Conclusions

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CONCLUSIONS

Hand-assistedlowanteriorresectionisanacceptablealternativeto laparoscopyandcertainlyadvantageousoveropenlowanteriorresection.

RECOMMENDEDREFERENCESAND READINGS

BenliceC,CostedioM,KesslerH,RemziFH,GorgunE.Comparisonofstraightvshand-assisted

laparoscopiccolectomy:anassessmentfromtheNSQIPprocedure-targetedcohort.AmJSurg

2016;212:406–12. FleshmanJ,BrandaM,SargentDJ,etal.Effectoflaparoscopic-assistedresectionvsopen

resectionofstageIIorIIIrectalcanceronpathologicoutcomes:TheACOSOG

Z6051randomizedclinicaltrial.JAMA2015;314:1346–55. LeeSW,SonodaT,MilsomJW.Expeditingoflaparoscopicrectaldissectionusingahand-access

device.DisColonRectum2007;50:927–9. LeeSW,YooJ,DujovnyN,SonodaT,MilsomJW.Laparoscopicvshand-assistedlaparoscopic

sigmoidectomyfordiverticulitis.DisColonRectum2006;49:464–9. LjungqvistO,ScottM,FearonKC.Enhancedrecoveryaftersurgery:areview.JAMASurg

2017;152(3):292–8. MarcelloPW,FleshmanJS,MilsomJW,etal.Hand-assistedlaparoscopicvslaparoscopic

colorectalsurgery;amulticenter,prospective,randomizedtrial.DisColonRectum

2009;51:818–26. PyoDH,HuhJW,ParkYA,etal.Acomparisonofhand-assistedlaparoscopicsurgeryand

conventionallaparoscopicsurgeryinrectalcancer:apropensityscoreanalysis.SurgEndosc

2016;30:2449–56. SamalaviciusNE,GuptaRK,DulskasA,KazanaviciusD,PetrulisK,LuneviciusR.Clinical

outcomesof103hand-assistedlaparoscopicsurgeriesforleft-sidedcolonandrectalcancer:

singleinstitutionalreview.AnnColoproctol2013;29:225–30. SpanjersbergWR,vanSambeeckJD,BremersA,RosmanC,vanLaarhovenCJ.Systematicreview

andmeta-analysisforlaparoscopicversusopencolonsurgerywithorwithoutanERAS

programme.SurgEndosc2015;29:3443–53. WolfJSJr,MoonTD,NakadaSY.Hand-assistedlaparoscopicnephrectomy:comparisonto

standardlaparoscopicnephrectomy.JUrol1998;160:22–7. ZhuangCL,HuangDD,ChenFF,etal.Laparoscopicversusopencolorectalsurgerywithin

enhancedrecoveryaftersurgeryprograms:asystematicreviewandmeta-analysisof

randomizedcontrolledtrials.SurgEndosc2015;29:2091–100.

Chapter19

HybridLaparoscopic/Open LowAnteriorResection

AmyL.LightnerandEricJ.Dozois

INTRODUCTION

Thehybridlowanteriorresection(LAR),asoriginallydescribed,isan operationinwhichthefirstpartoftheprocedure(leftcolonandsplenic flexuremobilization)islaparoscopicallyperformedandthesecondpart (pelvicdissection)isaccomplishedusingopenmethodsviaaPfannenstiel orlowermidlineincision.Thehybridapproachtosphincter-savingrectal resectionswasfirstintroducedadecadeagowhenlimiteddatawere availableregardingtheoncologicoutcomesofalaparoscopicapproachto colonandrectalcancercases.Theoriginatorsofthehybridmethod, convincedofthebenefitsoflaparoscopy,soughtmeansofutilizing laparoscopictechniquestosignificantlydecreaseoverallincisionlength andphysiologicimpact,whilepermittinganopentotalmesorectal excision(TME)untildatawaspublishedregardingtheoncologic outcomeswithlaparoscopy.WhentheresultsfromtheClinicalOutcomes ofSurgeryTherapy(COST),ConventionalversusLaparoscopic-Assisted SurgeryInpatientswithColorectalCancer(CLASSIC),andCOlorectal cancerLaparoscopicorOpenResection(COLOR)trialswerepublished statingthatlaparoscopicsurgerywasequivalenttoopensurgeryforcolon cancer,severalsurgeonsmovedawayfromthehybridapproachtowarda completelaparoscopictechniqueforbothcolonandrectalcancercases.

Thehybridapproach,asdescribedinthefollowingtext,allowsforan openTMEwhileminimizingincisionlengthwithalaparoscopicsplenic flexuremobilization.Intheauthors’view,limitingtheincisionrelatedto flexuremobilizationstillprovidessignificantbenefittothepatientin termsofcosmeticoutcome,decreasedrecoverytime,anddecreased narcoticuse,allofwhichadvocatefortheuseofthishybridapproach.

INDICATIONSANDCONTRAINDICATIONS

AhybridLARcanbewidelyutilizedforanyrectalcancerpatientwithout arelativeorabsolutecontraindicationtolaparoscopicsurgery.Relative contraindicationstoalaparoscopicapproachincludepriorabdominal operations,bowelobstructionwithdilatedloopsofbowel,chronic obstructivepulmonarydisease,andsignificantcardiacdisease.

PREOPERATIVEPLANNING

Planningbeforeanypelvicoperationshouldincludephysical examination,tissuediagnosis,localandsystemicstaging,andreviewof anypriorimagingandoperativereports.Ifimagingisnotrecentor adequate,itshouldberepeatedduringthepreoperativeevaluation. Patientsshouldhavehadacomputedtomographyscanofthechest, abdomenandpelvisforsystemicstaging,andamagneticresonance imagingoftherectumforlocalstaging.Pathologyslidesshouldbe obtainedforreviewandconfirmationbyalocalpathologistifthereisany questionofanaccuratediagnosis.Atthetimeoftheoutpatientvisit, digitalrectalexaminationshouldbeperformedonallpatients,regardless ofdictatedlocationofthecanceronendoscopyorimagingreports.If unabletofeelthelesioninitsentirety,weperformaflexible sigmoidoscopyintheofficetonotethelocationandsizeofthetumor.If notalreadyperformed,completioncolonoscopyshouldbeperformedto ensuretherearenosynchronouslesions.

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p.154

Becausetheriskofanastomoticleakforlow-to-midrectalcancer approaches15%,mostpatientswillbediverted,especiallyinthesetting ofpreoperativeradiation.Therefore,patientsshouldhaveaclear understandingastothelikelihoodofastoma,andmeetwithan enterostomaltherapistforcounselingandmarkingbeforetheir operation.Inaddition,theriskofconvertingtoanopenoperation requiringalargermidlineincisionshouldbediscussed.

SURGERY

OrderofOperationandDivisionofTasks

Thelaparoscopicportionoftheoperationisperformedfirst,followedby theopenportiontocompletetheprocedure.ThestepsoftheLAR undertakenthroughthelaparoscopicapproachinclude(a)splenicflexure mobilization,(b)proximalvesselligation,(c)divisionofthecolonand mesentery,and(d)theinitialmobilizationoftherectum.After completionofthesesteps,theabdomenisdesufflatedandalowmidline oraPfannenstielincisionismadeandthecaseiscompletedusingopen methods.

LAPAROSCOPICPORTION

Thepatientisplacedinthemodifiedlithotomypositionwithbotharms tuckedtothesideandabladdercatheterisplaced.Standardanesthesia monitoring,perioperativeantibiotics,andsubcutaneousheparinare administered.Afour-portarrangementisutilizedbytheauthorssothat boththesurgeonandthefirstassistanthaveportsavailabletothem.A5or10-mmcameraportisplacedjustcaudadtotheumbilicus.Inthe lowerpartoftherightlowerquadrant,a12-mmport(toallowfor intracorporealstapling)isplacedatthesiteofthedivertingileostomy marking.Twoadditional5-mmportsareplaced;oneisinthesuprapubic positioninthemidlineandtheotherintheleftlowerquadrant(Fig.19-

1).

FIGURE19-1Portsitesetupforthelaparoscopic

portionoftheoperation.

Thesplenicflexureismobilizedfirstbecauseifthisportionisnot amenabletolaparoscopicmethods,earlyconversioncanbeinitiated.

Therearefourbasicapproachestoflexuretakedown:(a)lateralto medial,(b)medialtolateral,startingjustcaudaltothesacralpromontory ontherightsideofthesigmoidmesentery,(c)medialtolateral,starting attheleveloftheinferiormesentericvein(IMV),and(d)startingwith theomental“peel”atthelevelofthedistaltransversecolon(seldom used).Regardlessoftheapproachthatisutilized,theflexure,the descendinganddistaltransversecolon,aswellasthemesenterymustbe fullymobilized(Fig.19-2).

FIGURE19-2Mobilizationofthesplenicflexure.

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MedialtoLateralStartingattheInferiorMesenteryVein

ThepatientisplacedinthereverseTrendelenburgpositionwiththeright sidedown.Thesurgeonandcamerapersonstandonthepatient’sright side,thelatteratthelevelofthepatient’sthighsandtheformerjust cephalad.Thesecondassistantstandsbetweenthepatient’slegs(Fig.19-

3).Theareatobeexposedisthebaseofthedistaltransverseand

descendingcolonmesenteryadjacenttotheligamentofTreitz.Thedistal transversecolonisgentlygraspedbythefirstassistantviatheupperport ontheleftandretractedupwardandcephalad.Theproximaldescending colonisgrasped,alsobythefirstassistantviathelowerleftport,and retractedupandtotheleft.Thislattermoveshouldrevealthelocationof theleftcolicvesselsthatappearasabowstring.Thesurgeonthengently movesthesmallboweltotherightandcaudalaspectoftheabdomenthat shouldrevealtheligamentofTreitz,theproximaljejunum,andtheIMV atthebaseofthedescendingmesentery.Obtainingthismedialand centralexposureisthemostdifficultpartofthisapproach(Fig.19-4).

FIGURE19-3Positioningofthepersonnelinthe

operationroom.

FIGURE19-4TheligamentofTreitz,theproximal

jejunum,andtheinferiormesentericveinatthebase ofthedescendingmesentery.Obtainingthismedial andcentralexposureisthemostdifficultpartofthis medial-to-lateralapproach.

Theperitoneumofthemesenteryisthenscoredwithascissorsparallel toandashortdistanceaboveorbelowtheIMVdependingonwhether thisveinistobesacrificedorpreserved.Thisopeningisenlargedwitha bipolarorultrasonicshears(monopolardevicesareavoidedwhen workinginthiscentrallocation)andtheplanebetweentheposterior surfaceofthedescendingcolonmesenteryandtheanterioraspectof Gerota’sfasciaisestablished.Thisbloodlessplaneisusuallymore superficialthananticipated;ifminorbleedingisencounteredwhendoing thisdissection,itislikelythatoneisworkingdorsaltotheanteriorlayer ofGerota’sfascia.Thecorrectplane,oncefound,isfurtherdevelopedin thelateral,caudad,andcephaladdirections,thuscreatingapocket.The laterallimitofdissectionisthewhitelineofToldt,whereasthecephalad limitistheedgeoftheinferiorborderofthepancreas.Oncethepocketis established,thefirstassistant’sgraspersareplacedinsidethepocketand usedtobetterexposetheretroperitonealfieldofdissection.IftheIMVis dividedatthispoint,orearlier,thentheexposureisimproved.

Iftheinferiormesentericartery(IMA)istobetransectedearly,thenits locationmustbeestablishedandthevesselexposedbyscoringthe peritoneummediallyandinferiorlytowardthepelvis(Fig.19-5).The retroperitonealdissectioniscontinuedcaudallyfromthealready establishedIMVpocket.TheIMAisdividedonlyafteritiscertainthat

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