Laparoscopic Versus Open Colectomy:Case Selection and Techniques

Anthony J. Senagore, MD, MBA, MS, FACS, FASCRS Vice President and Chief Academic Officer

Spectrum Health Medical Group 

Professor of SurgeryMichigan State University

College of Human MedicineEast Lansing, Michigan

It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.

Dr. Senagore has received grants/research support from Deltex Medical, ElectroCore Medical, LifeCell Corporation, and NiTi Surgical Solutions. He has served as a consultant for Ethicon, Inc and Tranzyme Pharma and has received honoraria from Adolor, Covidien, and GlaxoSmithKline.

Faculty Disclosure

Educational Learning Objectives• Describe the importance of improving time to

gastrointestinal recovery that occurs postsurgery and consider how this affects length of hospital stay and overall quality of patient care

• Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures

• Describe how interprofessional collaboration surrounding gastrointestinal surgery can result in better alignment with current surgical quality measures and formulate strategies to integrate this into current practice

Initial Case Presentation

• 65-year-old AA male diagnosed with a 4 cm, nonobstructing adenocarcinoma of the sigmoid colon (at 40 cm)– Meds: atenolol; simvastatin– Past history

Surgery: tonsillectomy & adenoidectomy; laparoscopic cholecystectomy

Medical: hypertension; hyperlipidemia

The Colectomy Package

• Preoperative evaluation• Prehabilitation• Operative care

– SCIP – infectious prophylaxis– Fluid management– Minimally invasive surgery

• Enhanced recovery protocol

SCIP: Surgical Care Improvement Project

Preoperative Evaluation:Surgical Risk

• ASA score• ECG• Complete blood count and complete

metabolic panel• Type and screen• Carcinoembryonic antigen1

– If elevated conveys higher risk of metastatic failure especially if fails to return to normal after surgery

1.Goldstein M, Mitchell E. Cancer Invest. 2005;23(4):338-351.

Patient Case–Staging Workup

• Chest X-ray normal• Computed tomography (CT) scan

– No evidence of metastatic disease; thickening of mid-sigmoid consistent with lesion

• Positron emission tomography (PET) scan– No clear indication in primary colon cancer

Tumor Staging

• Survival (5-year by Dukes stage)

• A = 90–95%• B = 70–80%• C = 55–65%• D = 5%

Preoperative Education

Educational Imperatives

• Review pertinent risks and indications for procedure

• Discuss anticipated recovery milestones (on instruction sheet)

• Review anticipated discharge criteria• Assure access to follow-up and questions

Surgical Options: Sigmoid Colectomy

• Laparoscopic surgery– Probably preferred approach with training and

experience

• Hand-assisted laparoscopic surgery– May have shorter/different learning curve

compared to straight lap

• Open surgery– Standard approach

What are the advantages of laparoscopic versus open colorectal surgery?

Risk Reduction

Laparoscopic Colorectal SurgeryMorbidity/Mortality

Lumley J, et al. Dis Colon Rectum. 1996;39(2):155-159.Franklin M, et al. Dis Colon Rectum. 1996;39(10S):S35-46.Reissman P, et al. World J Surg. 1996;20(3):277-281.Bennett C, et al. Arch Surg. 1997;132(1):41-44.Senagore A, Delaney C. Am J Surg. 2006;191:377-380.

Series Patients Morbidity/Complications Mortality

Lumley ‘96 240 2.5 % (leak) 1.6%

Franklin ‘96 191 17% NA

Reissman ‘96 100 22% 0%

Bennett ‘97 1194 15% NA

Senagore ‘06 1000 9.9% NA

POSSUM Score:Laparoscopic (LAP) Colectomy

N = 251 LAP

Observed/Expected(Op score = 4)

Observed/Expected(Op Score = 2)

Observed/Expected(Op Score = 1)

Mortality 0.8% / 3.5% 0.8% / 2.6% 0.8% / 1%

Morbidity 6.8% / 12.4% 6.8% / 9.6% 6.8% / 7%

Senagore AJ, et al. Br J Surg. 2003;90:1280-1284.

POSSUM: Physiological and Operative Severity Score for the enUmeration of Mortality and morbidityExpected mortality rates based on either POSSUM or Porstmouth POSSUM scoring systemsOp score: score for open colectomy, with 4 being the standard score

Laparoscopic vs Open Colectomy17735 open vs 709 lap (Nationwide Inpatient samples)

• Wound complications less (2% vs 1%)• Pulmonary complications less (6.2% vs 2.5%)• Cardiovascular complications less (2.4% vs 0.7%)• Mortality less (2.5% vs 0.3%)• LOS less (9.3 vs 5.7 days)

Guller U, et al. Arch Surg. 2003;138:1179-1186.

Short-term Benefits of Laparoscopic vs Open Surgery for Colorectal Resection

Meta-analysis of 22 trials (n = 2965) of colorectal surgery Reduced blood loss of 71.8 mL (95% CI, 30.8-113 mL; P = 0.0006) Reduced postoperative pain by 9.3/100 (95% CI, 5.4-13.2; P < 0.0001) Earlier flatulence by 1 day (95% CI, 0.76-1.3; P < 0.0001) Earlier bowel movement by 0.9 days (95% CI, 0.74-1.13; P < 0.0001) Lessened ileus (RR = 0.40 95% CI, 0.22-0.73; P = 0.003) Reduced wound infections (RR = 0.56 95% CI, 0.39-0.89; P = 0.002) Shortened hospital length of stay (LOS) by 1.5 days (95% CI, 1.12-1.94;

P < 0.0001)

Schwenk W, et al. Cochrane Database Syst Rev. 2005;CD003145.

Incidence of Hernia/Small Bowel Obstruction:CCF Index Segmental Colectomies

LABS OPEN P-value*

211 (100%) 505 (100%)

Hernia 5 (2.4%) 65 (12.9%) 0.00002

Reoperation for Hernia 4 (1.9%) 28 (5.5%) 0.03SBO (non-surgical treatment) 4 (1.9%) 31 (6.1%) 0.016SBO (surgical treatment) 3 (1.4%) 8 (1.6%) 0.87

LABS: laparoscopic-assisted bowel resection*Chi-square Test

Duepree HJ, et al. J Am Coll Surg. 2003;197:177-181. CCF: Cleveland Clinic Foundation

Laparoscopic Colorectal Surgery

• Compared with open colorectal surgery, laparoscopic surgery is associated with

– Reduced surgical trauma

– Reduced postoperative morbidity/complications

– Reduced postoperative pain

– Earlier passage of flatus and earlier bowel movement

– Reduced length of hospital stay

– Similar oncologic outcome

Standardized Technique:Laparoscopic Sigmoid Colectomy

• Medial approach to vascular pedicle

• Identification of left ureter from IMA origin to pelvic inlet

• Division of proximal vascular pedicle (IMA)

• Mobilization of mesocolon off retroperitoneum to the lateral attachments

• Lateral release of desc/sigmoid colon

• Release of splenic flexure (if needed)

• Mobilization/division of proximal rectum

• Exteriorization of specimen via LLQ muscle splitting incision with wound protector

• Primary end-to-end colorectal anastomosis

IMA: inferior mesenteric artery; LLQ: left lower quadrant

Senagore AJ. Surg Clin N Am. 2005;85:19-24.

Medial Approach to Left Ureter

IMA

IMA: inferior mesenteric artery

Medial Approach to Left Ureter

Left Ureter

Inferior Mesenteric Artery Pedicle

Vascular Division

Completed Dissection

Rectal Transection

Predictors of ConversionLaparoscopic to Open Surgery

• Obesity (BMI > 30)• Inflammatory Masses• Adhesions• Intraoperative

complications– Bleeding– Bowel injury

• Odds ratios (900 cases)– BMI 1.07– ASA score 1.63– Left vs right colorectal

procedures 1.5– Abscess 5.0– Enteric fistula 4.6– Experience 0.9 per 10 additional

cases

Tekkis P, et al. Ann Surg. 2005;242:83-91.

Laparoscopic ColectomyImpact of Obesity

• Non-obese (BMI < 30)– Conversion: 11% – Morbidity: 13% – Leak rate: 1%

• Obese (BMI ≥ 30)– Conversion: 24% – Morbidity: 22% – Leak rate: 5%

Senagore AJ, et al. J Gastrointest Surg. 2003;7:558-561.

Reasons for Conversion

Technical

Adhesions

Infection

Bleeding

Ureter identification

%

Casillas S, et al. Dis Colon Rectum. 2004;47(10):1680-1685.

0

5

10

15

20

25

30

35

40

45

Stage of Conversion

Prior to vascular pedicle/ ureter identification

Related to intracorporeal vascular ligation

Presacral dissection/ bowel transection

50%

35%

15%

Casillas S, et al. Dis Colon Rectum. 2004;47(10):1680-1685.

What are the postoperative elements of an enhanced recovery pathway?

Enhanced Recovery Pathway Standardized Order Set

Enhanced Recovery Pathway (ERP) Key Postoperative Components

• No routine NG tubes• Foley out first day• Narcotic-sparing analgesics

– Ibuprofen 800 mg po q 8 hrs– Gabapentin 300 mg po q 8 hrs

• Early ambulation• Early resumption of diet

National Surgical Quality Improvement Program (NSQIP) Length of Stay Analysis

Cohen ME, et al. Ann Surg. 2009;250:901-907.

Table 3. LOS, Morbidity, and Risk Characteristics for Patients Included in Different Models

No Complications Complications Present Low Risk Moderate Risk High Risk

N (% of total) 20,039 (86.8%)

3059 (13.2%)

7699 (33.3%)

7700 (33.3%)

7699(33.3%)

Mean LOS (d) 6.1 16.1 5.4 7.0 9.9

SD (d) 3.8 14.2 3.9 5.6 9.7

Median LOS (d) 5 12 5 6 7

> 75% ile LOS (d) 8 20 7 9 12

Morbidity rate (%) 0 100 22.4 38.7 60.0

Mean estimated morbidity risk (%)

12.4 18.8 6.2 10.9 22.6

Range estimated morbidity risk (%)

0.01–70.2 11.8–87.7 0.01–0.08 0.08–14.2 14.2–87.7

Enhanced Recovery Pathway (ERP) Impact on Length of Stay (LOS)

1991–19991999 March–June/2000

n LOSn LOS n LOS

DRG 148ERP open 1784 9.5

185 8.6 62 5.7 *other CR teams 6459 9.8 8248.8 162 10.1ERP/lap

24 3.2 *

DRG 149ERP open 742 6.4 69 5.2 44 3.5 †other CR teams 2256 6.4 3275.1 111 4.5ERP/lap

18 2.5 *

DRG 148 & 149ERP open 2526 8.6

254 7.7 106 4.7 §other CR teams 8715 8.9 1151

7.7 273 7.7ERP/lap

42 2.9 *

* P < 0.0001; † P = 0.002; § P < 0.001, Student’s t test

Delaney C, et al. Br J Surg. 2001;88:1533-1538.LAP: laparoscopyCR: colorectal surgery

“The 48-Hour Colectomy”

“The 23-Hour Colectomy”

Outcome of Unplanned Readmission (UR)(DRG Codes 146 to 149)

• 553 colorectal resections in 6 months; 56 UR (10%)• No predictors (complications, WBC, hemoglobin,

antibiotics, comorbidity, fever, urgency of procedure, presence of a stoma, length of stay)

• Matched non-readmitted cases had shorter primary LOS (6 vs 5 days, P = 0.049)

• UR had more perioperative steroids (32 vs 17%, P = 0.03)• No adverse event related to delayed diagnosis

• Conclusion: unplanned readmission is unpredictable, not related to LOS, and doesn’t affect overall outcome

Kiran RP, et al. J Am Coll Surg. 2004;198:877-883.

Patient Case Continued

• Patient underwent a laparoscopic sigmoid colectomy

• Transitioned to oral ibuprofen and gabapentin on POD 1

• Resumption of a general diet on POD 1• Discharged without complications after

having a bowel movement on POD 2

Enhanced Recovery Pathway Key Components

• Laparoscopic approach preferred• No routine NG tubes• Foley out first day• Narcotic sparing analgesics

– Ibuprofen 800 mg po q 8 hrs– Gabapentin 300 mg po q 8 hrs

• Consider alvimopan where appropriate to reduce POI risk

• Early ambulation• Early resumption of diet

Why It Works

• Fast-track pathways are a win-win situation

• Include all groups– Nurses (including enterostomal therapy nurses),

residents, pharmacists, surgeons, anesthesiologists

• Evidence-based decisions not compromise and consensus