Chapter 23. Colectomy

• Colon cancer.
• Colon polyps not amenable to colonoscopic polypectomy.
• Diverticular disease.
• Perforation of the colon for which ostomy is not needed.
• Inflammatory bowel disease.
• Volvulus.
• Stricture.
• Ischemia.
• Bleeding.
• Slow-transit constipation refractory to medical therapy.

• Widely metastatic colon cancer that is nonoperative or requires a palliative ostomy.
• Severe peritonitis requiring diverting ostomy, in which primary anastomosis would have an unacceptable leak rate.
• Hemodynamic instability requiring expeditious ostomy, making primary anastomosis inappropriate.

Expected Benefits

• Treatment of established colon cancer (or prevention of development).
• Relief of functional or mechanical colonic obstruction.
• Treatment (or prevention) of intra-abdominal sepsis secondary to colonic perforation.
• Treatment of colonic bleeding.

Potential Risks

• Bleeding.
• Infection.
• Damage to adjacent structures, including ureter, bowel, spleen, and others.
• Need for further operations.
• Anastomotic leak.
• Need for ostomy.
• Unresectability.
• Recurrence of cancer.
• Cardiopulmonary or other organ failure.
• Death.

• Bookwalter or similar self-retaining abdominal retractor.
• Long instruments.
• Gastrointestinal anastomosis (GIA), linear cutting stapler.
• Linear thoracoabdominal (TA) stapler.
• Intraluminal circular end-to-end anastomosis (CEEA) stapler.
• Laparoscopic equipment if procedure will be performed using laparoscopic techniques, to include:
  • Angled laparoscope.
  • Atraumatic bowel graspers.
  • Laparoscopic GIA staplers.
  • Device for dividing mesenteric vasculature (ie, GIA vascular staple load, LigaSure device, etc).

• Preoperative blood work:
  • Complete blood count to rule out anemia.
  • Type and screen.
  • Carcinoembryonic antigen level.
• Examination of abdomen for prior incisions.
• Full colonoscopy to cecum before elective operation, and tattooing of lesions with permanent ink as appropriate.
• CT scan of abdomen and pelvis with oral and intravenous contrast to evaluate for liver metastasis in patients with cancer.
• Other diagnostic imaging as appropriate.
• Mechanical bowel preparation.
• Deep vein thrombosis prophylaxis with sequential compression devices and consideration of subcutaneous heparin dosing before induction of anesthesia, especially if the patient has been diagnosed with cancer.
• For patients older than 50 years, β-blockade before induction of anesthesia.
• General anesthesia.
• Foley catheter.
• Nasogastric tube.
• Preoperative antibiotics covering skin and bowel flora (eg, second- or third-generation cephalosporin or penicillin derivative).

• The patient should be supine, with the entire abdomen prepared and draped.
• Consider lithotomy position if splenic flexure mobilization may be necessary, and for sigmoid colectomy.

• Laparotomy is performed via a midline incision about the umbilicus.
• The abdomen is explored to palpate the liver for metastasis, visualize peritoneum, examine omentum and lymph nodes, and "run" the bowel. A Bookwalter retractor is placed.
• Figure 23–1: Vascular anatomy of the colon.
  • The superior mesenteric artery (SMA) supplies the cecum, ascending colon, and proximal transverse colon. The SMA divides into the ileocolic artery (ICA), right colic artery (RCA), and middle colic artery (MCA). Note the hepatic (right) and left branches of the middle colic artery.
  • The inferior mesenteric artery (IMA) supplies the distal transverse colon, splenic flexure, descending colon, sigmoid colon, and upper rectum. The IMA divides into the left colic artery (LCA) and the sigmoid artery (SA), and terminates in ...