Open Left Colectomy for Colon Cancer: Left Colon and Sigmoid Resection with Colostomy Formation
Table of Contents
An open colectomy is the resection of all or part of the colon, typically through a midline incision in the abdomen. This procedure is often indicated for the treatment of colonic diseases such as bowel obstruction, diverticulitis, inflammatory bowel disease, and colon cancer. The patient in this case was a C6 quadriplegic male who presented with colon cancer near the splenic flexure. He also suffered from colonic dysmotility and severe constipation. He was treated with an open left colectomy through an upper midline laparotomy. Regarding the procedure, once the abdomen was entered, the peritoneal cavity was explored, and the tumor was identified. The colon was mobilized, starting with the transverse colon, which was extended laterally to take down the hepatic flexure followed by mobilization of the right colon in a lateral to medial fashion. Next, the splenic flexure was mobilized followed by the descending colon, again in a lateral to medial fashion. Once mobilized, the margins of transection were identified, and the intervening mesocolon was ligated in a cut and tie fashion. The colon was then transected using and ILA stapler to include the distal transverse, descending and proximal sigmoid colon. Finally, the proximal cut end of the transverse colon was brought up through a left-sided end colostomy. In this video, the key steps of the procedure are demonstrated, and we provide analysis regarding our intraoperative decision making.
Colon cancer is a malignant process involving the epithelial lining of the colon. It is the third most common cancer in the world, accounting for approximately 9% of new cancer diagnoses.1 The incidence of colon cancer is geographically variable, suggesting that both genetic and lifestyle factors contribute to the development of disease. Western Africa has the lowest incidence, with a rate of 3-4 cases per 100,000 persons per year, whereas North America has an annual incidence of 26 per 100,000 persons.2 In addition, colon cancer represents the fourth most common cause of cancer-related death with over 700,000 cases annually.3 Taken together, this condition represents a major global health issue for both developed and developing nations.
Risk factors for colon cancer include age, environmental factors, and genetic predisposition. The median age of diagnosis is 67 years for men and 71 years for women.4 While the advent of regular screening colonoscopy has helped to reduce the incidence of colon cancers in patients greater than 50 years old, there has been a doubling in the incidence of colon cancer amongst younger patients, primarily aged 40-49, over the last several decades.5 The rise in incidence in younger populations is likely associated with increasing rates of obesity, sedentary lifestyle, Western diet, metabolic syndrome, as well as alcohol and tobacco use. These observations have been similarly observed in other industrialized countries. Finally, familial studies indicate that up to 30% of colon cancers are related to an inherited form of disease, and approximately 5% of cases are linked to highly penetrant colorectal cancer syndromes including familial adenomatous polyposis (FAP), Lynch syndrome, and hamartomatous conditions.6
Surgical resection remains the only curative therapy for colon cancer. Once a diagnosis is established, most commonly through screening colonscopy, patients are fully staged using the American Joint Committee on Cancer (AJCC) TNM system. For patients with localized or regional disease, colectomy with a yield of at least 12 lymph nodes is the standard of care. Adjuvant chemotherapy is considered for patients with high risk features or positive node status. Finally, for patients presenting with metastatic disease, the majority of these cases are considered incurable and patients are treated with palliative chemotherapy. Survival for colon cancer has significantly improved with better surgical techniques and chemotherapy regimens. The average 5-year-survival rate for early stage disease is greater than 90%; involvement of lymph nodes reduces this to approximately 70%, and metastatic disease is still associated with a dismal prognosis with less than 15% of patients surviving beyond 5 years.7
In this video, we perform an open left colectomy on a 65-year old patient who presented with a large bowel obstruction secondary to tumor. In this procedure, the colon is mobilized bilaterally, including takedown of both the hepatic and splenic flexures. The distal transverse, descending, and proximal sigmoid colon are resected and an end colostomy is created. Therefore, this procedure adequately resects the diseased portion of the colon, effectively treating this condition.
The patient is a 63-year old male with quadriplegia after a traumatic C6 cord injury who presented to an outside hospital with new onset nausea, vomiting, and obstipation. His workup included an abdominal CT scan with evidence of an obstructing mass in the transverse colon. He was clinically stable and was transferred to the Massachusetts General Hospital for further care. His medical history is notable for chronic constipation, recurrent decubitus ulcers treated with multiple operations, including a Girdlestone procedure, and recurrent pyelonephritis secondary to kidney stones status post lithotripsy and left-sided percutaneous nephrostomy tube placement. He has an American Society of Anaesthesiologist score (ASA) of 3 and his body mass index (BMI) is 25. Given that he was obstructed, the patient was taken directly to the operating room for definitive treatment.
The patient had an unremarkable physical exam. In the office, he presented in a wheelchair and was in no apparent distress with normal vitals. He had a normal habitus. His abdominal exam was significant for prior surgical scars, no evidence of hernias, and no tenderness to palpation. His abdomen was distended but soft.
Figure 1: Abdominal and pelvic CT scans CT scan of the abdomen and pelvis with intravenous and oral contrast showing evidence of an obstructing transverse colon mass. The diseased tissue is shown (A) axial, (B) coronal, and (C) sagittal views. Yellow arrows point towards the diseased segment of the colon.
Multiple pathogenic mechanisms have been implicated in the development of colon cancer. For the majority of patients, a stepwise sequence of genetic and epigenetic alterations in colonic epithelia leads to development of benign polyp neoplasms that can progress to invasive carcinoma over a period of years, as initially described by Vogelstein et al.8 Genetic alterations have been shown to occur in three main mechanisms, including chromosomal instability, microsatellite instability, and CpG island methylation.9 In addition, a subset of patients may develop colon cancer secondary to significant chronic inflammation that can incur dysplastic changes without polyp formation, typically in individuals with ulcerative colitis or Crohn’s colitis. Similarly, individuals with Lynch syndrome, a germline condition resulting in microsatellite instability, will develop colon cancers without polyp formation. Once an invasive cancer has developed, malignant cells invade and disrupt surrounding tissues and can spread to distant sites via lymphatic, perineural, and hematogenous invasion.
For patients with localized, regional metastatic, or certain instances of oligometastatic colon cancer, surgical resection remains the only potential curative therapy. Nonetheless, the patient should discuss the risks and benefits of an operation with their surgeon. Adjuvant chemotherapy is frequently indicated for disease with aggressive features or disease that has spread to lymph nodes or distant organ sites. However, chemotherapy alone cannot cure this condition.
In general, the goal of surgical resection is complete extirpation of malignant tissue, thus a curative intent.
There can be certain instances in which the cancer has spread to distant sites though a complication with the primary tumor has occurred, including significant bleeding, perforation, or obstruction. In these situations, a surgeon may decide to operate as an acute life-saving intervention without a goal of disease clearance. In this video, the patient presented with a complication, a large bowel obstruction, but fortunately did not have evidence of metastatic disease.
As we have shown in this video, the main procedural steps for this operation are as follows: (1) perform midline laparotomy and survey the peritoneal cavity, (2) mobilize the transverse colon via take-down of the gastrocolic ligament and entry into the lesser sac, (3) hepatic flexure takedown and lateral to medial mobilization of the ascending colon, (4) splenic flexure takedown and lateral to medial mobilization of the descending and sigmoid colon, (5) identify margins of resection and ligate intervening mesocolon, (6) transect the colon using an ILA-100 stapler, and (7) create an end colostomy in a brooked fashion. This approach to an open colectomy results in extensive mobilization of the entire colon, allowing a large resection and a subsequent tension-free end colostomy on the left-side of the abdomen. The middle colic artery is preserved, ensuring adequate blood supply to the remaining, distal transverse colon.
For colon cancer surgery, the extent of nodal yield and mesocolic excision remains an area of open debate. Le Voyer et al. previously showed that the number of lymph nodes analyzed in colon cancer specimens was associated with survival.10 Consequently, current guidelines recommend that a minimum of 12 lymph nodes be resected with the cancer specimen for adequate staging. The reason for why a higher nodal yield is linked to better survival outcomes is not fully understood. Stage migration, in which cancers are upstaged with higher nodal yields as the likelihood of finding a positive node increases, is thought to contribute to a certain extent.11 However, it has also been proposed that a more extensive mesocolic excision provides a more adequate extirpation of regional micrometastatic disease.12 In support of this reasoning, multiple studies have shown that extensive mesocolic excision is associated with improved disease-free and overall survival rates amongst colon cancer patients.13, 14 In this video, the mesocolon was taken close to the vascular takeoffs to provide a larger mesocolic specimen.
Going forward, there will continue to be improvements in non-surgical treatments for colon cancer. With improved rates of screening colonoscopy, earlier detection and endoscopic polypectomy have been shown to be sufficient for the treatment of very early cancers, obviating the need for an operation in a subset of individuals.15 Systemic therapies have also undergone significant evolution and improvement. Newly designed targeted therapies against vascular endothelial growth factor (VEGF), epidermal growth factor receptor (EGFR), and components of the KRAS pathway might have added benefit to current chemotherapy regimens and are undergoing clinical investigation.16, 17 Finally, the recent development of immunotherapy might have promise for the subset of colon cancers defined by microsatellite instability.18
Operative time: 90 minutes
Estimated blood loss: 400 mL
Fluids: 4600 mL crystalloid
Length of Stay: Discharged from hospital to home with visiting nursing assistance on postoperative day 9
Morbidity: no complications
Final pathology: pT4aN2bM0, 8 of 17 positive nodes, histology: poorly differentiated with lymphovascular invasion, surgical margins all negative
- 10-blade scalpel
- Debakey forceps
- Abdominal wall hand-held retractor
- Schnidt clamp
- 3-0 and 2-0 silk ties for ligation of mesentery
- Metzenbaum scissors
- 100mm blue load ILA stapler
- 4-0 vicryl for maturing colostomy
- 1-0 Prolene suture for fascial closer
- Skin stapler
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
We would like to thank Theresa Kim, MD for assisting in this operation.
- Mattiuzzi C, Sanchis-Gomar F, Lippi G. Concise update on colorectal cancer epidemiology. Ann Transl Med 2019;7:609. https://doi.org/10.21037/atm.2019.07.91
- Kuipers EJ, Grady WM, Lieberman D, Seufferlein T, Sung JJ, Boelens PG, van de Velde CJ, Watanabe T. Colorectal cancer. Nat Rev Dis Primers 2015;1:15065. https://doi.org/10.1038/nrdp.2015.65
- Mortality GBD, Causes of Death C. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385:117-71. https://doi.org/10.1016/S0140-6736(14)61682-2
- Siegel R, Desantis C, Jemal A. Colorectal cancer statistics, 2014. CA Cancer J Clin 2014;64:104-17. https://doi.org/10.3322/caac.21220
- Stoffel EM, Murphy CC. Epidemiology and Mechanisms of the Increasing Incidence of Colon and Rectal Cancers in Young Adults. Gastroenterology 2020;158:341-53. https://doi.org/10.1053/j.gastro.2019.07.055
- Jasperson KW, Tuohy TM, Neklason DW, Burt RW. Hereditary and familial colon cancer. Gastroenterology 2010;138:2044-58. https://doi.org/10.1053/j.gastro.2010.01.054
- DeSantis CE, Lin CC, Mariotto AB, Siegel RL, Stein KD, Kramer JL, Alteri R, Robbins AS, Jemal A. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin 2014;64:252-71. https://doi.org/10.3322/caac.21235
- Vogelstein B, Fearon ER, Hamilton SR, Kern SE, Preisinger AC, Leppert M, Nakamura Y, White R, Smits AM, Bos JL. Genetic alterations during colorectal-tumor development. N Engl J Med 1988;319:525-32. https://doi.org/10.1056/NEJM198809013190901
- Erstad DJ, Tumusiime G, Cusack JC, Jr. Prognostic and Predictive Biomarkers in Colorectal Cancer: Implications for the Clinical Surgeon. Ann Surg Oncol 2015;22:3433-50. https://doi.org/10.1245/s10434-015-4706-x
- Le Voyer TE, Sigurdson ER, Hanlon AL, Mayer RJ, Macdonald JS, Catalano PJ, Haller DG. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 2003;21:2912-9. https://doi.org/10.1200/JCO.2003.05.062
- Kim YW, Kim NK, Min BS, Lee KY, Sohn SK, Cho CH. The influence of the number of retrieved lymph nodes on staging and survival in patients with stage II and III rectal cancer undergoing tumor-specific mesorectal excision. Ann Surg 2009;249:965-72. https://doi.org/10.1097/SLA.0b013e3181a6cc25
- Rahbari NN, Bork U, Motschall E, Thorlund K, Buchler MW, Koch M, Weitz J. Molecular detection of tumor cells in regional lymph nodes is associated with disease recurrence and poor survival in node-negative colorectal cancer: a systematic review and meta-analysis. J Clin Oncol 2012;30:60-70. https://doi.org/10.1200/JCO.2011.36.9504
- Bertelsen CA, Neuenschwander AU, Jansen JE, Wilhelmsen M, Kirkegaard-Klitbo A, Tenma JR, Bols B, Ingeholm P, Rasmussen LA, Jepsen LV, Iversen ER, Kristensen B, Gogenur I, Danish Colorectal Cancer G. Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study. Lancet Oncol 2015;16:161-8. https://doi.org/10.1016/s1470-2045(14)71168-4
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Table of Contents
- Midline abdominal incision
- Entry to the Lesser Sac and Splenic/Hepatic Flexure Take Down
- Division of Mesenteric Vessels
- Mobilization of Volvulus
- Division of Distal Colonic Margin
- Division of Proximal Colonic Margin
- Removal of Specimen and Hemostasis
- Removal of Specimen and Hemostasis
- Mobilization to Allow for Stoma Maturation
- Identification of Stoma Site in LUQ
- Creation of Stoma
- Abdominal Fascia closed with #1 Running Prolene
- Skin closed with Staples
- Colostomy Maturation and Ostomy Bag Fixation
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.