Trends in Clinical Practice

Laparoscopic Bowel Resection: Advantages and Limitations

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Steven D. Wexner and Olaf 6. Johansen

Laparoscopic surgery has been successfully employed for many years by gynecologic surgeons. Over the last several years, a tremendous increase in the enthusiasm towards laparoscopic surgery has reached the general and colorectal surgical communities. This enthusiasm was initially directed towads laparoscopic cholecystectomy but subsequently has expanded to laparoscopic appendectomy and laparoscopic bowel resection. Currently, laparoscopic bowel surgery is undergoing critical appraisal. Through meaningful prospective data retrieval, answers are being obtained to questions dealing with the efficacy and utility of this technique for colorectal diseases. Specifically, although laparoscopic colorectal surgery is feasible, one cannot definitively attest to its superiority over or even equivalence to standard open laparotomy at the present time. However, in small select series, including our own, our preliminary experience indicates that laparoscopic surgery may well, in the near future, be an acceptable substitute for standard laparotomy. This article will discuss the techniques of, instrumentationfor, and preliminary results with a program of laparoscopic bowel resection. Key wors: Colectomy; laparoscopic colectomy; colon resection; therapeutic laparoscopy; colorectal carcinoma; inflammatory bowel disease. (Annals of Medicine 24: 105-1 10, 1992)

Laparoscopic surgery has been successfully employed for more than fifteen years by gynecological surgeons (1). The majority of these procedures have been diagnostic, although therapeutic intervention has recently gained wide acceptance. General surgeons subsequently adopted pelvic laparoscopictechniques for other intra-abdominal applications. Specifically, cholecystectomy, appendectomies, and herniorrhaphy have recently gained widespread popularity. Much of the enthusiasm has resulted from claims of decreased pain and shorter hospitalization associated with this minimally invasive surgery (2). Because of the pain, disability, and cosmetic insult related to traditional open procedures, there has been a great impetus in development of newer, less invasive methodsfor dealing with many of the common surgical ailments. Laparoscopic surgery appears to be rapidly fulfilling this need, the question no longer being whether laparoscopic techniques have a place in general surgery, but rather what are the limits of its application. The first laparoscopic procedure to be performed within the realm of general surgery were appendectomies. Initially From the Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida, USA. Address and reprint requests: Steven D. Wexner, M.D., Department of Colorectal Surgery, Cleveland Clinic Florida, 3000 W. Cypress Creek Rd. Fort Lauderdale, Florida, USA. 33309.

(1983) these were done as secondary procedures during gynecologicalsurgery; however, in certain localizedcenters, it soon became the modality of choice when dealing with acute appendicitis (3). In 1987, Mount of Lyon, France, already facile in laparoscopic techniques from his experience with laparoscopic gynecologic surgery and laparoscopic appendectomies, turned his attention to the right upper quadrant and performed the first laparoscopic cholecystectomy (1). This promising new technique rapidly spread after an American experience was published by Reddick in 1989 (4). The laparoscopic cholecystectomies were initially condemned by both the European and the American academic surgical communities because all of the reports which extolled its virtues were based upon anecdotal experiences, the safety of laparoscopic cholecystectomy being initially subject to question. However, despite the delay caused by appropriately cautious skepticism, eventual critical appraisal confirmed the acceptable morbidity associated with the technique when performed by appropriately trained and credentialed individuals. Regardless of which operation one performs on the gastrointestinal tract, basic surgical principles must be followed in order to achieve a successful outcome. There must be excellent exposure of the operative field, allowing the surgeon adequate visualization of all vital structures. Often times, this means that retraction of one form or

Wexner Johansen

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Table 1. Possible indicationsfor laparoscopic intestinal surgery.’

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Indication

Procedure

Carcinoma

Segmental resection with intra or extracorporealanastomosis Abdominoperineal resection

Diverticulitis

Segmental resection with anastomosis of Hartmann

lnflammatoty bowel disease

Proctocolectomy with restorative ileoanal anastomosis

Massive colonic bleeding

Segmental or subtotal colectomy

Ischemic colitis

Segmental or subtotal colectomy

Polyposis

Subtotal or proctocolectomy with ileorectal anastomosis or ileoanal pouch

Colonic inertia

Subtotal colectomy with ileorectalanastomosis

Trauma

Segmental resection or primaty repair

Other

Closure of ileostomyor colostomy to Hartmann’s pouch Creation of loop ileostomy Creation of loop colostomy Resection with creation of sigmoid colostomy and Hartmann’s procedure Resection with creation of end Brooke ileostomy and Hartmann’s procedure

Not meant to be a complete list

another is required. If resection is planned, the target organ must be mobilized by dividing its attachments to other viscera and retroperitoneal structures, and its vascular supply interrupted. At time of resection, there should be no spillage of enteric contents in the peritoneal cavity. The specimen must be retrieved intact in order to attain a complete pathologicalanalysis. The anastomosis must be circumferentially intact, tension free, and well vascularized. These tenets have held true over the decades of evolving technology.As such, these basic precepts are of paramount importance regardless of the anastomotic technique employed. The excitement of the availability of new “minimal access” surgicaltechniques must not defocusthese sharply delineated surgical axioms. Compromise of established proven surgical principles cannot be accepted to facilitate technique but rather technical advances must keep pace with the rigors of sound surgery. With these thoughts in mind, this chapter reviews the available options for laparoscopic and laparoscopically-assisted intestinal anastomoses.

Indications and Contraindications Current indications for laparoscopic bowel resections include both benign and malignant conditions (Table 1). Because of the rapid development of new technology to facilitate additional procedures, however, this list must be constantly amended. In theory, all of these conditionscould be successfully treated by a laparoscopic approach. However, it would seem prudent, at least initially, to limit laparoscopicbowel resectionsto electivesituations in which the bowel is noncompromisedand has been properly preparedwith a mechanical bowel prep. Other than gross fecal peritonitis, specific contraindications are not uniformly accepted, although the level of frustration is certainly an important factor. Specifically,obese patients, patients who have had prior laparotomies resulting in extensive adhesions, patients with large carcinomas, and patients with large phlegmons will provide challenge for the surgeon. The range of available instrumentation is constantly

increasing. Initial products were small and were designed for laparoscopic cholecystectomy. Present enthusiasm regarding the potentialcolorectal applicationsof laparoscopy, however, have led to the development of instruments more appropriate for intestinal surgery.

Preoperative Preparation and the Initiation of Laparoscopic Surgery Our preoperative preparation is the same as for open procedures (5). All patients undergo a standard mechanical cathartic bowel preparation (four liters of a polythylene gut lavage solution (Golytely, Braintree, Massachusetts)on the day prior to surgery. In addition, both oral and broadspectrum parenteral antibiotics are administered. After the inductionof general endotrachealanesthesia,a nasogastric tube and an in-dwelling bladder catheter are placed to minimizethe risk of trocar injury to the stomach and bladder, respectively. The patient is placed in the supine modified lithotomy position in the Allen stirrups (Allen Medical, Bedford Heights, Ohio). This allows transanal colonic access should colonoscopic identification of the site of a small lesion be required. This is more important in a laparoscopic colectomythan in a laparotomysituationas tactile sensation is lost in the former condition. In addition, current technological constraints demand either the (often prohibitively) expensive use of multiple staplers or force a compromise in basic surgical tenets. Exercise of this latter option requires leaving open ends of bowel within the peritoneal cavity during at least part of the anastomotic procedure. The sequelae of fecal contamination are potentially disastrous. Therefore, the ability to use the colonoscope for intraoperative intracolonic lavage and verification of bowel preparation is an added advantage of the supine modified lithotomy position. Figures 1-3 illustratepossible port and personnel placement. The abdomen is prepped and draped in the standard fashionto providewide exposure. The patient is then placed in steep Trendelenburg position and a 1 cm transverse incisionis madejust below the umbilicus. The Verres needle

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Laparoscopic Bowel Resection: Advantages and Limitations

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Figure 1. Port and personnel placement for right hemicolectomy (patient in lithotomy position). 10/11 mm port placement X= S= Surgeon Assistant A= Monitor M= __-= Incision to perform extracorporeal anastomosis and remove specimen. Additional ports maybe necessary

Figure 2. Port and personnel placement for sigmoid colectomy (patient in lithotomy position). X= 10111 mm port placement S= Surgeon A= Assistant M= Monitor ___ - Incision to remove specimen and perform extracorporeal anastomosis. Additional ports maybe recessary

is introduced and correct placement is verified. This is done in four ways. Firstly, the surgeon should have a manual tactile sense that the needle has entered the peritoneal cavity. Secondly, an audible noise should be appreciatedas the needle enters the abdominal cavity. Thirdly, a few cc of sterile water are placed on top of the vertically held needle conus. By lifting the anterior abdominal wall, negative intraabdominal pressure is created and the liquid is drawn into the abdominal cavity. Lastly, high flow insufflation should result in a gradual rise in intra-abdominalpressure. A rapid rise in pressure or the appearanceof subcutaneouscrepitus indicate preperitonealneedle placement.After pneumoperitoneum is established with CO, to a pressure of 15 mmHg, the Verres needle is removed and a 10 mm trocar is placed through this infraumbilical port site. The camera is then introducedthrough the port and all subsequent work is done under direct endoscopic visualization.

should be at least 10 mrn in diameter fortwo reasons. Firstly, in gallbladder surgery, the target organ is fixed and localized, minimizing or eliminating the need for camera and instrument movement. In intestinal surgery, however, there is a need for frequent repositioning of both the camera and the instruments. Hence, use of all 10 mm ports permits maximal surgical flexibility. This issue highlights an impor-

Subsequent Port Placement Regardless of the type of resection contemplated, there must be adequate exposure of the operative fields allowing the surgeon and his assistants good visualization. Thus, as in open procedures where incision location and length are of paramount importance to facilitate these goals, port placement for laparoscopic intestinal surgery assumes an equally important role. The selection of port sites depends upon the proposed operation. In general, it is important that ports be close enough to one another so that instruments can reach the operative field with ease, yet not so close that there is ongoing intra-corporeal clashing of the instrument, so called “sword-fighting”.If any future incisions are planned, such as for a stoma, drain, or for an extracorporeal anastomosis, attempts should be made to place ports at these sites. Therefore, the port sites can subsequently be either enlarged or incorporatedwithin these other incisions. All ports

7

X

\

x2

/

Figure 3. Port placement for total or subtotal colectomy. (patient in lithotomy position) X= 10/11 mm port placement Port site and future site for temporary diverting loop X, = ileostomy Port site and future site for axion drain X, = X= Addition port sites 0= Umbilicus -_- -- Suprapubic incision for ileoanal reservoir construction or for ileorectal anastomosis. Additional ports maybe recessaly

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tant difference between gallbladder surgery and bowel surgery. Secondly, in orderto significantfydecreasethesize of a Kocher cholecystectomy incision, the ports utilized for laparoscopic cholecystectomy must be as few in number and as small in diameter as possible. This is crucial since a Kocher incision is often only 8-10 cm in length. However, an appreciable reductionfrom a standard 25-30 cm midline celiotomy incision can be realizedeven after introductionof five 12 mm ports. For right colectomies, two monitors are employed, each positioned at a 45 degree angle, one near the head of the bed, the other near the foot. The surgeon and assistant stand on the left side of the patient. After the initial umbilical port is placed, subsequent ports are placed under direct vision, one suprapubic to the right of the midline and the other halfway between the umbilicusand xiphoidjust to the right of the midline. This latter position avoids the falciform ligament. Afourth trocar may be needed in the rightsubcostal midclavicular line to fully mobilizethe hepatic flexure. However, this fourth port is initially omitted and is inserted only if the situation warrants. For sigmoid colectomies, both the surgeon and assistant stand to the right side of the patient, while the monitors are being placed to the patient‘s left and at the foot of the bed at 45 degree angles. After the initial umbilical port is placed, a second trocar is placed in the suprapubic position, slightly to the left of the midline while a third port is placed at the same level as the infraumbilical port in the midclavicular line. Thus, an extracorporealanastomosis can be performed through an incision which connects the two superior port sites. It should be noted that optimal port placement for various bowel resections is still evolving as experience is being gained. Certainly, “ideal” port placements will vary depending on the habitus of the patient and the individual preferences of the surgeon. For this reason, we prefer not to place all ports prior to commencement of the dissection,but rather to add ports as needed after the internalanatomy has been assessed.

Dissection and Mobilization Before mobilizationis attempted, a thorough visual inspection of the abdominal contents is petformed and adhesions are lysed. This is best accomplished by a combination of traction and adhesive band division with the monopolar electrocautery. There are many advantages of the monopolar cautery over lasers for laparoscopic colectomy, including greater operator familiaritywith cautery, much lower overall costs, and less equipment in an already crowded operating room. Furthermore, the potential for inadvertent injury to adjacent organs is a major drawback to the use of the laser. Table positioning can facilitate the retraction of loops of bowel from the operative field. For example, when mobilizing the sigmoid colon, placing the table in Trendelenburg position and tilted to the right can help to keep the loops of small bowel out and away from the pelvis. Similarly, when mobilizingthe hepatic flexure, reverse Trendelenburgand a table tilt to the left can be helpful. If further retraction is needed, an assistant can insert a laparoscopic retractor through one of the ports. Mobilization of the colon from the retroperitoneum is accomplished by graspingthe colon with speciallydesigned non-crushing intestinal clamps and retracting in a medial

direction, thereby exposing the the Line of Toldt. This a vascular plane is then divided with a combination of blunt and sharp dissection;electrocautery is used for both dissection and hemostasis. Larger vessels located at the flexures are ligatedwith either surgical clips or endoloops. Once full mobilization has been accomplished, the mesenteric vascular supply is divided. If an extracorporeal anastomosis is planned, this vascular ligation can also be done in an extracorporeal fashion. However, intracorporeal vascular division is mandatory if an intracorporeal anastomosis is planned and can also be performed prior to exteriorization for an extracorporealanastomosis. Vascular division is best facilitatedby skeletonizationof the vessels and ligation with either clips or suture material. Most vessels are either doubly ligated or doubly clipped. Alternatively, an endoscopic linearkutter stapler with a 30 mm vascular cartridge can be used for mesenteric division. Once the mesentery is divided, and the lines of resectionare free of vessels, division of the bowel is ready for transection.

Segmental Resection lntracorporeal Anastomosis The technique used in dividing the bowel is an important step in the subsequent anastomosis of the two bowel ends. The endoscopic linear-cutter stapling instrument creates two stapled ends of bowel, thereby minimizing spillage of intraluminal contents. This is preferred to the potential spillage which can easily occur if the bowel is transectedand left opened within the peritoneal cavity. Despite diligent preoperative bowel preparation and the use of atraumatic occlusive clamps, fecal contamination is possible and its sequelae are potentiallydisastrous. Furthermore, if boththe proximal and distal limbs of the bowel are occluded with clamps, two less ports are available for subsequent manipulationand anastomosis.Therefore, the endoscopic stapler is a very valuable instrument not only for anastomotic construction but also for preliminary bowel transection. Routine use of the original endoscopic stapling instruments was precluded due to their short length (30 mm staple line). Adequate construction of an ileocolonic anastomosis demanded the application of the stapler at least 7 times, not counting any additional use for mesenteric vascular division. Thus, a minimum of 500 British pounds sterling in stapling costs would be accrued to create an anastomosis which could be much more inexpensively executed in an extracorporeal manner. However, newer longer instruments will soon be available and may make intracorporeal anastomosis a viable option. After each end of the bowel is divided, the bowel ends are grasped with Babcock clamps and the antirnesenteric corners of each staple line are excised. A side-to-side (functional end-to-end) anastomosis is then created with one or more additional applications of the endoscopic stapler. The cut edges of the bowel are then grasped with Babcock clamps and the anastomosis is inspected for hemostasis. The lumen can be irrigated with saline, povidone-iodine,or both. The opposing cut edges of the bowel are then held with Babcock clamps and the enterotomy is closed with one or more additional firings of the stapler. The excess excised bowel is then removed through one of the large ports. The mesenteric defect can either be closed with a suture or with a series of clips.

Laparoscopic Bowel Resection: Advantages and Limitations

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Table 2. Laparoscopic procedures performed (8191 to 9/91).

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Age Indication

Procedure

1. 82 Adenocarcinoma right colon

Richt hemicolectomy with ileocolonic anastomosis

2. 17 Familial adenomatous polyposis

Proctocolectomy with restorative ileoanal anastomosis

3. 69 Cecal carcinoma

Right hemicolectomy with ileocolonic anastomosis

4. 39 Colonic inertia

Subtotal colectomy with ileorectal anastomosis

5 76 Rectal carcinoma at 8 cm

Low anterior resection

6 65 Rectal carcinoma at 12 cm

Anterior resection

7. 27 Ulcerative colitis

Proctocolectomy with restorative ileoanal anastomosis

8. 63 Malignant sigmoid polyp

Sigmoid resection

9. 38 Familial adenomatous polyposis

Proctocolectomy with restorative ileoanal anastomosis

10. 43 Familial adenomatous polyposis

Proctocolectomy with restorative ileoanal anastomosis

11. 72 Right colon carcinoma

Right hemicolectomy with ileocolonic anastomosis

12. 32 Ulcerative colitis

Proctocolectomy with restorative ileoanal anastomosis

Retrieval of the resected specimen can pose a dilemma. There are those who believethat in some situationstransanal extraction of the resected colon can be performed. However, for the bulky lesion, or for a specimen containing carcinoma, this option is clearly contraindicated. One requisitesequelaof suchan illfatedadventureis the unphysiologic anal sphincter dilation necessaryto deliverthe left colon and its attendant mesentery out of the anus. Moreover, tumor seeding throughout the rectum and at the cut edge is certainly a possibility. Clearly, however, the bulky colon does not readily pass through standard size ports. Until larger ports are developed, in most situations, the surgeon will need to enlarge one of the port sites in order to retrieve the specimen. Moreover, if a neoplasm has been resected, the specimen should be placed in a plastic bag prior to transabdominal extraction. If the decision is made to retrieve the specimen through an abdominal incision, consideration should be given to extracorporealanastomosis. After full intracorporealmobilization, a small incision is made in the abdominal wall, usually by enlarging one of the laparoscopic ports, through which the mobilized colon is then delivered. The bowel is divided, and either a handsewnor a stapled anastomosis is created. This technique takes advantage of the ability to laparoscopically mobilize, thereby permitting a reduction in the size of the incision requiredto remove the specimenand create the anastomosis. At the Cleveland Clinic Florida, we have initiated a Laparoscopic Colon Surgery Registry. Our initial experience on 12 patients is based on the application of this combined intracorporeaVextracorporea1approach. The results of this pilot series are detailed in Table 2. Such a combinedapproach providesa reasonable point from which to initiate a laparoscopic colorectal surgical program by utilizing the advantages of both techniques. The mobilization of the colon can be performedwith excellent visualization, while the resection and anastomosis can be accomplished in the more familiar standard fashion. In addition, performance of an extracorporeal anastomosis allows for suture reinforcement of any nonhemostatic portions of the staple line. Furthermore, imbrication of the closed apical

enterotomy and placement of a stitch to remove tension from the end of the staple line can be undertaken.

Anterior Resection An intracorporeal stapled anastomosis is appealing due to the avoidanceof the tedious laparoscopicsuturing demanded to effect a hand sewn anastomosis. Transanal circular stapler introduction is a procedure already familiar to all surgeons. After laparoscopic mobilization of the sigmoid colon, its vascular supply is interrupted. There are a variety of options available to create the end-to-end anastomosis.

Hand-sewn Extracorporeal Pursestring The rectum is mobilized to a point sufficiently distal to the tumor to permit endoscopic linear cutter stapler application without compromise of cure. Sigmoidoscopicverification of stapler position and sigmoidoscopic rectal washout prior to stapler application are useful adjuncts. This point again highlights the value of the supine modified lithotomy position. The left lower quadrant port is then removed and the incision enlarged to permit extracorporeal delivery of the sigmoid colon. The proximal pursestring can then be applied in any manner desired as the specimen is removed. Subsequently,the anvil from a circular stapler is introduced into the proximal bowel and the bowel is then returnedto the peritoneal cavity. The port site is then occluded with a large (20 mm or larger) port; any excess incision is sutured closed. After re-establishment of pneumoperitoneum, the circular stapler is introduced transanally. The trocar of the circular stapler is then used to pierce the rectal staple line. The circular stapler detachable trocar can be removed through a 10 mm port, and the anvil reintroduced into the receptacle post. The anastomosis is then created in the standard fashion including inspection of the donuts and either air or povidone-iodine verification of anastomotic integrity. Although not aesthetically pleasing, the bowel can be transected intracorporeally and a distal hand-sewn

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pursestringsuture can be applied. This, however, requires infinite patience and has the potential for pelvic contamination. Alternatively, although not physiologically sound, the rectum can be everted through the anus to permit either cross-stapling with a standard linear stapler. The stapled rectum is then reduced into the pelvis with the circular stapler with the trocar recessed within the cartridge. The trocar can then be made to protrude through the staple line and is then removed through one of the ports. The anvil within the proximal bowel is then reaffixedto the receptacle port within the cartridge and the stapler is fired as described above. Another potential technique is the triple-stapling technique. In this variation, the detachable head of the circular stapler, under colonoscopicguidance, is transanally inserted to a level proximal to the proximal line of resection. The bowel is transected at proximal and distal ends with a linear stapling instrument. The shaft of the proximal cartridge is then delivered through the linear staple line. The stapling instrument is then transanally introduced, and an anastomosis is performed in the same fashion as describedabove for the double-stapled technique. This triple-stapled anastomosis has the advantage of obviating the need for a proximal or distal pursestring, but the disadvantage of technical difficulties in positioning the cartridge above the line and potentially seeding malignant cells at the proximal resection line in the process. Other applications of laparoscopy include both stoma creation and closure, abdominoperineal resection, and total proctocolectomy.

Conclusions Throughoutthe preliminarydevelopmentalphases of laparoscopic colorectal surgery, enthusiasm must be tempered with reality. The true morbidity, mortality, and long-term sequelae of the technology remain unknown. Results must be carefully assessed in a meaningful prospective fashion by qualified surgeons. We must, therefore, continue to review these parameters in a meaningful, prospective fashion in order to perform the necessary statistical evaluations neededto decide what role laparoscopiccolonic surgerywill have in our future surgical armamentarium.

Reference 1. 2.

3. 4. 5.

Dubois F. Laparoscopic cholecystectomy:Historicalperspective and personalexperience. Surg Laparosc Endosc 1991; 1: 52-7. Spau A, Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy: Analysis of 500 procedures. Surg Laparosc Endosc 1991; 1: 2-7. Gotz F, Pier A, Bacher C. Modified laparoscopic appendectomy in surgery. Surg Endosc 1990; 4: 6-9. Reddick EJ, Olsen DO, Daniel1JF, et al. Laparoscopiclaser cholecystectomy. Laser Med Surg News 1989; 7: 3 8 4 0 . Wexner SD,Beck DE. Sepsis prevention in colorectal surgery. In: Fielding LP, Goldberg SM; eds. Operative surgery: Colon, rectum, and anus. 5th ed. London: Butterworth Heinemann, 1992 (in press).

Laparoscopic bowel resection: advantages and limitations.

Laparoscopic surgery has been successfully employed for many years by gynecologic surgeons. Over the last several years, a tremendous increase in the ...
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