Minimally Invasive Surgery


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Minimally Invasive Surgery

  1. 1. Minimally Invasive SurgeryThere are two major types of minimally invasive surgery: laparoscopic and robotic.Minimally invasive laparoscopic and robotic colon and rectal surgery allows the samesurgical operations to be performed through small incisions rather than one large incision.This advance in technology may allow many patients to have less pain after surgery, tohave quicker return of bowel function, to leave the hospital sooner, and return to normalactivities more quickly than patients having the same operation through a standard longopen incision.Laparoscopic surgery is now available for a wide variety of colorectal diseases includinginflammatory bowel disease, diverticulitis, and colorectal cancer. We participated in alarge national randomized controlled trial that was published in the New England Journalof Medicine (COST Study 2004). This study included 872 patients from 48 institutionsand concluded that the rate of cancer recurrence and survival is the same after open andlaparoscopic techniques for colon cancer (1). This has led to the increased utilization oflaparoscopic surgery for this and other diseases.Conduct of the OperationLaparoscopic surgery is done with standard laparoscopic video equipment which includesa lighted camera, television monitor, and instruments designed to work in small incisions.Instead of one long incision, several small incisions are made through which devicescalled trocars are placed that enable the abdomen to be filled with carbon dioxide. Thisprovides an environment which enables the liver, spleen, stomach, intestines, and otherorgans to be clearly visualized by way of a television monitor. Instruments are thenplaced through these trocars which allow the operation to be performed in a similarfashion as a standard open operation. The affected segment of bowel is then removedthrough one of the incisions after it is enlarged to a length of 4-8 centimeters.There are times when adhesions from previous surgeries, body habitus, or other technicaldifficulties make laparoscopic surgery difficult or impossible resulting in the need toconvert the procedure to a standard open operation. This happens between 5-20% of thetime.
  2. 2. Potential Benefits1) Pain After Surgery The need for narcotic pain medication may be reduced by laparoscopic surgery. Inthe COST trial cited above, patients needed narcotic pain medication for 1 day less thanthose who had open surgery (3.2 days vs 4.0 days). Other studies have shown an evengreater reduction in the need for narcotic pain medications (2)2) Return of Bowel Function Patients who have laparoscopic surgery may pass gas (flatus) and may be able toeat sooner than those who have standard open procedures (3, 4)3) Hospital Stay Patients who have laparoscopic surgery may have shorter hospital stays aftersurgery by a mean of 1-2.7 days (1, 4)4) Other Potential Benefits a) decreased blood loss during surgery b) decreased wound infections c) quicker return of lung function to normal after surgery d) less suppression of the immune system e) quicker return to normal activity after surgery f) better cosmetic resultsComplications There is the potential to injure bowel, blood vessels, and other organs (ureter,bladder) with the instruments placed into the abdomen. This is very rare. Those who havehad previous surgeries may be at increased risk for this complication. Other rare risksinclude hernias at incision sites, bleeding at instrument insertion sites, heart rhythm andlung problems associated with the gas inserted into the abdomen. Risks for openprocedures also apply to laparoscopic surgery. There is a possibility that because ofprevious surgeries or other technical factors, the laparoscopic operation may need to beconverted to a standard open incision.
  3. 3. Robot SurgeryLike, laparoscopic surgery, robotic surgery is performed through small incisions. All ofthe benefits listed above for laparoscopic surgery also apply to robotic surgery, includingdecreased blood loss, decreased pain after surgery, quicker return of bowel function,decreased wound infections, shorter hospital stay, and better cosmetic results.The robots arms are connected to trocars which are inserted into the abdomen in the samefashion as with laparoscopic surgery. Very fine instruments are attached to the robot. Thesurgeon controls these very fine instruments in a console attached to the robot. Theadvantages of robotic surgery include 1) a high quality 3D imaging system which allowsfor the best possible view of the surgical site, 2) surgical movements which more closely
  4. 4. mimic human wrist movements, and 3) potentially fewer conversions to open surgery.The high tech computerized robot allows movements through greater range of motionthan laparoscopic instruments. In addition, tremors are filtered by the robot and sutureand knot tying are more easily performed.Any Questions ?For more information regarding minimally invasive surgery, talk to your Colon andRectal Surgeon and see the references and websites below.References1) The Clinical Outcomes of Surgical Therapy Study Group. N Engl J Med2004;350:2050-20592) Hasegawa H, et al Surg Endosc 2003;17:636-6403) Milsom JW, et al J Am Coll Surg 1998;187:46-554) Lacy AM, et al Lancet 2002;359:2224-22295) Hellan M, Pigazzi A, et al Ann Surg Oncol 14:3168, 20076) Baik SH, et al Ann Surg Oncol March 20097) Spinoglio G, et al Dis Colon Rectum 51:1627, 2009Websites 1) 2) 3) 4) 5) 6) 7)