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Ростовский Государственный Медицинский Университет
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Медицина общая
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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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Theauthorsalsoutilizegoal-directedintraoperativefluidtherapytotry tomaintainidealormaximalstrokevolumewhileminimizingfluid resuscitationviaesophagealDopplerorvariousothercommercially availablenoninvasivehemodynamicmonitoringdevices.

SURGERY

Theroomsetup,equipment,andpersonnelareessentialtothesuccessof thisprocedure.Threemonitorsareoptimalforthisprocedure;one monitorshouldbeoverthepatient’srightshoulder,thesecondoverthe leftshoulder,andthethirdneartheleftfoot.Oncetheportsareplaced, boththeassistantandthesurgeonstandtothepatient’srightside,with theassistantstandingabovethesurgeonwhilecontrollingthe laparoscopeandassistingviatheleft-sidedports.Itisusually unnecessarytohaveanadditionalassistantwiththissetup.
Positioning
Thepatientisplacedinthesupineposition;andafterintubation,the patientisplacedintothelowlithotomypositionwithbotharmstucked. Thekneesshouldbenohigherthantheshoulderstominimizethe potentialforinterferencewiththeinstrumentsduringsplenicflexure mobilization.Theperinealareaandbuttocksshouldoverhangtheedgeof thebedbyabout3inchessothataccesstotheperineumandanusisnot obstructedandsothestaplercanbeeasilyangulatedupwardor downward.Thechestissecuredtothebedtoallowfortheextreme TrendelenburgandlateraltiltrequiredduringalaparoscopicLAR.
ConductofProcedure
Afterabladdercatheterisplaced,theabdomenispreppedanddrapedin theusualsterilemanner,aVeressneedleisplacedintheleftupper quadrant,andtheabdomenisinsufflatedwithCO2.Afterachieving
pneumoperitoneum,theVeressneedleisreplacedwitha5-mmport. Diagnosticlaparoscopyisthenperformedtoensurethatthereisno evidenceofperitonealcarcinomatosis,livermetastasis,orotherfactors thatmayaltertheoperativeplan.Afterexploration,thefollowingports areplacedunderdirectlaparoscopicvisualization:asupraumbilical12­mmtrocar,a5-mmleftiliacfossatrocar,a5-mmrightupperquadrant port,anda12-mmrightiliacfossatrocar.The5-mmcameraisusually upsizedtoa10-mm,30-degreelaparoscopebecausethe10-mm laparoscopeprovidesabetterqualityimageandrequiresfewercamera exchanges.
Thesigmoidcolonisplacedontensionsuchthattheinferior mesentericartery(IMA)isclearlyidentifieddowntoitsorigin. Electrocauteryisusedtoincisetheinvestinglayerattherootofthe rectosigmoidmesentery.Themesenteryisscoredatapointjustabovethe
sacralpromontorybutbeneaththesuperiorrectalarteryandtheincision istakentowardtherootoftheIMA.Thelooseareolarplanebetweenthe undersideofthesigmoidmesenteryandtheretroperitoneumisidentified andthedissectionproceedslaterallywiththegoalofidentifyingtheleft ureterandtheleftgonadalvessels.TheoriginoftheIMAisskeletonized andtheureterisonceagainidentifiedbeforeperformingahighligation oftheIMA.Theinferiormesentericvein(IMV)isthenligatedproximalto anybranchpoint.ThehighligationoftheIMAandtheIMVisnecessary notonlyfromanoncologicperspectivebutalsotoensurethattheleft colonconduitcanreacheasilyintothepelvisforatension-free anastomosis.
Thedissectionisthencontinuedunderneaththesigmoidandtheleft colonmesenteryuntiltheleftabdominalsidewallisencountered.The left/sigmoidcolonisdisplacedandthewhitelineofToldt(nowpurplein color)easilytakenwiththescissorsoranenergydevice.
Thenexttaskistoperformacompletelaparoscopicmobilizationofthe splenicflexure.Thelessersacisenteredandthesplenicflexureis mobilizedfromthetransversecolonsideandfromtheleftgutter. Attentionisthenturnedtowardtherectaldissection.
RectalDissection
Theassistantcarefullyretractstherectosigmoidjunctiontowardthe abdominalwallandslightlyleftward.Theoperatingsurgeonretractsthe rectumupwardandtowardthepubicsymphysistoaccentuatetheplane betweenthepresacralfasciaandthefasciapropriaoftherectum;this planeisreferredtoas“theholyplane.”Posteriorly,theleftandright hypogastricnervesareidentifiedandkeptoutofharm’sway.Theloose areolarfibersareposteriorlydivided,identicallyinthemannerofaTME, pastthetipofthecoccyx,dividingWaldeyer’sfasciauntilthesuperior portionofthelevatorsareencountered.Thelateralstalksaredividedin thesamemannerdowntothepelvicfloor.Anteriorly,theplanebetween therectumandtheseminalvesicles/prostateorvaginamustbecarefully dissectedsoasnottoinjuretheprostate/vaginaorthesexualfunction controllingnervesthatlieadjacenttoDenonvilliers’fascia.Therectum mustbeanteriorlyfreeddowntothepelvicfloorsothatastaplercanbe usedtotransecttherectumflushwithorevendistaltothelevators.The rectumiscarefullyretractedupwardoutofthepelvisandleftward,and thenalaparoscopicbowelstaplerisbroughtinthroughtherightiliac fossa12-mmtrocarandarticulatedsothattheanglebetweenthestaple lineandrectumisascloseto90degreesaspossible.Ifthepelvisisnot wideenoughtoaccommodatea60-mmstapler,a45-mm-or30-mm­longstaplercanbeused.Thestaplerisadvancedacrosstherectumasfar aspossibleandisthenfired.Itisrarethattherectumcanbecompletely
transectedwithonestaplefire;however,minimizingthenumberoffires willminimizethenumberofcrossingstaplelinesandsubsequentlythe likelihoodofastaplelineleak.Oncetherectumistransected,the specimenisexteriorizedthroughanyoneofanumberofincisionssuchas aperiumbilicalincision,aleftlowerquadrantincision,orfromthesite thatwillbeusedfortheileostomy.Afterextractingthespecimen,the colonisdividedproximallyatthesigmoidcolon/leftcolonjunction. Usually,iftheexteriorizedleftcoloncanreachthepubicsymphysis,there issufficientlengthforalowcolorectalanastomosis.Indocyaninegreen (ICG)perfusionassessmentcanbeusedtohelpverifybloodsupply.
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Apursestringisplacedattheopenendoftheleftcolonandtheanvilof thecircularstaplerisplacedintothecolonandsecuredwiththepurse string.Thecolonisreducedbackintotheabdomenandtheabdomenis reinsufflated.Thecolonisgraspedandextremecareistakentoensure thatthecolonandmesenteryarenottwisted.Ananvilgrasperisusedto lowertheanvilintothepelvis.Theassistantthentransanallypassesthe staplerandengagesitwiththetrocarunderdirectlaparoscopic visualization.Infemalepatientscaremustbetakentoexcludethe posteriorwallofthevaginaasthestaplerisclosed;avaginalexamination ishelpful.
Thestapleristhenfiredandtheanastomoticdonutsareexaminedfor completeness.Thepelvisisthenfilledwithirrigantsuchthatthe anastomosisisunderthewaterlevel.Thecolonproximaltothe anastomosisisthenoccluded,pushingitagainstthesacralpromontory, andtheassistantinsufflatestherectumusingtherigidproctoscopeor flexiblesigmoidoscopy.Incaseofapositiveairleak,manyatimetheair leakcanbetransanallyrepaired.ICGperfusionassessmentcanbe performedbeforeand/orafterfiringthecircularstapler.
Thecreationofanileostomyisrecommendedforpatientswhohave hadneoadjuvantchemoradiotherapy.Underlaparoscopicvisualization, anileostomyiscreatedbybringingoutaloopofterminalileum approximately25–40cmproximaltotheileocecalvalve.
POSTOPERATIVECARE
Allpatientsundergoingopenandlaparoscopiccolonandrectalresection atDukeUniversityMedicalCenter(DUMC)followadefinedenhanced recoveryaftersurgery(ERAS)protocolthatemphasizespreoperative education,optimizationofpremorbidconditionsandnutritionalstatus, minimalpreoperativefastingandcarbohydrateloadingimmediately beforesurgery,goal-directedintraoperativefluidmanagement,useof thoracicepiduralanalgesia,earlyinitiationoforaldiet,andearly mobilization.TheDukeEnhancedRecoveryProgramwasbasedinitially ontheprinciplespresentedbytheEnhancedRecoveryAfterSurgery (ERAS)Societyguidelinesforelectiverectal/pelvicsurgery.TheDuke colorectalERASprotocolissummarizedinTable14-1.
TABLE14-1 SynopsisofDukeEnhancedRecoveryafterSurgery
(ERAS)Protocol
Phaseofcare Intervention
Surgicalplanning
Routinepreoperativescreening/medicalclearance Optimizationofcomorbidities ERASteachingandwritteninformation Smokingcessation Nutritionalsupplementation
Immediate preoperativeperiod
FullmechanicalbowelpreparationwithPOantibiotics Chlorhexidinepreoperativeshowers Fastinglimitedto3hpreoperatively Carbohydratedrink3hbeforesurgery
Dayof surgery/intraoperative
Thoracicepiduralplacement Venousthromboembolic(VTE)prophylaxiswith5,000USQ heparin Sequentialcompressiondevices(SCDs) Intravenous(IV)antimicrobialprophylaxis Goal-directedIVfluidtherapy Removaloforogastrictubeatconclusionofprocedure
Postoperative
EarlyinitiationofPOintake(4hpostoperatively) Earlyambulationincludingdayofsurgery Earlyremovalofurinarycatheter(postoperativeday[POD] 1or2) Useofpro-motilitymedications(i.e.,alvimopan),oral laxatives,chewinggum
ConversionofepiduraltoPOpaincontroloncegoodPO intake Useofadjunctpainmedication(i.e.,Neurontin, acetaminophen,nonsteroidalanti-inflammatorydrugs (NSAIDs)) Continuationoflow-molecular-weightheparin(LMWH)VTE prophylaxispost-dischargefortotalof28post-operative days
FollowinglaparoscopicLAR,initialpaincontrolisachievedwith epiduralanalgesia.Intraoperativelyplacedorogastrictubesareremoved attheconclusionoftheprocedure,andsurgicaldrainsarenotroutinely used.Patientsareofferedanoraladlibitumdiet(postsurgicalbland) starting4hoursaftersurgery.Oralnutritionalsupplementsmaybe addedwhenclinicallyindicated.Allpatientsreceivemultimodality prophylaxisagainstpostoperativenauseaandvomitingwithantiemetic medications.Patientsareencouragedtobeoutofbedfor2hoursonthe dayofsurgeryandfor6hoursoneachsuccessivepostoperativeday. Transurethralbladdercathetersaretypicallyremovedonthemorningof postoperativeday1,regardlessofwhetheranepiduralcatheterisin place.Otheradjunctstominimizepostoperativeileusincluderoutineuse oftheperipherallyactingμ-opioidreceptorantagonistalvimopan (Entereg),judicioususeoforallaxatives,andchewinggum.Once patientsaretoleratingPO,theirepiduralcathetersare“paused”andthey undergoatrialofPOpainmedication.Patientswhosepainisadequately controlledwithPOpainmedicationhavetheirepiduralcatheters removed.Adjunctanalgesicsincludingacetaminophen,nonsteroidal anti-inflammatorydrugs(NSAIDs),andNeurontinareutilizedto minimizetherequirementforPOnarcotics.Patientsreceivedeepvenous thromboembolism(VTE)prophylaxisbefore,during,andaftersurgery withlow-molecular-weightheparin(LMWH).Allcolorectalcancer patientsundergoingmajorabdominal/pelvicsurgeryaredischargedwith LMWHforatotalof28postoperativedays.
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p.106
InstitutionoftheDukecolorectalERASprotocolhasshowntoresultin asignificantlydecreasedlengthofhospitalstay(LOS),aswellasa decreasedincidenceofurinarytractinfections(13%vs.24%)and readmissionrate.Inaddition,theimprovementinLOSwassignificantin thelaparoscopiccohortaswell(4vs.6days),demonstratingtheadditive valueofanERASprotocoleveninpatientsundergoingminimally invasiveprocedures.Othershavereportedsimilarfindings.Withinthe
ERASsetting,theadditionofalvimopanhasalsobeenshowntohave benefitwithregardtofasterreturnofbowelfunction,decreased incidenceofpostoperativeileus,andshorterLOS.Overall,utilizationof anERASprogramforrectalsurgeryhasbeenshowntoreduceLOSby3– 5days,withoutanyincreaseinmorbidityormortalityorreadmission rates.CompliancewithanERASprotocolmayalsoresultinimproved long-termoncologicoutcome.

OUTCOMES

MorbidityandMortality
Advantagesoflaparoscopiccolonandrectalresectioncomparedtoopen resectionarewelldocumentedandincludefasterreturnofbowel function,decreaseduseofnarcoticpainmedications,anddecreasedLOS. PatientsundergoinglaparoscopicLARhavebeenshowntoreceive postoperativechemotherapyapproximately25dayssoonerthanthose undergoingopenLAR.However,laparoscopicrectalresectionis associatedwithsignificantlylongeroperativetimes.
Thesafetyofthelaparoscopicapproachforcolonandrectalresection hasbeenwellestablished.LaparoscopicLARcanbeperformedby appropriatelytrainedsurgeonswithlowintraoperativeconversionrates (1–16%)andequivalentperioperativemorbidityandmortalitycompared toopenLAR.Inthreelargerandomizedcontrolledtrialsoflaparoscopic versusopensurgeryforrectalcancer,perioperativemorbiditywas18– 40%inthelaparoscopicgroupversus14–37%intheopengroup (differencesnotstatisticallysignificant).Similarly,perioperative mortalityalsodidnotdiffersignificantlybetweenthelaparoscopic(0– 4%)andopen(0–5%)groups.Laparoscopicrectalresectionisalso associatedwithdecreasedmorbiditycomparedtoopenresectionin morbidlyobesepatients.
p.106
p.107
Short-andLong-TermOncologicOutcomes
Earlyrandomizedtrialssuggestedthatlaparoscopicresectionforrectal cancerresultsinanoncologicallysoundprocedure.Distaland circumferentialresectionmargin(CRM)status,lymphnodeyield,and completenessoftotalmesorectalexcision..Tworecentlypublishedlarge prospectivetrials,however,havecalledintoquestiontheroutineuseof laparoscopicresectionforrectalcancer.InboththeAmericanCollegeof SurgeonsOncologyGroup(ACOSOG)Z6051trial(UnitedStates)andthe AustralasianLaparoscopicCanceroftheRectum(ALaCaRT)trial (Australia),thecriterionfornon-inferioritywasnotachievedfor laparoscopicrectalresectionwithregardtoCRM,completenessofTME, andoverallsuccessfulresection(completeTME,negativedistalresection marginandCRM).Bothstudiesconcludedthattheirfindingsdonot supporttheroutineuseoflaparoscopicresectionforrectalcancer.
Unfortunately,theseidenticalconclusionswerebasedontheuseofnon­validatedcompositeendpoints.
However,recentupdatesfromtheConventionalversusLaparoscopic­assistedSurgeryInpatientswithColorectalCancer,theComparisonof
OpenversuslaparoscopicsurgeryformidorlowREctalcancerAfter Neoadjuvantchemoradiotherapy(COREAN),andtheCOlorectalcancer LaparoscopicorOpenResectionII(COLORII)trialsdemonstrate
equivalent3-,5-,and10-yeardisease-freesurvival,localcontrol,and overallsurvivalcomparedtoopenresection.Similarly,apooledanalysis ofthreerandomizedcontrolledtrialsfromthePrinceofWalesHospitalin HongKongwithamedianfollow-upof124.5monthsreportedequivalent 10-yearlocoregionalrecurrence,cancer-specificsurvival,andoverall survivalbetweenlaparoscopicandopensurgicalgroups.
Mostrecently,analysisofover14,000patientsintheNationalCancer Databaseundergoingeitherminimallyinvasive(laparoscopicorrobotic LAR)oropenLARrevealedequivalent3-yearoverallsurvivalinthe minimallyinvasivegroup.Inaddition,patientsintheminimallyinvasive grouphadsignificantlydecreasedlengthofhospitalization.Despitethese encouragingresults,thefinalwordonlaparoscopicresectionforrectal cancerawaitslong-termresultsfromthelargerandomizedcontrolled trials.Assuch,laparoscopicrectalresectionforcancershouldprobably belimitedtotheclinicaltrialsettingorperformedinspecialtycenters.
FunctionalOutcomes/QualityofLife
Genitourinary
Autonomicnerveinjurywithresultingsexualdysfunction(impotenceand retrogradeejaculationinmen;decreasedvaginallubrication, dyspareunia,decreasedsexualarousal,anddifficultyachievingorgasmin women),aswellasbladderdysfunction,occursinapproximately10–35% ofpatientsundergoingproctectomyforbenignandmalignantconditions. Datafromprospectivetrialsoflaparoscopicrectalresectionindicatethat autonomicnervepreservationcanbeachievedwithlaparoscopicrectal resectionandthattheincidenceofgenitourinarydysfunctionisnot significantlydifferentcomparedwiththatofopenrectalresection.Self­reportedoutcomesfromtheCOLORIIrandomizedtrialconfirmedno significantdifferencesinsexualandbladderfunctionat1year postoperativelybetweenlaparoscopicandopenresectionforrectal cancer.IntheCOREANtrial,theincidenceofmicturitiondifficultywas lessfrequentinbothmenandwomenundergoinglaparoscopicresection. Theauthorsopinedthatthemagnificationprovidedbythelaparoscope mayhavefacilitatedvisualidentificationoftheautonomicnerves.
BowelFunction/Defecation
FollowingrestorativeLAR,somedegreeofboweldysfunctionisreported by70–90%ofpatients,oftennegativelyaffectingqualityoflife.The additionofpreoperativechemoradiationgreatlyincreasesthelikelihood ofbowel-relatedqualityoflifeimpairment.Preoperativediscussionof anticipatedpostsurgicalfunctioniscrucialtomanagingexpectationsand makinginformedchoicesbetweenprimaryanastomosisandapermanent colostomyinborderlinecases.Manypatientsoftensufferfroma constellationofsymptomsincludingincontinence,frequencyand clusteringofbowelmovements,andurgency,collectivelyknownaslow anteriorresectionsyndrome(LARS).ThecauseofLARSislikely multifactorial,includingcolonicdysmotility,surgery-andradiation­relatedsphincterinjuryandneorectalreservoirdysfunction,andpelvic nerveinjury.PreviousstudieshaveshownthatseverityofLARS,assessed byLARSscore,correlatessignificantlywithoverallqualityoflifeafter restorativerectalresection.Althoughthereisnogoldstandardtreatment forLARS,multimodalitytreatmentalgorithmsincludebulkinglaxatives, pelvicfloorstrengtheningexercises,antimotilityagents,sacralnerve stimulation,biofeedback,retrograderectalirrigation,andconversiontoa stomaforsevere,refractorycases.
p.107
p.108
Comparedtoopensurgery,patientsundergoinglaparoscopicrectal resectiontypicallyhaveatleastequivalentbowelfunctionandbowel­relatedqualityoflife.IntheCOREANrandomizedtrial,patientsinthe laparoscopicgroupreportedsignificantlylessseveregastrointestinal symptomsingeneral,aswellaslessseveredefecationdifficulties.The severityofLARShasnotbeenshowntodifferbetweenpatients undergoinglaparoscopicandopenLAR.Thenatureofthereconstruction (straightcoloanalvs.colonicJ-pouch)mayhowevercorrelatewiththe defecation-relatedcomponentsofLARS.Forthisreason,wefavortheuse ofacolonicJ-pouchoranend-to-sideanastomosisiftechnicallyfeasible.
OtherQualityofLifeOutcomes
Thelaparoscopicgroupinonerandomizedtrialreportedbetterphysical functioningandlessfatigueat3monthsaftersurgerycomparedtothe opensurgerygroup,indicatingthattherecoveryadvantagesofthe laparoscopicapproachextendbetweentheimmediatepostoperative period.
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