Laparoscopic Colorectal surgery

1. Laparoscopy in Colorectal Surgery
Past , Present & Future
Dr K Sendhil Kumar, MS, DNB (Surg Gastro), FICS, FACS (USA),FAIS
Dr. Piyush Patwa, DNB (Gen. Surg), FMAS, FIAGES
Gateway Clinics
Coimbatore

2. History
• The first laparoscopically-assisted colectomy was reported by
Jacobs et al in 1991

3. Laparoscopi Colorectal Surgery
Widely adopted
Up to 60% of elective colectomies are performed by laparoscopy
•Multi port
•Single port
•Hand assisted
•Robotic

4. Difficulties and Concerns
• Multi quadrant surgery
• Technically demanding
• Concerns - lap colorectal resections in malignancy
Potential violation of oncologic principles
Port site metastasis
CO2 effects

5. Benefits
• Many controlled studies & meta-analyses have shown that
laparoscopic colorectal surgery is associated with lesser pain,
earlier recovery of bowel transit and shorter hospital stay as
compared to open surgery

6. Colectomy in Benign Conditions
• Technical difficulties are Higher for benign conditions than with
cancer, particularly when treating patients with inflammatory
disorders such as Diverticular disease or Inflammatory Bowel
Disease, which frequently involves adjacent structures. (Because
of Pericolic fibrosis & lost planes)
Blackmore AE, Wong MT, Tang CL. Evolution of laparoscopy in colorectal surgery:
an evidence-based review. World J Gastroenterol. 2014;20:4926–4933.

7. IBD
• In Crohn’s disease there is a wide range of potential procedures
Stoma
Ileocaecal Resection
Segmental resection
 In Ulcerative Colitis, restorative proctocolectomy is the standard
technique in the elective setting
Other options : Total colectomy with ileostomy
Total colectomy with IRA

8. IBD – Crohn’s Disease

17. Restorative Proctocolectomy
Ileal pouch anal anastomosis (IPAA)
• Operation of choice for highly selected patients with familial
adenomatous polyposis (FAP) and ulcerative colitis (UC)
Elective colectomy at the age of late teens or early twenties in FAP
Surgery in UC – Not responding to drugs, drugs related
complications, megacolon, bleeding, perforation, stricture, severe
dysplasia, stricture and malignancy
Like CD, UC and FAP generally affect young, motivated patients to whom
cosmetic outcome of surgery can be an important factor.

18. Ulcerative Colitis – TPC with IPAA

19. Rectal Prolapse
• Abdominal Vs Perineal Approach
• Laparotomy Vs Laparoscopy
• Resection Vs No resection
• Suture Vs Mesh
• Ventral Vs Dorsal Mesh

29. Perineal Procedure for Rectal Prolapse

33. Sigmoid Diverticulosis
• Common condition in people on a traditional Western diet; 10 to∼
25% of those with diverticulosis will develop diverticulitis
• Medical management is an effective strategy for the majority of
cases of uncomplicated diverticulitis
• Surgery may be performed after 2 to 3 attacks of uncomplicated
diverticulitis
• Complicated diverticulitis is an episode associated with abscess,
fistula, obstruction, bleeding, or free perforation

42. Sigmoid Volvulus

48. Hartmann’s Reversal
Advantages of Laparoscopy Compared with open surgery
• The size of the abdominal incision is minimized, reducing the risk
of wound infection—a frequent complication with colostomy reversal
• Splenic flexure mobilization is facilitated by laparoscopic
visualization of the upper abdomen without extending an incision
into the midepigastrium

57. Mucocele of Appendix
• The mucocele of the appendix is a descriptive & unspecific term to
define the cystic dilation of the appendix caused by the
accumulation of mucus secretion
• This process is slow & gradual, with no signs of infection inside the
organ
• It results from the lumen obstruction in the appendix, which is
secondary to the inflammatory or neoplastic proliferation of the
appendix mucosa, or of lesions in the cecum, adjacent to the
appendiceal ostium

60. Tuberculosis
• The most common site of GI involvement is the ileocecal region
which is involved in 64% of cases of gastrointestinal TB
• Isolated involvement of colon is 10.8%.

61. ICJ TB in a case of suspected Appendicitis

62. Transverse colon mass?

65. Laparoscopic Colorectal Surgery for
Malignancy

66. Surgical technique – Same concept
• Proximal vessel ligation depending on tumour
• Enbloc mesocolic / Mesorectal excision with adequate tumour free
radial margins
Medial to Lateral Dissection

67. Concepts that No longer exist
• Extended lymphadenectomy
• Extended resection margin
• No touch technique
• Early ligation of vessels in medial to lateral approach

68. Things to be avoided
• Excessive force
• Use of instruments not suitable for handling bowel
• Tumour perforation – has increased risk of tumour recurrence
• decreased 5 yr survival
• Non-adherence to oncological principles

69. Tumour localisation
• Concern in early lesion - permanent tattooing before surgery
• Intraoperative colonoscopy – CO2 to be used for rapid absorption

70. Bowel Preparation before surgery
Mechanical bowel preparation - a standard practice
• Met analysis – no clear benefit
• RCT – no benefit
Bowel preparation facilitates bowel manipulation and readies colon
for intra op colonoscopy

71. EVIDENCES
• European RCT – Barcelona trial – survival advantage , fast recovery
• Barcelona trial – AJCC stage III had better overall survival and decreased recurrence rate for
lap than open surgery
• COLOR ( colon cancer ) trial ( 1248)– non significant 3 yr Disease survival advantage
for open than lap surgery
• COLOR II - lap vs open - no difference ( 2015 – long term results )
• COLOR III – Ta TME vs lap TME
Lacy AM, Garcia-Valdecacas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open
colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet
Kuhry E, Bonjer HJ, Haglind E, et al. COLOR Study Group. Impact of hospital case volume on
short-term outcome after laparoscopic operation for colonic cancer. Surg Endosc 2005

72. No difference in OS , DFS and local
recurrence
• CLASSIC trial (794 – colorectal cancer ),
• COST trial ( 872 – colon cncer )
• Lap. Colon sugery is an Acceptable alternative to open
colon cancer surgery
• RCT from Australian and New Zealand
Clinical Outcomes of Surgical Therapy Study Group. A comparison of
laparoscopically assisted and open colectomy for colon cancer. N Engl J Med
2004;350(20):2050-9

73. Systematic review : 2014

74. LATEST TECHNOLOGICAL INNOVATIONS
• Single incision laparoscopic surgery (SILS): a unique port is used,
usually in the umbilicus or at the site where a stoma is planned.
• Robotic laparoscopic colorectal surgery
• Natural orifice transluminal endoscopic surgery (NOTES)
• Transanal excision (TAE)
• Transanal minimally invasive surgery (TAMIS) - by Atallah et al. in
2010
• Transanal endoscopic microsurgery (TEM)-Buess G,Theiss
R,Günther M, Hutterer F,Pichlmaier H Leber Magen Darm.1985
Nov; 15(6):271-9.

75. SILS – a safe and feasible technique
Pelosi et al - 1992
• Minimises trocar related complications
• Reduces inflammatory response
• special forceps and colon lifting technique
• No difference between SILS and Lap Colorectal surgery
• Maggiori L, Gaujoux S, Tribillon E, Bretagnol F, Panis Y. Single- incision laparoscopy for colorectal resection: a
systematic review and meta-analysis of more than a thousand procedures. Colorectal Dis 2012;
• Zhou YM, Wu LP, Zhao YF, Xu DH, Li B. Single-incision versus conventional laparoscopy for colorectal
disease: a meta-analysis. Dig Dis Sci 2012
• Fung AK, Aly EH. Systematic review of single-incision laparo- scopic colonic surgery. Br J Surg 2012

76. Robotic colorectal surgery
• Safe and feasible option
• Better short term results
• More nodes harvested and more resection margins –
• No difference in Disease free survival , overall survival and local
recurrence rates
Araujo SE, Seid VE, Klajner S. Robotic surgery for rectal cancer: current immediate clinical and
oncological outcomes. World J Gastroenterol 2014
Park EJ, Cho MS, Baek SJ, Hur H, Min BS, Baik SH, Lee KY, Kim NK. Long-term oncologic
outcomes of robotic low anterior resection for rectal cancer: a comparative study with laparoscopic
surgery. Ann Surg 2015
Yang Y, Wang F, Zhang P, Shi C, Zou Y, Qin H, Ma Y. Robot- assisted versus conventional laparoscopic
surgery for colorectal disease, focusing on rectal cancer: a meta-analysis. Ann Surg Oncol 2012

77. IRIS – self illuminating B/L ureteric stents

78. Technical aspects in laparoscopic
Colorectal surgery in Malignancy

79. Laparoscopic Anterior Resection : Video

80. Surgical approaches for
Rt colectomy
• Maedial to lateral
• Laterl to medial
• Top down
• Inferior to superior

81. Laparoscopic Right Hemicolectomy
colorectal presentationLap Right Hemi 5 min.avi

82. Conclusion
• The applicability of laparoscopy to many complex colorectal
procedures continues to expand, and has been shown to be
feasible and safe in experienced hands
• Clinically relevant advantages have been clearly demonstrated in
selected patient populations. Laparoscopic surgery for benign &
Malignant colorectal disease should be considered in patients
suitable for this approach to an open abdominal operation