New Surgical Modalities in the Management of the Colon and Rectal Cancer

Ted Voloyiannis, M.D., F.A.C.S., F.A.S.C.R.STed Voloyiannis, M.D., F.A.C.S., F.A.S.C.R.S

Clinical Assistant Professor in SurgeryClinical Assistant Professor in SurgeryUniversity of Texas Houston, Health Sciences CenterUniversity of Texas Houston, Health Sciences Center

Houston, TexasHouston, TexasColon and Rectal SurgeryColon and Rectal Surgery

Memorial Hermann Medical GroupMemorial Hermann Medical GroupChairman of SurgeryChairman of Surgery

Memorial Hermann Hospital SEMemorial Hermann Hospital SE

What is a Colorectal Surgeon ?

• Specialist for the Diagnosis and Treatment of diseases involving the Colon, Rectum, and Anus. (surgeon and proctologist)

• Board certified in General Surgery and Colorectal Surgery

• American Society of Colon and Rectal Surgery

• www.fascrs.org

• www.mhmedicalgroup.org

Common Colon and Rectal Surgery Diseases and Conditions

• Colon Cancer• Rectal Cancer• Anal Cancer• Diverticulitis• Colitis

– Crohn’s disease– Ulcerative colitis

• Constipation

• Colonoscopy

HemorrhoidsFissuresFistulasAnal WartsRectal BleedingIncontinence

Every March in the USA is theColon and Rectal Cancer Awareness Month

Colon and Rectal Cancer:Why Surgery?

• Early Colon and Rectal Cancer can be cured with surgery only. If localized, 80-90% survival.

• Surgery as part of the multi treatment modality for advanced Colon and Rectal Cancer.

• Palliative Surgery for Colon and Rectal Cancer.

When Do I Need Surgery?

• Colon or Rectal cancer

• A polyp with cancer within it

• A large polyp (greater than 2 cm)

• A polyp that cannot be removed safely with a colonoscopy

Anatomy

Colon and Rectal Surgical Options

• Open Abdominal Surgery

• Combined approach (abdominal and perineal)

• Laparoscopic Abdominal via a Hand port or via a Single Port

• (Robotic) DaVinci Laparoscopic Assisted

• Anorectal -local surgery or via a Single Laparoscopic Port

Open or Laparoscopic Abdominal Procedures

� Right Colectomy� Extended Right Colectomy (Right

and Transverse)� Transverse Colectomy� Left Colectomy� Extended Left Colectomy

(Transverse and Descending)� Sigmoid Colectomy

Open or Laparoscopic Procedures on the Rectum

• LAR – Low Anterior Resection– With or without ileostomy

• APR- Abdomino-Perineal Resection– Permanent colostomy

LAR APR

Type of anastomosis

• Anastomosis:

(Connecting two ends of bowel together)– Hand sewn– Stapled

– end to end– side to side– others

End to End Anastomosis

Side to side anastomosis

Side to side anastomosis

Side to side anastomosis

Ostomies

• End Colostomy

• End Ileostomy

• Loop Ileostomy

Loop ileostomy

Innovative Techniques

• Laparoscopic Surgery via a Single Port

• Robotic – DaVinci Assisted Surgery

• Transanal Surgery via a Single Port

Laparoscopic Surgery

• Innovative method of operating and performing surgery through very small incisions

• Also called “minimally invasive surgery”• “Laparoscope” is a lens and video camera • Laparoscope placed through “port” (small incision),

surgical instruments through 2 or 3 other “ports” to allow surgeon to work inside the abdomen

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Laparoscopy v. “open” surgery

Laparoscopic SurgeryOpen Surgery

Laparoscopic Surgery

� Smaller incisions

� Less postop pain

� Less hospital stay

� Faster return of GI function

� Faster return to full activity

� May take longer

� More expensive

� Often more challenging technique

Robotic – “DaVinci” Assisted Laparoscopic Surgery

• The same advantages as in laparoscopic surgery plus:

• Promises unsurpassed visualization, precision, dexterity and control for rectal / pelvic surgery

• Equivalent outcomes to the Laparoscopic Surgery

Robotic Colon and Rectal Surgery

Robotic Surgical Platform

Robotic Surgery

Transanal Surgery for Mid or Low Early Rectal Cancer

Anorectal Surgery

• Mostly outpatient or 23 hour admission for observation

Role of genetic testing in Colon and Rectal Cancer

• 5-6% of colorectal cancers have a known genetic mutation

• Hereditary Non Ponpolyposis Coli Syndrome, Familial Adenomatous Polyposis and other syndromes

• Young-age-of-onset colorectal cancer and other organs

• Genetic counseling and testing useful when prophylactic surgery is considered

Single Incision-Single Port Laparoscopic Colon Surgery

Single Incision Surgery

• New tools and platforms • Keep the procedure simple and safe• Cost effective

SILS strategy

• Easily reproducible by surgeons with advanced laparoscopic skills

• Eliminate use of single use items• Use equipment that hospital already has available• Eliminate additional training for OR personnel, surgical

assistant

Colon Resection

• Still <25% of colon surgery is performed laparoscopically across the nation

• Majority of laparoscopic colon surgery is performed via the HALS technique

• Most laparoscopic colon surgery is performed for right colectomy• Multiport laparoscopy for colon surgery is performed still by the

minority of laparoscopists.• Single incision port laparoscopy is “raising the bar” in colon and

rectal surgery

Less is More

• Technologic advances have allowed more surgical diseases to be treated laparoscopically and have prompted us to refine our techniques

• Smaller and fewer incisions and less trauma to benefit our patients

• Natural orifice surgery has given birth to many areas of surgical research

• New Surgical instruments• Single incision surgery: a refinement of laparoscopic surgery,

introducing a multichannel port site with a 25-50mm total incision

New surgical instruments

• Wristed instruments• Deflectable tip laparoscopes• New endoscopic instruments for cutting, retrieving, and closing

devices• New platforms for single incision surgery

SIL Devices

• SILS port (Covidien, Norwalk, CT, USA)• GELPOINT access platform (Applied Medical, Rancho Santa

Margarita, CA, USA)• GELPORT access platform (Applied Medical)• TriPort system (Advanced Surgical Concepts, Wicklow, Ireland)• Single Site Laparoscopy (SSL) Access Systems (Ethicon Endo-

Surgery Inc., Cincinnati, OH, USA)• Quadport access system (Olympus AMerica, Center Valley, PA, USA)• Spider Surgical system (Transenterix, Durham, NC)• R-Port System (Advanced Surgical Concepts)• Uni-X Single Port Access Laparoscopic System (Pnavel Systems,

Morganville, New Jersey, USA)

Single incision ~ 2.5-3.5cm

Single incision for laparoscopic colectomy!

SILS incision

ProstatectomyScar

Single incision scar 4 weeks postop sigmoid colectomy

Single incision scar 4 weeks postop sigmoid colectomy

Stretching the incision

Extraction of the specimen

Laparoscopic Single Port “INCISION-LESS”Low Anterior Resection/Loop Ileostomy

SIL Colon and rectal surgery: Applications

• Ileocecal resection• Right colectomy• Extended right colectomy• Transverse colectomy• Left colectomy• Sigmoidectomy• Low anterior resection w/wo ileostomy• Restorative proctocolectomy with IPAA• Colostomy• Ileostomy• Benign: polyp, diverticulitis, colo-vesical/vaginal fistula, IBD • Colorectal malignancy

SILS is applicable to colorectal surgery Advantages

• Improved cosmesis-shorter skin incision• Less pain compared to multiport and hand assisted laparoscopy• Option for convertion to multiport or hand assisted laparoscopy• No difference in conversion to open laparotomy• Similar morbidity• Similar operation time• Similar oncologic outcomes for colorectal cancer surgery• Safe compared to conventional laparoscopy• Shorter hospital stay compared to conventional laparoscopy?• Less total hospital cost compared to multiport laparoscopy and

laparotomy

SILS is applicable to colorectal surgery Disadvantages

• Instrument conflict: Reduced excursion-cluster effect around hands and camera

• Difficulty with exposure, ergonomics• Cost for technology• New and high learning curve that can complicate an already

challenging operation• SILS is inherently a one-operating surgeon technique-potential

impact on resident education

Conclusion

• Single incision laparoscopic colectomy is a safe and viable improvement on conventional multiport laparoscopic colectomy.

• Shorter hospital stay, less pain, improved cosmesis, faster recovery, similar oncologic safety.

• Future Randomized prospective trial between MLPS and SILS.

• SILS ASCRS databank

India Ink Injection

The setupThe setupThe roomThe room

The ideal roomThe ideal room

Life in the real worldLife in the real world

The setupThe setupThe bedThe bed

Ports, Camera, Cables

Bariatric camera,additional ports

Right angle for light source, extra grasper

The InstrumentsThe InstrumentsVascular Ligation Bowel divisionVascular Ligation Bowel division

• Stapler– Cost $250/$90 per

reload– Safe for large

vessels– Can divide bowel– Easy and efficient

The InstrumentsThe InstrumentsVascular LigationVascular Ligation

• Energy devices– High energy

coagulators, – Vessels up to

7mm in size– Infinite

applications– 5mm and 10mm

units– Easy to use– Has difficulty with

calcified vessels

Single Port Laparoscopic Colon Surgery in action!

Other applications of single portin advanced laparoscopic colorectal surgery

• Splenic flexure mobilization, then LAR via Pfannenstiel incision.• Ileostomy/colostomy reversal with ileorectal/colorectal anastomosis• LAR with loop ileostomy for rectal CA/other (incision-less single port!)• Lap APR• Lap LAR with Coloanal anastomosis• Lap TPC with IPAA, loop ileostomy• Lap Total colectomy• Lap Right colectomy, extended Right.• Transverse colectomy: laparoscopic resection with hand sewn

anastomosis?• Takedown of colo-vesical/vaginal fistula

da Vinci Single Site

Using da Vinci Si system with 8.5mm 3D HD endoscope

Curved Instrument Cannulae 5mm, non-wristed, semi-rigid

instruments

Instruments and accessories shown have not been cleared by the FDA

(da Vinci Single Site prototype)

scope

Advanced Single Port or NOTES

Flexible Systems

Single Port ~20mm diameter da Vinci-like capability Large range-of-motion

(multi-quadrant capability)

Robotic Systems – Single Port Surgery

Instruments and Accessories shown are currently under product development and have not been cleared by the Food and Drug Administration (FDA).

Summary

• Surgery in early Colon and Rectal Cancer can cure!

• Numerous surgical options and minimally invasive techniques.

• Your surgeon will advocate the most suitable option.

• Genetic testing may be recommended.

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Which surgery is best for me?

• There are many factors involved in determining the best operative approach

• This question needs to be answered on an individual basis between the patient and surgeon