Laparoscopic Colorectal Surgery

Part I. Colon Surgery

Albert Wolthuis, prof. A. D’HooreDepartment of Abdominal Surgery

University Hospital Leuven

Q. I personally performed

1. 0 laparoscopic colorectal procedures

2. < 10

3. < 20

4. > 20

LEFT-Sided Disease

RIGHT-Sided Disease

MalignantBenign

DiverticulitisAdenomaEndometriosisCrohn….

CrohnAdenoma….

AdenocarcinomaLymphomaSarcoma….

AdenocarcinomaLymphomaSarcoma….

Laparoscopic assistedright hemicolectomy Schlinkert RTDis Colon Rectum 1991 ; 34 : 1030 - 1031

Minimally invasive colon resection (laparoscopic colectomy).Jacobs M, et alSurg Laparosc Endosc. 1991 Sep;1(3):144-50.

early days : technical difficulties

Laparoscopically assisted – Hand-assisted

American approach first colonic mobilisation = ‘laparoscopic facilitated’

Young-Fadok, H Nelson (Mayo Clinic) Dis Colon Rectum 2000;43:267-273

Port – site Metastasis : learning curve - effect

< 1995 : 0.6 – 21 %>1995 / n = 1.769 0.85 %recent n = 1.114 1 %

Called for a temporary moratorium ( 1994 – 99 )

Different ‘approaches’

• Open• Lap hand-assisted• Lap assisted• Totally laparoscopic (NOSE)• Single port (SILS)

Q. Laparoscopy for colonic cancer

1. Is still investigational ( performed in RCT )

2. Oncologic outcome beter than open

3. Same oncologic outcome but short-term outcome is better

4. Only a cosmetic benefit

1991: first laparoscopic colectomy

• COST: Clinical Outcomes of Surgical Therapy– 1995

• CLASICC: Conventional vs Lap-Assisted Surgery in Colorectal Cancer– 1996

• COLOR: Colon cancer Laparoscopic or Open Resection– 1997

RCT-Lap vs Open, n=794CLASICC-trial-Overall survival 5y

Guillou, Lancet 2005Jayne, BJS 2010

Oncological safety of laparoscopic surgeryWound/port site metastasis in Lap-group: 2.4%

RCT-Lap vs Open, n=1248COLOR-trial, DFS 3y

Buunen, Lancet Oncol 2009

DFS 3y:82% lap84% Open (p=0.45)

Hazard Ratio : disease free survival at 3 years

Ration

Kuhry et aL. Lapsc. Surgery for colonic cancer - PhDThesis

Short Term Morbidity

lapsc Open P Milsom 15 % 15 % ns

Delgado < 70 11.4 % 20.3 % ns

> 70 10.2 % 31.3 % 0.0038

Lacy 8 % 30.8 % 0.04

Schwenk 7 % 27 % 0.08

Morbidity (meta-analysis)

Hospital stay

Lapsc. Open pLacy (2002) 5.2 7.9 0.005Color I (2005) 8.2 9.3 <0.001COST (2005) 5 6 <0.001Classic (2005)

colon 9 9rectum 11 13

Senagore (2005) 3.7

Lap + ERASLAFA-trial

Lap + ERAS

Open + ERAS

Lap + Standaard

Open + Standaard P

Total LOS 5 7 6 7 <0.001

Postop LOS

5 6 6 7 <0.001

Vlug, Ann Surg 2011

Discharge criteria:(1)adequate pain control with paracetamol and/or NSAID’s (2)ability to tolerate solid food (3)absence of nausea (4)passage of first flatus and/or first stool (5)mobilization as preoperative, and (6)acceptance of discharge by the patient

Laparoscopic colon surgerycompared to open

• Same effectiveness• Comparable oncologic outcome• Shorter hospital stay• Less morbidity

Guillou, Lancet 2005Fleshman, Ann Surg 2007Buunen, Lancet Oncol 2009Darai, Ann Surg 2010Jayne, BJS 2010

From feasiblity to standardised surgical technique

- rules for oncologic resection

- ‘ergonomics’

- reproducible

- implementation in surgical training

Medial to lateral approach= ideal surgical strategy for cancer

1. Vascular ligation first (Turnbull ‘no-touch’)

2. Broad mesenteric dissection

3. Controls the retroperitoneum ureter, gonadal vesselsduodenum, autonomic nerves

4. Lateral attachments - tumor mobilisation last step

Surgical Technique

1. Left colon- approach in benign disease- splenic flexure mobilisation- approach in cancer

2. Right colon- lap-assisted- approach in cancer

Laparoscopic colorectal surgery

Modified Lloyd – DavisArms along the bodyMoldable bean bag

Surgeon 1

Surgeon 2

monit I

monit II

TrendelenburgRight sided tilt

Surgeon 3

Q. Sigmoid resection for diverticulitis

1. Resection is limited to the inflamed zone

2. All proximal diverticulae should be included in the resection (I will extend my resection if needed)

3. The distal margin is more important than the proximal margin (I will deliberately leave diverticulae behind)

Anatomical landmarks

Medial to Lateral approachThe left Colon

Pelvic exposure

- Trendelenburg

- Temporary hysteropexy

° trans fundic° round ligament

Anatomy Left Colon

Anatomy Left Colon (proximal)

Benign lesions: location~Diverticular disease, endometriosis, adenoma

- RX Colon contrast (Contrast enema)

- Preoperative staining : not always accurate

- Peroperative colonoscopy : left colon

Inkting preoperative

Perop colonoscopic lesion location

Diverticular disease

- Recurrent diverticulitis ( > 2 attacks )

- Internal fistula (15%)

- Diagnostic doubt (ca)

- (recurrent bleeding, stenosis)

Trend toward a more conservative approach

Pelvic diverticulitis

Diverticular sigmoidovesical fistula

Resection margins in diverticular disease~recurrence?

Benn PL,Wolff BC,et al. Level of anastomosis and recurrent diverticulitis.Am J Surg 1986;269-271.

Mayo Clinic Study Wolff BC, Ready RL, MacCarty RL Dis Colon Rectum 1984;27:645-647

Importance distal resection margin : colo-rectal anastomosis12.5 % (distal sigmoid) vs 6.7 % rectum (p<0.03)

Proximal resection margin : no correlation with recurrence

Surgeon 1

Surgeon 2

monit I

monit II

TrendelenburgRight sided tilt

Vascular control

1. SRA -sparing

2. LCA - sparing

2

1

AMI

LCASRA

LCA-sparing, cross-stapling SRA

1

2

SRALCA

High tie AMI

Mobilization of the splenic flexure a medial to lateral approach

• Complete mobilization of the left colon– TME-surgery (CAJP)– Proximal diverticulitis– Total colectomy (UC, Slow colon, FAP, …)

Masterclass Laparoscopic Colorectal Surgery

Splenic flexurePreserve arterial bloodsupply from middle colic artery

Surgeon 1

Surgeon 2

monitor

reversed – Trendelenburg

right sided tilt

Step I : exposure

- reversed – Trendelenburg

- flip-over the omentum

- incision Treitz’s ligament

- first jejunal loop to the right

II. Ligation IMVOpening lesser sac

lateral to the middle colic vessels

III. omental release

difficulties – reasons for conversion

1. Exposure / ‘jejunum at risk’

2. Obliterated lesser sac- enter through the omentum- enter more lateral

3. Transverse colon – descending colon

Mesorectal transsection (PME)

extraction

- site- supra pubic - left flank

- use a woud – protector- wound infections- tumour implants

double stapling (Knight & Griffen 1984)

difficulty : the high anastomosis

- Anastomosis on the rectum ? ( circular muscle coat)

- Further mobilize the rectum- Use the sizers to straighten the rectum (flatten Houston valves)- Insufflate the rectum - More distal recoupe- ( lateral anastomosis on the anterior aspect of the rectum )

High double-stapled colorectal anastomosis

LEFT-Sided Disease

RIGHT-Sided Disease

MalignantBenign

DiverticulitisAdenomaEndometriosisCrohn….

CrohnAdenoma….

AdenocarcinomaLymphomaSarcoma….

AdenocarcinomaLymphomaSarcoma….

Surgery for Crohn’s disease

laparoscopic ileocaecal resection

stricture plasty

Need for Surgery:ileocaecal Crohn 's disease

0102030405060708090

1 5 10years of diagnosis / follow-up

%primarysecundary

Risk Factors for surgery and recurrence in 907 patients with primary ileocecal Crohn's disease .Br J Surg 2000;87:1697

Global picture

Surgical management of CD: challenging

~ severity of inflammation~ prior resection~ complex fistulas~ use of immunosuppressive medication

clinical judgement is an essential componentin conjunction with evidence-based data

Long-term benefitsBody Image - Cosmesis

sub-/peri-umbilical incision

transumbilical (up-down)

Pfannenstiehl

Associated surgery(42.2 %)

Lap.ass.conv

Openopen total

stricturoplasty (n) 7 (25) 1 (2) 5 (14) 6 (16) 19 (57)segmental enterectomy 8 2 7 9sigmoid resection 3 4 11 15wedge rectosigmoid 15 7 5 12wedge transversum - - 1 1wedge duod/stomach - - 3 3closure bladderfistula 2 - 1 1cholecystectomy 1 - 1 1drainage abscess 1 - 1 1resection livertumor 1 - - -

28.1% 78.5% 62.7% 65.7% P < 0.0001

Ileosigmoidal fistula in Crohn’s disease

Surgical technique = lapsc assisted

1. Complete Small Bowel – Colonic exploration

2. Take down internal fistulae

3. Mobilisation Right Colon / terminal ileum

Vascular controlAnastomosis through Utility incision

Laparoscopic assisted technique

- sub - mesenteric approach

- control of the retroperitoneal plane

- ureter- duodenum

-mobilisation of the hepatic flexure

monitor

Surgeon 2

Surgeon 1optic

Ports for lapsc ileocaecal resection for Crohn’s

Laparoscopic exploration- extent of disease- skip areas- feasibility

OPEN PROCEDURE LAPAROSCOPIC PROCEDURE

‘early conversion’

‘late conversion’

Vascular controlAnastomosis

UTILITY INCISION

Laparoscopic Right Hemicolectomyfor cancer

Optimizing outcome in colorectal surgery

• Rectal cancer Total MesorectalExcision

• Colon cancer Complete MesocolicExcision

Q. Segmental resection for colon cancersegment is determined by

1. Proximal and distal margins from the tumor

2. Venous drainage of the segment

3. Arterial blood supply of the segment

Aspects of Quality in colonic cancer resection

1. Margins

2. Integrity mesocolon

3. Vascular pedicle ligation

4. Extent lymphadenectomy

Achievable in a laparoscopic approach ?

1. Extend medially the mesocolic mobilisationsaveguard the pancreaticoduodenal vein

2. Dissection upon root VMSmedial to the duodenal window

Supraduodenal window delineatesD2 resection

D3

D3

monitor

Surgeon 2

Surgeon 1

Port placement

(Reversed) Trendelenburg

Left sided tilt

anatomic variability

- ‘troublesome’ venous bleeding

- exposure

VMSMCV

sGDVGEV

Henle venous confluens

Right branches of the middle colics

Laparoscopic approach

SMV

gastro-epiploics

Right branch of middle colic artery

Arterial Supply determines resection margins

Predominant ‘watershed’ of lymphatic drainage

Anastomosis

1. Through extraction site

- manual

- stapled : functional end-to end ( Barcelona )

Caveat !!! : mesenteric twist

Close the mesenteric window ?

Laparoscopy for colorectal diseaseis not the end of the future

So, remain alert !SILS

Transrectal specimen delivery (NOSE)NOTES

The future will probably be far less invasive