Laparoscopic Sigmoid Colon Resection forDiverticular Disease

George Ferzli, MD, FACSProfessor of Surgery, SUNY Downstate Health Science Center, Brooklyn, NY

How is it done?

1. Lateral Approach2. Anterior Approach

Patient With Large Ventral Hernia

Lateral patient position

• Patient positioned on right side

• Hand rotated in semicircle over sigmoid for trocar placement (more like triangle)

Trocar placement : Lateral Position

Lateral positionSplenic Flexture Mobilization

Lateral ApproachInferior Mesenteric Artery

Lateral Position

Lateral trocar cuts sigmoid

Repair - Lateral Position

If proximal colon can be brought through lateral incision tension-free, the repair will be tension free

End to End Anastomosis

Lap. Sigmoidectomy - Lateral Position

Laparoscopic Sigmoidectomy – Lateral Position

Lateral Approach

Lateral ApproachAdvantages and Disadvantages

Advantages• Easy mobilization of

splenic flexture• Easier identification of

ureter• Small bowel out of the

way in case of ventral hernia

Disadvantages• Inability to evaluate

liver• Poor access to

adhesions or lesions on the right side of the recto-sigmoid

• In females, ovary may interfere

Anterior Approach

• Patient supine

• Position hand over sigmoid and rotate in semi-circle to place trocars (3)

Trocar Placement : Anterior Position

Anterior position

1

2

Trocar in inguinal crease cuts sigmoid

Repair - Anterior Position

If proximal colon can be brought through inguinal crease trocar incision, tension free repair will be successful

Anterior Approach

Anterior Approach

Laparoscopic Sigmoid ColectomyTotal (n) = 62 pts Lateral (24) Anterior (38)

Age 48 (32 - 70) 46 (27 - 86)

Sex, M:F 23:1 35:3

Indications:

• Diverticulitis 16 (2 abscess) 20 (4 abscess)

• Polyp 3 6

• Carcinoma 5 12

Complications 1 hematoma flank,

1 re-op for SBO,

1 leak (cut.drainage)

1 leak (re-op hartman)

Hospital Stay 2.2 (2 - 10) 2.4 (2 - 9)

OR Time 142 (98 – 216) 147 (110 – 279)Ferzli G et al. (2000 – 2001) Unpublished Data

Laparoscopic Sigmoid ColectomyTotal (n) = 62 pts Lateral (24) Anterior (38)

Age 48 (32 - 70) 46 (27 - 86)

Sex, M:F 23:1 35:3

Indications:

• Diverticulitis 16 (2 abscess) 20 (4 abscess)

• Polyp 3 6

• Carcinoma 5 12

Complications 1 hematoma flank,

1 re-op for SBO,

1 leak (cut.drainage)

1 leak (re-op hartman)

Hospital Stay 2.2 (2 - 10) 2.4 (2 - 9)

OR Time 142 (98 – 216) 147 (110 – 279)Ferzli G et al. (2000 – 2001) Unpublished Data

Laparoscopic Versus Open Colectomy for Cancer

Colorectal ResectionLaparoscopic vs. open resection for carcinoma

0

10

20

30

40

RHC Trans AR Sig LAR APR Total

Ave

. # ly

mp

h no

des

0

5

10

15

20

25

RHC Trans AR Sig LAR APR

Ave

. spe

cim

en le

ngth

, cm

0

4

8

12

16

20

RHC Trans AR Sig LAR APR

Ave

. dis

tal m

arg

in, c

m

LCR OCR

0

7

14

21

28

35

RHC Trans AR Sig LAR APR

Ave

. pro

xim

al m

arg

in, c

m

LCR OCR

RHC = Right hemicolectomy; Trans = Transverse; AR = Anterior resection; Sig = Sigmoid; LAR = Low anterior resection; APR = Abdominoperineal resection

Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46

Colorectal ResectionLaparoscopic vs. open resection for carcinoma

Laparoscopic

(n=192)

Open

(n=224)

Hospitalization, days 5.6 9

Blood loss, mL 150 450

Wound complications 0.5% 6%

Recurrence rates 12.2% 22%

Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III)

13% 19.1%

Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46

Colorectal ResectionLaparoscopic vs. open resection for carcinoma

Follow-up Lap. Open

No. of cases (n) 40 43

Overall metastases 8 (20%) 10 (23%)

Single site metastases 3 5

Liver 2 4

Regional 1 1

Multiple site metastases 5 5

Liver+ Peritoneum 4 4

Liver+Peritoneum+

Trocar-site or scar

1 1

Five-year overall survival

0

20

40

60

80

100

0 12 24 36 48 60

Follow-up (months)

Sur

viva

l (%

)

Five-year disease-free survival

0

20

40

60

80

100

0 12 24 36 48 60

Follow-up (months)

Sur

viva

l (%

)

Lap OpenSantoro E et al, Hepato-Gastroenterology 1999; 46:900-904

Colorectal ResectionLaparoscopic vs. open resection for carcinoma

Lap (n=18) Open (n=18) Converted (n=7)

Operating room time (min) 210 138 242

Blood loss (mL) 284 407 683

ICU stay (days) 3 4 6

Clear liquids (days) 2.7 4.4 5

Regular diet (days) 4.1 5.8 7

Length of stay (days) 5.2 7.3 8

Complications (n, %) 1, 5% 5, 28% 8, 100%

Length of specimen (cm) 26 26 32

Number of lymph nodes 11 10 12

Late death from cancer (mean follow-up 4.9 years)

4 6 1

Recurrence 0 1 1

Curet MJ et al, Surg Endosc (2000) 14: 1062-1066

Long-Term Survival After Laparoscopic Colon Resection For Cancer

• Aim: To evaluate long-term survival after curative, laparoscopic resection for colorectal cancer.

• Design: Retrospective review of 102 consecutive patients with laparoscopic colon resection between 1991 and 1996 with 5-year follow-up. Comparison made to open colectomy at the same institution and National Cancer Database during similar time period.

Lujan HJ et.al. Dis. of Colon and Rectum;45:491-405,April 2002

Long-Term Survival After Laparoscopic Colon Resection For Cancer

02040

6080

100

0 1 2 3 4 5

Time in years

% s

urv

iva

l

Lap

Open0

20406080

100

0 1 2 3 4 5

Time in years

% s

urvi

val

Stage I Stage II Stage III Stage IV

Long-Term Survival After Laparoscopic Colon Resection For Cancer

02040

6080

100

0 1 2 3 4 5

Time in years

% s

urv

iva

l

Lap

Open – Nat.Ca. Database

020406080

100

0 1 2 3 4 5

Time in years

% s

urvi

val

Stage I Stage II Stage III Stage IV

Long-Term Survival After Laparoscopic Colon Resection For Cancer - Conclusions

• Laparoscopic colectomy for cancer is safe and feasible

• 5-year survival after laparoscopic colon resection for cancer is similar to survival after conventional surgery

• Prospective randomized trials currently under way will likely confirm these results

Lujan HJ et.al. Dis. of Colon and Rectum;45:491-405,April 2002

Lap (LCR) Versus Open (OCR) ColectomyAuthor/Year Study Design N Mean

/Median Follow-up

Recurrence / Long-term

Survival

Lujan, 2002 Retrospective review 102 64.4 + 2.8 LCR=OCR

Poulin, 2002 Retrospective review

of prospective data

80 31 Stg I-III

15.5 Stg IV

LCR=OCR

Lechaux, 2002 Retrospective review 206 60 LCR=OCR

Champault, 2002 Prospective, Non-Randomized (NR)

157 60 LCR=OCR

Lezoche, 2002 Prospective, NR 248 42 LCR=OCR

Anderson, 2002 Prospective, NR 100 40.3 LCR=OCR

Feliciotti, 2002 Prospective, NR 197 48.9 LCR=OCR

Lacy, 2002 Prospective,Randomized 219 43 LCR>OCR

*Nelson, 2001 Prospective,Randomized 1200

*Hazebroek2002 Prospective,Randomized 1200

Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic

colon cancer: a randomized trial

End-point P Value And the winner is…….

Peristalsis detection 0.001 Laparoscopic colectomy

Oral-intake times 0.001 Laparoscopic colectomy

Hospital stay 0.005 Laparoscopic colectomy

Overall morbidity 0.001 Laparoscopic colectomy

Cancer-related survival

0.02 Laparoscopic colectomy

Overall survival NS

Antonio M. Lacy et al. The Lancet June 2002, Vol.359, Issue 9325, p.2224-9

Questions!