Open left colon resection

Abstract

Open left colon resection, performed principally for primary adenocarcinoma of the proximal sigmoid or descending colon is based on the arterial blood supply and lymphatic drainage of the hemi-colon. Although modern surgical practices, that largely employ the speed and efficiency of automated stapling devices, have decreased operative times, the pathophysiologic basis for this operation originates from techniques and observations made during the early part of the 20 th century. In 1908, Ernest Miles described the “upward zone of spread,” of lymphatic metastases from a rectal cancer along the superior hemorrhoidal artery. 1 Jemieson and Dobson corroborated this observation in 1909 by astutely identifying an orderly and regular pattern of spread from colon to regional lymph nodes along the named arterial blood supply for any colon cancer, regardless of its site of origin. More importantly, they argued that the critical technical aspect of the operation involved ligation of the total arterial blood supply to that colonic segment at its origin (the so called “high ligation”), along with its associated mesentery containing the regional draining lymph nodes. 2 In 1941, Coller and associates noted that the orderly, sequential spread of lymph node metastases allowed for long term cures, not similarly seen with malignancies which originate from other visceral organs. 3 By 1954, Rosi demonstrated that by converting his practice from a limited segmental to an anatomic resection based on the vascular and lymphatic drainage, he could increase the relative cure rates from 55% to 73% and decrease the local recurrence rates from 18% to 2.8%. 4 Since then, other investigators have supported these findings, but no other significant surgical technique has altered the cure or recurrence rates for carcinoma of the colon, short of those that employ the use of adjuvant chemotherapy. The left colectomy, as described, is also used for treating benign colonic disease, such as diverticular disease, Crohn’s disease, or ischemic colitis. Although, the anatomic resection for a nonmalignant disease of the colon might appear unduly “radical,” we believe that the same operation, whether done for cancer or benign disease, obliges the surgeon to identify the vascular anatomy and correct tissue planes that ensure adequate colonic mobilization required for a tension free and well perfused anastomosis. While the treatment of these benign diseases does not, per se, call for ligation of named mesenteric vessels at their origin, the experienced surgeon will recognize that there are technical advantages to full mobilization of the bowel and keeping the vascular dissection at the base of the mesentery. Even when there is dramatic inflammation, scarring and edema in the mesentery near the bowel wall, the base of the mesentery is often uninvolved. This often makes dissection and ligation of vessels at the base of the mesentery cleaner, less bloody, and therefore, safer. Complete mobilization along proper tissue planes combined with ligation of the mesenteric vessels near, or at, their origin are also the keys to getting the transverse colon to easily reach down to the top of the rectum or even down into the depths of the pelvis. GENERAL CONSIDERATIONS