J Gastrointest Surg (2015) 19:344–349 DOI 10.1007/s11605-014-2689-8

ORIGINAL ARTICLE

Micro-laparoscopic Colectomy: Initial Experience Christopher M. Foglia & Stuart Blackwood

Received: 25 April 2014 / Accepted: 22 October 2014 / Published online: 11 November 2014 # 2014 The Society for Surgery of the Alimentary Tract

Abstract Introduction Single-port surgery (SPS) has been growing in acceptance as an alternative to traditional laparoscopic surgery. With SPS, there are technical skills required that are not routine to standard laparoscopy. We explored the feasibility of microlaparoscopic colectomy (MLC) using 3 mm instruments in patients eligible for standard laparoscopic surgery. Methods We performed an IRB approved retrospective review of all segmental colectomy performed by a single surgeon in selected patients using a micro-laparoscopic technique. We utilized two 3-mm trocars and one 12-mm Hasson umbilical incision, which was later widen for specimen extraction. Results Eighty patients underwent MLC: Twenty-six for diverticulitis, 26 for cancer, 22 for polyps, 3 for Crohn’s disease, and 3 for volvulus. Eight patients were converted into either laparotomy or hand port (10 %) and three patients required the addition of one 5-mm trocar. Mean final extraction incision length was 3.9 cm. In cancer patients, the average lymph node harvest was 26 (range 13–70). The 30-day mortality was zero and the anastomotic leak rate was 1.3 %. Conclusions MLC is safe and feasible when performing colon resections for benign and oncologic pathology. Extraction incision length is small and offers similar cosmesis to SPS without the steep learning curve needed to learn this technique. Keywords Micro-laparoscopy . Minimally invasive colectomy . Mini-laparoscopy

Introduction Moises Jacobs performed the first laparoscopic colectomy in June of 1990.1 Since that time, the use of laparoscopy has steadily grown in colon surgery as it has been shown to be safe for both benign and malignant conditions.2,3 The use of small laparoscopic incisions has proven beneficial in decreasing postoperative pain, expediting postoperative recovery time, improving cosmesis, and overall improving patient This manuscript was a poster presentation at the 2012 Digestive Disease Week Conference in San Diego, California, May 19th–22nd, 2012. C. M. Foglia (*) Department of Surgery, New York Hospital Queens, 56-45 Main Street, Suite W-LL300, Flushing, NY 11355, USA e-mail: [email protected] S. Blackwood Department of Surgery, Danbury Hospital, Danbury, CT, USA

satisfaction in elective cases.4–8 As minimally invasive surgery aims to improve cosmesis while maintaining the integrity and efficacy of the procedure, many different approaches to intra-abdominal surgery have been advocated. These include single-port surgery (SPS), the use of micro-laparoscopic instruments, as well as novel endoscopic approaches. We conducted this study to evaluate the safety and feasibility of using micro-laparoscopic colectomy (MLC) for benign and malignant colon pathology.

Material and Methods Between May 1, 2009 and March 1, 2013, we examined all the segmental colectomies performed by a single surgeon (CF) using a micro-laparoscopic technique in a community teaching hospital, starting with the first patient on whom this procedure was performed. This technique entailed the use of two 3 mm trocars (Ethicon Endo-Surgery, Cincinnati, OH) and a 12 mm Hasson umbilical trocar (Ethicon Endo-Surgery, Cincinnati, OH), which was later widened for specimen extraction. A 3 mm laparoscope (Karl Storz Endoscopy,

J Gastrointest Surg (2015) 19:344–349

Tuttlingen Germany) as well as 3 mm dissectors and graspers (Karl Storz Endoscopy, Tuttlingen Germany) were used through the 3 mm ports. Figure 1 demonstrates a photo of a 3 mm camera, grasper and trocar compared to their 5 and 10 mm counterparts. During the study period, all cases performed laparoscopically were performed with 3 mm ports as opposed to 5 mm ports. When performing left sided procedures, based on surgeon preference and comfort, there were patients where a hand port was placed at the onset of the operation to facilitate dissection. These cases were excluded from the study. Subjective reasons for the placement of a hand port initially included tumors below the peritoneal reflection, anticipated difficult splenic flexures, and dense inflammation in the pelvis. Also, cases were excluded where a second procedure was performed in addition to the colectomy. With IRB approval, a retrospective review of these cases was conducted. Multiple variables including indication for surgery, conversion rate, and reason for conversion, hospital stay, incision length, and postoperative complications within the first 30 days after surgery were reviewed. Conversions were defined as the need to upsize to trocars 5 mm in size or greater, add a hand port, or make a laparotomy incision. For patients with malignant disease, pathologic T stage, tumor size, specimen size, and nodal harvest were recorded. Surgical Technique Access to the abdomen was gained by Hasson technique at the umbilicus through which a 12 mm trocar was placed. Subsequently, two 3 mm ports were placed on the side of the abdomen contralateral to the colon to be removed (Figs. 2 and 3). The vascular pedicle was isolated and ligated intracorporeally. This was done using an endoscopic stapler (Ethicon Endo-Surgery, Cincinnati, OH) placed through the 12mm umbilical port and a 3 mm camera placed through one of the lateral working ports. When performing a right MLC, the bowel was mobilized in an inferior to superior fashion, followed by widening of the umbilical incision for the placement of a wound protector and subsequent exteriorization of the bowel. An extracorporeal resection, followed by side-to-side anastomosis with either Fig. 1 A 3 mm camera, grasper, and trocar

345

Fig. 2 Left micro-laparoscopic colectomy (MLC)

laparoscopic or open linear and linear cutting staplers (Ethicon Endo-Surgery, Cincinnati, OH), was then performed. For a left MLC, dissection proceeded medially to laterally after intracorporeal ligation of the vascular pedicle. With a 3 mm camera through a lateral port, an intracorporeal distal transection of the colon or upper rectum was performed using an endoscopic stapler through the umbilical port. The proximal bowel and specimen were then exteriorized through a wound protector at a widened umbilical skin incision and the proximal resection was performed. An EEA anvil (Ethicon EndoSurgery, Cincinnati, OH) was then placed into the proximal bowel extracorporeally, and the colon was placed back into the abdomen for a stapled end-to-end intracorporeal anastomosis.

Results Eighty patients were identified who had undergone MLC. Patient demographics, operative results, and indications for

346

J Gastrointest Surg (2015) 19:344–349 Table 2 Indications for colectomy

Fig. 3 Right micro-laparoscopic colectomy (MLC)

surgery are outlined in Tables 1 and 2. There were 49 rightsided procedures (44 right hemicolectomies, 3 ileocecectomies, and 2 extended right hemicolectomies) and 31 left-sided colectomies (28 sigmoid resections, 2 low anterior resections, and 1 extended left hemicolectomy). Patients who had a cancer operation had an average lymph node harvest of 26 (range 13–70 nodes) with oncologically adequate margins. Patients had an average final extraction incision length of 4.2 cm (3.9 cm when excluding those converted). The average length of hospital stay was 5 days with a median of 4 days. Table 3 lists all patients who were approached using MLC and required either conversion to laparotomy or hand port (GelPort, Applied Medical, Rancho Santa Margarita, CA) and their reasons for conversion. Eight of 80 patients (10 %) Table 1 Operative results and demographics Variables Average age (range)

65 (16–92) years

Average BMI (range) Male, n (%) Female, n (%) Operative time (including conversions) right MLC (range) Operative time (including conversions) left MLC (range) EBL (range) Average incision length, excluding conversions (range) Average diameter of colon specimen (range) Median hospital stay Average lymph node harvest resections (range)

27 (17–39) kg/m2 37 (46 %) 43 (54 %) 186 (113–349) min 264 (171–510) min 70 (10–500) ml 3.9 (2.5–6.5) cm 3.7 (1.1–8.3) cm 4 days (range 2–20) 26 (13–70)

Operative Indication

n=80

%

Diverticulitis Cancer Polyps Crohn’s Disease Volvulus

26 26 22 3 3

32.5 32.5 28 3.5 3.5

were converted to laparotomy (n=4) or hand-assist (n=4). One of the conversions to laparotomy was first converted into 5 mm ports before a laparotomy was finally performed due to difficult visualization and an iatrogenic transverse colostomy. There were no other patients where conversion to 5 mm ports was required. Of those converted to laparotomy or hand port, dense adhesions were the most common reason for conversion (n=4) followed by excessive visceral fat (n=3), poor visualization (n=2), positive intraoperative anastomotic leak tests (n=2), iatrogenic injury (n=2), short operating instruments (n=2), and bleeding (n=1). Three patients required the addition of one 5 mm trocar to supplement the 3 mm ports used. Of the patients where additional 5 mm ports were added, reasons for the addition included inadequate length of the 3 mm instruments, use of a 5 mm suction irrigator, and for ease in using a 5 mm energy source (EnSeal G2 Tissue Sealer, Ethicon Endo-Surgery, Cincinnati, OH) as equivalent 3 mm alternatives were not available. As excess fat and poor visualization were the major contributors for conversion, we examined BMI as a possible risk factor for conversion. Of the 80 patients in our highly selective group, there were only 18 patients who had a BMI greater than 30 (6 with left colectomy and 12 with right colectomy). Three of these 18 patients (16.6 %) required conversion (2 laparotomy and 1 hand port). Five of the remaining 62 (8.1 %) patients with BMI

Micro-laparoscopic colectomy: initial experience.

Single-port surgery (SPS) has been growing in acceptance as an alternative to traditional laparoscopic surgery. With SPS, there are technical skills r...
367KB Sizes 2 Downloads 6 Views