Colon Resection

11/3/21, 8:44 AM Overview of colon resection - UpToDate
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Overview of colon resection

Author: Miguel A Rodriguez-Bigas, MD
Section Editor: Martin Weiser, MD
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2021. | This topic last updated: Jun 23, 2020.
INTRODUCTION
Colon resection is needed to manage a variety of malignant and benign colon lesions, including
trauma. Planning colon resection needs to take into account the nature of the lesion and its
location within the colon.
The general issues surrounding resecting the colon are reviewed here. Techniques for colon
resection are reviewed separately. (See "Right and extended right colectomy: Open technique"
and "Left colectomy: Open technique" and "Minimally invasive techniques: Left/sigmoid
colectomy and proctectomy" and "Right and extended right colectomy: Minimally invasive
techniques".)
INDICATIONS FOR COLON RESECTION
The indications for colon resection include benign and malignant conditions.
Malignancy
● Malignant and premalignant colon lesions (see "Surgical resection of primary colon
cancer")
● Appendiceal cancer (see "Well-differentiated neuroendocrine tumors of the appendix")
● Colonic carcinoid (see "Staging, treatment, and post-treatment surveillance of non-

metastatic, well-differentiated gastrointestinal tract neuroendocrine (carcinoid) tumors",
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section on 'Colon')
● Colonic gastrointestinal stromal tumors (GIST) (see "Local treatment for gastrointestinal
stromal tumors, leiomyomas, and leiomyosarcomas of the gastrointestinal tract", section
on 'Colon and rectum')
● Metastatic tumor
Benign disease
● Crohn disease (see "Overview of medical management of high-risk, adult patients with
moderate to severe Crohn disease")
● Colon polyp unresectable through a colonoscope (see "Overview of colon polyps")
● Colonic ischemia (see "Colonic ischemia")
● Colon trauma (see "Traumatic gastrointestinal injury in the adult patient", section on
'Colorectal injuries')
● Fulminant Clostridioides (formerly Clostridium) difficile colitis
● Volvulus (see "Cecal volvulus" and "Sigmoid volvulus")
CONTRAINDICATIONS
An absolute contraindication to elective resection may occur when the clinician estimates that
the operative risks outweigh the benefits of surgery, which could be due to patient
comorbidities or extent of disease. As an example, patients with widespread metastatic disease
and asymptomatic primary tumor will not benefit from definitive colectomy and should not be
subjected to the procedure. (See 'Medical risk assessment' below and "Surgical resection of
primary colon cancer", section on 'Complicated disease'.)
Relative contraindications include those patients with no social support and/or psychological
issues where the magnitude of the procedure could be crippling and the patients would not be
able to take care of themselves.
PREOPERATIVE EVALUATION
Medical risk assessment — Prior to elective colon surgery, major medical conditions should be
identified and optimized before proceeding. (See "Evaluation of cardiac risk prior to noncardiac
surgery" and "Evaluation of preoperative pulmonary risk".)
Patients with colon cancer are older and tend to have more comorbidities and a higher
incidence of postoperative morbidity and mortality; otherwise, their disease prognosis is
comparable to that of younger patients [1]. (See 'Perioperative morbidity and mortality' below
and "Overview of the management of primary colon cancer", section on 'Prognosis'.)
In older patients, it is also important to assess nutritional status and the level of social support.
The clinician should identify any patient who lives alone to allow social services to identify any
relevant issues and identify a nursing facility for temporary placement during the patient's
recovery. Until this is settled, elective colectomy can be postponed.
The same factors should be considered for emergency colectomy as for elective colectomy,
except that at times there is no time for a complete evaluation due to the nature of the
emergency.
Preoperative imaging — Prior to colon resection, regardless of indication, a contrast-enhanced

computed tomography (CT) scan of the abdomen and pelvis should be obtained. If the patient
has a cancer, clinically staged II or higher, then a CT scan of the chest is also warranted. Under
most circumstances, contrast-enhanced CT scan should provide adequate information
regarding the mesenteric vasculature, such that standard arteriography is rarely needed. (See
"Surgical resection of primary colon cancer", section on 'Preoperative evaluation' and "Clinical
presentation, diagnosis, and staging of colorectal cancer", section on 'Staging'.)
PREOPERATIVE PREPARATION
Intravenous antimicrobial prophylaxis — The general issues surrounding the use and timing
of intravenous antimicrobial prophylaxis for prevention of surgical site infection following
gastrointestinal procedures are discussed separately ( table 1 and table 2) [2]. Prior to
elective colon surgery, we recommend intravenous antibiotic prophylaxis. We do not continue
prophylaxis (intravenous or oral) postoperatively. (See "Antimicrobial prophylaxis for prevention
of surgical site infection following gastrointestinal procedures in adults" and "Antimicrobial
prophylaxis for prevention of surgical site infection in adults", section on 'Timing'.)
Bowel preparation — In patients undergoing elective colon resection, we suggest the use of a
mechanical bowel preparation combined with oral antibiotics:
● Mechanical bowel preparation is usually accomplished with polyethylene glycol solution.
● Oral antibiotics should follow mechanical bowel preparation in the afternoon or evening
before surgery. Three repeated doses of one of the following combinations of antibiotics
are given orally over a period of approximately 10 hours [3]:
• Neomycin sulfate 1 gram and erythromycin base 1 gram, or
• Neomycin sulfate 1 gram and metronidazole 1 gram.
Our suggestion is consistent with surgical site infection guidelines issued by the American
College of Surgeons and Surgical Infection Society (2017) [4] and the American Society of
Colorectal Surgeons (2019) [5].
Traditionally, mechanical bowel preparation was used with oral antibiotics to prepare for all
elective colon surgeries [3,6]. Subsequently, several randomized trials reported no benefit from
mechanical bowel preparation [7-9], oral antibiotics [10], or both [11]. As a result, the practice of
colon resection without preoperative bowel preparation (and without oral antibiotics) became
widespread.
However, results from several studies suggest that the use of mechanical bowel preparation
combined with oral antibiotics is associated with more favorable outcomes [12-16], despite a
potential increase in the rate of C. difficile infection in some [13,17] but not other studies [18].
According to a meta-analysis, preoperative antibiotics were associated with a higher rate of C.
difficile infection among four trials but not among six comparative cohort studies. However, the
absolute incidence was extremely low at <1 percent [19].
The best data come from three large retrospective cohort studies of the American College of
Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted colectomy data
[14,20,21]. In the largest study, 45,724 elective colectomies with anastomosis were performed
from 2012 to 2015: 37 percent after both mechanical bowel preparation and oral antibiotics, 33
percent after mechanical bowel preparation only, 4 percent after oral antibiotics only, and 25
percent with no bowel preparation [20]. Compared with other bowel preparation strategies, the
combination of mechanical bowel preparation and oral antibiotics was associated with lower
rates of surgical site infection (2.9 versus 4.6 percent with oral antibiotics only, 5.9 percent with
mechanical bowel preparation only, and 6.7 percent with no preparation), anastomotic leaks (2.2
versus 2.9, 3.5, and 4.2 percent), overall complications (10 versus 13.2, 15, and 17.3 percent),
and 30 day mortality (0.4 versus 0.8, 0.7, and 1.4 percent). By multivariate analyses, the
combination of mechanical bowel preparation and oral antibiotics, compared with no
preparation, was associated with few surgical site infections in right colectomy (odds ratio [OR]
0.40, 95% CI 0.33-0.50), left colectomy (OR 0.57, 95% CI 0.47-0.68), and segmental colectomy (OR
0.43, 95% CI 0.34-0.54); the same combination was associated with fewer anastomotic leaks in
left (OR 0.50, 95% CI 0.37-0.69) and segmental colectomy (OR 0.53, 95% CI 0.36-0.80).
Similarly, a 2015 meta-analysis of seven randomized trials showed that, compared with patients
who received a mechanical bowel preparation, patients who received oral antibiotics plus a
mechanical bowel preparation had a significantly lower rate of overall surgical site infection (7
versus 16 percent) and superficial surgical site infection (5 versus 12 percent) but not deep
surgical site infection (4 versus 5 percent) [22].
In most studies, oral antibiotics were coadministered with mechanical bowel preparation to a
majority of patients. Given the existing data, oral antibiotics are best administered in
conjunction with mechanical bowel preparation for bowel preparation before elective colorectal
surgery. This recommendation is consistent with the World Health Organization global
guidelines for the prevention of surgical site infection [23]. In a network meta-analysis of 38
randomized trials, mechanical bowel preparation with oral antibiotics was associated with the
lowest risk of surgical site infection. Oral antibiotics only were ranked as the second best, but
based on limited data. There was no difference in surgical site infection rate between
mechanical bowel preparation only and no preparation [24].
In rare situations where mechanical bowel preparation is contraindicated, there is suggestion

that oral antibiotics should be administered anyway. In one study, preoperative antibiotics,
independent of mechanical bowel preparation, were associated with lower morbidity and
mortality rates compared with no oral antibiotics, although only 4 percent of the study cohort
received oral antibiotics only [20].
Selective decontamination of the digestive tract (SDD), a concept of using orally administered,
nonabsorbable antibiotics and fungicides to eliminate pathogenic bowel organisms, has been
shown to benefit patients in the intensive care unit [25] and undergoing esophagogastric [26] or
gastrointestinal surgery [27]. In the SELECT trial, a combination of amphotericin B, colistin, and
tobramycin administered for six or more days perioperatively in patients undergoing colorectal
cancer surgery reduced the overall rate of infectious complications but not anastomotic leaks
compared with no oral antibiotics [28]. More data are required before SDD can be
recommended for routine use. Until then, our suggestion for oral antibiotics is described above.
Prophylactic ureteral stenting — The key to preventing ureteral injury is intraoperative

identification. Placement of ureteral stents can help identify the ureters but will not prevent
injury. Some surgeons routinely consult a urologist to have ureteral stents placed. However, a
more selective approach may be prudent, only placing ureteral stents for those patients at high
risk for ureteral injury, such as those with bulky tumors, obesity, undergoing reoperations
(benign or recurrent disease), prior pelvic surgery, and/or prior radiation. (See "Placement and
management of indwelling ureteral stents".)
Thromboprophylaxis — Patients undergoing colon resection frequently are at moderate-to-

high risk for developing a deep venous thrombosis (DVT) given their age, presence of
malignancy, and nature and duration of surgery ( table 3) [29].
Patients identified as having moderate-to-high risk of developing a venous thromboembolic

event (DVT or pulmonary embolism [PE]) should be given chemical thromboprophylaxis in
addition to mechanical prophylaxis. Chemical prophylaxis is typically administered as
subcutaneous injections of unfractionated heparin or low-molecular-weight heparin starting
either immediately before surgery or shortly thereafter.
In a randomized trial of 376 patients undergoing colorectal surgery, patients who received
chemical prophylaxis before surgery had similar rates of DVT postoperatively (1.6 versus 2.6
percent) and at 30 days (1.6 versus 3.6 percent) compared with those who only received
chemical prophylaxis postoperatively [30]. The two groups of patients had similar rates of
bleeding events that required reoperation (0.5 versus 1.6 percent). No PE was reported in either
group. Thus, when the first dose of chemical prophylaxis should be given remains unclear and
continues to be dictated by surgeon preferences and local practices.
DVT prophylaxis in surgical patients, including the duration of therapy, is discussed in detail
separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical
patients", section on 'Selecting thromboprophylaxis' and "Prevention of venous
thromboembolic disease in adult nonorthopedic surgical patients".)
Anticipated splenectomy — When the surgeon anticipates that left hemicolectomy will require
splenectomy (eg, large splenic flexure cancers, local invasion of the spleen), vaccination to
prevent sepsis should ideally be administered two weeks prior to colon surgery [31]. Specific
vaccines and vaccine schedules are discussed elsewhere. (See "Prevention of infection in
patients with impaired splenic function", section on 'Vaccinations'.)
MINIMALLY INVASIVE COLON RESECTION
Several systematic reviews and meta-analyses of randomized trials have compared outcomes
for open versus laparoscopic colectomy for patients undergoing resection for colon cancer,
diverticular disease, and colitis [32-37]. Although laparoscopic colectomy may take longer than
open colectomy, it is associated with short-term benefits, fewer complications, and no
differences for long-term outcomes. Thus, for patients with uncomplicated localized colon
disease not involving or invading adjacent organs, and who have not had prior extensive
abdominal surgery, we suggest laparoscopic colectomy rather than open colectomy whenever a
surgeon experienced with advanced laparoscopic colectomy techniques is available, provided
there are no contraindications to the technique (eg, severe pulmonary disease).
Short-term (perioperative) outcomes — Laparoscopic colon surgery has been associated with

a lower perioperative morbidity in most studies and a lower perioperative mortality in some
reports.
In a review of National Surgical Quality Improvement Program (NSQIP) data that included
12,455 laparoscopic and 33,190 open colectomies performed between 2005 and 2008, overall
morbidity was 34.9 percent for open colectomy and 19.9 percent for laparoscopic colectomy
[38]. In a separate review of the same database, patients undergoing laparoscopic colectomy
between 2006 and 2007 had significantly fewer superficial wound infections (6.6 versus 10.3
percent), deep wound infections (1.0 versus 2.4 percent), organ space infections (2.4 versus 4.3
percent), and wound dehiscence rates (0.85 versus 2.7 percent) [39].
In another study using the same dataset (2005 to 2008), patients who underwent laparoscopic
surgery were 2.3- to 5.5-fold less likely to have a severe complication (Dindo-Clavien Class 4 or 5
( table 4)) than those who underwent open surgery [40]. The odds ratio remained between 1.6
and 2.2, favoring laparoscopic surgery after multivariable adjustment [40].
Long-term outcomes — Laparoscopic surgery is associated with less intra-abdominal adhesion

formation, which could reduce the risk of postoperative bowel obstruction. The best evidence
comes from a 2016 meta-analysis of 24 randomized trials and 88 observational studies.
Compared with open surgery, laparoscopic surgery was associated with fewer early (106
studies, odds ratio [OR] 0.62, 95% CI 0.54-0.72) and late (12 studies, OR 0.61, 95% CI 0.41-0.92)
postoperative bowel obstructions [41].
Laparoscopic colectomy can be performed with the single-incision technique or the standard
multiport technique. In a randomized trial involving 200 patients, single-incision laparoscopic
colectomy was not superior to standard laparoscopic colectomy except for requiring a shorter
total skin incision length (4.4 versus 6.8 cm) [42]. Single-incision laparoscopic techniques are
discussed elsewhere. (See "Abdominal access techniques used in laparoscopic surgery", section
on 'Single-incision ports and placement'.)
Robotic colectomy — Robot-assisted laparoscopic procedures combine the advantages of the

laparoscopic approach (eg, less postoperative pain, faster recovery) with the advantages of the
open approach (eg, high-quality three-dimensional vision, restoration of the eye-hand-target
axis) [43-45]. The disadvantages of robotic surgery include high cost, long intraoperative setup
times, and long procedure times [46]. There are no data from randomized trials comparing
survival and disease-related outcomes for procedures performed by the robotic-assisted
approach with either the open or the laparoscopic approach.
Nevertheless, a population-based study of Medicare beneficiaries undergoing colectomy

reported that the proportional use of robotic colectomy rose from 0.7 percent in 2006 to 10.9
percent in 2010 in all hospitals and from 0.8 to 32.8 percent in hospitals with the highest
adoption rate of robotic colectomy [47]. In those hospitals, robotic colectomy displaced
laparoscopic colectomy (43.8 to 25.2 percent) more than it did open colectomy (55.4 to 41.9
percent). In this study, robotic colectomy was associated with minimal safety benefit over open
colectomy (17.6 versus 18.6 percent of overall complication rate) and no benefit over
laparoscopic colectomy. Another study reported that the use of robotic colectomy increased
from 2.5 to 16.3 percent from 2012 to 2018 using data from the Michigan Surgical Quality
Collaborative [48].
Techniques of minimally invasive colorectal resection are discussed elsewhere. (See "Minimally
invasive techniques: Left/sigmoid colectomy and proctectomy" and "Right and extended right
colectomy: Minimally invasive techniques".)
COLON RESECTION
Types of colon resection — Types of colon resection are described below. Resections are based
anatomically on the location of the lesion, blood supply ( figure 1 and figure 2) and, for
malignant lesions, the lymphatic drainage of the colon ( figure 3). Resection margins must be
chosen to ensure adequate blood supply in the remaining colon. (See "Left colectomy: Open
technique" and "Right and extended right colectomy: Open technique".)
● Segmental colectomy – Segmental resection, which removes only an affected portion of

bowel, can be performed when a lesser resection is indicated (eg, trauma, polyp), provided
the anastomosis will be performed in well-vascularized bowel ( figure 4).
● Ileocecectomy – Ileocecectomy resects a portion of the distal ileum and the cecum (
figure 5).
● Right hemicolectomy – Right hemicolectomy removes a portion of the distal ileum, the
cecum, ascending colon, and the transverse colon to the right of the middle colic artery (
figure 6A-B).
● Extended right hemicolectomy – Extended right hemicolectomy expands right

hemicolectomy to include the transverse colon over to the splenic flexure ( figure 7).
● Transverse colectomy – Transverse colectomy removes the transverse colon ( figure 8).
Transverse colectomy is uncommonly performed for malignancy as cancers are generally
to the right or left of the midline and, thus, a right extended or left hemicolectomy should
be performed to achieve an adequate lymphadenectomy.
● Left hemicolectomy – Left hemicolectomy removes the transverse colon to the left of the
middle colic artery and the left colon and sigmoid colon to the level of the upper rectum (
figure 9A-C).
● Sigmoidectomy – Sigmoidectomy removes the sigmoid colon ( figure 10).
● Total colectomy – Total colectomy removes the entire colon, whereas total abdominal
colectomy removes the entire intraperitoneal colon ( figure 11).
Benign versus malignant disease
The extent of colon resection depends upon the disease process being treated. (See 'Types of
colon resection' above.)
● Benign lesions are generally removed using a segmental resection or hemicolectomy

(right or left). For localized benign conditions of the colon (eg, trauma, diverticular disease,
inflammatory bowel disease), a segmental resection with a primary anastomosis in well-
vascularized colon and a limited mesenteric resection can be performed. Diverticular
disease, typically treated with a sigmoidectomy, may require a left hemicolectomy if the
descending colon is unsuitable for an anastomosis. Extended resection (extended right or
left colectomy) or subtotal colectomy may be needed for more extensive benign disease of
the colon (eg, inflammatory bowel disease, diverticular disease, fulminant C. difficile
colitis). For large polyps that require resection because of a possible malignancy, the
authors perform a formal cancer operation.
● Malignant lesions located in the appendix, cecum, and ascending colon can be resected by
a right hemicolectomy. Malignant lesions located in the hepatic flexure or proximal to the
midtransverse colon are resected with an extended right colectomy. Malignant lesions of
the left colon are typically resected with a left hemicolectomy. For malignant lesions of the
splenic flexure, a limited resection extending from the transverse to the sigmoid colon can
be performed, but the pedicle of the left colic artery and the first sigmoid branch should
be included in the specimen. A small number of transverse tumors may be amenable to
transverse colectomy. The surgical margins for a curative resection for colon cancer should
be at least 5 cm from the tumor on both sides [49].
The extent of the mesenteric resection also varies according to whether the resection is being
performed for benign conditions or malignancy. Figures that show these differences are given
in the section above. (See 'Types of colon resection' above.)
● For benign disease including trauma, mesenteric vessels can generally be divided close to
the mesenteric border of the colon since it is unnecessary to resect draining lymph nodes.
However, in settings of severe mesenteric inflammation (eg, diverticulitis, inflammatory
bowel disease) and thickening of the mesentery near the bowel wall, a more extensive
mesenteric dissection may be necessary.
● For malignancy, a complete mesocolic resection ligates the mesenteric vessels close to
their root to optimally resect the lymphovascular tissue. As an example, for left colectomy,
the inferior mesenteric artery is ligated at its origin from the aorta and the inferior
mesenteric vein is ligated at the level of the pancreas; the mesentery and draining
lymphatics are removed with the vascular pedicle.
Complete mesocolic excision has been reported to improve oncologic outcomes but could result
in higher morbidity. In one study, complete mesocolic excision was associated with more
intraoperative injuries to other organs (9.1 versus 3.6 percent), postoperative sepsis (6.6 versus
3.2 percent), and respiratory failure (8.1 versus 3.4 percent) compared with conventional
surgery [50]. In the same study, the 30 day (odds ratio [OR] 1.07, 95% CI 0.62-1.80) and 90 day
mortality (OR 1.25, 95% CI 0.77-1.94) associated with complete mesocolic excision were higher
but not statistically different from those of conventional surgery. The two techniques have not
been directly compared in prospective trials. Attention to surgical technique, dissecting along
the embryological plane between the visceral and parietal fascia just as it is done in total
mesorectal excision, is advocated.
BOWEL ANASTOMOSIS
There is insufficient evidence to suggest that the method of performing the colon anastomosis
(hand sewn or stapled), or its configuration (end to end, end to side, side to side) is better
functionally or less likely to leak [51]. Experience, surgeon preference, and availability of
equipment dictate the type of anastomosis a surgeon performs in a given situation. Stapling the
anastomosis requires less time to perform and offers the potential for reduced fecal
contamination but at times may not be practical. Specific types of anastomoses (ileocolic, colo-
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colonic, colorectal) are discussed separately. (See "Right and extended right colectomy: Open
technique" and "Left colectomy: Open technique" and "Bowel resection techniques".)
Stapled versus sutured anastomosis — Stapled and hand-sewn anastomosis have long been
considered equivalent, to be chosen by the operating surgeon depending on personal
preference, past experience, and anatomical/clinical conditions of the patient. Until data
demonstrate conclusively the superiority of one technique, we continue to recommend that
surgeons become facile with both techniques and tailor their use to each individual patient
situation.
The surgeon has to be comfortable with the technique he/she is using and perform it
meticulously. As an example, when closing the common enterotomy with a stapler, one staple
line should not lie on top of the other. With either technique, if there is any question of ischemia
or any other problems (eg, the anastomosis does not look "right") at the end of the
anastomosis, the surgeon must take the time to take it down and redo it. (See "Bowel resection
techniques".)
Ileocolic anastomosis following a right hemicolectomy is the most studied anastomosis because
its technique is standard and its leak rate the lowest among all colorectal procedures. However,
trials and observational studies draw completely opposite conclusions:
● A 2011 Cochrane review of 11 trials (1125 ileocolic anastomoses; 441 stapled, 684
handsewn) reported fewer leaks following stapled anastomosis than handsewn
anastomosis (2.5 versus 6.1 percent; odds ratio 0.48, 95% CI 0.24-0.95) [52]. A subgroup
analysis of cancer patients confirmed that there were also fewer leaks with stapled
anastomosis (1.3 versus 6.7 percent; odds ratio 0.28, 95% CI 0.10-0.75).
● On the contrary, several observational studies from Europe reported more leaks following
stapled anastomosis than handsewn anastomosis [53-57]. As an example, a study from
Denmark analyzed 1414 patients who underwent colon surgery for right-sided cancer [56].
The leak rates following stapled and handsewn anastomosis were 5.4 and 2.4 percent,
respectively. All of these studies were large (involving from 400 to 3400 patients) and
contemporary (published between 2015 and 2019); most patients underwent surgery for
cancer or Crohn disease. Stapled anastomosis was associated with more leaks with an
odds ratio in the range of 1.43 to 2.41. However, these results should be interpreted with
caution as the study populations are heterogeneous and the surgical techniques are not
standardized.
Intraoperative anastomotic perfusion assessment — Although inadequate blood supply is

believed to be a major risk factor for bowel anastomotic complications, para-anastomotic
perfusion is most often only assessed subjectively by the surgeon. Indocyanine green (ICG)
angiography using near-infrared (NIR) imaging has emerged as a new technology that permits
real-time assessment of intestinal microvascularization. (See "Instruments and devices used in
laparoscopic surgery", section on 'In vivo fluorescence imaging'.)
NIR imaging with ICG has been associated with reduced rates of anastomotic complications in
observational studies [58-60] (meta-analyzed in [61]) but not randomized trials. In one study,
ICG angiography was successful in all 504 patients who underwent mostly colorectal surgery
and resulted in a change in the site of bowel division in 5.8 percent with no subsequent leaks in
those patients [62]. The overall leak rate was lower than that of historic controls at the same
centers (2.6 versus 5.8 percent), and the improvements were more significant for left-sided
resections (2.6 percent with NIR versus 6.9 percent control) and low anterior resections (3
versus 10.7 percent) than for right-sided resections (2.8 percent with NIR versus 2.6 percent
control).
If its efficacy in reducing anastomotic complication can be confirmed by randomized trials (at
least one is under way [63]), ICG angiography using NIR imaging may become a useful tool for
assessing perfusion before and after a bowel anastomosis.
Primary closure versus ostomy — Most patients can have a primary colon anastomosis to
restore continuity of the bowel. Although a primary anastomosis is the preferred goal for
patients with perforated or obstructing lesions, it may not be possible if the patient is too sick to
undergo a definitive procedure (eg, intraoperative medical instability, generalized peritonitis), in
which case a staged approach may be needed if the latter were used.
Drain (not routine) — We do not routinely place drains in the abdomen or pelvis after colon
resection due to a lack of clinical benefit. A meta-analysis of four trials that compared drained
versus undrained patients undergoing colorectal anastomosis found similar rates of clinical
leaks, radiological leaks, mortality, overall morbidity, wound infection, pelvic sepsis, bowel
obstruction, and reintervention for abdominal complications [64].
POSTOPERATIVE CARE AND FOLLOW-UP
Postoperative management of colectomy patients emphasizes reduced perioperative fluid

volume, early postoperative feeding, and early ambulation [65-72]. (See "Enhanced recovery
after colorectal surgery".)
The majority of patients tolerate partial colectomy with only minor physiologic consequences
related to fluid absorption, such as temporary loose stools [73-75]. There is great variability in
frequency, with most patients having a minimal increase in frequency, but some have at least a
temporary increase to four or more movements per day. Such patients may benefit from the
addition of dietary fiber and, when necessary, an antimotility agent. The remaining colon will
often adapt over a four-to-six-month period, gradually returning to a more normal bowel
pattern.
At the time of discharge from the hospital, the patient is instructed to avoid strenuous activity
and heavy lifting for four to six weeks following surgery but is encouraged to participate in light
activity, such as walking, and to return if unexpected symptoms such as significant abdominal
pain, nausea/vomiting, obstipation, fevers and chills, or signs of wound infection including
redness or drainage occur. Otherwise, patients should return for an outpatient visit 10 to 14
days after hospital discharge for wound examination and skin staple removal.
PERIOPERATIVE MORBIDITY AND MORTALITY
Perioperative morbidity and mortality following colon resection depends, to a large extent,
upon whether the procedure is performed under elective or emergency circumstances (eg,
obstructing lesion, bowel perforation) and the patient's associated comorbidities (eg,
cardiopulmonary disease, multiple trauma). Patients with colon cancer are older and tend to
have more comorbidities and as a result have a higher incidence of postoperative morbidity and
mortality [1]. Longer-term survival is disease specific (eg, colon cancer) and is reviewed in
separate topic reviews for various conditions [1,76-78]. (See "Overview of the management of
primary colon cancer", section on 'Prognosis'.)
Complications of colectomy include surgical site infection, ureteral injury, anastomotic leak,
intra-abdominal abscess, enteric fistula, bleeding, and postoperative bowel obstruction. The
frequency and management of intra-abdominal complications, including anastomotic
complications, of colorectal surgery are reviewed elsewhere. (See "Management of anastomotic
complications of colorectal surgery" and "Management of intra-abdominal, pelvic, and
genitourinary complications of colorectal surgery".)
● A later study included data from the University Health System Consortium Data Base on
patients undergoing right (n = 9336) or left (n = 5744) hemicolectomy for colon cancer at
academic medical centers between 2002 and 2006 [79]. The overall complication rate was
comparable to that reported by the VA study and similar for right and left hemicolectomy
(26.8 and 28.3 percent, respectively). The most common complications were wound and
pulmonary related. Thirty-day in-hospital mortality rates were 1.4 and 1.3 percent for right
and left hemicolectomy, respectively, much lower than in the VA study [79].
● The frequency of surgical site infection after colorectal surgery for benign and malignant
disease was evaluated in a review from the National Surgical Quality Improvement
Program (NSQIP) of patients in the database between 2006 and 2007. The overall rate of
surgical site infection was 14 percent and was significantly lower in patients undergoing
laparoscopic compared with open colectomy (9.5 versus 16.1 percent) [39]. (See 'Minimally
invasive colon resection' above.)
● Obese patients have more postoperative complications after colon surgery. In a

retrospective review of 1048 patients undergoing colon resection for cancer, a one-
category increase in body mass index (eg, from normal weight to overweight, or from
overweight to obese) ( table 5) was associated with a 1.6-fold increase in wound
infections and a 1.5-fold increase in slow wound healing [80]. The risk of fascial dehiscence
was also increased in obese patients, but only with open procedures.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Colorectal cancer" and
"Society guideline links: Colorectal surgery for cancer".)
SUMMARY AND RECOMMENDATIONS
● Colon resection is needed to manage benign disease (eg, volvulus, ischemia,

endoscopically unresectable polyps), traumatic injuries, and malignant tumors of the
colon. (See 'Indications for colon resection' above.)
● Assessment of the patient prior to elective colon resection includes evaluation of medical
comorbidities, functional status, and social support. Planning colon resection takes into
account the nature of the lesion, its location within the colon, and the status of the colonic
circulation. Regardless of indication, we obtain a contrast-enhanced computed
tomography (CT) scan of the abdomen and pelvis and include a CT scan of the chest if the
patient has a colon cancer staged II or higher. (See 'Preoperative evaluation' above.)
● In patients undergoing elective colon resection, we suggest mechanical bowel preparation

combined with oral antibiotics rather than mechanical bowel preparation alone or no
preparation (Grade 2C). Typical oral antibiotics regimens are neomycin plus erythromycin
or neomycin plus metronidazole. Administering oral antibiotics independently of
mechanical bowel preparation is of unproven benefit. (See "Antimicrobial prophylaxis for
prevention of surgical site infection following gastrointestinal procedures in adults" and

'Bowel preparation' above.)
● In addition, we recommend preoperative intravenous antibiotic prophylaxis immediately

prior to colon resection rather than no intravenous antibiotics (Grade 1B). (See
'Intravenous antimicrobial prophylaxis' above.)
● For patients with uncomplicated colon disease not involving or invading adjacent organs,
and who have not had prior extensive abdominal surgery, laparoscopic colectomy rather
than open colectomy is suggested whenever a surgeon experienced with advanced
laparoscopic colectomy techniques is available, provided there are no contraindications to
abdominal insufflation. (See 'Minimally invasive colon resection' above.)
● The different types of colon resections are based upon the arterial anatomy of the colon to
ensure adequate blood supply in the remaining colon. Examples of conditions or lesions
resected using each of these are listed below. (See 'Types of colon resection' above.)
• Segmental resection – Focal traumatic colon injury

• Ileocecectomy – Benign disease
• Right hemicolectomy – Right-sided cancer
• Extended right hemicolectomy – Proximal transverse colon cancer
• Transverse colectomy – Extensive trauma
• Left hemicolectomy – Left-sided colon cancer
• Sigmoidectomy – Refractory sigmoid diverticulitis
• Subtotal colectomy – Fulminant Clostridioides (formerly Clostridium) difficile
For malignant diseases, the surgical margins should be at least 5 cm from the tumor on
both sides.
● The extent of the mesenteric resection varies according to whether the resection is being
performed for benign conditions or for malignancy. For benign disease including trauma,
mesenteric vessels can generally be divided close to the mesenteric border of the colon,
provided the anastomosis will be well vascularized. For malignant tumors, the mesenteric
vessels should be ligated close to their origin to optimally resect the lymphovascular
tissue. (See 'Benign versus malignant disease' above.)
● The experience and preference of the surgeon generally dictates whether the colon
anastomosis is hand-sewn or stapled or configured end to end versus end to side or side
to side. Restoring gastrointestinal continuity using a primary colon anastomosis is the goal
for most patients following colon resection. For patients undergoing colon surgery for
perforated or obstructing colon lesions, definitive surgery may not be possible, and a
staged approach may be needed. (See 'Bowel anastomosis' above.)
● For postoperative management, a "fast-track" protocol includes oral feedings on

postoperative day 1, solid foods on postoperative day 2, and early ambulation. (See
'Postoperative care and follow-up' above and "Enhanced recovery after colorectal
surgery".)
● Complications of a colectomy include surgical site infection, ureteral injury, splenic injury,
anastomotic leak, intra-abdominal abscess, enteric fistula, bleeding, and postoperative
bowel obstruction, among others. (See 'Perioperative morbidity and mortality' above and
"Management of anastomotic complications of colorectal surgery" and "Management of
intra-abdominal, pelvic, and genitourinary complications of colorectal surgery".)
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Topic 15261 Version 25.0
GRAPHICS
Antimicrobial prophylaxis for gastrointestinal surgery in adults
Nature of Common Recommended Usual adult Redose

operation pathogens antimicrobials dose* interval¶
Gastroduodenal surgery
Procedures Enteric gram- CefazolinΔ <120 kg: 2 g IV 4 hours

involving entry negative bacilli,
≥120 kg: 3 g IV
into lumen of gram-positive
gastrointestinal cocci
tract
Procedures not Enteric gram- High risk◊ only: <120 kg: 2 g IV 4 hours
involving entry negative bacilli, cefazolinΔ
≥120 kg: 3 g IV
into lumen of gram-positive
gastrointestinal cocci
tract (selective
vagotomy,
antireflux)
Biliary tract surgery (including pancreatic procedures)
Open procedure Enteric gram- CefazolinΔ¥ <120 kg: 2 g IV 4 hours

or laparoscopic negative bacilli, (preferred)
≥120 kg: 3 g IV
procedure (high enterococci,
risk)§ clostridia OR cefotetan 2 g IV 6 hours
OR cefoxitin 2 g IV 2 hours
OR ampicillin- 3 g IV 2 hours
sulbactam
Laparoscopic N/A None None None

procedure (low
risk)
Appendectomy‡
Enteric gram- CefazolinΔ For cefazolin: For cefazolin:

negative bacilli,
PLUS <120 kg: 2 g IV 4 hours
anaerobes,
metronidazole
enterococci ≥120 kg: 3 g IV For metronidazole:
(preferred)
For metronidazole: N/A
500 mg IV
OR cefoxitinΔ 2 g IV 2 hours
OR cefotetanΔ 2 g IV 6 hours
Small intestine surgery
Nonobstructed Enteric gram- CefazolinΔ <120 kg: 2 g IV 4 hours

negative bacilli,
≥120 kg: 3 g IV
gram-positive
cocci

CefazolinΔ For cefazolin: For cefazolin:
Obstructed Enteric gram-
PLUS <120 kg: 2 g IV 4 hours
negative bacilli,
metronidazole
anaerobes, ≥120 kg: 3 g IV For metronidazole:
(preferred)
enterococci For metronidazole: N/A
500 mg IV
Hernia repair
Aerobic gram- CefazolinΔ <120 kg: 2 g IV 4 hours
positive organisms
≥120 kg: 3 g IV
Colorectal surgery†
Enteric gram- Parenteral:
negative bacilli,
CefazolinΔ For cefazolin: For cefazolin:
anaerobes,
enterococci PLUS <120 kg: 2 g IV 4 hours
metronidazole
≥120 kg: 3 g IV For metronidazole:
(preferred)
For metronidazole: N/A
500 mg IV
OR ampicillin- 3 g IV (based on 2 hours

sulbactamΔ, ** combination)
Oral (used in conjunction with mechanical bowel preparation):
Neomycin PLUS ¶¶ ¶¶
erythromycin
base or
metronidazole
IV: intravenous.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before
the procedure. If vancomycin or a fluoroquinolone is used, the infusion should be started within 60 to
120 minutes before the initial incision to have adequate tissue levels at the time of incision and to
minimize the possibility of an infusion reaction close to the time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns,
additional intraoperative doses should be given at intervals one to two times the half-life of the drug.
Δ For patients allergic to penicillins and cephalosporins, clindamycin (900 mg) or vancomycin (15 mg/kg
IV; not to exceed 2 g) with either gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV), levofloxacin (500 mg
IV), or aztreonam (2 g IV) is a reasonable alternative. Metronidazole (500 mg IV) plus an aminoglycoside
or fluoroquinolone are also acceptable alternative regimens, although metronidazole plus aztreonam
should not be used, since this regimen does not have aerobic gram-positive activity.
◊ Morbid obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric
bleeding, malignancy or perforation, or immunosuppression.
§ Factors that indicate high risk may include age >70 years, pregnancy, acute cholecystitis,
nonfunctioning gall bladder, obstructive jaundice, common bile duct stones, immunosuppression.
¥ Cefotetan, cefoxitin, and ampicillin-sulbactam are reasonable alternatives.
‡ For a ruptured viscus, therapy is often continued for approximately five days.
† Use of ertapenem or other carbapenems not recommended due to concerns of resistance.
** Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillin-sulbactam, local

sensitivity profiles should be reviewed prior to use.
¶¶ In addition to mechanical bowel preparation, the following oral antibiotic regimen is administered:
neomycin (1 g) plus erythromycin base (1 g) OR neomycin (1 g) plus metronidazole (1 g). The oral regimen
should be given as three doses over approximately 10 hours the afternoon and evening before the
operation. Issues related to mechanical bowel preparation are discussed further separately; refer to the
UpToDate topic on overview of colon resection.
Data from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infec
(Larchmt) 2013; 14:73.
Graphic 65369 Version 34.0
Timing of prophylactic antibiotic administration and subsequent rates of SSIs
Time of
Percent with SSI Odds ratio¶ 95% CI
administration*
Early 3.8 4.3 1.8-10.4
Preoperative 0.6 1 -
Perioperative 1.4 2.1 0.6-7.4
Postoperative 3.3 5.8 2.4-13.8
SSI: surgical site infection.
* "Early" denotes 2 to 24 hours before incision, "preoperative" 0 to 2 hours before incision,

"perioperative" within 3 hours after incision, and "postoperative" more than 3 hours after incision.
¶ Odds ratio determined by logistic-regression analysis.
Data from: Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of
surgical-wound infection. N Engl J Med 1992; 326:281.
Modified Caprini risk assessment model for VTE in general surgical patients
Risk score
1 point 2 points 3 points 5 points

Age 41 to 60 years Age 61 to 74 years Age ≥75 years Stroke (<1 month)
Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty
BMI >25 kg/m2 Major open surgery (>45 Family history of VTE Hip, pelvis, or leg
minutes) fracture
Swollen legs Laparoscopic surgery Factor V Leiden Acute spinal cord injury
(>45 minutes) (<1 month)
Varicose veins Malignancy Prothrombin 20210A
Pregnancy or Confined to bed (>72 Lupus anticoagulant

postpartum hours)
History of unexplained Immobilizing plaster Anticardiolipin

or recurrent cast antibodies
spontaneous abortion
Oral contraceptives or Central venous access Elevated serum

hormone replacement homocysteine
Sepsis (<1 month) Heparin-induced

thrombocytopenia
Serious lung disease, Other congenital or

including pneumonia acquired thrombophilia
(<1 month)
Abnormal pulmonary
function
Acute myocardial
infarction
Congestive heart failure

(<1 month)
History of inflammatory
bowel disease
Medical patient at bed

rest
Interpretation
Surgical risk Score Estimated VTE risk in

category* the absence of
pharmacologic or
mechanical
prophylaxis (percent)
Very low (see text for 0 <0.5
definition)
Low 1 to 2 1.5
Moderate 3 to 4 3.0
High ≥5 6.0
VTE: venous thromboembolism; BMI: body mass index.
* This table is applicable only to general, abdominal-pelvic, bariatric, vascular, and plastic and
reconstructive surgery. See text for other types of surgery (eg, cancer surgery).
From: Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and
prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practical guidelines. Chest 2012;
141:e227S. Copyright © 2012. Reproduced with permission from the American College of Chest Physicians.
Dindo-Clavien classification of surgical complications
Grade Definition
Grade I Any deviation from the normal postoperative course without the need for
pharmacologic treatment or surgical, endoscopic, and radiological interventions.
Allowed therapeutic regimens are drugs as antiemetics, antipyretics,
analgetics, diuretics, electrolytes, and physiotherapy.
This grade also includes wound infections opened at the bedside.
Grade II Requiring pharmacologic treatment with drugs other than such allowed for grade I
complications.
Blood transfusions and total parenteral nutrition are also included.
Grade IIIa Requiring surgical, endoscopic, or radiological intervention not under general
anesthesia.
Grade IIIb Requiring surgical, endoscopic, or radiological intervention under general

anesthesia.
Grade IVa Life-threatening complication (including CNS complications)* requiring IC/ICU

management, single organ dysfunction (including dialysis).
Grade IVb Life-threatening complication (including CNS complications)* requiring IC/ICU

management, multiorgan dysfunction.
Grade V Death.
CNS: central nervous system; IC: intermediate care; ICU: intensive care unit.
* Brain hemorrhage, ischemic stroke, subarachnoidal bleeding, but excluding transient ischemic attacks.
Adapted from: Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a
cohort of 6336 patients and results of a survey. Ann Surg 2004; 240:205. Copyright © 2004 American Surgical Association and
European Surgical Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this
material is prohibited.
Blood supply to the colon and rectum
The blood supply to the colon originates from the SMA and the IMA. The SMA
arises approximately 1 cm below the celiac artery and runs inferiorly toward the
cecum, terminating as the ileocolic artery. The SMA gives rise to the inferior
pancreaticoduodenal artery, several jejunal and ileal branches, the middle colic
artery, and the right colic artery.
As a general rule, the middle colic artery arises from the proximal SMA and
supplies blood to the proximal to midtransverse colon. However, it occasionally
provides the predominant blood flow to the splenic flexure.
The right colic artery supplies blood to the mid-distal ascending colon. In
anatomical studies, the right colic artery arises independently from the SMA in
28% of individuals, which is depicted in this figure. More frequently, the right
colic artery arises with, or as a branch of, the middle colic, ileocolic, or left colic
arteries. The right colic artery is absent in 13% of individuals.[1]
The ileocolic artery supplies blood to the distal ileum, cecum, and proximal
ascending colon.
The IMA arises approximately 6 to 7 cm below the SMA. The IMA gives rise to
the left colic artery and sigmoid arteries continuing as the superior rectal
(hemorrhoidal) artery. It is largely responsible for supplying blood distal to
the transverse colon.
SMA: superior mesenteric artery; IMA: inferior mesenteric artery.
Reference:
1. Bergman RA, Thompson SA, Afifi AK, Saadeh FA. Compendium of Human Anatomic
Variation: Text, Atlas, and World Literature, Urban & Schwarzenberg, Baltimore, MD 1988.
Venous drainage of the colon and rectum
The mesenteric veins parallel their corresponding arteries. The SMV drains the
small intestine, cecum, and ascending and transverse colon via the jejunal, ileal,
ileocolic, right colic, and middle colic veins. The IMV drains the descending colon
through the left colic, the sigmoid through the sigmoid vein, and the rectum
through the superior rectal vein. The IMV fuses with the splenic vein, which then
joins the SMV to form the portal vein.
SMV: superior mesenteric vein; IMV: inferior mesenteric vein.
Lymphatic drainage of the colon and rectum
This figure depicts the lymphatic drainage of the colon and rectum.
Segmental resection of a benign left colon lesion
This figure depicts a limited or segmental resection of a benign

lesion in the left colon. Note the smaller extent of colon and
mesentery excised.
Ileocecectomy
Ileocecectomy resects the cecum along with 12 to 15 cm of small

bowel for benign pathologies.
Right colectomy for benign disease
In benign pathologies (diverticular disease, volvulus), a segmental or an anatomic

resection can be performed, but the vessels need not to be divided at their origin.
Right colectomy for malignancy
This figure illustrates the extent of a right colectomy. For malignant

lesions, the resection involves isolating and dividing the ileocolic
vessels, right colic vessels, and either the right or hepatic branch of
the middle colic artery and vein at their origins.
Extended right colectomy for malignancy
This figure depicts the boundaries of an extended right

hemicolectomy, which includes the resection of the distal transverse
colon and sometimes the splenic flexure, and, for cancer, involves
ligating the ileocolic, right colic, and middle colic vessels at their
origin.
Colectomy for mid-transverse colon cancer
This figure depicts the extent of resection for a malignant lesion

located in the mid-transverse colon.
Left hemicolectomy for a benign process
This figure depicts a resection of the left colon for a benign process,
such as colitis. The mesentery is not resected at its root, and care
must be taken to anastomose the bowel in areas of adequate blood
supply.
Left colon resection for a splenic flexure lesion
This figure depicts a left colectomy for a malignant lesion located at

the splenic flexure.
Left colectomy for malignancy
This figure depicts the extensive resection of a left colon cancer.

Note the ligation of the inferior mesenteric artery at its origin from
the aorta and the ligation of the inferior mesenteric vein near the
distal pancreas. A minimum 5-cm margin is obtained both proximal
and distal to the malignant lesion.
Resection of diverticular disease
Two-stage procedures are used in emergency situations where there has

been peritoneal contamination. Common among the approaches is that
the offending segment of diverticular disease is resected at the first
operation.
(A) Stage 1 consists of the Hartmann's procedure; the diseased sigmoid

colon is removed, the fecal stream is diverted, and the rectum is oversewn.
In stage 2, intestinal continuity is reestablished by a descending
colorectostomy.
(B) In stage 1, the diseased sigmoid is removed, and both ends of bowel
are brought to the surface, one as an end colostomy and the other as a
mucus fistula. In stage two, intestinal continuity is reestablished as in panel
A.
Total abdominal colectomy for cancer
Total abdominal colon resection for cancer removes the entire colon,
including the associated mesentery, with the mesenteric
vessels ligated close to their origin to optimally resect
lymphovascular tissue.
Classification of body mass index
Underweight – BMI <18.5 kg/m2
Normal weight – BMI ≥18.5 to 24.9 kg/m2
Overweight – BMI ≥25 to 29.9 kg/m2
Obesity – BMI ≥30 kg/m2
Obesity class 1 – BMI 30 to 34.9 kg/m2
Obesity class 2 – BMI 35 to 39.9 kg/m2
Obesity class 3 – BMI ≥40 kg/m2
BMI classifications are based upon risk of cardiovascular disease. These classifications for BMI have been
adopted by the NIH and WHO for White, Hispanic, and Black individuals. Because these cutoffs
underestimate risk in the Asian population, the WHO and NIH guidelines for Asian individuals define
overweight as a BMI between 23 and 24.9 kg/m2 and obesity as a BMI >25 kg/m2 . Some investigators
employ four classes of obesity such that class 3 is defined as BMI 40 to 49.9 kg/m2 and super obesity is
defined as BMI ≥50 kg/m2 .
BMI: body mass index; NIH: National Institutes of Health; WHO: World Health Organization.
References:
1. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults – the evidence report.
National Institutes of Health. Obes Res 1998; 6 Suppl 2:51S.
2. Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser
2000; 894:i.
3. WHO Expert Consultation. Appropriate body mass index for Asian populations and its implications for policy and
intervention strategies. Lancet 2004; 363:157.
Contributor Disclosures
Miguel A Rodriguez-Bigas, MD Consultant/Advisory Boards: AstraZeneca [Gastrointestinal (colorectal)
oncology]. Martin Weiser, MD Consultant/Advisory Boards: PrecisCa [Gastrointestinal surgical
oncology]. Wenliang Chen, MD, PhD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

Colon Resection

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11/3/21, 8:44 AM Overview of colon resection - UpToDate

Official reprint from UpToDate®

Overview of colon resection

INDICATIONS FOR COLON RESECTION

● Appendiceal cancer (see "Well-differentiated neuroendocrine tumors of the appendix")

● Colonic carcinoid (see "Staging, treatment, and post-treatment surveillance of non-

● Colon polyp unresectable through a colonoscope (see "Overview of colon polyps")

● Colonic ischemia (see "Colonic ischemia")

● Fulminant Clostridioides (formerly Clostridium) difficile colitis

● Volvulus (see "Cecal volvulus" and "Sigmoid volvulus")

Preoperative imaging — Prior to colon resection, regardless of indication, a contrast-enhanced

● Mechanical bowel preparation is usually accomplished with polyethylene glycol solution.

• Neomycin sulfate 1 gram and erythromycin base 1 gram, or

• Neomycin sulfate 1 gram and metronidazole 1 gram.

In rare situations where mechanical bowel preparation is contraindicated, there is suggestion

Prophylactic ureteral stenting — The key to preventing ureteral injury is intraoperative

Thromboprophylaxis — Patients undergoing colon resection frequently are at moderate-to-

Patients identified as having moderate-to-high risk of developing a venous thromboembolic

MINIMALLY INVASIVE COLON RESECTION

Short-term (perioperative) outcomes — Laparoscopic colon surgery has been associated with

Long-term outcomes — Laparoscopic surgery is associated with less intra-abdominal adhesion

Robotic colectomy — Robot-assisted laparoscopic procedures combine the advantages of the

Nevertheless, a population-based study of Medicare beneficiaries undergoing colectomy

● Segmental colectomy – Segmental resection, which removes only an affected portion of

● Extended right hemicolectomy – Extended right hemicolectomy expands right

● Sigmoidectomy – Sigmoidectomy removes the sigmoid colon ( figure 10).

Benign versus malignant disease

● Benign lesions are generally removed using a segmental resection or hemicolectomy

Intraoperative anastomotic perfusion assessment — Although inadequate blood supply is

POSTOPERATIVE CARE AND FOLLOW-UP

Postoperative management of colectomy patients emphasizes reduced perioperative fluid

PERIOPERATIVE MORBIDITY AND MORTALITY

● Obese patients have more postoperative complications after colon surgery. In a

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Colon resection is needed to manage benign disease (eg, volvulus, ischemia,

● In patients undergoing elective colon resection, we suggest mechanical bowel preparation

prevention of surgical site infection following gastrointestinal procedures in adults" and

● In addition, we recommend preoperative intravenous antibiotic prophylaxis immediately

• Segmental resection – Focal traumatic colon injury

● For postoperative management, a "fast-track" protocol includes oral feedings on

Use of UpToDate is subject to the Subscription and License Agreement.

8. Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated

9. Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective

45. Heemskerk J, Zandbergen R, Maessen JG, et al. Advantages of advanced laparoscopic

Surg 2020; 155:41.

Antimicrobial prophylaxis for gastrointestinal surgery in adults

Nature of Common Recommended Usual adult Redose

Procedures Enteric gram- CefazolinΔ <120 kg: 2 g IV 4 hours

Biliary tract surgery (including pancreatic procedures)

Open procedure Enteric gram- CefazolinΔ¥ <120 kg: 2 g IV 4 hours

Laparoscopic N/A None None None

Enteric gram- CefazolinΔ For cefazolin: For cefazolin:

Small intestine surgery

Nonobstructed Enteric gram- CefazolinΔ <120 kg: 2 g IV 4 hours

OR ampicillin- 3 g IV (based on 2 hours

Oral (used in conjunction with mechanical bowel preparation):

¥ Cefotetan, cefoxitin, and ampicillin-sulbactam are reasonable alternatives.

† Use of ertapenem or other carbapenems not recommended due to concerns of resistance.

** Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillin-sulbactam, local

Graphic 65369 Version 34.0

Timing of prophylactic antibiotic administration and subsequent rates of SSIs

Perioperative 1.4 2.1 0.6-7.4