Laparoscopic Welti's Maneuver: A Single-Center Experience

Introduction

Left hemicolectomy is the standard surgical operation for a variety of colonic diseases, both benign and malignant. When colonic resection is extended, relocation of the small bowel loops can be difficult; leaving these loops in the right side of the abdomen can lead to straining of the colorectal anastomosis, thus increasing the risk of ischemia of the anastomosis and consequently anastomotic leak. Several techniques have been described to reposition the small intestine. In 1960, H. Welti proposed the repositioning of the whole small bowel in the left side of the abdomen, by passing the last ileal loop under the neo descending colon transposed.^1,2 Toupet, in 1963, suggested a variation of the Welti's technique, which included the passage of colon through an avascular breach in the mesentery of the last ileal loop.^2,3 In this article, we describe our experience of the Welti's technique after extended left hemicolectomy performed with minimally invasive technique.

Materials and Methods

Results

Twenty-three patients (11 females and 12 males) were included in the study. They all underwent laparoscopic left colonic resection with a reconstruction according to Welti's technique. Demographics and clinical characteristics are summarized in Table 1. Reasons for surgery, operative data, and postoperative data are listed in Table 2. Reasons for Welti's reconstruction are summarized in Table 3. Median operative time was 215 minutes (142–395). Intraoperative complications occurred in 2 patients who experienced the accidental damage of the vascular arcade of the descending colon; in another case we observed the agenesis of the Riolano arcade. These three conditions resulted in ischemia of the neo descending colon, requiring additional colonic resection and the reconstruction according to Welti's technique.

Median length of the resected colon was 51 cm (30–95). Excluding 2 patients with ileostomy we observed resumption of gas emission with a median of 3 days (2–6) and resumption of stool emission at a median of 4 days (2–9) after surgery. In the postoperative period we observed 3 cases of anemia that required blood transfusions, 1 case of atrial fibrillation, and 1 case of acute vestibular vertigo. We neither observed a slow recovery of intestinal motility nor episodes of acute intestinal obstruction. Median time of hospital discharge was on postoperative day 8 (5th–37th). One patient was lost to follow-up and 1 patient died for progression of the disease. With a median follow-up of 15 months (3–132) we have not observed in any patient bowel obstruction after hospital discharge (Table 2).

Discussion

In 1960, H. Welti published a variation in the technique of left hemicolectomy with reperitoneization. In case of tumors of the descending colon or the left flexure, he proposed an extended left hemicolectomy, rather than a standard left colectomy, to obtain a greater oncological radicalità.^1,5,6 A more extensive colonic resection can cause a reduction of the space in the center of the abdomen, where the small intestine is normally located; this situation can cause excessive tension on the colorectal anastomosis, with the risk of ischemia and anastomotic leak; furthermore, the large mesenteric defect created with such a colonic resection should be closed to avoid the development of internal hernias, with the risk of intestinal obstruction and ischemia of the herniated bowel loops.

Welti's technique was originally described for laparotomic surgery, but it can be performed laparoscopically as well. To our knowledge, this is the first article in the literature on laparoscopic Welti's technique after extended left hemicolectomy. This technique is reproducible and does not require complex maneuvers even in laparoscopic surgery.

Considering our series of standard left hemicolectomies, we observed a median duration of surgery of 180 minutes. In patients undergoing the Welti's technique, the median operative time is 215 minutes. The operating steps to perform the Welti's technique require about 20–30 minutes; this difference in time is minimal showing how Welti's technique does not prolong so much the duration of surgery.

Welti's technique is a safe procedure. The passage of the last ileal loop below the colon could potentially be responsible for acute bowel obstruction. Actually this does not occur, because the space for the passage of the last ileal loop under the neo descending colon is sufficient to avoid stenosis; furthermore, the stitches that anchor the last ileal loop to the descending colon are loose, in order not to cause an iatrogenic stenosis. In our experience we have not observed side effects of the Welti's technique, neither in the short- or in the long-term period. The use of Welti's technique did not result in a delay in the recovery of intestinal function, with a median time to resumption of gas and stool emission of 3 and 4 days after surgery, respectively.

With regard to the length of hospital stay, we observed a delayed discharge only in 1 patient undergoing ileostomy, in which prolonged hospitalization was caused by dehydration due to excessive fluid loss from the ileostomy; for the remaining patients the median hospitalization was 8 days. Furthermore, during the long-term follow-up, none of the patients experienced episodes of acute or chronic intestinal obstruction. These data show how the reconstruction according to Welti's technique is safe and does not cause a delay in the patient's functional recovery when compared with standard left hemicolectomy with classic reconstruction.

Welti's technique is not clearly the standard reconstruction technique after left hemicolectomy. We suggest it could be useful in case of the following: 1.

Extended colonic resection for

The Welti's technique does not include only the repositioning of the small bowel loop, but it also includes the closure of the mesenteric defect to reduce the risk of internal hernia. Symptomatic internal hernia after laparoscopic colorectal surgery is a rare complication, with a prevalence of 0.5%;^7,8 however, despite being rare, this event can be a serious complication because it potentially leads to bowel ischemia or necrosis if herniated loops are trapped below the mesenteric defect.

We recently published our experience of 1.300 laparoscopic colorectal resections, reporting a prevalence of symptomatic internal hernia of 0.4%, which was 0.6% after left hemicolectomy, requiring emergency surgery in all the 5 patients of our series. ⁹ We know that closing the mesenteric defect is a technically challenging and time-consuming step with the potential risk of damaging the retroperitoneal structures (ureter) or the marginal arcade; however, we prefer to close the mesenteric defect, especially in cases of extended left hemicolectomy when the mesenteric defect is greater, the colicresection is more extensive and the risk of internal hernia after surgery higher.

Conclusions

Welti's technique even when performed laparoscopically is a safe technique, is not associated with an increase in the rate of intestinal obstruction or delayed discharge. This technique is useful if extended left hemicolectomy is needed and the repositioning of the small bowel loops can be a problem. We believe that the Welti's technique should be part of the background of the colorectal surgeon.