Transcript Document 7168251

Minimally Invasive Procedures
in Colon & Rectal Surgery
Alan E. Harzman, M.D.
Outline
• Endoscopy
- TEM
- Combined approaches
- Colonic Stents
• Laparoscopy
– “Pure” laparoscopy vs. Hand-assisted
• NOTES
• Laparoscopic Techniques
Goals of Minimally Invasive
Techniques
• Equivalent or improved outcomes
• Equivalent or improved oncologic
outcomes
• Avoid excessive cost
Learning New Techniques
Training Issues
• Learning Curve (20-50 cases)
– ABS Recertification Reports (General Surgeons)
• Mean 11 colectomies/year
• 90th percentile – 23/year
– I did about 40 laparoscopic colectomies as a
fellow.
Rewards of Minimally Invasive
Techniques
Risk/Effects
Of Anesthesia,
Trauma, Etc.
Benefits of
New
Techniques
Operative Time
Endoscopy
Transanal Endoscopic
Microsurgery (TEM)
Transanal Endoscopic
Microsurgery (TEM)
Richard Wolf Medical Instruments Corporation
Transanal Endoscopic
Microsurgery (TEM)
• Suggested uses
– Benign tumors mid to upper rectum
• 5% recurrence
– T1 low-risk lesions
• 3% recurrence
– Palliation or high-risk patients
• Overall 8% recurrence
• Large, long-term, randomized numbers lacking
(Bemelman, 2005)
(Middleton et al, 2005)
Transanal Excision
• Similar
indications
• Similar results
• Lower lesions
only
Nova Plastics
How do you apply principles of
local resection to the rest of the
colon?
• Step 1 – Combine
laparoscopic and
endoscopic resection
• Step 2 – Under
development
(OmicronLab, 2007)
Combined Laparoscopy and
Colonoscopy
(Bemelman, 2005)
Colonic Stents
for Obstructing Tumors
Colonic Stents
• As a bridge to surgery, in hopes of
avoiding a colostomy
• Possibly as a definitive measure in
patients with widespread disease
• 84-96% clinical success rate
• Complications (~25%) include perforation,
stent migration, fistula, reobstruction,
tenesmus (if too low), stool impaction,
bleeding
(Wolff, 2007)
Colonic Stents
(Camunez et al, 2000)
Colonic Stents
Camúñez Study
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•
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Placement in 70 of 80 patients
Resolved obstruction in 67
2 perforated, 1 died
33 patients had surgery after 7 days
Used as final treatment in 35
– Estimated primary patency of 91% at 6
months
(Camunez et al, 2000)
Laparoscopy
Laparoscopy
• Laparoscopic – “Pure”
• Hand-Assisted Laparoscopic
– Is not “lap converted to open”
Laparoscopic Approach
Consideration of Cost
• Time - Per Minute Charge
• Equipment
– Energy devices
• Ligasure
• Harmonic Scalpel
• Electrocautery
– Staplers
– Access devices
• Trocars
• Hand ports
Standard - O.R. Care Time $43.00
ACGME Competency-Based
Goals and Objectives
• Surg 2 Chief Resident
– Systems-based Practice
• Will refine operative skills including cost-effective
utilization of equipment.
Laparoscopy
• Goal - Do the same (oncologic) resection
– 12 lymph nodes
– Ligate feeding vessel at its origin
• Currently little data on RECTAL resection
for cancer
– Societies currently discourage laparoscopic
proctectomy outside clinical trials
Preoperative Considerations
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Site (Right and sigmoid easier)
Tumor size/invasion
Obesity
Previous surgery
Almost always get a pre-op CT (cancer)
Must talk with patient about need for
conversion to open
• Must be able to find tumor/polyp (tattoo!,
0.5cc India ink in 3-4 sites)
Tattoo
Preoperative Considerations
Continued
• Can also locate with BE
• Having to do intraoperative colonoscopy is
a flail
– CO2 colonoscopy may be better
• Bowel Preparation
– Utility is debatable, but with laparoscopy it
makes bowel easier to handle
Conversion to Open
• 10-25%
– Obesity
– Prior surgery
– Acute inflammation
• Fistula – 50% conversion
– Tumor bulk
• Not a failure
• Early conversion preserves good
outcomes
(Wolff, 2007)
Evaluating Outcomes
• Tracking Outcomes
– Current national push
– To be included in “Maintenance of
Certification”
• “Intention to Treat”
– If you started laparoscopically and had to
open, it’s not fair to put that patient’s outcome
in “open” group.
(Wolff, 2007)
Laparoscopic Colectomy
What difference does it make?
Laparoscopic Colectomy
What difference does it make?
•It helps you get a job
•Patients like it (thanks to the internet)
•Referring doctors like it
•But what difference does it really make
Outcomes
• Ileus – average 1-2 days shorter with
laparoscopy
• Less need for narcotics
• Quicker return of pulmonary function
• Length of stay ~1 day less
• May be influenced by biased expectations
– Who cares?
(Wolff, 2007)
Outcomes – Page 2
• Return to work and quality of life
– No statistical change
– Anecdotally improved
• Cost
– Equipment costs and OR time are greater
– May be balanced or outpaced by shorter
hospital stay
• Time – Average 30-60 minutes longer
(Wolff, 2007)
Port-Site Metastasis
• Initial concern greatly slowed development
of laparoscopic colectomy
• Not born out in major trials
Specific Trials
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Antonio Lacy
COST
COLOR
MRC CLASSIC
Antonio Lacy, et al 2002
• 219 patients
(Lacy et al, 2002)
Antonio Lacy, et al
Overall Survival
p=0.16
(Lacy et al, 2002)
Cancer Related Survival
p=0.02
Antonio Lacy, et al 2008
(Lacy et al, 2008)
COST Trial
Clinical Outcomes of Surgical Therapy Study Group
• 872 patients with colonic adenocarcinoma
• Recurrence
– 16% lap
– 18% open
• Survival
– 86% lap
– 85% open
• Post-operative stay
– 5 days lap
(COST Study, 2004)
– 6 days open
COST Trial
Clinical Outcomes of Surgical Therapy Study Group
• 5 year data published October 2007
• Disease-free 5 year survival
– 68.4% Open
– 69.2% Laparoscopic
• Overall survival
– 74.6% Open
– 76.4% Laparoscopic
• Recurrence
– 21.8% Open
– 19.4% Laparoscopic
(COST Study, 2007)
COLOR Trial
COlon cancer Laparoscopic or Open Resection
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1248 patients
17% conversion to open
BMI>30 excluded (because started in 1997)
Pathologic criteria no different
Time to GI recovery, 1st BM, hospital stay
all one day less
• Complications were equivalent
(COLOR Trial, 2005)
MRC CLASSICC
Medical Research Council trial of
Conventional versus LaparoscopicASsisted Surgery In Colorectal Cancer
• 794 patients
• Pathologic specimens, complications were
similar
• Time to 1st BM 1 day shorter
• Time to diet and discharge similar
between groups
(Guillou et al, 2005)
Hand Assisted Laparoscopy vs.
“Pure” Laparoscopy
• May reduce learning curve
• May be used “up front” or as a “pseudoconversion”
• Need to make an incision large enough for the
specimen anyway
• Outcomes similar to laparoscopy, with operative
times usually shorter
Hand-assist vs. Laparoscopy
(Targarona et al, 2002)
Hand-assist vs. Laparoscopy
(Targarona et al, 2002)
Hand-assist vs. Laparoscopy
Marcello et al
• 95 patients - left or total colectomy
• Randomized to HA vs LAP
• Left colectomy
– 175 minutes HA, 208 LAP (p=0.021)
– Flatus 2.5 vs 3 days (p=0.64)
– Length of stay 5 vs 4 days (p=0.55)
• Total colectomy
– 127 vs 184 minutes (p=0.015)
(Marcello et al, 2008)
In a comparison of “pure”
laparoscopy and HALS, what
does no significant difference
mean?
It means that if you can do it more
easily with one hand in, why not do it?
Robotic Assisted
So far not advantageous, encumbered
by time and cost
(Minimally Invasive
Robotics Association,
2002)
NOTES
Natural Orifice Transluminal
Endoscopic Surgery
(Pai et al, 2006)
(Pai et al, 2006)
Techniques in Laparoscopic
Colon and Rectal Surgery
Laparscopic Hemicolectomy
Technique
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Access
Takedown of previous adhesions
Mobilization and vascular division
Intestinal division
Anastomosis
Closure of mesenteric defect
– Usually skipped
• Closure
Laparoscopic Colectomy
Right Hemicolectomy
Right Hemicolectomy
The Radical Appendectomy Method
= 5mm
=12mm
Extraction
Incision
Right Hemicolectomy
= 5mm
=12mm
Extraction
Incision
Right Hemicolectomy
= 5mm
=12mm
Extraction
Incision
Right Hemicolectomy
= 5mm
=12mm
Hand
Port
Laparoscopic Right Hemicolectomy
Approaches
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Medial-Lateral
Inferior
Lateral-Medial
Top-Down
Largely
Independent
of trocar
placement
If you elevate the right colic
mesentery, what do you find?
(Netter, 1997)
Don’t burn the duodenum!
Don’t laugh. It’s happened more than once.
(Netter, 1997)
Laparoscopic Right Hemicolectomy
Medial Approach
(Netter, 1997)
Laparoscopic Right Hemicolectomy
Medial Approach
Laparoscopic Right Hemicolectomy
Medial Approach
Laparoscopic Right Hemicolectomy
Inferior Approach
Laparoscopic Right Hemicolectomy
Inferior Approach
Laparoscopic Right Hemicolectomy
Lateral Approach
Laparoscopic Right Hemicolectomy
Top Down Approach
Laparoscopic Colectomy
Left Hemicolectomy
Sigmoidectomy
Low Anterior Resection
Left Hemicolectomy
= 5mm
=12mm
Hand
Port
Applied Medical Gelport
Ethicon Lap Disk
Laparoscopic Left Hemicolectomy
Approach
• Mobilize splenic
flexure
• Mobilize sigmoid
• Presacral space
• Divide rectum
• Divide vessels
• Divide sigmoid
vessels
• Exteriorize & place
anvil
• Return & fire EEA
Laparoscopic Left Hemicolectomy
Hand Approaches
• Put 1-2 laps in to retract small bowel and
clean camera
• Sling for splenic flexure
• Handshake for sigmoid vessels
Laparoscopic Left Hemicolectomy
Hand Approaches
Laparoscopic Left Hemicolectomy
Hand Approaches
Summary of Techniques
There are many ways to skin a cat
• Convert what we do “open” to
laparoscopic
• Come up with new ways
• Use new toys
• Undo the embryology
• Be careful!
(Kneen, 2007)
Most useful quote from my fellowship:
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
Summary
• Much to the chagrin of surgery residents,
we continue to search for new ways to
invade the body less to achieve more.
– Less morbidity
– Less mortality
– Less recurrence
– More quality
– More life
Bibliography
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Bemelman, WA (2005).Minimally invasive surgery for early lower GI cancer.
Best Practice & Research Clinical Gastroenterology. 19, 993-1005.
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.
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.
The COlon cancer Laparosopic or Open Resection Study Group,
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Bibliography
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Fleshman, J, Sargent, DJ, Green, E, Anvari, M, Stryker, SJ, Beart, RW,
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Bibliography
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