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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1084_Библиотеки_им_академика_М_И_Перельмана.pdf
xiv
Ismail Hamzaoglu, MD Department of General Surgery, Acibadem Mehmet Ali Aydinlar
University, School of Medicine, Istanbul, Turkey
Cristina R. Harnsberger, MD Department of Colon and Rectal Surgery, University of
Massachusetts Medical School, Worcester, MA, USA
CraigS.Johnson, MD Department of Surgery, Oklahoma Surgical Hospital, Tulsa, OK, USA
Tayfun Karahasanoglu, MD Department of General Surgery, Acibadem Mehmet Ali
Aydinlar University, School of Medicine, Istanbul, Turkey
ShawnaR. Kleban, MD Department of Plastic Surgery, University of Nevada, Las Vegas
School of Medicine, Las Vegas, NV, USA
KunalKochar, MD Department of Colon and Rectal Surgery, Advocate Lutheran General
Hospital, Park Ridge, IL, USA
DavidW.Larson, MD Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN,
USA
SangW.Lee, MD Division of Colorectal Surgery, University of Southern California, Keck
School of Medicine, Los Angeles, CA, USA
AmyL.Lightner, MD Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN,
USA
Contributors
Shanglei Liu, MD, MAS Department of General Surgery, University of California San
Diego, San Diego, CA, USA
JoshuaMacDavid, MD Department of Surgery, UNLV School of Medicine, Las Vegas, NV, USA
Slawomir Marecik, MD, FACS, FASCRS Department of Colon and Rectal Surgery,
Advocate Lutheran General Hospital, Park Ridge, IL, USA
Department of Colorectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
RachelMartin, MD Department of Colorectal Surgery, Colon and Rectal Clinic of Orlando,
Orlando, FL, USA
JustinAMaykel, MD Department of Colon and Rectal Surgery, University of Massachusetts
Medical School, Worcester, MA, USA
ErikR.Noren, MD Department of General Surgery, University of Southern California, Keck
School of Medicine, Los Angeles, CA, USA
John J. Park, MD Department of Colon and Rectal Surgery, Advocate Lutheran General
Hospital, Park Ridge, IL, USA
KristenRumer, MD, PhD Department of General Surgery, University of Stanford, Palo Alto,
CA, USA
DanaSands, MD Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL,
USA
IpekSapci, MD Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
AntónioS.Soares, MD, MSc Division of Surgery and Interventional Sciences, University
College Hospital, London, UK
MarkSoliman, MD Department of Colorectal Surgery, Colon and Rectal Clinic of Orlando,
Orlando, FL, USA
KarenZaghiyan, MD Division of Colon and Rectal Surgery, Cedars Sinai Medical Center,
Los Angeles, CA, USA
Laparoscopic-Assisted Polypectomy
ErikR.Noren andSangW.Lee
1
Introduction
This chapter presents a historical overview of laparoscopicassisted polypectomy and detailed description of surgical
technique. We will a additionally describe several variations
and advanced maneuvers that extend the application of the
technique to more difcult lesions. Tips and tricks will be
highlighted to help navigate the procedure throughout the
chapter. Finally, we will discuss special considerations in
challenging cases and provide guidance for management of
complications.
Background
Adoption of colorectal cancer screening has been effective in reducing the overall incidence and mortality from
the disease. Concurrently, there has been an increase in
the detection of large and complex polyps not amenable
to simple endoscopic resection alone. Traditionally, these
patients were referred for surgical management by segmental colon resection. In fact, surgery for benign
colorectal polyps has increased significantly from 5.9 per
100,000 patients in 2000 to 9.4 per 100,000 patients in
2014, which represents more than 28,000 colectomies
performed every year in the United States for benign
lesions [1]. Although the development of laparoscopic
colorectal surgery and deployment of enhanced recovery
protocols has markedly reduced the surgical trauma, cost,
E. R. Noren
Department of General Surgery, University of Southern California,
Keck School of Medicine, Los Angeles, CA, USA
e-mail: Erik.Noren@med.usc.edu
S. W. Lee (
Division of Colorectal Surgery, University of Southern California,
Keck School of Medicine, Los Angeles, CA, USA
e-mail: sangwl@med.usc.edu
*)
and complication rate associated with colon resection,
there remains significant morbidity for patients undergoing colectomy.
Innovative combined endoscopic and laparoscopic surgery (CELS) approaches have been developed that leverage
the capabilities of each technology for removal of difcult
polyps without colon resection [2–6]. Laparoscopicassisted polypectomy was rst described in 1993 as a
method for complete excision of moderate-sized sessile
polyps that avoided colon resection in select patients [3].
Subsequently described techniques include laparoscopicassisted colon wall excision and full-thickness CELS [7].
In the following decades, several retrospective series have
conrmed the safety and effectiveness of the procedures for
management of such difcult lesions [8–11]. A systematic
review of CELS experiences found low complication rates
and high (74–91%) rates of successful resection with colon
preservation [12]. In studies with long-term follow-up,
there were no cases of malignant lesions developing in
patients with completely resected histopathologically
benign polyps [8, 10].
Cost analysis demonstrates that utilization of CELS benets the healthcare system in addition to the benets for
patients. The majority of CELS patients will be discharged
on the day of surgery or the following day, so while CELS
has slightly higher equipment costs, this is more than surpassed by the savings from substantial reductions in inpatient hospital utilization. Sharma et al. identied the total
cost per CELS procedure at $6554 compared with $12,585
per laparoscopic segmental resection and $18,216 per open
resection [13].
Current indications for CELS encompass benignappearing polyps not amenable to simple endoscopic resection. Often this is the result of polyp size or location on a
luminal fold, colon exure, proximity to the appendiceal orice, or ileocecal valve. Eligible polyps may be pedunculated
or sessile, appear soft with regular contours, have no central
depression or ulceration, and lift with submucosal injection.
© Springer Nature Switzerland AG 2019
O. Bardakcioglu (ed.), Advanced Techniques in Minimally Invasive and Robotic Colorectal Surgery,
https://doi.org/10.1007/978-3-030-15273-4_1
1
2
E. R. Noren and S. W. Lee
Polyps with irregular vascular or pit pattern when viewed
with narrow-band imaging are suspicious for invasive malignancy and may not be appropriate for CELS.
Preoperative Planning
Evaluation of the patient referred for an endoscopically unresectable polyp begins with a thorough history and physical
exam with particular attention paid to the medical and surgical history as well as family history of colorectal cancer
and inammatory bowel disease. Patients should undergo
appropriate preoperative cardiopulmonary evaluation for
their age and existing comorbidities. Review of the colonoscopy report with relevant images and pathology report
conrming a benign lesion is necessary to determine if a
patient is indeed a candidate for CELS.In-ofce evaluation
of left-sided lesions by exible endoscopy allows verication of polyp location, size, and the absence of concerning
characteristics.
It is necessary to counsel patients that, in the event that a
lesion cannot be removed by CELS or if the lesion is found
intraoperatively to have features concerning for malignancy,
the operating surgeon will proceed with a laparoscopic colon
resection. Additionally, patients should understand the possibility that a successfully removed polyp may be found on
pathologic evaluation to contain malignancy which may
necessitate a subsequent formal resection.
Full mechanical bowel preparation the day before surgery
is necessary for utilization of the endoscope during the procedure. Subcutaneous heparin and prophylactic parenteral
antibiotics are administered within 1hour prior to surgical
incision.
Room Setup andPositioning
After induction of general anesthesia, the patient is placed in a
modied lithotomy position to allow simultaneous access to the
anus and abdominal approach. Both arms are tucked at the
patient’s side with care to ensure adequate padding of the hands,
wrists, and all pressure points as the operating table position is
often adjusted throughout the case. Nasogastric drainage tube
and Foley catheter are placed and pneumatic compression
devices are applied to the bilateral lower extremities.
Positioning of the laparoscopic viewing monitors is dependent on the anticipated lesion location. Right colon lesions
will require the laparoscopic surgeon, often with an assistant,
to stand on the patient’s left side with the monitor off the right
side and slightly biased toward the shoulders and head
(Fig.1.1). The opposite for left colon lesions with monitors on
the patients left biased toward the waist and feet. Monitors for
transverse colon lesions should be positioned at the head of the
bed. The endoscopist will work from between the patient’s
legs. The endoscopy cart, including high- denition monitor
and CO
the patient as the laparoscopic monitor, though this is adjustable for strong surgeon preference or better comfort.
scopic colon resection available in the room in addition to
that required for the CELS procedure in the event a formal
resection is required.
insufator, is usually positioned on the same side of
2
It is important to have all equipment required for a laparo-
Colonoscope Processor
CO
Feeding System
2
Monitor
Surgeon
Assistant
Anesthetist
Colonoscopist
Monitor
Fig. 1.1 Operating room setup and positioning for excision of right colon lesion by laparoscopic-assisted polypectomy
Scrub Nurse
1 Laparoscopic-Assisted Polypectomy
3
Port Placement
Placement of abdominal trocars is typically deferred until
the target lesion has been identied by intraoperative endoscopy and conrmed to be amenable to CELS resection.
Trocar placement necessarily depends on the location of the
lesion.
Abdominal access is achieved with placement of a
5 mm periumbilical trocar by standard technique and
pneumoperitoneum established. Insertion of a laparoscope
allows identication of the target lesion, either by tattoo
identication or endoscopic transillumination of the colon
wall. We recommend using a high-denition exible-tip
laparoscope for enhanced visualization and adaptability
during mobilization. A pair of 5mm working trocars is
placed with intent to triangulate on the target lesion,
though 3 mm microlaparoscopic trocars may be substituted if available. Place trocars in the right lower quadrant
and suprapubic positions for left-sided lesions and in the
left lower quadrant and suprapubic positions for rightsided lesions. Transverse colon lesions may be accessed by
placement of bilateral 5mm working trocars in the upper
or lower quadrants.
Mobilization
The great advantage CELS provides over solitary endoscopic
approaches is the ability to externally manipulate the colon.
The location of the polyp will dictate the degree of manipulation and in many cases mobilization of the colon that is
required.
Polyps located along the edge or back side of folds are
difcult to approach endoscopically. Directed laparoscopic
manipulation repositions the colon wall exposing the lesion
for endoscopic resection (Fig.1.2). Polyps located behind
exures and kinks from scarring often will not respond to
simple manipulation of the colon wall and will require
mobilization of the corresponding segment of colon to
straighten out the tissue and expose the polyp. Additionally,
polyps located on the mesenteric or retroperitoneal side of
the colon lumen require laparoscopic mobilization of that
segment of the colon. This is performed with a similar technique as for a laparoscopic colon resection, utilizing an
energy device to divide attachments along the embryologic
tissue planes. It is helpful to have an assistant piloting the
exible-tip laparoscope to free the surgeon to work with
both hands.
Operative Steps
Operative steps
1. Colonoscopy 1
2. Mobilization 2–4
3. Polypectomy 3
4. Full-thickness CELS 7
5. Colonoscopy-assisted
laparoscopic cecectomy
6. Leak test 2
Degree of technical difculty
(scale 1–10)
3
Colonoscopy
The use of CO2 insufation is decidedly superior to room air
when performing CELS procedures. More rapid absorption
of CO2 minimizes unnecessary colon distention and allows
for optimal simultaneous laparoscopic and endoscopic visualization [14].
The endoscopist begins the procedure with insertion
of the colonoscope and advancement to identify the target lesion. It should be examined to confirm the location,
size, and absence of concerning features such as hardness, fold convergence, expansile growth, and depression
or ulceration. Having confirmed the lesion is amenable
for CELS resection, the surgeon may proceed with incision and port placement as described in the previous
section.
Polypectomy
Submucosal injection to lift the polyp is performed with an
endoscopic injection needle through the working channel of
the colonoscope. Dilute solution (50/50) of indigo carmine
or methylene blue and either saline or albumin is used to
both mark the location of the lesion and elevate the mucosalbased lesion. Injection into the submucosal space forms a
broad smooth cushion barrier between the polyp and the
underlying muscular layer. Failure to create this effect likely
indicates injection into a deeper layer of the colon wall;
slowly pull back the injection needle while slowly injecting
to nd the correct plane. It may be necessary to repeat injection later in the procedure if the elevated cushion has
dissipated.
Be cautious with a lesion that does not elevate with submucosal injection as this may be an indication of an invasive
tumor. Evaluate for additional concerning signs as mentioned previously. If there is concern for an invasive lesion,
laparoscopic colectomy should be performed. If the polyp
truly appears benign, the failure to lift may be the result of
scarring from previous biopsies, and endoscopic removal
may proceed. Overall the incidence of cancer found in
benign-appearing lesions after CELS resection is low (~2%)
[8], and those patients are able to undergo a subsequent
resection as necessary.
The target polyp is removed by electrosurgical snare
polypectomy. The laparoscopic instrument is utilized to
4
E. R. Noren and S. W. Lee
Fig. 1.2 Laparoscopic instrument positions a difcult polyp for snare polypectomy
Fig. 1.3 Laparoscopic suture
reinforcement for thermal
colon injury
position and deliver the polyp into the snare loop. Large
or complex lesions may need to be removed in several
piecemeal snare excisions. Do not lose track of the specimens prior to collection. Specimens removed by polypectomy are typically removed endoscopically with a Roth
Net. However, specimens that are small (<5 mm) or
excised in a piecemeal fashion can be removed by colono-
scope suction with a specimen trap attached in line to the
suction device.
The laparoscope is used to monitor the serosal side of the
polypectomy site for any sign of thermal injury or weakness
created by the procedure. Such areas can immediately be
reinforced or repaired with a laparoscopic imbricating suture
(Fig.1.3).
1 Laparoscopic-Assisted Polypectomy
5
Full-Thickness CELS
An extension of the CELS technique allows for full- thickness
excision of polyps that may be difcult to remove with snare
polypectomy, particularly large serrated adenomas and polyps with signicant scarring due to prior biopsies [15].
Submucosal dilute dye injection is utilized, as described
in the prior section, to elevate and mark the polyp (Fig.1.4).
Once the entire area of the lesion is elevated with dye, the
circumference of the resection area is marked on the serosal
surface from the laparoscopic approach using monopolar
cautery. The seromuscular layer is then divided along the circumference of the marked resection, taking particular care
Fig. 1.4 Submucosal dilute
dye injection elevates the
target polyp
not to cause a full-thickness perforation by injuring the
mucosal layer (Fig. 1.5). The dissected resection area can
now be invaginated into the colon lumen with the assistance
of a laparoscopic instrument. The formerly at and adherent
lesion is now visualized endoscopically protruding into the
lumen and can be delivered into a polypectomy snare
(Fig. 1.6). The snare is carefully closed, without dividing,
pulling together the edges of the serosal dissection. The seromuscular defect is closed with a running 3-0 vicryl laparoscopic suture, an additional layer of imbricating sutures may
additionally be placed (Fig.1.7). Once the defect is closed,
the snare polypectomy is completed and the lesion collected
in a Roth net and removed from the colon (Fig.1.8).
Fig. 1.5 Division of the
seromuscular layer of the
colon during full-thickness
CELS technique
Fig. 1.6 Laparoscopic
instrument used to invaginate
the polyp for endoscopic
snare placement
6
Fig. 1.7 Laparoscopic suture
repair of the seromuscular
defect prior to transection of
the polyp
Fig. 1.8 Energy is applied to
the snare for full-thickness
excision of the lesion. The
repaired seromuscular defect
E. R. Noren and S. W. Lee
Colonoscopic-Assisted Laparoscopic Partial Cecectomy
Polyps located in the thin-walled cecum and proximal
ascending colon are effectively managed with laparoscopic
stapled wall excision or partial cecectomy performed under
colonoscopic guidance. These polyps are often located
within close proximity of the ileocecal valve or appendiceal
orice. This technique ensures complete full-thickness excision of even wide sessile polyps while protecting the aforementioned structures from damage [16].
The polyp is identied by colonoscopy as previously
described. A 12mm trocar is substituted for the usual 5mm
in the left lower quadrant to accommodate a laparoscopic
linear cutting stapler. It may be necessary, in some cases, to
mobilize the cecum and proximal ascending colon by dividing the peritoneum and lateral attachments using electrocautery. Placing the patient in Trendelenburg position with the
right side elevated is also helpful. While positioning the stapler, the colonoscope is used to conrm the line of resection
including the entire lesion. Intubation of the terminal ileum
allows the colonoscope to function as a mechanical barrier,
like a Bougie, when positioning the stapler for resection of a
lesion in close proximity to the terminal ileum. The resected
specimen is withdrawn from the abdomen in a laparoscopic
Endo Catch bag.
Leak Test
An air leak test can be performed using CO2 colonoscope
insufation and laparoscopic irrigation. Adjust the operating
table to place the tested colon in a dependent position, irrigate the abdomen and submerge. The absence of bubbles
indicates a negative leak test.
Postoperative Care
The majority of patients who undergo CELS laparoscopicassisted polypectomy can go home the same day as their procedure. Patients that undergo full-thickness excision,
colonoscopic-assisted laparoscopic wall excision, or partial
cecectomy or in cases in which a full- or partial-thickness
injury was noted intraoperatively, patients will have a short
hospital stay. The diet is advanced as tolerated, though we
recommend monitoring until there is return of bowel function prior to discharge.
1 Laparoscopic-Assisted Polypectomy
7
The importance of diligent surveillance colonoscopy
must be emphasized, as there is a known incidence of polyp
recurrence, reported at 10% over the course of a 10-year
series [8]. We perform a follow-up colonoscopy at 3months.
The majority of detected recurrent polyps are managed
endoscopically.
Special Considerations andComplications
The overall complication rate in multiple series reporting on
CELS cases is low, 4–13% [2, 17, 18], and consists primarily
of ileus and wound complications. Lee etal. report a complication rate of 4.2% over 10years, most commonly consisting
of urinary retention and wound hematoma [8].
Contraindications
Laparoscopic-assisted polypectomy should not be performed
in patients with a known malignancy or for management of
lesions with high risk features. Biopsied polyps demonstrating high-grade dysplasia but absent any other concerning
features may be amenable to CELS.It is important to obtain
tissue slides for review and diagnosis conrmation by your
institution’s own pathologist. Patients with a known polyposis syndrome or patients with additional polyps that cannot
be removed endoscopically or by CELS should not undergo
this procedure. Adhesive disease in patients with a history of
multiple prior abdominal operations makes manipulation
and mobilization of the colon difcult and increases the likelihood that a patient will require a surgical resection.
Morbid Obesity
etal. [2] and in 43% of cases by Yan etal. [5]; however, in
both series there were no reported incidences of fullthickness perforation. Rather, intraoperative suture placement in these cases represented detection of partial-thickness
injury or colon wall weakness following polypectomy and
prophylactic measures to reinforce the area.
Bleeding
Post-polypectomy bleeding has not been reported with signicant incidence in the available series of CELS patients, likely
because the majority of bleeds are detected and managed during the procedure. However, it is a known complication of polypectomy and endoscopic interventions, and thus the surgeon
performing CELS procedures should be prepared to manage it.
Immediate bleeding from polypectomy sites can be controlled using the polypectomy snare to deliver electrocautery. In rare cases injection of epinephrine or placement of
endoscopic clips may be required. Delayed bleeding may
occur up to a month after the procedure. Management consists of resuscitation followed by repeat endoscopy with epinephrine injection or clipping in most cases [20].
Summary
Techniques for combined endoscopic and laparoscopic surgery (CELS) including laparoscopic-assisted polypectomy
have demonstrated safety and effectiveness for management
of benign polyps not otherwise amenable to endoscopic
removal. Since initial description well over a decade ago, utilization of CELS has allowed a great number of patients to
avoid the substantial morbidity of colectomy with faster
recovery and lower cost.
Morbid obesity is not a contraindication for CELS procedures.
Placement of laparoscopic trocars may need to be adjusted
nearer to the target lesion to maintain triangulation with
increased abdominal girth, and in patients with super- morbid
obesity, bariatric trocars and instruments may be required.
Perforation
The rate of iatrogenic colon perforation during purely endoscopic procedures is reported as less than 1% [19]. A primary
advantage of CELS over totally endoscopic resection techniques is the continuous laparoscopic monitoring and leak
testing during the procedure. This allows intraoperative
detection of perforation or partial-thickness injury and
immediate suture repair. Suture placement was reported in
10% of laparoscopic-assisted polypectomy cases by Franklin
References
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A, Koruda M, Grimm IS.Increasing rates of surgery for patients
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2. Franklin ME, JA D-E, Abrego D, Parra-Dávila E, Glass
JL. Laparoscopic-assisted colonoscopic polypectomy: the
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3. Beck DE, Karulf RE. Laparoscopic-assisted full-thickness endo-
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JW.Treatment for right colon polyps not removable using standard
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J.Combined endoscopic and laparoscopic surgery may be an alternative to bowel resection for the management of colon polyps not
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Endoscopic Submucosal Dissection
IpekSapci andEmreGorgun
Abbreviations
EMR Endoscopic mucosal resection
ESD Endoscopic submucosal dissection
HES Hydroxyethyl starch
Introduction
This chapter will review the advanced endoscopic resection
technique of endoscopic submucosal dissection. The steps of
this novel method will be described in detail accompanying
brief literature review on this approach. Equipment, tips, and
key points for endoscopic submucosal dissection will be
summarized with supplementary images and video clips.
Background
Colorectal cancer is the second most common cause of cancer death in the US population and was estimated to result
in 50,260 deaths in 2017 [1]. Screening colonoscopy with
polypectomy has been shown to decrease the incidence of
colorectal cancer and its related mortality [2]. Most colorectal polyps are suitable for snare or cold forceps removal;
however, some lesions may not be t for conventional resection. For these lesions, advanced oncological resections are
performed frequently, and a recent study reported that it can
be an overtreatment for 92% of the patients [3].
Advanced polypectomy techniques such as endoscopic
mucosal resection (EMR) and endoscopic submucosal dis-
Electronic Supplementary Material The online version of this chapter
(https://doi.org/10.1007/978-3-030-15273-4_2) contains supplementary
material, which is available to authorized users.
I. Sapci · E. Gorgun (*)
Department of Colorectal Surgery, Cleveland Clinic,
Cleveland, OH, USA
e-mail: sapcii@ccf.org; gorgune@ccf.org
2
section (ESD) were developed to ll the gap in-between to
prevent overtreatment and achieve complete resection of difcult lesions. EMR resulted in insufcient piecemeal specimens in the upper gastrointestinal tract, and this lead to the
development of endoscopic submucosal dissection [4].
ESD became popularized mainly in Asia, and it is still
not commonly performed in Western countries. In fact, 87%
of the published literature is from Asia [5]. Regardless of
the growing interest for ESD around the world, acceptance
levels remain low. Recently, it became an integral part of the
clinical practice for colorectal lesion removal in Japan [6]. In
spite of reports of this procedure to be safe and feasible for
colorectal lesions by a wide array of studies, a standardization is yet to be accomplished [5, 7].
ESD was developed to facilitate excision of the lesions
that are difcult to remove with regular snaring [8, 9]. The
main goals of ESD are to achieve an R0 resection for early
cancerous lesions and accomplish an en bloc resection suitable for meticulous histopathological examination [6]. A
recent meta-analysis reported R0 resection rates of 13,833
lesions as 83% with en bloc endoscopic resection rate of
92% for ESD.When R0 resection is achieved, risk of recurrence was reported to be 4in 10,000 [5].
Widespread use of this novel method in the colon has also
been restricted due to technical difculties resulting from the
anatomy and physiology of the colon [6, 10]. The colon is
anatomically challenging to perform ESD in the sense that it
consists of folds and exions and exhibits peristalsis [6]. In
addition, the colonic wall is thinner in comparison to other
locations of the alimentary tract which places a greater risk
for perforations during the procedure.
ESD was reported to have higher perforation rates and
longer procedural time when compared with EMR but also
had higher en bloc resection rate and a lower recurrence rate
when compared with EMR [11]. Size, localization, morphology, granularity, and experience level of the endoscopist are
the factors that affect the decision to either perform simple
snaring, EMR, ESD, or oncological resection [9].
© Springer Nature Switzerland AG 2019
O. Bardakcioglu (ed.), Advanced Techniques in Minimally Invasive and Robotic Colorectal Surgery,
https://doi.org/10.1007/978-3-030-15273-4_2
9