it emphasizes the different types of colectomies, anatomy of colon, and principles of laparoscopic colectomy

1. Colectomies
BY DR SAJID ALI
PG TRAINEE SURGICAL D UNIT

2. colectomy
• A colectomy is a surgical procedure in which all or part of the
large intestine is resected.

3. TOPICS TO BE DISCUSSED
• types of colectomies
• Indications
• Anatomy of colon and important structures
• TNM classification
• Procedure for lap colectomy

4. Types of colectomies
• Right hemi colectomy
• Left hemi colectomy
• Transverse colectomy
• Anterior resection
• Abdominoperineal resection
• Subtotal colectomy
• Sigmoid colectomy
• Proctectomy

6. Indications
• COLON CANCER
• RECTAL CANCER
• ULCERATIVE COLITIS (3-5% DEVELOP CA,PANCOLITIS,
AGE<15YEARS)
• SIGMOID DIVERTICULITIS
• INHERITED POLYPOSIS SYNDROMES (FAP, GARDNER,
TURCUT SYNDROME, PEUTZ JEGHER)

7. Anatomy
• Posterior relations of cecum
• Ascending
• Transverse
• Descending
• Sigmoid
• Rectum
• Anal canal

8. General outline

9. Cecum

10. Ascending colon

11. Transverse colon

13. Sigmoid mesocolon and ileal region

14. Anal canal

15. Blood supply of colon

16. Complete Mesocolic excision

17. Complete Mesocolic excision
• first aim of this procedure is to remove the
• afflicted colon and its accessory lymph vascular supply
• by resecting the colon and mesocolon in an intact
• envelope of visceral peritoneum, which holds potentially
• involved lymph nodes.
• The second component of CME
• is a central vascular tie to remove completely all lymph
• nodes in the central (vertical) direction

18. Complete Mesocolic excision
• Separation of visceral from parietal plane
• Mobilization of colon
• Dissection off the retroperitoneal plane
• Containing ureter, gonadal ovarian vessels
• Just anterior to Toltd fascia
• Way to standardize colon cancer surgery

20. MESOCOLIC EXCISION PLANE

21. Total mesorectal excision?

23. TME
• Rectovesical fascia
• Denonviller fascia
• Levator ani
• Coccyx
• Transverse perineal muscles
• Taking care of ureters, sacral sympathic nerves pass post to common
iliac, parasympathetic pelvic splanchnic nerves S234, seminal vesicles

25. TNM CLASSIFICATION ajcc 8th edition
• Tis Carcinoma in situ: intraepithelial or or intramucosal carcinoma (involvement
of lamina propria with no extension through the muscularis mucosa)
• T1 Tumor invades submucosa (through the muscularis mucosa but not into the
muscularis propria)
• T2 Tumor invades muscularis propria
• T3 Tumor invades through the muscularis propria into the pericolorectal
tissues
• T4 Tumor invades the visceral peritoneum or invades or adheres to adjacent
organ or structure
• T4a Tumor invades through the visceral peritoneum (including gross perforation
of the bowel through tumor and continuous invasion of tumor through areas of
inflammation to the surface of the visceral peritoneum)
• T4b Tumor directly invades or is adherent to other organs or structures

26. Lymph nodes
• Regional lymph nodes (N)
• N0 No regional lymph node metastasis
• N1 Metastasis in 1-3 regional lymph nodes (tumor in lymph
nodes measuring ≥0.2 mm) or any number of tumor deposits
are present and all identifiable nodes are negative
• N2 Metastasis in 4 or more lymph nodes
• N2aMetastasis in 4-6 regional lymph nodes
• N2b Metastasis in 7 or more regional lymph nodes

27. Distant Mets
• M0 No distant metastasis by imaging or other studies, no evidence of
tumor in distant sites or organs. (This category is not assigned by
pathologists.)
• M1 Metastasis to one or more distant sites or organs or peritoneal
metastasis
• M1a Metastasis confined to 1 organ or site (eg, liver, lung, ovary, non
regional node) without peritoneal metastasis
• M1b Metastasis to two or more sites or organs without peritoneal
metastasis
• M1c Metastasis to the peritoneal surface alone or with other site or organ
metastases

28. Why laparoscopic colectomy
• Faster recovery
• Reduced post-op pain
• Decreased wound infection rates
• Outcome comparable to open surgery
• Better anatomical details

30. Difficulties
• Long learning cure
• Need at least 30 resections to achieve learning curve
• Start with right colon surgeries
• Lesions in sigmoid and rectum need much expertise
• Obesity
• Previous abdominal surgery
• Cardiopulmonary dysfunction tolerate pneumoperitoneum poorly
• Lack of tactile sensations

31. Instruments needed
• 30 degree telescope
• 3 to 4 atraumatic forceps
• 2 grasping forceps
• Ultrasonic dissection device e.g. ligasure 5,10mm
• Endoscopic clip applicator
• Endostaplers blue gold green for bowel, white for vascular division
• CDH STAPLERS

32. Instruments

33. Endo staplers

34. laparoscopic
Procedure Start End Other
LEFT HEMI
COLECTOMY
SPLENIC FLEXURE
MOBILIZATION
RECTO SIGMOID
JUNCTION (pelvic
brim)
CDH TRANSANAL
COLORECTAL
ANASTAMOSIS
ANTERIOR
RESECTION
SIGMOID
MOBILIZATION
PELVIC FLOOR
(LOW AR)
TME FOR LOW R
MID RECTUM, CDH
COLOANAL
ANASTAMOSIS
APR SIGMOID
MOBILIZATION
PERIANAL
PROCEDURE
WIDE ELAPE FOR
LEVATOR ANI
INVOLEMENT

35. How to prepare
• Do not give bowel preparation
• Place in lithotomy loyld davis position
• Steep Right side tilt
• Perform DRE
• Pass NG tube
• Insert urinary Cather
• Thromboprophylaxis

36. Positioning and ports

38. Procedure steps
Medial to lateral approach
Incise peritoneum at pelvic brim/sac promontory and continue anterior
to aorta until IMA
lateral to IMA is IMV
Splenic flexure mobilization
Blunt dissection in avascular plane between descending colon
mesentery and retroperitoneal fascia till splenic flexure
Start lateral dissection in mid transverse colon

39. STEPS
• Sigmoid colon mobilization
• Lateral to medial approach
• Toltd fascia is incised
• Identify left gonadal vessels and ureter just above iliac vessels
• Enter presacral space anterior to left hypo gastric nerve (at level of
sacral promontory)

40. STEPS
• Free the whole left side colon
• Splenic flexure should reach pelvis easily without tension
• Perform cytocidal lavage
• Deliver the specimen though pfannenstiel incision 5 to 6cm
• Transect with linear cutting stapler
• Proximal end should reach the symphysis
• Insert the CDH (31mm) transanal and perform colorectal anastomosis

41. Anterior resection

42. Abdomino perineal excision
• Start with sigmoid colon mobilization
• Medial approach
• Reach the IMA and divide at its origin
• Identify left ureter and gonadal vessels
• Stay in mesorectal plane and preserve presacral sympathetic nerves
• dissect until u see seminal vesicles anterior to rectum

43. Perineal operation
• Prone jackknife position for better exposure
• Make elliptical incision around the closed anus
• Lift it towards ur side
• And start dissection around
• Posterior lateral dissection and then
• Dissection anterior to rectum
• Plane between rectum and prostate

45. ANATOMY MALE VS FEMALE

46. SPECIMEN AFTER AR/APR

47. ELAPE (extra levator APE)
• Prone jackknife position
• Coccyx is excised
• Extend the dissection outside external sphincter
• Divide levator muscles laterally at their origin
• Primary suture is gona fail
• Reconstructive options mesh, omentoplasty, VRAM flap