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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_917_Библиотеки_им_академика_М_И_Перельмана.pdf
31 Minimizing Conversion inLaparoscopic Colorectal Surgery: FromPreoperative…
LOS
(Days)
Conversion
rate (%) Complications
# of
institutions Pnts # (Op/Lap)
27 737 (253/484) 34% 13% –
3 340 (170/170) 1% – –
30 1044 (345/699) 16% – –
35 462 (222/240) 11.3% 22% 7
24 457 (237/238) 9% – –
48 863 (428/435) 21% 21% 5
1 1082 (546/536) 19% 21% 8.2
27 737 (253/484) 25% 7% –
491
(continued)
Design Year Study Comparison
Title
Table 31.1 Major colorectal laparoscopy trials
open survival and
recurrence
Rectal procedure studies
CLASICC trial [15, 19] RCT 2007 Laparoscopic vs.
COREAN trial [20] RCT 2014 Laparoscopic vs.
open survival
outcomes
open survival and
recurrence
open pathological
outcomes
open pathological
RCT 2015 Laparoscopic vs.
A randomized trial of laparoscopic
versus open surgery for rectal cancer
[7]
ACOSOG Z6051 [21] RCT 2015 Laparoscopic vs.
ALaCaRT [22] RCT 2015 Laparoscopic vs.
outcomes
open survival and
Colon studies
COST [16] RCT 2004 Laparoscopic vs.
recurrence
open clinical
outcomes
COLOR [23] RCT 2005 Laparoscopic vs.
CLASICC trial [15, 19] RCT 2007 Laparoscopic vs.
open survival and
recurrence
492
LOS
(Days)
J. Byrn and H. Yeo
Conversion
rate (%) Complications
1536 (740/796) 19%
# of
institutions Pnts # (Op/Lap)
open survival
outcomes
2007 Laparoscopic vs.
Design Year Study Comparison
Meta-
analysis
10.1% 26% 7
402 32,733
Retrospective 2008 Laparoscopic vs.
8.4% – –
(21,689/11,044)
10,898
(9360/1538)
open clinical and
economic outcomes
open clinical
2010 Laparoscopic vs.
Meta-
analysis
Multicenter 425 (213/212) 15% – –
outcomes
open symptoms and
QoL
Title
Table 31.1 (continued)
Clinical outcomes and resource
utilization associated with
laparoscopic and open colectomy
using a large national database [25]
Elective open versus laparoscopic
sigmoid colectomy for diverticular
disease: A meta-analysis with the
sigma trial [26]
Laparoscopically assisted vs open
colectomy for colon cancer [24]
ALCCaS trial [27] RCT 2018 Laparoscopic vs.
31 Minimizing Conversion inLaparoscopic Colorectal Surgery: FromPreoperative…
493
much of a deleterious effect. Hence, the decision to attempt a laparoscopic approach
should balance the benets of a laparoscopic approach, and the risks of complications
including consequences of conversion to open surgery with the understanding that a
preemptive conversion, before complications or injury arises, may mitigate the impact
of conversion on outcomes. Although a laparoscopic approach may be highly desirable in complex cases based on the clinical benets incurred from avoidance of a laparotomy, early and preemptive conversion should be considered in the face of failure to
progress or impending complications. When conversion is performed early, it may
mitigate the morbidity incurred from reactive conversion in the face of a complication.
When interpreting the literature on the negative impact of conversion on oncologic
and infectious outcomes, surgeons should not become discouraged from attempting
laparoscopy for fear of conversion but be prepared for this possibility and realistic
with respect to when to convert. This clinical judgment is part of the laparoscopic
learning curve and can only be nessed through experience gained when attempting
complex cases. As a general rule, surgeons should consider diagnostic laparoscopy,
with a low threshold to convert when the risk of injury and/or prolonged operative
time outweighs the benets of persisting with a laparoscopic approach.
High conversion rates for any given surgeon should prompt careful review of
case logs, with specic focus on patient selection and risk factors for conversion,
case volume, and experience with specic cases. This will in turn identify areas for
improvement and strategies to mitigate the risk of conversion.
Preoperative Planning, Patient Work-Up, andOptimization
Patients undergoing laparoscopic colorectal surgery need a detailed medical history,
physical exam, and colorectal cancer staging if the pathology is a colorectal malignancy. Particular attention should be paid to the number and type of previous
abdominal surgeries and any history of abdominal infections, radiation, or surgical
complications. The operative reports from previous abdominal surgeries should be
reviewed. Patients can then proceed with standard preoperative blood work-up,
electrocardiogram, and chest X-ray as indicated. A focused physical abdominal
exam will appreciate previous surgical scars, the approach to previous surgeries
(Pfannenstiel vs. midline laparotomy), and the presence of incisional hernias. The
most important ndings on history and physical are related to cardiopulmonary
debilitation. A patient with poor functional status and non-optimized cardiac and
pulmonary comorbidity often needs further specialty care through cardiology and
pulmonology before surgery. Increases in preoperative activity and smoking cessation, prehabilitation, are of proven benet in surgical outcomes.
When considering segmental colectomy for malignant polyps or tumors, localization of the tumor is key and achieved through a combination of cross-sectional
imaging and endoscopy. Colonoscopy reports are valuable, as endoscopic tattoo
placement or clipping may be crucial to localizing the pathology and planning your
resection during the procedure. Preoperative planning entails reviewing all images
prior to surgery. A CT scan is not only useful to localize disease but is also helpful
to assess the thickness of the abdominal wall, location of the top of the splenic exure, and other important surgical landmarks, which can help in port planning.
494
Table 31.2 Risk factors for conversion
Patient related
Advanced age (>80)
Male gender
Obesity (BMI >30)
ASA classication (class 4)
Previous surgery
Ascites
Cardiopulmonary
comorbidities
Disease related
Anatomical site (rectum and transverse
colon)
Pathology (Crohn’s disease)
Presentation (emergency setting)
J. Byrn and H. Yeo
Surgeon related
Experience (low
volume)
Patient Risk Factors forConversion (Table31.2)
Studies on the patient-related risk factors for conversion have almost exclusively retrospective single institution case series but are still worth considering for anyone
adopting laparoscopy into his or her practice. Patient-related factors that have been
shown to increase risk of conversion include advanced age, obesity, gender, ASA classication, previous surgery, and cardiopulmonary comorbidity. For patients undergoing colectomy, those older than 80 have a 73% higher chance of conversion compared
to patients younger than 50 [8]. Male gender is also associated with a higher risk of
conversion in colectomy [9, 10]. Obese patients (BMI >30kg/m
the chance of conversion by 31% compared to patients with normal BMI [8]. While
there is an increasing epidemic of obesity in the USA, the technical difculty of performing laparoscopic colorectal resections increases with BMI, particularly in individuals with a BMI >40 or super obesity. In elective cases, we often council patients
regarding weight loss strategies preoperatively, as this can signicantly impact outcomes. Obesity contributes to difculty with exposure as these patients often have a
shortened mesentery and retraction of the small bowel can be difcult. Please refer to
Chap. 32 on laparoscopic colorectal surgery in the obese and morbidly obese patient
for more details on preoperative strategies and surgical techniques.
Patients with ascites have been found to be approximately three times more
likely to require conversion as ascites may represent underlying primary liver disease or malignant ascites secondary to peritoneal carcinomatosis [8]. In addition,
those with cardiopulmonary comorbidities are of increased risk of conversion, as
the CO
pneumoperitoneum may lead to hemodynamic and pulmonary function
2
alterations. Patients with Society of Anesthesiologists (ASA) class 4 have 68%
increased odds of conversion when compared to patients with ASA class 1, hence
the importance of patient selection and preoperative risk assessment.
2
) showed increasing
Disease-Related Factors forConversion
Conversion rates vary depending on the specic type of colectomy performed. In a
review of National Inpatient Sample data from 2009 and 2010, it was found that proctectomy was associated with the highest rates of conversion (31.3%), followed by
transverse colectomy (20.5%), with lower rates for left and right colectomy, sigmoid
31 Minimizing Conversion inLaparoscopic Colorectal Surgery: FromPreoperative…
495
colectomy, and total colectomy [10]. Transverse colon and rectal lesions were originally excluded from laparoscopic trials, as they required advanced skills. These rates
also vary depending on indications, with the highest rates of conversions in patients
undergoing resection for Crohn’s disease (20.2%) relative to other pathologies, including benign and malignant tumors, diverticulitis, and ulcerative colitis [10].
The nature of presentation of colorectal pathology also plays into the conversion
rate. Patients admitted as an emergency are less likely to undergo emergency laparoscopic procedures. In one study, the percentage of surgeons using an open technique rose from 8% in an elective setting to 47% in an emergency setting [11].
Careful consideration should be given to patients presenting with Crohn’s disease or diverticulitis with abscess/phlegmon, especially in reoperative cases. The
risks of conversion are high, as well as that of inadvertent injury to the bowel or
surrounding structures. In patients with visceral obesity and a short, bulky transverse colon mesentery, the surgeons should proceed cautiously during laparoscopic
resection of transverse colon cancer as it may be difcult to obtain a high ligation
on the middle colic vessels and an adequate lymphadenectomy in this patient habitus. Additionally, great care should be taken when performing laparoscopic procedure in the setting of large or small bowel obstruction, fulminant colitis, or toxic
megacolon, with an increased risk of intraoperative perforation during laparoscopic
manipulation of the bowel, which will increase the risk of serious post-operative
infectious complications. Our recommendation is to conduct a careful diagnostic
laparoscopy with a low threshold to convert.
Patients deemed to be at high risk for conversion should be counseled preoperatively with respect to the likelihood of requiring conversion and the risk of organ
injury and other complications incurred from attempting laparoscopy in the face of
one or more risk factors for conversion.
Surgeon-Related Factors
One of the factors that clearly plays a role in conversion during laparoscopic
colorectal surgery is the surgeon’s experience and comfort during complex laparoscopic colon or rectal resections. A recent study of laparoscopic colorectal procedures showed that regardless of the training, high-volume laparoscopic surgeons
(≥100 laparoscopic procedures) have lower rate of conversion compared to lowvolume laparoscopic surgeons (<100 laparoscopic procedures) [5]. This trend was
also seen in a nationwide study comparing high-volume surgeons (>15 procedures/
year) with low-volume surgeons (≤15 procedures/year), with high-volume surgeons
not only having lower rates of conversion but also lower incidence of prolonged
length of stay, bile duct injury, and mortality [12].
Bowel Preparation
While bowel preparation for colon and rectal surgery has waxed and waned in perceived efcacy to reduce surgical site infection, it remains widely adopted by many
496
J. Byrn and H. Yeo
surgeons who nd the colon easier to manage laparoscopically if the bowel has been
prepped. Combined mechanical bowel preparation with oral antibiotics has recently
been reinstituted into standard enhanced recovery protocols for colorectal procedures,
as it has reduced surgical site infections and anastomotic leak rates compared to patients
who did not receive either mechanical or antibiotic bowel prep [13]. A prepped bowel
is easier to manipulate laparoscopically, and an additional benet of operating on a
prepped colon includes localization of the pathology, such as an unexpectedly inconspicuous tumor requiring direct palpation or intraoperative colonoscopy.
Ureteral Stents
Visualization and identication of the ureters before transection of the mesenteric vessels and the mesentery is crucial to prevent ureter injuries, and the inability to do so is a
risk factor for conversion to open surgery. Intraoperative identication of the ureter can
be challenging, especially in the setting of visceral obesity, inammation, and during
reoperative pelvic surgery. Some surgeons will opt for prophylactic ureteral stent placement to help with ureter identication and facilitate recognition of an inadvertent injury.
However, their use is controversial because of the complications that accompany stenting, such as obstructive oliguria, ureteral injury, or urinary tract infection. In addition,
there is no evidence that stents decrease the risk of ureteral injury, of conversion rates,
but they may facilitate ureteral identication in difcult cases and help recognize ureteral injuries intraoperatively. Thus, for reoperative colorectal procedures, acute or complicated diverticular disease or Crohn’s disease, bulky and locally advanced rectal or
sigmoid cancers, we recommend prophylactic ureteral stent placement.
A ureter that is difcult to identify can slow progress signicantly in laparoscopic
colorectal surgery. Common scenarios are when dissecting inamed mesentery off the
left or right retroperitoneum. A medial to lateral approach to the mesentery is preferred where early identication of the correct anatomic planes, meticulous hemostasis, and careful dissection are your best ally. If oozing from the retroperitoneum is
limiting progress, a lap pad or sponge introduced into the abdomen may allow for
improved tamponade and visualization. If the patient is obese and there is difculty
with visualization medially, a lateral to medial approach can be used instead.
Key Point
There should be a low threshold to call a urologist or colleague to assist
in identication of the ureters if and when difculty is encountered. Intraoperative
ureteral stents can help with early laparoscopic identication of the ureters, and
prophylactic stenting should be considered in complex colorectal cases.
Operative Setup andOperative Techniques
Patient Positioning
Patients must be placed securely in the supine or lithotomy position, depending on
the planned procedure, and should be well padded. With patients positioned securely,
31 Minimizing Conversion inLaparoscopic Colorectal Surgery: FromPreoperative…
497
the surgeon obtains the ability to place the patient into steep Trendelenburg or
reverse Trendelenburg. Steep Trendelenburg position in particular makes it much
easier to retract the small bowel out of the pelvis when approaching a rectal or sigmoid dissection. For almost all colon resections, the authors prefer the lithotomy
position which allows for intraoperative colonoscopy for air leak testing and localization of the pathology when needed and for positioning of an operator between the
patient’s legs if needed. Regardless of positioning, patients’ arms are usually tucked
to the sides, allowing for safe frequent position changes that lead to successful laparoscopic surgery. Many other commercial products are available to help secure the
patient; these may vary by institution and mimic a “bean bag” device that hold
patients in place without sliding during extremes in left and right tilt as well as in
Trendelenburg position.
One of the main obstacles in achieving and maintaining good exposure during
laparoscopic colorectal procedures is adequate retraction of the small bowel. Patient
positioning should use gravity to help expose the operative site; therefore, attention
should be paid to padding and securing the patient to the table during steep position,
especially for obese patients. Good exposure can be the difference between conversion and no conversion.
Key Point For obese patients, we prefer to use pink foam and tape to secure the
patients to the operating table.
Pneumoperitoneum
Establishing pneumoperitoneum is a key rst step in laparoscopic surgery, and it
may result in vascular or visceral injury if not performed carefully. Adequate pneumoperitoneum can be established and maintained under an appropriate muscle
relaxation. Usually, the intra-abdominal pressure should be between 10 and 12mm
Hg to provide sufcient laparoscopic visualization and working space.
Key Point
cardiopulmonary disease to minimize the effect that it has on cardiac output.
peritoneum, closed technique (Veress needle) method is the most frequently used.
Although open Hasson technique is routinely used by some surgeons, it did not
show any superior results regarding bowel injury [14]. However, it is primarily used
in reoperative cases and when dense intra-abdominal adhesions are suspected.
Another alternative to establish pneumoperitoneum is to use optical access trocar.
The trocar used in this technique allows visualization of the dissected planes using
the laparoscopic camera. It is best used in patients with a thick abdominal wall,
where an “open” technique is difcult.
Key Point In reoperative cases where dense intra-abodminal adhesions are suspected, the Hasson technique is the preferred method for laparoscopic access.
We recommend starting with low-ow insufation in any patient with
Although there is no consensus regarding the best method to establish pneumo-
498
J. Byrn and H. Yeo
Laparoscopic Exposure: Trocars
In most colorectal procedures, three to ve trocars are typically used: one for the
camera, two for the operating surgeon, and one or two for the assistant. Trocar
placement is dependent on surgeon’s preference, prior abdominal surgeries, body
habitus, and type of procedure. Please see Figs.31.1, 31.2, and 31.3 for our recommended port placement for (1) laparoscopic left colectomy (Fig.31.1), (2) laparoscopic sigmoid colectomy (Fig. 31.2), and (3) laparoscopic rectal resection
(Fig. 31.3). In most instances, the camera trocar is placed in the midline at the
umbilicus, while the operating surgeon trocars are placed on the opposite side of the
pathology under laparoscopic guidance. Additional consideration should be given
to the distance between trocars, which should be at least 8cm to ease the movement
of the instruments. Additional care must be taken for lower abdominal trocars so
that collision with the legs of the patient (this can occur in supine o lithotomy position) can be prevented.
Fig. 31.1 Trocar placement for left colectomy. (Courtesy of Yuko Tonohira)
31 Minimizing Conversion inLaparoscopic Colorectal Surgery: FromPreoperative…
499
Fig. 31.2 Sigmoid colectomy port placement. Additional port for splenic exure mobilization on
the right. (Courtesy of Yuko Tonohira)
Key Point There is minimal morbidity with the addition of one or more 5mm trocars. When struggling to achieve appropriate exposure laparoscopically, additional
trocars should be placed.
Laparoscopic Adhesiolysis
For patients with complex adhesions, there are several tricks that our authors prefer
using. Several instruments can be very benecial, and one should be willing to add
additional 5mm ports where needed. For sharp adhesiolysis, we prefer the disposable microshears as these have a smaller cut length and are better for delicate dissection than traditional or reusable sheers (Fig.31.4). In addition, the endo peanut
is a good instrument to separate areas between the bowel and other areas where you
do not want to perform sharp dissection (i.e., by the ureter). Adhesiolysis should be
500
J. Byrn and H. Yeo
Fig. 31.3 Port placement for rectal resection. The suprapubic port is optional. (Courtesy of Yuko
Tonohira)
Fig. 31.4 Laparoscopic
lysis of adhesions
facilitated by
laparoscopic endo
peanuts and cold
endoshears. (Courtesy of
Patricia Sylla, MD)