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3
Laparoscopic colorectal surgery
James W Fleshman and Jonathan S Chun
CHALLENGING CASE
A 28-year-old male is undergoing an ileocolic resection for Crohn’s
disease. During insertion of a right lower quadrant (RLQ) trocar, significant bleeding is observed from the right lower retroperitoneum.
MANAGEMENT
It appears that the right iliac vein has been injured by the trocar. A
Babcock clamp is used to temporarily occlude the bleeding using
direct pressure. The anesthesia personnel are informed of the possibility of significant blood loss. While pressure is continued by an
assistant, the surgeon rapidly opens the abdomen using a vertical
midline incision. With a retractor in place, the Babcock is replaced by
the surgeon’s hand. With continued tamponade, proximal and distal
control of the vessel is obtained. The venotomy can now be repaired
using vascular techniques. It is usually not possible to repair a major
vascular injury with laparoscopic techniques. If proximal and distal
control can be obtained an experienced laparoscopic surgeon may
attempt the repair, but the threshold for opening should be low.
INTRODUCTION
The rising demand for laparoscopic techniques for colorectal surgery
arises from a number of purported benefits, including a reduction
in postoperative ileus, decreased pain, earlier recovery, fewer adhesions, and smaller incisional hernias. This enthusiasm, however,
has been tempered by, among other things, the long learning curve,
increased operative times, and concerns about the oncologic outcomes of laparoscopic resection for curable colon cancer. Concern
over cancer implants in trocar sites led to a temporary national
moratorium on laparoscopic resection for colon cancer from 1994
to 2004, and multiple national surgical societies called for these procedures to be performed only under the auspices of controlled trials.
A number of prospective, randomized trials, including the Colon
carcinoma Laparoscopic or Open (COLOR), Conventional versus
Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC),
and Clinical Outcomes in Surgical Therapy (COST) studies, have
helped address some of these concerns and delineate some of these
advantages and disadvantages.(1–7) This chapter will address some
of these concerns and address how best to optimize outcomes for
laparoscopic surgery in various colorectal disease processes.
ADVANTAGES
Postoperative pain and suppression of pulmonary function are
well-known sequelae of abdominal surgery. While physician bias
and patient expectations make a truly objective assessment of
pain difficult, multiple prospective, randomized trials have found
a reduction in narcotic requirements in patients undergoing
laparoscopic colectomy.(5, 6, 8) In the COST trial, patients who
underwent successful laparoscopic resections had decreased use
of both oral and intravenous analgesics.(1)
In an attempt to document improved pulmonary function
in patients undergoing laparoscopic surgery for colon cancer at
the Cleveland Clinic, preoperative and postoperative spirometry
was performed every 12 hours postoperatively in 55 patients
randomized to the laparoscopic surgery group and 54 patients
in the open surgery group.(5) These measurements consisted
of an 80% recovery of baseline forced vital capacity and forced
expiratory volume in-second from each patient. The median
recovery for the laparoscopic group was 3 days vs. 6 days in the
conventional group. Schwenk et al. had similar results in a similarly designed trial.(8) These results suggest a reduction in postoperative pain and quicker recovery of pulmonary function in
patients undergoing laparoscopic colectomy.
Reduction in postoperative ileus is another proposed major
advantage of laparoscopic surgery. Time to recovery of bowel function, either flatus or tolerance of food, and time to bowel movement are surrogate markers for the length of the postoperative ileus
most patients experience after abdominal operations. Virtually all
publications, whether retrospective or prospective, have shown a
statistically significant reduction in the time to recovery of bowel
function. The advantage appears to be 1–2 days in these studies. The
mechanism by which ileus is reduced is unknown, but may relate to
decreased bowel manipulation, decreased intestinal exposure to air,
exposure to the protective effects of carbon dioxide pneumoperitoneum, or reduced narcotic demands from a smaller incision.
The biases of the treating physician and the higher expectations of patients undergoing laparoscopic surgery make it difficult to accurately and reliably determine the true time to ileus
resolution. Investigators have, therefore, sought to more formally
evaluate the return of bowel function. Canine and porcine models have looked at intestinal myoelectric activity as well as radionucleotide techniques in animals that underwent laparoscopic
resection.(9–11) These studies confirmed a quicker return of
bowel function following laparoscopic vs. open resection.
The combination of reduced ileus, decreased pain, and quicker
recovery of pulmonary function would logically add up to a reduced
length of stay for patients following laparoscopic resection. This benefit
appears to be a 1–2 day advantage among patients undergoing laparoscopic resection. The introduction of clinical pathways has been particularly effective and more reliable in patients undergoing minimally
invasive approaches.(12, 13) Early ambulation, early feeding protocols,
and early switch to nonnarcotic oral analgesics have reduced length of
stay for laparoscopic and open procedures. “Fast-tracking” has shown
that a 2 day stay after laparoscopic or open colectomy is possible.(14)
This may be useful, as patients get used to transferring in-hospital care
to home care and become invested in the short hospital stay.
Though it is widely accepted that laparoscopic surgery results in
fewer adhesions than open surgery, this is difficult to quantify in the
context of a clinical trial. A recent observational study by Dowson
et al. however, looked at 46 patients (13 laparoscopic and 33 open)
who underwent laparoscopy after a previous colectomy. They
found a statistically significant difference in adhesions between the
two groups, with the laparoscopic group having a lower score.(15)
laparoscopic colorectal surgery
While this study was limited due to its small sample size, it does
confirm long-held beliefs about decreased adhesions after laparoscopic vs. open surgery, which should help to make later reoperations safer. In the past, 3-stage operations for inflammatory bowel
disease were felt to be a disadvantage to both the surgeon and the
patient. However, laparoscopic total abdominal colectomy and
ileostomy to remove the inflamed ulcerative colitis colon, wean
steroids, and improve nutrition can be performed without risking
increased adhesions at the time of ileal pouch construction and
completion proctectomy. The time between these two procedures
can also be reduced using laparoscopic approaches.
Fertility, especially in females, is an issue after pelvic surgery,
particularly restorative proctocolectomy. Multiple studies have
suggested that fertility is adversely affected in women undergoing restorative proctocolectomy.(16–18) This is likely related to
adhesions in the pelvis causing scarring of the Fallopian tubes.
Laparoscopy, with its decreased adhesion formation, may offer
benefits in preserving fertility in reproductive-age females.
Obesity and a large amount of visceral fat can make laparoscopic
colorectal procedures particularly challenging. The associated
comorbid illnesses often associated with obesity, however, would
seem to make this group of patients the ideal group to benefit from
laparoscopy. Delaney et al., in a case-matched comparative study
of patients with a body mass index >30, found no difference in
median operating time, complications, readmission, or reoperation rates.(19) The median length of stay, however, was significantly
shorter (3 vs. 5.5 days) after laparoscopic colectomy. Twenty-eight
patients did require conversion, but the lengths of stay, complication, readmission, and reoperative rates were no different than for
patients undergoing open colectomy.
Senagore et al. studied a series of 260 patients and compared
outcomes between patients with a BMI above 30 and those with
a BMI below 30 undergoing segmental colectomy.(20) The obese
group had a significantly higher rate of conversions (23.7% vs.
10.9%), longer operative times (109 minutes vs. 94 minutes),
higher morbidity rate (22% vs. 13%), and a higher anastomotic
leak rate (5.1% vs. 1.2%). While this increase in complications
paralleled those in obese patients undergoing open colectomy,
Senagore et al. concluded that laparoscopic colectomy is feasible
and safe, with the main benefit of a shorter hospital stay.
While operative times are longer in obese patients, the use
of a hand-assist device may offer the surgeon a useful tool to
cut down these times, particularly in this challenging group of
patients. Marcello et al. found that the use of a hand-assist device
allowed for the more efficient completion of technically challenging and complex procedures while preserving the benefits
of a laparoscopic approach.(21) The average BMI of patients in
their study was only 28.1 in the hand-assist group vs. 26.3 in the
straight laparoscopic group. While their results cannot be used
to definitively state that a hand-assisted approach is superior in
obese patients, they do suggest that it could be a useful tool to
overcome the challenge of completing laparoscopic procedures
on these patients.
DISADVANTAGES
A number of challenges have prevented laparoscopic colorectal
surgery from becoming more widely accepted and utilized by surgeons. Most general surgeons perform fewer than 50 segmental
colon resections per year. Laparoscopic colectomy, unlike laparoscopic cholecystectomy, requires working in multiple quadrants
of the abdomen, making depth perception and proprioception
more difficult. Several studies have evaluated the learning curve
for laparoscopic colectomy and suggested that this curve ranges
from 20–50 cases, but may be as high as 150 before the surgeon
is able to handle all eventualities during a laparoscopic colectomy. The standardization of technique required for entry into
the COST trial resulted in no detriment in oncologic outcomes
even though the study was undertaken during early laparoscopic
experience and the conversion rate was 20% (25% first half to
19% second half).(22–24)
The CLASICC trial, which was a prospective, randomized trial
comparing laparoscopic and open resection of both colon and
rectal cancer in the United Kingdom, also required that surgeons
perform at least 20 laparoscopic resections in order to enter the
study.(2) Even with this level of experience, the rate of conversion
decreased from 38% to 16% over the course of the study—July
1996 to July 2002. This suggested that 20 cases were likely not
enough to reach the plateau of the learning curve. The COLOR
trial also highlighted the value of surgeon volume in improving
patient outcomes.(3) In this trial out of Europe, the median operative time for high-volume (>10 cases/year) vs. low-volume (<5
cases/year) hospitals was 188 minutes vs. 241 minutes. Conversion
rates were 9% with high-volume groups vs. 24% for low-volume
groups. High-volume groups resected more lymph nodes, had
fewer complications, and shorter hospital stays, but there was no
difference in oncologic outcomes.
Operative times are generally longer with a laparoscopic
approach. This difference is approximately 40–60 minutes
longer for the laparoscopic technique depending on the portion
of colon removed (left > right). While operating times decrease
with surgeon experience, they do not reliably decrease to the level
of an open approach. The use of a hand-assist device may be a
viable solution to decrease the operative times while still maintaining the benefits of a laparoscopic approach. A multicenter,
prospective, randomized trial by Marcello and colleagues, comparing short-term outcomes of left/sigmoid colectomies and
total colectomies with a hand-assisted approach vs. a straight
laparoscopic approach showed a statistically significant decrease
in operating times with a hand-assisted approach (reduced by
33 minutes for sigmoid colectomy, reduced by 57 minutes for
total colectomy).(21) They also found no differences in the time
to return of bowel function, tolerance of diet, length of stay,
postoperative pain scores, or narcotic usage between the two
groups. The MITT Study group did not include right colectomy
since this procedure is routinely performed via a straight laparoscopic or laparoscopic-assisted approach in the same time as
an open operation.(21)
TREATABLE CONDITIONS
Colon Cancer
The treatment of colorectal cancer has been among the most controversial topics in the discussion surrounding the application of
laparoscopic techniques to colorectal surgery. This controversy
centered on early reports of cancer implants at trocar and incision sites and the fear of an inadequate oncologic resection. While
improved outcomes in colon and rectal surgery
later studies suggested that the incidence of wound implants was,
in fact, no greater than in open surgery when performed by experienced surgeons, the controversy was one of the main factors that
resulted in a call for a moratorium on laparoscopic resection for
colon cancer outside of the auspices of a randomized, controlled
trial.(25, 26) This resulted in a variety of randomized, controlled
clinical trials which served to put to rest many of these concerns
and help delineate the true advantages and disadvantages of a
laparoscopic approach.(1–5, 8, 27)
The first large single-center randomized controlled trial was
published by Lacy et al. in 2002, with a median follow-up of 39
months.(4) They, in fact, reported a higher cancer-related survival
for the laparoscopic group. While there was no difference between
the laparoscopic and open groups in Stage II cancers, they reported
a significantly improved survival in the laparoscopic group for Stage
III cancers. The results of the COST trial, which consisted of nearly
900 patients randomized to open or laparoscopic colon resection,
showed no difference in overall or disease-free survival between the
two groups.(1, 28) It also did not report the same advantage for
Stage III patients that Lacy et al. did. As Fleshman et al. point out,
the survival advantage that Lacy and colleagues reported may be the
result of an underpowered subset analysis. The theory that the survival advantage was due to some physiologic benefit of laparoscopy
is not borne out by the results of the COST trial.(28) Reassuringly,
the COST trial reported only two wound recurrences in the laparoscopic group, and one in the open group. The CLASICC trial out
of the United Kingdom also showed similarly reassuring results,
though the rate of conversions was higher.(2) The meta-analysis of
these trials by Bonjer et al. confirms the equivalence of open and
laparoscopic treatment of colon cancer.(29)
The results of these large, multicenter, randomized trials illustrate a number of important points in maximizing the outcomes
for laparoscopic colon resection. The importance of surgeon experience and judgment cannot be overstated. The consequences of
using laparoscopic resection for potentially curable malignancies as “learning cases” are potentially devastating to the patient.
Strict adherence to oncologic principles, just as in open surgery, is
paramount, and the dangers of sacrificing these principles in the
name of a minimally invasive approach are obvious. The importance of rigorously testing new techniques under the auspices of
a randomized, controlled trial is also highlighted by these results.
The controversy and emotion that arose over the initial reports
of wound implants following laparoscopic colectomy have been
laid to rest by the results of these multiple trials. It is safe to say
that laparoscopic colon resection for cancer, when guided by the
proper principles, is as safe as open resection, with a number of
tangible benefits to the patient.
Endoscopically unresectable “benign” polyps, at first glance,
would appear to be an ideal case for a laparoscopic resection by a
surgeon who is still on their “learning curve.” However, multiple
authors have reported that upwards of 18–22% of these “benign”
lesions are found to have adenocarcinoma on final pathology.
(30–32) Large, flat lesions with high-grade dysplasia are more
likely to have cancer present and these criteria should guide the
surgeon in their decision making. Thus, a surgeon with little
experience with laparoscopic resection should approach these
cases with great caution. It is vital that these cases be approached
as formal cancer operations, with strict adherence to the usual
oncologic principles.
INFLAMMATORY BOWEL DISEASE
While Crohn’s disease presents its own unique set of challenges for
a minimally invasive approach, it can also provide a unique opportunity. In severe Crohn’s disease, severe inflammatory changes in
the mesentery, the presence of abscesses or fistulae, and the difficulty in assessing bowel involvement are all challenges that need
to be overcome by the surgeon. Isolated terminal ileal disease, however, would seem to be an ideal setting for a minimally invasive
approach, especially for the relatively inexperienced laparoscopist.
The high incidence of reoperation in Crohn’s patients makes laparoscopy for the initial surgery an appealing option. While randomized, controlled trials are scarce, multiple recent studies support
laparoscopy as a viable option in many cases.(33–39)
The advantages associated with a laparoscopic approach in
Crohn’s disease are the same as those seen in the previously
described cancer trials. Resolution of ileus, resumption of diet,
postoperative pain, and length of stay were all improved with a
laparoscopic approach. In a prospective, randomized trial from
Milsom et al. of patients undergoing open or laparoscopic ileocolic
resection for refractory Crohn’s disease, the pulmonary function,
morbidity, and length of stay were all improved in the short-term
with a laparoscopic approach.(40) These studies support the use
of laparoscopy in Crohn’s disease, even, in the right setting, for the
inexperienced laparoscopist. As always, the surgeon’s judgment is
paramount, and there should be a low threshold to switch to an
alternate approach in the right situation. There is no difference in
recurrence of Crohn’s disease between patients treated by a laparoscopic or open surgical approach.(37)
Ulcerative Colitis
The slow acceptance of laparoscopic total proctocolectomy revolves
around a couple of factors. First, the early reports of laparoscopic
total colectomy were unfavorable. The Cleveland Clinic Florida
group published several reports of their results with laparoscopic
proctocolectomy for ulcerative colitis in the early 1990s.(41, 42)
They reported longer operative times and higher blood loss than
in the open group without the desired benefits. At that time, the
authors discouraged the laparoscopic approach to total colectomy.
These initial reports highlight the importance of the aforementioned learning curve. As surgeons have gained experience with
segmental resection, and as technology has advanced, the role of
laparoscopic total colectomy for inflammatory bowel disease is
being reevaluated and is gaining wider acceptance.
More recent reports support the use of laparoscopy for total colectomy and proctocolectomy with and without ileoanal pouch construction, with the same advantages for laparoscopy for segmental
resections. While some groups have performed laparoscopic total
colectomy on an urgent basis for patients with refractory colitis, it
is not routinely recommended for those patients with toxic colitis.
(43) A recent study from Chung et al. (44) compared their results of
a laparoscopic or open approach to total abdominal colectomy for
severe colitis and its impact on subsequent restorative proctectomy.
They found that patients undergoing a laparoscopic approach had
a faster resumption of diet, less narcotic usage, shorter hospital
laparoscopic colorectal surgery
stays, and a shorter time to subsequent restorative proctectomy and
ileostomy takedown. The rate of complications between the laparoscopic and open groups was similar. Stewart et al. showed that
accelerating doses of immune suppressants and steroids resulted
in higher rates of complications. Thus, utilization of laparoscopoic
abdominal colectomy as the initial operation to treat severe ulcerative colitis, with few adhesions and quicker arrival to the final goal
of reconstructive surgery, is a good alternative to continued medical therapy in some cases.(45)
Laparoscopic total colectomy and proctocolectomy are technically challenging operations with 3 to 5 hour operative times. The
use of hand-assisted techniques may be a way to cut down on this
time while still realizing the benefits of laparoscopy. Rivadeneira
et al. in a comparative study from the Lahey Clinic, compared the
hand-assisted approach to conventional laparoscopy in patients
undergoing laparoscopic proctocolectomy (10 HAL, 13 standard
laparoscopy).(46) The operative times decreased in the HAL group
(mean 247 minutes), while remaining constant in the laparoscopic
group (mean 300 minutes, p < 0.05) over the course of the study.
There was no disadvantage in terms of bowel function, length of
stay, or outcome in this study.
STOMA CREATION
The creation of a stoma can be an ideal scenario in order for a surgeon to gain experience in laparoscopic colorectal surgery. It is an
excellent way to achieve the benefits of minimally invasive surgery
while not dealing with the same ramifications as discussed with surgery for resectable colon cancer. There are studies that have shown
that laparoscopic stoma creation is a viable alternative to an open
approach, with benefit shown in several studies in both morbidity
and mortality.(47, 48) The key, just as in open surgery, is to ensure
that the limbs of the stomas are oriented properly and that the fascial opening is adequate in order to preserve the blood supply. Also,
adequate mobilization of the bowel in order to eliminate tension
on the stoma is critical. In particularly obese patients, the surgeon
should give consideration to a divided loop-end stoma. By leaving
the stapled closed distal limb within the abdomen and delivering
only the proximal functioning end through the fascia, less tissue
needs to be brought through the abdominal wall opening. However,
when creating an end stoma, it is critical to ensure that the proximal
limb is opened. Measures such as marking proximal and distal limbs
of bowel with sutures or clips, insuflating air into the distal bowel
via the anus, or performing flexible endoscopy of the stoma are routine procedures in many center to minimize this occurence.
Potential complications of laparoscopic stoma formation
include those related to laparoscopy itself—including insufflation needle or trocar injury, air embolism, arrhythmias, CO2
intolerance, and subcutaneous emphysema—and those related
to laparoscopic colorectal surgery in particular. These particular
complications mostly relate to unfamiliarity with the anatomy
as seen through the laparoscope and include ureter, iliac, and
mesenteric vessel injury, as well as improper orientation of the
limbs of the stoma. As with all laparoscopic surgery, it is critical
not to retract or grasp out of the field of view in order to avoid
any collateral injury that is not immediately recognized.
If tension is noted on the loop of bowel selected for the stoma
site, further mobilization may be of benefit to release the bowel or
colon from the retroperitoneal fixation. This should also reduce
the incidence of retraction and stricturing at the stoma site. A
particular skill needed in the performance of laparoscopic stoma
construction is the knowledge of bowel/colon anatomy and relationships of the intestine to adjacent structures as well as vascular
anatomy to provide adequate blood supply even to a stoma pulled
through a thick abdominal wall. Thus, even though considered a
basic laparoscopic case, a certain level of colorectal surgical skill
is needed.
DIVERTICULITIS
Laparoscopy for diverticulitis, while not fraught with the oncologic ramifications of colorectal cancer, presents its own set of
challenges, both in the elective and the acute setting. The fibrosis
associated with recurrent disease in the elective setting, and the
inflammatory changes in the acute setting present their own set
of technical issues, and the inexperienced laparoscopist in particular should proceed with caution and retain a low threshold for
conversion to an open approach or a hand-assisted approach.
As laparoscopy gains more popularity in the management of
acute intraabdominal processes like appendicitis or perforated
peptic ulcers, the question arises as to whether it may be of benefit
in management of diverticulitis in the acute setting. The mainstay
of treatment for generalized peritonitis secondary to diverticulitis remains open sigmoid resection with end-colostomy.(49) The
subsequent colostomy reversal, however, can be difficult because
of the significant adhesions that result. In an effort to ease some
of those difficulties, different groups have experimented with
various strategies, including a laparoscopic Hartmann’s procedure, and laparoscopic peritoneal lavage with no resection and
subsequent elective, one-stage resection.(50, 51)
Bretagnol et al. looked at 24 patients who underwent laparoscopic management of perforated sigmoid diverticulitis, of whom
19 were found to have purulent or fecal (Hinchey III or IV) peritonitis. They noted a morbidity of 8%. Laparoscopic sigmoid
resection was ultimately performed on these patients electively,
with a conversion rate of 16%.(50) Myers et al. in a prospective
study of 100 patients, attempted laparoscopic peritoneal lavage
on all consenting patients with generalized peritonitis from perforated diverticulitis.(51) Their primary endpoints were operative success and resolution of symptoms. They were successful
in 92 patients, with morbidity and mortality rates of 4 and 3%.
Two patients developed postoperative pelvic abscesses requiring
drainage while two patients represented with diverticulitis at a
mean follow-up of 36 months. While they did not look at later
reoperation, their results do suggest that laparoscopic peritoneal
lavage in expert hands may be a viable option in the acute setting
and allow avoidance of a colostomy.
The timing of surgery after an acute attack of diverticulitis also
remains a question. Zingg et al. in a retrospective study of 178
patients undergoing laparoscopic-assisted sigmoid resection for
diverticulitis found that patients undergoing surgery during the
same hospitalization had a significantly higher conversion rate,
37.7% vs. 12.9%.(52) In addition, the converted patients had an
increased surgical morbidity, though this was not statistically significant (23.8% vs. 19.1%). Hospitalization was significantly longer
at 13.5 vs. 10.5 days. Their results suggest that patients who respond
3
improved outcomes in colon and rectal surgery
to initial antibiotic therapy and wish to undergo laparoscopicassisted sigmoid resection would be better served by delaying
colectomy for 6 or more weeks. Similarly, Reissfelder et al. looked
prospectively in 2006 at 210 patients who underwent laparoscopic
sigmoid resection for acute diverticulitis.(53) They were divided
into two groups, one with an elective resection 5–8 days after initial
antibiotic treatment, and the other 4–6 weeks after their initial hospitalization. There was a statistically significant increase in conversions and anastomotic leaks in the early group, again supporting
the idea of delayed resection after the initial episode.
As noted earlier in this chapter, a hand-assisted approach is
a potentially attractive way to preserve the benefits of laparoscopy while cutting down on operative times and conversion
rates. These benefits may be applied to surgery for diverticulitis,
particularly in complicated cases (i.e., abscess or fistula). Lee et al.
in 2006 compared operative times and outcomes between patients
undergoing hand-assisted laparoscopic sigmoid resections and
those undergoing a totally laparoscopic approach.(54) Patients
with complicated diverticulitis were found to have significantly
shorter operative times and lower conversion rates when compared to those undergoing a totally laparoscopic approach.
Ureteral stents should also be considered in patients undergoing
laparoscopic surgery for diverticulitis. The indications, however,
are the same as in open surgery—reoperation, severe inflammation, or the presence of an abscess. Lighted stents are generally not
necessary, as the stents can be felt by the surgeon, even in a totally
laparoscopic approach. The surgeon should resist the temptation
to utilize stents too liberally, as they carry their own set of risks,
including bleeding, ureteral obstruction, and perforation.
The existing data suggests that a laparoscopic approach to treatment of sigmoid diverticulitis may offer a number of benefits over
an open approach. Case selection and surgeon experience, as with
other disease processes, is paramount. Strong consideration should
be given to a hand-assisted approach in complicated cases. As a
general principle in the treatment of diverticulitis, the use of laparoscopic techniques should not compromise the surgical procedure
by reducing the amount of colon removed or failing to resect to the
level of soft, normal rectum on the distal resection margin.
RECTAL PROLAPSE
Abdominal fixation procedures for rectal prolapse may offer an ideal
opportunity for a laparoscopic approach. The lack of a specimen or
an anastomosis solves two of the most potentially vexing problems
in laparoscopic colorectal surgery. Laparoscopically-assisted resection rectopexy, however, also may offer many of the same benefits
over the open procedure. Whether a resection is involved or not,
abdominal fixation procedures may offer an excellent opportunity
to learn how to mobilize the rectum laparoscopically, which can
then be applied to more extensive procedures, including proctocolectomy or rectal cancer surgery.
Ashari et al. in 2005, looked at ten years’ worth of prospectively collected data of patients undergoing laparoscopicallyassisted resection rectopexy for full-thickness rectal prolapse.(55)
A total of 117 patients were included in the study. Operative times
decreased from a median of 180 minutes in their early experience, down to 110 minutes in the latter part of their experience.
At a median follow-up of 62 months, only 2.5% of patients had
full-thickness prolapse recurrence. Mucosal prolapse recurred
in 18% of patients, while 4% of patients required dilation of an
anastomotic stricture. This mucosal prolapse recurrence may be a
result of less adhesion formation in the pelvis after a laparoscopic
dissection.
Solomon et al. in 2002, published the findings of a randomized
clinical trial of laparoscopic vs. open abdominal rectopexy for rectal prolapse, with a total of 40 patients with full-thickness rectal
prolapse randomized to the laparoscopic and open group.(56)
Patients were placed on a clinical pathway, which was designed
to result in discharge before postoperative day 5. Not surprisingly, mean surgical time was greater in the laparoscopic group
(153 vs. 102 minutes, p < 0.01). Nineteen of twenty patients in the
laparoscopic group were discharged by day five, while only nine
of nineteen in the open group were able to achieve that goal. Total
narcotic usage was less in the laparoscopic group as well.
While these results are encouraging, the follow-up on these
patients is short. In addition, the 18% mucosal prolapse reported
by Ashari et al. is concerning. Long-term follow-up is essential
in these patients before laparoscopy for rectal prolapse can be
considered the gold standard. Other considerations such as anterior deep pelvis mobilization, preservation of the anterior lateral
stalks, and combination of sigmoid resection and rectopexy will
need to be evaluated to derive the true place of laparoscopic treatment of rectal prolapse.
COLONOSCOPIC PERFORATION
Iatrogenic perforation of the colon during colonoscopy is a fortunately rare complication. Treatment has generally consisted of
laparotomy and repair vs. resection. Because the colon has usually undergone mechanical bowel preparation, simple oversewing
of the defect is generally safe and effective. Just as laparoscopy is
being applied more often to the repair of perforated peptic ulcers,
it would seem logical that it may offer benefits in the treatment
of colonoscopic perforation. Bleier et al. in 2008, looked at a
series of 18 patients in a four-year period who underwent surgical treatment of iatrogenic perforation.(57) Eleven patients in
the laparoscopic group and seven patients in the open group had
similar operative times. The patients in the laparoscopic group,
however, had statistically significant shorter lengths of stay, fewer
complications, and shorter incision lengths. Laparoscopic repair
of colonoscopic perforation may become the next step after conservative therapy fails and avoid major morbidity and prolonged
recovery if accomplished in a timely fashion.
TECHNICAL CONSIDERATIONS OF GOOD
LAPAROSCOPIC PRACTICE IN COLORECTAL SURGERY
A significant part of minimizing morbidity and mortality and maximizing outcomes in laparoscopic colorectal surgery centers around
a number of technical considerations, including trocar placement,
use of instruments, and techniques for vascular control.
TROCAR PLACEMENT
The most commonly used trocars are 5 or 10 mm, depending on
whether a stapler will be used, and the size of the camera. When
selecting the sites, it is important to place them far enough apart
to avoid “swordfighting.” They must be placed in a position that
laparoscopic colorectal surgery
allows the surgeon to reach the extremes of the opposite quadrants with the instruments. It is important that the trocars and
the monitors be placed, and the surgeon and assistant positioned
such that the surgeon is working in-line with the camera, the
intraabdominal pathology, and the monitors. This maximizes
the ability of the surgeon to work efficiently while minimizing the
potential awkwardness of working against the camera.
The trocars should be placed in such a manner that they are
inserted above the level of the bowel. This avoids the potential
danger of sticking the bowel or other structures with the instruments each time they are inserted through the trocars. The skin
incisions should be large enough to allow the trocars to be placed
without undue skin trauma, but should be small enough to avoid
unnecessary movement of the trocars, air leaks through the skin
site, or falling out of the trocars.
When inserting the trocars, the surgeon should take care to
insert them at right angles to the tangent of the curve of the
abdominal wall to avoid tearing the peritoneum and reduce the
risk of an oblique insertion. The abdominal wall should always
be illuminated to avoid injury to blood vessels, which can cause
nuisance bleeding throughout the operation. The trocars should
always be inserted under direct vision and the surgeon should
always look at the trocar after placement to ensure that any bleeding from the abdominal wall is dealt with early. In addition, the
surgeon should make sure the retainer rings are visible on the
peritoneum, so that the trocar is fully fixed in place, and will not
move unnecessarily.
Nonbladed trocars hold a number of advantages over bladed
trocars. They may help to avoid bowel injury, and also limits the
size of the peritoneal opening. The healing pattern of nonbladed
trocars through the peritoneum is also better than that of bladed
trocars.
The options for insertion of the initial trocar are an open technique and a closed technique using a Veress needle. While both
methods have their proponents, it is the opinion of the authors
that an open technique should always be utilized in a patient who
has undergone previous abdominal surgery. The risk of injury to
bowel or blood vessels is significantly higher with a blind insertion
in a patient with adhesions. Options for open insertion include
the use of a Hasson trocar, or in the case of a hand-assisted laparoscopic operation, direct guidance through the hand-port.
In nearly all cases, the bladder should be decompressed with
a Foley catheter. This is particularly important in cases where
a suprapubic trocar will be placed, so as to avoid any injury to
the bladder upon insertion. An oral gastric tube will also insure
gastric decompression.
INSTRUMENTS
One of the mantras for open surgery has included avoidance of
direct handling of the bowel with instruments, especially forceps.
The lack of hands inside the abdomen should not change this
dictum, if at all possible. The surgeon should try to avoid unnecessary grasping of the bowel. If needed, the instruments should
instead be used to push and retract. Rather than grasp the bowel
directly, the surgeon should try to grasp the surrounding fat
instead. The use of the most atraumatic graspers possible, such
as the “wavy” grasper, is essential. When retracting, the surgeon
should make every effort to retract in a 3-dimensional manner so
as to maximize the effectiveness of the retraction.
Wound protectors and specimen bags are two ways in which
to avoid contamination of the wound by the specimen. This can
have particular implications when dealing with a cancerous specimen, or a contaminated specimen, such as the acutely inflamed or
perforated appendix. The skirt of the handport used in a handassist case is a very effective wound protector. If the handport is
not available, some form of ring drape should be used.
Placing a sponge into the abdomen, either through a 10 mm port,
or through the handport, can be a very effective technique. It can be
used to pack the bowel out of the way, protect the bowel, or reduce
free-flowing blood which can impair visualization. It can be a very
effective way to protect the bowel during retraction so that the surgeon is pushing on the sponge instead of directly on the bowel.
VASCULAR CONTROL
Methods for vascular control include monopolar cautery, ultrasonic coagulation, clips, staplers, and bipolar devices. While each
method has its advantages and disadvantages, it is important to
keep several issues in mind. The monopolar device should never
be used on larger vessels (i.e., ileocolic artery, inferior mesenteric
artery, inferior mesenteric vein). While the ultrasonic shears are
effective for vessels <7 mm in size, they have not been proven
to be effective on vessels larger than that. Bipolar devices have
been proven to be effective on vessels as large as 7 mm and can
be an effective and efficient way to manage vascular pedicles.
While staplers are also effective for large vascular pedicles, two
caveats should be kept in mind. The stapler requires the use of
at least a 10 mm trocar, and the surgeon must beware of bleeding through the staples as well. No matter what the method of
control, the surgeon should always make sure to have an alternate means of control available in the operating room. Perhaps
the two most common and simplest methods are the Endoloop
or surgical clips.
CONCLUSION
Laparoscopic colorectal surgery offers many potential benefits
over traditional open surgery, including quicker return of bowel
function, decreased pulmonary morbidity, shorter hospital stays,
and improved cosmesis. Its widening use across the spectrum
of colorectal diseases, while exciting, is also cause for caution
amongst all colorectal surgeons. The key to optimizing outcomes in laparoscopic colorectal surgery lies in following several
key principles, including careful patient selection, strict adherence to oncologic principles, meticulous attention to technical
details, and a willingness to alter one’s approach when needed.
The surgeon should not look upon conversion as a failure, but
rather as a switch to an alternative approach. The judicious use
of a hand-assisted approach may offer a way for the surgeon to
preserve the benefits of laparoscopy while providing a means to
complete complex and time-consuming cases in a safer and more
efficient manner.
Ultimately, randomized, controlled trials with long-term
follow-up will be needed to truly determine the role of laparoscopy
in managing colorectal diseases. If the aforementioned benefits are
maintained in the long run with durable results, then laparoscopy,
improved outcomes in colon and rectal surgery
performed in expert hands, may ultimately become the standardof-care for treating many of these disease processes.
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