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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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Postoperative Care
Most EMR patients can be safely discharged the day of the procedure.
ESD patients are admitted under observation for 24 hours.
No extended perioperative antibiotics are typically needed.
Diet is advanced routinely directly following the procedure, except in fullthickness resections that typically started on clears and then advanced
once confirmed stable.
Follow-up on the pathology is critically important to determine
surveillance strategies or, in the case of malignancy, potential formal
resection.
Suggested Readings
Benlice C, Gorgun E. Endoscopic mucosal dissection. In: Lee SW, Ross HM, Rivadeneira DE, Steele
SR, Feingold DL, eds. Advanced Colonoscopy and Endoluminal Surgery. Cham, Switzerland:
Springer Publishing; 2017:159-169.
Gamaledin M, Benlice C, Delaney CP, Steele S, Gorgun E. Management of the colorectal polyp
referred for resection: a case-matched comparison of advanced endoscopic surgery and
laparoscopic colectomy. Surgery. 2018;163(3):522-527.
Gorgun E, Benlice C, Abbas MA, Steele S. Experience in colon sparing surgery in North America:
advanced endoscopic approaches for complex colorectal lesions. Surg Endosc.
2018;32(7):3114-3121.
Chapter 5
Combined Endoscopic and
Laparoscopic Surgery
EMRE GORGUN
Perioperative Considerations
Combined endoscopic and laparoscopic surgery (CELS) enables
mobilization of the colon to provide ease in colonoscopic dissection and
removal of colon lesions, and synchronized visualization of the colonic
wall after lesion removal and prompt closure of full-thickness defects,
when necessary.
CELS can be used for large benign lesions or lesions that are located in
areas that make the endoscopic resection difficult (ie, flexures and folds).
CELS can also be preferred in lesions where endoscopic resection was
attempted multiple times and scarred. These lesions have a higher risk of
full-thickness defect during removal and may require minimally invasive
approaches for repair.
Benign lesions and lesions with high-grade dysplasia can also be removed
using CELS (Fig. 5-1).
FIGURE 5-1 Operating room setup for combined endoscopic laparoscopic surgery.
The operating room should be equipped with a colonoscope, most
importantly with CO2 insufflation for the colonoscopy unit.
Two monitors should be placed depending on the surgeon’s position to
allow for visualization of the endoscopic portion and abdominal portion.
An experienced assistant or an attending physician should be present to
perform either the laparoscopic or the colonoscopic part of the procedure
and aid the primary surgeon accordingly (Fig. 5-2).
FIGURE 5-2 Two monitors are placed depending on the surgeon’s position. It is
important that both the colonoscopy and laparoscopy monitor are visible by the operating
team.
Equipment
Adult colonoscope
CO2 insufflation unit
Assorted snares, baskets, and irrigation for the colonoscope
Bipolar and monopolar endoscopic energy unit
10- and 5-mm abdominal trocars
Standard laparoscopic abdominal colectomy set with bowel graspers
(atraumatic)
Endovascular gastrointestinal anastomosis or other mechanical staplers
Technique
Under general anesthesia, stabilize the patient on the operating table and
place orogastric tube and Foley catheter.
Choose a pediatric or adult colonoscope to use.
Start by introducing the colonoscope to locate the lesion. If lesion is
amenable to endoscopic removal, it can be removed at this stage without
further need for laparoscopy.
If the lesion shows nonlifting sign or displays signs of malignancy, the
lesion can biopsied intraoperatively for frozen sections, and CELS or
formal oncological resection should be performed.
If polyp can’t be removed using endoscopic approach only, proceed with
laparoscopy (Fig. 5-3).
FIGURE 5-3 Simultaneous combined approach with colonoscopy and laparoscopy
enables the surgeon to view and manipulate the bowel accordingly.
Make a periumbilical incision and enter the fascia with sharp dissection.
Use a 10-12 mm balloon port and start insufflation.
Insert two or three 5-mm trocars, depending on the location of the lesion.
For lesions located in the left colon, enter the trocars in the right lower
quadrant and suprapubically.
For lesions in the right colon and ileocecal valve, enter the trocars on the
left lower quadrant and suprapubically.
Enter a separate 5-12-mm port if stapling is necessary or use 5-mm scope
and utilize the supraumbilical trocar for stapling.
After locating the lesion using colonoscopy, use transillumination or
endoscopic manipulation to locate the lesion laparoscopically.
Mobilize the colon laterally if the lesion is retroperitoneal.
Mobilize the colon if the lesion is located on a difficult-to-reach area.
Lift the polyp using an injection solution.
After lifting the mucosa from the submucosa and creating a cushion for
snaring/dissection, align the snare on top of the lesion.
Use the laparoscopic instruments to manipulate the colon wall (Video 5-
1), and after making sure the lesion is completely included in the snare,
proceed with snaring the lesion.
Observe the serosa after snaring with laparoscopic camera for thermal
injury or any defects.
If a defect is observed, place sutures and close the defect laparoscopically.
If the lesion is difficult to remove due to scarring or underlying fibrosis,
proceed with full-thickness CELS (Fig. 5-4).
FIGURE 5-4 After endoscopic lesion removal is completed, laparoscopy can be used
to suture the defects.
Use laparoscopic hot scissors to create a defect in the bowel wall up to the
submucosal layer.
Following this, manipulate the lesion to fall into the colonic lumen and
proceed with snaring.
Prior to snaring, close the defect laparoscopically by suturing and continue
with snaring endoscopically.
Combined Wedge Resection
If the lesion is located on the cecum (or in any colon segment and not
amenable for snare resection), wedge resection can be performed
laparoscopically.
Attention should be paid not to occlude the lumen, ileocecal valve, or
appendiceal orifice. This can be assessed via the passage of the scope
through the lumen and direct visualization of the aforementioned structure.
Enter an additional 5-12 mm trocar if necessary to insert stapler (Fig. 5-5).
FIGURE 5-5 Stapler can be used to complete full-thickness combined endoscopic and
laparoscopic surgery for lesions not amenable for endoscopic resection, and simultaneous
scoping can be used to assess the passage and ensure that lumen is not occluded
during/after resection.
Insert the stapler and simultaneously coordinate with endoscopy to place
the stapler across the bowel, ensuring adequate margins (Fig. 5-6).
FIGURE 5-6 For lesions located on difficult-to-reach areas such as the cecum, wedge
resection can be performed to remove the lesion.
After stapling, observe the colon wall for defects and repair if any defect is
present.
Check for hemostasis in the abdomen and terminate the procedure.
PEARLS AND PITFALLS
The CO2 colonoscope is critical for this procedure. Normal air
colonoscopy will dilate the bowel too much and prevent visualization
from the abdominal side.
Position the patient for a combined procedure, and prep the patient’s
abdomen for a formal resection.
Should the combined approach not be feasible, ensure that both the
patient and your staff are prepared to undergo a standard resection at
that time.
Postoperative Care
We typically admit patients following CELS for operation.
Patients may resume routine enhanced recovery care pathways following
CELS.
Avoidance of nasogastric tube
Early urinary catheter removal
Early diet initiation
Venous thromboembolism chemoprophylaxis (may consider holding
pending specifics on the procedure and patient risk)
Early ambulation
Multimodality, narcotic-sparing, pain control
Suggested Readings
Gorgun E, Benlice C. En bloc resection of a 5-cm flat ascending colon lesion with endoscopic
submucosal dissection combined with laparoscopy. Dis Colon Rectum. 2016;59(12):1230.
Gorgun E, Benlice C, Abbas MA, Steele S. Experience in colon sparing surgery in North America:
advanced endoscopic approaches for complex colorectal lesions. Surg Endosc.
2018;32(7):3114-3121.
Chapter 6
Interventional Inflammatory Bowel
Disease: Endoscopic Management of
Complex Inflammatory Bowel Disease
BO SHEN
ENDOSCOPIC BALLOON DILATION OF STRICTURES
Perioperative Considerations
Stricture is a common complication of inflammatory bowel disease (IBD),
including Crohn disease (CD) and ulcerative colitis.
Strictures may result from the chronic process of inflammation and tissue
repair of underlying disease, as well as tissue healing of inflammation
from medical therapy, the concurrent use of nonsteroidal antiinflammatory drugs, or surgery-associated ischemia.
Strictures in IBD can be classified as follows: (1) primary (ie, disease
associated) versus secondary (eg, anastomotic), based on etiology (Figs. 61 and 6-2); (2) short (<4 cm) versus long (≥4 cm), based on the length; (3)
inflammatory versus fibrostenotic versus mixed; and benign versus
malignant, based on histology; (4) mild versus moderate versus severe,
based on the degree; (5) various locations, such as ileocolonic anastomosis
(Fig. 6-2) and strictureplasty site (Fig. 6-3); and (6) associated conditions
(eg, fistula, abscess, malignancy).
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