basics skills for laparoscopic colon surgery bradley r. davis, md, facs, fascrs associate professor...

Basics Skills for Laparoscopic Colon Surgery

Bradley R. Davis, MD, FACS, FASCRS

Associate Professor of Surgery

University of Cincinnati

Program Director Residency in General Surgery

Director of Minimally Invasive Colorectal Surgery, University Hospital

Laparoscopic Colectomy:You’ve Come a Long Way Baby!

• Improved instrumentation

• Improved techniques

• Standardized approach

• Large experience by a few surgeons

• Still not routine

Barriers to Implementation

• Access to cases

• Technique often differs from open approach– Medial vs. lateral– Comfort in major pedicle ligation (aortic

branches)

• Requirements for more than one skilled surgeon

• Time

Skill Sets

• Multi quadrant surgery– Skilled camera operator– Ability to work against the camera

• Colon not always fixed– Tension created by two operators – both

skilled

• Knowledge of energy devices and endo staplers

Other Considerations

• Loss of tactile feedback– Diverticulitis– Crohn’s disease– Location of tumor/polyp

• Learning curve– Surgeon– Surgical Team– Referring Docs

Preparation - The Patient

• Preoperative evaluation– few additional studies necessary

– additional invasive monitoring unusual

• Flexibility of hips and legs

Room Setup

What we hope for…

What we get…

Set Up: The Bed

• Electric bed

• Bean bag

• Velcro bag to bed

• Bottom of bag at break

Set Up: The Patient

• Modified lithotomy

• Minimize hip flexure

• Arms tucked

• Padding for shoulder

Set Up: The Patient

• Minimize hip flexion

• 10o at most

• More flexion may limit access to transverse colon

Even Better

Set Up: The Patient

• Padding for neck and shoulder

• 3” silk around chest to prevent lateral slippage

Set Up: The Room

Preparation - Surgeon: General Recommendations

• Be prepared for the day

• Don’t book too many cases

• Keep your cool

• Pick the easy lay-up

• Find some good help

Preparation - Surgeon: Learning Curve

• Steep (20-50 cases)– Depth perception

– Multiple quadrants

– Reverse angles

– Coordination of team

Operative times

Conversion rates

Conversions – Does it matter

• Conversion – an ugly word

• Increased operative times

• Increase length of stay

• Increase 30 day readmission/morbidity

• Increase cost

Conversions

Conversions

• No difference in outcomes when compared to an open cohort of similar patient

• KEY is to make a decision to ALTERNATE the approach early

Dis Colon Rectum. 2004 Oct;47(10):1680-5

Alternatives to Conversion

• Pfannenstiel incision after:– mobilization of splenic flexure– division of vascular pedicle

• Hand-assisted

laparoscopy– allows tactile sensation– blunt separation

Preparation - Surgeon: Developing a Systematic Approach

• Develop an approach and stick with it

• Initial survey

• Port placement

• Vascular ligation and medial mobilization

• Lateral mobilization

• Extraction and anastomosis

Laparoscopes• 10mm 0o

– Easy orientation– May be inadequate at the flexures

• 10mm 30o

– Better visualization at flexure and pelvis– Disorientation

• Flexible tip lens

Instrumentation

Conclusion

• Don’t wait for the perfect case

• Be prepared

• If you are going to alternate – do it quickly

• Have fun

Thanks