Technical note

Laparoscopic left hemicolectomy with intracorporeal colosigmoid anastomosis:

technical report

Dimitrios Ntourakis MD, PhD 1,2, Stylianos Kykalos MD, MSc, PhD 3, Adamantios Michalinos MD, PhD 2

1. Minimally Invasive Surgery Clinic, Athens Medical Group – Paleo Faliro Clinic, Athens, Greece

2. School of Medicine, European University Cyprus, Nicosia, Cyprus

3. Second Department of Propaedeutic Surgery, "Laiko" General Hospital, National and Kapodistrian

University of Athens, Medical School, Athens, Greece

Corresponding author:

Dimitrios Ntourakis

European University Cyprus School of Medicine

6 Diogenous street, Engomi, 2404, Cyprus

Tel: +35722559410

Fax: +35722713172

Email: dntourakis@hotmail.com

Short title: Laparoscopic left colectomy & intracorporeal anastomosis

Disclosure: The authors do not have any conflict of interest to declare.

This work did not receive any funding

Word count: 1486 words

Abstract

Technique:

The patient is placed in the Lloyd-Davies position with the surgeon and the assistant on the right side.

One optic port, three working and one retracting ports are used. The dissection is medial to lateral with

low ligation of the left colic artery, the left branch of the middle colic artery and the inferior mesenteric

vein. The left colic flexure is mobilized with lateral, medial and coloepiploic dissection. After resection of

the colon with endoscopic staplers, an intraperitoneal side-to-side isoperistaltic stapled anastomosis

between the transverse and sigmoid colon is created. The specimen is removed through a mini

Pfannenstiel incision centered on the suprapubic port. The mesenteric defect is not routinely closed, and

no drain is used.

Results:

All lymph nodes of the left branch of the middle colic artery, left colic artery and inferior mesenteric vein

are harvested. Analgesia is achieved with paracetamol and by an epidural catheter inserted

preoperatively. Flatus is expected on the first postoperative day and bowel movement before the second

postoperative day. The patient is discharged between the third and fourth postoperative day.

Conclusion:

This work presents a comprehensive approach to a totally laparoscopic left hemicolectomy, describing the

technique and presenting a video with commentary.

MESH Keywords:

Colon cancer (C06.405.469.491.307.180), minimally invasive surgical procedures (E04.502), large bowel

resection (E04.210.219), education (I02), video-audio media (V02.970), colorectal surgery

(H02.403.810.208), technical report (V02.935)

Introduction:

Adenocarcinomas of the descending colon and the left colic flexure are resected with a left

hemicolectomy removing the left half of the transverse colon along and the descending colon with

preservation of the sigmoid colon [1]. A laparoscopic left hemicolectomy can achieve good oncologic

outcome in combination while improving the patient’s quality of life [2]. It is, however, more technically

challenging compared to a laparoscopic sigmoidectomy as it requires invariably a large mobilization of the

left colic flexure up to the middle of the transverse colon. In addition, an anastomosis between the

transverse and sigmoid colon may pose difficulties as it cannot be practically constructed with a transanal

circular stapler due to the distance of the anastomotic site from the anus. This technical report describes

a pure laparoscopic left hemicolectomy with construction of an intracorporeal side-to-side anastomosis

and provides a narrated video of the procedure.

Surgical technique:

The patient is placed in the Lloyd-Davies position with the arms tucked along the body and with shoulder

supports. Antithrombotic pneumatic compression devices are used for the lower extremities. Use of a gel

honeycomb mattress helps to stabilize the patient on the operating table and protect against pressure

points.

The surgeon stands on the patient’s right side with the assistant standing left of the surgeon (fig. 1). A

pneumoperitoneum of 12 mmHg is created with the Hasson or Veress technique. Five ports are used: a

10mm optic port over the umbilicus, one 5mm working port in the right flank, one 12mm working port in

the right iliac fossa and two 5mm retracting ports in the suprapubic area and the left flank (fig. 2). After

placing the patient in a steep Trendelemburg position with right tilt, the major omentum is retracted over

the liver and the small bowel is swept towards the right hypochondrium. As such the mesocolons of the

transverse and descending colon are exposed and the inferior mesenteric vein is identified at the

duodenomesenteric fossa (fig. 3).

A medial to lateral dissection of the mesocolon is performed. The sigmoid colon is retracted cephalad with

the use of a grasping forceps passed through the suprapubic port. With this maneuver peritoneal folds are

created at the origin of the inferior mesenteric artery (IMA) and the left colic artery (LCA). The peritoneum

of the left mesocolon is dissected one centimeter away from the aorta and the left colic artery is

skeletonized and controlled (fig. 4). The dissection is continued cephalad, and the inferior mesenteric vein

is controlled just below the inferior border of the pancreas. In order to protect the ureter, the dissection

remains always at the plane of Toldt, in front of the retroperitoneal fascia and Gerota’s fascia [3]. The

sigmoid vessels are dissected and selectively controlled with metallic clips while the superior rectal artery

is preserved (fig. 5). The sigmoid colon is transected with an endoscopic linear stapler of 60mm length,

3.5 mm staple size.

The descending colon is mobilized along the white line of Toldt as high as the lower pole of the spleen. In

tall patients, using the 5mm port of the left flank as a working port helps the surgeon to reach higher. The

left colic flexure can be mobilized with a combination of lateral dissection, medial dissection and

coloepiploic separation. For the coloepiploic separation the major omentum is retracted cephalad while

the transverse colon falls caudally, allowing the section of the coloepiploic attachment and giving access

in the lesser omental bursa (fig. 6). The dissection is pursued towards the spleen, until the left half of the

transverse colon and the left colic flexure are mobilized. With transverse colon retracted cephalad, the left

branch of the middle colic artery is identified at its origin and controlled. Then the transverse colon is

transected with an endoscopic stapler similarly to the sigmoid colon.

An intracorporeal side-to-side isoperistaltic antimesenteric colosigmoid anastomosis is performed. The

transverse colon and sigmoid colon are apposed with stay sutures. Enterotomies are created at the

antimesenteric colic tenias of the transverse colon and of the sigmoid colon. An endoscopic stapler of

45mm length and 3.5mm staple size is introduced through the enterotomies and fired to create the

anastomosis (fig. 7). The enterotomy opening is closed in a single layer with two seromuscular

extramucosal running sutures starting from the two ends of the enterotomy and tied together in the middle

(fig. 8). The mesenteric defect is not routinely closed [4]. The specimen is extracted in a laparoscopic bag

through a mini Pfannenstiel incision of 4 cm centered on the suprapubic port with the added protection of

a laparoscopic wound protector/retractor. No abdominal drainage is used. The specimen is oriented and

marked with sutures indicating the vascular trunks.

Results:

For the postoperative course, the patient is mobilized and allowed oral intake on the evening of surgery.

Analgesia is achieved with paracetamol and by an epidural catheter inserted preoperatively. Flatus is

expected on the first postoperative day and bowel movement before the second postoperative day. The

patient is discharged between the third and fourth postoperative day.

All lymph nodes from the left colic artery the inferior mesenteric vein and the left branch of the middle

colic artery are harvested.

Discussion:

A vaery important technical details of the procedure is the patient’s position on the operating table. In

patients with visceral obesity a very steep Trendelemburg position of 30o and a right tilt is necessary to

retract the major omentum and small bowel out of the operative field. Several means can be used to

avoid the patient slipping out of the table. Shoulder supports can be used but must be padded with gel to

avoid pressure points. The arms should be tucked along the patient’s body as there are reports of

brachial plexus compression during prolonged laparoscopic colectomies from compression of the brachial

plexus at the shoulder [5]. A vacuum mattress can be used to stabilize the patient in place without the use

of shoulder supports in theory reducing the risk of brachial plexus compression [6]. A more economical

alternative is the use of a gel honeycomb mattress. During the procedure it is prudent to check that the

patient’s shoulders and arms are not compressed against the table supports. We have had two cases of

patients with paresis and paresthesia of the right antebrachium and arm due to brachial plexus

compression. In both cases the neuropathy disappeared completely within two weeks of the procedure.

One of the questions often posed is whether the dissection should start from the inferior mesenteric artery

or the inferior mesenteric vein. A recent randomized single blinded clinical trial compared the two

approaches for the laparoscopic resection of sigmoid and rectal cancer. It found that both approaches are

safe and effective but that the inferior mesenteric vein first approach had a higher conversion rate and

increased postoperative bleeding [7]. In the case of laparoscopic left hemicolectomy the left colic artery

must be identified and ligated and as such it is more practical to start the dissection at the level of the

inferior mesenteric artery, completing the most delicate part of the procedure early on. Alternatively, if the

dissection starts from the inferior mesenteric vein, then it can be followed caudally until the origin of the

left colic artery (fig. 4). Our method of choice for vascular control is the application of metallic or self-

locking clips. Nevertheless, it has been demonstrated that bipolar vessel sealing devices can be safely

used for the control of large vessels during laparoscopic colectomies [8].

In a left hemicolectomy, a transanal anastomosis with a circular stapler is not practically feasible. The

options available are to create the anastomosis through a small laparotomy (extracorporeal anastomosis)

or create a side-to-side purely laparoscopic anastomosis (intracorporeal anastomosis). There seem to be

several advantages to an intracorporeal anastomosis with a smaller length of the mini laparotomy incision

and a reduced hospital stay [9]. A meta-analysis comparing intracorporeal with extracorporeal

anastomoses in right hemicolectomies found that the overall complication rate, wound infection rate, time

to first oral intake, length of hospital stay and minilaparotomy size were shorter in patients with

intracorporeal anastomoses [10]. In general, an intracorporeal anastomosis provides superior

visualization, exposure and avoids pulling of the mesocolic vessels during the exteriorization of the bowel

through a small abdominal incision. On the other hand, an intracorporeal anastomosis is more difficult and

requires laparoscopic suturing skills. We find it easier and safer to close the enterotomies used for a

stapled anastomosis with two running sutures starting from opposing ends. In this way there is no risk of

leaving a gap due to poor visualization when the suture line reaches the lower end of the enterotomy.

In conclusion, this work intends to act as a comprehensive approach to a totally laparoscopic left

hemicolectomy with an intracorporeal anastomosis. The technique is described with emphasis on pearls

and pitfalls, along with a narrated video of the procedure to be used as educational material for surgeons

wishing to learn this procedure.

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Figures:

Figure 1: Patient and surgical team setup. S: Surgeon, A: Assistant, N: Scrub nurse.

Figure 2: Port placement.

Figure 3: Retraction of the major omentum and exposure of the tranverse colon & descending colon

mesenteries with visualization of the inferior mesenteric vein (IVC) at the duodenomesenteric fossa.

Figure 4: Dissection of the left colic artery. The black arrow shows the direction of retraction for the

sigmoid colon in order to create mesocolic folds exposing the vessels. IMA: Inferior mesenteric artery,

LCA: Left colic artery, SRA: Superior rectal artery, ST: sigmoid trunk.

Figure 5: Dissection of the sigmoid arteries with preservation of the superior rectal artery. The black arrow

shows the direction of retraction for the sigmoid colon in order to expose the vessels. IMA: inferior

mesenteric artery, LCA: Left colic artery stump, ST: Sigmoid trunk, SA: Sigmoid arteries, SRA: Superior

rectal artery, SRV: Superior rectal vein

Figure 6: Cephalad retraction of the major omentum in order to dissect the colo-epiploic attachment and

expose the lesser omental bursa. This facilitates the transverse colon and the left colic flexure

mobilization.

Figure 7: Intracorporeal stapled side-to-side isoperistaltic antimesenteric colosigmoid anastomosis. The

stapler is introduced through enterotomies in the sigmoid colon and transverse colon antimesenteric

tenias. SC: Sigmoid colon, TC: Transverse colon.

Figure 8: Enterotomy closure. Two running sutures starting from opposing ends are tied in the middle.