Laparoscopic Colorectal Surgery

Laparoscopic Colorectal Surgery




Laparoscopic Colorectal Surgery

Prof. Dr. R. K. Mishra INTRODUCTION Laparoscopic colon resections are being performed with increasing frequency all over the world. However, the use of minimal access surgery in colorectal surgery has lagged behind its application in other surgical fields. Since the first laparoscopic colectomy was described in 1991, a great deal of controversy has surrounded its use, particularly in the management of colorectal cancer. After the successful introduction of laparoscopic colectomy by Jacobs, laparoscopic surgery for the treatment of colorectal cancer, especially laparoscopic rectal surgery, has been developed considerably. Several new important studies have demonstrated the benefits and safety of laparoscopic colorectal surgery, making it now the preferred approach in the surgical management of many colorectal diseases. The technique of laparoscopic colectomy has a long learning curve because of the advanced laparoscopic skills it entails. Unlike other laparoscopic procedures, such as the Nissen fundoplication or cholecystectomy, colorectal procedures involve dissection and mobilization of intraabdominal organs in multiple quadrants. Tilting of the operating-room table in various positions during an operation uses gravity to allow intra-abdominal organs to fall away from the area of dissection, providing necessary exposure that would normally be achieved through the use of retractors. Intestinal resection requires laparoscopic ligation of large A vessels, mobilization and removal of a long floppy segment of the colon, and restoration of intestinal continuity. Once the colon segment has been thoroughly mobilized and its blood supply divided, a small skin incision is made to exteriorize the colon, then resection and anastomosis are performed extracorporeally, and the rejoined colon is placed back into the abdomen. The laparoscopic approach continues to gain popularity and has evolved to include not just “pure” laparoscopic techniques but also hand-assist devices. Hand-assisted surgery can be used as a bridge for surgeons who are not completely familiar or facile with laparoscopic techniques, and even for the most experienced laparoscopic surgeons, it is often the preferred technique for surgery involving left-sided pathology (Figs. 1A and B). The use of a handassist device provides tactile feedback for the surgeon and shortens operating-room time while still preserving many of the advantages of laparoscopic surgery. By combining laparoscopic surgery with the tactile feedback of a handassisted device, surgeons can reduce operating-room time and have a lower procedure conversion rate. The technique involves making an incision the width of a hand and placing a hand-assist device to facilitate laparoscopic dissection. New handport devices make this technique possible without loss of pneumoperitoneum, which is essential for performing laparoscopic procedures. Because an incision B Figs. 1A and B: Hand-assisted colorectal surgery.

Laparoscopic Colorectal Surgery

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(4–5 cm) is necessary to remove the colon specimen at the end of a laparoscopic operation, the difference between a pure laparoscopic procedure and a hand-assisted operation is generally a few additional centimeters (3–4 cm) of incision length. Several clinical trials have demonstrated that there is no difference in patient recovery or discharge for laparoscopic versus hand-assisted techniques. Larger incisions are often needed, and because of the increased risk of wound infections and pulmonary complications, this technique has particular advantages with overweight or obese patients. Most patients are candidates for a laparoscopic approach. When the surgeon is experienced, even patients with a history of abdominal surgery can form possible candidates. Though there are clear benefits, they have not been as compelling when compared to the clear advantages associated with other laparoscopic procedures. The main reason is that a colectomy, whether open or laparoscopic, results in a delayed return of bowel function. Though recovery of bowel function is quicker after laparoscopic surgery, the difference is on the order of 1 or 2 days, resulting in a similar reduction in length of hospital stay. Also, the laparoscopic approach is associated with longer operating-room times. Even if longterm benefits are equivalent between open and laparoscopic techniques, the short-term benefits are real advantages for patients. In practical terms, the laparoscopic approach is associated with less pain, a faster recovery, earlier return of bowel function, a shorter hospital stay, possible immune benefits, and smaller scars, making it the preferred method for intestinal resection. The lack of tactile feedback during laparoscopic surgery can make tumor localization difficult, especially if the lesion location has not been tattooed on the colon wall before surgery. It is imperative that the exact location of the tumor is known prior to proceed with colectomy. Even when the lesion location has been tattooed onto the colon, often the mark can be challenging to see, or there may be confusion regarding the location of the tattoo in relation to the tumor (proximal or distal), which can affect surgical margins. A Intraoperative colonoscopy is a way of definitively localizing a lesion and should be available during all laparoscopic colectomies. A traditional colonoscopy uses room air as the insufflating gas, which leads to significant bowel distension and requires clamping of the proximal colon to minimize this effect. Clamping the bowel can lead to injury, and even when it is successfully performed, the degree of distension often makes simultaneous laparoscopic visualization difficult. These problems can be circumvented with the use of CO2, rather than room air, as the insufflating gas. Because CO2 is absorbed much more rapidly than room air, bowel distension is minimized and dissipates quickly, making proximal clamping unnecessary. The use of CO2 allows for laparoscopic and endoscopic procedures to be performed simultaneously, and this technique has been shown to be safe and clinically useful. Besides tumor localization, CO2 colonoscopy may have other potential applications. PORT-SITE METASTASIS In the early experience of laparoscopic colectomy for cancer, a few reports described immediate tumor recurrence at the laparoscopic incision sites, referred to as port site recurrences (Figs. 2A and B). It was hypothesized that such early cancer recurrence happened after laparoscopy due to tumor shedding and/or accelerated tumor growth, secondary to the presence of gas in the peritoneal cavity. However, multiple reviews have indicated that this is not the case. In one such study, which included over 2,600 cases, the rate of port-site recurrence was approximately 1%, which is similar to that noted in open colorectal surgery. It is not currently believed that laparoscopic colectomy is associated with early wound recurrences. Port-site implantation was a concern in the early period, but it has been shown now that it can be prevented by: ■ Proper protection of port site while delivering the specimen. (Endobags® and pouches). ■ Avoid squeezing of the specimen by taking a liberal incision. B Figs. 2A and B: Port-site metastasis after laparoscopic surgery. 341

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SECTION 2: Laparoscopic General Surgical Procedures ■ Thorough wash to the wound, 5FU solution irrigation of all ports ■ Slow-release of pneumoperitoneum ■ Lap-lift technique The cost can be brought down by either doing a handsewn anastomosis through the specimen delivery site or use of conventional stapler for extracorporeal stapled anastomosis. Minimal use of disposable ports and instruments can further cut down the cost. The use of ultrasonic energy sources in the form of harmonic shears (Ethicon® and USSC®) has added to some of the cost of lap surgery. The two burning issues are port-site metastasis in malignancies and cost factor due to the use of endo staplers. As mentioned earlier, for a benign condition such as rectal prolapse, adenomas, rectal polyposis, and inflammatory condition such as tuberculosis, ulcerative colitis, and simple diverticulitis, laparoscopic surgery offers a patient-friendly technique. Crohn's disease, though not very common in India, laparoscopy can be offered for the diagnosis, lymph node sampling, and curative resection. Ileocecal tuberculosis is commonly seen in our country, and it is an excellent option to provide the benefits of laparoscopy to these patients whenever surgery is indicated. Incidental colonic resection is unlikely to help the laparoscopic surgeon team in mastering the techniques. The reduction of OT time due to better coordination and cost-benefit to patients can only be offered by repetitive performances. A dedicated team effort will surely bring this specialty under the umbrella of minimal access surgery as has happened in the western world. BOWEL PREPARATION IN COLORECTAL SURGERY Though widely accepted as sensible and logical, it has never been subjected to any stringent scrutiny. The ideal method of mechanical preparation should be simple, inexpensive, without distress, and side effects to the patient. However, such an ideal method does not exist. It must be chosen with respect to patient acceptability, efficiency and influence on fluid and electrolyte imbalance and fecal microflora. The conventional method involves a 3-day regimen consisting of low residue and clear liquid diet combined with purgation using laxatives and enemas. Although satisfactory in bowel cleansing in about 70% of patients, it is rather exhausting due to reduced calorie intake. It is time-consuming and may result in dehydration if the patient drinks an inadequate amount of fluids. These disadvantages stimulated the development of more reliable, efficient, and quicker methods, which are given in the following text. Elemental Diets Low residue liquid or elemental diets were used with the intention that nutrients could be absorbed in the small intestine. Although, these results in low fecal bulk, satisfactory cleansing is obtained in only 17% of the patients. Nausea and vomiting can occur, and the evidence does not favor elemental diets as a sole means of bowel preparation. Whole-gut Irrigation Saline: Normal saline is instilled through a nasogastric tube at a constant rate of 50–70 mL/min in 4 hours, requiring a total of 10–14 L of fluid. Cleansing effect is achieved in 90% of the patients; however, the concentration of colonic bacteria is not reduced unless antibiotics are added. Many patients complain of abdominal distension, nausea, and vomiting. Other drawbacks of this method include the large volume of irrigants, need of nasogastric tube, risk of electrolyte disturbance and water retention, and nursing care required to assist the patient. It is contradicted in patients with gastrointestinal obstruction, perforation, and toxic colitis and has to be used with caution in patients with cardiac problems. Castor oil: It (30–60 mL) orally achieves good cleansing but requires a large volume of magnesium citrate purgative to achieve the desired results and requires to be given 2 days before surgery followed by anal washouts a day prior which entails preoperative admissions for 3–4 days. Unpalatabilty is another drawback. Mannitol: Mannitol is a nonabsorbable oligosaccharide which acts as an osmotic agent by pulling fluid into the bowel and producing a purgative effect by irritating the colon. Being a sugar, it is quite palatable and can be flavored by mixing it with fruit juice. Usually, 4 L of 5% solution is consumed over 4 hours, which can be difficult and can result in abdominal discomfort and nausea. To avoid these side effects, hypertonic solutions (10–20%) can be used but these predispose to dehydration and electrolyte losses. Overall, good cleansing is produced in about 80% of the patients, but leads to a high wound infection rate probably by acting as a bacterial nutrient and production of explosive gases as a result of fermentation into methane and hydrogen by anaerobic bacteria is seen. The same can be overcome by using of an antibiotic. Polyethylene glycol (PEG): To overcome the drawbacks of mannitol, PEG (PEGLEC) in a balanced electrolyte solution was introduced which also acts as an osmotic purgative (Fig. 3). To achieve satisfactory cleansing in >90% of the patients, an average of 2–4 L of PEGLEC solution must be ingested with tea and lemon. Studies using PEG have shown a significantly lower incidence of fluid retention and lesser aerobic and anaerobic fecal bacterial counts compared to other agents. It is nowadays used as an agent of choice for preparations of the bowel before endoscopy and colonic surgery in a nonobstructed patient.

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Fig. 3: Bowel preparation in colorectal surgery. Picolax: It (sodium picosulfate and magnesium citrate) is a stimulant purgative that acts mainly on the left colon after activation by colonic bacteria and on osmotic laxative that cleanses the proximal colon. Two sachets in 2 L of water are administered with dietary restrictions to improve effectiveness. Although acceptable cleansing is achieved in 85% of patients undergoing barium enema and colonoscopy, its efficacy for elective colorectal operations is poorly documented. Picolax is well tolerated but does produces fluid and electrolyte losses. ANTIBIOTIC BOWEL PREPARATIONS Mechanical cleansing alone has failed to achieve a significant reduction in the total bacterial load of the colon and, therefore, the associated septic complications. Addition of antibiotics, oral as well as parenteral, to mechanical cleaning has resulted in a significant reduction of the infection rate from 30 to 60% in an uncovered patient to as low as 2–10% in otherwise patients covered with broad-spectrum antibiotics. Oral Antibiotics Because the aerobic Escherichia coli and the anaerobic Bacteroides fragilis are frequently involved organisms in septic complications following colorectal operations; oral antibiotics active against both types of bacteria must be given. Oral administration of erythromycin, neomycin, and metronidazole are popular. Several studies have documented the efficacy of oral antibiotics; however, an antimicrobial used alone without mechanical cleansing has little impact on the postoperative infection rate. Parenteral Antibiotics Since parenteral antibiotics are valid only when adequate tissue levels are present at the time of contamination, systemic administration should start immediately before the surgery. A second- or third-generation cephalosporin with metronidazole is the most commonly preferred agent. Studies had shown conflicting results when parenteral antibiotics were compared with oral or both. Whether antibiotics bowel preparation should be oral, systemic, or both are still a controversial issue. The majority of the surgeons would prefer parenteral antibiotics or with concomitant administration of oral antimicrobials together with oral PEGLEC electrolyte solution as the method of choice of preoperative bowel preparation. Though observational data suggest that mechanical bowel preparation before colorectal surgery reduces fecal mass and bacterial count in the lumen, but the practice has been questioned because the bowel preparation liquefies feces, which could increase the risk for intraoperative spillage, and may be associated with bacterial translocation and electrolyte disturbance. Though commonly practiced without the benefit of evidence from randomized trials, and two of three meta-analyses suggest a higher rate of anastomotic leakage with mechanical bowel preparation thus calling for an end to the practice of mechanical bowel preparation in view of the possible disadvantages of this practice, patient discomfort, and the absence of clinical value. There are others who accept that though routine preoperative bowel cleansing is no longer justified prior to colorectal surgery in general, they call for further evaluation in cases such as total mesorectal resection with low anastomosis where it may still have a role and therefore to consider each case carefully, otherwise the chance of making an inappropriate decision exists with significant consequences for patients. The majority of surgeons believe that patients should have a standard bowel preparation 48 hours before the operation and should receive a single-dose antibiotic dose immediately preoperatively. For the bowel preparation, patients follow a strictly fiber-free diet eight days before surgery and take a sodium phosphate oral solution the day before surgery. This method is very useful because it ensures an empty digestive tract and a flat small bowel, which facilitates the layering of intestinal loops, a crucial point for achieving adequate exposure. Alternatively, the PEG can be used. In this case, administration 2 days before surgery is preferable to avoid distension of small bowel loops that may be difficult to handle during the surgery. RIGHT COLECTOMY A right colectomy or ileocolic resection is the removal of all or part of the right colon and part of the ileum (Fig. 4). 343

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SECTION 2: Laparoscopic General Surgical Procedures Equipment and Instruments Fig. 4: Section to be removed in right colectomy. These operations are performed for the removal of cancers, certain non-cancerous growths as well as severe Crohn's disease. If performed by an expert laparoscopic surgeon, laparoscopic right colectomy and ileocolic resection are as safe as “open” surgery in carefully selected cases. Indications The advanced laparoscopic skills required for laparoscopic resection of the colon and rectum have precluded wide dissemination of this procedure. By applying certain key principles, laparoscopic right hemicolectomy can be made simple, reproducible, easy to teach, easy to learn, and cost-effective. Although benign tumors not resectable by a colonoscopic procedure and structuring inflammatory bowel disease may be good indications for laparoscopy, they are not so common. The most common disease for right colectomy is right-sided colon cancer. Colon cancer seems to be a good indication for laparoscopic surgery if performed using proper oncologic methods, i.e., early proximal ligation of the major mesenteric vessels and wide mesenteric and intestinal resection with complete lymphadenectomy. For right colectomy, either laparoscopic mobilization of the bowel and/or mesenteric resection, both are performed as for open colectomy, and bowel division and creation of the anastomosis can be performed extracorporeally. Contraindications ■ Patients with complete obstruction caused by the cancer ■ Cancer extensively invading adjacent organs ■ Bulky cancer >10 cm in size should be excluded. According to these concepts, a proper oncologic approach using laparoscopy for right colon cancer is described in this chapter. One can use the same basic equipment, such as light source, insufflator, 30° angled laparoscope, and 5-mm graspers. To this basic equipment, can be added reusable instruments such as Babcock and alligator clamps, which should be at least 38–40 cm in length to reach from the depths of the pelvis to the upper abdomen using limited port sites. In developing countries, these reusables can be used if necessary but trying to keep disposable equipment to a minimum. Three 10 or 12 mm trocars with stability threads, plus reducers for 5-mm instruments should be used. Cannulas should allow instruments to move through smoothly while maintaining a good seal after multiple instrument passages. An energy source device of one's choice can also be added, such as bipolar, LigaSuretm, or harmonic scalpel. Additional disposable equipment is kept readily available in the operating room and used only as needed. These include a clip applier, linear vascular stapler, suction irrigator, and fan retractor. Patient Positioning and Operating Room Setup The patient is placed supine, and straps are used to secure the patient during steep table position changes. The patient is fixed in a moldable “bean bag” form with both arms tucked in, and placed in a modified lithotomy position using levitator stirrups (Figs. 5 and 6). A urinary catheter is placed in the bladder, and the stomach is decompressed with a nasogastric tube. Identical operating room personnel is used for the laparoscopic case as for an open right hemicolectomy. The nurse is on the patient’s right. This is also where the assistant stands, with the surgeon on the patient’s left side facing the right colon. Hasson (open) technique is preferred to safely insert the first port through the umbilicus. After establishing pneumoperitoneum, the surgeon tries to expose the right mesocolon and to mark the lower border of the ileocolic vessels. After initial exploration ensures no prohibitive adhesions, two additional 10–12 mm ports are placed under direct visualization, one in the left upper quadrant (in or lateral to the rectus, avoiding the epigastric vessels, approximately a handbreadth from the supraumbilical port) and one in the suprapubic midline. Once all the trocars are in place, the assistant moves to the patient's left side to direct the camera. To start the initial dissection, the surgeon moves between the patient’s legs, the assistants position themselves on the patient’s left side, and the nurse stands near the patient’s right knee. The primary monitor is placed near the patient’s right shoulder to give the surgeon and the assistant’s optimal viewing (Fig. 7). The second monitor is placed on the left side close to the head, a location that gives the best view for the nurse.

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Fig. 5: Position of patient for colorectal surgery. Fig. 6: Shoulder support to prevent sliding during colorectal surgery. After completing the proximal vessel ligation with lymphadenectomy and mobilization of the terminal ileum and the cecum, the surgeon moves back to the patient’s left side, and the first assistant stands between the patient’s legs for take-down of right flexure and whole mobilization of the right colon (Fig. 8). Operative Technique Right colectomy can be broadly divided in the following steps: ■ Ligation of ileocolic vessels ■ Identification of right ureter ■ Dissection along the superior mesenteric vein ■ Division of omentum ■ Division of right branch of middle colic vessels ■ Transection of the transverse colon ■ Mobilization of the right colon ■ Transection of the terminal ileum ■ Ileocolic anastomosis ■ Delivery of specimen The patient is positioned in Trendelenburg with the right side inclined upward. This allows the small bowel and omentum to fall toward the left upper quadrant, exposing the cecum and assisting in retraction. The omentum and transverse colon are moved toward the upper abdomen, the ventral side of the right mesocolon is well visualized, and the optimal operative field can be achieved. The small bowel is mobilized out of the pelvis by grasping the peritoneum, not bowel wall, near the base of the cecum and pulling cephalad and to the left. The appropriate plane along the base of the small bowel mesentery and around the cecum can be seen and the peritoneum overlying it carefully opened, exposing the correct retroperitoneal plane. The ureter is identified either before opening the peritoneum in a thin patient or after, being visualized as it courses over the right iliac vessels. Dissection is then continued around the base of the cecum. Moving cephalad and laterally, the white line of Toldt is incised as the right colon is retracted medially and cephalad by grasping the cut edge of the peritoneum, not the bowel. 345

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SECTION 2: Laparoscopic General Surgical Procedures Fig. 8: Mobilization of cecum and right colon. Fig. 7: Position of surgical team during colorectal surgery. Before starting the dissection, the ileocolic pedicle must be definitively identified by retracting the right mesocolon. Various approaches, such as lateral-to-medial (lateral approach), medial-to-lateral (medial approach), and retroperitoneal approach, have been documented. The medial approach is quite effective for complete lymphadenectomy with early proximal ligation, minimal manipulation of the tumor-bearing segment, and ideal entry to proper retroperitoneal plane. Various approaches to the right colon mobilization have been described. ■ Lateral to medial (“classic” open approach) ■ Medial to lateral approach ■ Retroperitoneal approach It is believed that the medial approach is optimal in order to maintain conventional oncologic principles. First, the mesocolon near the ileocecal junction is lifted to confirm the ileocolic pedicle. The root of the ileocolic pedicle is usually located at the lower border of the duodenum. The independent right colic vessels, if present, are located at the upper border at the duodenum. However, the majority of patients do not have the independent right colic vessels (vessels originating directly from the superior mesenteric artery and vein (Figs. 9A and B). The surgeon should initially stand on the patient’s left side to confidently know the ileocolic pedicle from the superior mesenteric vessels, and to mark the lower border of the ileocolic pedicle. Once the ileocolic pedicle is identified, the surgeon moves between the patient’s legs and the scope is inserted through the suprapubic port. The medial side of the right mesocolon is first incised, starting from the previously marked region below the ileocolic pedicle, followed by the incision of the peritoneum over to the superior mesenteric vessels. This is done before mobilization of the right colon. With adequate traction of mesocolon toward the right upper quadrant, the ileocolic vessels are easily mobilized from the subperitoneal fascia leading onto the duodenum. Their origins are identified from the superior mesenteric vessels at the lower border of the duodenum and divided. The surgeon’s first step in the dissection is to mark the inferior border of the ileocolic pedicle. From between the legs, the surgeon dissects the peritoneum overlying the ileocolic vascular pedicle over to the superior mesenteric vessels. After mobilization of the ileocolic pedicle from the duodenum, the dissection of the ventral side of the superior mesenteric vein (SMV) leads to the dissection of the origin of the ileocolic artery. In type B, the ileocolic artery is running behind the superior mesenteric vein. After mobilization and division of the ileocolic pedicle from the duodenum, the dissection of the ventral side of the SMV leads to a complete dissection of the root of the middle colic artery and vein. Careful dissection onto the duodenum and the caudad portion of the pancreas must be exercised in the exposure of the middle colic vessels. Dissection around Henle’s trunk (the truck of mesenteric veins consisting of the gastroepiploic vein fusing with the right branch of the middle colic vein or the main middle colic vein) may lead to the exposure of an accessory right colic vein. Accessory right colic vein and right branches of middle colic vessels are clipped and divided. However, if an accessory right colic vein is difficult to confirm in this situation, this vein may be easily detected later at the take-down of the right flexure. After securing the vessels, the operating table is tilted into the steep Trendelenburg position with the right side down to move the small intestine toward the right upper quadrant. After confirming the right ureter and gonadal vessels

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A B Figs. 9A and B: (A) Position of major blood vessels at the time of surgery; (B) Important vessels supplying right side of colon. A B Figs. 10A and B: Specimen of right side of colon after right colectomy. through the subperitoneal fascia at the right pelvic brim, the peritoneum is incised along the base of the ileal mesentery upward to the duodenum, and the ileocecal region is mobilized medially to lateral. After this mobilization, the surgeon moves back to the patient’s left side, and the scope is inserted through the umbilical port. The right mesocolon is mobilized from medial to lateral. Again, this approach allows dissection into the proper retroperitoneal plane. The right gonadal vessels and ureter are safe from injury in this plane, so exposing them is not necessary. This approach also allows the surgeon to work in a straight path from medial to lateral, without tissue to obstruct the vision that can occur while working from lateral to medial. This plane connects the previous dissection plane from the caudad side. The anatomy around the right flexure is essential to avoid inadvertent bleeding, especially from around Henle's (gastrocolic) trunk. However, if the previous mesenteric dissection is fully performed from the caudad side and the accessory right colic vein is divided, the right flexure is easily taken down only by dividing the hepatotoxic ligament. If the accessory right colic vein is difficult to detect at the previous dissection, it can be easily confirmed from Henle’s trunk at this situation and should be divided before extracting the right colon to avoid its injury. Up to this point, the primary tumor has been minimally manipulated using medial to lateral approach. Finally, the right flexure and right colon, including the tumor-bearing segment, are detached laterally, which completes the mobilization of the entire right colon (Figs. 10A and B). Once the entire right colon is freed, it is withdrawn through an enlargement of the port site at the umbilicus. The wound must be covered with a wound protector to prevent contamination or metastasis. The resection of ileum and transverse colon, and the anastomosis are accomplished extracorporeally by the functional end-to-end anastomotic method using conventional staplers or by a hand-sewn method (Figs. 11A and B). The anastomotic site is returned to the peritoneal cavity. Wounds and peritoneal cavity are copiously irrigated. All wounds are closed, and operation is completed. The identification of a small tumor in the colon may be difficult even in conventional open surgery. In laparoscopic surgery, where there is no tactile sensation, pre- or intraoperative marking of the tumor is frequently needed. 347

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SECTION 2: Laparoscopic General Surgical Procedures A B Figs. 11A and B: Transaction of ileum by the stapler. Various kinds of marking methods are available, e.g., dye injection and mucosal clip placement by preoperative colonoscopy, which has been reported for the tumor localization. Several reports demonstrated the usefulness of tattooing the colonic wall adjacent to the tumor with India ink in four quadrants using preoperative colonoscopy. However, effective injection in all four points of the bowel is sometimes challenging to achieve. In some cases, surgeons failed to achieve serosal staining visible at laparoscopy, which forced them to use intraoperative colonoscopy. This complicated the laparoscopic colonic resection because of the distended bowel related to air insufflation during colonoscopy. Conclusion Right-sided colon cancer can be adequately treated by proper laparoscopic procedures adherent to the oncologic principles. Port-site metastasis after laparoscopic colon cancer surgery is unlikely to be a major risk factor when the procedure is performed according to oncologic principles. It is believed that laparoscopic right colectomy for cancer performed by expert surgeons is accepted as less invasive surgery without sacrificing the survival benefit compared with conventional open right colectomy. SIGMOIDECTOMY Laparoscopic sigmoid colon resection is indicated for both benign (diverticulitis, segmental Crohn's disease, polyp unresectable by colonoscopy) and malignant (primary colon cancer) etiologies, and is one of the most common operations done by laparoscopic methods. In chronic diverticular disease, the indications for laparoscopic sigmoid resection are the same as for open surgery. Sigmoid colectomy for diverticulitis can be technically challenging because of severe inflammation in the left lower quadrant and pelvis. Patient Positioning and Operating Room Setup A proper patient position is key to both facilitating operative maneuvers and preventing complications such as nerve and vein compression and traction injuries to the brachial plexus. The patient is placed supine, in the modified lithotomy position, with legs abducted and slightly flexed at the knees. The patient’s right arm is alongside the body, whereas the left arm is usually placed at a 90° angle. Adequate padding is used to avoid compression on bone prominences. A nasogastric or orogastric tube and a urinary catheter are placed. Adequate thromboembolism prophylaxis should be used, as preferred by the surgeon, and intermittent leg compression stockings can be used as well. The procedure is usually performed with two assistants and a scrub nurse (Fig. 12). The surgeon is on the right side of the patient, and the second assistant is also on the right side. The first assistant stands between the patient's legs and the scrub nurse at the lower right side of the table. The team remains in the same position throughout the entire procedure. It is advisable to use a table that can be easily tilted laterally and placed into steep Trendelenburg and reverse Trendelenburg position in order to facilitate exposure of the pelvic space and of the splenic flexure. The laparoscopic unit with the main monitor is located on the left side of the table. It is useful to use a second monitor placed above the patient’s head. Cannula Positioning Standardize cannula placements are five or six cannulae for left-sided colectomies. This allows us to achieve excellent exposure, which may be particularly valuable at the beginning of a surgeon’s learning curve. Using six cannulae allows the use of more instruments in the abdominal cavity for retraction of bowel and structures, especially in the presence of abundant intra-abdominal fat or the dilated small bowel, as well as during mobilization of the splenic flexure. Cannula fixation to the abdominal wall is essential, to avoid CO2 leakage, and in cases of malignancy, to minimize the passage of tumor cells and help reduce the incidence of port-site metastases. This is mainly achieved by fitting the size of the incision to the cannula size or by fixing the

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