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Minimally Invasive Procedures in Colon


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Minimally Invasive Procedures in Colon

  1. 1. Minimally Invasive Procedures in Colon & Rectal Surgery Alan E. Harzman, M.D.
  2. 2. Outline <ul><li>Endoscopy </li></ul><ul><ul><li>TEM </li></ul></ul><ul><ul><li>Combined approaches </li></ul></ul><ul><ul><li>Colonic Stents </li></ul></ul><ul><li>Laparoscopy </li></ul><ul><ul><li>“ Pure” laparoscopy vs. Hand-assisted </li></ul></ul><ul><li>NOTES </li></ul><ul><li>Laparoscopic Techniques </li></ul>
  3. 3. Goals of Minimally Invasive Techniques <ul><li>Equivalent or improved outcomes </li></ul><ul><li>Equivalent or improved oncologic outcomes </li></ul><ul><li>Avoid excessive cost </li></ul>
  4. 4. Learning New Techniques Training Issues <ul><li>Learning Curve (20-50 cases) </li></ul><ul><ul><li>ABS Recertification Reports (General Surgeons) </li></ul></ul><ul><ul><ul><li>Mean 11 colectomies/year </li></ul></ul></ul><ul><ul><ul><li>90 th percentile – 23/year </li></ul></ul></ul><ul><ul><li>I did about 40 laparoscopic colectomies as a fellow. </li></ul></ul>
  5. 5. Rewards of Minimally Invasive Techniques Operative Time Benefits of New Techniques Risk/Effects Of Anesthesia, Trauma, Etc.
  6. 6. Endoscopy
  7. 7. Transanal Endoscopic Microsurgery (TEM)
  8. 8. Transanal Endoscopic Microsurgery (TEM) Richard Wolf Medical Instruments Corporation
  9. 9. Transanal Endoscopic Microsurgery (TEM) <ul><li>Suggested uses </li></ul><ul><ul><li>Benign tumors mid to upper rectum </li></ul></ul><ul><ul><ul><li>5% recurrence </li></ul></ul></ul><ul><ul><li>T1 low-risk lesions </li></ul></ul><ul><ul><ul><li>3% recurrence </li></ul></ul></ul><ul><ul><li>Palliation or high-risk patients </li></ul></ul><ul><li>Overall 8% recurrence </li></ul><ul><li>Large, long-term, randomized numbers lacking </li></ul>(Bemelman, 2005) (Middleton et al, 2005)
  10. 10. Transanal Excision <ul><li>Similar indications </li></ul><ul><li>Similar results </li></ul><ul><li>Lower lesions only </li></ul>Nova Plastics
  11. 11. How do you apply principles of local resection to the rest of the colon? <ul><li>Step 1 – Combine laparoscopic and endoscopic resection </li></ul><ul><li>Step 2 – Under development </li></ul>(OmicronLab, 2007)
  12. 12. Combined Laparoscopy and Colonoscopy (Bemelman, 2005)
  13. 13. Colonic Stents for Obstructing Tumors
  14. 14. Colonic Stents <ul><li>As a bridge to surgery, in hopes of avoiding a colostomy </li></ul><ul><li>Possibly as a definitive measure in patients with widespread disease </li></ul><ul><li>84-96% clinical success rate </li></ul><ul><li>Complications (~25%) include perforation, stent migration, fistula, reobstruction, tenesmus (if too low), stool impaction, bleeding </li></ul>(Wolff, 2007)
  15. 15. Colonic Stents (Camunez et al, 2000)
  16. 16. Colonic Stents Camúñez Study <ul><li>Placement in 70 of 80 patients </li></ul><ul><li>Resolved obstruction in 67 </li></ul><ul><li>2 perforated, 1 died </li></ul><ul><li>33 patients had surgery after 7 days </li></ul><ul><li>Used as final treatment in 35 </li></ul><ul><ul><li>Estimated primary patency of 91% at 6 months </li></ul></ul>(Camunez et al, 2000)
  17. 17. Laparoscopy
  18. 18. Laparoscopy <ul><li>Laparoscopic – “Pure” </li></ul><ul><li>Hand-Assisted Laparoscopic </li></ul><ul><ul><li>Is not “lap converted to open” </li></ul></ul>
  19. 19. Laparoscopic Approach Consideration of Cost <ul><li>Time - Per Minute Charge  Standard - O.R. Care Time $43.00 </li></ul><ul><li>Equipment </li></ul><ul><ul><li>Energy devices </li></ul></ul><ul><ul><ul><li>Ligasure </li></ul></ul></ul><ul><ul><ul><li>Harmonic Scalpel </li></ul></ul></ul><ul><ul><ul><li>Electrocautery </li></ul></ul></ul><ul><ul><li>Staplers </li></ul></ul><ul><ul><li>Access devices </li></ul></ul><ul><ul><ul><li>Trocars </li></ul></ul></ul><ul><ul><ul><li>Hand ports </li></ul></ul></ul>
  20. 20. ACGME Competency-Based Goals and Objectives <ul><li>Surg 2 Chief Resident </li></ul><ul><ul><li>Systems-based Practice </li></ul></ul><ul><ul><ul><li>Will refine operative skills including cost-effective utilization of equipment. </li></ul></ul></ul>
  21. 21. Laparoscopy <ul><li>Goal - Do the same (oncologic) resection </li></ul><ul><ul><li>12 lymph nodes </li></ul></ul><ul><ul><li>Ligate feeding vessel at its origin </li></ul></ul><ul><li>Currently little data on RECTAL resection for cancer </li></ul><ul><ul><li>Societies currently discourage laparoscopic proctectomy outside clinical trials </li></ul></ul>
  22. 22. Preoperative Considerations <ul><li>Site (Right and sigmoid easier) </li></ul><ul><li>Tumor size/invasion </li></ul><ul><li>Obesity </li></ul><ul><li>Previous surgery </li></ul><ul><li>Almost always get a pre-op CT (cancer) </li></ul><ul><li>Must talk with patient about need for conversion to open </li></ul><ul><li>Must be able to find tumor/polyp (tattoo!, 0.5cc India ink in 3-4 sites) </li></ul>
  23. 23. Tattoo
  24. 24. <ul><li>Can also locate with BE </li></ul><ul><li>Having to do intraoperative colonoscopy is a flail </li></ul><ul><ul><li>CO 2 colonoscopy may be better </li></ul></ul><ul><li>Bowel Preparation </li></ul><ul><ul><li>Utility is debatable, but with laparoscopy it makes bowel easier to handle </li></ul></ul>Preoperative Considerations Continued
  25. 25. Conversion to Open <ul><li>10-25% </li></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Prior surgery </li></ul></ul><ul><ul><li>Acute inflammation </li></ul></ul><ul><ul><ul><li>Fistula – 50% conversion </li></ul></ul></ul><ul><ul><li>Tumor bulk </li></ul></ul><ul><li>Not a failure </li></ul><ul><li>Early conversion preserves good outcomes </li></ul>(Wolff, 2007)
  26. 26. Evaluating Outcomes <ul><li>Tracking Outcomes </li></ul><ul><ul><li>Current national push </li></ul></ul><ul><ul><li>To be included in “Maintenance of Certification” </li></ul></ul><ul><li>“ Intention to Treat” </li></ul><ul><ul><li>If you started laparoscopically and had to open, it’s not fair to put that patient’s outcome in “open” group. </li></ul></ul>(Wolff, 2007)
  27. 27. What difference does it make? Laparoscopic Colectomy
  28. 28. What difference does it make? Laparoscopic Colectomy <ul><li>It helps you get a job </li></ul><ul><li>Patients like it (thanks to the internet) </li></ul><ul><li>Referring doctors like it </li></ul><ul><li>But what difference does it really make </li></ul>
  29. 29. Outcomes <ul><li>Ileus – average 1-2 days shorter with laparoscopy </li></ul><ul><li>Less need for narcotics </li></ul><ul><li>Quicker return of pulmonary function </li></ul><ul><li>Length of stay ~1 day less </li></ul><ul><li>May be influenced by biased expectations </li></ul><ul><ul><li>Who cares? </li></ul></ul>(Wolff, 2007)
  30. 30. Outcomes – Page 2 <ul><li>Return to work and quality of life </li></ul><ul><ul><li>No statistical change </li></ul></ul><ul><ul><li>Anecdotally improved </li></ul></ul><ul><li>Cost </li></ul><ul><ul><li>Equipment costs and OR time are greater </li></ul></ul><ul><ul><li>May be balanced or outpaced by shorter hospital stay </li></ul></ul><ul><li>Time – Average 30-60 minutes longer </li></ul>(Wolff, 2007)
  31. 31. Port-Site Metastasis <ul><li>Initial concern greatly slowed development of laparoscopic colectomy </li></ul><ul><li>Not born out in major trials </li></ul>
  32. 32. Specific Trials <ul><li>Antonio Lacy </li></ul><ul><li>COST </li></ul><ul><li>COLOR </li></ul><ul><li>MRC CLASSIC </li></ul>
  33. 33. Antonio Lacy, et al 2002 <ul><li>219 patients </li></ul>(Lacy et al, 2002)
  34. 34. Antonio Lacy, et al Overall Survival p=0.16 Cancer Related Survival p=0.02 (Lacy et al, 2002)
  35. 35. Antonio Lacy, et al 2008 (Lacy et al, 2008)
  36. 36. COST Trial Clinical Outcomes of Surgical Therapy Study Group <ul><li>872 patients with colonic adenocarcinoma </li></ul><ul><li>Recurrence </li></ul><ul><ul><li>16% lap </li></ul></ul><ul><ul><li>18% open </li></ul></ul><ul><li>Survival </li></ul><ul><ul><li>86% lap </li></ul></ul><ul><ul><li>85% open </li></ul></ul><ul><li>Post-operative stay </li></ul><ul><ul><li>5 days lap </li></ul></ul><ul><ul><li>6 days open </li></ul></ul>(COST Study, 2004)
  37. 37. COST Trial Clinical Outcomes of Surgical Therapy Study Group <ul><li>5 year data published October 2007 </li></ul><ul><li>Disease-free 5 year survival </li></ul><ul><ul><li>68.4% Open </li></ul></ul><ul><ul><li>69.2% Laparoscopic </li></ul></ul><ul><li>Overall survival </li></ul><ul><ul><li>74.6% Open </li></ul></ul><ul><ul><li>76.4% Laparoscopic </li></ul></ul><ul><li>Recurrence </li></ul><ul><ul><li>21.8% Open </li></ul></ul><ul><ul><li>19.4% Laparoscopic </li></ul></ul>(COST Study, 2007)
  38. 38. COLOR Trial COlon cancer Laparoscopic or Open Resection <ul><li>1248 patients </li></ul><ul><li>17% conversion to open </li></ul><ul><li>BMI>30 excluded (because started in 1997) </li></ul><ul><li>Pathologic criteria no different </li></ul><ul><li>Time to GI recovery, 1 st BM, hospital stay all one day less </li></ul><ul><li>Complications were equivalent </li></ul>(COLOR Trial, 2005)
  39. 39. MRC CLASSICC Medical Research Council trial of Conventional versus Laparoscopic-ASsisted Surgery In Colorectal Cancer <ul><li>794 patients </li></ul><ul><li>Pathologic specimens, complications were similar </li></ul><ul><li>Time to 1 st BM 1 day shorter </li></ul><ul><li>Time to diet and discharge similar between groups </li></ul>(Guillou et al, 2005)
  40. 40. Hand Assisted Laparoscopy vs. “Pure” Laparoscopy <ul><li>May reduce learning curve </li></ul><ul><li>May be used “up front” or as a “pseudo-conversion” </li></ul><ul><li>Need to make an incision large enough for the specimen anyway </li></ul><ul><li>Outcomes similar to laparoscopy, with operative times usually shorter </li></ul>
  41. 41. Hand-assist vs. Laparoscopy (Targarona et al, 2002)
  42. 42. Hand-assist vs. Laparoscopy (Targarona et al, 2002)
  43. 43. Hand-assist vs. Laparoscopy Marcello et al <ul><li>95 patients - left or total colectomy </li></ul><ul><li>Randomized to HA vs LAP </li></ul><ul><li>Left colectomy </li></ul><ul><ul><li>175 minutes HA, 208 LAP (p=0.021) </li></ul></ul><ul><ul><li>Flatus 2.5 vs 3 days (p=0.64) </li></ul></ul><ul><ul><li>Length of stay 5 vs 4 days (p=0.55) </li></ul></ul><ul><li>Total colectomy </li></ul><ul><ul><li>127 vs 184 minutes (p=0.015) </li></ul></ul>(Marcello et al, 2008)
  44. 44. In a comparison of “pure” laparoscopy and HALS, what does no significant difference mean? <ul><li>It means that if you can do it more easily with one hand in, why not do it? </li></ul>
  45. 45. Robotic Assisted <ul><li>So far not advantageous, encumbered by time and cost </li></ul>(Minimally Invasive Robotics Association, 2002)
  46. 46. NOTES Natural Orifice Transluminal Endoscopic Surgery
  47. 47. (Pai et al, 2006)
  48. 48. (Pai et al, 2006)
  49. 49. Techniques in Laparoscopic Colon and Rectal Surgery
  50. 50. Laparscopic Hemicolectomy Technique <ul><li>Access </li></ul><ul><li>Takedown of previous adhesions </li></ul><ul><li>Mobilization and vascular division </li></ul><ul><li>Intestinal division </li></ul><ul><li>Anastomosis </li></ul><ul><li>Closure of mesenteric defect </li></ul><ul><ul><li>Usually skipped </li></ul></ul><ul><li>Closure </li></ul>
  51. 51. Right Hemicolectomy Laparoscopic Colectomy
  52. 52. Right Hemicolectomy = 5mm =12mm Extraction Incision The Radical Appendectomy Method
  53. 53. Right Hemicolectomy = 5mm =12mm Extraction Incision
  54. 54. Right Hemicolectomy = 5mm =12mm Extraction Incision
  55. 55. Right Hemicolectomy = 5mm =12mm Hand Port
  56. 56. Laparoscopic Right Hemicolectomy Approaches <ul><li>Medial-Lateral </li></ul><ul><li>Inferior </li></ul><ul><li>Lateral-Medial </li></ul><ul><li>Top-Down </li></ul>Largely Independent of trocar placement
  57. 57. If you elevate the right colic mesentery, what do you find? (Netter, 1997)
  58. 58. Don’t burn the duodenum! Don’t laugh. It’s happened more than once. (Netter, 1997)
  59. 59. Laparoscopic Right Hemicolectomy Medial Approach (Netter, 1997)
  60. 60. Laparoscopic Right Hemicolectomy Medial Approach
  61. 61. Laparoscopic Right Hemicolectomy Medial Approach
  62. 62. Laparoscopic Right Hemicolectomy Inferior Approach
  63. 63. Laparoscopic Right Hemicolectomy Inferior Approach
  64. 64. Laparoscopic Right Hemicolectomy Lateral Approach
  65. 65. Laparoscopic Right Hemicolectomy Top Down Approach
  66. 66. Left Hemicolectomy Sigmoidectomy Low Anterior Resection Laparoscopic Colectomy
  67. 67. Left Hemicolectomy = 5mm =12mm Hand Port
  68. 68. Applied Medical Gelport
  69. 69. Ethicon Lap Disk
  70. 70. Laparoscopic Left Hemicolectomy Approach <ul><li>Mobilize splenic flexure </li></ul><ul><li>Mobilize sigmoid </li></ul><ul><li>Presacral space </li></ul><ul><li>Divide rectum </li></ul><ul><li>Divide vessels </li></ul><ul><li>Divide sigmoid vessels </li></ul><ul><li>Exteriorize & place anvil </li></ul><ul><li>Return & fire EEA </li></ul>
  71. 71. Laparoscopic Left Hemicolectomy Hand Approaches <ul><li>Put 1-2 laps in to retract small bowel and clean camera </li></ul><ul><li>Sling for splenic flexure </li></ul><ul><li>Handshake for sigmoid vessels </li></ul>
  72. 72. Laparoscopic Left Hemicolectomy Hand Approaches
  73. 73. Laparoscopic Left Hemicolectomy Hand Approaches
  74. 74. Summary of Techniques There are many ways to skin a cat (Kneen, 2007) <ul><li>Convert what we do “open” to laparoscopic </li></ul><ul><li>Come up with new ways </li></ul><ul><li>Use new toys </li></ul><ul><li>Undo the embryology </li></ul><ul><li>Be careful! </li></ul>
  75. 75. 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:
  76. 76. Summary <ul><li>Much to the chagrin of surgery residents, we continue to search for new ways to invade the body less to achieve more. </li></ul><ul><ul><li>Less morbidity </li></ul></ul><ul><ul><li>Less mortality </li></ul></ul><ul><ul><li>Less recurrence </li></ul></ul><ul><ul><li>More quality </li></ul></ul><ul><ul><li>More life </li></ul></ul>
  77. 77. Bibliography <ul><li>Bemelman, WA (2005).Minimally invasive surgery for early lower GI cancer. Best Practice & Research Clinical Gastroenterology . 19 , 993-1005. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  78. 78. Bibliography <ul><li>Fleshman, J, Sargent, DJ, Green, E, Anvari, M, Stryker, SJ, Beart, RW, Hellinger, M, Flanagan, R, Peters, W & Nelson, H (2007). Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Annals of Surgery, 246 , 655-664. </li></ul><ul><li>Guillou, PJ, Quirke, P, Thorpe, H, Walker, J, Jayne, DG, Smith, AM , & Heath, RM (2005). Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial). Lancet, 365 , 1718-26. </li></ul><ul><li>Kneen, B (2007, February). Issue 244. Retrieved December 9, 2007, from The Ram's Horn Web site: </li></ul><ul><li>Lacy, AM, Garcia-Valdecasas, JC, Delgado, S, Castells, A, Taura, P, Pique, J, & Visa J (2002). Laparoscopic-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet, 359 , 2224-29. </li></ul><ul><li>Lacy, AM, Delgado, S, Castells, A, Prins, HA, Arroyo, V, Ibarzabal, A, & Pique, J (2008). The Long-term results of a randomized clinical trial of laparoscopy –assisted vs open surgery for colon cancer. Annals of Surgery, 248 , 1-7. </li></ul>
  79. 79. Bibliography <ul><li>Marcello, PW, Fleshman, JW, Milson, JW, Read, TE, Arnell, TD, Birnbaum, EH, Feingold, DL, Lee, SW, Mutch, MG, Sonoda, T, Yan, Y, Whelan, RL (2008) . Hand-assisted laparoscopic vs. laparoscopic colorectal surgery, a multicenter, prospective, randomized trial. Diseases of the Colon and Rectum. 51 , 818-828. </li></ul><ul><li>Middleton, PF, Sutherland, LM, & Maddern, GJ (2005). Transanal endoscopic microsurgery: a systematic review. Diseases of the Colon and Rectum . 48 , 270-284. Minimally Invasive Robotics Association, (2002). Telerobotic surgery. Retrieved October 21, 2007, from Telerobotic Surgeons Web site: </li></ul><ul><li>Netter, F (1997). The Netter Collection of Medical Illustrations . Summit, NJ: Novartis. </li></ul><ul><li>OmicronLab, (2007). Avro Keyboard - Screenshot. Retrieved December 11, 2007, from Omicronlab Web site: </li></ul>
  80. 80. Bibliography <ul><li>Pai, R, Fong, D, Bundga, M, Odze, R, Rattner, D, & Thompson, C (2006). Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model. Gastrointestinal Endoscopy, 64 , 428-34. </li></ul><ul><li>Targarona, EM, Gracia, E, Garriga, J, Martinez-Bru, C, Cortes, M, Boluda, R, Lerma, L, & Trias, M (2002). Prospective randomized trial comparing conventional laparoscopic colectomy with hand-assisted laparoscopic colectomy. Surgical Endoscopy . 16 , 234-239. </li></ul><ul><li>Wolff, B (2007). The ASCRS Textbook of Colon and Rectal Surgery . New York: Springer. </li></ul>