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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1375_Библиотеки_им_академика_М_И_Перельмана.pdf
The 3 A.M.Laparoscopic Bowel Surgery:
Selection, Preparation andTechniques
O.N.M.Panton
Introduction
Laparoscopic management of acute colorectal diseases and trauma is slowly evolving despite the fact that scheduled laparoscopic surgery has become the gold standard for many procedures such as cholecystectomy and anti-reux surgery [1, 2].
Laparoscopic colorectal surgery is not inferior to open surgery for curable cancer
[3]. Surgeons have been slow to adopt emergency colorectal surgical techniques
because of the learning curve, technical challenges with access, adhesiolysis, purulent abdominal contamination, loss of domain related to inammation and bowel
distension and lack of evidence to support adoption. Organizing after-hours laparoscopic surgery poses challenges with operating room access, team composition and
equipment especially in rural hospitals. Team composition has been demonstrated
to inuence operative performance [4].
Advances in technology have facilitated performance of more difcult advanced
laparoscopic surgery. Hand ports were introduced in the 1990s, and hand-assisted
emergency colectomy is an alternative to open colectomy [5]. The availability of
ultrasonic and bipolar energy sources facilitates safe efcient dissection and vessel
sealing.
8
Patient Selection
Patient selection is key to the successful management of patients with acute colorectal disease. Relative contraindications include obesity, extensive adhesions due to
multiple prior abdominal operations, bleeding dyscrasias and inability to tolerate
the carbon dioxide pneumoperitoneum. Haemodynamic instability secondary to
O.N.M. Panton (*)
Division of General Surgery, Vancouver General Hospital, Vancouver, BC, Canada
e-mail: neely.panton@vch.ca
© Springer International Publishing AG 2018
C.M. Schlachta, P. Sylla (eds.), Current Common Dilemmas in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-70117-2_8
97
98
haemorrhagic shock or sepsis is a contraindication for laparoscopic management
[1]. Emergency colectomy is associated with a higher mortality in immunosuppressed patients [6]. Distended small and large bowels due to ileus or mechanical
obstruction may compromise abdominal domain and are relative contraindications.
O.N.M. Panton
Preparation
With respect to preoperative management, the standard approach to performing
emergency abdominal surgery is applicable when considering a laparoscopic
approach. Anaesthetic consultation and a strategic plan discussion with the operative nursing team are vital. Preparation of the operating room is second only to
patient selection in the priority order. Modern laparoscopic towers, high-resolution
videolaparoscopy (VL), trocars to permit insertion of all required instruments, needle drivers, retrieval bags, haemostatic clips, efcient suction and irrigation devices,
advanced instrumentation including angled scopes, hand ports (HP), vessel-sealing
devices, endoscopic staplers and smoke evacuation devices are essential. The patient
must be secured to the operating table to permit extremes of positioning. Lithotomy
position is key for trans-anal stapling.
Specific Applications
Emergency laparoscopic colectomy is currently performed for lower GI bleeding,
colonic obstruction including cancer, iatrogenic perforation, complicated diverticulitis and inammatory bowel disease [1, 2, 5, 7].
Diverticular Perforation
In the pre-laparoscopic era, exteriorization or resection with colostomy was recommended for perforated diverticulitis [8, 9]. The surgical approach to the management of diverticulitis has changed radically in the past decade [1]. Twenty years ago
laparoscopic peritoneal lavage in combination with intravenous antibiotics was
introduced as an alternative to resection with stoma formation in Hinchey III diverticulitis [10]. In most patients with perforated diverticulitis and generalized peritonitis, there is no evidence of faecal contamination. At the time of surgery, the
perforation has sealed or cannot be found [11].
Nineteen articles were published between 1996 and 2013 addressing laparoscopic peritoneal lavage. Ten were cohort studies, eight case series and one controlled clinical trial reporting a success rate of 24.3%. The overall conversion rate
for Hinchey III and IV was 1% and 45%, respectively. The 30-day mortality was
2.9% [2]. The rst results from the randomized controlled trial DIverticulitisLAparoscopic LAvage versus resection (DILALA) comparing peritoneal lavage
versus Hartmann resection demonstrated no difference in morbidity and mortality
8 The 3 A.M.Laparoscopic Bowel Surgery: Selection, Preparation andTechniques
99
[12]. The Ladies trial was split into two arms: the LOLA arm comparing laparoscopic lavage with sigmoidectomy and the DIVA arm comparing Hartmann resection with sigmoidectomy plus primary anastomosis. Between July 1, 2010 and
February 22, 2013, 90 patients were randomly assigned in the LOLA arm of the
trial. The study was terminated by the data and safety monitoring board because of
an increased event rate in the lavage group. By 12months four patients had died
after lavage and six after sigmoidectomy (p=0.43) [13]. Because the safety of laparoscopic lavage for purulent or faecal peritonitis remains to be proven, these patients
require close monitoring for postoperative complications [14]. This approach will
be further elaborated in a subsequent chapter.
Hinchey II classication patients with planned intravenous antibiotics and percutaneous drainage management are potentially candidates for laparoscopic drainage
if the percutaneous drainage fails or is not feasible (Fig.8.1).
Complicated sigmoid diverticulitis can be managed with laparoscopic resection
(LR) or hand-assisted laparoscopic surgical (HALS) resection with primary anastomosis. Ureteric stents aid identication and preservation of the ureters. HALS facilitates exposure, retraction and dissection. Port placement is optional. The author’s
preference is to place the hand port in a lower epigastric midline incision. A 5mm
trocar is inserted in a right lateral position for the VL, and a 12mm trocar is placed
in the right lower quadrant for dissecting and stapling and a 5mm suprapubic trocar
for smoke evacuation, dissection and retraction (Fig.8.2).
Current evidence indicates that HALS reduces operating time and conversion
rates [16]. Surgeons who prefer LR have the established options of Veress needle
technique, Hasson technique or optical trocar entry for access and establishing the
pneumoperitoneum. Trocar size and placement are similar to scheduled colectomy.
Additional ports may be required for visualization, retraction and dissection
(Fig. 8.3). Port placement for complicated right-sided diverticulitis is shown in
Fig.8.4 and can be congured according to surgeon preference.
Laparoscopic Hartmann resection remains an option if anastomosis is deemed
unsafe by the surgeon. Hartmann colostomy closure is associated with signicant
morbidity and mortality. A signicant percentage of these patients do not have
colostomy reversal [2, 15, 16].
Obstructing Cancers
Obstructing right colon cancer can be managed with LR or HALS techniques.
Comparative studies have reported smaller incisions, less blood loss and earlier
recovery in comparison to open right hemicolectomy [17, 18]. The author places the
HP in a midline sub-umbilical position, a 5mm trocar adjacent to the HP for dissecting and a 5mm left subcoastal trocar for the VL.Five millimeter right upper and
right lateral abdominal ports are necessary for insufation and smoke evacuation
when using 5mm instruments but not essential if 10mm trocars are used (Fig.8.5).
The VL and instruments can be repositioned to facilitate visibility and surgical performance. Port placement for LR is discussed above.
100
Fig. 8.1 Laparoscopic
drainage of sigmoid
diverticular abscess
Fig. 8.2 Hand-port and
trocar placement for HALS
sigmoid resection
O.N.M. Panton
Emergency left colon resections can also be managed by LR or HALS.Trocar
placement was previously described. Stenting of these tumours is an option allowing decompression, mechanical preparation and scheduled surgery [19]. A prospective multicentre trial from Japan reported clinical and technical success rates of
95.5% and 97.9%, respectively, in 513 cases. Of these 71.8% were left colon
tumours [20]. Another Japanese prospective multicentre study on stents as a bridge
to surgery reported technical and clinical success rates of 98 and 92%, respectively;
elective surgery was performed in 297 patients and emergency surgery in eight
patients for complications. Open and laparoscopic surgery was performed in 121
and 184 patients, respectively [21].
8 The 3 A.M.Laparoscopic Bowel Surgery: Selection, Preparation andTechniques
Fig. 8.3 Port placement
for laparoscopic sigmoid
and left colon resection
101
Inflammatory Bowel Disease
In the elective setting, laparoscopic surgery has been shown to be a safe alternative
to open resection for Crohn’s disease and ulcerative colitis with faster recovery and
shorter length of stay. Laparoscopic colon surgery in the emergency setting for
inammatory bowel disease has been reported, but there is a lack of high-level data.
Most studies reporting management of Crohn’s disease and inammatory bowel disease are case-matched. Published data reports shorter hospital stay, increased operating room time and morbidity which is equivalent or better than open surgery [19].
Colonoscopic Perforations
Colonoscopic perforations are fortunately rare but can result in serious complications. The incidence for diagnostic colonoscopy is between 0.03–0.8% and 0.15–
3% for therapeutic interventions. Laparoscopic management has been reported
since the 1990s. Surgical techniques include primary sutured or stapled repairs,
segmental resection and resection with diversion in contaminated cases. Enhanced
recovery, smaller incisions and reduction in morbidity are reported outcome
improvements in comparison to open surgery [22, 23]. A large retrospective Korean
study reviewed 48,088 colonoscopies with 28 (0.06%) perforations. Thirteen
patients from other centres were enrolled. Fourteen patients had diagnostic and 27
102
Fig. 8.4 Port placement
for right hemicolectomy
O.N.M. Panton
therapeutic colonoscopy. Conservative management was attempted in 20 patients
and successful in 90%. Endoscopic clipping was done in nine patients with a success rate of 78%. Twenty-one patients underwent surgery plus two failures after
conservative therapy. Eight patients were managed laparoscopically, ve had primary closure and three had segmental colectomy. One patient in the laparotomy
group required a second laparotomy for leakage. Fifty-six percent of perforations
were in the rectum and sigmoid colon. The laparoscopic group had faster recovery
and fewer adverse events [24].
Small Bowel Obstruction
Laparoscopic adhesiolysis for mechanical small bowel obstruction is a wellestablished option in selected patients. Safe abdominal access can be challenging in
the patient with multiple prior laparotomies; loss of domain due to the distended
bowel can make visibility and dissection difcult. Mechanical intestinal obstruction
is associated with intra-abdominal hypertension and compartment syndrome.
Correa-Martin etal. conducted a mechanical obstruction study in a porcine model
similar to the human pathophysiology. Systemic vascular resistance, central venous
pressure, pulse pressure variation, airway resistance and lactate increased within 2h
8 The 3 A.M.Laparoscopic Bowel Surgery: Selection, Preparation andTechniques
Fig. 8.5 Hand-port and
trocar placement for HALS
right hemicolectomy
103
from starting intra-abdominal hypertension [26]. Theoretically the pneumoperitoneum could aggravate intra-abdominal hypertension and lead to gut ischaemia.
Okamoto etal. reported 28 patients undergoing laparoscopic adhesiolysis comparing outcomes with 25 patients undergoing conventional laparotomy [27].
Laparoscopic adhesiolysis was completed in 89% of patients; operating time was
112min in the laparoscopic group and 79in the open group. Patients in the laparoscopic group resumed oral intake at 3days versus 6.5in the open group, and length
of stay was shorter for the laparoscopic group. Complications were higher in the
open group.
Kelly etal. reported a large series of small bowel obstruction cases selected from
the ACS National Surgical Quality Improvement Program [28]. There were 9619
cases included in the analysis; 14.9% had laparoscopic adhesiolysis. Patients in the
laparoscopic group had shorter operating times and decreased postoperative length
of stay. After controlling for comorbidities and surgical factors, the laparoscopic
group was less likely to develop major complications and incision complications.
The 30-day mortality was 1.3% in the laparoscopic group versus 4.7% in the open
group.
Byrne et al. reported a cohort of 269 patients with mechanical small bowel
obstruction [29]. One hundred and eighty six had open and 83 laparoscopic adhesiolysis. 38.65% of the laparoscopic group were converted to open surgery. Recovery
was faster and complications lower in the laparoscopic group.
104
O.N.M. Panton
Conclusions
In the last 25years, surgeons have adopted laparoscopic techniques for the management of emergency bowel surgery. Despite the fact that advanced laparoscopic
scheduled surgery was introduced in the 1990s, the management of acute bowel
conditions has not been disseminated to the same extent as scheduled colorectal
surgery. The increased numbers of patients undergoing screening colonoscopy had
resulted in increased numbers of iatrogenic perforations [24]. A national population-based study from the USA reviewed 22,719 non-elective colectomies between
2008 and 2011. 95.8% of patients had open management. Most cases were performed at urban non-teaching hospitals by general surgeons. Colorectal surgeons
were more likely to perform laparoscopic surgery. Laparoscopic cases had signicantly better mortality, lower complication rates, reduced length of stay and lower
costs. Less than 5% of urgent and emergent colectomies in the USA were performed
laparoscopically [25].
Adhesiolysis for mechanical small bowel resection is being reported with increasing frequency, but there are no prospective randomized series reported to date.
Surgeons must make a global effort to disseminate and incorporate laparoscopic
management of acute colorectal and small bowel conditions in an attempt to provide
better patient outcomes. Surgical training programmes will have to continue to train
general laparoscopic surgeons to deliver optimal care for patients requiring interventions for colorectal emergencies.
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