Open Left Colon Resection
Kirk A. Ludwig, MD, and Christopher Touloukian, MD
pen left colon resection, performed principally for
O primary adenocarcinoma of the proximal sigmoid or
descending colon is based on the arterial blood supply
and lymphatic drainage of the hemi-colon. Although
modern surgical practices, that largely employ the speed
and efficiency of automated stapling devices, have de-
creased operative times, the pathophysiologic basis for
this operation originates from techniques and observa-
tions made during the early part of the 20th century. In
1908, Ernest Miles described the “upward zone of
spread,” of lymphatic metastases from a rectal cancer
along the superior hemorrhoidal artery.1 Jemieson and
Dobson corroborated this observation in 1909 by astutely
identifying an orderly and regular pattern of spread from
colon to regional lymph nodes along the named arterial
blood supply for any colon cancer, regardless of its site of
origin. More importantly, they argued that the critical
technical aspect of the operation involved ligation of the
total arterial blood supply to that colonic segment at its
origin (the so called “high ligation”), along with its asso-
ciated mesentery containing the regional draining lymph
nodes.2 In 1941, Coller and associates noted that the
orderly, sequential spread of lymph node metastases al-
lowed for long term cures, not similarly seen with malig-
nancies which originate from other visceral organs.3 By
1954, Rosi demonstrated that by converting his practice
from a limited segmental to an anatomic resection based
on the vascular and lymphatic drainage, he could increase
the relative cure rates from 55% to 73% and decrease the
local recurrence rates from 18% to 2.8%.4 Since then,
other investigators have supported these findings, but no
other significant surgical technique has altered the cure or
recurrence rates for carcinoma of the colon, short of those
that employ the use of adjuvant chemotherapy.
The left colectomy, as described, is also used for treat-
ing benign colonic disease, such as diverticular disease,
Crohn’s disease, or ischemic colitis. Although, the ana-
tomic resection for a nonmalignant disease of the colon
might appear unduly “radical,” we believe that the same
operation, whether done for cancer or benign disease,
Department of Surgery, Duke University Medical Center, Durham, NC.
Address reprint requests to Kirk A. Ludwig, MD, Assistant Professor of Surgery,
Duke University Medical Center, Duke Hospital North, Room 3454B, Durham,
North Carolina 27710.
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0504-0003$30.00/0
doi:10.1053/j.optechgensurg.2003.10.001
Operative Techniques in General Surgery, Vol 5, No 4 (December), 2003: pp 199-213
obliges the surgeon to identify the vascular anatomy and
correct tissue planes that ensure adequate colonic mobi-
lization required for a tension free and well perfused anas-
tomosis. While the treatment of these benign diseases
does not, per se, call for ligation of named mesenteric
vessels at their origin, the experienced surgeon will rec-
ognize that there are technical advantages to full mobili-
zation of the bowel and keeping the vascular dissection at
the base of the mesentery. Even when there is dramatic
inflammation, scarring and edema in the mesentery near
the bowel wall, the base of the mesentery is often unin-
volved. This often makes dissection and ligation of vessels
at the base of the mesentery cleaner, less bloody, and
therefore, safer. Complete mobilization along proper tis-
sue planes combined with ligation of the mesenteric ves-
sels near, or at, their origin are also the keys to getting the
transverse colon to easily reach down to the top of the
rectum or even down into the depths of the pelvis.
GENERAL CONSIDERATIONS
1. For patients being prepared for an operation, a thor-
ough preoperative assessment of cardiac, pulmonary and
nutritional status should be made. Appropriate diagnostic
studies, may include arterial blood gas analysis, pulmo-
nary function tests, electrocardiograms, and cardiac
stress tests (pharmacologic or exercise-induced). Smok-
ing cessation and nebulizer therapy may also be required
before a patient can be safely brought to the operating
room. Patients presenting with significant malnutrition, a
loss of more than 10% to 15% of their baseline body
weight over a short period of time (3 to 4 months) along
with low serum albumin levels (less than 3 g/dL), are at
increased risk for multiple significant postoperative com-
plications including superficial and intraperitoneal infec-
tion, and fascial or anastomotic dehiscence. Under these
circumstances the surgeon should consider (if at all fea-
sible) the use of preoperative nutritional supplementa-
tion.
2. For patients presenting with a nonobstructing, non-
perforated colonic carcinoma, we recommend a preoper-
ative colonoscopy to exclude synchronous benign polyps,
which have been reported to occur in 12% to 62% of
patients, and synchronous cancers, which have been
identified in 2% to 8% of cases. If the operative indication
is a lesion that may not be well appreciated by manual
palpation in the operating room, such as a small cancer, a
polyp that cannot be removed colonoscopically, or a ma-
199
200
lignant polyp, then the colonoscope can be used to mark
the lesion with a permanent India ink tattoo. In addition,
we obtain a routine chest X-ray and computed tomogra-
phy (CT) scan of the abdomen and pelvis to exclude the
presence of metastatic disease.
3. Patients with Crohn’s colitis require operative ther-
apy for obstruction, fistula formation, anemia from bleed-
ing, pain, and disease refractory to medical management.
Proctocolectomy with ileostomy has been the historical
treatment of choice, largely because of recurrence rates
within the unresected colon and frequent involvement of
the entire organ. Nevertheless, in selected patients with
disease confined to a segment of colon (in this case, the
left colon), anatomic resections can be employed with a
high degree of success.
4. Despite the operative indication, the surgeon can
significantly decrease the risk of an infectious complica-
tion by reducing the bacterial inoculum within the co-
lonic lumen. We employ a standard regimen to mechan-
ically cleanse the bowel, using either 4 L of polyethylene
glycol (GoLYTELY) over 2 to 3 hours or two doses, sep-
arated by 2 to 3 hours, of an oral sodium phosphate
solution. The mechanical preparation is performed in the
morning on the day before operation. This is followed
later that day by the oral antibiotic preparation, with three
doses of neomycin and either erythromycin or met-
ronidizole taken in the afternoon and evening. Intrave-
nous antibiotics are additionally administered on the day
of operation in the preoperative holding area.
5. If the patient is being prepared for an elective left
colon resection with an ostomy, it is important to ensure
that an appropriate stoma site is located and marked on
the abdominal wall. We advise using an India ink tattoo.
One drop of the ink is placed on the site and the skin is
pricked two to three times with a 25-guage needle. If
available, it can be extremely helpful to have an experi-
enced enterostomal therapist visit with the patient and
family preoperatively to discuss lifestyle changes and
management issues associated with a stoma.
6. The surgeon should be aware of several well-de-
scribed complications from colon surgery, these include:
would infection, intra-abdominal abscess formation,
anastomotic leak and bleeding, and abdominal wound
dehiscence. These are general complications of almost
any colorectal operation. More unique to the left colec-
tomy are injury to adjacent organs such as the ureter and
spleen.
The most common sites of ureteral injury during a left
colectomy are near the origin of the inferior mesenteric
artery and over the iliac vessels. These injuries are
avoided by staying in the correct anatomic plane, starting
mobilization of the left colon away from the pelvic inlet,
and making sure that the ureter is pushed posterior out of
the operative field before ligating the inferior mesenteric
artery. As emphasized in the figures, the left ureter lies
Ludwig and Touloukian
beneath Toldt’s fascia in the retroperitoneum. If the sur-
geon consistently finds himself behind the ureter, he/she
is in the wrong plane.
Splenic injury is also avoided by carefully staying in the
correct anatomic plane during splenic flexure mobiliza-
tion. The omentum comes off of the splenic flexure close
to the bowel, and the base of the mesentery at the trans-
verse colon is along the inferior edge of the pancreas,
away from the spleen. While there are splenic flexures
that are truly tucked into the splenic hilum, the vast
majority are not. During the majority of left colectomies,
the spleen should hardly come into play. Most splenic
injuries are capsular avulsions as a result of over aggres-
sive downward traction on the omentum and the flexure.
Mobilizing the flexure from behind, over Gerota’s fascia,
up-to the pancreas, as apposed to pulling down vigor-
ously of the bowel, will help avoid this complication.
Fortunately, the vast majority of splenic bleeding can be
controlled without the need for splenectomy.
Sexual and/or bladder dysfunction, from injury to the
sympathetic nerves or the hypogastric nerves can also
complicate left colectomy. These complications can be
avoided by indentifying the sympathetic nerves behind
the inferior mesenteric artery and keeping the subsequent
dissection just behind the artery. The nerves are the subtle
cord-like structures just deep to the inferior mesenteric
artery. The hypogastric nerves can be avoided by keeping
the dissection on the fascia propria of the mesorectum as
one nears the distal margin of resection in the upper
rectum. Peroneal nerve injury is another potential hazard
and can be avoided by proper utilization of stirrups (see
Fig 1) used to put the patient in the low lithotomy posi-
tion.
OPERATIVE TECHNIQUE
Following the induction of general anesthesia, a Foley
catheter is inserted, and the patient is placed in the low
lithotomy position using Allen stirrups (Allen Medical
Systems, Bedford Height’s, OH). The hips and knees are
just slightly flexed so that the thighs do not interfere with
the abdominal field (Fig 1). The left arm is always tucked
at the patient’s side for left sided colon operations. This
gives extra room on the left side of the patient so that an
assistant can help with retraction on the left costal margin
during mobilization of the splenic flexure. Pneumatic
compression devices are placed around both calves to
minimize the risk of deep venous thrombosis formation.
The rectum is then digitally inspected before it is irrigated
with saline and betadine delivered through a 32 French
Pezzar catheter. The catheter is left in place to drain into
a plastic bag or rubber glove. It will be used later for a final
distal irrigation before placing a staple line on the rectum.
For the purposes of this discussion, the operation will
be performed with the surgeon standing on the patient’s
right side and the assistant standing on the left. The sur-
1 Low lithotomy position. The hips and knees are just slightly flexed so that the thighs are not in the operative field. The thighs
should be almost parallel to the floor.

2 The Balfour retractor is pre-

ferred for ease of set-up and the fact
that it keeps the wound at a mini-
mum depth so that the small bowel
can be eviscerated. This gives the
surgeon an excellent view of the
base of the left colon mesentery.
202
geon will provide the exposure and the assistant will do
most of the cutting using the electrocautery.
The peritoneal cavity is entered through a midline in-
cision, the length of which varies based on the patient’s
body habitus and mobility of the colon. Adhesions from
previous abdominal surgical procedures, if present, are
carefully lysed and a thorough examination of all abdom-
inal quadrants is performed with particular attention to
the liver, omentum and peritoneal surfaces. In women,
the ovaries are also carefully inspected to rule out meta-
static disease. The small bowel is examined from the lig-
ament of Treitz to the ileocecal valve and the entire colon
is manually inspected to identify the location of the pri-
mary lesion.
A self-retaining retractor is placed. We prefer a Balfour
retractor for most colon resections. The principle advan-
tages of the Balfour retractor are its simplicity in set-up
and placement, and the fact that it does not increase the
depth of the wound. This is important in that it allows the
Ludwig and Touloukian
3 The base of the left colon mes-
entery is at the aorta and the base of
the transverse colon mesentery is
along the inferior edge of the pan-
creas. For formal left colectomy the
proximal point of resection is the
mid-transverse colon and the distal
point of resection is the upper rec-
tum.
surgeon to completely eviscerate the small bowel giving
an excellent view of the base of the left colon mesentery
(Fig 2). This is preferable to packing the bowel into the
right abdomen, as with other types of retractors. The
principle disadvantage of the Balfour retractor is that
someone will need to help with retraction on the left
costal margin during flexure mobilization. For a thin pa-
tient, the assistant can do this with one arm while using
the electrocautery in the other hand to cut along the tissue
planes exposed by the surgeon. For a heavy patient or a
patient with a very high splenic flexure, a second assistant
or the scrub nurse may have to help.
The primary anatomic considerations that drive open
left colectomy are as follows: (1) Once fully mobilized,
the left colon is a midline structure. The base of the left
colon’s mesentery is at the aorta. The base of the trans-
verse colon’s mesentery is along the inferior edge of the
pancreas (Fig 3). (2) There is a clear plane that separates
the colon mesentery from the retroperitoneum. The ret-
Open Left Colon Resection 203

4 The proper plane of dissection between the mesentery and the retroperitoneum is schematically illustrated. The retroperito-
neum is covered by a thin smooth layer known as Toldt’s fascia. The proper plane is just over Toldt’s fascia. An incorrect plane in
the retroperitoneum takes the surgeon directly onto or behind the gonadal vessels and the ureter. The psoas muscle should not
routinely be visualized.

roperitoneum is covered by a thin membranous fascia
known as Toldt’s fascia. The plane of dissection is be-
tween Toldt’s fascia and the mesentery. The gonadal ves-
sels and the ureter are deep to this fascia: the surgeon
should not be (Fig 4). (3) The vessels taken during a
formal left colectomy are the inferior mesenteric artery
(IMA) at the aorta, the marginal vessel (left branch of the
middle colic artery) along the mid transverse colon, and
the superior hemorrhoidal vessels just over the sacral
promontory. The inferior mesenteric vein (IMV) is taken
at the inferior edge of the pancreas (Fig 5). (4) The trans-
verse colon is divided at its midpoint and the bowel is
divided distally in the upper rectum where the tenia con-
verge. (5) In most cases, the entire dissection can be
performed with the electrocautery or with scissors. The
proper tissue planes are avascular aside from the occa-
sional vein that bridges between the retroperitoneum and
the mesentery. The majority of splenic flexure mobiliza-
tions should be performed in an avascular plane, as well.
(6) The splenic flexure is approached from both direc-
tions. The descending colon is mobilized first, over
Gerota’s fascia to the midline, the omentum is taken off
the transverse colon over to the flexure, and finally the
base of the transverse colon mesentery is taken at the
inferior edge of the pancreas.
When doing a left colectomy for cancer, we routinely
irrigate the rectum before placing a distal staple line. This
is done in an attempt to wash the lumen of any shed
tumor cells that may otherwise be trapped in a staple line.
A right angle bowel clamp is placed distally, an assistant
irrigates through the previously placed rectal tube, and
the staple gun is placed distal to the right angle bowel
clamp in the washed rectum. We routinely utilize beta-
dine for this washout.
Depicted in Figures 6-13 are the details of performing a
formal left colectomy, including mobilization of the
204 Ludwig and Touloukian

SURGICAL TECHNIQUE

5 The anatomic extent of a formal

left colectomy with the named mes-
enteric vessels taken at their origin.
Open Left Colon Resection 205

6 The left colon is mobilized from

its lateral and retroperitoneal attach-
ments by incising along the white
line of Toldt. This should start in the
more proximal sigmoid colon, not
over the iliac vessels. The colon is
retracted medially and the incision
is always just medial to the white
line that is continually moving me-
dial toward the aorta. The proper
plane is between the smooth poste-
rior surface of the left colon’s mesen-
tery and the thin, but distinct,
Toldt’s fascia over the retroperito-
neum (see Fig 4). Too deep a plane
takes the surgeon directly onto the
gonadal vessels, ureter or the psoas
muscle. These retroperitoneal struc-
tures are deep to the dissection be-
hind the overlying Toldt’s fascia.
These retroperitoneal structures
should not be routinely encoun-
tered. Once the proper plane is ex-
posed medially and the gonadal ves-
sels and the ureter are safely pushed
posterior, out of harms way, the dis-
section can proceed distally to free
the rectosigmoid colon from its lat-
eral attachments.
206 Ludwig and Touloukian

7 The dissection then moves up and over the left kidney. Much will be gained by taking this dissection as high and as medial as
possible into the left upper quadrant along the duodenum to the inferior edge of the pancreas even before the lateral attachments
of the descending colon are taken down. The surgeon lifts up on the left colon with his left hand and pushes down on the kidney
with his right hand to expose the plane for the assistant standing on the patient’s left. Before taking down the flexure, the transverse
colon is approached.
8 At the midpoint of the trans-
verse colon, the lesser sac is entered
by taking the omentum off of the
transverse colon. The posterior wall
of the stomach should be visualized
as well as the anterior surface of the
pancreas. The surgeon lifts the
omentum away from the colon with
his left hand and pushes down on
the colon with his right hand. The
omental attachments on the colon
are trapped between the surgeon’s
right index and second finger and
the assistant cuts just over the fin-
gers. This plane should be avascular
and it continues to usually just past
the splenic flexure. The spleen
should, for the most part, be hidden
from view behind the elevated
omentum. During this part of the
operation, the best place for the as-
sistant, especially when a second as-
sistant can help with retraction on
the left costal margin, is between the
patient’s legs looking into the left
upper quadrant.

9 With the omentum off of the

transverse colon, the flexure is mo-
bilized. The surgeon comes behind
the descending colon with his right
hand, palm side up, and exposes the
remaining lateral attachments for
the assistant. The left hand is used to
push down on the colon just at the
flexure. As these final lateral attach-
ments are mobilized, the plane starts
to move medial as the base of the
mesentery follows the inferior edge
of the pancreas. The dissection con-
tinues medially over to the middle
colic vessels.
208 Ludwig and Touloukian

10 The entire left colon is now

mobilized to the midline and the
surgeon incises the peritoneum to
the right of the inferior mesenteric
artery. The incision is first made dis-
tally near the sacral promontory and
then moves more proximally toward
the inferior mesenteric artery’s ori-
gin. The inferior mesenteric vein
should be clearly visible as it courses
along the duodenum. The peritoneal
window just to the left of the duode-
num and just beneath the IMV is in-
cised and the window above the IMV
is incised. The sympathetic nerves
are identified along the anterior sur-
face of the aorta. By staying just be-
hind the IMA they are avoided. The
IMA is clamped and ligated at it’s
origin and the IMV is clamped and
ligated just at the inferior edge of the
pancreas.
Open Left Colon Resection 209

11 With the IMA and the IMV

ligated, the dissection moves up
into the transverse colon mesen-
tery and the marginal vessel is
clamped and ligated. The bowel is
then divided in the mid-transverse
colon with a linear cutting stapler.
210 Ludwig and Touloukian

12 The bowel is now packed into the upper abdomen and attention is turned toward the distal resection line in the upper rectum.
The peritoneum on either side of the rectum is incised and a space is created behind the rectum but in front of the superior
hemorrhoidal vessels. They are taken with clamps and suture ligated. A right angle bowel clamp is placed across the distal sigmoid
and the rectum is washed out from below with betadine. The bowel is then divided distal to the bowel clamp with a stapler.
Open Left Colon Resection 211

13 In most situations the colon is

brought down to the rectum along the left
retroperitoneum and the small bowel is
laid on top of the colon (A). The retro-ileal
route is an alternative in situations where
reach is a problem. A window in the small
bowel mesentery is made between the su-
perior mesenteric artery and the ileocolic
artery. The transverse colon is then
brought through this window, behind the
ileum, to the top of the rectum (B).
212 Ludwig and Touloukian

14 The preferred technique for a colorectal anastomosis after left colectomy is a double staple end-to-end anastomosis. A
proximal pursestring is placed (we generally use an automatic pursestring applier in the interest of efficiency and to minimize
potential contamination) and the circular stapler is brought up from below. The spike is driven through the top of the stump, either
through or immediately adjacent to the transverse staple line. The two pieces of the stapler are then put together and the instrument
deployed. The donuts are checked to be sure they are complete, the pelvis is filled with saline, the proximal bowel is occluded and
an air-leak test is made by insufflating from below with a proctoscope.
Open Left Colon Resection
bowel, division of the mesenteric vessels, colon, and rec-
tum, and routing of the transverse colon down to the
rectum.
While the colorectal anastomosis can be hand-sewn
end-to-end or stapled side-to-end, we prefer an end-to-
end double-stapled anastomosis for ease and efficiency
(Fig 14). Circular staplers less than 28 mm should not be
utilized.
Postoperative management is not different than that
following any major abdominal operation. A nasogastric
tube placed by the anesthesiologist is removed at comple-
tion of the operation, clear liquids are started early, and
the diet is advanced as bowel function returns. Early am-
bulation is encouraged and the urinary catheter is gener-
213
ally removed on postoperative day 3 when the patient is
mobile. Most patients are ready for discharge to home
within a week.
REFERENCES
1. Miles WE: A method of performing abdominoperineal excision for
carcinoma of the rectum and of the terminal portion of the pelvic
colon. Lancet 2:1812, 1908
2. Jemieson VK, Dobson VF: The lymphatics of the colon. Ann Surg
50:1077, 1909
3. Coller FA, Kay EB, MacIntyre RS: Regional lymphatic metastases of
carcinoma of the colon. Ann Surg 114:56, 1941
4. Rosi PA: Selection of operations for carcinomas of the colon. Surg
Clin N Am 34:221, 1954