Video Summary

This is a demonstration of an open left hemicolectomy with lateral-to-medial approach to mobilize the left colon. The technique involves dissection of the bloodless embryonic fusion plane between the mesocolon and the retroperitoneum and begins with dissection inferior and posterior to the IMA and continues superiorly to the IMV.

Video

Teaching Points

1. Patient preparation
   1. In a 74-year-old woman, a proximal sigmoid cancer was found. Histopathology report showed moderately differentiated adenocarcinoma with lymphovascular invasion. Computed tomography of the chest, abdomen, and pelvis showed no distant metastasis. CEA level should be assessed before treatment initiation.
   2. The patient underwent bowel preparation with enemas and injection of low-molecular-weight heparin before surgery.
   3. Just before the surgery, patient received antibiotics (500 mg of metronidazole and 1.5 g of cefuroxime).
2. Patient position
   1. Patients placed with both arms positioned 90 degrees from the patient and both legs slightly spread.
   2. Avoid patient slipping.
3. Critical steps
   1. The rectosigmoid is grasped and lifted up and medially. Lateral-to-medial dissection was performed: white line of Toldt. Identify the plane between the Gerota and mesocolic fascia. Preserve the fascia.
   2. Identify and preserve the left ureter and gonadal vessels.
   3. Medial infrainferior mesenteric artery (IMA) dissection.
   4. Identify and preserve the hypogastric plexus and hypogastric nerves.
   5. Infrainferior mesenteric artery division under no tension (with left ureter seen).
   6. Inferior mesenteric vein (IMV) ligation just below the lower pancreatic border (without tension).
   7. Splenic flexure mobilization after entering lesser sac and freeing transverse colon, “dropping down” the pancreas for sufficient bowel length.
4. Technical pearls/tips
   1. Use no tension when dissecting IMA and IMV.
   2. Clean lymph nodes from the roots of IMA. Ligate it 2 cm from aorta; will preserve the nerves.
   3. If you are doing high ligation or complete mesocolic excision, you have to ligate 1 to 2 cm after branching the aorta with clearing these apical lymph nodes. If you are performing the D2 lymph node dissection, left colic artery may be preserved. There is also the third option: preserving the left colic artery and clearing the apical lymph nodes as it is performed in some Asian countries.
   4. Always see the left ureter before clipping the IMA.
   5. Effective use of assistant for optimal exposure: traction and countertraction.
   6. Use tattooing if the tumor is small and not in the cecum.
5. Potential areas for injury/complication
   1. Be careful with IMV; if avulsion happens, vein will hide beneath the pancreas.
   2. Be careful dissecting IMV; avoid injury to pancreas and duodenum.
   3. When entering the lesser sac just above the pancreas, the Moskowitz artery can be injured. If the artery is met here, abort the medial-to-lateral mobilization of splenic flexure.
   4. Always keep in the avascular plane during the total mesorectal excision. Avoid tearing.
   5. While mobilizing the splenic flexure, avoid tension; see the spleen and preserve it.
   6. Always find and preserve the left ureter.