When is laparoscopic left hemicolectomy contraindicated?

Updated: Apr 13, 2020
  • Author: David B Stewart, Sr, MD, FACS, FASCRS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed)  more...
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Answer

The list of contraindications for laparoscopy is more difficult to define than the list of indications because contraindications often depend on the surgeon’s level of expertise with less straightforward patients and diseases. Certainly, hemodynamic instability or cardiopulmonary disease that is severe enough to make peritoneal insufflation and Trendelenburg positioning dangerous represents a physiologic derangement that precludes the safe application of laparoscopy.

The author believes that these two states represent the only firm, absolute contraindications for laparoscopy. Whereas it is true that what constitutes instability or heart and lung disease too severe for laparoscopy may fall along a spectrum, it is also true that these clinical indices are more readily identified and are more consistently acknowledged between surgeons than other factors are.

In terms of relative contraindications, morbid obesity obscures major mesenteric vessels from view, inhibits effective tissue retraction, and can make tissue dissection more difficult because of the thicker visceral fat; all of these effects can conduce to the easier commission of technical errors.

Locally advanced cancers that may be amenable to an R0 resection should be carefully considered for a preemptive conversion when discovered unexpectedly during laparoscopy; however, more experienced oncologic surgeons have demonstrated that en-bloc resections of organs such as kidneys and the small intestine are possible, with cancer-related outcomes similar to those of open surgery.

Phlegmonous tissue, such as would be encountered in severe, complicated Crohn disease or in diverticulitis, may not be resectable via laparoscopy, because of tissue friability, bleeding, and a distortion of the patient’s anatomy that necessitates open exposure; however, laparoscopic treatment has also been reported to be successful in this scenario when carried out by an experienced surgeon.

Large intestinal obstructions can be quite challenging to address laparoscopically, depending on the degree of proximal intestinal dilatation present; the more limited volume of unencumbered working space, coupled with the higher risk of iatrogenic intestinal perforation from retracting instruments, may warrant an open approach.

Carcinomatosis may or may not represent an indication for open surgery; whereas biopsies of peritoneal implants are easily accomplished laparoscopically, extensive resections, especially of the parietal peritoneum, should be approached via laparotomy.

Adhesions pose a technical challenge to the minimally invasive surgeon, especially when their location is between two segments of small intestine. In this situation, both small-intestine segments may be mobile enough to prevent adequate tissue distraction and delineation of each segment, with the two limbs of bowel moving as a single entity during retraction.

Furthermore, adhesions to the anterior abdominal wall may promote bowel injuries upon trocar placement or during adhesiolysis. Laparoscopic adhesiolysis requires advanced technical skill both with the use of laparoscopic scissors and with intracorporeal suturing to address the lacerations that will inevitably be encountered at some point.


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