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A. T. Hawkins and C. H. Olson
abc
Fig. 10.5 (a–c) Three different techniques to retract the uterus, cul-de-sac, and vagina during low
anterior resection. (a) A suture is placed laparoscopically through the uterus using a Keith needle,
and the uterus is suspended superiorly. (b) Multiple retractors are used to retract the uterus and
cul-de-sac superiorly in order to expose the anterior rectal wall. (c) A sizer is inserted transvaginally and used to retract the vaginal anteriorly and facilitate exposure of the rectovaginal plane.
(All: Courtesy of Patricia Sylla, MD)
(Fig.10.5a–c). Magnetic retractors that work through the abdominal wall have also
been developed and have demonstrated clinical utility [15]. All these techniques
introduce additional complexity to an operation, and close attention must be paid to
the location of assistant’s instruments, and in the case of intraperitoneal retractors/
assists, these are removed at the completion of the operation.
Laparoscopic Visualization
Poor visualization can hamper the safe completion of laparoscopic procedures.
Ideally, a clear view of the operative eld should be present at all times. Fogging is a
common problem which can be remedied by using pre-warmed laparoscopic lenses,
warm air insufation, and moving the insufator away from the camera port. Fogging
from smoke production during use of cautery or energy devices also occurs and can
be improved by use of suction irrigation, venting a laparoscopic port, and use of a
smoke evacuation device. Specialized laparoscopes with built-in heaters to warm the
lens are available; also, the use of conductive lubrication on cautery instruments can
greatly reduce the amount of smoke produced. Other impediments to visualization
include dirty lenses from passing the scope through soiled ports. Here, cleaning the
port regularly can help, as well as upsizing the port to allow for easier introduction of
the lens. The suction irrigator can also be used to clean the lens by blowing clear uid
across it and then using the suction to remove remaining water vapor.
Control ofSurgical Bleeding
Bleeding is a common operative problem and can be the cause of conversion to an
open procedure. Increasing operative experience decreases the number of signicant bleeding complications as well as the need to convert the case to address
10 Essentials onTroubleshooting During Laparoscopic Colorectal Surgery
149
bleeding [16]. As always, prevention is better than reaction, and appropriate exposure of the operative eld can reduce the incidence of bleeding and facilitate control. The rst response should generally be control of the bleeding as quickly as
possible using an instrument already present in the abdomen. This could be either a
grasper or an energy device. Modern laparoendoscopic energy devices use endothermal bipolar vessel sealing or ultrasonic energy to coagulate tissue. Both can
close vessels up to 7mm in diameter; however, endothermal bipolar vessel sealing
devices have signicantly less heat production, decreasing possible thermal injury
to nearby structures. A small randomized controlled trial showed a signicant
reduction in blood loss and operative times with the use of endothermal bipolar
devices [17]. The choice of particular device is largely dependent on individual
surgeon’s preference and experience.
In the event bleeding cannot be controlled with an energy device, other options
are available. Larger vessels with signicant calcication may not be adequately
sealed with coagulation alone. It is important to note that bipolar devices will malfunction when in proximity to a foreign body such as metal. Bleeding through staple
lines must be controlled with alternative measures. Laparoscopic clips or endoloops
are more effective means of control. Clips are available in either the traditional
metal style or locking plastic clips. Endoloops are very effective to control bleeding
from a major colonic vessel such as the ileocolic, inferior mesenteric, or middle
colic pedicle. Slow bleeding through a staple line can also be managed with monopolar cautery, suture ligature, or application of a laparoscopic hemostatic agent.
Splenic Bleeding
Bleeding from the spleen can be difcult to control and lead to conversion to open
and even splenectomy, which has long-term immunologic consequences. Rates of
splenic injury vary from 0.5 to 1% for laparoscopic colorectal resections. For minor
splenic bleeding, the best initial route is application of a surgical hemostatic agent
and tamponade. If this proves ineffective, monopolar cautery or argon beam coagulation can be attempted; however, these can worsen the area of injury and lead to
more severe bleeding. Devascularization of the inferior pole of the spleen has also
been reported as a salvage technique and may prove effective [18]. Should splenectomy be required, the patient should receive the appropriate vaccinations prior to
hospital discharge.
Organ Injury
Organ injuries that occur during laparoscopic colorectal resection should ideally be
identied and repaired at the time of the procedure. Commonly injured organs
include the small bowel and ureter, and special precautions can be taken to help
avoid these complications. Other organs at risk include the spleen, pancreas, liver,
bladder, and vagina. As with many aspects of surgery, most repairs can be accomplished laparoscopically; however, a low threshold for conversion to an open is
150
A. T. Hawkins and C. H. Olson
appropriate. Knowledge of the anatomy and proper exposure are the rst line of
defense. Please see Chap. 31 on strategies to minimize conversion in laparoscopic
colorectal surgery for more technical details.
Small Bowel Injury
Serosal tears affect the outer muscular layer of the intestine while leaving the inner
muscular layer and mucosa intact. Small serosal tears likely require no repair.
Larger tears benet from closure with Lembert sutures. This can be accomplished
laparoscopically in the traditional interrupted fashion or as a running suture.
Absorbable sutures should be used, and unidirectional sutures can be employed as
well. Repair should occur in a transverse fashion to avoid stenosis of the bowel
lumen. Full thickness injuries of the intestine mandate repair. These are repaired
most effectively with a running suture, and the use of unidirectional suture greatly
facilitates laparoscopic closure and has been shown to be safe (Fig. 10.6) [19].
Again, repair should occur along the transverse axis of the bowel. Thermal injuries
to the intestine are more difcult to identify [20]. Signs of thermal injury can be
subtle, and surgeons should have a high index of suspicion if energy was used in
close proximity to the bowel. Thermal injury can appear as a whitish discoloration,
or in severe cases, the tissues may appear bruised or charred and have a contracted
appearance. Often, these injuries may be missed altogether. If an area of injury is
identied, it should be debrided and repaired as a full thickness injury.
Ureteral Injury
Injuries to the ureter occur in up to 1% of all laparoscopic colorectal operations and
are one of the most commonly litigated areas in colorectal surgery [21]. Repair of
ureter injuries should involve the consult of a urologic surgeon and ideally be identied and performed at the time of surgery. Delay in identication of ureteral injuries
leads to increased risk of loss of kidney function and further complications [21].
Fig. 10.6 Bowel repair. Repair of bowel injuries is performed transversely to avoid structuring of
the intestine
10 Essentials onTroubleshooting During Laparoscopic Colorectal Surgery
Fig. 10.7 Indocyanine
green dye can be injected
through ureteral stents to
aid in ureteral
visualization. (Courtesy of
Jeffrey Gahan, MD, UT
Southwestern Medical
Center)
151
Prevention of ureter injuries is guided primarily by knowledge of the pelvic anatomy, proper exposure, and review of preoperative imaging. Ureteral stents can also
play an important role. Stents are unlikely to prevent injuries but may aid intraoperative recognition of ureteral injuries, facilitating early repair. A 2018 analysis of
NSQIP data demonstrated a protective effect of ureteral stents in high-risk cases
[22]. Newer technologies such as lighted stents and immunouorescence can aid
further in intraoperative identication of the ureters, saving operative time and possibly reducing injury rates (Fig. 10.7) [23, 24]. Complications of ureteral stent
placements occur approximately 2% of cases and include acute renal injury, obstruction and hydronephrosis, urinary tract infection, and ureteral perforation [25]. For
this reason, many employ a selective stenting policy based on preoperative index of
suspicion for a difcult case.
Trocar Site Closure
Hernias at port sites occur, and the question of which port sites to close remains
controversial to this day. Generally, 5mm port sites have a low risk of hernia, and
closure is unnecessary. Consideration to closure should be given if the port has
fallen out and been replaced several times during the operation, inadvertently creating a larger fascial defect. Hernias at 8mm ports have been reported; however, common practice remains to not close the fascia at these defects as large series show
these hernias are rare [26]. 10–12mm ports have reported rates of hernia around
1%, making some authors recommend fascial closure of port site [27]. Risks of
closure include vessel injury and bleeding, as well as increased postoperative pain.
Port site closure can be accomplished with a laparoscopic suture passer or one of the
several commercially available devices.
Conclusion
Laparoscopic colorectal surgery is a challenging endeavor that requires greater cognitive involvement and training when compared to traditional open surgery. Constant
vigilance and anticipation and knowledge of potential problems can lead to improved
intraoperative management and patient outcomes.
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A. T. Hawkins and C. H. Olson
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injury during open and laparoscopic colorectal surgery: a single center experience and review
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catheters for colectomy: a National Surgical Quality Improvement Program-Based analysis.
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lighted ureteral stenting in laparoscopic colectomy. JSLS. 2002;6(1):49–52.
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following robotic colorectal surgery. Surg Endosc. 2016;30(8):3505–10.
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153
Principles ofComplete Mesocolic
Excision forColon Cancer
IanM.Paquette andFergalFleming
Introduction andRationale
Since the initial description by Heald of total mesorectal excision (TME) [1–3],
there has been a steady interest in the relationship between the quality of a rectal
cancer resection and oncologic outcomes. The fact that a well-executed TME as
judged by the quality of the mesorectal specimen is clearly associated with better
oncologic outcomes has led to some authors to postulate that similar principles
should be applied to colon cancer. The current point of controversy is the role for
complete mesocolic excision (CME) in colon cancer surgery [4]. The effort to standardize colon cancer surgery has brought forth many new and often contradicting
denitions. CME, “high-tie,” “D3” resection, and others are often incorrectly used
interchangeably in the literature. To be able to understand the literature on this topic,
we must rst understand the meaning of the various denitions which have been
proposed. We will then examine the impact of these techniques on survival after
colon cancer surgery and the evolving role of minimally invasive surgery in these
techniques.
11
Definitions
Many reports in the literature use the terms CME and central vascular ligation
(CLV) interchangeably. There are three components to CME.The rst component
involves sharp dissection between the parietal fascia and mesenteric plane and
I. M. Paquette (*)
University of Cincinnati College of Medicine, Cincinnati, OH, USA
e-mail: ian.paquette@uc.edu
F. Fleming
Department of Colorectal Surgery, University of Rochester Medical Center,
Rochester, NY, USA
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020
P. Sylla et al. (eds.), The SAGES Manual of Colorectal Surgery,
https://doi.org/10.1007/978-3-030-24812-3_11
155
156
I. M. Paquette and F. Fleming
removal of the mesenteric tissue within a complete envelope of fascia and peritoneum [5]. The second component is the central vascular tie at the most proximal
extent of the feeding blood vessel, and the nal component is removal of an adequate length of bowel either side of the tumor to remove potentially involved lymph
nodes in a longitudinal direction [6]. Where the confusion often arises is in the
extent of lymphadenectomy that is done. CME requires proximal vascular ligation
at the origin of the feeding vessels but does not require dissection of the root vessels
(e.g., superior mesenteric artery or vein). The denitions of extent of lymph node
dissection described in the following sections are based on the guidelines of the
Japanese Society of Cancer of the Colon and Rectum (JSCCR) [7, 8] It is important
to note that most of the literature reported below describes a CME dissection with a
standard high ligation of the feeding vessel and does not include an extended
lymphadenectomy.
D3
The Japanese classication references levels as D1–D3, as highlighted in Fig.11.1.
D1 lymph node resection represents transection of the mesenteric vessels at the
level of the marginal vessel; D2 is a more traditional resection of the main feeding
vessel to a given colonic segment at its origin. D2 dissection is equivalent to transection of the ileocolic artery at its origin off the superior mesenteric artery (SMA) or
ligation of the inferior mesenteric artery at the takeoff of the left colic artery. A D3
dissection for a right-sided tumor includes lymph nodes along the anterior aspect of
the superior mesenteric vein (SMV) and SMA (central lymph nodes) and for a leftsided tumor includes lymph nodes around the inferior mesenteric artery at the origin
off the aorta [7].
Central Venous Ligation (CVL)
The group from Erlangen, Germany, has proposed nodal dissection even more
extended than the D3 standard proposed by the Japanese, noted as central vascular
ligation [7]. This description is pertinent to a right colectomy. Dissection in the
plane of Toldt’s fascia between the mesocolic fascia and the retroperitoneum is performed with sharp dissection. Surgery involves a Kocher maneuver and takedown of
the mesenteric attachments to the duodenum and uncinate process of the pancreas
with complete dissection around the superior mesenteric vein and superior mesenteric artery. For tumors of the cecum and proximal ascending colon, the right
branches of the middle colic artery and middle colic vein are ligated centrally. For
tumors located more distally in the ascending colon, hepatic exure or proximal
transverse colon (proximal to the left branch of middle colic artery) lymph node
removal is taken down to origin of the middle colic and ileocolic artery with these
arteries divided centrally. For tumor in the distal transverse colon, lymph nodes in
the gastrocolic ligament are included in the resection, as are gastroepiploic vessels,
11 Principles ofComplete Mesocolic Excision forColon Cancer
157
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211
201
221
211
211
201
221
222(r) 222(I)
212
202
201
213
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221
221
214
251
253
216
251
221
231
221
231
232
216223
252
252
242
241
242
242
241
231
-241
241
231
241
Fig. 11.1 Mesocolic lymph node stations according to the Japanese Society for Cancer of the
Colon and Rectum. D1–D4 dened by colors: D1red, D2 blue, D3 green, and D4 black. Right
colic artery (dotted). (Used with permission of Wolters Kluwer from Bertelsen etal. [41])
and their branches to the stomach are divided for a length of approximately 10cm
either side of the tumor. It is important to understand this denition, in contrast to
the denition of D3, and they are often inappropriately discussed interchangeably in
the literature.
Role forMinimally Invasive Surgery inCME
Laparoscopic colectomy is widely accepted as a preferred surgical technique for
colon cancer [9]. CME was initially described as a massive open operation, albeit
with good oncologic outcomes. The challenge for the surgeon is to use minimally
invasive techniques to achieve the same oncologic outcomes while maintaining the
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I. M. Paquette and F. Fleming
benets of MIS approach. Many reports continue to emerge describing the technical
considerations for achieving a CME resection for colon cancer using laparoscopic
or robotic surgery [10–15]. Most of these studies examine outcomes in resection of
either the right colon or the transverse colon, as a proximal lymphadenectomy in a
left colectomy is not technically difcult and is often performed [10]. Of these types
of resection, transverse colectomy tends to be more technically difcult, with longer
operative times due to increased technical complexity [16]. The technical complexity comes from dealing with the intricacies of the middle colic vessels, which are
often shorter and have more varied branching patterns than often seen in other segments of the colon. A study by Spinoglio and coauthors of 202 robotic vs. 101 laparoscopic right colectomies with CME indicated a lower rate of conversion to open
surgery (0% vs. 6.9%) in robotic vs. laparoscopic surgery (p=0.01), with no difference in 5-year overall or disease-free survival [17]. A recent literature review comparing laparoscopic vs. open CME included 1 RCT and 11 non-randomized studies
(4 from Europe and 7 from Asia) [14]. As expected, laparoscopic surgery offered
faster return of gastrointestinal function and less complications. There were no differences in the quality of the resected specimen based on lymph node harvest and
distance from tumor to the mesenteric transection. The laparoscopic approach
offered better 3-year overall survival (OR 2.02, p=0.001) and disease-free survival
(PR 1.45, p=0.05) [14]. These results suggest that a minimally invasive approach
is at least feasible, but the survival results need to be interpreted with some caution
as these studies were fraught with selection bias, and in many instances, laparoscopic resections were offered to lower-risk tumors. Although little has been published on the learning curve during CME, the few publications on this topic have
demonstrated a long learning curve as demonstrated by longer operative time and
time to achieve CME specimens of satisfactory quality [18, 19].
Please refer to Chap. 13 on laparoscopic right colectomy for malignant disease
for details on operative setup and techniques of laparoscopic right colectomy with
CME.
Perioperative Outcomes ofCME
The extensive dissection close to or around the root of the major blood vessels in
both CME and D3 lymphadenectomy has led to understandable concerns about possible morbidity compared to conventional colon cancer resection which does not
mandate as an extensive dissection. Tables 11.1 and 11.2 summarize publications to
date where either CME or D3 resections were compared to either a concurrent or
historical control group who underwent conventional or “standard” colon cancer
resection. Operative blood loss was reported on in three studies, with one study
reporting a signicantly higher blood loss in the CME group, with no difference
noted in the other two studies [20–22] (Table11.1). A recent pooled analysis by
Alhassan and coauthors comparing [23] conventional colectomy and CME for
colon cancer found a similar rate of pooled overall complications for conventional
resection of 19.6% (95% CI:13.6–25.5) and 22.5% (95% CI:18.4–26.6) for CME