Colectomy (col- + -ectomy) is
bowel resection of the
large bowel (sometimes referred to as the
colon which more precisely denotes a part of the large bowel). 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.
Indications
Some of the most common indications for colectomy are:
Inflammatory bowel disease such as
ulcerative colitis or
Crohn's disease. Colectomy neither cures nor eliminates Crohn's disease, instead only removing part of the entire diseased large intestine. A colectomy is considered a "cure" for ulcerative colitis because the disease attacks only the large intestine and therefore will not be able to flare up again if the entire large intestine (cecum, ascending colon, transverse colon, descending colon and sigmoid colon) and rectum are removed. However, it does not always take away extra-intestinal symptoms.
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[update] 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[citation needed]
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. 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;
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.[citation needed]
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.[citation needed]
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]
^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.
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^Enersen, Ole Daniel.
"Lane's operation". whonamedit.com. Retrieved 2009-07-19.
^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.
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^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.
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^Rattner, David (2016). "Laparoscopic Right Colectomy". Journal of Medical Insight.
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