1. Laparoscopic Sigmoid Colon Resection for Diverticular Disease George Ferzli, MD, FACS Professor of Surgery, SUNY Downstate Health Science Center, Brooklyn, NY

2. How is it done? 1. Lateral Approach 2. Anterior Approach

3. Patient With Large Ventral Hernia

5. Trocar placement : Lateral Position

6. Lateral position Splenic Flexture Mobilization

7. Lateral Approach I nferior Mesenteric Artery

8. Lateral Position Lateral trocar cuts sigmoid

9. Repair - Lateral Position If proximal colon can be brought through lateral incision tension-free, the repair will be tension free

10. End to End Anastomosis

11. Lap. Sigmoidectomy - Lateral Position

12. Laparoscopic Sigmoidectomy – Lateral Position

13. Lateral Approach

16. Trocar Placement : Anterior Position

17. Anterior position 1 2 Trocar in inguinal crease cuts sigmoid

18. Repair - Anterior Position If proximal colon can be brought through inguinal crease trocar incision, tension free repair will be successful

19. Anterior Approach

20. Anterior Approach

23. Laparoscopic Versus Open Colectomy for Cancer

24. Colorectal Resection Laparoscopic vs. open resection for carcinoma RHC = Right hemicolectomy; Trans = Transverse; AR = Anterior resection; Sig = Sigmoid; LAR = Low anterior resection; APR = Abdominoperineal resection Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46

25. Colorectal Resection Laparoscopic vs. open resection for carcinoma Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46 19.1% 13% Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III) 22% 12.2% Recurrence rates 6% 0.5% Wound complications 450 150 Blood loss, mL 9 5.6 Hospitalization, days Open (n=224) Laparoscopic (n=192)

26. Colorectal Resection Laparoscopic vs. open resection for carcinoma Santoro E et al, Hepato-Gastroenterology 1999; 46:900-904 1 1 Liver+Peritoneum+ Trocar-site or scar 4 4 Liver+ Peritoneum 5 5 Multiple site metastases 1 1 Regional 4 2 Liver 5 3 Single site metastases 10 (23%) 8 (20%) Overall metastases 43 40 No. of cases (n) Open Lap. Follow-up

27. Colorectal Resection Laparoscopic vs. open resection for carcinoma Curet MJ et al, Surg Endosc (2000) 14: 1062-1066 1 6 4 Late death from cancer (mean follow-up 4.9 years) 12 10 11 Number of lymph nodes 32 26 26 Length of specimen (cm) 8, 100% 5, 28% 1, 5% Complications (n, %) 8 7.3 5.2 Length of stay (days) 7 5.8 4.1 Regular diet (days) 5 4.4 2.7 Clear liquids (days) 6 4 3 ICU stay (days) 683 407 284 Blood loss (mL) 242 138 210 Operating room time (min) Converted (n=7) Open (n=18) Lap (n=18) 1 1 0 Recurrence

29. Long-Term Survival After Laparoscopic Colon Resection For Cancer Lap Open

30. Long-Term Survival After Laparoscopic Colon Resection For Cancer Lap Open – Nat. Ca. Database

32. Lap (LCR) Versus Open (OCR) Colectomy 1200 Prospective,Randomized *Hazebroek2002 1200 Prospective,Randomized *Nelson, 2001 LCR>OCR 43 219 Prospective,Randomized Lacy, 2002 LCR=OCR 48.9 197 Prospective, NR Feliciotti, 2002 LCR=OCR 40.3 100 Prospective, NR Anderson, 2002 LCR=OCR 42 248 Prospective, NR Lezoche, 2002 LCR=OCR 60 157 Prospective, Non-Randomized (NR) Champault, 2002 LCR=OCR 60 206 Retrospective review Lechaux, 2002 LCR=OCR 31 Stg I-III 15.5 Stg IV 80 Retrospective review of prospective data Poulin, 2002 LCR=OCR 64.4 + 2.8 102 Retrospective review Lujan, 2002 Recurrence / Long-term Survival Mean /Median Follow-up N Study Design Author/Year

33. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial Antonio M. Lacy et al. The Lancet June 2002, Vol.359, Issue 9325, p.2224-9 NS Overall survival Laparoscopic colectomy 0.02 Cancer-related survival Laparoscopic colectomy 0.001 Overall morbidity Laparoscopic colectomy 0.005 Hospital stay Laparoscopic colectomy 0.001 Oral-intake times Laparoscopic colectomy 0.001 Peristalsis detection And the winner is……. P Value End-point

34. Questions!