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There are a number of surgical options for colon cancer.

Their choice is dictated by the localization of the tumor, the prevalence tumor process, features clinical course And general condition sick.

A.M. Ganichkin (1970) divided all the main methods of operations into 5 groups:

1. Simultaneous resections with primary restoration of intestinal continuity through anastomosis.

2. Simultaneous resections with primary restoration of intestinal continuity through anastomosis with the simultaneous application of a discharge fistula.

3. Two-stage resections with external diversion of intestinal contents.

4. Two-stage resections with preliminary internal diversion of intestinal contents through anastomosis.

5. Three-stage operations with preliminary external diversion of intestinal contents.

Simultaneous colon resections with primary restoration of intestinal continuity

Simultaneous resection of the colon with primary restoration of intestinal continuity is the method of choice for uncomplicated colon cancer, and may also be acceptable in case of some complications: bleeding, inflammatory infiltrate. Depending on the location of the tumor, operations of varying scope are performed.

For cancer of the cecum, ascending colon, a right hemicolectomy is performed (Fig. 18.1). This surgery involves removing the entire right half of the colon, including the proximal third of the transverse colon.

Rice. 18.1. Scheme of right hemicolectomy

The ileocolic, right colic and right branches of the middle colic vessels intersect. The distal portion must also be removed ileum 25-30 cm long. Together with the intestines, the posterior layer of the parietal peritoneum with vessels, lymph nodes and retroperitoneal fatty tissue is removed as a single block. An end-to-side or side-to-side anastomosis is performed between the ileum and transverse colon.

For cancer of the right (hepatic) flexure of the colon and the proximal (right) third of the transverse colon, an extended right hemicolectomy should be performed (Fig. 18.2).

Rice. 18.2. Scheme of extended right hemicolectomy

The limits of resection expand to the middle third of the transverse colon. In this case, the middle colonic vessels are intersected. An anastomosis is formed between the ileum and transverse colon.

In cases where the blood supply to the remaining parts of the colon is insufficient, removal of the colon to the proximal part of the sigmoid may become necessary (Fig. 18.3). An anastomosis is performed between the ileum and sigmoid colon.

Rice. 18.3. Scheme of extended right hemicolectomy to the proximal part of the sigmoid colon

For cancer of the middle third of the transverse colon, it is possible to perform two types of radical surgery. With a small local spread of the tumor, without germination of the serous membrane and the absence of metastases to regional lymph nodes, as well as in the serious condition of elderly patients, resection of the transverse colon is permissible (Fig. 18.4).

Rice. 18.4. Transverse colon resection

The volume of resection should be 5-6 cm long sections of intestine on both sides of the tumor edge. In this case, the middle colonic vessels are intersected at the base and the mesentery is removed from lymphatic vessels. Intestinal continuity is restored by end-to-end or side-to-side anastomosis.

When using the latter, it is necessary to additionally mobilize the hepatic and splenic flexures of the colon. With a small length of the transverse colon and its short mesentery, technical difficulties are possible when applying such an anastomosis and there is a real danger of suture failure.

In this regard, the question may arise about the use of a multi-stage operation or the imposition of a discharge fistula, as well as about expanding the scope of the operation, which uses the nature of a subtotal colectomy (Fig. 18.5).

Rice. 18.5. Subtotal colectomy

Subtotal colectomy is considered by many to be the optimal intervention for colon cancer and from the standpoint of oncological radicality. It is known that cancerous tumors the middle third of the transverse colon can metastasize not only to the lymph nodes along the middle colic vessels, but also to the lymph nodes located along the right and left colic vessels and even to the cleocecal group of lymph nodes.

With a subtotal colectomy, the right, middle and left colonic vessels are intersected at the base. The distal ileum, cecum, ascending colon, transverse colon and descending colon are removed.

In this case, anastomosis is performed between the ileum and sigmoid colon. Another variant of this operation is acceptable, in which the cecum is preserved (Fig. 18.6). The conditions for its implementation are the presence of the mesentery of the cecum and the absence of metastases to the lymph nodes along the a.ileocolica and its branches. In this case, an anastomosis is performed between the preserved cecum and sigmoid colon.

Rice. 18.6. Subtotal colproctectomy with preservation of the cecum

Subtotal colectomy is considered by some to be an adequate intervention for cancer of the left (distal third of the transverse colon, splenic" (left) flexure of the colon and descending colon). However, most surgeons perform a left hemicolectomy in these cases.

If the cancer is localized in the left third of the transverse colon and in the area of ​​the splenic flexure, resection is carried out ranging from the middle third of the transverse colon to the mobile part of the upper third of the sigmoid colon (Fig. 18.7) with the intersection of the middle colic vessels and the lower part of the mesenteric artery.

Rice. 18.7. Left hemicolectomy

The intestine is resected proximally in the area of ​​​​the blood supply of the right colic artery and distally in the middle third of the sigmoid colon (Fig. 18.8), this corresponds to an expanded left hemicolectomy. An anastomosis is performed between the mobilized proximal part of the transverse colon and the remaining part of the sigmoid colon.

Rice. 18.8. Extended left hemicolectomy

Cancer of the descending colon in the upper and middle third allows for left-sided hemicolectomy (Fig. 18.9) with anastomosis between the transverse colon and sigmoid colon.

Rice. 18.9. Left hemicolectomy

For cancer of the lower part of the descending colon and any part of the sigmoid colon, the required volume of radical surgery is left-sided hemicolectomy. Resection is performed at the level of the border of the middle and left third of the transverse colon proximally and at the level of the sigmorectum - distally.

The inferior mesenteric vessels are divided. Restoration of intestinal continuity is achieved by anastomosis of the transverse colon with the rectum. In this case, it is necessary to cut the gastrocolic ligament along its entire length and mobilize the hepatic flexure.

In rare cases, with cancer of the middle and lower third of the sigmoid colon of small size and in the absence of metastases in the lymph nodes located at the inferior mesenteric artery, resection of the sigmoid colon is possible with the intersection of the sigmoid and superior rectal arteries, but with preservation of the ascending branch of the inferior mesenteric artery and vein.

Intestinal continuity is restored by anastomosis between the descending and rectum. In all other cases, a complete left-sided hemicolectomy with mandatory removal of the lymph nodes at the root of the inferior mesenteric artery should be preferred.

For cancer of the distal third of the sigmoid colon, the option of its resection, in which the sigmoid rectal arteries are intersected at the point of origin from the inferior mesenteric artery, and the superior rectal artery is preserved, should not be used, since it does not meet the requirements of ablastics.

In these cases, resection of the sigmoid colon should be performed according to the method of S.A. Holdina (1977). In this case, the inferior mesenteric artery is intersected at the point where the left colic artery originates from it. The entire mesentery of the sigmoid colon with vessels and lymph nodes is removed.

The intestine is resected in the distal direction at a distance of at least 5 cm from the edge of the tumor, and in the proximal direction - at least at a distance of 8-10 cm from the tumor. The anastomosis is formed in the pelvis. In elderly and weakened patients, if there are technical difficulties in performing an anastomosis, the operation should be completed using the Hartmann method, when the proximal segment of the intestine is brought out onto the anterior abdominal wall in the form of a colostomy, and the distal segment is sutured tightly.

If the lower third of the sigmoid colon is affected over a large area with transition to the rectum, abdominal-anal resection of the sigmoid and rectum should be used with the reduction of the remaining part of the sigmoid colon by the transectal sphincter (Fig. 18.10).

Rice. 18.10. Volume surgical intervention for cancer of the distal part of the sigmoid colon

In primary multiple syngeronic colon cancer, the choice of method and extent of radical surgery is a difficult task. Depending on the location of the tumor, various operations. In case of multiple synchronous tumors in the right half of the colon, a simultaneous extended right hemicolectomy should be performed. For left-sided localization of multiple tumors, left-sided hemicolectomy is also performed in a more expanded volume than for solitary cancer.

Primary multiple colon cancer localized in the right and left halves, as well as cancer against the background of total polyposis, are indications for total colectomy with removal of the rectum and reduction of the cecum and part of the ascending colon through the anal sphincter or, as an extreme option, total colectomy with application of an ileostomy.

If cancer of one or another part of the colon spreads to neighboring organs and tissues in the absence of distant metastases, then a combined operation is indicated. Complete or partial removal of the affected organs and tissues is performed along with resection of one or another part of the colon. Part may be removed small intestine, spleen, resection of the liver, stomach, excision of the anterior abdominal wall etc. The issue of kidney removal needs to be addressed more carefully.

If the patient is in a weakened condition or in old age, combined operations should be avoided. You should also refrain from surgery if the tumor grows into large vessels: the portal or inferior vena cava, aorta, common iliac arteries and veins.

Simultaneous operations with primary restoration of intestinal continuity with the imposition of an unloading intestinal fistula

The difference between these operations and the previous group is that simultaneously with bowel resection, a discharge fistula is applied. Thus, after a right-sided hemicolectomy, it is possible to impose a fistula on the ileum according to Witzel or perform a hanging ileostomy according to the method of S.S. Yudina.

There have been proposals to place a fistula along the anastomotic line or on the stump of the anastomosed ileum. Currently, these operations have lost their significance and are practically not used for cancer of the right half of the colon.

A correctly applied ileotransverse anastomosis quickly begins to perform an evacuation function. Moreover, there is a well-proven method of nasogastrointestinal drainage according to Wangensteen. Colon emptying can also be significantly improved by re-stretching the anal sphincter.

More often, unloading fistulas are used after one-stage resections for cancer of the left half of the colon. If there is the slightest doubt about the reliability of the blood supply and anastomotic sutures, it is recommended to end the operation with the imposition of a relief fistula. This fistula can be placed on any part of the transverse colon proximal to the anastomosis, as well as on the cecum. Currently, most surgeons rarely resort to the application of these fistulas. This especially applies to the application of a cecostoma, which, according to many, is not capable of adequately unloading the intestines.

Two-stage colon resections with external diversion of intestinal contents have been proposed for the prevention of postoperative peritonitis. Its danger is especially great if surgery is performed for complicated forms of colon cancer. For the first time, the justification for the principle of two-stage operations was formulated by J. Mikulicz. Subsequently, various modifications of these operations were proposed (Grekov I.I., 1928; Hartmann N., 1922; Rankin F.W., 1930; Lahey, 1939, 1946).

Operation I.I. Grekova (1928) combines the principles of external and internal diversion of intestinal contents. After mobilizing the section of the intestine affected by the tumor and suturing the peritoneum and mesentery, a lateral anastomosis is performed between the afferent and efferent segments of the intestine. In case of intestinal obstruction proximal to the tumor, the intestine is opened and the anastomosis is unloaded.

In the absence of obstruction, resection of the section of intestine with the tumor can be performed after 2-4 days. After cutting it off, the ends of the intestine are sutured and gradually, as the wound heals, they are gradually drawn into the abdominal wall. This operation is now rarely used for tumors of the sigmoid colon, complicated by obstruction, necrosis, or perforation.

For cancer of the right half of the colon, Lahey (1946) proposed his own modification of the operation. The transverse colon and part of the ileum are brought out into the wound and sutured with a catgut suture. The suture line is wrapped in omentum and sutured into the abdominal wall. A drainage tube is inserted into the ileum for emptying. After 4-5 days, a specially left section of the ileum is cut off. The septum between the ileum and colon is divided using an enterotribe. After a few months, the fistula is eliminated by excision and suturing of the edges of the intestine.

Another improvement to the two-stage operation was proposed in 1942 by F.W. Rankin. First, the segment of intestine affected by the tumor is removed from the abdominal cavity and a clamp is applied to both parallel pieces of intestine proximal and distal from the tumor. The withdrawn loop is cut off. The clamp is left for several days. The spur is then crushed with a clamp. The second stage is to close the fistula.

More common than those described is the operation of N. Hartmann (1922). It occupies an intermediate position between one-stage and two-stage interventions with external diversion of intestinal contents. The operation is proposed for the treatment of cancer of the sigmoid colon and rectosigmoid region. Its advantage is that resection of the area of ​​the intestine affected by the tumor is carried out in accordance with the oncological principles described above.

The operation does not end with an anastomosis, but with tightly suturing the distal section and bringing the proximal section out as a colostomy. Restoration of intestinal continuity may not be carried out at all or may be performed after a certain time, when the patient’s condition improves and there is confidence in the absence of relapse or metastasis of the tumor.

The use of the Hartmann operation is justified in weakened elderly and senile patients, with complications such as intestinal obstruction, perforation or inflammation with the development of peritonitis. In this case, the tumor is radically removed, conditions are created for external drainage of intestinal contents, and the dangers associated with the anastomosis are mitigated.

A serious disadvantage of this operation is the reduction in quality of life and possible complications due to the presence of a colostomy. Restoring intestinal continuity requires repeated laparotomy and is often associated with certain technical difficulties in mobilizing sections of intestine for anastomosis and its application.

However, reconstructive operations in patients with colostomies after two-stage operations are indicated and effective in most patients. They allow you to restore intestinal function, improve the quality of life and restore ability to work, and provide physical and social rehabilitation.

It is advisable to restore intestinal continuity when the length of the assembled section is more than 10 cm using intraperitoneal colorectal anastomoses. If the length is less than 10 cm and the anal sphincter is preserved, extraperitoneal colorectal and coloanal anastomoses should be recommended with the colon brought down along the side wall of the pelvis without mobilizing the remaining part of the rectum.

Two-stage resections with external diversion of intestinal contents in the treatment of patients with uncomplicated forms of colon cancer are now rarely used. Their feasibility and effectiveness in complicated forms will be assessed in the next section.

Two-stage resection of the colon with internal diversion of intestinal contents

Two-stage resections of the colon with internal diversion of intestinal contents can be used for any location of cancer complicated by intestinal obstruction or paracancrosis inflammation. The first stage of these operations is to perform an interintestinal anastomosis, bypassing the area affected by the tumor. The second stage involves removing the tumor. This idea was first implemented by H. Hochenegg (1895).

Two-stage resection for cancer of the right half consists of a preliminary ileotransverse anastomosis with unilateral or bilateral exclusion (Fig. 18.11).

Rice. 18.11. Two-stage operations for cancer of the right half of the colon. Stage I: application of preliminary ileotransversoanastomosis in various options(a) with one-way (b) or two-way (c) shutdown

After the elimination of intestinal obstruction, a right hemicolectomy is performed in two to three weeks (Fig. 18.12). The most common are conventional ileotransverse anastomosis or unilateral shutdown. Bilateral shutdown is almost never used due to the complexity and presence of an external fistula.

Rice. 12.18. Right hemicolectomy options

Three-stage operations with preliminary external diversion of intestinal contents

The most common type of these interventions is the Zeidler-Schloffer operation. It should be clarified that the authors after whom the operation is named proposed two different, although similar in concept, options.

Schloffer (1903) proposed that in case of cancer of the left half of the colon, the first stage is to perform a laparotomy, in which the possibility of a radical operation in the future is determined and an external fistula is applied to the sigmoid or transverse colon.

In the second stage, resection of the affected area is performed, restoring intestinal continuity using anastomosis, and in the third stage, the colostomy is eliminated. G.F. Zeidler (1897) proposed the first stage to be the imposition of a discharge fistula on the cecum (cecostoma), the second - resection of the colon and the third - closure of the fistula.

IN Lately Most surgeons dispute the possibility of good bowel movement using a cecostomy. In addition, the disadvantage is the multi-stage nature of the operation. However, in a number of patients with cancer of the left half of the colon, which occurs with complications, this operation may be useful.

For cancer of the ileocecal angle complicated by intestinal obstruction, A.M. Ganichkin proposed an original three-stage operation. Its first stage is the application of a double-barreled ileostomy at a distance of 20-25 cm from the ileocecal angle. The second stage consists of a right-sided hemicolectomy, and the third stage involves the implementation of cleotransverse anastomosis.

Yaitsky N.A., Sedov V.M.

Indications: stage 11B-III cancer, left-sided complicated ulcerative colitis, polyposis with malignancy, complicated diverticulitis, etc.

During this operation, the left third of the transverse colon, the left flexure, the descending colon and the sigmoid colon to the middle or lower third are removed (Fig. 25), with the imposition of a transversosigmoid anastomosis (incomplete left-sided hemicolectomy), more often the entire sigmoid colon is removed to the rectum ( Fig. 26) with transversorectal anastomosis or ileocoloplasty (complete left-sided hemicolectomy).

Operation: wide median laparotomy. After opening the abdominal cavity, an inspection is performed. The nature and distribution of the pathological process is clarified. The scope of the operation is outlined.

The loops of the small intestine are moved to the right and fenced off with a damp towel.

To mobilize the left half of the colon, the sigmoid colon is retracted to the midline. Using scissors, the outer layer of the peritoneum is dissected at the root of the mesentery of the sigmoid colon along the left lateral canal, extending the incision under visual control downward to the rectum and upward along the outer edge of the descending colon to the left bend (Fig. 27, a). To facilitate the dissection of the peritoneum and its detachment, a 0.25% solution of novocaine in an amount of 100-120 ml is first introduced under it throughout.

Rice. 26. Complete left-sided hemicolectomy (the inferior mesenteric artery was ligated with a transversorectal anastomosis (diagram).

Rice. 25. Incomplete left-side hemicolectomy (the left colic and sigmoid arteries are ligated) with a transversosigmoid anastomosis (diagram).

The retroperitoneal tissue together with the mesentery is displaced with a tupper towards the intestine. In this case, at the root of the mesentery of the sigmoid colon in the retroperitoneal space, the ureter is exposed, which is retracted outward so as not to damage it during manipulation. The sigmoid colon is retracted outward, while its mesentery is slightly stretched, which allows free dissection of the internal layer of the peritoneum at the root of the mesentery of the sigmoid colon, where the inferior mesenteric artery and its branches are exposed.

With incomplete hemicolectomy, the lower mesenteric artery preserved, but crossed between the clamps and ligated only one or two upper sigmoid arteries (except for the lower) and the left colic artery at the place of their origin from the inferior mesenteric artery (Fig. 27, b). During hemicolectomy for cancer in order to prevent hematogenous metastasis, it is advisable to first ligate the indicated vessels along their length before mobilizing the intestine. For the same purpose, especially with disintegrating cancer, it is recommended to bandage the intestine with two gauze strips 3-4 cm above and below the tumor. In case of incomplete hemicolectomy, the inferior sigmoid artery and the superior rectal artery, which supplies the upper parts of the rectum, are preserved.

With a complete hemicolectomy (see Fig. 26), the inferior mesenteric artery is crossed between clamps at the site of its origin from the aorta and ligated with two silk ligatures (b/o). The incision of the internal layer of the mesentery of the sigmoid colon is continued downward to the rectum and upward, onto the mesentery of the left third of the transverse colon, thereby exposing the inferior mesenteric vein, which is also crossed between the clamps and tied with silk. The next stage of the operation is the mobilization of the left flexure of the colon and the left third transverse colon. To do this, the diaphragmatic-colic ligament is crossed between the clamps and tied with silk, and then the gastrocolic ligament to the middle third of the transverse colon, preserving the vessels of the greater curvature of the stomach. When isolating the left flexure, care must be taken not to damage the vessels of the spleen and tail of the pancreas. In this regard, the transverse colon and descending colon are slightly pulled downward and inward, thereby facilitating access to the diaphragmatic-colic and gastrocolic ligaments. The greater omentum is cut off with scissors to the level of resection of the left third of the transverse colon with ligation of the vessels with 4/0 silk (for cancer of the greater omentum, the entirety of the omentum is removed) .

Rice. 27. Left-sided hemicolectomy. Stages of the operation.

a - dissection of the peritoneum of the left lateral canal, diaphragmatic-colic and part of the gastrocolic ligament with ligation of blood vessels; b - dissection of the mesentery of the sigmoid colon and part of the mesentery of the transverse colon with intersection and ligation of the left colon and sigmoid arteries and veins (the dotted line indicates the boundaries of resection):

1 - left colon artery; 2 - sigmoid artery

After mobilization of the sigmoid colon, descending colon and left flexure with the left third of the transverse colon, check the sufficiency of blood supply to the remaining upper and lower segments and, within healthy, well-supplied areas, apply intestinal clamps to the left third of the transverse colon (closer to the left flexure) and on the mobilized segment of the sigmoid colon or

rectosigmoid section (hard clamps on the part to be removed, soft clamps on the remaining ends of the intestine). The intestine is crossed between the clamps and the entire left half of the colon is removed along with the retroperitoneal tissue. The remaining ends of the transverse colon and sigmoid colon (or rectosigmoid colon) are treated with 3% alcohol solution iodine or 0.02% aqueous solution chlorhexidine. Next, the end of the transverse colon is brought down and a transversosigmoid (or transvesorectal) anastomosis is applied end to end with two rows of interrupted silk sutures according to the usual technique. After anastomosis, the edges of the mesentery are sutured and the integrity of the peritoneum of the left lateral canal is restored. In order to unload the anastomosis, a wide gas outlet pipe beyond the line of anastomosis into the colon. For the same purpose, in case of insufficient bowel preparation or when completing the operation with ileocoloplasty, it is advisable to apply a unloading cecostomy. A drainage tube with one or two side holes is brought to the anastomosis area, which is removed through an incision in the left lumbar region and fixed to the skin. The abdominal wall wound is sutured in layers.

When tensioning the anastomosed ends of the transverse colon and rectum, in order to avoid possible divergence of the anastomosis, it is recommended to cut in parts between the clamps and ligate the gastrocolic ligament to the right bend, and, if necessary, mobilize it by crossing the hepatocolic ligament between the clamps and ligating it. However, sometimes this does not allow the transverse colon to be brought down in order to impose a direct transversorectal anastomosis (with a short, scarred or fatty mesentery, scattered vessels, pericolitis phenomena). In these cases, to avoid the imposition of a permanent unnatural anus, replacement is indicated extensive defect distal sections colon with a gonocolic transplant (ileocoloplasty).

sti (of course, with appropriate indications). For example, this suture can be used after right-sided hemicolectomy for obstruction caused by a tumor on the right side of the colon to create an ileotransserostomy.

If the tumor has spread to neighboring organs, then resection becomes impossible. In this case, as well as if there are widespread metastases in the peritoneum (peritoneal carcypomatosis), in the liver, and the patient is at risk of intestinal obstruction (scarpus scirrhus), one should strive to avoid the occurrence of intestinal obstruction by applying bypass anastomosis: for a tumor of the right side of the colon, an ileotransversostomy is applied, and for a tumor of the splenic flexure or descending colon- transverse sigmoidostomy.

If, with an inoperable tumor, there is no threat of intestinal obstruction, then the abdominal cavity is sutured without any further manipulation, and only tissue is taken from the tumor or any compacted lymph node for histological analysis. Proximal unloading colostomy should be applied only in cases where there is no other option. There is no need to burden the patient’s already short life with troubles associated with a stercoral fistula. If we are afraid of obstruction (with sigmoid colon cancer), then the transverse colon should be placed in a subcutaneous tunnel, so that later, if obstruction occurs, only a small skin incision can be made to perform a colostomy.

Right hemicolectomy

After opening and inspecting the abdominal cavity and making a decision on one intervention or another, the intestine central and distal to the planned cut-off site is ligated. Having felt the pulsating in the mesentery of the ascending part of the intestine right artery colon, it, together with the accompanying vein (and lymphatic vessels) is ligated. This is followed by mobilization of the right half of the colon. On right side of the ascending part of the intestine, from its bend to the cecum, the parietal peritoneum is dissected. The ascending part of the intestine, together with its mesentery, is bluntly pushed in the medial direction (rice. 5-263). The preparation should be made in such a layer that the descending part of the duodenum and its lower horizontal part remain on the posterior abdominal wall, as well as the right internal artery and vein of the spermatic cord extending beyond the duodenum and the right ureter lateral to them.

Then, on the outer side of the hepatic flexure between the ligatures, the hepatocolic ligament is dissected. There are no large ones in this bunch

rice. 5-263. Right hemicolectomy, 1. Mobilization of the colon and mesentery of its ascending part

Rice. 5-264. Right hemicolectomy, II. The mesentery of the ascending colon is divided as close to the center as possible

Principle of right hemicolectomy- oncological resection of the right half of the colon with ligation of the vascular pedicle and corresponding lymphadenectomy.

A) Location. Hospital, operating room.

b) Alternative:
Laparoscopic access.
Extended right hemicolectomy (including both flexures and part of the descending colon).
Hartmann's operation with a long stump and end ileostomy.

V) Indications for right hemicolectomy: cancer of the right colon, diverticular disease, cecal volvulus.

G) Preparation:
Full examination colon in all planned cases, marking (tattooing) of small tumors is desirable.
Mechanical bowel preparation (traditional) or no bowel preparation (an evolving concept).
Installation of ureteral stents in cases of repeated operations or pronounced anatomical changes (for example, inflammation).
Marking the stoma site.
Antibiotic prophylaxis.

d) Stages of right hemicolectomy surgery:

1. Patient position: supine, modified position for perineal stone section (surgeon's preference).
2. Laparotomy: mid-median, right transverse (from the navel), subcostal incision on the right.
3. Installation of an abdominal retractor and hand mirrors for exposure of the right colon.
4. Revision of the abdominal cavity: local resectability, secondary pathological changes (liver/gallbladder, small/large intestine, female genital organs), other changes.

5. Determination of resection boundaries:
A. Cecum/ascending colon: right branch of the middle colic artery.
b. Hepatic flexure: extended right hemicolectomy.

6. Mobilization of the right half of the colon: starts from the ileocecal junction and continues along the lateral canal to the hepatic flexure. Anatomical landmarks: ureter, duodenum (avoid injury!).
7. Dissection of the omental bursa: oncological principles of resection require at least hemiomentectomy on the tumor side; The division of the gastrocolic ligament is carried out in several stages (in case of a benign disease, the omentum can be preserved by separating it from the transverse colon).
8. Identification of the ileocolic vascular bundle: contoured by traction on the cecum towards the right lower quadrant.
9. Oncological ligation (ligation with suturing) of the vessels of the right half of the colon. Before cutting tissue, it is necessary to ensure the safety of the ureter.
10. Step-by-step ligation in the direction of the right branch of the middle colic artery.

11. Crossing the intestine and forming a side-to-side ileotransverse anastomosis with a stapler.
12. Removal and macroscopic examination of the drug: verification pathological changes and resection boundaries.
13. Strengthening the fastening seam with separate interrupted seams.

14. Suturing the window in the mesentery.
15. Drainage is not indicated (except special occasions). There is no need for (NGZ).
16. Suturing the wound.

e) Anatomical structures at risk of damage: right ureter, duodenum, superior mesenteric vein, middle colon artery.

and) Postoperative period: “fast-track” management of patients: taking fluids on the first postoperative day (in the absence of nausea and vomiting) and rapid expansion diets as tolerated.

h) Complications of right hemicolectomy:
Bleeding (associated with surgery): traction on the superior mesenteric vein, inadequate ligation of the vascular pedicle, middle colic artery.
Anastomotic failure (2%): technical errors, tension, inadequate blood supply.
Damage to the ureter (0.1-0.2%).

Left hemicolectomy– a surgical intervention in which resection of the left half of the large intestine is performed with the formation of an anastomosis or a colostomy. Indications for left hemicolectomy include colon cancer, benign and precancerous polyps, Crohn's disease, ulcerative colitis, colonic bleeding, colonic perforation, and sigmoid volvulus. Hemicolectomy is performed laparoscopically (minimally invasive) or open. The operation is performed under general anesthesia epidural analgesia may be used to improve pain relief during surgical intervention and in the postoperative period. Potential complications include deep vein thrombosis, bleeding, infection, intestinal obstruction, and anastomotic leak.

Left hemicolectomy– a surgical intervention in which resection of the left half of the large intestine is performed with the formation of an anastomosis or a colostomy. Indications for surgery include colon cancer, benign and precancerous polyps, Crohn's disease, ulcerative colitis, colonic bleeding, colonic perforation and sigmoid volvulus. Hemicolectomy is performed laparoscopically (minimally invasive) or open. The operation is performed under general anesthesia; epidural analgesia is possible to improve pain relief during surgery and in the postoperative period. Potential complications include deep vein thrombosis, bleeding, infection, intestinal obstruction, and anastomotic leak.

Hemicolectomy is a surgical procedure used in the treatment process various diseases large intestine. Applicable in abdominal surgery, oncology and proctology. The history of colon resections begins in 1832, when Dr. Raybord reported the first successful operation with an interintestinal anastomosis. The first laparoscopic hemicolectomy was performed in the United States in 1990 by Dr. Jacobs.

Depending on the part of the colon to be removed, a distinction is made between left-sided and right-sided hemicolectomy. Both operations are performed open or laparoscopically. In an open hemicolectomy, half of the intestine is removed through a large incision in the abdominal wall. When using the laparoscopic technique, colon resection is performed through small holes under the control of a video camera using endoscopic equipment. The advantage of the open method is that there is no need for expensive laparoscopic equipment, Better conditions visual overview, the ability to obtain tactile information about the condition of the abdominal organs, more low prices. The advantages of laparoscopic hemicolectomy include shorter recovery times, less intensive pain syndrome, absence of large scars, reduced risk infectious complications and postoperative hernias, early restoration of intestinal functions.

Indications

Left-sided hemicolectomy is performed for cancer of the descending colon, sigmoid or rectum, polyposis and diverticulosis of the left half of the colon, ischemic and ulcerative colitis, perforation of the colon, bleeding from the left half of the colon and volvulus of the sigmoid colon.

Contraindications

Absolute contraindications to urgent hemicolectomy according to vital signs No. An example of such a situation would be intestinal perforation with peritonitis. In oncological diseases, hemicolectomy is contraindicated in patients with acute intestinal obstruction and the presence of distant metastases. In such cases, surgeons form a bypass interintestinal anastomosis or remove the stoma, since radical surgical intervention does not improve the patient’s condition, but exposes him to high risk development of complications and causes unjustified delay of systemic chemotherapy. Surgeons must carefully weigh possible benefit and the potential risks of hemicolectomy in each patient.

Elective resection of the left colon is not performed in patients with severe concomitant diseases of cardio-vascular system and blood clotting disorders. Performing hemicolectomy routinely in the presence of acute infection, severe renal or liver failure, decompensated diabetes mellitus, or other systemic diseases possible only after stabilization of the patient's condition.

Contraindications to laparoscopic hemicolectomy include cancer spreading to adjacent organs, big sizes tumors, perforation and intestinal obstruction with severe distension of the colon, the presence of adhesions or scars in the abdominal cavity from previous operations, the inability to pump carbon dioxide due to decompensation of cardiovascular or pulmonary diseases, shock, increased intracranial pressure, severe obesity.

Preparing for surgery

Before the operation, endoscopy of the large intestine (colonoscopy or sigmoidoscopy) is performed, during which, if indicated, a tissue biopsy is performed from the site of the disease to confirm the diagnosis. If it is impossible to use endoscopic techniques perform irrigoscopy - X-ray contrast examination of the intestines with barium administered through an enema. For malignant neoplasms, the examination plan is supplemented with computed tomography and other diagnostic methods, allowing us to clarify the extent of tumor spread. General clinical examination before hemicolectomy includes general analysis blood, general urine test, blood group determination, biochemical analysis blood, fluorography, Wasserman reaction, ECG, consultation with a cardiologist, and, if necessary, other specialists.

Before a planned hemicolectomy, preoperative preparation is carried out, including correction of water and electrolyte metabolism and deficiency nutrients. Treatment is prescribed if necessary concomitant diseases in order to achieve a state of remission or compensation. In addition, before hemicolectomy it is necessary to prevent infectious complications with antibiotics. Intestinal cleansing begins in advance. To do this, the day before surgery, the patient is allowed to drink only clear liquids (water, broth, soup), laxatives are prescribed, and enemas are given. In some cases, the enema is repeated in the morning directly on the day of surgery. Before the intervention, the patient needs to take a hygienic shower.

Methodology

Open and laparoscopic hemicolectomy are performed under general anesthesia. Sometimes, for postoperative pain relief and to reduce the dose of administered narcotic substances, epidural anesthesia is performed before surgery. To accurately measure the amount of urine during surgery and in the early postoperative period, catheterization is performed Bladder Foley catheter. For the purpose of decompression, a gastric tube is installed.

An open hemicolectomy is performed through a single large midline incision in the abdominal wall. After opening the abdominal cavity, an inspection is carried out, with oncological pathology pay Special attention on the condition of the liver and other organs in order to detect metastases. To reduce the risk of possible spread of malignant cells, the neoplasia is covered with a damp cloth, and the arteries supplying it are ligated and crossed as quickly as possible. Between the clamps, the mesentery of the left half of the large intestine is mobilized, stitching and ligating the blood vessels.

The splenic flexure of the colon is mobilized by dividing the phrenic-colic ligament. After this, soft clamps are applied to the intestine and crossed from the proximal and distal sides. Holding the intestinal stumps on clamps, a transversorectal anastomosis is formed according to the “end to end” type (anastomosis between the transverse colon and rectum). Then the hole in the mesentery is sutured and the integrity of the parietal peritoneum is restored. In some cases (for example, with intestinal obstruction or peritonitis), interintestinal anastomosis is not indicated; surgeons create a colostomy on the abdominal wall, and the distal intestinal stump is sutured. At the end of the operation, sutures are placed on the tissue of the anterior abdominal wall, and the wound is drained.

Laparoscopic technique

In a laparoscopic hemicolectomy, the operation is performed through several small holes. Surgeons insert the first trocar near the navel, carbon dioxide is supplied through it and a video laparoscope is inserted, with the help of which a thorough examination of the abdominal cavity is performed. The second (suprapubic) trocar is inserted to the right of the midline, the third - below the right hypochondrium along the midclavicular line, the fourth - into the left lower quadrant of the abdomen. The first stage of laparoscopic left hemicolectomy consists of dissecting the fold of peritoneum in the area of ​​the lateral left canal. To do this, using a laparoscopic clamp, the sigmoid colon to the midline and cut the fold with laparoscopic scissors. After mobilizing the left half of the colon, the mesenteric vessels are isolated and ligated with clips, then crossed with scissors.

If pathological process is localized in the upper part of the left half of the large intestine, the colon is removed through an incision in the abdominal wall, and resection and formation of an interintestinal anastomosis are carried out externally. After this, the colon is returned to abdominal cavity, the incision of the anterior abdominal wall is sutured and pneumoperitoneum is restored. If the pathological process is located in the lower part of the left half of the colon (the area of ​​the sigmoid and rectum), it is impossible to bring the affected part out. In this case, resection and anastomosis using a laparoscopic stapler are performed inside the abdominal cavity. After the anastomosis is formed, drains are installed, carbon dioxide is released from the abdominal cavity and the holes are sutured.

After left hemicolectomy

After the operation, the patient is taken to the ward of the specialized department or to the anesthesiology department and intensive care, where his condition is monitored. Infusion therapy, antibiotics and painkillers are continued, and deep vein thrombosis is prevented. After 24 hours, the patient is allowed to drink clear liquids. If the body absorbs them and the intestines begin to function, the diet is slowly expanded. Otherwise, infusion therapy is continued and parenteral nutrition is prescribed. Activation of patients begins the next day after surgery.

Sometimes in the postoperative period, patients develop intestinal paresis. To eliminate paresis, sufficient infusion therapy, adequate pain relief, correction of electrolyte imbalance and early activation. Patients with vomiting and bloating may experience relief after insertion nasogastric tube, although this measure in itself does not eliminate intestinal paresis. Introduction narcotic drugs worsens intestinal peristalsis Therefore, it is better to use epidural analgesia for pain relief. Sometimes, with paresis, drug stimulation of the intestines is required, but it should be started only if other methods are ineffective and not from the first day postoperative period. Proserin is used for stimulation (the use of the drug is limited side effects), metoclopramide and alvimopan. After a few days, the drains are removed from the abdominal cavity.

After laparoscopic hemicolectomy, the sutures are removed on days 6-7, and after open surgery - on days 9-10. The patient is then discharged home. After discharge, daily short hiking with a gradual increase in duration. It is allowed to go down and up the stairs, in initial period recovery, the patient needs the help of another person. Immediately after discharge, you can lift weights up to 5 kg; after a month, the weight of the load can be gradually increased.

Showering can be done two days after laparoscopic surgery (if the patient is able to do so). The incision sites should be washed carefully, without using soap, followed by thorough drying. With open hemicolectomy hygiene procedures must be postponed until the sutures are removed. Working capacity is usually restored within 6-8 weeks. If colon resection was performed for malignant neoplasm, after receiving the results of histological examination, the patient may need chemotherapy.

Complications

The development of complications is possible after any surgery, including hemicolectomy. Complications of this intervention include adverse reactions for anesthesia, bleeding into the abdominal cavity, toxic-infectious processes, intestinal obstruction, anastomotic leakage, deep vein thrombosis and cardiovascular events.

Cost of left-sided hemicolectomy in Moscow

One of the main factors influencing the price of the operation is the type of intervention (using laparotomy or laparoscopic access). Laparoscopic techniques are more expensive than traditional ones due to the need to use special equipment and involve specialists who have undergone appropriate training. In addition, the price of left-sided hemicolectomy in Moscow may vary depending on the order of the operation (planned or emergency), type medical institution(private or public), volume of preoperative preparation, duration of hospitalization, presence of complications, list therapeutic measures before and after the intervention.