributed To: Contributed by T. Silappathikaram

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Colon Resection - Questions

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A 52-year-old male has been diagnosed with adenocarcinoma of the ascending colon. Staging scans confirm the location of the tumor and do not show metastatic disease. The patient has no other comorbidities and exercises regularly. He is a nonsmoker. You discuss surgery with him. Which of the following options would you consider the best choice of treatment for him?



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A 72-year-old patient has been diagnosed with adenocarcinoma of the mid-transverse colon. Staging CT scan confirms the location of the tumor and shows no evidence of metastatic disease. The patient has hypertension, which is well controlled on oral antihypertensives and diabetes mellitus, and well controlled on oral antihyperglycemic agents. You are discussing surgery to remove cancer with him. Which of the following options would be the best choice of treatment for him?



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You are performing an anterior resection for an 83-year-old patient with a distal sigmoid colon carcinoma. The patient has been pre-operatively assessed to be of moderate cardiovascular risk. He had an acute myocardial infarct five years prior and has been asymptomatic on treatment since. The surgery is progressing well; you have mobilized the sigmoid and descending colon, divided the inferior mesenteric vein and artery, and have just carried out the distal transection at the upper rectum when you notice that the entire left-sided colon has turned a blueish purple color. On further inspection, you find that the transverse colon looks pink, but there is an abrupt color change at the splenic flexure. What are you going to do now?



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A laparoscopic right hemicolectomy is being performed for a tumor in the ascending colon. Which of the following structures should be actively visualized to avoid inadvertent injury?



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The splenic flexure is being mobilized during a laparoscopic resection for a descending colon cancer. Which of the following anatomical structures will be encountered during this maneuver?



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Colon Resection - References

References

Hiroishi A,Yamada T,Morimoto T,Horikoshi K,Nakajima Y, Three-dimensional computed tomographic angiography with computed tomographic colonography for laparoscopic colorectal surgery. Japanese journal of radiology. 2018 Sep 14     [PubMed]
Cleary RK,Morris AM,Chang GJ,Halverson AL, Controversies in Surgical Oncology: Does the Minimally Invasive Approach for Rectal Cancer Provide Equivalent Oncologic Outcomes Compared with the Open Approach? Annals of surgical oncology. 2018 Sep 5     [PubMed]
Neale JA, Surgical Management of Diverticular Disease in the Elective Setting. Clinics in colon and rectal surgery. 2018 Jul     [PubMed]
Zattoni D,Popeskou GS,Christoforidis D, Left colon resection with transrectal specimen extraction: current status. Techniques in coloproctology. 2018 Jun     [PubMed]
Zhu XL,Yan PJ,Yao L,Liu R,Wu DW,Du BB,Yang KH,Guo TK,Yang XF, Comparison of Short-Term Outcomes Between Robotic-Assisted and Laparoscopic Surgery in Colorectal Cancer. Surgical innovation. 2018 Sep 7     [PubMed]
Špičák J,Kučera M,Suchánková G, Diverticular disease: diagnosis and treatment. Vnitrni lekarstvi. 2018 Summer     [PubMed]
Alhassan N,Yang M,Wong-Chong N,Liberman AS,Charlebois P,Stein B,Fried GM,Lee L, Comparison between conventional colectomy and complete mesocolic excision for colon cancer: a systematic review and pooled analysis : A review of CME versus conventional colectomies. Surgical endoscopy. 2018 Sep 12     [PubMed]
Lasinski AM,Gil L,Kothari AN,Anstadt MJ,Gonzalez RP, Defining Outcomes after Colon Resection in Blunt Trauma: Is Diversion or Primary Anastomosis More Favorable? The American surgeon. 2018 Aug 1     [PubMed]
Trautmann F,Reißfelder C,Pecqueux M,Weitz J,Schmitt J, Evidence-based quality standards improve prognosis in colon cancer care. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2018 Sep     [PubMed]
Fowler KJ,Kaur H,Cash BD,Feig BW,Gage KL,Garcia EM,Hara AK,Herman JM,Kim DH,Lambert DL,Levy AD,Peterson CM,Scheirey CD,Small W Jr,Smith MP,Lalani T,Carucci LR, ACR Appropriateness Criteria{sup}®{/sup} Pretreatment Staging of Colorectal Cancer. Journal of the American College of Radiology : JACR. 2017 May     [PubMed]
McCombie AM,Frizelle F,Bagshaw PF,Frampton CM,Hewett PJ,McMurrick PJ,Rieger N,Solomon MJ,Stevenson AR, The ALCCaS Trial: A Randomized Controlled Trial Comparing Quality of Life Following Laparoscopic Versus Open Colectomy for Colon Cancer. Diseases of the colon and rectum. 2018 Oct     [PubMed]

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