Chapter 23. Colectomy

• Colon cancer.
• Colon polyps not amenable to colonoscopic polypectomy.
• Diverticular disease.
• Perforation of the colon for which ostomy is not needed.
• Inflammatory bowel disease.
• Volvulus.
• Stricture.
• Ischemia.
• Bleeding.
• Slow-transit constipation refractory to medical therapy.

• Widely metastatic colon cancer that is nonoperative or requires a palliative ostomy.
• Severe peritonitis requiring diverting ostomy, in which primary anastomosis would have an unacceptable leak rate.
• Hemodynamic instability requiring expeditious ostomy, making primary anastomosis inappropriate.

• The patient should be supine, with the entire abdomen prepared and draped.
• Consider lithotomy position if splenic flexure mobilization may be necessary, and for sigmoid colectomy.

• Diet is advanced as tolerated after confirming flatus.
• A Foley catheter is inserted to monitor adequacy of urine output for the first 24 hours.
• β-Blockade is continued if appropriate.
• Deep vein thrombosis prophylaxis should be continued.
• Patients are encouraged to be ambulatory and should be out of bed three times daily on postoperative day 1.

Intraoperative and Technical

• Injury to the ureter.
• Injury to the duodenum.
• Injury to other bowel.
  • Small deserosalizations can be repaired with Lembert stitches. Care should be taken to avoid grasping the bowel during the operation. Epiploic appendages should be grasped instead.
• Injury to the spleen.
  • A topical hemostatic agent can be applied or splenorrhaphy or splenectomy performed.
• Inadequate blood supply at the anastomosis.
  • Additional bowel should be resected. Consider using Doppler ultrasound to evaluate blood flow to the anastomosis if concerned.
• Anastomosis under tension.
  • Additional bowel can be mobilized.
• Stool spillage and tumor cell spillage, creating the potential for abscess or "drop metastases."
  • Noncrushing bowel clamps should be used proximal and distal to the line of colonic division.

Early Postoperative Period

• Wound infection.
  • Staples should be removed as needed, followed by confirmation that fascia are intact. The wound should then be packed and allowed to heal by secondary intention.
• Anastomotic leak.
  • In some patients, tachycardia may be the only sign; others may have prolonged ileus or appear septic.
• Intra-abdominal abscess.
  • Typically diagnosed by CT scan on postoperative days 5–7.
  • Can often be treated using a percutaneous drain placed by the radiology service.
  • May be secondary to an anastomotic leak.
• Colocutaneous fistula.

Late Postoperative Period

• Anastomotic stricture.
• Anastomotic recurrence of cancer.
• Incisional hernia.
• Internal hernia.
• Ureteral stricture from ureteral devascularization.