Laparoscopic Sigmoid Colon Resection for Diverticular Disease

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  • 1. Laparoscopic Sigmoid Colon Resection for Diverticular Disease George Ferzli, MD, FACS Professor of Surgery, SUNY Downstate Health Science Center, Brooklyn, NY
  • 2. How is it done? 1. Lateral Approach 2. Anterior Approach
  • 3. Patient With Large Ventral Hernia
  • 4. Lateral patient position
    • Patient positioned on right side
    • Hand rotated in semicircle over sigmoid for trocar placement (more like triangle)
  • 5. Trocar placement : Lateral Position
  • 6. Lateral position Splenic Flexture Mobilization
  • 7. Lateral Approach I nferior Mesenteric Artery
  • 8. Lateral Position Lateral trocar cuts sigmoid
  • 9. Repair - Lateral Position If proximal colon can be brought through lateral incision tension-free, the repair will be tension free
  • 10. End to End Anastomosis
  • 11. Lap. Sigmoidectomy - Lateral Position
  • 12. Laparoscopic Sigmoidectomy – Lateral Position
  • 13. Lateral Approach
  • 14. Lateral Approach Advantages and Disadvantages
    • Advantages
    • Easy mobilization of splenic flexture
    • Easier identification of ureter
    • Small bowel out of the way in case of ventral hernia
    • Disadvantages
    • Inability to evaluate liver
    • Poor access to adhesions or lesions on the right side of the recto-sigmoid
    • In females, ovary may interfere
  • 15. Anterior Approach
    • Patient supine
    • Position hand over sigmoid and rotate in semi-circle to place trocars (3)
  • 16. Trocar Placement : Anterior Position
  • 17. Anterior position 1 2 Trocar in inguinal crease cuts sigmoid
  • 18. Repair - Anterior Position If proximal colon can be brought through inguinal crease trocar incision, tension free repair will be successful
  • 19. Anterior Approach
  • 20. Anterior Approach
  • 21. Laparoscopic Sigmoid Colectomy Ferzli G et al. (2000 – 2001) Unpublished Data 147 (110 – 279) 142 (98 – 216) OR Time 2.4 (2 - 9) 2.2 (2 - 10) Hospital Stay 1 leak (re-op hartman) 1 hematoma flank, 1 re-op for SBO, 1 leak (cut.drainage) Complications 12 5
    • Carcinoma
    6 3
    • Polyp
    20 (4 abscess) 16 (2 abscess)
    • Diverticulitis
    Indications: 35:3 23:1 Sex, M:F 46 (27 - 86) 48 (32 - 70) Age Anterior (38) Lateral (24) Total (n) = 62 pts
  • 22. Laparoscopic Sigmoid Colectomy Ferzli G et al. (2000 – 2001) Unpublished Data 147 (110 – 279) 142 (98 – 216) OR Time 2.4 (2 - 9) 2.2 (2 - 10) Hospital Stay 1 leak (re-op hartman) 1 hematoma flank, 1 re-op for SBO, 1 leak (cut.drainage) Complications 12 5
    • Carcinoma
    6 3
    • Polyp
    20 (4 abscess) 16 (2 abscess)
    • Diverticulitis
    Indications: 35:3 23:1 Sex, M:F 46 (27 - 86) 48 (32 - 70) Age Anterior (38) Lateral (24) Total (n) = 62 pts
  • 23. Laparoscopic Versus Open Colectomy for Cancer
  • 24. Colorectal Resection Laparoscopic vs. open resection for carcinoma RHC = Right hemicolectomy; Trans = Transverse; AR = Anterior resection; Sig = Sigmoid; LAR = Low anterior resection; APR = Abdominoperineal resection Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46
  • 25. Colorectal Resection Laparoscopic vs. open resection for carcinoma Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46 19.1% 13% Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III) 22% 12.2% Recurrence rates 6% 0.5% Wound complications 450 150 Blood loss, mL 9 5.6 Hospitalization, days Open (n=224) Laparoscopic (n=192)
  • 26. Colorectal Resection Laparoscopic vs. open resection for carcinoma Santoro E et al, Hepato-Gastroenterology 1999; 46:900-904 1 1 Liver+Peritoneum+ Trocar-site or scar 4 4 Liver+ Peritoneum 5 5 Multiple site metastases 1 1 Regional 4 2 Liver 5 3 Single site metastases 10 (23%) 8 (20%) Overall metastases 43 40 No. of cases (n) Open Lap. Follow-up
  • 27. Colorectal Resection Laparoscopic vs. open resection for carcinoma Curet MJ et al, Surg Endosc (2000) 14: 1062-1066 1 6 4 Late death from cancer (mean follow-up 4.9 years) 12 10 11 Number of lymph nodes 32 26 26 Length of specimen (cm) 8, 100% 5, 28% 1, 5% Complications (n, %) 8 7.3 5.2 Length of stay (days) 7 5.8 4.1 Regular diet (days) 5 4.4 2.7 Clear liquids (days) 6 4 3 ICU stay (days) 683 407 284 Blood loss (mL) 242 138 210 Operating room time (min) Converted (n=7) Open (n=18) Lap (n=18) 1 1 0 Recurrence
  • 28. Long-Term Survival After Laparoscopic Colon Resection For Cancer
    • Aim : To evaluate long-term survival after curative, laparoscopic resection for colorectal cancer.
    • Design : Retrospective review of 102 consecutive patients with laparoscopic colon resection between 1991 and 1996 with 5-year follow-up. Comparison made to open colectomy at the same institution and National Cancer Database during similar time period.
    Lujan HJ et.al. Dis. of Colon and Rectum;45:491-405,April 2002
  • 29. Long-Term Survival After Laparoscopic Colon Resection For Cancer Lap Open
  • 30. Long-Term Survival After Laparoscopic Colon Resection For Cancer Lap Open – Nat. Ca. Database
  • 31. Long-Term Survival After Laparoscopic Colon Resection For Cancer - Conclusions
    • Laparoscopic colectomy for cancer is safe and feasible
    • 5-year survival after laparoscopic colon resection for cancer is similar to survival after conventional surgery
    • Prospective randomized trials currently under way will likely confirm these results
    Lujan HJ et.al. Dis. of Colon and Rectum;45:491-405,April 2002
  • 32. Lap (LCR) Versus Open (OCR) Colectomy 1200 Prospective,Randomized *Hazebroek2002 1200 Prospective,Randomized *Nelson, 2001 LCR>OCR 43 219 Prospective,Randomized Lacy, 2002 LCR=OCR 48.9 197 Prospective, NR Feliciotti, 2002 LCR=OCR 40.3 100 Prospective, NR Anderson, 2002 LCR=OCR 42 248 Prospective, NR Lezoche, 2002 LCR=OCR 60 157 Prospective, Non-Randomized (NR) Champault, 2002 LCR=OCR 60 206 Retrospective review Lechaux, 2002 LCR=OCR 31 Stg I-III 15.5 Stg IV 80 Retrospective review of prospective data Poulin, 2002 LCR=OCR 64.4 + 2.8 102 Retrospective review Lujan, 2002 Recurrence / Long-term Survival Mean /Median Follow-up N Study Design Author/Year
  • 33. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial Antonio M. Lacy et al. The Lancet June 2002, Vol.359, Issue 9325, p.2224-9 NS Overall survival Laparoscopic colectomy 0.02 Cancer-related survival Laparoscopic colectomy 0.001 Overall morbidity Laparoscopic colectomy 0.005 Hospital stay Laparoscopic colectomy 0.001 Oral-intake times Laparoscopic colectomy 0.001 Peristalsis detection And the winner is……. P Value End-point
  • 34. Questions!