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298
K.A. Garrett and S.W. Lee
Polyp Retrieval
• For polyp retrieval, an endoscopic Roth net ® (US Endoscopy,
Mentor, OH) can be used if the polyp is resected en bloc.
For polyps that are resected piecemeal, a trap can be added
to the suction device, and the polyp can be suctioned
through the scope.
Postoperative Care
For patients that undergo standard snare polypectomy and
there are no concerns intraoperatively, these patients may have
a very short hospital stay and may even go home the same day
as the procedure. Most groups report length of stay between 1
and 2 days, although other large studies report a mean length
of stay of 4–8 days [ 9 , 12 , 16 ]. Patients that have a partial- or
full-thickness injury or undergo colonoscopic- assisted laparoscopic wall excision should be monitored in the hospital for
observation and to await return of bowel function. These
patients should be admitted to the hospital and treated like any
patient that has had a laparoscopic abdominal procedure.
Patients are encouraged to ambulate early and frequently and
use incentive spirometry to avoid postoperative morbidity.
Venous thromboembolism (VTE) prophylaxis is used consisting of subcutaneous heparin and sequential compression
devices. Diet is advanced as tolerated, and once patients have
return of bowel function, intravenous fl uids and pain medications are discontinued. Patients will usually follow up within
2 weeks after discharge for review of the fi nal pathology and
determination if additional treatment is needed.
Complications
Intraoperative complications can be related to the endoscopic
portion of the procedure or to laparoscopic port placement
and mobilization.
In a large retrospective study, the risk of colonoscopic
perforation for all comers was less than 1 % [ 18 ]. The benefi t
of the laparoscopic and endoscopic combined approach is
that any full-thickness injury to the colon from electrocautery, barotrauma, or scope trauma can be immediately recognized and repaired. Franklin et al. reported a 10 % rate of
serosal suture placement [ 16 ]. Our group reported a higher
rate of 43 %. However, in all of these patients, there was no
evidence of a full-thickness injury, but rather concern that
the wall appeared to have a partial-thickness compromise
that could easily be prepared at the time [ 9 ]. The other ben-
efi t of doing a concomitant colonoscopy is that a leak test can
be performed to assess the site of injury and repair.
The risk of laparoscopic complications should be similar
to any other laparoscopic abdominal procedure and potentially even less if no mobilization of the colon is required.
There is risk of abdominal wall and intra-abdominal injury
with port placement, bowel injury related to grasper trauma,
or the use of an energy device and injury to surrounding viscera such as the bowel, the ureter, or the gonadal or iliac
vessels.
For patients that undergo a successful CELS procedure,
postoperative morbidity is low as reported in the literature.
Franklin reported a 9 % postoperative complication rate, with
all complications being minor and mostly consisting of ileus,
atelectasis, and seroma [
rate of 4.2 %, with postoperative complications including
urinary retention and wound hematoma [ 7 ].
16 ]. Our group reported an overall
Outcomes
There are few large studies that report on the combined
approach of laparoscopy and colonoscopy for polyp removal.
The longest follow-up for these patients is a median of 65
months, which is reported by both our group and Franklin’s
group [
undergoing CELS is excellent. For patients with benign polyps that are successfully resected with a CELS technique,
there are variable recurrence rates in the literature. Our group
reports a recurrence in fi ve patients (10 %). Four of these
patients underwent a repeat colonoscopic polypectomy, and
one patient had a subsequent laparoscopic segmental colectomy, and all patients had benign pathologies [ 7 ]. Franklin’s
group reports no recurrences over a median follow-up of
65 months, but three patients were reoperated on for polyps
in different locations [ 16 ].
nosed with a cancer on fi nal pathology that there are potential
risks associated with a potential perforated cancer. However,
although follow-up is limited in patients that have had evidence
of cancer on fi nal pathology and have then gone on to have
formal resection, there are no reports of tumor recurrence [ 16 ].
7 , 16 ]. Overall, the long-term outcome of patients
There is concern that with patients that ultimately are diag-
Pearls and Pitfalls
In the preoperative workup of these patients with benign
polyps, there should be awareness that there can be discrepancy in pathology. It is important to have pathology slides
reviewed by pathologists at your own institution to make
sure there is consensus. In addition, the colonoscopy report
should be reviewed, as well as pictures of the polyp, to ensure
that the polyp seems to be acceptable for CELS.
It is important to perform colonoscopy fi rst in the operating room prior to laparoscopic port placement. Intermittently,
the polyp, which may have previously been deemed
unresectable by a referring gastroenterologist, may actually
be amenable to traditional colonoscopic polypectomy alone.
26 Combined Endo-Laparoscopic Surgery (CELS)
299
This combined technique can be technically demanding,
and the surgeon must be profi cient in both laparoscopic and
endoscopic techniques. For the fi rst several cases, it is useful
to have an assistant that is profi cient in both of these techniques in order to be successful.
During the CELS procedure, it is important to try and
recognize the signs of a potential malignancy. Many times,
polyps that have been biopsied or previously had attempts at
snaring may be scarred and diffi cult to lift with submucosal
injection. These fi ndings must be contrasted with fi ndings of
a possible cancerous polyp. These fi ndings include central
umbilication, ulceration, vascular pattern on narrow band
imaging, and fi rmness. If these fi ndings are present, options
are to continue with CELS and perform an intraoperative frozen section or to proceed to formal colectomy. We do not feel
that it is necessary to perform frozen section on all polyps
resected as this can add to the operative time and cost of the
case. In our experience, the rate of cancer on polyps that
were thought to be benign was only 2 % (1/48). Therefore,
frozen section should only be done on patients with suspicion of malignancy. In our experience, 12 patients underwent
colectomy instead of CELS for suspected malignancy,
and only 4 (33 %) of these patients actually had cancer.
7
Although this is a low sensitivity, this may refl ect our overly
cautious attempts to avoid performing CELS for potential
malignancy.
Conclusion
Combined endo-laparoscopic surgery (CELS) appears to be
a safe and effective for the treatment of benign colon polyps
and may help to avoid laparoscopic colectomy in most cases.
References
1. Fujishiro M, Goto O, Kakushima N, Kodashima S, Muraki Y,
Omata M. Endoscopic submucosal dissection of stomach neoplasms after unsuccessful endoscopic resection. Dig Liver Dis.
2007;39(6):566–71.
2. Zhou PH, Yao LQ, Qin XY. Endoscopic submucosal dissection for
colorectal epithelial neoplasm. Surg Endosc. 2009;23(7):1546–51.
3. Franklin Jr ME, Diaz-E JA, Abrego D, Parra-Davila E, Glass
JL. Laparoscopic-assisted colonoscopic polypectomy: the Texas
Endosurgery Institute experience. Dis Colon Rectum. 2000;43(9):
1246–9.
4. Beck DE, Karulf RE. Laparoscopic-assisted full-thickness endoscopic polypectomy. Dis Colon Rectum. 1993;36(7):693–5.
5. Guller U, Jain N, Hervey S, Purves H, Pietrobon R. Laparoscopic
vs open colectomy: outcomes comparison based on large nationwide databases. Arch Surg. 2003;138(11):1179–86.
6. Ommer A, Limmer J, Mollenberg H, Peitgen K, Albrecht KH, Walz
MK. Laparoscopic-assisted colonoscopic polypectomy—indications
and results. Zentralbl Chir. 2003;128(3):195–8.
7. Lee SW, Garrett KA, Shin JH, Trencheva K, Sonoda T, Milsom
JW. Dynamic article: long-term outcomes of patients undergoing
combined endolaparoscopic surgery for benign colon polyps. Dis
Colon Rectum. 2013;56(7):869–73.
8. Lee MK, Chen F, Esrailian E, et al. Combined endoscopic and laparoscopic surgery may be an alternative to bowel resection for the
management of colon polyps not removable by standard colonoscopy. Surg Endosc. 2013;27(6):2082–6.
9. Yan J, Trencheva K, Lee SW, Sonoda T, Shukla P, Milsom
JW. Treatment for right colon polyps not removable using standard
colonoscopy: combined laparoscopic-colonoscopic approach. Dis
Colon Rectum. 2011;54(6):753–8.
10. Wilhelm D, von Delius S, Weber L, et al. Combined laparoscopicendoscopic resections of colorectal polyps: 10-year experience and
follow-up. Surg Endosc. 2009;23(4):688–93.
11. Franklin Jr ME, Leyva-Alvizo A, Abrego-Medina D, et al.
Laparoscopically monitored colonoscopic polypectomy: an established form of endoluminal therapy for colorectal polyps. Surg
Endosc. 2007;21(9):1650–3.
12. Winter H, Lang RA, Spelsberg FW, Jauch KW, Huttl
TP. Laparoscopic colonoscopic rendezvous procedures for the
treatment of polyps and early stage carcinomas of the colon. Int J
Colorectal Dis. 2007;22(11):1377–81.
13. Feussner H, Wilhelm D, Dotzel V, Papagoras D, Frimberger
E. Combined endoluminal and endocavitary approaches to colonic
lesions. Surg Technol Int. 2003;11:97–101.
14. Mal F, Perniceni T, Levard H, Boudet MJ, Levy P, Gayet B. Colonic
polyps considered unresectable by endoscopy. removal by combinations of laparoscopy and endoscopy in 65 patients. Gastroenterol
Clin Biol. 1998;22(4):425–30.
15. Le Picard P, Vacher B, Pouliquen X. Laparoscopy-assisted colonic
polypectomy or how to be helped by laparoscopy to prevent colectomy in benign colonic polyps considered to be unresectable by
colonoscopy. Ann Chir. 1997;51(9):986–9.
16. Franklin Jr ME, Portillo G. Laparoscopic monitored colonoscopic
polypectomy: long-term follow-up. World J Surg. 2009;33(6):
1306–9.
17. Nakajima K, Lee SW, Sonoda T, Milsom JW. Intraoperative carbon
dioxide colonoscopy: a safe insuffl ation alternative for locating
colonic lesions during laparoscopic surgery. Surg Endosc. 2005;
19(3):321–5.
18. Hamdani U, Naeem R, Haider F, et al. Risk factors for colonoscopic
perforation: a population-based study of 80118 cases. World J Gastroenterol. 2013;19(23):3596–601.
P a r t V
Special Situations
Emergent Laparoscopic Colorectal Surgery
Rodrigo Pedraza and Eric M. Haas
K e y P o i n t s
• Laparoscopic colorectal surgery is both safe and feasible
in many emergent cases. Proper patient selection is crucial to for optimal outcomes.
• Port placement is challenging, as the left upper quadrant
is typically used for access however, if there is any question of safety, the right upper quadrant may be used as the
fi rst point of access, taking care to avoid liver injury.
• Optical trocars are preferred to gain abdominal access.
• For colonoscopic perforations, laparoscopic procedures
range from primary single-layer repair to segmental resection—with or without ostomy creation.
• For perforated diverticulitis, emergent interventions range
from laparoscopic lavage to resection with diversion,
depending on the case.
• Small bowel obstruction are ideal emergent laparoscopic
cases, since the majority require only a lysis of adhesions
with no bowel resection.
• Managing malignant obstructions laparoscopically, can
be fraught with major morbidity and intraoperative complications intervention is often limited to proximal diversion and distal decompression.
27
Introduction
Over the past two decades, laparoscopic colorectal surgery
has gained acceptance and rates of adoption are increasing
with proven clinical advantages. Recent reports demonstrate nearly 45 % of elective colectomies are performed
laparoscopically [ 1 – 3 ]; however, emergent laparoscopic
colorectal surgery is less common. Current use in the emergent setting is be than 10 %, refl ecting the complexity and
challenges even in expert hands.
The ability to use laparoscopy for colorectal emergencies
depends on both patient and surgeon factors. The most common utilizations include acute diverticulitis and malignant
obstruction. In addition, emergent laparoscopy for colonoscopic perforations has also been advocated [ 4 ]. However,
each case is individualized to determine the safety, risk, and
benefi ts for laparoscopy compared with open laparotomy.
The ultimate success lies in proper patient selection.
In this chapter, we address the trends in utilization, indications, technical considerations, and pitfalls of emergent
laparoscopic colorectal resection. The descriptions are based
on generalities in the urgent setting; specifi c presentations
may require alternative approaches.
Advantages and Disadvantages of Emergent Laparoscopic Colorectal Surgery
The principles of laparoscopic colorectal surgery can be
Electronic supplementary material: Supplementary material is available
in the online version of this chapter at
Videos can also be accessed at
978-1-4939-1580-4
R. Pedraza , M.D. • E. M. Haas , M.D., F.A.C.S., F.A.S.C.R.S. (*)
Division of Minimally Invasive Colon and Rectal Surgery,
Department of Surgery , The University of Texas Medical School
at Houston , 7900 Fannin Street, Suite 2700 ,
Houston , TX 77030 , USA
ehaas@houstoncolon.com
e-mail:
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_27, © Springer Science+Business Media New York 2015
.
10.1007/978-1-4939-1581-1_27 .
http://www.springerimages.com/videos/
employed in the emergency setting. The absolute contraindications for laparoscopy include an unstable patient who cannot tolerate pneumoperitoneum, inability to safely access the
abdomen, and insuffi cient laparoscopic experience.
Despite its challenges, laparoscopic colorectal surgery
has many advantages in the emergent context. With initial
laparoscopic intervention, the surgeon is able to thoroughly
evaluate the peritoneal cavity and establish the most appropriate intervention without committing the patient to a large
303
304
R. Pedraza and E.M. Haas
incision. Often the pathology can be addressed maintaining a
laparoscopic approach. Even if the condition requires an
open incision, the laparoscopic exploration affords accurate
identifi cation of the pathology, leading to a better localization, smaller incisions, less subsequent pain, less postoperative complications, and faster recovery. In some cases, the
benefi ts of a minimally invasive approach can be salvaged
when conversion is required by utilizing hand-assisted laparoscopic surgery.
In the emergent setting, avoiding open laparotomy has many
advantages. First, large incisions may be diffi cult to close, with
a risk of abdominal compartment syndrome. The small incision
size also has advantages in this patient population, where
immunosuppression, sepsis, or shock are common and can
jeopardizing healing and wound integrity. Laparoscopy lowers
the risk of wound complications (e.g., dehiscence, evisceration,
and infection), q major source of postoperative morbidity and
mortality. Moreover, wound complications may result in hernia
formation, which ultimately require further surgery.
Consequently, wound complications result in signifi cant
increases in hospital resource utilization and cost.
Despite the advantages of laparoscopic emergent colorectal intervention, there are several limitations. Safe abdominal
entry may be compromised, risking injury to bowel, solid
organs, and vascular structures. This may turn an already diffi cult scenario into a disastrous one. We recommend extensive experience with various laparoscopic entry techniques,
especially direct visualization with optical trocars, such as
with the OptiView
®
(Ethicon Endo- Surgery, Cincinnati, OH)
and Visiport™ Plus (Covidien, Mansfi eld, MA, USA).
Another important consideration is the hemodynamic
instability that can result from decreased venous return and
increased peripheral vascular resistance after establishing
pneumoperitoneum. The surgeon and anesthesiologist must
communicate about the patient’s condition; release of pneumoperitoneum facilitates prompt recovery of hemodynamic
parameters and may allow fi nishing with through a the minimally invasive approach.
Additional factors hampering the utilization of laparoscopy in emergent colorectal surgery include the relative
inability to place the patient in extreme positions as well as
the lack of available instrumentation and trained staff during
non-elective procedure times.
Approach and Abdominal Entry
Consideration to the minimally invasive technique to gain
safe entry is crucial. Emergency patients often present with
extreme abdominal distension and rigid abdomens, and caution must be taken during entry. Such presentations may
deter from considering laparoscopic intervention; however,
after anesthesia induction and ensuing relaxation of the
abdominal wall muscles, laparoscopic approach may be very
reasonable. Once abdominal entry is accomplished, the
placement of the remaining laparoscopic ports may remain
challenging, since in severe infl ammatory cases, the omentum is friable and tends to adhere to the peritoneum
(Video 27.1 ). We typically utilize either conventional multiport laparoscopy or hand-assisted laparoscopic surgery. The
abdominal entry is commonly safely achieved through a port
placed in the left upper quadrant along the costal margin
(Fig.
27.1 ). Alternatively, when access to the left upper quad-
rant is unsafe, access through the right upper quadrant may
be accomplished inferior to the costal margin to avoid liver
injury. We favor direct visualization with an optical trocar for
abdominal entry, as it provides a safer approach when compared with blind access. This approach is also advantageous
for patients with prior abdominal surgery or when the source
or extent of pathology is unknown. An alternative is handassisted or single-incision laparoscopic surgery, though the
abdominal laparotomy entry may still be diffi cult. These are
most appropriate when it is safer to enter the abdomen
through a direct mini-laparotomy incision.
Indications
Colorectal Perforation
Acute Colonoscopic Perforation
Laparoscopic intervention can be a suitable approach for both
acute and delayed colonoscopic perforations. The procedure
depends on the degree and cause of perforation, timing following the event, degree of peritoneal contamination, and
overall clinical condition of the patient. Nearly all cases can
be managed laparoscopically, whether primarily repairing the
perforation or resecting with or without ostomy creation.
Procedure Steps
• Abdominal entry: left upper quadrant port placement
under direct visualization.
• Exploration: the abdominal and pelvic cavities are explored
to assess the location, extent of injury, and presence of
fl uid or fecal contamination. If fecal contamination is
encountered, conversion to hand-assisted laparoscopic surgery or laparotomy for lavage, bowel resection, and fecal
diversion is recommended. Fecal washout cannot often be
adequately performed with pure laparoscopic techniques.
However, if minimal contamination is recognized, the
bowel injury can often be primarily repaired. The entirety
of the large bowel is examined to identify the perforation.
Intraoperative colonoscopic assistance utilizing carbon
dioxide may be required to aid visualization of the perforation. Once identifi ed, proximal bowel clamping is performed to avoid further contamination.
27 Emergent Laparoscopic Colorectal Surgery
305
Fig. 27.1 Port placement alternatives for emergent colorectal surgery
Fig. 27.2 Intraoperative view of a colonic perforation following colonoscopy ( arrows ). The perforation was successfully repaired with single-
layer primary colorrhaphy
• Laparoscopic management alternatives:
(a) Laparoscopic colorrhaphy (Video 27.2 ): the perfora-
tion borders are defi ned and debrided if devitalized tissue is encountered. The repair is achieved with a
one-layer colorrhaphy with absorbable suture
(Fig.
27.2 ). The use of multiple layer colorrhaphy may
potentially result in lumen narrowing, especially in the
sigmoid colon. Following the repair, an air insuffl ation
test and direct intraluminal visualization of the perforation site should be performed to confi rm the integrity
of the repair. Injuries extending into the mesentery
may be more challenging to repair, and care must be
taken to identify the entire extent of the perforation.
The borders of the mesentery, which often bleed, may
obscure the view and lead to failure to recognize and
address the entire extent of the perforation.
306
R. Pedraza and E.M. Haas
(b) Segmental resection: after visualizing the perforation,
if primary repair is not appropriate, laparoscopic segmental colectomy may be performed with or without
ostomy creation. The same principles of laparoscopy
in the elective setting are followed and often a medialto-lateral approach is favored to avoid the infl amed
bowel with associated adhesions and friable tissue.
(c) Bowel diversion: in extreme cases, proximal diversion
with colonic lavage may be a temporary measure.
Concomitant diversion is also considered following (a)
or (b) above, under the discretion and judgment of the
surgeon at the time of the operation.
Acute Perforated Diverticulitis
The management of acute perforated diverticulitis varies
depending on the clinical presentation of the patient and
must be approached on an individual basis. Those who
require emergent intervention typically present with free perforation, with an intra-abdominal abscess and/or peritonitis.
Laparoscopic surgery in this setting can be both diagnostic
and therapeutic. The therapeutic measures can include drainage of abscesses, lavage, primary closure of perforation,
resection, and/or diversion. Although, it has been generally
agreed that the presence of fecal peritonitis requires an open
lavage, we have been successful using hand-assisted technique to effectively evacuate the contamination while maintaining a minimally invasive platform.
Procedure Steps
• Abdominal entry: left upper quadrant optical trocar port
placement under direct visualization.
• Abdominopelvic exploration: often, the omentum is
infl amed and adhered to the peritoneal lining and pelvis
requiring mobilization to explore the abdomen. The peritoneal cavity is then thoroughly examined to evaluate the
nature of the contamination. For patients with Hinchey 3
(purulent peritonitis), we perform laparoscopic lavage
with or without over-sewing the bowel wall with placement of drains through the port sites. It is important to
evaluate for inter-loop abscesses, which may be a case
for treatment failure if not identifi ed and adequately
drained during the procedure. It is also important to
locate the perforation site itself, as an occult abscess may
be present at or adjacent to this area, which is often
shielded by infl amed tissue (Video 27.3 ). For those presenting with Hinchey 4 (fecal peritonitis), we typically
perform hand- assisted laparoscopic technique, which
allows evacuation of the fecal content as well as sigmoid
resection with colostomy. A 5–7 cm umbilical or
Pfannenstiel incision can be used to place the hand assist
device. However, if this technique does not afford complete evacuations of the fecal contents, an open laparotomy is required.
• Lavage: it is necessary to lavage all four quadrants including perihepatic, perisplenic, right and left gutters, and
pelvis (Video 27.3 ). Often occult fl uid collections are
identifi ed and attended to in this process. Although no
standard volume of irrigation has been reported, we recommend lavage until the fl uid return is clear. The laparoscopic lavage is an excellent device to episode jet
irrigation and allows litters of heated fl uid to be utilized in
an expeditious fashion.
• Management of perforation site: the diverticular perforation is typically walled off; however, gentle teasing of the
tissues around the perforation should be performed, as
occult abscesses may lie around the perforation. In the
case that the diseased sigmoid is densely adhered, aggressive mobilization should be avoided, since this may result
in an uncontained perforation. If perforation site is visualized, some advocate over-sewing the perforation or
placing a tissue patch with adjacent epiploica or omentum. There is, however, no consensus and these various
maneuvers all warrant consideration on an individual
basis. The fallback “conservative” approach, however,
typically involves resection of the diseased segment.
• Bowel diversion: if diversion is considered, laparoscopic
loop ileostomy or colostomy may be performed depending
on the clinical presentation of the patient. The laparoscopic
technique is accomplished in a conventional fashion (Chap.
15 ). In either case, if diversion is performed without bowel
resection, on-table lavage of the distal segment should be
performed to clear the intraluminal fecal content.
• Laparoscopic resection: in some cases segmental colectomy
may be warranted during the emergent presentation. In such
cases, a laparoscopic sigmoid colectomy is performed
utilizing a medial-to-lateral approach (Chap. 6 /Chap. 7 ) to
afford early identifi cation and preservation of the critical
vascular structures and the left ureter. Placement of ureteral
stents and hand-assisted techniques should all be entertained
in this scenario.
Postoperative Anastomotic Perforation
Anastomotic perforation may manifest with peri- anastomotic
abscess and purulent or fecal peritonitis. An isolated abscess
can often be managed with image-guided drainage, whereas
peritonitis or the presence of multiple abscesses may require
laparoscopic lavage and further interventions. Although such
perforations are typically approached with open surgery,
laparoscopic reoperation is a safe and feasible alternative for
those with technical expertise [ 5 ].
Procedure Steps
• Abdominal entry: left upper quadrant port placement
under direct visualization.
• Exploration: as with any type of perforation, the entirety
of the peritoneal cavity is explored. It is common to
27 Emergent Laparoscopic Colorectal Surgery
307
experience a hostile intra-abdominal environment with
infl amed and adhered omentum and mesentery.
• Lavage: thorough peritoneal washout is performed to
clear out the contamination.
• Anastomotic takedown and diversion: anastomotic resection should be contemplated in all cases with proximal
diversion. In cases in which the anastomosis is not accessible for resection—such as those deep in the pelvis—
diversion alone must be accompanied with on-table
lavage.
Bowel Obstruction
Postoperative Small Bowel Obstruction
Small bowel obstruction is the ideal scenario for laparoscopic intervention. Since the majority of cases do not
require bowel resection, a sizable incision of any length is
usually not required. The general principles of management
of bowel obstruction are followed including gastrointestinal
decompression and fl uid/electrolyte replacement before
operative intervention. Patients with small bowel obstruction
may seem severely distended on clinical exam, causing many
surgeons to abort the laparoscopic approach; however, upon
induction of anesthesia, the distention diminishes signifi cantly, allowing safe laparoscopic entry.
Procedure Steps (Video 27.4 )
• Abdominal entry: left upper quadrant access with an optical trocar. If the patient has prior scars in this region, right
upper quadrant can be used. Once entered, a second trocar
is placed at any location in which the laparoscopic visualization permits. Often, placement of the second trocar is
the most diffi cult. Once 2 trocars are placed, lysis of adhesions can be initiated allowing for multiple ports. If one
cannot safely gain entry in this fashion, a hand port can be
placed through a midline infraumbilical incision. Handassisted laparoscopic surgery, however, is less useful in
small bowel obstruction due to the loss of abdominal
domain from the distended bowel.
• Exploration: Abdominal and pelvic exploration is performed to identify the etiology of the obstruction.
• Resection: if the case warrants segmental resection, such
as in severe strangulation with bowel infarction, the
affected segment is mobilized and extracorporealized
through a wound protector (Fig. 27.3 ). Resection and pri-
mary anastomosis can then readily be achieved
extracorporeally.
Malignant Obstruction
Malignant obstruction encountered in the emergent setting
typically involves the left colon, and the disease is usually
locally advanced. It is also commonly associated with massi-
Fig. 27.3 Gangrenous bowel from bowel obstruction
vely dilated and fragile proximal colonic dilation. In this
setting, primary resection can be fraught with major morbidity and intraoperative complications. Therefore, attempts at
nonoperative intervention, such as intraluminal stenting for
decompression should be strongly considered before committing to surgical intervention. Laparoscopic intervention is
often limited to creation of proximal diversion to decompress the obstruction and allow resuscitation and recovery. In
addition, this will allow the size mismatch to resolve that
frequently would prevent creation of an anasto mosis in the
acute setting. Therefore, distal decompression is required
with either loop colostomy or end colostomy with mucus
fi stula.
Procedure Steps
• Abdominal entry: laparoscopic abdominal entry is challenging in patients with bowel obstruction secondary
to abdominal distention, with the risk for perforation
especially high during laparoscopic access. For multiport
approach, left or right upper quadrant access is preferred,
depending on the location of the disease. For cases requiring ostomy alone, a single-incision laparoscopic surgery
with the single-access port placed at the proposed ostomy
site is another option. In cases in which resection is
contemplated, hand-assisted laparoscopic surgery is the
preferred approach in our institution. This approach affords
safe abdominal entry and domain allowing for adherence
to the principles of an oncologic resection. The incision
depends on the location of the tumor: for right-sided and
mid transverse colon tumors, a midline mini-laparotomy
308
R. Pedraza and E.M. Haas
incision is made, whereas for left-sided tumors, a
Pfannenstiel incision is preferred.
• Bowel decompression: in cases in which there is severe
distention and an ostomy is necessary, one can extracorporealize the bowel, perform an enterotomy for decompression, and utilize this segment for further ostomy creation.
Once decompressed, it is often possible to perform the
resection while maintaining a minimally invasive platform,
typically utilizing hand-assisted laparoscopic surgery.
• Segmental resection: a conventional laparoscopic technique for segmental resection in a medial-to-lateral fashion
with oncologic principles is performed (Chaps.
4 – 7 ). Even
if laparotomy is required, we favor performing some portions of the procedure (e.g., splenic and hepatic fl exure
takedown) laparoscopically to minimize the incision length.
Pearls and Pitfalls
• Know your limitations and choose your patients wisely.
Wasting time with a minimally invasive approach in a
septic patient may result in more risk and worse outcomes
than open laparotomy.
• Mobilization of a perforated diverticulum may identify
occult abscesses, but avoid the urge to mobilize densely
adhered bowel, as this may result in additional bowel
injury and the need for resection.
• Gravity is your friend to help with visualization and
keeping the small bowel out of the way. However, as you
may encounter infl amed bowel, dilated bowel, or intra-
abdominal stool or purulence), have additional sponges on
hand to keep the fi eld of view “clean.”
• The omentum is often adherent and restricts visibility; the
adhesions must be released, especially those tethering
the omentum to the pelvic structures. The omentum is
mobilized caudally and fl ipped over the transverse colon
for optimal exposure.
• The laparoscopic irrigator is essential, as it provides jet
irrigation in an expeditious fashion. Irrigation is required
in the perisplenic and perihepatic areas as well as the gutters and pelvis to help minimize risk of postoperative
abscesses.
References
1. Haas EM PR, Ragupathi M, Carman R, Nieto J. Is laparoscopic
colectomy a clinically and economically favorable approach in the
modern health care environment: results from a cohort of 56,000
patients. Abstract S12 The American Society of Colon and Rectal
Surgeons annual meeting; 2013.
2. Delaney CP, Chang E, Senagore AJ, Broder M. Clinical outcomes and
resource utilization associated with laparoscopic and open colectomy
using a large national database. Ann Surg. 2008;247:819–24.
3. Fox J, Gross CP, Longo W, Reddy V. Laparoscopic colectomy for
the treatment of cancer has been widely adopted in the United
States. Dis Colon Rectum. 2012;55:501–8.
4. Haas EM, Pedraza R, Ragupathi M, Mahmood A, Bartley
PT. Laparoscopic primary colorrhaphy for acute iatrogenic perforations during colonoscopy. Minim Invasive Surg. 2013;2013:823506.
5. Haas EM PR, Faraj C, Ragupathi M, Pickron TB. Reoperative minimally invasive surgery for the management of colorectal surgical
complications. Abstract Society of American Gastrointestinal and
Endoscopic Surgeons; 2013.
Laparoscopy in the Elderly Patient
Joshua I. S. Bleier and Brian R. Kann
28
K e y P o i n t s
• Assessment of the elderly patient is based on physiologic
age rather than chronologic age.
• Preoperative assessment is based on a careful history and
physical examination aimed at determination of high-risk
comorbidities.
• Preoperative testing is based on functional assessment
and presence of known comorbidities.
• Laparoscopic colectomy in the elderly is increasing commensurate with the overall increase in laparoscopic
colorectal surgery across all ages.
• Laparoscopic colectomy in the elderly seems to yield
similar benefi ts when using an enhanced recovery protocol as seen in younger patients.
• Pneumoperitoneum induces myriad physiologic changes
that may have more signifi cant effects in the elderly with
comorbid conditions.
Introduction
Aging is, of course, defi ned chronologically; however,
subjectively, physiologically, and medically, it is more often
a function of “how old you feel.”
To a large degree, management of colorectal issues,
whether benign or malignant, is pathology driven. In most
instances, colon cancers that are resectable should be resected,
J. I. S. Bleier , M.D., F.A.C.S., F.A.S.C.R.S. (*)
Division of Colon and Rectal Surgery, Pennsylvania Hospital ,
University of Pennsylvania , 800 Walnut St. 20th Floor ,
Philadelphia , PA 19106 , USA
joshua.bleier@uphs.upenn.edu
e-mail:
B. R. Kann , M.D., F.A.C.S., F.A.S.C.R.S.
Division of Colon and Rectal Surgery, Pennsylvania Hospital ,
University of Pennsylvania , 51 N. 39th St Suite W-266 ,
Philadelphia , PA 19104 , USA
brian.kann@uphs.upenn.edu
e-mail:
metastatic disease is an indication for adjuvant therapy, multiple recurrent attacks of diverticulitis indicate resection, and
low rectal cancers that don’t involve the sphincters may be
treated by sphincter-sparing operations, including colo-anal
anastomoses. However, the wise surgeon knows that indications are only part of the decision process. Pathology alone
may provide the indication for surgery, but not necessarily
the decision for it. Patient factors must be taken into consid-
eration. Every assessment of the potential surgical patient
takes into account fi tness for surgery, as well as the assessment of being able to tolerate the outcome. But where does
age play into this equation? Age is a nonspecifi c factor that
may provide predictive information about how well a patient
will tolerate a procedure. In general, the older the patient,
the more comorbidities, the higher the risk for healing problems, the worse the baseline continence and sphincter function, and the higher the risk for concomitant cardiovascular
disease. Chronologic age is indisputable, but physiologic
age is variable. Consider the unfortunate condition of progeria, in which children succumb to the physiologic maladies
of advanced age such as heart attack, stroke, and atherosclerotic disease—and rarely live past the age of 13—to the
100-year-old man who completed a marathon in Toronto in
2011! The concept of physiologic age truly determines the
assessment of the elderly patient. Determination of the physiologic age of the patient is an amalgam of all of the physiologic
parameters that will be affected by the operation and its
recovery. Prior dogma dictating age as a relative contraindication to surgery has been replaced by determination of
fi tness. Advances in perioperative management have demonstrated that mere chronologic age does not directly
determine fi tness and the ability to recover from surgery.
Rather, it merely informs us of the increased possible
risks, while overall fi tness for intervention is determined
by factors that are projected to be affected by the surgery.
The use of laparoscopic surgery has further redefi ned risks
and must be incorporated into our decision-making processes. This chapter will deal with these issues and the factors that affect them.
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_28, © Springer Science+Business Media New York 2015
309