Colorectal Surgery
Colorectal Surgery
Colorectal Surgery
Colorectal surgery
EVOLUTION OF COLORECTAL SURGERY
LAPAROSCOPIC SURGERY
Single incision/NOTES/NOSE
ROBOTICS
Milestones in colorectal surgery
In1980
–Prof Richard Heald developed a resection technique based on the
embryologic development of the hindgut. He excised the tumor and
mesorectum en bloc. He termed his technique "total mesorectal excision".
DON’T DON’T
DON’T TALK
HEAR SEE LAP
LAP LAP
Past concerns
Schlachta CM et al , Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum 2001;44: 217–22.
Slim K et al, Highmorbidity rate after converted laparoscopic colorectal surgery.Br J Surg 1995; 82: 1406–8.
Technological Improvements
Energy sources
Harmonic scalpel
Ligasure
Staplers
Endo-flex & circular
Advantages of laparoscopy
– Diminished pain
– Earlier return of bowel function
– Better preserved pulmonary function
– Decreased abdominal wound infection rate
– Reduced incidence of postoperative adhesions
– Shorter hospitalization
Better cosmesis & patient satisfaction
Bessler M, et al Is immune function better preserved after laparoscopic versus open colon resection? Surg Endosc 1994; 8:881–3.
Teoh TA et al , Enhancing cosmesis in laparoscopic colon and rectal surgery. Dis Colon Rectum 1995; 38: 213–4.
Expansion of Indications
– Diverticular disease
– Inflammatory bowel disease
– Tuberculosis
Laparoscopic rectopexy
Laparoscopic resection in malignancy
Lap hemicolectomy
Lap subtotal colectomy
Lap rectopexy
LAPAROSCOPY IN COLORECTAL MALIGNANCY
Laparoscopy for colonic cancer
Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically
assisted resection in colorectal cancer. British Journal of Surgery 2013; 100:75–82.
Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN
trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncology (Jul 2010): 637-45.
Lap. Oncosurgical Principles
Easy to perform
Takes lesser time
Less invasive
– Protection of ureter
– Other structures : Duodenum & IVC
Laparoscopic colorectal cancer surgeries
– Right Hemicolectomy
– Lap AR
– Lap APR
– Subtotal Colectomy
– Total Proctocolectomy
IRETA - Initial Retrocolic Endoscopic Tunnel Approach
KIDNEY
DUODENUM
PSOAS
URETER
MIS - Right Hemicolectomy
Post-Operative Care – FAST TRACKING!
Principles
Radical resection
Sphincter and Autonomic nerve preservation
Class 1 Evidence
Lacy AM et al, Lap assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized
trial. Lancet 2002; 359: 2224–9.
Braga M et al , Laparoscopic versus open colorectal surgery. A randomized trial on short-term outcome. Ann Surg 2002;
236: 759–67.
Ca Rectum : Lap resection
No difference in
Distal margin
Number of lymph nodes found in the resected specimen
Overall morbidity
Operative mortality
Coloanal anastomosis
Anastomosis at or below the level of dentate line
LAPAROSCOPY IN BENIGN DISEASES
Lap Total proctocolectomy with
ileal pouch-anal anastomosis
Ky AJ et al, One-stage laparoscopic restorative proctocolectomy: an alternative to the conventional approach? Dis Colon Rectum
2002;45:207–211.
Theatre setup
Theatre setup
41
PORTS
Procedure
• Minilaparotomy
• Exteriorisation , Division of terminal ileum
• Creation of ileal pouch
• Pneumoperitoneum
• Ileal pouch anastamosis with circular stapler
• Protective ileostomy
Ileo Anal Pouch Anastomosis
GEM Experience
Number of Patients - 73
Mean Blood Loss - 170 ML
Mean Operating Time - 210 MINS
Average hospital stay - 8days
SILS -5
Single Incision vs NOTES
Ø No visceral injury
Ø Safer
Ø Similar cosmetic outcome
Ø Allows advanced laparoscopic procedures
SIMPS
Innovations used
Single incision multiport technique
Conventional instruments and reusable trocars
Overcoming loss of triangulation
– Mini triangulation externally
– Creating triangulation internally – curved tip instruments
Advantages
No added cost
Less postoperative pain
Reduced hospital stay
High patient acceptability
Ease of specimen extraction
Combined procedures possible
Excellent cosmesis
SILS colorectal surgery
Conclusion: SILC can successfully and safely be performed with standard laparoscopic
instruments. This technique might be an alternative procedure to conventional
laparoscopic colectomy with better cosmetic result.
Ann Surg. 2012 Jan;255(1):66-9.
Single-incision versus standard multiport laparoscopic colectomy: a
multicenter, case-controlled comparison.
Champagne BJ, Papaconstantinou HT, Parmar SS, Nagle DA, Young-Fadok TM, Lee EC,
Delaney CP.
CONCLUSIONS:
SILC is feasible when performed on select patients by surgeons with extensive
laparoscopic experience. Outcomes were similar to MLC, except for a
reduction in peak pain score on the first postoperative day. Prospective
randomized trials should be performed before incorporation of this technology
into routine surgical care.
Ann Surg. 2012 Apr;255(4):667-76
Feasibility and safety of single-incision laparoscopic colectomy: a
systematic review.Makino T, Milsom JW, Lee SW.
CONCLUSIONS:
In early series of highly selected patients, SILC appears to be feasible and safe
when performed by surgeons who are highly skilled in laparoscopy. Despite
technical difficulties, there may be potential benefits associated with SILC over
MLC/HALC but it is yet to be proven objectively .
SILS surgeries Gem Experiance
Right hemicolectomy 18
Extended right hemicolectomy 5
Left hemicolectomy 3
Anterior resection 10
Abdominoperenial resection 3
Total proctocolectomy 5
Mesh Rectopexy 4
Total 48
SIMS
Placement of incision
Ø Transumblical
Ø Ileostomy site
Types of ports
Ø Single multiport trocar
SSAT/SAGES Joint Symposium. Indications and Techniques of Transanal Endoscopic Microsurgery (TEMS). Journal of
Gastrointestinal Surgery. Published online: June 2011
TAMIS
Minimally Invasive
Surgery
Remote Surgery
Intra-operative navigation
Conclusion