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