Segmental left colectomy: a modified caudal-to-cranial approach

Marco Milone, Francesco Milone, Milone F
Surgical endoscopy · 2017 · doi:10.1007/s00464-016-5100-x · PMID:27444827
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This paper describes a modified caudal-to-cranial approach for laparoscopic left colectomy in 21 patients with benign sigmoid lesions, reporting low operative times, minimal blood loss, and no major complications.

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This technical report describes a modified caudal-to-cranial surgical approach for laparoscopic segmental left colectomy that preserves the inferior mesenteric artery. The authors detail specific dissection techniques involving Gerota’s fascia and sequential sectioning of sigmoid arterial branches to facilitate specimen extraction and transanal anastomosis. In a cohort of 21 patients with benign conditions, including diverticulitis, polyps, and bowel endometriosis, the procedure demonstrated safety with no conversions to open surgery or major complications. Relevance to endometriosis: listed as one indication for the surgical technique, though the paper's main focus is on the mechanical aspects of left colectomy rather than endometriosis pathophysiology or comprehensive management.

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Abstract

BACKGROUND: We have designed a modified caudal-to-cranial approach to perform laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases. METHODS: IRB approval and informed consent have been obtained. A dissection is conducted to separate the descending mesocolon of the Gerota's plan from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. These maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. The specimen is extracted by a pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to Knight-Griffin technique. RESULTS: We performed a laparoscopic segmental colectomy using this approach for 21 patients with benign sigmoid lesions: 13 diverticulitis, 3 flat polypoid lesions (no lift-up sign), and 5 bowel endometriosis. The mean operative time and blood loss were 161.4 ± 15.7 min and 50 ± 40 ml, respectively. There were not a single conversion to open surgery and no any leakage or stricture. Only 2 cases of intraluminal bleeding and 1 case of wound infection (treated conservatively) were observed. CONCLUSION: We consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall.
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Abstract

Background We have designed a modified caudal-to-cra- nial approach to perform laparoscopic left colectomy pre- serving the inferior mesenteric artery for benign colorectal diseases.

Methods

IRB approval and informed consent have been obtained. A dissection is conducted to separate the descending mesocolon of the Gerota’s plan from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. These maneuvers permit to straighten the mesen- tery simplifying the identification and cutting of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. The specimen is extracted by a pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to Knight–Griffin technique.

Results

We performed a laparoscopic segmental colec- tomy using this approach for 21 patients with benign sig- moid lesions: 13 diverticulitis, 3 flat polypoid lesions (no lift-up sign), and 5 bowel endometriosis. The mean oper- ative time and blood loss were 161.4 ± 15.7 min and 50 ± 40 ml, respectively. There were not a single con- version to open surgery and no any leakage or stricture. Only 2 cases of intraluminal bleeding and 1 case of wound infection (treated conservatively) were observed.

Conclusion

We consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall.

Keywords

Left colectomy /C1Segmental /C1Caudal to cranial /C1Diverticulitis /C1Bowel endometriosis /C1Polypoid lesions Compliance with ethical standards Disclosures Marco Milone and Francesco Milone have no conflicts of interest or financial ties to disclose. Electronic supplementary material The online version of this article (doi: 10.1007/s00464-016-5100-x) contains supplementary material, which is available to authorized users. & Marco Milone [email protected] 1 Department of Surgical Specialities and Nephrology, University of Naples ‘ ‘Federico II’ ’, Via Pansini 5, 80131 Naples, Italy 123 Surg Endosc (2017) 31:1487 DOI 10.1007/s00464-016-5100-x and Other Interventional Techniques

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Condition tags

endometriosisbowel_endometriosis

MeSH descriptors

Colectomy Colon, Sigmoid Diverticulitis Endometriosis Laparoscopy Mesentery Sigmoid Diseases Blood Loss, Surgical Colectomy Colon, Sigmoid Conversion to Open Surgery Dissection Dissection Diverticulitis Endometriosis Female Humans Laparoscopy Mesenteric Artery, Inferior Mesentery

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