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INDICATIONS

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The operation is performed chiefly for tumor of the left colon or a complication of diverticulitis.

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PREOPERATIVE PREPARATION

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Tumors of the left colon are frequently of the stenosing type. Patients with this condition often come to the surgeon with symptoms of impending intestinal obstruction.

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When obstruction is not complete, the bowel can best be prepared over a period of days by oral administration of the appropriate cathartics and a clear liquid diet for the last 48 hours. The frequency with which cathartics and cleansing agents are administered will vary depending upon the amount of obstruction. The level and nature of the obstruction may be confirmed by barium enema; however, colonoscopy allows biopsy for pathologic identification, identification and removal of additional lesions such as polyps, and potential evaluation of the proximal colon. In the presence of total obstruction, a nasogastric tube is passed for decompression and the colon is emptied from below with enemas. Evaluation of the distal colon with colonoscopy is valuable. A virtual colonoscopy may be obtained with special CT imaging to evaluate the proximal colon, although it requires bowel preparation and air insufflation and not an obstruction in patients with near or complete obstruction. A baseline carcinoembryonic antigen (CEA) blood test is obtained. If this and enzymatic liver function tests are elevated, CT or imaging scans of the abdomen and liver may be obtained to evaluate metastatic spread. Perioperative antibiotics are given. A Foley catheter is inserted after induction of anesthesia.

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ANESTHESIA

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General anesthesia is preferred.

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POSITION

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The patient is placed in a comfortable supine position and rotated slightly toward the operator. A slight Trendelenburg position may be used, although it can rarely lead to lower extremity compartment syndrome. If the colon tumor or process is in the lower left colon or sigmoid region, most surgeons will position the patient in a modified lithotomy manner using Allen stirrups supporting the knees and ankles. This will allow for prepping and draping of the rectal region for potential passage of a circular stapling device. The legs are spread and the knees elevated sufficiently to provide this access to the rectum but not so high or wide as to interfere with the abdominal portion of the operation. If there is any doubt as to the location of the tumor, lithotomy position is recommended.

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OPERATIVE PREPARATION

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The skin is prepared in the routine manner.

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INCISION AND EXPOSURE

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The operator stands on the patient’s left side. A liberal midline incision is made centered below the level of the umbilicus. The liver as well as other possible sites for metastasis are explored. The small intestines are then packed away medially with warm, moist packs. A pack is placed toward the pelvis and another along the lateral wall up ...

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