Open Left Colectomy (Left Hemicolectomy)

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Left hemicolectomy (left colectomy) is the surgical removal of the left side of the large bowel (see the first figure below); sigmoid colectomy is the surgical removal of the sigmoid colon (see the second figure below). These operations are mostly performed for cancers of the left colon and sigmoid colon, ^{[1, 2]} though they have several other indications, as described later in this article.

In most instances, surgical treatment of tumors of the left colon requires a left hemicolectomy. This procedure involves taking the inferior mesenteric blood supply, along with its branches (left colic artery and sigmoid arteries), which supply the splenic flexure to the proximal sigmoid colon. Tumors of the sigmoid colon can be removed by means of a sigmoid resection. This procedure encompasses the distal descending colon and the sigmoid colon, sacrificing the sigmoid and superior rectal arteries. ^{[3, 4, 5]}

Indications for left hemicolectomy are as follows:

One contraindication for left colectomy is metastatic colon cancer without complications. In such a case, surgical removal of the colon will not benefit the patient; instead, it will put the patient at risk for surgical complications and cause an unnecessary delay in systemic chemotherapy.

A second contraindication is surgically curable colon cancer in patients with severe medical comorbidities and/or those who are unstable and critically ill. Such patients cannot tolerate a major surgical procedure requiring general anesthesia.

The left colon begins at the midtransverse colon and includes the splenic flexure, the left (descending) colon, and sigmoid colon. The midcolon and the distal transverse colon are covered by peritoneum, and they are relatively mobile, except for the splenic flexure (because of the presence of the splenocolic ligament).

The descending colon is covered by peritoneum on the anterior and lateral surfaces and attaches to the retroperitoneum on the posterior side. The sigmoid colon is completely covered by peritoneum and is attached to the abdominal wall by a lateral peritoneal attachment termed the white line of Toldt, which extends upward to include attachment of the left colon as well.

Structures beneath the descending colon include the left kidney, the proximal ureter, and the inferior mesenteric vein (IMV). The intersigmoid fossa is a recess at the base of the mesosigmoid that provides an anatomic landmark for locating the left ureter, which courses beneath the fossa and runs parallel and just medial to the gonadal vein. Mobilization of the flexure requires division of the splenocolic ligament, a maneuver that must be performed carefully to prevent splenic capsular tearing.

Embryologically, the blood supply of the left colon is from the inferior mesenteric artery (IMA). The marginal artery of Drummond provides a vascular anastomosis between the superior mesenteric artery (SMA) and the IMA. In general, the distal transverse colon, including the splenic flexure and the descending colon, is supplied by the left branch of the middle colic artery, which is a branch of the SMA. The rest of the left colon is supplied by branches of the IMA.

The vascular supply of the sigmoid colon comes from the IMA and its sigmoidal and superior rectal artery branches. Collateral flow is provided by the marginal arteries and the arc of Riolan, a meandering artery from the middle colic artery to the IMA. Venous drainage is via the IMV, which joins the splenic vein and the superior mesenteric vein (SMV) to form the portal vein.

The lymphatic drainage follows the arterial supply. Since the main route of spread of carcinoma of the colon is via the lymphatics, an oncologic resection includes resection of the draining lymph nodes along with the lesion.

The superior hypogastric plexus is situated at the bifurcation of the aorta in close proximity to the IMA pedicle, and it provides sympathetic innervation for erectile function. Retrograde ejaculation in male patients can occur if care is not taken to avoid division of the nerve fibers during high IMA ligation and division. ^{[3, 4, 5]}

For more information about the relevant anatomy, see Colon Anatomy, Large Intestine Anatomy, Lower GI Tract Anatomy, and Liver Anatomy.

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Lee EC, Garrett K. Left colectomy: open and laparoscopic. Evans SRT, ed. Surgical Pitfalls: Prevention and Management. Philadelphia: Saunders Elsevier; 2009. 265-72.

Weiser MR. Left hemicolectomy for treatment of malignancy. Fischer J, ed. Fischer’s Mastery of Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. 162.

Lagares-Garcia JA, Sturrock PR. Left colon: open medial to lateral. Wexner SD, Fleshman JW, eds. Master Techniques in General Surgery: Colon and Rectal Abdominal Operations. Philadelphia: Lippincott Williams & Wilkins; 2012. 59.

Fleshman JW, Mutch MG. Open left and sigmoid colectomy. Wexner SD, Fleshman JW, eds. Master Techniques in General Surgery: Colon and Rectal Abdominal Operations. Philadelphia: Lippincott Williams & Wilkins; 2012.

Simorov A, Shaligram A, Shostrom V, Boilesen E, Thompson J, Oleynikov D. Laparoscopic colon resection trends in utilization and rate of conversion to open procedure: a national database review of academic medical centers. Ann Surg. 2012 Sep. 256(3):462-8. [Medline].

Midura EF, Jung AD, Hanseman DJ, Dhar V, Shah SA, Rafferty JF, et al. Combination oral and mechanical bowel preparations decreases complications in both right and left colectomy. Surgery. 2018 Mar. 163 (3):528-534. [Medline].

Borie F, Bigourdan JM, Pissas MH, Ripoche J, Millat B. The best surgical approach for left colectomy: a comparative study between transverse laparotomy, midline laparotomy and laparoscopy. J Gastrointest Surg. 2014 May. 18(5):1010-6. [Medline].

Mullen MG, Hawkins RB, Johnston LE, Shah PM, Turrentine FE, Hedrick TL, et al. Open Surgical Incisions After Colorectal Surgery Improve Quality Metrics, But Do Patients Benefit?. Dis Colon Rectum. 2018 May. 61 (5):622-628. [Medline].

Vásquez W, Hernández AV, Garcia-Sabrido JL. Is gum chewing useful for ileus after elective colorectal surgery? A systematic review and meta-analysis of randomized clinical trials. J Gastrointest Surg. 2009 Apr. 13 (4):649-56. [Medline].

Kobayashi T, Masaki T, Kogawa K, Matsuoka H, Sugiyama M. Efficacy of Gum Chewing on Bowel Movement After Open Colectomy for Left-Sided Colorectal Cancer: A Randomized Clinical Trial. Dis Colon Rectum. 2015 Nov. 58 (11):1058-63. [Medline].

Yuan L, O’Grady G, Milne T, Jaung R, Vather R, Bissett IP. Prospective comparison of return of bowel function after left versus right colectomy. ANZ J Surg. 2018 Apr. 88 (4):E242-E247. [Medline].

Yun GY, Moon HS, Kwon IS, Kim JS, Kang SH, Lee ES, et al. Left-Sided Colectomy: One of the Important Risk Factors of Metachronous Colorectal Adenoma After Colectomy for Colon Cancer. Dig Dis Sci. 2018 Apr. 63 (4):1052-1061. [Medline].

Fuccio L, Spada C, Frazzoni L, Paggi S, Vitale G, Laterza L, et al. Higher adenoma recurrence rate after left- versus right-sided colectomy for colon cancer. Gastrointest Endosc. 2015 Aug. 82 (2):337-43. [Medline].

Juan L Poggio, MD, MS, FACS, FASCRS Associate Professor of Surgery, Chief, Division of Colorectal Surgery, Department of Surgery, Drexel University College of Medicine

Juan L Poggio, MD, MS, FACS, FASCRS is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Abhiman B Cheeyandira, MD, MRCS(Eng) General and Bariatric Surgeon, Nazareth Hospital

Abhiman B Cheeyandira, MD, MRCS(Eng) is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Royal College of Surgeons of England, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Andrew C Raissis, MD Fellow, Department of Colon and Rectal Surgery, MedStar Washington Hospital Center

Andrew C Raissis, MD is a member of the following medical societies: American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

David E Stein, MD Chief, Division of Colorectal Surgery, Associate Professor, Department of Surgery, Director, Mini-Medical School Program, Drexel University College of Medicine; Chief, Division of Colorectal Surgery, Department of Surgery, Hahneman University Hospital; Consultant, Merck; Consultant, Ethicon Endo-Surgery; Consultant, Health Partners; Consultant, Cook Surgical

David E Stein, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Surgical Education, Pennsylvania Medical Society, Society for Surgery of the Alimentary Tract, Crohn’s and Colitis Foundation of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Merck<br/>Serve(d) as a speaker or a member of a speakers bureau for: Merck.

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Open Left Colectomy (Left Hemicolectomy)

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