Laparoscopic Colorectal Surgery

Part I. Colon Surgery

A.D’Hoore MD PhD, A. Wolthuis MD F. Penninckx MD,PhD

Department of abdominal SurgeryUniversity Hospital Leuven

Q. I personally performed

1. 0 laparoscopic colorectal resections

2. < 10

3. < 20

4. > 20

Q. my personal exposureduring training

1. 0 laparoscopic colorectal resections

2. < 20

3. < 50

4. > 50

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

A complex journeyfacilitated – gasless – hand assisted

later to medial , medial to lateral

Q. Laparoscopy for colonic cancer

1. Is still investigational ( performed in PRT )

2. Oncologic outcome beter than open

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

4. Only a cosmetic benefit

Hazard Ratio : disease free survival at 3 years

Ration

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

Morbidity (meta-analysis)

Hospital Stay: multifactoriallaparoscopic open p

Lacy 2002 5.2 7.9 0.005COLOR I 2005 8.2 9.3 <0.001COST 2005 5 6 <0.001CLASSIC 2005

colon rectum

9 911 13

Senagore et al. 2005 3.7

12/04/2011

Sustained when implementing ERAS ?

Long-term wound advantages

Laurent C et al. Br J Surg 2008;95:903-90812/04/2011

Operating time ~ case-load

> 50 cases included in COLOR I

Same Oncologic OutcomeSame Oncologic Outcome

Short termShort termClinical benefitsClinical benefits

Laparoscopy = better approachLaparoscopy = better approach

Older patientCompromised

HOW IMPORTANT ?

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 ( 1994-1999)

Surgical Technique

1. Left colon- approach in benign disease- splenic flexure mobilisation- approach in cancer (cfr. rectal cancer)

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

Laparoscopic colorectal surgery

Modified Lloyd – DavisArms along the bodyMoldable bean bag

Pelvic exposure

- Trendelenburg

- Temporary hysteropexy

° trans fundic° round ligament

Anatomical landmarks

Medial to Lateral approachThe left Colon

Final release

Laparoscopic approach medial to lateral

Diverticular disease

- Recurrent diverticulitis ( > 2 attacks )

- Internal fistulae (15%)

- Diagnostic doubt (ca)

- (recurrent bleeding)

Trend toward a more conservative approach

Common fistulas

-BladderFoley cathether 5-7 d

-Vagina

-Small bowel

resection margins in diverticular disease

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

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

TrendelenburgRight sided tilt

Pelvic diverticulitis

Vascular control

1. SRA -sparing

2. LCA - sparing

SRA-sparing vascular control

Cross-stapling SRA/SRV left colic artery sparing

double stapling (Knight & Griffen 1984)

double stapled anastomosis

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 )

Benign lesions: location

- RX Colon contrast

- Preoperative staining : not always accurate

- Peroperative colonoscopy : left colon

IMA – High Ligation

Surgeon 1 Surgeon 2

monitor

Trendelenburg

Right sided tilt

11

22

SRALCA

Splenic flexurePreserve arterial blood

Mobilisation Bowel

Release- lateral attachments (Toldt)- superior (splenocolic ligament)- omentum- adhesions lesser sac

Level of vascular ligation- high/low tie (left colic preservation)- high venous ligation

Griffith’s point

Sudeck’s point

Low tie + High venous ligation providesfull mobility

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

predictable difficultiesfused mesentery transverse / descending colon / omentum

TCDC

Splenic flexure avoid medial to lateral dissection

“en bloc” exteriorization

disssection will eventuallyyeopardise blood supply DC

extraction

- Site- supra pubic - left flank- NOSE

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

Transrectal specimen retrieval ?

Akamatsu H et al. Surg Endosc. 2009 Mar 6. [Epub ahead of print]Totally laparoscopic sigmoid colectomy: a simple and safe technique for intracorporeal anastomosis.

12/04/2011

Surgery for Crohn’s disease

laparoscopic ileocaecal resection

stricture plasty

natural history of Crohn’s disease

Cosnes J et al. Inflamm Bowel Dis 2002;8(4):244-50Beaugerie et al. Gastroeneterology 2006;130:650-656

medical therapy

Need for Surgery:ileocaecal Crohn 's disease

0102030405060708090

1 5 10

years 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

National trends for surgical therapy of ileocolonic Crohn’s disease

Independent predictors

-Female

-Teaching Hospital

-Primary resection

-Primary disease stage

-Ileocaecal disease

laparoscopic open PLOS (days) 6 9 <0.01morbidity 1.2% 3.2% <0.01Total charges 2.267 36.342 <0.01

J Gastrointest Surg 2009;13:1251-1259

Surgical technique = lapsc assisted

1. Complete SB – colonic exploration

2. Take down internal fistulae

3. Mobilisation Right Colon / terminal ileum

Vascular controlAnastomosis through Utility incision

Surgeon 2

Surgeon 1

monitor

TrendelenburgLeft sided tilt

Exploration – hepatic flexure

Dissection

associated surgery in 20 %

Lap.ass.[n=117] Open[n =125]

strictureplasty 7 pts [ 27 ] 3 pts [ 12 ] segm. enter. 6 3 sigmoid resection 5 anterior resection 4 wedge rectosigmoid wedge transverse wedge duodenum

9 1

9 1 1

CCE 1 drainage abscess 4 rectopexy 1

Ileosigmoidal fistula (10-15%)sensitivity of diagnostic tests

Melton G et al. Cleveland Clinic experience J Gastrointest Surg 2009;13:839-845

Colonoscopy (fistula) 11%Colonoscopy (fistula- erythema) 54%CT-scan (fistula) 41%CT-scan (indirect) 78%Fluoroscopic contrast 53%

Important information

1. State of the sigmoid

2. Anal stricture ?

3. Sphincters ?

SILS ileocaecal for complexe Crohn

Aspects of Quality in colonic ca resection

1. Margins

2. Integrity mesocolon

3. Vascular pedicle ligation

4. Extent lymphadenectomy

Arterial Supply determines resection margins

colonic flexure and transverse colon tumours

more complexe lymphatic drainage

Extended Right Hemicolectomy vs Left Hemicolectomy

middle colic vessels

excluded from randomised trials (COLOR I, COST)

meso-colic dissection

West NP, Lancet Oncol 2008; 9: 857-865

Supraduodenal window delineates

D2 resection

D3

D3

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, duodenum, autonomic nerves

4. Lateral attachments - tumor mobilisation last step

°1965, male

monitor

Surgeon 2

Surgeon 1optic

Ports for lapsc Right Hemicolectomy for cancer

stapler

Submesocolic dissection

Difficulty : branches middle colics

- anatomic variability

- ‘troublesome’ venous bleeding

- exposure

VMSMCV

sGDVGEV

Henle venous confluens

Laparoscopic approach

SMV

gastro-epiploics

Anastomosis

1. Through extraction site

- manual

- stapled : functional end-to end ( Barcelona )

Caveat !!! : mesenteric twist

Close the mesenteric window ?

2. Laparoscopic anastomosis

Preop - perop assesment

OPEN expl LAPAROSCOPY

lapsc. assisted resection

5 %

conv :5 %

35-40%

Laparoscopyfor colorectal disease

is not the end of the futureSo, remain alert !

SILSTransrectal specimen delivery

The future will probably be far less invasive