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Fig. 20.2 The base of the
mesentery is visualized to
make sure it is not twisted
before making the
isoperistaltic anastomosis
Fig. 20.3 Stapler applied
at a right angle to the colon
wall. Notice the clear
difference in vascularity. It
is important to make sure
the stapler is in the
well-vascularized portion
B. Salky
Anastomosis
The next step is to align the two ends of the bowel properly. The base of the mesentery is identied, and the mesentery on each side is traced back to the bowel wall.
This will prevent a twist of the mesentery prior to the anastomosis (Fig.20.3).
I prefer an isoperistaltic anastomosis, but I know that many surgeons use a reverse
peristaltic conguration. It just seems to me that we should try to restore bowel
continuity as close to the original position as possible (no science behind that).
Enterotomies are made with hook electrode on 30watts of cutting current. I use
cutting current, as the waveform is much less traumatic to the tissues than coagulation current. It is important to make sure the enterotomy is all the way into the bowel
lumen, and I conrm that by either seeing the mucosa or placing a Maryland-type
grasper into the opening (Fig.20.4). It is not impossible to make a false lumen with
the stapling instruments. It is important to make the enterotomies large enough to
admit the prole of each side of the stapler.
20 Intracorporeal Anastomosis forRight Colon Resection…
Fig. 20.4 Conrmation
that the small enterotomy
is actually into the lumen
is important. I prefer a
5mm Maryland-type
grasper for this, but this is
purely the surgeon’s
preference
Fig. 20.5 I prefer an
isoperistaltic anastomosis.
Both the small bowel
(foreground) and the colon
(background) are aligned.
Good vascularity is seen,
and there is no tension on
either piece of intestine
223
Fig. 20.6 Bulldog clamp
is applied to proximal
distended small bowel to
prevent spillage
Special Considerations
A special note about obstructed small bowel as commonly seen in Crohn’s disease
cases: I apply a laparoscopic bulldog to the dilated bowel to prevent abdominal cavity
contamination in these cases (Figs.20.5 and 20.6). I use a linear cutting stapler instrument to construct a side-to-side, functional end-to-end, isoperistaltic anastomosis. It is
224
B. Salky
easier to apply the rst prole of the stapler into the bowel that is closest to the surgeon.
In general, this is the ileum. Once the ileum is cannulated with one arm of the stapler,
it is held in place by the assistant’s grasper (epigastric port). Next, the other arm is
inserted into the colonic enterotomy. The surgeon should try to make each limb of the
bowel equal in length on each arm of the stapler (Fig.20.7). This will facilitate closure
of the common enterotomy when the stapler is closed, red, and removed.
A trick I have learned over the years is to have the assistant’s grasper hold the
distal part of the anastomosis up after the stapler is removed (Fig.20.8). This will
prevent any spillage of intestinal material while preparing for closure of the enterotomy. Another “trick” is to position the stapler (after ring it) inside the 12mm
trocar and remove the trocar from the abdominal wall. I then wash and clean the
inside of the stapler and the trocar before reinsertion. (I replace the trocar with a new
one only if I can’t clean the rst one well). Have the assistant or scrub nurse put a
nger into the trocar incision to maintain pneumoperitoneum while the trocar
cleaning/exchange occurs.
Fig. 20.7 The 60mm
linear cutting stapler is
inserted onto both limbs of
the intestine, closed and
activated
Fig. 20.8 The intestine is
aligned so that the suture
will pass through the bowel
wall at 90° angles. Notice
the assistant’s grasper
elevating the bowel away
from the surgeon. This will
help in preventing any
intestinal content from
escaping from the lumen
while suturing or closing
the defect
20 Intracorporeal Anastomosis forRight Colon Resection…
225
Fig. 20.9 This is a picture
of the nal 3-0 Prolene
suture being tied to
complete the closure of the
common enterotomy.
Ileum is to the right and
colon to the left
®
Enterotomy Closure
After the trocar has been reinserted, the enterotomy is ready for closure. I was
trained in a two-layer closure, but I know that some surgeons do this in one layer. I
use 2-0 polyglactin continuous sutures for the inner layer and 3-0 polypropylene
continuous seromuscular sutures for the outer layer. I try to place the latter in
between the former. I also sew away from myself. I have found over the years that
it is much simpler to sew away from than toward yourself, as it allows easier positioning of the sutures in the bowel (Fig.20.9). Barbed sutures have recently been
introduced. For those surgeons performing a single-layer anastomosis, they are an
option. They seem inherently more traumatic to the bowel wall than a smooth
suture, but I don’t know of any data to show a higher leak rate with their use.
Closure of the mesenteric defect has always been controversial. I do not close it,
and to my knowledge, I have not had any patient present with an internal hernia with
obstruction in more than 700 ileocolic resections. However, I do not have 100%
follow-up. I do cover the defect with omentum.
Once the anastomosis is completed, the area is irrigated with saline (no science
here), and a thorough check for hemostasis is made. I have not had any take backs
for postoperative hemorrhage with the use of the bipolar energy device.
The specimen is extracted through a relatively small, muscle-splitting Pfannenstiel
incision. As the specimen can now be extracted on end, the incision size is solely
dictated by the diameter of the bowel to be removed. In laparoscopic-assisted surgery, a loop of bowel has to be removed which necessitates a larger incision. No
matter how it is extracted, the wound is protected with plastic sleeve to help prevent
infectious contamination or implantation of malignant cells.
The fascia of the 12mm port is sutured closed.
Results
We published our initial results on comparing intracorporeal to extracorporeal
anastomoses in 2010 [1]. It was a consecutive series, single surgeon (me). As
Tables 20.1 and 20.2 show, the demographics and the operative events were
226
B. Salky
similar, respectively, with the only difference being a longer operative time for the
intracorporeal patients. Table20.3 details the morbidity in this series. The results
were so overwhelming in favor of intracorporeal anastomoses that it became the
standard procedure for all of these cases.
Since switching to an intracorporeal anastomosis in 2007, I have had experience
with more than 200 intracorporeal anastomoses for ileocolic, right hemicolectomy,
left hemicolectomy, and high ileosigmoid both for benign and malignant disease.
All extractions have been muscle-splitting Pfannenstiel incisions. While my experience is heavily weighted toward right-sided disease, few patients undergoing left
hemicolectomy for cancer in this series and subtotal colectomy with a high ileosigmoid anastomosis had similar outcomes as right-sided intracorporeal cases. To date,
there have been no incisional hernias and no postoperative obstructions from internal hernia, twisting, or adhesions. In patients who have had both extracorporeal and
intracorporeal anastomoses (previous IBD patients), the difference in pain management and overall feeling is dramatically better in the intracorporeal group. There
have been two leaks (0.9%). Similar results have been obtained in a recently published series as well [2]. A recent meta-analysis also conrms the advantage of
intracorporeal anastomoses with the addition of a decreased incisional hernia rate
compared to extracorporeal anastomosis [3].
Conclusion
Laparoscopic intracorporeal anastomosis has been found to have advantages over
the extracorporeal anastomotic method in both the short-term (decreased pain and
shorter LOS) and the long-term (incisional hernia). This technique does require
suturing and knot-tying skills. There will be an increase in the initial operative time
with the rst few cases, but this will dissipate as suturing and knot-tying skills are
acquired. From a patient perspective, this should be the preferred approach.
References
1. Grams J, Tong W, Greenstein AJ, Salky B.Comparison of intracorporeal versus extracorporeal
anastomosis in laparoscopic-assisted hemicolectomy. Surg Endosc. 2010;24(8):1886–91.
2. Shapiro R, Keler U, Segev L, Sarna S, Hatib K, Hazzan D.Laparoscopic right hemicolectomy
with intracorporeal anastomosis: short- and long-term benets in comparison with extracorpo-
real anastomosis. Surg Endosc. 2015;30(9):3823–9.
3. Carnuccio P, Jimeno J, Pares D.Laparoscopic right colectomy: a systematic review and meta-
analysis of observational studies comparing two types of anastomosis. Tech Coloproctol.
2014;18(1):5–12.
Transrectal Specimen Extraction: Should
This BeCatching On?
AlbertM.Wolthuis
Introduction
Over the last 20years, laparoscopic colorectal surgery has shown equal efcacy in
cancer treatment as open surgery [1]. In comparison to open colorectal surgery, a
laparoscopic approach reduces postoperative morbidity and shortens hospital stay
[2]. With the introduction of enhanced recovery protocols, hospital stay after a laparoscopic colorectal resection has been further reduced [3–5]. Fast-track programs
or so-called enhanced recovery after surgery protocols, pioneered by Kehlet, were
developed to reduce the surgical stress response, organ dysfunction, and morbidity.
Postoperative recovery is enhanced by a multimodality set of measures proposed by
the various stakeholders in postoperative care [3]. However, a laparoscopic approach
still has inherent drawbacks, such as incision-related complications (wound infection/
incisional hernia). Moreover, incision-related pain and long-term cosmetic outcomes
are important issues regarding the laparoscopic (assisted) approach. In the quest to
optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma
by means of laparoscopic natural orice specimen extraction (NOSE) colectomy is a
possible way to improve recovery. NOSE could be the key to reducing access trauma
in laparoscopic colorectal surgery, with the subsequent reduction of postoperative
pain, improvement of patient recovery, and positive long-term outcomes including
cosmesis and incisional hernia rates. Because the length of the abdominal incision is
directly related to the incisional hernia rate [6], avoiding laparotomy might inuence
the rate of postoperative wound complications. In NOSE, the specimen is delivered
via a natural orice, and the anastomosis is created intracorporeally. Different methods
are used to extract the specimen and to create a bowel anastomosis. Currently, specimens can be delivered transcolonically, transrectally, transanally, or transvaginally.
21
A.M. Wolthuis (*)
Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
e-mail: albert.wolthuis@uzleuven.be
© 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_21
227
228
Each of these NOSE procedures raises specic issues with regard to operative technique and application. Transrectal specimen extraction could be performed during a
sigmoid or high anterior resection, in contrast to transanal specimen extraction, which
is performed after a TME [7]. The aim of this chapter is to discuss laparoscopic NOSE
colectomy with transrectal specimen extraction and its current position in the armamentarium of minimally invasive surgery.
A.M. Wolthuis
Background
Franklin etal. developed the concept of a totally laparoscopic approach for a sigmoid
resection in the early 1990s, and Darzi etal. described the technique of a laparoscopic
sigmoid resection with transrectal extraction in 1994 [8–10]. However, the technique of a
laparoscopic NOSE colectomy did not gain widespread popularity. With recent advances
in minimally invasive surgery, a new era has dawned to further minimize access trauma
and to explore the surgical possibilities in bridging conventional laparoscopic colorectal
surgery and true human natural orice transluminal endoscopic surgical (NOTES) procedures. NOSE [11] could be the answer to avoid small laparotomy for specimen extraction
leading to a totally laparoscopic sigmoid resection. NOSE in laparoscopic colorectal surgery has the potential advantage of decreasing surgical trauma to the abdominal wall,
resulting in a lower complication rate, faster recovery, and shorter length of hospital stay.
A review performed in 2012 showed lack of evidence (level IV–V) for NOSE colectomy
[12]. Because of the heterogeneity and the bias of the studies included, no recommendations could be made, and clear answers to questions about postoperative recovery, cosmesis, and functional outcomes could not be given. Standardization of technique and
terminology and comparison with conventional laparoscopic resection are necessary to
solve the problems mentioned above. We reported our technique in a step-by-step
approach in 2011 and some modications in 2015 [13–15].
Indications
Previously, we reported that standardized laparoscopic left-sided NOSE colectomy is
feasible and safe [16]. Laparoscopic NOSE colectomy for left-sided disease involves
transrectal specimen extraction and intracorporeal colorectal anastomosis formation. A
specimen retrieval pouch can be used to extract the specimen. However, positional
changes of the specimen and air trapping in the bag can hamper extraction. Extraction of
lengthy and voluminous specimens could be problematic. Therefore, we propose the use
of a laparoscopic camera sleeve through the anorectum to extract the specimen longitudinally [15]. This modication may expand the indications and feasibility for left-sided
NOSE colectomy to extract larger specimens or to perform subtotal colectomy. To date,
indications for laparoscopic NOSE colectomy are benign or malignant sigmoid colon
diseases, such as diverticular disease (elective sigmoid resections for recurrent diverticulitis), endometriosis, a benign adenoma or lipoma, or a non-transmural carcinoma smaller
than 4cm in diameter. Some criteria to exclude patients from NOSE relate to specic
patient and pathologic features. Patient-specic exclusion criteria are pregnancy, body
21 Transrectal Specimen Extraction: Should This BeCatching On?
229
mass index (BMI) >35kg/m2, being on immunosuppressive medication or immunocompromised, abnormal blood coagulation, undergoing peritoneal dialysis, and history of
anal surgery. Pathology-specic exclusion criteria are diverticulitis of the proximal sigmoid colon, acute diverticulitis including Hinchey stages 1 to 4, and advanced colon
carcinoma, dened as clinically staged T3 or T4 tumors.
Technical Aspects
The patient is placed in a modied Lloyd-Davies position on a moldable beanbag
and a standardized four-port laparoscopic approach is used. First, vessel ligation by
conventional medial-to-lateral approach and isolation of the specimen was performed. After the proximal and distal margins have been established, the sigmoid
mesentery is divided. The devascularized specimen is isolated, and both the proximal sigmoid colon and proximal rectum are tied off. The anvil of a 28 or 29mm
circular stapler was delivered into the peritoneal cavity via proximal rectotomy
(Figs.21.1 and 21.2). The spike with a monolament suture is mounted onto the
Fig. 21.1 Operative view: critical steps of laparoscopic transrectal NOSE colectomy. (a) Anvil
insertion into the abdominal cavity via proximal rectotomy. Note the spike and the monolament
suture already mounted onto the anvil. (b) Anvil insertion into the descending colon. (c, d) Anvil
retrieval by pulling on the anti-mesenteric placed stitch. (e) The proximal bowel is divided with a
60-mm endoscopic linear stapler
230
A.M. Wolthuis
Fig. 21.2 Schematic drawing of the rst steps of laparoscopic transrectal NOSE colectomy.
Preparation of the proximal part of the anastomosis (a–e)
anvil. A camera sleeve is inserted through the anorectum to protect the rectal lumen
and to facilitate specimen extraction. A proximal colotomy is performed, and the
anvil is inserted into the descending colon. The needle attached to the suture and the
spike is used to place an anti-mesenterical stitch. This stitch is placed from within
the bowel lumen to the outside. Thereafter, gentle pulling on the mounted spike and
suture retrieves the anvil through the colon. Now, the anvil is in place for the future
circular anastomosis. The colotomy is closed and cross-stapled with an endoscopic
linear stapler, so that the proximal part of the colorectal anastomosis is ready for
use. The rectum is transected and the isolated specimen is extracted transrectally in
a longitudinal way (Figs.21.3 and 21.4). The rectum is closed with an endoscopic
linear stapler, and a circular stapled colorectal anastomosis is completed.
21 Transrectal Specimen Extraction: Should This BeCatching On?
Fig. 21.3 Operative view: critical steps of laparoscopic transrectal NOSE colectomy. A plastic
camera sleeve was inserted to protect the rectum. The specimen was extracted transrectally in a
longitudinal way by pulling on the grasping forceps (a–d)
231
Fig. 21.4 Schematic drawing of the nal steps of laparoscopic transrectal NOSE colectomy.
Transrectal longitudinal specimen extraction via a protected rectum with a camera sleeve (a and b).
The rectum was closed with an endoscopic linear stapler and a circular stapled colorectal anastomosis was made (c and d)