Open Left Colectomy (Left Hemicolectomy) Periprocedural Care

Updated: Mar 04, 2022
  • Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Vikram Kate, MBBS, PhD, MS, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, FFST(Ed), MAMS, MASCRS  more...
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Periprocedural Care

Preprocedural Planning

A thorough history and physical examination are essential. Special emphasis should be placed on cardiopulmonary status so as to optimize the patient;s condition for tolerating surgical stress. A complete preoperative workup should be performed in order to establish the stage of the cancer. This includes, at a minimum, computed tomography (CT) of the abdomen and pelvis and radiography of the chest. A carcinoembryonic antigen (CEA) level is ordered for colon cancer at the time of diagnosis.

If the colonic lesion was diagnosed via flexible sigmoidoscopy, a full colonoscopy is essential to evaluate for synchronous lesions, and all lesions should be tattooed so that they can be identified at the time of surgery. Patient counseling about the risks and complications of the surgery, including the possibility of creating an ostomy, should be performed.

Mechanical bowel preparation is started the day before the operation to clear the bowel of fecal material, which would otherwise make it difficult to manipulate the colon during surgery. [7]  In a retrospective series on mechanical and oral antibiotic bowel preparation Koskenvuo et al  reemphasized that bowel preparation did not decrease the rate of surgical-site infection or complications in patients undergoing left or right hemicolectomy when compared with no bowel preparation. [8]

Some surgeons also prefer that the patient have an enema on the morning of the surgical procedure. A clear-liquid diet is allowed the day before the procedure. All oral intake is stopped the night before the operation, and only the essential medications are allowed, with a sip of water, on the morning of the procedure.

Preoperative antibiotics to cover gram-negative and anaerobic organisms (eg, piperacillin-tazobactam or ertapenem or a combination of a second-generation cephalosporin and metronidazole) are given within 1 hour of the incision time. Many surgeons also start alvimopan, a drug that helps prevent postoperative ileus, and continue it until the patient's bowel function has returned or for up to 7 days postoperatively. Deep vein thrombosis prophylaxis is also started on the day of surgery.

The SELECT trial, a multicentric randomized controlled trial, evaluated selective decontamination of the digestive tract (SDD) in patients with colorectal cancer who underwent elective curative surgery with a primary anastomosis. [9] The digestive tract was decontaminated with oral colistin, tobramycin, and amphotericin B in the treatment (SDD) group and with intravenous (IV) cefazolin and metronidazole in both the treatment and the control group. Patients in the SDD group had less anastomotic leakage than those in the control group, but the difference was statistically insignificant. The infectious complication rate was lower in the SDD group than in the control group.


Patient Preparation

The patient is placed in a lithotomy Trendelenburg (modified Lloyd-Davis) position with both arms abducted on arm boards. The legs are placed on stirrups, with adequate soft padding to prevent pressure sores on the skin and pressure-related nerve injury to the common peroneal nerves. Antiembolic stockings or compression devices are applied to the legs.

Ureteral catheters are used in left-side colectomies to prevent ureteral injury; however, because of the rarity of these injuries, the role and morbidity of ureteral catheters in these procedures is not well documented. In a study using data from the National Surgical Quality Improvement Project (NSQIP), Dolejs et al did not find a significant difference in the incidence of ureteral injury between left-side colectomy/proctectomy patients who underwent ureteral catheterization (0.7%; n = 8419) and similar patients who did not (0.9%; n = 128,021). [10] They concluded that ureteral catheters were associated with a longer operating time and increased overall morbidity and hence might not be necessary.