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INDICATIONS

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

PREOPERATIVE PREPARATION

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.

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 24 hours. The frequency with which cathartics and cleansing agents are administered will vary depending on the amount of obstruction. The level and nature of the obstruction may be confirmed by barium enema, but colonoscopy allows biopsy for pathologic identification, tattooing lesions with ink, 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 computed tomography (CT) imaging to evaluate the proximal colon, although this requires bowel preparation and air insufflation and cannot be performed in patients with near or complete obstruction. A baseline carcinoembryonic antigen blood test is obtained. CT scans of the chest, abdomen, and pelvis should be obtained to evaluate metastatic spread. Perioperative antibiotics are given. A Foley catheter is inserted after induction of anesthesia.

ANESTHESIA

General anesthesia is preferred.

POSITION

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 located in the lower left colon or sigmoid region, most surgeons 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, the lithotomy position is recommended.

OPERATIVE PREPARATION

The skin is prepared in routine manner. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

The operator stands on the patient’s left side. A liberal midline incision is made centered below the level of the umbilicus. The liver and other possible sites for metastasis are explored. The small intestine is then packed away medially with warm, moist packs. A pack is ...

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