LETTERS TO THE EDITOR
Laparoscopic Colorectal Surgery To the Editor--Until very recently, laparoscopy (or as some like to call it, pelviscopy) was solely the domain of the gynecologic surgeon. It has been used primarily for diagnosis, fulguration of endometrial implants, and tubal ligation. With the introduction of laparoscopic cholecystectomy by general surgeons, laparoscopy has taken on an entirely n e w life. This may be the most significant new wave to hit general surgery in decades. All sorts of arguments may be made about the advisability of this approach and the likely increase in complications such as biliary ductal injuries. Regardless, this technique is here to stay. The public wants it, and there are clear advantages in many situations: hospital stays are shorter, pain is less, and recuperation is faster. The applications are growing rapidly even though the technology is having trouble keeping up. Dozens of companies are trying to get into the act as this new market opens up. Certainly all of this is spurring the development of new techniques and instruments. In a very short time, laparoscopic cholecystectomy has become the de facto standard in most institutions for the treatment of nonacute gallbladder disease. At the time of this writing, laparoscopic appendectomies and retroperitoneal lymph node dissections have become commonplace in many operating rooms. The envelope is now being pushed with nephrectomies and intestinal resections. And, as is often the case, much of this pioneering work has been done in private hospitals and clinics and not at major universities. The major question for us is "how is this going to affect the practice of colon and rectal surgery?" In my mind, there is no question that laparoscopic surgery will become a daily part of every colorectal practice and this will happen very soon. Because of laparoscopic cholecystectomy, the technology already exists in most hospitals, and it is a small step to obtain a few new instruments specifically designed for bowel surgery. Anyone who is able to remove a gallbladder laparoscopically is equipped to do an appendectomy. In many ways an appendectomy is easier. Since it may be neces614
sary to mobilize the cecum for an appendectomy, it is a short step to doing a complete right colon mobilization, and mobilizing the sigmoid and left colon is even easier. The difficulty lies in compensating for the loss of touch and manual manipulation and in the loss of the three-dimensional view from varying angles. Learning careful technique in the use of the instruments and taking one's time initially will, to some extent, make up for the loss of touch. Also, the use of flexible scopes transanally will help in localizing intraluminal pathology that is not readily apparent from the serosal aspect of the bowel. The laparoscopic camera generates an excellent picture, albeit two-dimensional and from only one viewpoint. It takes time and practice to adjust to this but will likely be easier for surgeons used to working through flexible endoscopes. The camera may also be used through any of the 10/11 mm ports in place, allowing for some alteration in viewing angle; also, scopes with angled views are becoming available. However, as with all new techniques, there is a significant learning curve. The first assistant may have the most difficult job. The camera is generally positioned to approximate the operating surgeon's viewpoint. This requires the first assistant to work in reverse or from a viewing point opposite to what would be expected were the patient open. Thus, every movement is the reverse of that expected. This requires some getting used to. It has been my observation that some surgeons master this quite rapidly, whereas others have great difficulty. The next great hurdle is to devise rapid and safe methods of intracorporeal anastomosis. Mobilization and resection may become fairly straightforward once mastered. To date, however, most anastomoses have been performed extracorporeally. An anastomosis to the sigmoid colon or rectum may be relatively easy, placing the proximal purse-string suture and the anvil extracorporeally and creating a double-stapled anastomosis with a transanally placed intraluminal circular stapler. Intracorporeal ileocolic, colocolic, or enteroenteric anastomoses present an additional dilemma, that is to avoid spillage of enteric contents and yet create a reliable anastomosis rapidly. To be sure, laparoscopic staplers are now available; however, these are very limited in design, size, and approach.
Vol. 35, No. 6
LETTERS TO THE EDITOR
This problem will undoubtedly be solved in the near future with more innovative approaches. The appropriate rote of colorectal surgeons and the American Society of Colon and Rectal Surgeons (ASCRS) in developing and adopting these techniques is a matter for some debate. There are those who would advise caution and careful assessment of results before attempting these new methods. Some would question the benefit of such approaches, noting that an open appendectomy may often be performed through a small incision with little morbidity and a short hospital stay. Despite this, I feel that we in colorectal surgery should be counted among the innovators and developers, that we should be on the cutting edge and should be defining the limits of these new techniques. Those who falter will be left behind because this methodology is advancing quickly. There is a natural tendency to avoid methods that are not tried and true, and I am not suggesting that every one of us needs to go out and take a very expensive course in the techniques of laparoscopy, or even to just start doing it. I am suggesting that the leaders in this revolution should include members of our field and our Society and that those who do not immediately attempt this should at least keep an open mind and closely observe the development of these approaches. Certainly, some prominent members of our field are actively involved, and they are to be commended. Yet our involvement needs to be more visible. We should be creating the standards of care for laparoscopic bowel surgery. The appropriate indications, contraindications, and techniques need to be worked out, and we should take a leadership role in this. The time will come when much of what we do will be done differently; laparoscopy is one of the major ways this will happen. Time, experience, research, and careful analysis of results will ultimately define the role laparoscopy will have in colon and rectal surgery. The registry recently created by the ASCRS is a step in this direction. Until
615
then, we as a group must be involved in both development and assessment. I believe that eventually laparoscopy will become an indispensable part of every surgeon's armamentarium. Bruce A. Orkin, M.D.
Washington, D. C
Method to Avoid Colostomy Soiling To the Editor--I read with interest Dr. Shpitz and colleagues' method of avoiding colostomy soiling (Dis Colon Rectum 1991;34:1038-39) and was able to put it to test twice in one week. On both occasions there was still soiling, not only from the feces that gets trapped between the Foley balloon and the stapled stump, but also following deflation of the balloon and removing it. The authors did not mention the number of cases on which their experience with this method was based. A reliable method, tested in more than 10 consecutive patients, that not only prevents soiling but also prevents postoperative retraction is as follows. The descending colon is adequately mobilized together with the splenic flexure. The proximal bowel is closed with a Zachary Cope's clamp or a stapling device, and the diseased bowel is resected. An "extra long" colostomy measuring between 8 and 10 cm is brought out through a left iliac fossa trephine incision. The abdomen is closed and the colostomy opened into a bowl, its length allowing this with minimal contamination. A colostomy bag is applied around the colostomy, which is not stitched or anchored in any way. The excess colon is trimmed to skin level five days later and stitches inserted subdermally without an anesthetic. B. Nathan, F.R.C.S.
Surrey, United Kingdom
Laparoscopic Colorectal Surgery To the Editor--Until very recently, laparoscopy (or as some like to call it, pelviscopy) was solely the domain of the gynecologic surgeon. It has been used primarily for diagnosis, fulguration of endometrial implants, and tubal ligation. With the introduction of laparoscopic cholecystectomy by general surgeons, laparoscopy has taken on an entirely n e w life. This may be the most significant new wave to hit general surgery in decades. All sorts of arguments may be made about the advisability of this approach and the likely increase in complications such as biliary ductal injuries. Regardless, this technique is here to stay. The public wants it, and there are clear advantages in many situations: hospital stays are shorter, pain is less, and recuperation is faster. The applications are growing rapidly even though the technology is having trouble keeping up. Dozens of companies are trying to get into the act as this new market opens up. Certainly all of this is spurring the development of new techniques and instruments. In a very short time, laparoscopic cholecystectomy has become the de facto standard in most institutions for the treatment of nonacute gallbladder disease. At the time of this writing, laparoscopic appendectomies and retroperitoneal lymph node dissections have become commonplace in many operating rooms. The envelope is now being pushed with nephrectomies and intestinal resections. And, as is often the case, much of this pioneering work has been done in private hospitals and clinics and not at major universities. The major question for us is "how is this going to affect the practice of colon and rectal surgery?" In my mind, there is no question that laparoscopic surgery will become a daily part of every colorectal practice and this will happen very soon. Because of laparoscopic cholecystectomy, the technology already exists in most hospitals, and it is a small step to obtain a few new instruments specifically designed for bowel surgery. Anyone who is able to remove a gallbladder laparoscopically is equipped to do an appendectomy. In many ways an appendectomy is easier. Since it may be neces614
sary to mobilize the cecum for an appendectomy, it is a short step to doing a complete right colon mobilization, and mobilizing the sigmoid and left colon is even easier. The difficulty lies in compensating for the loss of touch and manual manipulation and in the loss of the three-dimensional view from varying angles. Learning careful technique in the use of the instruments and taking one's time initially will, to some extent, make up for the loss of touch. Also, the use of flexible scopes transanally will help in localizing intraluminal pathology that is not readily apparent from the serosal aspect of the bowel. The laparoscopic camera generates an excellent picture, albeit two-dimensional and from only one viewpoint. It takes time and practice to adjust to this but will likely be easier for surgeons used to working through flexible endoscopes. The camera may also be used through any of the 10/11 mm ports in place, allowing for some alteration in viewing angle; also, scopes with angled views are becoming available. However, as with all new techniques, there is a significant learning curve. The first assistant may have the most difficult job. The camera is generally positioned to approximate the operating surgeon's viewpoint. This requires the first assistant to work in reverse or from a viewing point opposite to what would be expected were the patient open. Thus, every movement is the reverse of that expected. This requires some getting used to. It has been my observation that some surgeons master this quite rapidly, whereas others have great difficulty. The next great hurdle is to devise rapid and safe methods of intracorporeal anastomosis. Mobilization and resection may become fairly straightforward once mastered. To date, however, most anastomoses have been performed extracorporeally. An anastomosis to the sigmoid colon or rectum may be relatively easy, placing the proximal purse-string suture and the anvil extracorporeally and creating a double-stapled anastomosis with a transanally placed intraluminal circular stapler. Intracorporeal ileocolic, colocolic, or enteroenteric anastomoses present an additional dilemma, that is to avoid spillage of enteric contents and yet create a reliable anastomosis rapidly. To be sure, laparoscopic staplers are now available; however, these are very limited in design, size, and approach.
Vol. 35, No. 6
LETTERS TO THE EDITOR
This problem will undoubtedly be solved in the near future with more innovative approaches. The appropriate rote of colorectal surgeons and the American Society of Colon and Rectal Surgeons (ASCRS) in developing and adopting these techniques is a matter for some debate. There are those who would advise caution and careful assessment of results before attempting these new methods. Some would question the benefit of such approaches, noting that an open appendectomy may often be performed through a small incision with little morbidity and a short hospital stay. Despite this, I feel that we in colorectal surgery should be counted among the innovators and developers, that we should be on the cutting edge and should be defining the limits of these new techniques. Those who falter will be left behind because this methodology is advancing quickly. There is a natural tendency to avoid methods that are not tried and true, and I am not suggesting that every one of us needs to go out and take a very expensive course in the techniques of laparoscopy, or even to just start doing it. I am suggesting that the leaders in this revolution should include members of our field and our Society and that those who do not immediately attempt this should at least keep an open mind and closely observe the development of these approaches. Certainly, some prominent members of our field are actively involved, and they are to be commended. Yet our involvement needs to be more visible. We should be creating the standards of care for laparoscopic bowel surgery. The appropriate indications, contraindications, and techniques need to be worked out, and we should take a leadership role in this. The time will come when much of what we do will be done differently; laparoscopy is one of the major ways this will happen. Time, experience, research, and careful analysis of results will ultimately define the role laparoscopy will have in colon and rectal surgery. The registry recently created by the ASCRS is a step in this direction. Until
615
then, we as a group must be involved in both development and assessment. I believe that eventually laparoscopy will become an indispensable part of every surgeon's armamentarium. Bruce A. Orkin, M.D.
Washington, D. C
Method to Avoid Colostomy Soiling To the Editor--I read with interest Dr. Shpitz and colleagues' method of avoiding colostomy soiling (Dis Colon Rectum 1991;34:1038-39) and was able to put it to test twice in one week. On both occasions there was still soiling, not only from the feces that gets trapped between the Foley balloon and the stapled stump, but also following deflation of the balloon and removing it. The authors did not mention the number of cases on which their experience with this method was based. A reliable method, tested in more than 10 consecutive patients, that not only prevents soiling but also prevents postoperative retraction is as follows. The descending colon is adequately mobilized together with the splenic flexure. The proximal bowel is closed with a Zachary Cope's clamp or a stapling device, and the diseased bowel is resected. An "extra long" colostomy measuring between 8 and 10 cm is brought out through a left iliac fossa trephine incision. The abdomen is closed and the colostomy opened into a bowl, its length allowing this with minimal contamination. A colostomy bag is applied around the colostomy, which is not stitched or anchored in any way. The excess colon is trimmed to skin level five days later and stitches inserted subdermally without an anesthetic. B. Nathan, F.R.C.S.
Surrey, United Kingdom
