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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_861_Библиотеки_им_академика_М_И_Перельмана.pdf
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►Содержание►
POSTOPERATIVEMANAGEMENT
Enhancedrecoveryaftersurgeryprotocolsshouldbeusedfor postoperativemanagementwhenclinicallyappropriate.Patientsare transferredtotheregularsurgicalfloorunlesstherewasan intraoperativeconcernorcomorbidityrequiringadditionalmonitoring. Orogastrictubesandureteralstentsareremovedbeforethepatientexits theoperatingroom.Postoperativeantibioticsaregenerallynot administeredunlesstherewasaphlegmonorintra-abdominalabscess. Painiscontrolledwithmultimodaltherapy,includingbothpatient­controlledanalgesicswithintravenousnarcotics,aswellasnonnarcotic analgesicssuchasacetaminophen,gabapentin,andketorolac,intended toreducenarcoticrequirements.Intravenousnarcoticsareweanedas quicklyaspossible,ideallybypostoperativeday2.
Patientsareplacedonaclearliquiddietimmediatelyfollowingsurgery andadvancedtoalow-fiberdietwithpassageofflatus.Earlyambulation anduseofaninspiratoryspirometerisencouragedonpostoperativeday
1.Subcutaneousheparinisadministeredfordeepvenousthrombosis prophylaxis,andpatientswithadditionalriskareconsideredfor extendedprophylaxiswithenoxaparin.
Ifthepatientwasonlong-termpreoperativesteroids,astressdoseof hydrocortisoneisadministeredduringtheoperationandintravenous steroidsarecontinuedpostoperatively.Thepatientistransitionedtooral prednisoneoncetoleratingasoliddietandweanedslowlyoveraperiod ofweekstopreventadrenalinsufficiency.

COMPLICATIONS

Complicationsforlaparoscopicrightcolectomyarelowerthanthosefor opensurgery.Ameta-analysisconductedbyArezzoetal.reviewed27 studiesfrom1991to2004(N=3,049)thatcomparedlaparoscopicto openrightcolectomy.Laparoscopicrightcolectomyhadlowerincidences ofmortality(1.2%vs.3.4%;P=0.031)andoverallmorbidity(16.8%vs.
24.2%;P=0.007),earliertimetofirstflatus(2.7vs.3.7days;P<0.001), reducedratesofwoundcomplications(4.8%vs.9.0%;P=0.011),anda shorterlengthofhospitalstay(7.4vs.10.2days;P<0.001).Differences betweenlaparoscopicandopenapproacheswerenotstatistically significantwithrespecttoanastomoticleakrates(2.3%vs.2.4%),urinary tractinfections(3.6%vs.4.3%),andpulmonarycomplications(2.4%vs.
3.7%).
p.32
p.33
Thesenumbersaresimilartothoseobtainedrecentlyfromthe AmericanCollegeofSurgeonsNationalSurgicalQualityImprovement Program(ACS-NSQIP)database(N=6,521).Overallmorbidityand mortalitywerereportedas15%and0.4%,respectively.Surgicalsite infectionswerefoundtoberelativelyuncommon(superficial—4.9%,deep —0.5%,organ—2.7%),andratesofanastomoticleakagewerereportedly low(2.2%).

RESULTS

TherearelimitedpublishedresultscomparinglaparoscopicLAandMA rightcolectomy.Studyishinderedbyinherentbias,becausemost surgeonsstronglypreferaparticularmethod.Retrospectivecomparisons betweenLAandMAmaybeconfoundedbyuncontrolledsurgeon-specific variables,andrandomizedprospectivestudiescanbesubjecttoselection orintervention-choicebiases.Arandomized-controlledtrialthatforces surgeonstooperateusinganunfamiliarapproachwillbeconfoundedby differencesinsurgicalskill.
Despitethesedifficulties,fivestudiesaimedtocompareLAandMA colectomyandwerereviewedbyDingetal.inameta-analysis.Thefive studiesconsistedoftworandomized-controlledtrialsandthreenon­randomizedretrospectivestudies,includingatotalof881patients(MA: 416;LA:465).Severalofthepapersincludedmixedgroupsofrightand leftcolectomies.Whenpooledtogether,MAhadshorteroperativetime andlowerconversionratetoopensurgery,butLAhadgreaterlymph nodeharvest.Therewerenodifferencesinratesofcomplications, mortality,orrecurrence.Theauthorswereunabletodrawfirm conclusionsowingtostudyheterogeneitywithrespecttomethodsand outcomemeasures.

CONCLUSIONS

DefiningtechnicalfeaturesofLArightcolectomyincludealateral clockwisemobilizationthatbeginsattheileocolicangle,andprecedesthe identificationandligationofthevessels.Whilethereisnoevidence-based indicationforLAversusMArightcolectomy,LAmaybepreferred becauseithasdissectionplanessimilartothoseofopensurgery,anditis asaferapproachwhenmesentericplanesaredistortedbyinflammatory orneoplasticconditions.Ultimately,thebestapproachistheonemost familiarandcomfortablefortheoperatingsurgeonandbestsuitedforthe individualpatient.
RECOMMENDEDREFERENCESAND READINGS
ArezzoA,PasseraR,FerriV,GonellaF,CirocchiR,MorinoM.Laparoscopicrightcolectomy
reducesshort-termmortalityandmorbidity.Resultsofasystematicreviewandmeta-analysis.
IntJColorectalDis2015;30(11):1457–72. daSilvaG,BoutrosM,WexnerSD.Roleofprophylacticuretericstentsincolorectalsurgery.Asian
JEndoscSurg2012;5(3):105–10. DingJ,LiaoGQ,XiaY,etal.Medialversuslateralapproachinlaparoscopiccolorectalresection:a
systematicreviewandmeta-analysis.WorldJSurg2013;37(4):863–72. DolejsSC,WatersJA,CeppaEP,ZarzaurBL.Laparoscopicversusroboticcolectomy:anational
surgicalqualityimprovementprojectanalysis.SurgEndosc2017;31:2387–96. ElariniT,WexnerSD,IsenbergGA.Theneedforstandardizationofcolonoscopictattooingof
coloniclesions.DisColonRectum2015;58(2):264–7. GuenagaKF,MatosD,Wille-JorgensenP.Mechanicalbowelpreparationforelectivecolorectal
surgery.CochraneDatabaseSystRev2011(9):CD001544. Haito-ChavezY,LawJK,KrattT,etal.Internationalmulticenterexperiencewithanover-the-
scopeclippingdeviceforendoscopicmanagementofGIdefects(withvideo).Gastrointest
Endosc2014;80(4):610–22. KiranRP,MurrayAC,ChiuzanC,EstradaD,FordeK.Combinedpreoperativemechanicalbowel
preparationwithoralantibioticssignificantlyreducessurgicalsiteinfection,anastomoticleak,
andileusaftercolorectalsurgery.AnnSurg2015;262(3):416–25;discussion423–5. KopylovU,Ben-HorinS,ZmoraO,EliakimR,KatzLH.Anti-tumornecrosisfactorand
postoperativecomplicationsinCrohn’sdisease:systematicreviewandmeta-analysis.Inflamm
BowelDis2012;18(12):2404–13. LeeIK.Rightcolonicdiverticulitis.JKoreanSocColoproctol2010;26(4):241–5. ScarboroughJE,MantyhCR,SunZ,MigalyJ.Combinedmechanicalandoralantibioticbowel
preparationreducesincisionalsurgicalsiteinfectionandanastomoticleakratesafterelective
colorectalresection:ananalysisofcolectomy-targetedACSNSQIP.AnnSurg
2015;262(2):331–7. SlimK,VicautE,Launay-SavaryMV,ContantC,ChipponiJ.Updatedsystematicreviewand
meta-analysisofrandomizedclinicaltrialsontheroleofmechanicalbowelpreparationbefore
colorectalsurgery.AnnSurg2009;249(2):203–9.
Chapter5
RightColectomyRobotic Resection
JorgeA.Lagares-GarciaandCesarSantiago

INDICATIONS/CONTRAINDICATIONS

Forthepast25years,minimallyinvasiveapproachestocolonsurgery haveprogressivelyincreasedinacceptanceanduse.Prospective randomizedtrialshaveshownoncologicparityadoptionbetweenopen andlaparoscopiccolectomy.Adoptionhasprogressivelyincreased,but notallpatientswillreceivethisapproach.
Robotic-assistedcolectomy(RAC)hasbecomemorewidespreadinits applicationtosegmentalresectionandproctectomy.TheXiplatform (IntuitiveSurgical,Sunnyvale,CA)offersasinglerotationalboominthe topoftheframethatallowsanykindofdockingtothepatientandless bulkyinstrumentationandcamera.Thereisalackofdemonstrable superiorityoftherobotcomparedtothelaparoscopicapproach,although somestudieshaveshownalowerconversionrate,especiallyintheobese population.Advantagesincludethefacilitationoftheperformanceof intracorporealanastomosis,extractionofthespecimenoffthemidline, decreasedriskofincisionalhernia,andpotentialdecreaseinthehospital lengthofstay.
CurrentindicationsforRACarethesameaslaparoscopicsurgeryfor benignandmalignantconditions.Theonlyabsolutecontraindicationto RACwouldbeifthepatientismedicallyunfittoundergogeneral anesthesia.Relativecontraindicationsincludethelargesizeofthetumor ormultiplepriorlaparotomiesthatprecludetheentrancetothe abdominalcavity.Aswithanyothersurgicalapproach,thesurgeon shouldbeawareoflimitationsandpersonallearningcurve.RAChas demonstratedoperativetimessimilartothatoflaparoscopic.Dedication andconsistencyattheconsoleareprerequisitesofexcellentpractice.
AdvantagesoftheRoboticApproach
Regardlessoftheplatformgeneration,the3Dvisionenhancesthe surgeon’sabilitytoperformtheprocedure.Witheithersecondorthird generations,thesurgeonisabletousethreearmsandthecamera.
Thetraditionalimprovementsintremorelimination,7degreesof wristingcapabilities,andthemotionscalingarealsoimprovementsfrom thelaparoscopicapproach.OneoftheuniquefeaturesofRACisthe surgeoncomfortowingtotheergonomicdesignedconsole.Thesurgeon canpracticetheuseofinstrumentssuchasroboticstaplerorsuturing. Hand-sewingisgreatlyenhanced,enablingtheoperatortoperforman intracorporealanastomosis.
LimitationsoftheRoboticApproach
HapticFeedback
Thereisalackoftactilesensation.Thesurgeonisheavilydependenton the3Dvisionandpersonalexperiencewitheachinstrumenttogaugethe pressureandtensionplacedonthebowel,vessels,orotherimportant structures.Itisimportantforthenoviceroboticsurgeontoavoidextreme forcesandpulling,andusethegraspersmoreasaretractor.
Cost
RACcostishigherthanthatforlaparoscopicoropensurgery.Thecostin thehealthcaresystemmaybemitigatediftheconversionratecanbe decreased,andcomplicationsarereduced.Intracorporealanastomosis andhigherligationoftheileocolicpediclemayofferbettercancer staging.
PREOPERATIVEPLANNING
Preoperativeproperlocalizationofthepathologyisimportantinbenign andmalignantdisease.Itisourpracticetorequestthereferring endoscopisttoplaceproximalanddistaltattooingofthelesion.Ifthe clearlandmarksarelostduringendoscopy,averyhelpfulapproachisto placeanendoscopicclipandgetaplainabdominalX-ray.Donotperform abowelpreparationthedaybeforethesurgery.Patientsreceiveoral antibioticsandclearliquiddietupto6hoursbeforesurgeryfollowing anesthesiaprotocol.Carbohydrateloadhasbeenshowntoimprove outcomesincolonsurgerywhenassociatedwithenhancedrecovery protocols.Preoperativecardiopulmonaryclearanceisbasedonrisk factorsforgeneralanesthesia.Thenightbeforetheprocedure,thepatient istoshowerwithchlorhexidine.Deepvenousthrombosis(DVT) prophylaxisandantibioticsareadministeredperinstitutionalprotocol.

SURGERY

SetupandPreparation
SiRoboticPlatform
Thepatientisplacedinsupinepositiononabeanbag.Obesepatientsare tapedoverthechesttoavoidsliding.ReverseTrendelenburgpositionof about5–10degreesandleftsidedownabout5degreesishelpful.Itis importanttoalwaysvisualizetheelbowofarm3ontheplatformbecause itmayhitoverthefaceortheshoulderofthepatient.Onright-sided lesions,theplatformmayenterontherightside;however,onhepatic flexureorproximaltransverselesions,thebestapproachistodockfrom therightshoulderinanimaginarylinebetweentherightshoulderand theleftiliaccrest.
XiRoboticPlatform
Thepatientisplacedsupineontheoperatingroom(OR)table,making surethattheshortsidetothetableistowardthepatient’shead.The patientissecuredtothetablewiththeOpt-ShieldSUPINE(BCGMedical, SanDiego,CA),devicetopreventsliding,andthetableisairplanedright sideup(roughly15–20degrees)there.Thereisnoneedfor TrendelenburgorreverseTrendelenburg,althoughsometimesthese positionsareusedtoexposetheduodenum,dependingonthelocationof thetransversecolon(Fig.5-1).Theroboticplatformisbroughtoverthe rightsideataroundtheleveloftheaxilla.Rotatingtheboomonthe roboticplatformallowsforaccesstoallfourquadrantsoftheabdomen regardlessoftherobotdockinglocation.Theoperatingsurgeonshouldsit atalocationwhereheorshecanseetheroboticarmstocorrectexternal armcollisions,ifnecessary.Targetingofthelesionisperformedfollowing manufactureguidelinesandoptimalpositionofthearmsisperformedby thesystemtoavoidcollisions.
FIGURE5-1RoboticdockingXisystem.
PatientPositioning
Lithotomyandsupinepositionarebothacceptablepositions.The placementofthepatientinlithotomypositionmayinterferewiththe armsandcauseexternalcollisionswiththeleftleg.Thisproblemmaybe morepronouncedintheSiroboticplatform;thearmshaveaslimmer profileintheXisystem,therebyminimizingthisproblem.Thearmsare placedoneachsideofthepatient.Routinely,foampadsareusedoverthe lateralaspectsoftheelbows,wrists,shoulders,andneck.Usingthe beanbagstrappedtotheoperatingtableholdstheindividual.Placingthe bagovertheshoulderswillsecurethepatientwithminimalcranial displacement.Thisisnotasimportantinrightcolectomyasitisin roboticlowanteriorresections,wherethesubjectmayslidecraniallyin Trendelenburgposition.Inrightcolectomy,thedangeristhepatient slidingdownespeciallyinlithotomyifsteepreversedTrendelenburgis used.Thepatientistestedforsafetyandpossibleslidingbeforeprepping anddrapingthesubject.
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SiSystem
RoutineplacementoftheORtableisperpendiculartotheanesthesia cart.Oncethesystemisdockedandthepatientpositionisset,the platformcannotbemoved;movementmaycauseanirrecoverablefaultto
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