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30 Intraoperative Air Leak, Colonic Ischemia, or Tension: How toSalvage theFailed…
481
taking the patient out of steep Trendelenburg or reverse Trendelenburg position can
be performed to improve mean systemic lling pressure, venous return, and microcirculation associated with pneumoperitoneum [53]. Releasing any tension on the
mesentery is another important maneuver. If the tension was placed during transanal
extraction, the conduit should be returned intraabdominally to see if this improves
blood ow. Additionally, the mesentery should be assessed for avulsion of any
blood vessels that may be contributing to the ischemia.
If colonic ischemia persists despite all the above maneuvers, alternative reconstructive options vs conversion to permanent colostomy need to be considered
depending on the extent of the colonic ischemia. If this possibility was not discussed
with the patient prior to surgery, the surgeon is encouraged to discuss the ndings
with the patient’s family or emergency contact and obtain emergent informed consent for either conversion to permanent colostomy or attempt to alternative reconstructive options. In addition, the surgeon is encouraged to consult a surgical
colleague to assist with decision-making for the remainder of the case. Alternative
low pelvic reconstructive options utilize the right colon for low pelvic reconstruction and anastomotic options. In some cases, the transverse colon can be salvaged as
well [54]. While laparoscopic approaches have been described for alternative low
pelvic reconstruction [55–57], an open approach may be in the patient’s best interest
to facilitate reducing operative time and potentially preserving a longer segment of
the colon if feasible. The anatomy becomes signicantly altered and is typically
easier to visualize rather than described (Fig.30.6 AB).
Fig. 30.6 (a, b) Deloyers procedure. (Both: Used with permission of Springer Nature from Davis [70])
482
V. O. Shaer and E. C. McLemore
Deloyers procedure was rst described in 1964 and utilizes a right colon to low
pelvic rectal anastomosis as a salvage technique for low colorectal or coloanal anastomosis in the setting of ischemic left conduit. In the Deloyers procedure, the right
and middle colic arteries are ligated, and the right colon is inverted, so a right colon
to rectal anastomosis is created [58–60]. The left and transverse colon are frequently
removed secondary to ischemia during this approach. The right colon can be used
either in an isoperistaltic or antiperistaltic fashion, essentially whichever conduit
has less tension and better reach into the pelvis. An appendectomy is performed as
well to avoid future appendicitis and delay in diagnosis or inability to treat due to
the altered anatomic location of the retained appendix. The terminal ileum is relocated to the hepatic exure in cases in which an antiperistaltic right colorectal anastomosis is created. Another option similar to the Deloyers procedure is a cecum to
rectal anastomosis [61, 62]. A modication of the Deloyers technique involves
maintaining the orientation of the vascular pedicle but involves two anastomosis–
an antiperistaltic colorectal anastomosis and an ileocolonic anastomosis [63].
Surgeons have also described a retroileal transverse colon to rectum anastomosis. A
passage is created in an avascular plane in the transverse ileal mesentery to allow the
proximal transverse colon through to anastomose to the rectum [64]. If none of
these techniques are successful, an option for a subtotal colectomy with an ileorectal anastomosis is a possibility. In extreme cases, a delayed coloanal anastomosis,
Turnbull-Cutait [65, 66], may be attempted. In this technique, the colon is exteriorized through the anus and transected. A segment of the colon is left exteriorized
through the anus and afxed to the skin with sutures. A small venting hole is created
in the exteriorized colon with plans to return to the OR several days later. At the
second stage, the colon is transected at the level of the anal verge, and a handsewn
coloanal anastomosis is performed [65, 66]. Surgeons have found this technique to
be a valuable option in difcult situations [67–69].
Conclusion
There are many factors associated with creating a viable and intact anastomosis.
Intraoperative anastomotic interrogation with endoscopic evaluation for air leak as
well as mucosal perfusion is recommended for all low pelvic anastomosis. Colonic
ischemia and tension on the anastomosis are technical factors that can contribute to
anastomotic leak. Ischemia, tension, and anastomotic integrity should be evaluated
intraoperatively. When identied, the anastomosis can be salvaged with various
techniques including proximal colonic mobilization and anastomotic
reconstruction.
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V. O. Shaer and E. C. McLemore
Minimizing Conversion inLaparoscopic
Colorectal Surgery: FromPreoperative
31
Risk Assessment toIntraoperative
Strategies
JohnByrn andHeatherYeo
Introduction andRationale
More than 300,000 colorectal resections were performed in 2012 for benign and
malignant conditions in the United States [1]. Since 1991, the use of laparoscopy for
colorectal surgery has increased, reaching 22.7% in 2005 to 49.8% in 2014 [2]. This
steady increase in adoption results from improvements in instrumentation, standardization of surgical techniques through training, as well as mounting evidence
demonstrating the clinical benets and oncologic safety of laparoscopy from randomized controlled trials (RCTs) [3]. Compared to open surgery, minimally invasive colorectal resections result in less pain, less blood loss, shorter hospital stay,
and shorter recovery, with signicant cost savings [4].
Over the last two decades, laparoscopic techniques and instrumentation have
continued to improve. As laparoscopy continues to gain traction in colorectal surgery, it is important that surgeons become familiar with various techniques and tools
available in their armamentarium in order to minimize the risk of conversion.
Several factors, including unclear anatomy, bowel injury, and bleeding, can lead to
conversion. Reactive conversion follows an intraoperative complication (i.e., a vascular, ureteral, or bowel injury), while preemptive conversion is performed to avoid
complications (i.e., when there is difculty with structural identication or a decision that performing a procedure will be too difcult laparoscopically) [5]. While
no studies have evaluated the difference, it is our experience that reactive conversion
leads to worse outcomes as it is in response to a complication, and preemptive
J. Byrn
Division of Colorectal Surgery, Department of Surgery, University of Michigan,
Ann Arbor, MI, USA
e-mail: jcbyrn@med.umich.edu
H. Yeo (
*)
New York Presbyterian – Weill Cornell Medicine, Department of Surgery, New York, NY,
USA
e-mail: Hey9002@med.cornell.edu
© 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_31
489
490
conversion is done to avoid a complication. However, often a case that is difcult
laparoscopically may also be difcult as an open procedure.
The overall impact of conversion has been well studied with demonstrated negative
effects on costs, morbidity, and patient outcomes [6]. Several factors have been shown
to impact rates of conversion; however, while conversion rates have decreased over time
as experience with the minimally invasive technique has grown, the conversion rate is
still 10–25% nationally, and, as a result, techniques to mitigate these consequences have
important clinical benet. In this chapter, we discuss preoperative considerations and
intraoperative steps that may help to achieve the goal of decreasing conversion rates.
J. Byrn and H. Yeo
Indications andContraindications
Laparoscopic and minimally invasive approaches to colon and rectal resections have
become the preferred method over open surgery for nearly all colorectal surgical
procedures. They can be used for benign and malignant disease and have lowered the
morbidity and mortality of many procedures, especially colon resections, rectopexy,
and procedures for fecal diversion. There are no absolute contraindications to laparoscopic colorectal procedures [7], but much of the decision depends on the surgeon’s
experience and comfort with laparoscopy. Extra caution should be taken in patients
with a history of previous abdominal surgeries, a history of cardiopulmonary comorbidities, obese patients, pregnant patients, and patients with rectal cancer, where the
use of laparoscopy is more controversial. Absolute contraindications are emergency
patients with hemodynamic instability due to bleeding, sepsis, or trauma.
Principles andBenchmarks
While there are no benchmarks for conversion during laparoscopic surgery, most
major RCTs have reported conversion rates ranging between 1% and 25%
(Table31.1). The conversion rates from these trials should be evaluated with the
understanding that most of them included only experienced laparoscopists, so the
numbers may be lower than many surgeons might see in their own practice.
The practicing surgeon can easily determine his or her own laparoscopic conversion to open colectomy or proctectomy rate using his or her own institutional data.
This rough estimate may allow self-assessment and aids in determining if the surgeon is providing a certain measure of quality care. The COST trial conversion rate
for colectomy (excluding transverse colectomy) was 21%, and in the Z6051 trial, the
laparoscopic conversion to open proctectomy rate for rectal cancer was 11%. Both
trials involved expert surgeons with signicant laparoscopic experience (>20 lifetime
laparoscopic colectomies) and more importantly had undergone a credentialing process for the study where a video was reviewed for evaluation of surgical technique.
An important consideration when evaluating conversion rates is the impact of conversion on patient outcomes. While reactive conversion, for example, due to iatrogenic colotomy with gross fecal contamination is necessary and associated with worse
outcomes with respect to infectious complications, other conversions may not have as