Laparoscopic colonic procedures

World J. Surg. 17, 51-56, 1993

World Journal of Surgery 9 1993 by the Soci~t~ Internationale de Chirurgir

Laparoscopic Colonic Procedures M o r r i s E. F r a n k l i n J r . , M . D . , F . A . C . S . , R a u l R a m o s , M . D . , D a n i e l R o s e n t h a l , M . D . , and William Schuessler, M.D. Southeast Baptist Hospital, University of Texas Health Science Center, San Antonio, Texas, U.S.A. With the advent and general acceptance of laparoscopy as a means of surgically treating intraabdominal disease processes, procedures on organs other than the gallbladder and female genital tract have slowly evolved. After developing basic techniques in an animal model, a clinical series (n = 19) of laparoscopic procedures for a variety of colonic lesions was undertaken and is herein presented. It included both malignant and nonmalignant disease processes and has carried an acceptable complication rate and survival. The average age of our patients was 68, and except for two extended postoperative hospitalizations and one death for nonprocedure-related complications, the patients were generally ready for discharge in less than 96 hours. Our current techniques and indications for laparoscopic colonic surgery are detailed.

The advantages of a laparoscopic approach to biliary tract disease have been amply demonstrated by Reddick, Saye, Phillips, McKernan, and their colleagues [1-3]. The skills gained from laparoscopic cholecystectomy can be utilized in the performance of other procedures, including appendectomy, herniorrhaphy, and repair of perforated ulcer [4-6]. Formal bowel procedures have remained elusive, however, because of a lack of adequate instrumentation and slow development of suturing skills. After many hours of vigorous laboratory work with improvement in skills and refinement of techniques, we have approached colonic pathology and have found most procedures to be within the grasp of the experienced laparoscopist [7, 8]. The procedures and study reported herein were undertaken to assess laparoscopic/colonoscopic techniques applicable to management of a variety of colonic lesions. The techniques of combined laparoscopic and endosurgical maneuvers were developed in the animal laboratory and then taken to the clinical setting; the procedures can be considered to be in continuous evolution [9]. Although laparoscopic techniques had to be developed to accomplish the resection and repair of a proposed colonic procedure, colonoscopy was also essential to ensure a clean colon free of liquid stool and as an essential aid for locating a given lesion. Additionally, the colonoscope was found to be a valuable tool for retrieving specimens transanally.

Reprint requests: Morris E. Franklin Jr., M.D., 4242 E. Southcross, San Antonio, Texas 78222, U.S.A.

Material and Methods

Animal Studies Ten pigs weighing 20 to 30 kg had colon preparation accomplished with polyethylene glycol (PEG) solution and were administered parenteral gentamicin 3 mg/kg. After induction of endotracheal anesthesia the animal's abdomen was prepared and draped using sterile technique. Pneumoperitoneum was accomplished by insufflating CO2 through a Veress needle using an electronic pressure-controlled insufflator. An 11-mm incision was made infraumbilically and an Endopath Trocar | (Ethicon, Somerville, New Jersey, U.S.A.) was inserted; the laparoscope with camera was introduced, and a video monitor was used to visualize the peritoneal cavity. Three to five additional ports were placed in the lower abdomen to facilitate the dissection. Adequacy of bowel preparation was confirmed by visualizing the distal colon with a flexible sigmoidoscope. Because these procedures had not previously been performed to our knowledge, we began with simple laparoscopic operations to demonstrate the efficacy of this type of surgery. A colon wall incision and repair of the defect was performed in two pigs. A 2-cm full-thickness button of sigmoid colon was then excised using scissors and a KTP (potassium titanyl phosphate) 532 Laser | (Ethicon). The specimen was retrieved through the anus using a snare placed through the sigmoidoscope. The colotomy was closed in two layers with laparoscopic suturing techniques developed in our laboratory. The integrity of the suture line was tested laparoscopically by direct visualization after insufflating the segment with air through the sigmoidoscope. A sigmoid resection with hand-sewn anastomosis was then performed in three pigs, and a stapled anastomosis was completed in five pigs. The colonic resection was done by first dividing the lateral peritoneal attachment of the colon. The mesenteric vessels were controlled using endoclips prior to division. The bowel was transected using the KTP 532 L a s e r | at a setting of 12 watts. A colonoscopic snare was used to remove the divided segment through the anus. An anastomosis was then performed in one layer with running inverted 3-0 Vicryl | (Ethicon). After demonstrating that this procedure was technically feasible, subsequent anastomoses were performed using an ILS | circular stapler (Ethicon) introduced through the anus. Chromic catgut Endoloops | (Ethicon) were used as purse-string sutures,

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World J. Surg. Vol. 17, No. 1, Jam/Feb. 1993

f

r

Fig. 1. Sites for placement of trocars and intraabdominal locations of segment of involved colon.

the instrument fired, and the anastomotic integrity again checked by endoscopy with insufltation pressure. Human Studies S~,moid Colon Resection. Preoperative bowel preparation consists in oral PEG solution or clear liquids with milk of magnesia and standard parenteral and oral antibiotics. General endotracheat anesthesia is used with the patient in the modified lithotomy position with legs in Lloyd-Davies Stirrups* (FordDixon, Texas, U.S.A.). A nasogastric tube and Foley catheter are placed, and a pneumoperitoneum is created with a Veress needle. An 1 l-ram incision is then made at the level of the umbilicus and a 0 ~ laparoscope with attached video camera is introduced through a 10-11 trocar. The abdominal viscera are carefully inspected. If there is a tumor deposit in the liver a biopsy specimen is obtained percutaneously with a Tru-Cut Needle* (Travenol Laboratories, Deerfield, Illinois, U.S.A.). Five additional 10-ram ports are introduced under direct laparoscopic visualization: one suprapubic, two in the left lower abdomen, and two in the right lower quadrant (Fig. 1). Additional ports are added as needed. The patient is placed in steep Trendelenburg position with a slight tilt to the right side. Loops of small bowel are gently swept from the left lower quadrant, right lower quadrant, and pelvis. Adhesions are frequently encountered and must be incised sharply or with the laser. The lesion in question is assessed both laparoscopically and with the use of the flexible sigmoidoscope. The adequacy of the bowel preparation is confirmed with the flexible sigmoidoscope, and any residual intraluminal debris is thoroughly aspirated and the area irrigated with a solution of saline and 10% povidone-iodine. The usual adhesions of sigmoid colon to the pelvic peritoneum in the left pelvic wall are incised and the colon mobilized medially; the ureter must be visualized as this maneuver is performed. The extent of the resection is determined by a combined laparo-

Fig. 2. Segment of devascularized bowel (with contained lesion) ready for resection. Mesenteric vessels have been ligated, cauterized, or clipped depending on the size of the vessel.

scopic and colonoscopic evaluation followed by marking the anticipated proximal and distal lines of resection of the bowel either with a small mechanical cut or methylene blue injected through the flexible sigmoidoscope. These areas are then carefully cleaned of adipose tissue. The mesentery is transected using sharp and blunt dissection and electrocautery. The ruesenteric vessels are either iigated with sutures or transected after application of endoclips (Fig. 2). We have developed an extracorporeal ligation technique that can securely ligate vessels as large as the inferior mesenteric artery without slipping. The colon is divided proximally and distally with the KTP Laser* or electrocautery, and the specimen is removed through the anus with a snare passed via the flexible sigmoidoscope (Fig. 3). The proximal end of the colon is controlled and leakage prevented by newly developed laparoscopic Glassman Clamps* (Solos Instruments, Atlanta, Georgia, U.S.A.). The size of the speci-

M.E. Franklin Jr. et al.: Laparoscopic Colonic Procedures

53

oloop

ess bowel trimmed with KTP laser

Fig. 3. Divided segment of bowel is being removed by a colonoscope after capture by an endoscopic snare.

men to be removed is an important factor in determining the route of extraction. For small specimens the transanal route is desirable; however, large specimens must be placed in a specimen bag intraperitoneally; then, at the end of the procedure, the specimen is extracted by enlarging the infraumbilical port as needed to accommodate the specimen. Once the bowel is transected, the ILS | stapler is introduced transanally and opened. An Endoloop | is positioned over the distal end of the bowel and tightened, acting as a purse-string suture. It is convenient to leave excessive bowel in the Endoloop | to avoid slippage while this suture is tightened. Excessive tissue is then removed prior to firing the instrument. The proximal end of the bowel is then placed over the anvil of the stapler and again secured with an Endoloop| this particular step is difficult to perform and requires patience and coordination between surgeon, assistant, and endoscopist. Once the two ends of the bowel are secured over the instrument and trimming has been completed, the cartridge is closed, and the ILS | is fired under direct vision (Fig. 4). The ILS | is then removed, and the two donuts of tissue are inspected. The anastomosis is checked for integrity by irrigating saline in the pelvis and insufflating air through the sigmoidoscope, creating pressure in the colonic segment. Should there be an air leak, the defect is repaired with 3-0 Vicryl | suture. The anastomosis must be rechecked with air insuttlation under pressure to ensure the absence of leakage.

Colonic Polypectomy. Colonoscopic localization is mandatory at the time of polypectomy. The standard indications for open polypectomy are considered indications for laparoscopic coIonic polypectomy. It is desirable preoperatively to obtain as many biopsies as possible in an attempt to establish the presence or absence of malignancy. The patient position and insertion sites of working ports depends on the location of the lesion, which obviously varies with right, left, sigmoid, or transverse colon lesions. The position of the ports should not be immediately over the lesion but at a distant site for adequate triangulation and to avoid

Fig. 4. Colon is being anastomosed with a circular stapler (ILS | introduced transanally. Endoloops | are used to secure bowel to the stapler.

"dueling" between the instruments. After positioning the patient and placing the operating ports and the laparoscope, the colonoscope is introduced and the exact position of the polyp is demonstrated transluminally. This step may be difficult and requires a skilled colonoscopist. Continuous communication between laparoscopist and endoscopist is mandatory. Tattooing of the perimeter of the lesion's base with methylene blue or india ink is recommended so the colotomy is performed at the most desirable and convenient level once the lesion is located and the colon is rendered clean. A colotomy is performed to encompass the entire thickness of the colon wall and the base of the polyp. We have found the KTP 532 Laser | to be ideal for this step but have also found electrocautery and electrosurgical scissors to be useful. The specimen is placed back in the lumen of the colon and retrieved with the colonoscope. Plastic bags can also be used for specimen collection and obviously lessen the chance of tumor implantation should an unproved malignancy be present. The colotomy is then closed with two running layers of 3-0 Vicryl | sutures. Intracorporeal instrument knot tying is timeconsuming and difficult, but knowledge of this technique and skill in performing it is mandatory for these more difficult and advanced procedures. It is expected that the introduction of endostaplers should facilitate these procedures, but they do not negate the need for suturing. The abdominal wound is irrigated and the closure tested with colonoscopy-induced pressure. The

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World J. Surg. Voi, 17, No. 1, Jan./Feb. 1993

Table 1. Laparoscopic colon operations. Pathology findings

Complications

Coexisting medical problems

Adenomatous polyp Adenomatous polyp Endometriosis (n = 2) Villous adenoma (n = 1)

0 0 0 0

CAD 0 Arthritis Steroid-dependent arthritis

Sigmoid colon resection (n = 10) Benign (n = 6) Malignant (n = 4)

Diverticulitis Dukes B1; 14 negative lymph nodes

CVA (n = 1) Postop GI bleed

Severe PVD COLD, CAD

Left colon resection (n = 2)

Dukes D adenocarcinoma with liver metastasis

0

CAD

Low anterior resection (n = 3)

Perforated Dukes B adenocarcinoma

0

Prior CABG

Procedure Polypectomy (n = 6) Right colon (n = 2) Left colon (n = 1) Rectum (n = 3)

Abdominoperineal resection (n = 2) Adenocarcinoma of anus with bleeding

Postoperative pneumoniaa Severe COLD

aDied at 21 days. PVD: peripheral vascular disease; COLD: chronic obstructive lung disease; CAD: coronary artery disease; CABG; coronary artery bypass graft.

procedure is terminated with inspection and closure of the ports. Results

had audible bowel sounds within 24 hours or less, had a bowel movement by 30 hours, and were able to tolerate oral liquids by 36 hours. Operative procedures, pathologic findings, and complications are summarized in Table 1.

Experimental Studies

Discussion

All pigs survived the operation and were sacrificed after 1 to 4 months. The segment of colon operated on was examined, and all anastomoses were noted to have healed satisfactorily with adequate luminal diameter. Upon completion of the animal experiments over a 6-month period, we determined that laparoscopic colotomy, colorrhaphy, colectomy, and restoration of bowel continuity can be safely performed in the porcine model.

The advantages of the laparoscopic treatment of colonic lesions are (1) avoidance of a prolonged ileus; (2) avoidance of significant postoperative incisional pain; and (3) averting major morbidity secondary to large abdominal wounds. The improvement of the quantity and quality of life of the patient with metastatic disease and the prevention of ventral hernias are additional benefits. Initially, the amount of time spent completing the procedure was longer than for comparable open procedures, but the improved recovery and diminished physiologic insult to the patient seemed to make it worthwhile. It was expected that with improved instrumentation the procedure could be done more expeditiously. Our current procedures are now being done over time spans comparable to open procedures. Although certain patients in this study had significant postoperative problems, our general impression was that patients undergoing laparoscopic colon resections fared better than comparable patients with open procedures, and that the problems seen here were not the result of the surgical procedure. Duration of hospitalization in patients without major (nonsurgical) medical problems was definitely less; the patients required fewer analgesics; and there were no procedure-related complications. We do have several concerns regarding laparoscopic colon procedures, including the possibility of tumor spillage, the best technique for retrieval of large segments of colon, and the use of laparoscopic colonic resection as a curative procedure for malignancy. Tumor spillage from malignant polypectomy can easily be handled by primary segmental resection and placing the specimen in a closed bag prior to retrieval; we recommend and currently practice this procedure. Large segments of colon removed for benign diseases can be cut up and removed

Clinical Results We have performed 6 colotomies (4 polypectomies, 2 fullthickness excisions of endometrial implants), 10 sigmoid colon resections (6 benign, 4 malignant), 2 low anterior resections (1 for perforated carcinoma), 1 high left colon resection at 35 cm (malignant), and 2 abdominal perineal resections (Table 1). The mean hospital stay for all patients was 7.3 days; but excluding 3 patients with extraordinary problems including postoperative stroke, upper gastrointestional bleed, and postoperative pneumonia, the average postoperative stay was only 3.4 days. The prolonged postoperative stay for the three complicated cases was considered secondary to nonsurgical problems. One death occurred secondary to pneumonia in a 96-year-old patient 21 days after surgery. Two patients were reexplored: one for uncontrollable upper gastrointestinal bleeding due to a large gastric ulcer at the gastroesophageal junction (the colonic anastomosis was examined and found to be intact and healing); and one for suspected peritonitis (no abnormality found). There were no wound complications and no episodes of thrombophlebitis or other surgery-related complications. There were no postoperative pulmonary complications except for the patient who developed pneumonia 2 weeks after surgery. All patients

M.E. Franklin Jr. et al.: Laparoscopic Colonic Procedures

piecemeal or, alternatively, placed in a bag and removed transabdominally [10]. We believe that malignant segments of bowel should always be placed in impervious bags, tied, and removed after creation of the anastomosis (exceptions would be instances in which metastasis is established, e.g., liver metastasis). The efficacy of laparoscopy as a primary treatment of malignant disease is yet to be established, and we are reluctant to recommend this modality at this time. We do relate, however, that in our experience we were able to identify and ligate the inferior mesenteric artery at its origin on the aorta and to take the inferior mesenteric vein above it. We have also found that the number of lymph nodes we retrieve laparoscopically is similar if not greater than the number removed using open procedures. The place of primary laparoscopic treatment of malignancy is yet to be determined and requires further extensive study. Summary

Laparoscopic techniques for cholecystectomy, bile duct surgery, and a host of gynecologic procedures have been successfully performed for several years, resulting in reduced morbidity, shorter hospital stay, and less pain; moreover, the outcome is similar to if not better than that using open procedures. Our investigations in the laboratory and subsequently in human subjects have expanded this beneficial approach to colon procedures with similar results of safety, efficacy, and reduced morbidity for a variety of colon procedures. Herein we presented the results of our first 23 patients. R6sum6

Gr~ice aux progr~s accomplis en mati~re de chirurgie coelioscopique pour traiter la pathologie intra-abdominale, des proc6d6s autres que la choldcystectomie ou la chirurgie de l'appareil g6nital f6minin ont v u l e jour. Apr~s une exp6rimentation animale des techniques de chirugie colique, une s6rie de 19 interventions pour une varidt6 de maladies coliques, b6nigne et maligne, est pr6sent6e. Les taux de complications et de survie sont acceptables. L'gge moyen de nos patients a 6t6 de 68 ans et, except6s deux hospitalisations prolong6es et un d6c~s sans rapport avec le procdd6 chirurgical, t o u s l e s patients ont pu quitter l'h6pital en moins de 96 heures. Notre technique e t n o s indications actuelles de la chirurgie colique sont d6taill6es. Resumen

Con el advenimiento y la general aceptaci6n de la laparoscopia como modalidad quirtirgica en el tratamiento de procesos intraabdominales, se han desarrollado otros procedimientos sobre 6rganos diferentes a la vesfcula biliar y al tracto genital femenino. Luego del desarrollo de las t6cnicas b~isicas en un modelo animal, se presenta ahora una serie clinica de procedimientos laparosc6picos usados en el tratamiento de diversas lesiones del colon, incluso neoplasis malignas y entidades benignas con aceptables tasas de complicaci6nes y de sobrevida. La edad promedio de nuestros pacientes fue 68 afios, y excepto por dos hospitalizaci6nes prolongadas y una muerte pot complicacidnes no relacionadas con el procedimiento, los

55

pacientes estuvieron listos para egreso en menos de 96 horas. Se describen en detalle nuestras t6cnicas actuales y las indicaciones para cirugfa laparosc6pica de colon. References

1. Reddick, E.J., Olsen, D., Alexander, W., Bailey, A., Baird, D., Price, N., Pruitt, R.: Laparoscopic laser cholecystectomy and choledocholithiasis. Surg. Endosc. 4:133, 1990 2. McKernan, J.B., Saye, W.B,: Laparoscopic general surgery. J. Med. Assoc. Ga. 79:157, 1990 3. McKernan, J.B.: Laparoscopic cholecystectomy. Am. Surg. 57: 309, 1991 4. Perissat, J.: Laparoscopic cholecystectomy: gateway to the future. Am. J. Surg. 161:408, 1991 [Editorial] 5. Browne, D.S.: Laparoscopic-guided appendectomy. Aust. N.Z.J. Obstet. Gynaecol. 30:231, 1990 6. Gotz, F., Pier, A., Bacher, C.: Modified laparoscopic appendectomy in surgery. Surg. Endosc. 4:6, 1990 7. Cuschieri, A.: The laparoscopic revolution--walk carefully before we run. J. R. Coll. Surg. Edinb. 34:295, 1989 [Editorial] 8. Cuschieri, A.: Minimal access surgery and the future of interventional laparoscopy. Am. J. Surg. 161:404, 1991 9. Cotton, P.B., Baillie, J., Pappas, T.N., Meyers, W.S.: Laparoscopic cholecystectomy and the biliary endoscopist. Gastrointest. Endosc. 37:94, 1991 [Editorial] 10. Clayman, R.V., Kavoussi, L.R., Soper, N.J., Dierks, S.M., Meretyk, S., Darcy, M.D., Roemer, F.D., Pinsleton, E.D., Thomson, P.G., Lons, S.R.: Laparoscopic nephrectomy~ initial case report. J. Urol. 146:278, 1991 Update

Since the submission of the original manuscript for this paper, many modifications of technique have occurred and as familiarity with the procedure has increased, confidence has improved so that indeed a reliable, safe, efficient, and costeffective alternative to classical open colon resection is within grasp of careful and skilled surgeons. Based on the results obtained with 131 patients, we are now approaching all but a few pathological situations laparoscopically and have consequently arrived at a fairly consistent set of contraindications for which laparoscopic techniques should be abandoned in favor of open techniques. The most significant aspect of our series is that we now approach carcinoma with the knowledge that we are performing the same procedure as with open surgery and that the results are equally good or perhaps better. The second most significant change in our approach is that we place all specimens in a bag prior to removal regardless of the route of removal, be it transanally or transabdominally through an expanded infraumbilical incision or right lower quadrant incision in the case of right colon resections. The third aspect of our series is that we have continued to perform the entire procedure intraabdominally with no laparoscopically assisted procedures. Updated statistics for our series are in Tables 1-11.

Table 1. Demographics.

Age Weight

Average

Range

76 yrs 82 kg

22-99 yrs 55-125 kg

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World J. Surg. Vol. 17, No. 1, Jan./Feb. 1993

Table 2. Laparoscopic colotomy and polypectomy.

Table 8. Post-operative hospitalization (days).

Right colon Left colon Sigmoid Rectal Total

8 3 2 2 15

Average Range

Right

Transverse

Left

Sigmoid

LAR

APR

3-5 3-6

3.5 3-6

2.5 2-6

3.8 2-30

3.6 2-13

2.8 1.5-21

LAR, low anterior resection; APR, abdominal perineal resection.

Table 3. Laparoscopic monitored colonoscopic polypectomy. Right colon Left colon Recto-sigmoid Total

4 7 2 13

Table 4. Laparoscopic colonic resections. i1 2 10 32 22 14 91

Table 5. Procedure by disease process. Carcinoma Palliation Cure Diverticulitis

79 8 71 12

Table 6. Operating time, average, and range (hrs). Right

Transverse Left 2.1 1.75-2.75

Sigmoid LAR 2.2 1.5-3.5

Transverse

Left

Sigmoid

LAR

APR

6 4-10

8 6-12

6 4-12

7 4-31

11 7-35

10 7-15

APR

Table 10. Conversion to "open procedure." Right

3

Severe adhesions Extensive disease Bladder invasion Extensive disease Fistula Bladder invasion

Sigmoid Low anterior resection

1 2

Total

6 (4.5%)

1 1 1 1

Table 11. Contraindications to laparoscopic colon surgery. Cirrhosis of the liver Massive obesity Multiple adhesion Adjacent organ involvement Complicated diverticulitis

Large abdominal aortic aneurysm Diffuse peritoneal sailage Large pelvic carcinoma Acute inflammatory bowel disease

2.6 1.75 1,8-4.6 1.25-2.6

LAR, low anterior resection; APR, abdominal perineal resection.

Table 7. Delay before post op fluid intake (hrs).

Average Range

Average Range

Right

LAR, low anterior resection; APR, abdominal perineal resection.

Right colon Transverse Left colon Sigmoid Low anterior Abdominal perineal Total

Average 1.75 2.8 Range 1.5-3.5 2-3.5

Table 9. Return to full activity (days).

Right

Transverse

Left

Sigmoid

LAR

APR

24 12-36

30 18-40

24 16--36

24 12-36

30 18-40

18 6-30

LAR, low anterior resection; APR, abdominal perineal resection.

As confidence in this p r o c e d u r e grows and m o r e surgeons perform this type of surgery, the list of complications, indications, and contraindications will grow. W e feel v e r y strongly that all surgeons should approach these m u c h m o r e difficult and complicated highly technical p r o c e d u r e s v e r y slowly and only after adequate instruction, laboratory experience, and proctorship and/or o b s e r v a t i o n of those skilled in these operations so that they may avoid a rash of complications v e r y similar to many of the p r o b l e m s seen with the initial e x p e r i e n c e in laparoscopic c h o l e c y s t e c t o m y .