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Improvements in technique and surgical times have mirrored the development of instruments specifically designed for laparoscopic colectomies. Surgeons interviewed by Laparoscopy in Focus use a variety of instruments for the many procedures that they perform. Some, like the MULTIFIRE ENDO GIA* stapler and the PREMIUM CEEA* stapler, are used by nearly everyone for everything from simple Hartmann closures to more difficult low anterior anastomoses. Procedures and Techniques
And the recently introduced PREMIUM PLUS CEEA* stapler has a 5 cm-longer shaft length for optimal use in both open and endoscopic procedures. A flip-top anvil tilts on its side for easier removal. "I've only had the new PREMIUM PLUS CEEA* stapler a few months myself," said Dr. Fowler. "But it makes it easier to connect the bowel and to remove the stapler after completing the procedure. The low-profile anvil makes it easier to work with when it is in the bowel and the flip-top head makes it easier to remove" from the anastomotic site. The shaft of the instrument extends an additional 5 cm, making access easier, and centimeter markings along the shaft allow for more accurate placement. The PREMIUM PLUS CEEA* stapler, which is available in 21, 25, 28 and 31 sizes, opens and closes with just a few turns of the handle.
Dr. Uddo, who participated in field tests of the anvil for transanal anastomosis, said, "Honestly, this is a spectacular product. Whether it is open or laparoscopic, you can disengage the stapler from the bowel much easier than ever before." His technique is to place the PREMIUM PLUS CEEA* stapler transanally, connect the two pieces of bowel and fire the stapler. "The anvil traditionally was a fixed anvil, and one of the more difficult parts of the procedure was to remove the anvil along with the stapler after the anastomosis had been completed," Dr. Uddo said. "With the TILT TOP* anvil, you fire and, when you open it up, the anvil just flips sideways and slides right out. It's incredibly easy to remove." Dr. Ballantyne reports that his experiences with the new product have been favorable as well.
Sigmoid Resection and Right Colectomy
Dr. Dennis Fowler strategically places four ports when performing either sigmoid resection or right colectomy. "We usually use two ports for bowel-grasping devices and retractors," he explained, and then "scope through one port and dissect through another." For sigmoid resections, Dr. Fowler, who is clinical assistant professor of surgery at the University of Missouri-Kansas City School of Medicine, usually places the laparoscope in the umbilicus, the dissecting port at McBurney's point, and the two 5-mm ports for graspers in the suprapubic midline and in the left midabdomen. In right colectomies, Dr. Fowler puts the laparoscope in the left mid-abdomen, retracting ports in the right upper quadrant and in the suprapubic midline, and a 12-mm operating port either in the upper midline or left upper quadrant. In both operations, he begins the dissection by incising the lateral peritoneal reflection and mobilizing the mesocolon medially. He makes a window in the mesentery, which is then divided. Only the largest or "named vessels" are controlled with clips. The shears facilitate the dissection because they are fast and provide better hemostasis. "Once the mesentery is dissected, the bowel is divided at the lines of resection with the ENDO GIA* stapler," Dr. Fowler said. Specifically, in most cases he chooses to use the ENDO GIA* 30 stapler.
In cases of sigmoid resection, Dr. Fowler makes a 4-5-cm mirror-image muscle-splitting incision to remove the specimen. The technique includes placing purse-string sutures extracorporeally. He has removed some specimens transanally and thinks that with improved instrumentation this may increasingly become the removal route of choice. In right-colon resections, he creates the anastomosis extracorporeally. Dr. Ballantyne performs sigmoid resections by first transecting the proximal rectum. His assistant uses two ENDO BABCOCK* clamps to align the bowel perpendicular to the jaws of an ENDO GIA* 60 stapler. The clamps are used to push the bowel between the stapler's jaws, at which point the jaws are visualized to ensure that the inferior mesenteric vessels are not trapped there. Then, Dr. Ballantyne checks the position of the left ureter. The stapler is then fired, usually only once, and removed. Using either the ENDO GIA* 30 or 60 stapler, the mesosigmoid is divided and ligated. Hemostasis is achieved by the staggered rows of staples from the ENDO GIA* stapler. The stapler is applied during a segmental sigmoid resection on the proximal mesorectum between the rectum and the superior rectal vessels, which are preserved. The distal sigmoid vessels are divided with the ENDO GIA* stapler until the sigmoid colon is sufficiently freed for the retrieval of the specimen. Since complete exposure is sometimes difficult, transection and ligation of the proximal mesosigmoid colon can be easier if it is done extracorporeally. However, the mesosigmoid colon can be visualized in its entirety by using the ENDO BABCOCK* clamps and sequential applications of the ENDO GIA* stapler. Next, the PURSTRING* 65 instrument is closed around a 1-inch wide band of colon that has been cleared of mesenteric fat. A bowel clamp is applied across the specimen side of the point of resection, and a specimen is taken with a scalpel. The surgeon is now ready to insert the anvil-shaft assembly using the new PREMIUM PLUS CEEA* stapler.
Right Hemicolectomy
In cases of right hemicolectomy, Dr. Ballantyne first uses the ENDO BABCOCK* 10-mm clamp to retract the right colon towards the midline. He then opens the retroperitoneum using the ENDO SHEARS* instrument and the ENDO DISSECT* instrument and identifies the right ureter. The retroperitoneal attachments of the right colon and its mesentery are then divided with the ENDO GIA* 30 or the ENDO GIA* 60 stapler. The mesentery of the hepatic flexure and transverse colon are then elevated off the duodenum. The ileocolic vessels, the right colic vessels and the right branch of the middle colic artery are divided near their origins with the ENDO GIA* stapler. This can be accomplished with sutures or stapling devices. The terminal ileum is then divided with the ENDO GIA* stapler. A two- or three-inch incision is made near the umbilicus and the two ends of the divided small bowel are withdrawn. The right colon and proximal transverse colon are delivered through this incision. A point of distal transection is selected in the transverse colon and divided with the GIA* 60 stapler. The specimen is removed from the field. The two ends of the bowel are stapled together with the GIA* 60 stapler and the TA* 55 stapler, forming an ileocolic anastomosis.
Sigmoid Colectomy,
Dr. George Hoffman's technique for these procedures is to divide the bowel intracorporeally at the rectal level and deliver the specimen through a lower abdominal incision. The specimen is then resected and the proximal anastomotic EEA* anvil is placed extracorporeally. The proximal bowel and anvil are then reduced into the abdomen, the incision is closed and the abdomen is reinsufflated. The anvil is mated endoscopically with the transrectally introduced EEA* for the anastomosis. After completion of the anastomosis, Dr. Hoffman tries when possible to close the mesenteric defect. With the exception of the umbilical site, he does not routinely close the fascial defect at the trocar sites.
Low Anterior Resection and Left Colectomy
Right Intracorporeal Anastomosis
Dr. Uddo said that for the most part his technique for anastomosis has not changed a great deal since he first started doing it. The only significant change has been a reduction in the number of ports required for both right and left hemicolectomy.
After mobilizing the right colon, he divides the terminal ileum and transverse colon with an ENDO GIA* stapler. The mesentery is then divided. After lining up the terminal ileum and transverse colon, he stabilizes with bowel clamps. Next, he makes an enterotomy in each limb of the bowel. Once the bowel is lined up and the angle of the staple is ascertained, if an existing port does not provide the appropriate angle, then an additional port is placed for introduction of the stapler into the bowel limbs. "Obtaining the proper angle to introduce the stapling device into the bowel is very important because you don't have much flexibility inside the abdominal cavity," Dr. Uddo said. Dr. Uddo uses both the ENDO GIA* 30 and 60 staplers, depending upon the situation. "I almost always use the ENDO GIA* to perform intracorporeal division of the proximal and distal bowel," he said. "Both the ENDO GIA* 30 and 60 are comparable for providing excellent vascular control." To perform the intracorporeal anastomosis, the ENDO GIA* stapler is usually placed through a port in the right upper quadrant. A 12-mm port is required for the ENDO GIA* 30 and a 15-mm port for the ENDO GIA* 60. Dr. Uddo also places an ENDO GIA* stapler through the umbilical port to close the enterotomies.
As laparoscopic surgery continues to evolve, Dr. Uddo said he suspects that the ability to do intracorporeal anastomoses will help to avoid converting some laparoscopic resections to open procedures. Dr. Uddo pointed out that intracorporeal anastomosis is not difficult with experience, and noted that in some situations-obese patients, patients with thick abdominal walls and those with a short mesentery - an extracorporeal anastomosis cannot be safely performed. Further, intracorporeal anastomosis prevents undo tension on the mesentery, which can lead to mesenteric tears and bleeding, and permits complete visualization of the bowel throughout this portion of the procedure. Dr. Uddo does intracorporeal anastomosis for ileocecal resection, right hemicolectomy, and many segmental colon resections.
"I have found that flexibility in the placement of ports for right and transverse colon resections is beneficial in being able to successfully complete the procedure," he said. In left hemicolectomies he usually finds four ports to be sufficient. "I think it is imperative that, in any case done for cancer, both the proximal and distal extent of the resected bowel be divided intracorporeally and that mesenteric division should be performed intracorporeally. This is essential so that the specimen can be placed in a retrieval sack for transport out of the abdomen." Dr. Uddo usually uses the ENDO CATCH* specimen removal device. "Completing the intracorporeal anastomosis has become easier with increased experience. When the instrument angles line up well with the bowel, intracorporeal anastomosis can be accomplished very quickly."
Starting the Program
Transanal Technique
Another controversial aspect of laparoscopic colectomy is the issue of transanal removal of the specimen. The principal proponent of this technique is Dr. Morris Franklin, who has amassed an impressive record of 260 colon resections. Transanal specimen removal is a truly laparoscopic procedure, as opposed to a laparoscopic-assisted procedure, and makes a large incision unnecessary. But some fear that the technique is unproven and may be risky for the patient. "I am not currently doing transanal technique myself, and I think it takes an excellent surgeon with a meticulous technique to do that," said Dr. Whelan. The method used by Dr. Franklin involves placing the specimen in a bag inside the abdominal cavity. "With a diverticulitis patient, for example, there is nothing wrong with cutting the specimen into multiple parts, as long as there is no abscess, and taking it out in pieces. We have done many of our sigmoid diverticulitis patients that way," he said. "As far as cancer is concerned, we have to make a judgment whether or not we can remove it transanally based on the size of the cancer." In some lower lateral resections, for instance, Dr. Franklin has taken out tumors as large as 5-6 cm in diameter. "Colorectal surgeons will say that this may cause sphincter dysfunction, and there is no doubt that some transient dysfunction can occur, particularly as measured by electromyography," he said. "But functionally, is this a problem? The answer is no. If you do a digital examination of a patient, there is also a measurable transient dysfunction, but this is not a significant problem unless the patient has an anal stricture," Dr. Franklin said. "In fact, we dilate the anus only to the same degree as needed to insert a large stapling instrument through the anus, say a 31-mm PREMIUM PLUS CEEA* instrument. Most specimens will pass through that space." To keep the procedure purely intracorporeal, Dr. Franklin will place a cancer specimen in a retrieval bag and then pull it through the rectum. Still, others are cautious. Dr. Hoffman said he does not do transanal specimen removals and is concerned that it increases the chances of fecal contamination and injury to the rectum.
Dr. Uddo said he does not do transanal removal of the specimen either. "I'm not quite sure that I would feel comfortable doing it. I think I am getting excellent results without a transanal removal and I'm not certain what the advantages really are. I'm not strongly opposed to transanal removal of the specimen as long as the specimen is placed in a protective retrieval bag. It is a technique that I may evaluate in the future." "Rectal injury is a very serious potential risk in transanal removal," agreed Dr. Ballantyne. "You're leaving the bowel open for a prolonged period. In such a case, rips and injury to the rectal stump are a big consideration. I don't do it for that reason, and also because it would change the way I do the anastomosis. Since I do a double stapling technique when I'm transecting distally, it's much easier to just transect it with the MULTIFIRE ENDO GIA* stapler, whereas if you are trying to do a transanal removal there are more steps involved."
Dr. Franklin agrees that there are some risks, but with the proper training and technique he has achieved admirable results in a large series of patients. He offered some technical hints that he uses to overcome the risks of the procedure. For instance, rectal injury is most often a problem when the surgeon goes too high up into the pelvic girdle, where the rectum is characteristically smaller. "If you get too high and try to force a large specimen through, you can tear the rectum. So there has to be some sound surgical judgment in this process. All patients are not candidates for it." Dr. Franklin estimated that three quarters of his entire series of colon resections using transanal removal have been on low anterior sigmoid resections on the left side. He cautioned that when the distal line of resection is 12 cm or more proximal, these patients are not good candidates for transanal extraction of the tumor. "We have no patients with anal incontinence and no patients with prolonged disability," he added. Dr. Fowler has experimented with the transanal technique and believes it may become used more often as instruments and techniques improve. Dr. Franklin strongly believes that proper training is a must to perform this technique, and noted that "we have an open-door policy in our operating room."