minimally invasive procedures in colon
TRANSCRIPT
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Minimally Invasive Procedures in Colon & Rectal Surgery
Alan E. Harzman, M.D.
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Outline
• Endoscopy- TEM- Combined approaches- Colonic Stents
• Laparoscopy– “Pure” laparoscopy vs. Hand-assisted
• NOTES
• Laparoscopic Techniques
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Goals of Minimally Invasive Techniques
• Equivalent or improved outcomes
• Equivalent or improved oncologic outcomes
• Avoid excessive cost
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Learning New TechniquesTraining Issues
• Learning Curve (20-50 cases)– ABS Recertification Reports (General Surgeons)
• Mean 11 colectomies/year• 90th percentile – 23/year
– I did about 40 laparoscopic colectomies as a fellow.
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Rewards of Minimally Invasive Techniques
Operative Time
Benefits ofNew
Techniques
Risk/EffectsOf Anesthesia,Trauma, Etc.
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Endoscopy
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Transanal Endoscopic Microsurgery (TEM)
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Transanal Endoscopic Microsurgery (TEM)
Richard Wolf Medical Instruments Corporation
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Transanal Endoscopic Microsurgery (TEM)
• Suggested uses– Benign tumors mid to upper rectum
• 5% recurrence
– T1 low-risk lesions• 3% recurrence
– Palliation or high-risk patients
• Overall 8% recurrence• Large, long-term, randomized numbers lacking
(Bemelman, 2005)(Middleton et al, 2005)
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Transanal Excision
• Similar indications
• Similar results
• Lower lesions only
Nova Plastics
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How do you apply principles of local resection to the rest of the
colon?
• Step 1 – Combine laparoscopic and endoscopic resection
• Step 2 – Under development
(OmicronLab, 2007)
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Combined Laparoscopy and Colonoscopy
(Bemelman, 2005)
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Colonic Stentsfor Obstructing Tumors
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Colonic Stents• As a bridge to surgery, in hopes of
avoiding a colostomy
• Possibly as a definitive measure in patients with widespread disease
• 84-96% clinical success rate
• Complications (~25%) include perforation, stent migration, fistula, reobstruction, tenesmus (if too low), stool impaction, bleeding
(Wolff, 2007)
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Colonic Stents
(Camunez et al, 2000)
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Colonic Stents Camúñez Study
• Placement in 70 of 80 patients
• Resolved obstruction in 67
• 2 perforated, 1 died
• 33 patients had surgery after 7 days
• Used as final treatment in 35– Estimated primary patency of 91% at 6
months
(Camunez et al, 2000)
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Laparoscopy
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Laparoscopy
• Laparoscopic – “Pure”
• Hand-Assisted Laparoscopic– Is not “lap converted to open”
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Laparoscopic ApproachConsideration of Cost
• Time - Per Minute Charge Standard - O.R. Care Time $43.00
• Equipment– Energy devices
• Ligasure
• Harmonic Scalpel
• Electrocautery
– Staplers– Access devices
• Trocars
• Hand ports
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ACGME Competency-Based Goals and Objectives
• Surg 2 Chief Resident– Systems-based Practice
• Will refine operative skills including cost-effective utilization of equipment.
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Laparoscopy
• Goal - Do the same (oncologic) resection– 12 lymph nodes– Ligate feeding vessel at its origin
• Currently little data on RECTAL resection for cancer– Societies currently discourage laparoscopic
proctectomy outside clinical trials
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Preoperative Considerations• Site (Right and sigmoid easier)
• Tumor size/invasion
• Obesity
• Previous surgery
• Almost always get a pre-op CT (cancer)
• Must talk with patient about need for conversion to open
• Must be able to find tumor/polyp (tattoo!, 0.5cc India ink in 3-4 sites)
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Tattoo
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• Can also locate with BE
• Having to do intraoperative colonoscopy is a flail– CO2 colonoscopy may be better
• Bowel Preparation – Utility is debatable, but with laparoscopy it
makes bowel easier to handle
Preoperative ConsiderationsContinued
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Conversion to Open• 10-25%
– Obesity– Prior surgery– Acute inflammation
• Fistula – 50% conversion
– Tumor bulk
• Not a failure
• Early conversion preserves good outcomes
(Wolff, 2007)
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Evaluating Outcomes
• Tracking Outcomes– Current national push– To be included in “Maintenance of
Certification”
• “Intention to Treat”– If you started laparoscopically and had to
open, it’s not fair to put that patient’s outcome in “open” group.
(Wolff, 2007)
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What difference does it make?
Laparoscopic Colectomy
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What difference does it make?
Laparoscopic Colectomy
•It helps you get a job•Patients like it (thanks to the internet)•Referring doctors like it•But what difference does it really make
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Outcomes
• Ileus – average 1-2 days shorter with laparoscopy
• Less need for narcotics
• Quicker return of pulmonary function
• Length of stay ~1 day less
• May be influenced by biased expectations– Who cares?
(Wolff, 2007)
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Outcomes – Page 2
• Return to work and quality of life– No statistical change– Anecdotally improved
• Cost– Equipment costs and OR time are greater– May be balanced or outpaced by shorter
hospital stay
• Time – Average 30-60 minutes longer
(Wolff, 2007)
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Port-Site Metastasis
• Initial concern greatly slowed development of laparoscopic colectomy
• Not born out in major trials
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Specific Trials
• Antonio Lacy
• COST
• COLOR
• MRC CLASSIC
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Antonio Lacy, et al 2002
• 219 patients
(Lacy et al, 2002)
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Antonio Lacy, et al
Overall Survivalp=0.16
Cancer Related Survivalp=0.02
(Lacy et al, 2002)
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Antonio Lacy, et al 2008
(Lacy et al, 2008)
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COST TrialClinical Outcomes of Surgical Therapy Study Group
• 872 patients with colonic adenocarcinoma• Recurrence
– 16% lap– 18% open
• Survival– 86% lap– 85% open
• Post-operative stay– 5 days lap– 6 days open
(COST Study, 2004)
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COST TrialClinical Outcomes of Surgical Therapy Study Group
• 5 year data published October 2007• Disease-free 5 year survival
– 68.4% Open– 69.2% Laparoscopic
• Overall survival– 74.6% Open– 76.4% Laparoscopic
• Recurrence– 21.8% Open– 19.4% Laparoscopic
(COST Study, 2007)
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COLOR TrialCOlon cancer Laparoscopic or Open Resection
• 1248 patients
• 17% conversion to open• BMI>30 excluded (because started in 1997)
• Pathologic criteria no different
• Time to GI recovery, 1st BM, hospital stay all one day less
• Complications were equivalent
(COLOR Trial, 2005)
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MRC CLASSICCMedical Research Council trial of
Conventional versus Laparoscopic-ASsisted Surgery In Colorectal Cancer• 794 patients
• Pathologic specimens, complications were similar
• Time to 1st BM 1 day shorter
• Time to diet and discharge similar between groups
(Guillou et al, 2005)
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Hand Assisted Laparoscopy vs.“Pure” Laparoscopy
• May reduce learning curve• May be used “up front” or as a “pseudo-
conversion”• Need to make an incision large enough for the
specimen anyway• Outcomes similar to laparoscopy, with operative
times usually shorter
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Hand-assist vs. Laparoscopy
(Targarona et al, 2002)
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Hand-assist vs. Laparoscopy
(Targarona et al, 2002)
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Hand-assist vs. LaparoscopyMarcello et al
• 95 patients - left or total colectomy
• Randomized to HA vs LAP
• Left colectomy– 175 minutes HA, 208 LAP (p=0.021)– Flatus 2.5 vs 3 days (p=0.64)– Length of stay 5 vs 4 days (p=0.55)
• Total colectomy– 127 vs 184 minutes (p=0.015)
(Marcello et al, 2008)
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In a comparison of “pure” laparoscopy and HALS, what does no significant difference
mean?
It means that if you can do it more easily with one hand in, why not do it?
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Robotic Assisted
So far not advantageous, encumbered by time and cost
(Minimally Invasive Robotics Association, 2002)
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NOTESNatural Orifice Transluminal
Endoscopic Surgery
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(Pai et al, 2006)
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(Pai et al, 2006)
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Techniques in Laparoscopic Colon and Rectal Surgery
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Laparscopic HemicolectomyTechnique
• Access
• Takedown of previous adhesions
• Mobilization and vascular division
• Intestinal division
• Anastomosis
• Closure of mesenteric defect – Usually skipped
• Closure
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Right Hemicolectomy
Laparoscopic Colectomy
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Right Hemicolectomy
= 5mm
=12mm
ExtractionIncision
The Radical Appendectomy Method
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Right Hemicolectomy
= 5mm
=12mm
ExtractionIncision
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Right Hemicolectomy
= 5mm
=12mm
ExtractionIncision
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Right Hemicolectomy
= 5mm
=12mm
HandPort
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Laparoscopic Right HemicolectomyApproaches
• Medial-Lateral
• Inferior
• Lateral-Medial
• Top-Down
Largely
Independent of trocar
placement
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If you elevate the right colic mesentery, what do you find?
(Netter, 1997)
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Don’t burn the duodenum!Don’t laugh. It’s happened more than once.
(Netter, 1997)
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Laparoscopic Right HemicolectomyMedial Approach
(Netter, 1997)
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Laparoscopic Right HemicolectomyMedial Approach
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Laparoscopic Right HemicolectomyMedial Approach
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Laparoscopic Right HemicolectomyInferior Approach
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Laparoscopic Right HemicolectomyInferior Approach
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Laparoscopic Right HemicolectomyLateral Approach
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Laparoscopic Right HemicolectomyTop Down Approach
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Left HemicolectomySigmoidectomy
Low Anterior Resection
Laparoscopic Colectomy
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Left Hemicolectomy
= 5mm
=12mm
HandPort
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Applied Medical Gelport
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Ethicon Lap Disk
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Laparoscopic Left HemicolectomyApproach
• Mobilize splenic flexure• Mobilize sigmoid• Presacral space• Divide rectum• Divide vessels• Divide sigmoid vessels• Exteriorize & place
anvil• Return & fire EEA
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Laparoscopic Left HemicolectomyHand Approaches
• Put 1-2 laps in to retract small bowel and clean camera
• Sling for splenic flexure
• Handshake for sigmoid vessels
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Laparoscopic Left HemicolectomyHand Approaches
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Laparoscopic Left HemicolectomyHand Approaches
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Summary of TechniquesThere are many ways to skin a cat
(Kneen, 2007)
• Convert what we do “open” to laparoscopic
• Come up with new ways
• Use new toys
• Undo the embryology
• Be careful!
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If bad luck got you into a situation, there’s no reason to
think that good luck will get you out of it.-Warren Lichliter
Most useful quote from my fellowship:
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Summary
• Much to the chagrin of surgery residents, we continue to search for new ways to invade the body less to achieve more. – Less morbidity– Less mortality– Less recurrence– More quality– More life
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Bibliography• Bemelman, WA (2005).Minimally invasive surgery for early lower GI cancer.
Best Practice & Research Clinical Gastroenterology. 19, 993-1005.
• Camunez, F, Echenagusia, A, Simo, G, Turegano, F, Vazquez, J, & Barreiro-Meiro, I (2000). Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation. Radiology. 216, 492-497.
• The Clinical Outcomes of Surgical Therapy Study Group, (2004).A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer. New England Journal of Medicine. 350, 2050-9.
• The COlon cancer Laparosopic or Open Resection Study Group, (2005).Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncology. 6, 477-84.
• Delaney, C, Lynch, A, Sengaore, A, & Fazio, V (2003). Comparison of robotically performed and traditional laparoscopic colorectal surgery. Diseases of the Colon and Rectum, 46, 1633-1639.
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