Overview
Definition:
Transverse colectomy is a surgical procedure involving the removal of a segment of the transverse colon
Intracorporeal anastomosis refers to the creation of a new connection between the two cut ends of the bowel within the abdominal cavity, typically performed laparoscopically
This technique aims to minimize external incisions and improve patient recovery.
Epidemiology:
Indications for transverse colectomy include malignancy, inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis), diverticulitis with complications, and ischemic colitis
While specific incidence data for isolated transverse colectomies are scarce, large bowel resections for these conditions are common in surgical practice
Laparoscopic approaches are increasingly favored.
Clinical Significance:
This procedure is critical for managing various pathologies affecting the transverse colon, which is prone to volvulus, tumors, and extensive inflammatory processes
Laparoscopic intracorporeal anastomosis offers advantages such as reduced postoperative pain, shorter hospital stays, and improved cosmesis compared to open techniques, making it a key skill for surgical residents preparing for DNB and NEET SS examinations.
Indications
Malignancy:
Primary tumors of the transverse colon, including adenocarcinomas and neuroendocrine tumors
Metastatic disease to the transverse colon may also be resected.
Inflammatory Bowel Disease:
Severe, refractory Crohn's disease or ulcerative colitis involving the transverse colon that fails to respond to medical management or leads to complications like perforation or obstruction.
Diverticular Disease:
Complicated diverticulitis involving the transverse colon, such as perforation, abscess formation, or obstruction, particularly in cases of failure of conservative management or recurrent episodes.
Ischemia:
Segmental ischemia or infarction of the transverse colon due to mesenteric vascular compromise.
Obstruction And Perforation:
Acute colonic obstruction or free perforation of the transverse colon requiring resection and anastomosis.
Preoperative Preparation
Patient Assessment:
Thorough evaluation of patient's comorbidities, nutritional status, and cardiopulmonary reserve
Assessment of the extent and nature of disease via imaging (CT scan).
Bowel Preparation:
Mechanical bowel preparation (e.g., polyethylene glycol or sodium phosphate solutions) and often oral antibiotics (e.g., neomycin and metronidazole) to reduce bacterial load and risk of anastomotic leak.
Imaging:
Contrast-enhanced CT scan of the abdomen and pelvis to delineate the extent of disease, assess vascular supply, and rule out distant metastases
Colonoscopy may be performed preoperatively to rule out synchronous lesions.
Anesthesia And Consent:
General anesthesia with adequate muscle relaxation
Informed consent obtained covering risks, benefits, alternatives, and potential for conversion to open surgery.
Procedure Steps
Trocar Placement:
Typically, four or five trocars are inserted to allow for adequate triangulation and instrument manipulation
Initial port placement depends on the surgeon's preference and operative findings.
Mobilization Of Colon:
The transverse colon is mobilized by dividing its mesentery, preserving adequate vascular arcades
Careful identification and preservation of the middle colic artery and vein are crucial, depending on the planned resection margin.
Division Of Bowel:
The colon is divided proximally and distally to the diseased segment using laparoscopic staplers or energy devices
Specimen retrieval is usually performed through a wound protector in a laparoscopic bag.
Intracorporeal Anastomosis:
Creation of the anastomosis within the peritoneal cavity using either hand-sewn techniques or, more commonly, laparoscopic stapling devices (linear or circular staplers)
The choice of stapler size depends on the diameter of the bowel ends
Careful inspection for hemostasis and air-tightness of the anastomosis is performed.
Drainage And Closure:
Placement of a drain if deemed necessary
All port sites are closed, with fascial closure for larger ports (>10mm) to prevent incisional hernias.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and abdominal distension
Regular assessment for signs of anastomotic leak, such as fever, tachycardia, abdominal pain, and leukocytosis.
Pain Management:
Multimodal analgesia including patient-controlled analgesia (PCA), oral analgesics, and judicious use of opioids
Early mobilization is encouraged.
Dietary Advancement:
Gradual advancement of diet, starting with clear liquids once bowel function returns (e.g., passage of flatus)
Patients are typically encouraged to ambulate and resume oral intake as tolerated.
Complication Surveillance:
Vigilant monitoring for surgical site infections, ileus, and anastomotic leaks
A low threshold for investigative imaging (e.g., CT scan) if anastomotic leak is suspected.
Complications
Early Complications:
Anastomotic leak: a serious complication leading to peritonitis, sepsis, and potential need for reoperation
Intra-abdominal abscess
Bleeding: from staple lines or mesenteric defects
Injury to adjacent organs: spleen, stomach, duodenum, small bowel.
Late Complications:
Bowel obstruction due to adhesions
Incisional hernia at port sites
Stenosis of the anastomosis leading to obstructive symptoms
Chronic pain.
Prevention Strategies:
Adequate bowel preparation
Meticulous surgical technique with preservation of blood supply
Use of appropriate stapler sizes
Careful inspection of the anastomosis for leaks and hemostasis
Judicious use of drains
Early mobilization and proactive management of postoperative complications.
Key Points
Exam Focus:
Indications for transverse colectomy, contraindications to laparoscopic approach, critical steps in mobilization and division, types of intracorporeal anastomosis, and management of potential complications like anastomotic leak
Knowledge of bowel preparation protocols and postoperative care is essential for DNB/NEET SS.
Clinical Pearls:
Always assess the viability of the bowel ends before anastomosis
Ensure adequate length of bowel is mobilized to avoid tension on the anastomosis
Consider diverting ileostomy for high-risk patients or uncertain anastomotic integrity
Thorough preoperative counseling regarding potential for stoma formation is vital.
Common Mistakes:
Inadequate bowel preparation
Insufficient mobilization leading to tension
Poor staple line integrity or miscalculation of stapler size
Failure to identify and manage adjacent organ injuries
Delayed recognition of anastomotic leak
Over-reliance on drains without active investigation of suspected leaks.