Open Subtotal Colectomy: Left Colon and Sigmoid Resection with Colostomy Formation
Hi I’m Dave Berger. I’m a surgeon at Mass General. Today's 4th case is a gentleman who has a colon cancer that appears to be in the distal transverse colon by the splenic flexure. This gentleman unfortunately is a C6 quadriplegic, and so that's going to impact what we do. At present his bowel function is a little difficult; he has a lot of constipation, and in fact, he has to be disimpacted, so this is going to impact on our decision-making tree as to how we move forward. He has a lot of redundant colon, and he was transferred in from an outside hospital where we were told that his tumor was in his hepatic flexure. However, on the CT scan it certainly appears that the tumor is in his splenic flexure. Consequently, that's going to impact on what we do intraoperatively.
The surgery today will be revolving around removing the tumor, but at the same time, trying to address his bowel function. If this is in the transverse colon, more likely than not, I'll proceed with a subtotal colectomy and bring his ileum to his sigmoid colon. That should increase his bowel transit and make things a little bit easier for him. On the other hand, if this tumor is more distal, and this is just a redundant piece of sigmoid going up, then I'll probably remove the tumor and entertain the thought of giving him a colostomy as that will be easier to manage for him and his caregivers. He is rather adamant about not wanting to wear a diaper or lie in stool if he doesn't have to.
So we'll proceed with this operation by opening the midline and establishing where the tumor is. If the tumor is in the transverse colon and I'm going to do a subtotal colectomy, then I'll free the cecum and the ascending colon and take down the hepatic flexure and enter the lesser sac, and that way I can isolate out through to the middle colic artery. I’ll then take the ileocolic artery, the right colic, and the middle colic artery with 2-0 silks, and then I'll take the marginal artery and the ileocolic vessel, so I can free up the colon completely, and then I'll proceed with a side-to-side functional end-to-end anastomosis, which I'll do with two ILA 100 stapling devices, taking the ileum to the sigmoid colon.
If on the other hand I'm going to do a segmental resection - the tumor is more distal - I'll enter the lesser sac, and instead of proceeding to the right, I'll proceed to the patient's left and take down the splenic flexure and then free the descending colon. If I bring up a colostomy, I'll bring it up in the left flank, and I'll bring it through the fascia and then mature it in Brook fashion with six 4-0 vicryls.
Now I've got to come around the corner. Here, take that. And then we’ve got to come through this. Yep, smelling. So here's the right side. Handheld to me please. Okay, hold that with two hands. I got to go right there - yep. Now you’ve got to score over this cause we've got to take this out. It’s omentum and side wall, right? But because it’s struck to the omentum - make a hole there - that needs to be divided. Way up high - slide it up. Scissor, 2-0. Okay. Now have to take all this and bring this way. Alright, now, I got to come around the corner here. See this? It comes this way - yeah this way. Keep moving that up. Let’s just - the sigmoid volvulus is just ridiculous huh? Yeah. That's crazy - okay, open this up a bit. Come this way to here. Yellow to here. And around here - around this way. K - open this up. Turn around the corner. Open this here. Come this way. Okay, so this is this. This goes this way. And this - handheld. See, I don't know which goes to the out. That goes out - so that goes there - right along there. Pull up - with your sponge. Right along there. Push there. Right along there. Right here. Up there. Up higher. K - we need to free that last little bit up there. Pull that over. Take that right there - that - closer to the fat - to the fat. K, so we need to spread your hand. We need to get this out of there, right? You gotta have this on it. That right there. It’s up here.. Up here. Right there. Right there. Right there. Right here. No Teressa - right here. But isn’t that a piece of colon? No. Here - yes. And right there. Suction there Christina. Almost there. K - right there. Right there. Right there. Right here. Right there. Okay - right across here. Right here. Right there. He’s got retro-cranial fibrosis there. Right here - good. Right here. And right here.
Alright - take that out one sec. So we have that up pretty good. Now what we're missing - take this here. And that is just - sucks - and he had surgery back in his kidney, right? So now our question is what do we do. So clearly the volvulus needs to go, right? I mean I can't leave him with that so we could take this down, take all this out, and sew it to here.
Do like a transverse to - but this needs to go. And the alternative of a stoma - well, he doesn’t want a stoma - I talked to him about that. So score right along here. Hold on, it’s right here. Right through here. And then right along there - and then hold the stomach up here - go right - hold the stomach up - go right there. So if we take this, we keep the middle colic, which is right there, see it. We come through here. This free space here, so open this up here. Right along here. Up through here. Better circle back to be honest with you - I may just make an executive decision on that one. Schnitz. Marginal. 2-0? Yeah, that's fine. See the marginal right there? 3-0. Can I have the 100 next? This is free here. It’s all free. Now, you’re coming this way. You’re going to come, and we're going to take the left colic vessels, so score here. Score right down there, see it? Right through this. And right now we’re - we’re on the left - left side of the middle colic. That's her pancreas right there, see it? See that little piece? That's part of the pancreas. So now on this side, score this - just with your hand Christina take that that way. Score this right over here. Straight to there. We just want to score it, right? Alright. Schnitz. This is a little no name branch. 3-0. Yep. Right now, score right off to here. This is the edge of the pancreas, right? See it? And see where we are relative - right, this is all nothing. That’s nothing there. And now we have this vessel - this is nothing. And we got that, right? 2-0. K - hold that up. Now right in through here - get your cautery. There's very little in here now, right? Score there.
Schnitz. This is just a little left colic branch, right? 3-0. Okay, now we gotta keep moving around. It's all free there. And now we’re going to have another. This is where we're going to start to get stuck from his previous surgery, okay? Handheld. Come on out. Christina, if you could just sorta reach under here. You want to be holding up like that. Now score right there. Okay. Right up here. Very little in here, right? Now we’re going to move down again.
Now look - I got out of the way - this is where we're stuck from the - from the colon surgery - I mean the kidney surgery, right? And then we get into this up here. We obviously can't leave in this, right? No. Close that. Slide around this way. So I need you to hold that way - with this hand here - no there and here - here, here. That’s the point of tension, right? Now pull up - get your cautery. Pull up - get your cautery - right here. And right across here. Don’t worry about that. And we’re all stuck, right? Stuck right in there. Alright. Now, he’s got a big open incision on his side.
So now this is up on the vessel - score that. Yep. That’s free out here. This over there. Schnitz. Cut. Okay. And now we have this coming down into this - sheesh, huh? K - right through there. So this should have nothing, right? No, no it’s going to have some vessels in it - sigmoid branches. Kelly. Yep. We’ll leave his - but is there distal stuff or no? Yes, there’s this here, right? So we'll see. We're going to bring it to here. See this goes straight out. So score right here. Score this way. So we’re going to be here, now score - see I think even this bowel is going to be too big. Score right there, but we may be able to do is leave him with this and then come back. Score right there. Pick ups. Close. Okay. I’ll use an ILA 100 again. Cut.
But you were thinking about doing an amosa and a loop or just a colostomy. I’m thinking about doing just a colostomy. I just don't think... He’s got a - this is like the equivalent of a sigmoid volvulus - an unwrapped sigmoid volvulus - probably because of his quadriplegia and what's been going on, but I just don't think - I don't think it's going to be safe. I can't sew to that. It's not going to work - yeah, it's not going to work. We have a bag, which is reversible with another operation, when he’s better. ILA 100 please. So there’s no rectal stuff? So if we did an end - take it, staple it - we wouldn’t have to do a distal - no, you’d just have to get - yep, yep.
Yep. Yep. Do you want the stapler? Hold that over there. It’s a lot of chitlins man. It’s not a good situation for him. It’s not a bad situation - I mean, he’s going to be better off than before we started, judging by his tissue and his liver, and his - really not very good.
Well I don't think it was obstructed because that distal end - that big end is distal - so I doubt he was completely obstructed. So we’ve got - we still got a lot of bowel - you know. Don’t kid yourself. Okay, so we need to go right here. What do you want to call the stuff to me? Left colectomy, sigmoid resection, and we're going to do a end colostomy, and the procedure is going to be sort of of a Hartmann type. Go right there. Yeah. Yep. So this is just simply so that we can mature this - right - without any problems - yeah, I think we’ll bring it right up to the left. I don't think it will get reversed. The possibility is there for sure, but um… That's going to bleed there, so go down.
Yeah he said he didn't want a stoma because he thought it would be messy. I think that. I think it would be easier for him to be honest. And he did say last night - I mean I think he’d rather have a stoma than be like stooling or something. Alright. Kocher. But I think his life and his eating and everything is going to be easier now that we've taken out that - yeah - sort of - and there’s no reason to think that based on a normal colonoscopy there was some distal obstruction that was missed. Well, no - they went right past it on a colonoscopy - right - and you know, I think that that's just the extent of his normal - now we're going to make this higher than usual right cause we want it out of the way when he sits down. So we're going to put it like right up here. Cautery short please. No I want a…
It's amazing how well it's done all you really. All things considered. I mean 1971? Yeah. Kocher - I mean Babcock. Oh less. There’s easily two liters of ascites in there. Easy, but you can call it whatever you like - doesn't matter to me. Do what you want - honest. Number one prolene.
Big bites now right. Yeah but not big bites of the fat. Well don’t say sorry, just - I don’t want the fat. That’s better. I have one yeah. You have 10? Okay. I also think that being quad is a hell of a lot harder than being a para, right? Yeah, I mean there’s quality of life things, there’s also physical activity things you can do - as a para - yeah, there’s ton you can do - well not tons, but there’s stuff to do. No, there’s a lot that you can do, and also for like health purposes, he’s got to keep his ulcers as high as can be. Not everybody does it, but…
So if you guys wanted to take an image of the specimen. We already got it. You did.
Hi it's Dr. Berger. I just want to call to say the surgery is done. We did get the tumor out. We did get all around the tumor. He actually had a fair amount of ascites in his belly and very very dilated sigmoid colon. I ended up doing a colostomy. I didn't think it was safe to put him back together. I don't think he would have healed the anastomosis; I think he would have gotten quite ill. So hopefully this will actually work out better for him from a quality-of-life standpoint too. It is reversible, so we can do something different if necessary, but I don't think he would have tolerated anything else. I'll get in touch with you again. Thank you.
So next case we're going to go tuck as many arms as we can. If we can tuck none, we can tuck none. We're going to do the same thing I did in the first case. Alright. Thanks guys.