Laparoscopic total abdominal colectomy

Laparoscopic Total Abdominal Colectomy A Prospective Trial Steven D. Wexner, M.D., Olaf B. Johansen, M.D., Juan J. Nogueras, M.D., David G. Jagelman, M.D. From the Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida The aim of this study was to prospectively assess the impact of laparoscopy upon the outcome of total abdominal colectomy (TAC). Specifically, patients underwent standard laparotomy with TAC and ileoproctostomy (TAC + IP), TAC and ileoanal reservoir (TAC + IAR), laparoscopically assisted TAC + IP (L-TAC + IP), or laparoscopically assisted TAC + IAR (L-TAC + IAR). Parameters studied included the length of surgery, length of ileus, length of hospitalization, morbidity, and mortality. Five patients underwent standard TAC (Group I), and five underwent L-TAC (Group II). Group I consisted of five patients of a mean age of 32 (range, 24-51) years who had mucosal ulcerative colitis (n -- 1), familial adenomatous polyposis (n -- 3), or colonic inertia (n - 1). Group II consisted of five patients of a mean age of 33 (range, 17-43) years who had mucosal ulcerative colitis (n - 1), familial adenomatous polyposis (n - 3), or colonic inertia (n - 1). This preliminary prospective study indicates that laparoscopically assisted TAC is feasible. L-TAC resulted in a slightly longer length of ileus and length of hospitalization; these differences were not statistically significant. Moreover, the length of time required for the laparoscopic procedures was 35 percent longer than for the open procedures. Although these results may improve as more cases are performed, dramatic differences in rates of postoperative recovery have not yet been realized. In conclusion, L-TAC, while technically feasible, dose not appear to offer any immediately recognizable benefits to the patient as compared with standard laparotomy. [Key words: Laparoscopic colectomy; Laparoscopy; Ileoanal reservoir; Restorative proctocolectomy; Colonic inertia; Ulcerative colitis; Familial adenomatous polyposis]

rhaphy have gained widespread popularity. Much of the enthusiasm has resulted from claims of decreased pain and shorter hospitalizations associated with minimally invasive surgery. Postoperative pain, hospitalization, disability, and visible scars are all drawbacks to traditional o p e n procedures. These problems have p r o m p t e d a great impetus in less invasive surgical methods. The t h e o r y that laparoscopy is superior to standard surgery n e e d s to be tested in colonic surgery. Anecdotal case reports and small retrospective series have suggested that laparoscopic colorectal surgery is technically possible. However, the m e r e feasibility of a t e c h n o l o g y neither c o n d o n e s nor proves the appropriateness of its application. Thus, the aim of this study was to prospectively assess the results of laparoscopic total abdominal colectomy (L-TAC) as c o m p a r e d with standard total abdominal c o l e c t o m y (TAC). Specifically, we sought to identify any possible advantages or limitations to the use of laparoscopy. MATERIAL AND

METHODS

All patients who u n d e r w e n t L-TAC b e t w e e n March 1990 and N o v e m b e r 1991 were prospectively entered in a colorectal surgery registry. Inclusion criteria were strictly based u p o n pathology: mucosal ulcerative colitis (MUC), familial adenomatous polyposis (FAP), or colonic inertia (CI). Data were collected regarding the patients' age, sex, diagnosis, p r o c e d u r e p e r f o r m e d , length of surgery, length and type of incision, type of anastomosis, and postoperative course. In addition, postoperative variabilities analyzed included length of ileus, length of hospitalization, morbidity, and mortality. These same data were prospectively c o l l e c t e d during this same time p e r i o d for an age-, diagnosis-, and p r o c e d u r e - m a t c h e d cohort group. All data were collected by a single individual (O.B.J.) w h o was not the primary surgeon. The reason for the

Wexner SD, Johansen OB, Nogueras JJ, Jagelman DG. Laparoscopic total abdominal colectomy: a prospective trial. Dis Colon Rectum 1992;35:651-655. L

aparoscopic surgery has b e e n successfully emp l o y e d for m o r e than 15 years by gynecologic surgeons. The majority of these p r o c e d u r e s were initially restricted to diagnostic rather than therapeutic indications. Recently, however, general surgeons have a d o p t e d laparoscopy for other intraabdominal applications. Specifically, laparoscopic cholecystectomy, a p p e n d e c t o m y , and herniorAddress reprint requests to Dr. Wexner: Cleveland Clinic Florida, 3000 W. Cypress Creek Road, Fort Lauderdale, Florida 33309. 651

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selection of patients with CI, MUC, or FAP was that these are all benign conditions, cure of which is not potentially contingent upon proximal mesenteric vascular division and ligation. Obviation of this step facilitates the available laparoscopic technology without compromising the surgical goals. The techniques for laparoscopic colectomy have been described in detail elsewhere. ~ 3 Briefly, patients in both groups underwent the same bowel preparation. A standard mechanical cathartic bowel preparation (4 liters of polyethylene glycol) was administered one day prior to surgery. In addition, broad-spectrum parenteral antibiotics were given. The CI patient in Group I underwent a standard celiotomy with TAC and circular-stapled ileorectal anastomosis. The technique has been described in detail elsewhere. 4 The MUC and FAP patients underwent protocolectomy using the double-stapled technique for restorative proctectomy. This technique has also been described in detail elsewhere. 5 Patients in Group II underwent identical procedures, the only difference being that colonic mobilization was accomplished laparoscopically and the subsequent anastomosis was accomplished through a small lower midline or modified Pfannenstiel's incision (Fig. 1). In both groups, the patients were positioned in the i{lodified lithotomy position in Allen stirrups (Allen Medical Systems, Bedford Heights, OH),

•

X3

Figure 1. Illustrated are the patient, port, personnel, and monitor placement for a laparoscopic total abdominal colectomy (x, 10/1 l-ram port site; . . . . , choice of two incisions for ileoanal reservoir or for ileoproctostomy; xl, port

and loop ileostomy site; x2, port and drain site; xa, optional additional port site; S, surgeon; A, assistant; C, camera holder; M, monitor).

Dis Colon Rectum, July 1992

prepped, and draped in the standard fashion. After the induction of general endotracheal anesthesia, a nasogastric tube and an indwelling bladder catheter were placed. In the laparoscopic group, this presumably helped to minimize the risk of trocar injury to the stomach and bladder, respectively. Figure 1 illustrates the schema of port, personnel, and equipment placement around the patient. The patients were then placed in steep Trendelenburg's position, and a 1-cm transverse incision was made just below the umbilicus. The Verres needle was introduced and its correct placement verified. After pneumoperitoneum was established with CO2 to a pressure of 15 mm Hg, the Verres needle was removed and a 10/11-mm trocar (Ethicon, Inc., Somerville, NJ) was placed through this infraumbilical port site. The camera was then introduced through the 10/11-mm port, and all subsequent ports were placed under direct endoscopic visualization. All port sites were 10/11 mm in diameter to permit maximal surgical flexibility for frequent repositioning of both the camera and the instruments (Fig. 1). Before mobilization was performed, thorough visual inspection of the abdominal contents was undertaken and all adhesions were divided. To mobilize, table positioning was utilized to facilitate the retraction of loops of bowel from the operative field. For example, during mobilization of the sigmoid colon, placement of the table in Trendelenburg's position and tilting it to the right helped to keep the loops of small bowel away from the pelvis. Similarly, when mobilizing the hepatic flexure, reverse Trendelenburg's and table tilt to the left were helpful. Mobilization of the colon from the retroperitoneum was accomplished by grasping the colon with specifically designed noncrushing intestinal clamps (Ethicon, Inc., Somerville, NJ) (Fig. 2). Utilizing medial traction, the line of Toldt was exposed and divided with electrocautery. Larger vessels located at the flexures were ligated with endoscopic surgical clips (United States Surgical Corp., Norwalk, CT: Ethicon, Inc., Somerville, NJ). In patients with CI, mobilization was carried out to the level of the sacral promontory. In the four patients who underwent proctectomy and ileoanal reservoir creation, the upper two-thirds of the rectum was also laparoscopically mobilized with cautery dissection and cautery and clip hemostasis. Anterior, lateral, and presacral mobilization went as distal as could safely be accomplished with good

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Clinic Florida between March 1990 and November 1991. The details of these patients are shown in Table 1. The results of the procedure are detailed in Table 2. There was no major morbidity or mortality in either group. DISCUSSION

Figure2. Laparoscopic 10-mm-diameter bowel clamps (Ethicon, Inc., Somerville, NJ). Top to bottom: Babcock, Dennis, Allis, Kelly clamps.

visualization. No attempt was undertaken to perform laparoscopic division of the colonic mesentery. The rationale for this approach is enumerated in detail in the Discussion. After full mobilization of the intra-abdominal portion of the colon as well as partial mobilization of the rectum, the remainder of the operation was performed through either a small infraumbilical midline or modified Pfannenstiel's incision (Fig. 1). After the bowel was delivered through this incision, the mesentery was transected and the vessels were ligated in the standard fashion. The completion of the rectal dissection, transection of the bowel, and creation of the ileoanal reservoir and anastomosis were all performed in the standard fashion. 5 RESULTS Ten patients (seven females and three males) with CI, 2 FAP,6 or MUC2 underwent either TAC (five patients) or L-TAC (five patients) at Cleveland

This preliminary experience suggests that L-TAC is feasible. This small prospective pilot series resulted in a slightly, although not significantly, longer length of ileus and of hospitalization in the L-TAC group. Moreover, the laparoscopic procedure required an additional 35 percent of operative time. Because of this already lengthened anesthetic time, we elected not to proceed with laparoscopic mesenteric ligation and division. In addition to the added time that would have been required, there were three other mitigating factors in this decision. First, since these patients all had benign disease, proximal vascular ligation was superfluous. After full laparoscopic colonic mobilization, however, distal mesenteric vascular division was easily accomplished through the small incision needed to complete the procedure. Second, in addition to the substantial extra time needed for intracorporeal mesenteric harvesting with vessel loops and clips, these methods of vascular control are cumbersome in the setting of a TAC. These methods, however, are quite acceptable for limited organ retrieval, such as in the cases of cholecystectomy, appendectomy, or even segmental colectomy. Third, although various staplers for intracorporeal mesenteric division have been developed, their cost for use in a total colectomy would be prohibitive. Hopefully, increased laparoscopic experience and skill along with improved, less costly instrumentation will permit a greater proportion of the

Table 1. Details of Open vs. L-TAC Group II (Laparoscopically Assisted)

Group I (Open) Age Sex Indica- Procedure tion

OR Flatus (min) POD

Tolerate D/C Age Sex IndicaPO

POD

Procedure

tion

OR Flatus (rain) POD

Fluids 20 24 25 51 30

F F F F F

CI FAP MUC FAP FAP

TAC + IP TAC+IAR T A C + IAR TAC + IAR TAC+IAR

90 185 150 150 150

3 4 4 4 3

7 5 4 4 3

Tolerate D/C PO

POD

Fluids 10 7 7 9 7

39 17 27 43 38

F F F F F

CI FAP MUC FAP FAP

L-TAC + IP L-TAC+IAR L-TAC + IAR L-TAC + IAR L-TAG+IAR

240 300 210 180 240

7 5 3 3 4

7 5 4 3 8

9 10 7 9 11

OR = length of operation; POD = postoperative day; PO = by mouth (oral intake); D/C = discharge; IP =

ileoproctostomy; IAR = ileoanal reservoir.

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Dis Colon Rectum, July 1992

Table 2. Results

Length of surgery (min) Length of ileus (days) Length of hospitalization (days) Morbidity (%) Mortality (%)

procedure to be accomplished intracorporeally. These advances should ideally translate into significant reductions in the current time and cost of performing laparoscopic or laparoscopically assisted TAC. The additional gains of more rapid recovery and discharge from the hospital would be beneficial. However, based upon this preliminary experience, no such advantages have been realized. The factors that contribute to postoperative ileus and postoperative recovery are not fully understood. However, it is suspected that the length of surgery, intraoperative bowel manipulation, and postoperative analgesia are all contributory factors. This last variable may be determined, at least in part, by the length of the incision and the consequent degree of postoperative pain. Although laparoscopic TAC lengthens the operation by 35 percent, it also conversely reduces the length of the incision by more than 35 percent. This cosmetic advantage is not trivial to typical young active patients with CI, FAP, or MUC who undergo TAC with either ileoproctostomy or ileoanal reservoir. Though the same degree of bowel manipulation is required through this smaller incision, this manipulation may be accomplished with instruments rather than with normal traction. Our hypothesis, which might explain these surprisingly unimpressive results, is that, although a small and cosmetically superior incision is created, a tremendous amount of traction through this incision is necessary. Therefore, if the entire procedure could be accomplished with instruments as an intracorporeal technique, a more obvious benefit might be realized. This benefit might extend to one or more of the following advantages: reduced length of ileus, shortened hospital course, and decreased postoperative pain. Throughout the preliminary developmental phase of laparoscopic colorectal surgery, enthusi-

Group I

Group II

Mean (Range)

Mean (Range)

150 (90-195) 4.7 (3-7) 8.0 (7-10) 0 0

230 (180-300) 5.3 (3-9) 9.2 (7-11) 0 0

asm must be tempered with reality. Unlike the situation with the gallbladder, where laparoscopic surgery has revolutionized the management of gallstones, the advantages of laparoscopic colon resection are more elusive. It is too early to come to the conclusion drawn by others, though these reports have been strictly of segmental colonic resections .6 The fact that the above-cited resections were limited segmental resections may account for the difference in results between the above-cited series and those contained in the current report. Jacobs e t aL 6 have stated that laparoscopically assisted colectomies will become as accepted as laparoscopic cholecystectomies. While this may be true, it is incumbent upon the surgical community to either prove or disprove this supposition. Laparoscopic colectomy offers multiple theoretic advantages over the traditional open techniques. One distant disadvantage is the potential for compromise of cure when operating for colorectal carcinoma. Specifically, failure to adhere to basic proven surgical tenets in order to facilitate inadequate or cumbersome technology is unacceptable. We must, therefore, continue to assess the parameters in a meaningful prospective fashion in order to perform the necessary statistical evaluations needed to decide what role laparoscopic colon surgery will have in our future armamentarium. 7 The mere feasibility of laparoscopic colectomy does not equate with its appropriateness for the decision to use this technology. REFERENCES

1. Johansen OB, Wexner SD. Laparoscopic colectomy. In: Keighley MR, Williams NS, eds. Textbook of coloproctology. London: Balliere Tindall, 1992 (in press). 2. Wexner SD, Johansen OB. Laparoscopic bowel resection: advantages and limitations. Ann Med 1992;24:105-10.

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3. Nogueras JJ, Wexner SD. Laparoscopic colon resection. Perspect Colon Rectal Surg 1992;5:79-97. 4. Wexner SD, Daniel N, Jagelman DG. Colectomy for constipation: physiologic investigation is the key to success. Dis Colon Rectum 1991;34:851-6. 5. Wexner SD, James K, Jagelman DG. The doublestapled ileal reservoir and ileoanal anastomosis: a

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prospective review of sphincter function and clinical outcome. Dis Colon Rectum 1991;34:487-94. 6. Jacobs M, Verdeja GD, Goldstein DS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1992; 1:144-50. 7. Policy statement, American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1992;35(1):5A.