Minimally Invasive Procedures in Colon & Rectal Surgery

Alan E. Harzman, M.D.

Outline

• Endoscopy- TEM- Combined approaches- Colonic Stents

• Laparoscopy– “Pure” laparoscopy vs. Hand-assisted

• NOTES

• Laparoscopic Techniques

Goals of Minimally Invasive Techniques

• Equivalent or improved outcomes

• Equivalent or improved oncologic outcomes

• Avoid excessive cost

Learning New TechniquesTraining Issues

• Learning Curve (20-50 cases)– ABS Recertification Reports (General Surgeons)

• Mean 11 colectomies/year• 90th percentile – 23/year

– I did about 40 laparoscopic colectomies as a fellow.

Rewards of Minimally Invasive Techniques

Operative Time

Benefits ofNew

Techniques

Risk/EffectsOf Anesthesia,Trauma, Etc.

Endoscopy

Transanal Endoscopic Microsurgery (TEM)

Transanal Endoscopic Microsurgery (TEM)

Richard Wolf Medical Instruments Corporation

Transanal Endoscopic Microsurgery (TEM)

• Suggested uses– Benign tumors mid to upper rectum

• 5% recurrence

– T1 low-risk lesions• 3% recurrence

– Palliation or high-risk patients

• Overall 8% recurrence• Large, long-term, randomized numbers lacking

(Bemelman, 2005)(Middleton et al, 2005)

Transanal Excision

• Similar indications

• Similar results

• Lower lesions only

Nova Plastics

How do you apply principles of local resection to the rest of the

colon?

• Step 1 – Combine laparoscopic and endoscopic resection

• Step 2 – Under development

(OmicronLab, 2007)

Combined Laparoscopy and Colonoscopy

(Bemelman, 2005)

Colonic Stentsfor Obstructing Tumors

Colonic Stents• As a bridge to surgery, in hopes of

avoiding a colostomy

• Possibly as a definitive measure in patients with widespread disease

• 84-96% clinical success rate

• Complications (~25%) include perforation, stent migration, fistula, reobstruction, tenesmus (if too low), stool impaction, bleeding

(Wolff, 2007)

Colonic Stents

(Camunez et al, 2000)

Colonic Stents Camúñez Study

• Placement in 70 of 80 patients

• Resolved obstruction in 67

• 2 perforated, 1 died

• 33 patients had surgery after 7 days

• Used as final treatment in 35– Estimated primary patency of 91% at 6

months

(Camunez et al, 2000)

Laparoscopy

Laparoscopy

• Laparoscopic – “Pure”

• Hand-Assisted Laparoscopic– Is not “lap converted to open”

Laparoscopic ApproachConsideration of Cost

• Time - Per Minute Charge  Standard - O.R. Care Time $43.00

• Equipment– Energy devices

• Ligasure

• Harmonic Scalpel

• Electrocautery

– Staplers– Access devices

• Trocars

• Hand ports

ACGME Competency-Based Goals and Objectives

• Surg 2 Chief Resident– Systems-based Practice

• Will refine operative skills including cost-effective utilization of equipment.

Laparoscopy

• Goal - Do the same (oncologic) resection– 12 lymph nodes– Ligate feeding vessel at its origin

• Currently little data on RECTAL resection for cancer– Societies currently discourage laparoscopic

proctectomy outside clinical trials

Preoperative Considerations• Site (Right and sigmoid easier)

• Tumor size/invasion

• Obesity

• Previous surgery

• Almost always get a pre-op CT (cancer)

• Must talk with patient about need for conversion to open

• Must be able to find tumor/polyp (tattoo!, 0.5cc India ink in 3-4 sites)

Tattoo

• Can also locate with BE

• Having to do intraoperative colonoscopy is a flail– CO2 colonoscopy may be better

• Bowel Preparation – Utility is debatable, but with laparoscopy it

makes bowel easier to handle

Preoperative ConsiderationsContinued

Conversion to Open• 10-25%

– Obesity– Prior surgery– Acute inflammation

• Fistula – 50% conversion

– Tumor bulk

• Not a failure

• Early conversion preserves good outcomes

(Wolff, 2007)

Evaluating Outcomes

• Tracking Outcomes– Current national push– To be included in “Maintenance of

Certification”

• “Intention to Treat”– If you started laparoscopically and had to

open, it’s not fair to put that patient’s outcome in “open” group.

(Wolff, 2007)

What difference does it make?

Laparoscopic Colectomy

What difference does it make?

Laparoscopic Colectomy

•It helps you get a job•Patients like it (thanks to the internet)•Referring doctors like it•But what difference does it really make

Outcomes

• Ileus – average 1-2 days shorter with laparoscopy

• Less need for narcotics

• Quicker return of pulmonary function

• Length of stay ~1 day less

• May be influenced by biased expectations– Who cares?

(Wolff, 2007)

Outcomes – Page 2

• Return to work and quality of life– No statistical change– Anecdotally improved

• Cost– Equipment costs and OR time are greater– May be balanced or outpaced by shorter

hospital stay

• Time – Average 30-60 minutes longer

(Wolff, 2007)

Port-Site Metastasis

• Initial concern greatly slowed development of laparoscopic colectomy

• Not born out in major trials

Specific Trials

• Antonio Lacy

• COST

• COLOR

• MRC CLASSIC

Antonio Lacy, et al 2002

• 219 patients

(Lacy et al, 2002)

Antonio Lacy, et al

Overall Survivalp=0.16

Cancer Related Survivalp=0.02

(Lacy et al, 2002)

Antonio Lacy, et al 2008

(Lacy et al, 2008)

COST TrialClinical Outcomes of Surgical Therapy Study Group

• 872 patients with colonic adenocarcinoma• Recurrence

– 16% lap– 18% open

• Survival– 86% lap– 85% open

• Post-operative stay– 5 days lap– 6 days open

(COST Study, 2004)

COST TrialClinical Outcomes of Surgical Therapy Study Group

• 5 year data published October 2007• Disease-free 5 year survival

– 68.4% Open– 69.2% Laparoscopic

• Overall survival– 74.6% Open– 76.4% Laparoscopic

• Recurrence– 21.8% Open– 19.4% Laparoscopic

(COST Study, 2007)

COLOR TrialCOlon cancer Laparoscopic or Open Resection

• 1248 patients

• 17% conversion to open• BMI>30 excluded (because started in 1997)

• Pathologic criteria no different

• Time to GI recovery, 1st BM, hospital stay all one day less

• Complications were equivalent

(COLOR Trial, 2005)

MRC CLASSICCMedical Research Council trial of

Conventional versus Laparoscopic-ASsisted Surgery In Colorectal Cancer• 794 patients

• Pathologic specimens, complications were similar

• Time to 1st BM 1 day shorter

• Time to diet and discharge similar between groups

(Guillou et al, 2005)

Hand Assisted Laparoscopy vs.“Pure” Laparoscopy

• May reduce learning curve• May be used “up front” or as a “pseudo-

conversion”• Need to make an incision large enough for the

specimen anyway• Outcomes similar to laparoscopy, with operative

times usually shorter

Hand-assist vs. Laparoscopy

(Targarona et al, 2002)

Hand-assist vs. Laparoscopy

(Targarona et al, 2002)

Hand-assist vs. LaparoscopyMarcello et al

• 95 patients - left or total colectomy

• Randomized to HA vs LAP

• Left colectomy– 175 minutes HA, 208 LAP (p=0.021)– Flatus 2.5 vs 3 days (p=0.64)– Length of stay 5 vs 4 days (p=0.55)

• Total colectomy– 127 vs 184 minutes (p=0.015)

(Marcello et al, 2008)

In a comparison of “pure” laparoscopy and HALS, what does no significant difference

mean?

It means that if you can do it more easily with one hand in, why not do it?

Robotic Assisted

So far not advantageous, encumbered by time and cost

(Minimally Invasive Robotics Association, 2002)

NOTESNatural Orifice Transluminal

Endoscopic Surgery

(Pai et al, 2006)

(Pai et al, 2006)

Techniques in Laparoscopic Colon and Rectal Surgery

Laparscopic HemicolectomyTechnique

• Access

• Takedown of previous adhesions

• Mobilization and vascular division

• Intestinal division

• Anastomosis

• Closure of mesenteric defect – Usually skipped

• Closure

Right Hemicolectomy

Laparoscopic Colectomy

Right Hemicolectomy

= 5mm

=12mm

ExtractionIncision

The Radical Appendectomy Method

Right Hemicolectomy

= 5mm

=12mm

ExtractionIncision

Right Hemicolectomy

= 5mm

=12mm

ExtractionIncision

Right Hemicolectomy

= 5mm

=12mm

HandPort

Laparoscopic Right HemicolectomyApproaches

• Medial-Lateral

• Inferior

• Lateral-Medial

• Top-Down

Largely

Independent of trocar

placement

If you elevate the right colic mesentery, what do you find?

(Netter, 1997)

Don’t burn the duodenum!Don’t laugh. It’s happened more than once.

(Netter, 1997)

Laparoscopic Right HemicolectomyMedial Approach

(Netter, 1997)

Laparoscopic Right HemicolectomyMedial Approach

Laparoscopic Right HemicolectomyMedial Approach

Laparoscopic Right HemicolectomyInferior Approach

Laparoscopic Right HemicolectomyInferior Approach

Laparoscopic Right HemicolectomyLateral Approach

Laparoscopic Right HemicolectomyTop Down Approach

Left HemicolectomySigmoidectomy

Low Anterior Resection

Laparoscopic Colectomy

Left Hemicolectomy

= 5mm

=12mm

HandPort

Applied Medical Gelport

Ethicon Lap Disk

Laparoscopic Left HemicolectomyApproach

• Mobilize splenic flexure• Mobilize sigmoid• Presacral space• Divide rectum• Divide vessels• Divide sigmoid vessels• Exteriorize & place

anvil• Return & fire EEA

Laparoscopic Left HemicolectomyHand Approaches

• Put 1-2 laps in to retract small bowel and clean camera

• Sling for splenic flexure

• Handshake for sigmoid vessels

Laparoscopic Left HemicolectomyHand Approaches

Laparoscopic Left HemicolectomyHand Approaches

Summary of TechniquesThere are many ways to skin a cat

(Kneen, 2007)

• Convert what we do “open” to laparoscopic

• Come up with new ways

• Use new toys

• Undo the embryology

• Be careful!

If bad luck got you into a situation, there’s no reason to

think that good luck will get you out of it.-Warren Lichliter

Most useful quote from my fellowship:

Summary

• Much to the chagrin of surgery residents, we continue to search for new ways to invade the body less to achieve more. – Less morbidity– Less mortality– Less recurrence– More quality– More life

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