Colectomy

Colectomy (col- + -ectomy) is bowel resection of the large bowel (colon). It consists of the surgical removal of any extent of the colon, usually segmental resection (partial colectomy). In extreme cases where the entire large intestine is removed, it is called total colectomy, and proctocolectomy (procto- + colectomy) denotes that the rectum is included.

Colectomy
Micrograph of pseudomembranous colitis, an indication for colectomy. H&E stain.
ICD-9-CM45.8, 45.73
MeSHD003082

Indications

Some of the most common indications for colectomy are:

Basic principles

Traditionally, colectomy is performed via an abdominal incision (laparotomy), though minimally invasive colectomy, by means of laparoscopy, is growing both in scope of indications and popularity, and is a well-established procedure as of 2006 in many medical centers. Recent experience has shown the feasibility of single port access colectomy.[1]

Resection of any part of the colon entails mobilization and ligation of the corresponding blood vessels. Lymphadenectomy is usually performed through excision of the fatty tissue adjacent to these vessels (mesocolon), in operations for colon cancer.

When the resection is complete, the surgeon has the option of immediately restoring the bowel, by stitching or stapling together both the cut ends (primary anastomosis), or creating a colostomy. Several factors are taken into account, including:

  • Circumstances of the operation (elective vs emergency); In many cases, emergency resection of colon with anastomosis needs to be done and this carries a higher complication rate since proper bowel preparation is not possible in emergency situations
  • Disease being treated; (i.e., no colectomy surgery can cure Crohn's disease, because the disease usually recurs at the site where the healthy sections of the large intestine were joined together. For example, if a patient with Crohn's disease has a transverse colectomy, their Crohn's will usually reappear at the resection site of the ascending and descending colons.)
  • Acute physiological state of the patient;
  • Impact of living with a colostomy, albeit temporarily;
  • Use of a specific preoperative regimen of low residue diet and laxatives (so-called "bowel prep").

An anastomosis carries the risk of dehiscence (breakdown of the stitches), which can lead to contamination of the peritoneal cavity, peritonitis, sepsis and death. A number of factors may increase the risk of anastomotic dehiscence, either partial ('leak') or complete. Basic surgical principles include ensuring a good blood supply to the opposing ends, and a lack of tension at the join. The use of NSAIDS for analgesia following gastrointestinal surgery remains controversial, given mixed evidence of an increased risk of leakage from any bowel anastomosis created. This risk may vary according to the class of NSAID prescribed.[2][3][4]

Colostomy is always safer, but places a societal, psychological and physical burden on the patient. The choice is by no means an easy one and is rife with controversy, being a frequent topic of heated debate among surgeons all over the world.

Types
  • Right hemicolectomy and left hemicolectomy refer to the resection of the ascending colon (right) and the descending colon (left), respectively. When part of the transverse colon is also resected, it may be referred to as an extended hemicolectomy.[5]
  • Transverse colectomy is also possible, though uncommon.
  • Sigmoidectomy is a resection of the sigmoid colon, sometimes including part or all of the rectum (proctosigmoidectomy). When a sigmoidectomy is followed by terminal colostomy and closure of the rectal stump, it is called a Hartmann operation; this is usually done out of impossibility to perform a "double-barrel" or Mikulicz colostomy, which is preferred because it makes "takedown" (reoperation to restore normal intestinal continuity by means of an anastomosis) considerably easier.
  • When the entire colon is removed, this is called a total colectomy, also known as Lane's Operation.[6] If the rectum is also removed, it is a total proctocolectomy.
  • Subtotal colectomy is resection of part of the colon or a resection of all of the colon without complete resection of the colon.[7]

Laparoscopic surgery

As of 2012, more than 40% of colon resections in United States are performed via laparoscopic approach.[8]

To begin laparoscopic surgery for a colectomy typically 4 ports are placed in the abdomen to gain access to the peritoneal cavity. The next step is to mobilize the portion of the bowel that is to be resected. This is done by ligation of the mesentery and other peritoneal attachments. A stapler is used to resect the bowel and an anastomosis between the remaining bowel is created. [9]

History

Sir William Arbuthnot-Lane was one of the early proponents of the usefulness of total colectomies, although his overuse of the procedure called the wisdom of the surgery into question.[10]

See also

References
  1. Bucher P, Pugin F, Morel P (October 2008). "Single port access laparoscopic right hemicolectomy" (PDF). International Journal of Colorectal Disease. 23 (10): 1013–6. doi:10.1007/s00384-008-0519-8. PMID 18607608. S2CID 11813538.
  2. STARSurg Collaborative (2017). "Safety of Nonsteroidal Anti-inflammatory Drugs in Major Gastrointestinal Surgery: A Prospective, Multicenter Cohort Study". World Journal of Surgery. 41 (1): 47–55. doi:10.1007/s00268-016-3727-3. PMID 27766396. S2CID 6581324.
  3. STARSurg Collaborative (2014). "Impact of postoperative non-steroidal anti-inflammatory drugs on adverse events after gastrointestinal surgery". BJS. 101 (11): 1413–23. doi:10.1002/bjs.9614. PMID 25091299. S2CID 25497684.
  4. Bhangu A, Singh P, Fitzgerald JE, Slesser A, Tekkis P (2014). "Postoperative nonsteroidal anti-inflammatory drugs and risk of anastomotic leak: meta-analysis of clinical and experimental studies". World Journal of Surgery. 38 (9): 2247–57. doi:10.1007/s00268-014-2531-1. PMID 24682313. S2CID 6771641.
  5. Martin, Elizabeth A. (2015). Concise medical dictionary. Martin, E. A. (Elizabeth A.) (Ninth ed.). Oxford [England]. p. 347. ISBN 9780199687817. OCLC 926067285.
  6. Enersen, Ole Daniel. "Lane's operation". whonamedit.com. Retrieved 2009-07-19.
  7. Oakley JR, Lavery IC, Fazio VW, Jagelman DG, Weakley FL, Easley K (June 1985). "The fate of the rectal stump after subtotal colectomy for ulcerative colitis". Diseases of the Colon and Rectum. 28 (6): 394–6. doi:10.1007/BF02560219. PMID 4006633. S2CID 28166296.
  8. Simorov A, Shaligram A, Shostrom V, Boilesen E, Thompson J, Oleynikov D (September 2012). "Laparoscopic colon resection trends in utilization and rate of conversion to open procedure: a national database review of academic medical centers". Annals of Surgery. 256 (3): 462–8. doi:10.1097/SLA.0b013e3182657ec5. PMID 22868361. S2CID 37356629.
  9. , Rattner D, Harkins J M. Laparoscopic Right Colectomy with Ileocolic Anastomosis. J Med Ins. 2016;2016(125) doi:https://jomi.com/article/125
  10. Lambert, Edward C. (1978). Modern medical mistakes. Indiana University Press. p. 18. ISBN 978-0-253-15425-5.
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