Introduction

After the first realization in 1991 by Jacobs et al. (1)of a left colectomy performed by a mini-invasive ap-proach, laparoscopic colo-rectal surgery has been in-creasingly accepted and performed in several surgical cen-ters.

Initially performed for selected benign conditions, es-pecially colon diverticulitis, in the last ten years indica-tions has been extended to many other surgical entities,

either benign or malignant. Several controlled prospec-tive randomized studies (2-4) have confirmed the safe-ty and the oncologic appropriateness of the laparoscopicsurgery also in patients with colo-rectal cancer.

Data from the American Board of colo-rectal sur-gery published in 2006 (5) show the trend of per-formance of laparoscopic colo-rectal surgery in teach-ing programs. In 2005 almost 50% of surgical patientswith diverticulitis or colon cancer have been operatedon with the laparoscopic approach in institutions witha fellowship programs for colo-rectal surgery, a ratewhich is ten times higher when compared to data col-lected in 1994 in the same centers. The relative rate oflaparoscopic resections versus total number of resections(laparoscopic and open procedures) for cancer in thesame period of time has exactly increased from 5.6%in 1994 to 41.1% in 2005.

Mortality and morbidity of laparoscopic colo-rectalsurgery have been largely investigated. In various stud-

SUMMARY: Laparoscopic left colectomy: from the perfect knowledgeof surgical anatomy to the proper surgical technique.

R. VECCHIO, V. GELARDI, G. ALONGI, E. SWEHLI, S. VICARI, S. MARCHESE, E. INTAGLIATA

Laparoscopic colo-rectal surgery has been increasingly accepted andperformed in several surgical centres.

However, there are still concerns about the intra-operative risksand therefore on the safety of the procedure especially during the lear-ning curve. As a matter of fact, in approximately one third of laparo-scopic colo-rectal procedures, an intra-operative complication, mainlybleeding or iatrogenic injuries, may occur.

In this paper, according to our experience, we analyse step by stepthe surgical technique of the laparoscopic left colectomy and evaluatethe technical difficulties and complications in order to avoid them.

RIASSUNTO: Colectomia sinistra laparoscopica: dalla perfetta co-noscenza dell’anatomia alla pura tecnica chirurgica.

R. VECCHIO, V. GELARDI, G. ALONGI, E. SWEHLI, S. VICARI, S. MARCHESE, E. INTAGLIATA

La chirurgia laparoscopica del colon-retto si è di recente largamen-te diffusa in numerosi centri chirurgici.

Tuttavia, specie nella fase di apprendimento della procedura, rischie complicanze intraoperatori rappresentano un problema non infre-quente e molto dibattuto. Infatti, in circa un terzo delle procedure la-paroscopiche del colon-retto si può verificare una complicanza intrao-peratoria, consistente principalmente in emorragie o lesioni iatrogene.

In questo lavoro viene analizzata la nostra esperienza e vengono ri-ferite le fasi della tecnica chirurgica, al fine di evidenziare le difficoltàtecniche dell’intervento nell’ottica di ridurre le complicanze ad esse cor-relate.

KEY WORDS: Laparoscopy - Left colectomy - Surgical technique.Laparoscopia - Colectomia sinistra - Tecnica chirurgica.

Laparoscopic left colectomy: from the perfect knowledge of surgical anatomy to the proper surgical technique

R. VECCHIO, V. GELARDI, G. ALONGI, E. SWEHLI, S. VICARI, S. MARCHESE, E. INTAGLIATA

G Chir Vol. 31 - n. 5 - pp. 257-262Maggio 2010

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University of Catania, ItalyDepartment of Surgery Laparoscopic Surgery Unit

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ies of the literature, mortality following laparoscopic colo-rectal surgery ranges from 0 up to 1.8% and it is com-parable to open surgery (2-4, 6-13). Post-operative com-plications in laparoscopic surgery vary from 0 to 44.3%and their incidence is, at least, not higher than in opensurgery. Reviewing the literature (2-4, 6-15) in series com-paring laparoscopic and open surgery we notice in la-paroscopic cases an overall morbidity rate of 20%, where-as in open cases morbidity was 22.6%.

Although mortality and post-operative morbidity inlaparoscopic surgery are favorable compared to open ap-proach, the large and fast diffusion of the laparoscopicsurgery in colo-rectal diseases has raised concerns, how-ever, about the intra-operative risks and therefore on thesafety of the procedure especially during the learningcurve. Intra-operative accidents while performing la-paroscopic colo-rectal surgery are usually not reportedin the literature. When rates and reasons (16) for con-version to open surgery are analyzed, it is evident thatin 12.7-27.2% of cases troubles requiring conversion canoccur and in approximately one third of these cases anintra-operative complication, mainly bleeding or iatro-genic injuries, has occurred.

In this paper, according to our experience, we ana-lyze step by step the surgical technique of the laparoscopicleft colectomy and discuss some technical details in or-der to find out where risks and complication during sur-gery can occur and how to avoid them.

Risks and complications duringligation of inferior mesenteric vein and dissection of splenic flexure

The first step of left hemicolectomy is dissection andtying of the inferior mesenteric vein and mobilizationof splenic flexure. This step is essential to construct a fur-ther colo-rectal anastomosis without any tension, there-fore lowering risks associated with the anastomosis itself,like leaking or stenosis.

During this initial step of the operation potential com-plications are colic perforations, lesions to the colic vas-cular arcade, spleno-pancreatic injuries, lesions to the leftureter and gonadal vessels.

The knowledge of the anatomy is essential to avoidtroubles during this step of surgery.

The venous drainage of the left colon and rectum isanatomically more constant than the arterial supply. Thevenous blood from the colon and upper and middle rec-tum drains through the portal system, while the veinsof the lower rectum merge to the systemic circulationthrough the iliac system. The inferior mesenteric vein aris-es as superior rectal vein and receives blood from the sig-moid veins and the left colic vein. It drains into the splenic

vein and sometimes into the superior mesenteric vein pri-or to merging into the portal system. The middle rec-tal vein and the inferior rectal vein drain into the systemiccirculation through the internal pudendal and internaliliac veins.

The anatomy of the colon varies greatly as far as courseand relationships are concerned (17). The left colon inthe left upper quadrant of the abdomen is attached tothe diaphragm at the level of the tenth and eleventh ribsby the phrenocolic ligaments. The distal part of the trans-verse colon lies usually in front of the proximal descendingcolon. The stomach stands above and the spleen is lat-erally. The greater omentum descends from the great cur-vature of the stomach covering the transverse colon andclosing anterior the bursa omentalis. Usually the splenicflexure is high in left upper quadrant, describes an acuteangle and lies anterior to the left kidney. The descend-ing colon descends anteriorly to the left kidney and in-feriorly run in the groove between the psoas and the quad-ratus lumborum muscles. It is covered by peritoneum andin its distal portion is attached to the posterior abdom-inal wall by adhesion which needs to be dissected dur-ing left colectomy. Posterior, embryologic attachment cre-ates the so-called Toldt’s fascia whose knowledge is es-sential to perform a dissection in an avascular plain, sep-arated by the retroperitoneal structures, like ureter andgonadal vessels.

In our experience intra-operative complicationswhile tying the inferior mesenteric vein and dissectingthe splenic flexure can be reduced adopting the follow-ing laparoscopic technique.

With the patient positioned in reverse-Trendelemburgwith 30 degrees right rotation and after positioning ofthe trocars as described in Figure 1, we start the proce-dure mobilizing the inferior mesenteric vein at the lev-el of the inferior edge of the pancreas (Fig. 2). After itsisolation and dissection it appears an avascular plane inwhich medial to lateral dissection is carried out towardthe splenic flexure as much as we can. At the end of thisstep we put a sponge in the avascular plane we have dis-sected. This sponge will be a landmark in the next stepwhen we will mobilize the splenic flexure from lateral tomedial direction. The vein is then cut between metal-lic clips or using endo-GIA with white cartridge (TycoHealthcare Group LP, USA).

The next step is the left colic flexure mobilization.As mentioned above, the dissection moves on medio-lat-erally on the same plane, with respect of Toldt’s fasciawhose separation is further facilitated by the dissectingaction of CO2 insufflation.

The mobilization of the splenic flexure can be alsoachieved using other techniques. According to theanatomical variation we can adopt a lateral to medial ap-proach which, however, doesn’t allow an easy exposureof the inferior mesenteric vein (IMV). Another approach

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consists of blunt or sharp dissection of the gastro-colicligament in order to access the lesser sac.

In our experience, in the majority of cases to mobi-lize the splenic flexure we now use medial to lateral ap-proach and, on demand, a combined approach using at

least two of the above mentioned techniques (Fig. 3).It is essential during the dissection of splenic flexure

to avoid any risk in order not to damage the vessels ofthe colon with the Drummond arcade. A damage of thevessels can compromise the blood flow to the followingcolo-rectal anastomosis resulting in its dehiscence. Sim-ilarly, the dissection has to be smooth in order not to in-jury the colic wall or not to damage the spleen. Iatrogeniclesions to the pancreas, ureter and gonadal vessels are usu-ally easily avoided if the avascular plane with fascia ofToldt is respected during mobilization of the splenic flex-ure and descending mesocolon, without entering theretroperitoneum.

Risks and complications duringligation of inferior mesenteric arteryand mobilization of descending andsigmoid colon

During inferior mesenteric artery section and mo-bilization of the descending and sigmoid colon, intra-operative complications can occur and they consist inaorto-mesenteric injuries, lesions to the left colic artery,sympathetic nerves injuries, and ureteral iatrogenic le-sions.

Anatomically (18), the inferior mesenteric artery aris-es from the abdominal aorta, approximately 3-5 cm be-low the third portion of the duodenum. Then, it dividesin branches, namely the left colic artery and several (usu-ally one to four) sigmoid arteries, and terminates as su-perior rectal artery. The left colic artery divides into theascending and descending branches which will anastomisewith the left branch of the middle colic artery and thesigmoid arteries. It is important to notice that the left

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Laparoscopic left colectomy from the perfect knowledge of surgical anatomy to the proper surgical technique

Fig. 1 - Trocars’ placement in laparoscopic left colectomy.

Fig. 2 - Mobilization of the inferior mesenteric vein at the level of the inferioredge of the pancreas.M

Fig. 3 - Mobilization of the splenic flexure.Mobilization of the splenic flexure.

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colic artery may be absent in up to 6% of cases.From a surgical point of view, it is essential to know

that there are two important collaterals between the su-perior and the inferior mesenteric arteries, namely themarginal artery of Drummond and the arch of Riolano.The former runs about 1-8 cm from the mesenteric bor-der of the colon and it is composed of a series of vesselscomprising terminal portions of primary colic branch-es, from which the vasa recta arise. The integrity of mar-ginal artery at the splenic flexure, known as point of Grif-fith, is missing in about 40% of patients and in these cas-es blood supply after resection and anastomosis of thecolon could be a problem.

The other important collateral, arc of Riolano alsonamed meandering mesenteric artery, runs parallel to theleft branch of the middle colic artery, joining the prox-imal middle colic with the left colic artery. Integrity ofthe arc of Riolano is essential for a good blood supplyafter left colon resection. However, if before surgery be-cause of a superior mesenteric artery occlusion or crit-ical stenosis there was a retrograde blood flow from theinferior mesenteric artery system to the superior mesen-teric artery system, after division of the inferior mesen-teric artery a colonic and small intestinal infarction willlikely result.

While performing the mobilization of the descend-ing-sigmoid colon, besides the anatomical knowledge wealready discussed above, it is important to mention that,differently to the descending colon, the sigmoid colonhas a well- represented mesocolon which extends, witha shape of an inverted V, from the iliac fossa to the sec-ond-third sacral segment. It contains sigmoid and superiorrectal arteries with veins, lymphatic and autonomic nerveplexus, which will continue into the mesorectum. Theupper limbs of the mesosigma cross the left ureter andiliac vessels, whose recognition is essential to avoid ia-trogenic lesions.

In our surgical standard technique, in order to findthe IMA the land mark we use is the superior marginof the promontory medial to the right iliac artery. Thenwe proceed superiorly and we open the posterior pari-etal peritoneum keeping close to the left edge of aorta.Generally this maneuver facilitates the isolation of in-ferior mesenteric artery (IMA) which is divided by vas-cular linear endo-stapler. We usually divide IMA 1.5-2 cm from its aortic origin (Fig. 4), either in benign ormalignant diseases of the colon. Where to divide IMAit is important in order to push down the aorta alongwith surrounding sympathetic plexus and therefore inorder not to injure them during this maneuver. Dis-section of mesocolon along the plan of Toldt’s fascia andof mesosigma is then progressed until complete mobi-lization of descending sigmoid colon is achieved, in theanatomical respect of the retroperitoneal structures andleft ureter.

Risks and complications during rectumisolation and mesorectum dissection

During this step of the procedure lesions can occurto the sympathetic nerves, to the rectal wall, prostate, blad-der, ureter and seminal vesicular.

Knowledge of the anatomy is again essential to avoidthese complications.

The rectum has anatomical anterior relationships withthe bladder, the prostate and the seminal vesicles. It iscovered by the fascia propria and around this fascia, inthe posterior aspect, by the presacral or Waldeyer fasciaand anterior by the Denonvillier fascia. The sympatheticnerves form the hypogastric plexus at the bifurcation ofthe aorta toward the mesorectum. From the hypogastricplexus the hypogastric nerves arise and they run later-ally toward the lateral ligament of the rectum. Thesenerves finally merge with parasympathetic nerves intothe pelvic plexus which is located laterally and anteriorto the rectum, close to the seminal vesicle. Damage tothe sympathetic and parasympathetic nerves will resultin impotence. It is essential to know that the nerves areoutside to the Waldeyer and the Denonvillier fascia.Therefore dissection of the rectum in the avascular planebetween the fascia propria and the presacral and De-nonvillier fascia will preserve the autonomic nerves (19).

In our surgical standard technique, we start the dis-section of recto-sigmoid junction by changing the op-erating table into Trendelenburg position and by puttingthe camera in the right iliac fossa port. Then we proceedto mesorectal dissection. At this point left ureter shouldbe identified in order to avoid accidental injury, partic-ularly when there is inflammation around this area. Theplan of the dissection starts posterior at presacral regionin the avascular presacral space, paying attention not to

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Fig. 4 - Division of IMA 1.5-2 cm from its aortic origin.Miotomia esofagea: lun-ga circa 8 cm e si estende sullo stomaco per circa 2 cm.

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damage the sympathetic hypogastric plexus and the mid-dle sacral vein which, if severed, can be a source of veryserious bleedings.

The dissection of the mesorectum then continues lat-erally; first toward the right side of the rectum then to-ward the left one. Exactly at this phase, identification ofhypogastric nerves is essential. Saving sympathetic hy-pogastric plexus and the hypogastric nerves is importantto avoid “dry orgasm”.

Finally we proceed laterally with section of the lat-eral ligament of the rectum and then we go anteriorlydividing the anterior side of the rectum through a vir-tual space situated behind the fascia of Denonvillier. Inmales, attention should be paid to the seminal vesiclesand the prostate (Fig. 5), and to the pelvic sympathet-ic and parasympathetic plexus whose damage will resultin complete impotence in the male. In females we dis-sect the rectovaginal junction which can be better exposedby suspending the uterus with a transfixed suture. Be-low the seminal vesicles, the fascia of Denonvillier is di-vided close to the rectum until reaching the plane of theelevator ani muscle.

For rectal trans-section we use linear stapler. Proxi-mal colon then is exteriorized through a lower transversesoprapubic incision, or a lower midline or left parame-dian incision.

At this point we estimate the mobility of the left colonand the feasibility of a tension-free anastomosis.

The incision used to exteriorize the specimen is pro-tected by a plastic bag in order to prevent wound infectionand seeding with neoplastic cells. For the same purposea new device, namely lap disc, can be used. Then thecolon is exteriorized and the specimen is resected. At-tention should be paid to blood supply of the anastomosis.

This resection can be carried out using scalpel or amechanical linear stapler. The anvil of circular stapler is

introduced into the proximal stamp and fixed with apolypropylene purse-string suture. The choice of stapler’sdiameter depends on the size of large bowel.

The bowel is then returned to the abdominal cavi-ty, the incision is closed by suture or simply by inflat-ing the lap disc and pneumoperitoneum is re-established.

Finally, after gentle dilation of the anus, the handleof the stapler is inserted and the spike brought out ad-jacent to staple line in the rectum, maneuver which isfollowed under laparoscopic vision. The head of the sta-pler docked onto the handle and the stapler is re-ap-proximated. The first assistant fires the circular staplerafter insuring correct orientation of the proximal bowel,ultimately fashioning an end-to-end anastomosis (Fig. 6).

The surgeon checks the haemostasis and the integrityof anastomosis using a hydro-air test. At the end, the ab-domen is desufflated and the trocars are taken out afterirrigation of the abdominal cavity with saline solutionand positioning of a 19 French drainage in the Douglasspace. 10-12 mm trocar sites are closed by deep sited fas-cia closure.

Conclusion

Intra-operative complications related to laparoscop-ic colo-rectal surgery could lead to serious morbidity, af-fecting the patient postoperative outcome and increas-ing significantly hospital and social costs.

Standardization of laparoscopic colo-rectal surgery,with a proper training and an adequate learning curveis essential to avoid risks and complications during theseadvanced procedures. Knowledge of the anatomy and aprevious experience in open colo-rectal surgery ismandatory before embarking in this mini-invasive ap-proach.

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Fig. 5 - Visualization of the seminal vesicles and the prostate. Fig. 6 - End-to-end colorectal anastomosis.

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