|MAIN MENU||INTRODUCTION TO LAPAROSCOPIC COLECTOMY||HISTORY OF LAPAROSCOPIC COLECTOMY||
CARDIOVASCULAR CHANGES DURING
LAPAROSCOPIC COLECTOMY FOR
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|REVIEW OF 752 LAPAROSCOPIC COLECTOMIES||
(Laparoscopy In Focus Volume 3, Number 2, p. 2)
Laparoscopic Colectomy: An Update
GARTH H. BALLANTYNE, M.D., M.B.A.
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MAIN MENU INTRODUCTION TO LAPAROSCOPIC COLECTOMY HISTORY OF LAPAROSCOPIC COLECTOMY CARDIOVASCULAR CHANGES DURING
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REVIEW OF 752 LAPAROSCOPIC COLECTOMIES LAPAROSCOPIC COLECTOMY:
A laparoscopic right hemicolectomy
Surgeons are increasingly performing laparoscopic colectomy procedures, benefiting from both the advancements made in instrumentation and their own accumulating experience. "Laparoscopic colectomy techniques have evolved in just the past few years," said Dr. Dennis Fowler, a general surgeon in Olathe, Kan. Just a few years ago a laparoscopic right hemicolectomy "would take hours and could be a frustrating experience. I do them routinely now." "In comparison with, say, three years ago," Dr. Fowler said, "we have better visualization because of better cameras and better instruments. My average operating time now is about two hours, which is one half of what it was when I first started doing these procedures laparoscopically." Dr. Fowler added that he has now performed about 95 laparoscopic colectomies.
And as instrumentation and expertise have improved, so have the benefits to the patient of employing the minimally invasive approach to colectomy procedures. As the doctor's comfort level rises, he or she will increasingly view the laparoscopic colectomy technique as the preferable alternative.
The benefits of the laparoscopic approach are well known and well documented. Specifically, when compared to open procedures, patients:
- can expect to experience less pain since incision lines are much smaller, and thus typically require less narcotic pain medication
- will be required to remain in the hospital fewer days, thus reducing that part of their hospital bill
- will enjoy a much faster return to work and other normal activities
- will experience little or no ileus and will benefit from a speedier resumption of gastrointestinal activity, and
- will appreciate the better cosmetic result.
Dr. Morris Franklin, a general surgeon at the Texas Endosurgical Institute in San Antonio, summarized the benefits of laparoscopy this way: "With any surgery the patient takes a hit. The question is, do you want the patient to get hit by a Mack truck or by a bicycle? What laparoscopy does is offer the patient a lesser hit."
Various studies over the years have highlighted these patient benefits. One ongoing study was reviewed recently at the Long Island College Hospital Symposium on Minimally Invasive Surgery, held in Brooklyn, NY. Dr. Karl A. Zucker, professor of surgery at the University of New Mexico in Albuquerque, reported that he had enrolled 75 colectomy patients and that the results from the first 72 patients had been analyzed. Right colectomy, left hemicolectomy and low anterior resection were the types of colon resections included in the study; the patients had undergone the procedures for the treatment of benign disease, cancer palliation and localized malignancies. With a mean followup of 10 months, Dr. Zucker reported that there had been no port-site recurrences to date. There was one death, from a recurring melanoma that metastasized to the lung. Morbidity rates were 7% for the laparoscopy group, 26% for the laparotomy group, and 35% for the five conversions in the study. Mean hospital stays were significantly briefer for those undergoing laparoscopic (4.4 days) compared with open (7.7 days) surgery, as was the time spent in the ICU following surgery. This study is on-going, Dr. Zucker told attendees. Detailed reports of surgeons' experiences with laparoscopic colectomy have only recently been published and continue to be disseminated by a handful of experts, many of whom have themselves only been using the techniques for the past five years or so. Thus, diligent reporting of results by all surgeons engaged in laparoscopic colectomy is crucial for a complete appraisal of the success of the procedure.
In a paper published recently in Annals of Surgery (1994;6:732-45), Dr. George Hoffman, assistant professor of clinical surgery at Eastern Virginia Medical School in Norfolk, encouraged other surgeons to report their data to the registry established by the American Society of Colon and Rectal Surgeons and to participate in the trial being conducted at the National Cancer Institute. The trial, which is still enrolling surgical teams, will be the first of its kind to examine laparoscopic colectomy in detail and compare the results of the procedures with those of open laparotomy.
"We have better visualization because of better cameras and better instruments. My average operating time now is about two hours, which is one half of what it was when I first started doing these procedures laparoscopically."
-Dr. Dennis Fowler
"We need to pool all the available data on colectomies, and that is what both the ASCRS registry and the NCI trial are doing. Because if there is a problem and there is evidence of port-site recurrences and other problems in the longterm, we need to know about it so that we can stop what we're doing and reassess," Dr. Hoffman said. "But I really don't believe that we are going to see those kinds of things. I wouldn't continue to do these techniques if I thought they were bad for the patient." Dr. Richard Whelan, who is an assistant professor of surgery at Columbia University College of Physicians and Surgeons in New York City, agreed that the trials and protocols are essential to documenting the success of laparoscopic colectomy as well as any problems that might surface. "We've done all our cases under an IRB-approved protocol," he said, and recommended that others do the same. "Now that we are going to be doing colon cancers for cure laparoscopically we will be contributing our data to the NCI trial, and we think it is very important that others do the same."
The Laparoscopic Bowel Surgery Registry, compiled jointly by The American Society of Colon and Rectal Surgeons, The American College of Surgeons' Commission on Cancer and The Society of American Gastrointestinal Endoscopic Surgeons, now has information on over 1000 laparoscopic colectomies performed since 1991. A preliminary analysis of the data in the registry was recently reported by Dr. Adrian Ortega and Dr. Robert Beart in Diseases of the Colon& Rectum (1995;38:681-6). Of the 1056 cases contributed by 118 surgeons, 763 were completed laparoscopically. The most common reason for conversion to open laparotomy was problems stemming from unclear anatomy. The most common indication for surgery was cancer (453 cases). Of the 825 anastomoses performed, 61% were done extracorporeally. The postoperative complication rate was 15%; however, the type of complication was not specified due to limitations of the registry. Length of hospital stay averaged 5.6 days for patients completed laparoscopically and 8.4 days for those converted to open laparotomy. The difference in length of stay for intracorporeal anastomosis as compared with extracorporeal technique was minimal (5.8 vs. 6.1 days) but considered statistically significant (P<0.01).
In their conclusion, Drs. Ortega and Beart assert that laparoscopic colectomy and other minimally invasive procedures of the small and large intestine are safe. "[Laparoscopy's] application for treatment of malignancy seems reasonable vis-a-vis the observation of principles of cancer surgery, but further study is necessary," they added. The surgeons further suggested that at the present time an argument can be made for the use of extracorporeal anastomosis rather than the intracorporeal method because ease of technique has been demonstrated with the former.
The white trocar of a premium CEEA* circular stapling device poking through the closure of the rectal stump during a laparoscopic left hemicolectomy.
Dr. Joseph Uddo, Jr., a general surgeon in Metairie, La, is not participating in the NCI trial. He feels that it will take a combination of controlled clinical trials and independent trials conducted by surgeons who do a lot of laparoscopic colectomies to definitively prove the value of the techniques. "I agree that a controlled clinical trial is imperative to sort out problems that arise concerning laparoscopic colon resection for cancer," Dr. Uddo said. "Laparoscopic colon resection for benign disease, on the other hand, should not require such elaborate investigation as it, like laparoscopic cholecystectomy, affords obvious benefits to the patient. "It is important that everyone performing these new techniques should be willing to collect and share their data, but the most accurate and the fairest data will come from the surgeons who have been able to gain a depth of experience with these new procedures. Data gathered from multiple surgeons just embarking on laparoscopic colon resection would seem to be skewed toward the negative."
Operating Times Decrease, As Do Costs
Retrieval with an ENDO BABCOCK* clamp.
Photos courtesy Drs. Richard Marks and Garth H. Ballentyne
As Dr. Fowler observed and others who were interviewed by Laparoscopy in Focus echoed, the time spent in the OR decreases significantly with experience. According to Dr. Uddo, dramatic reductions in operating times are directly attributable to experience. "The more laparoscopic colon resections you do, the better you get at them. In my early experience, I was still learning my way around." Dr. Uddo, an assistant clinical professor of surgery at Louisiana State University School of Medicine in New Orleans, recently reported on 65 laparoscopic colectomies at a surgical conference.
"I feel that with increasing experience I have been able to significantly decrease operating time," said Dr. Uddo, whose average OR time is now 115 minutes. With decreased operating time comes savings. Dr. Uddo noted that total hospital charges have decreased by an average of more than $3000 since he first started doing laparoscopic colectomies, and stated that the average charges generated now for laparoscopic colectomy are slightly lower than the average hospital charge for an open colectomy at his hospital. "I'm coming in under open charges and I think that is directly related to experience and proper use of instrumentation.
The surgeon inserts the ENDO GIA* 60 stapler through the 15-mm trocar, applying it from the antimesenteric side of the rectum toward the mesentery.ry.
Probably the single most important factor in lowering average total cost for laparoscopic colectomy is decreased operating room time."
"Most of us, if not all of us, who have been doing this for a while see a big difference in our operating times and our level of comfort with the procedures that we do," Dr. Hoffman said. "We are increasingly seeing better instruments than we had in the beginning, and I think we will ncontinue to see that." In his first 40 cases, Dr. Hoffman said his average operating time was about three hours and forty minutes. In the next 40 cases, many of which were technically more complex, the average time dropped to about three hours.
"The learning curve is still such a big issue in laparoscopic bowel procedures," added Dr. Garth Ballantyne, director of the Center for Advanced Laparoscopic Surgery and chief of the division of laparoscopic surgery at St. Luke's-Roosevelt Hospital in New York City. "Technically, these procedures are much harder to master than laparoscopic cholecystectomy, which many people are doing now, and you need so much more experience with the laparoscopic colectomies to get good at them."
Dr. Ballantyne said his average operating time is about two hours and 15 minutes. "The people who are advancing with colectomies tend to be the busy general surgeons who are not only doing gallbladders but also laparoscopic hernia repairs and laparoscopic fundoplication," he added.
Dr. Whelan cautioned that practicing on animal models first is essential. "Especially if you are going to be doing these procedures when a cancer is involved, it is crucial that you have the lab work down. Nobody should be out there doing these procedures without a lot of animal work first," said Dr. Whelan, who has performed about 20 laparoscopic colectomies and is awaiting final approval to participate in a large study of the procedures sponsored by the National Cancer Institute.
Contraindications and Conversions
Very few contraindications for laparoscopic assisted bowel surgery have been identified in the literature. Dr. Ballantyne noted that "there are occasional patients who have such severe restrictive pulmonary disease that they cannot tolerate the acidosis generated by the carbon dioxide pneumoperitoneum." The restrictive pulmonary disease in these patients limits the rate of ventilation by the anesthesiologist. He suggests that in patients with large, bulky lesions that require large incisions for delivery of the specimen, it makes little sense to attempt a laparoscopic approach. Some characteristics unique to the patient may make it difficult to accomplish laparoscopic procedures, however. These characteristics include obesity, intraabdominal adhesions resulting from previous abdominal surgeries, bleeding disorders and pregnancy. In the latter instance, the enlarged uterus can obstruct the view of the videolaparoscope. It has also been noted that men may be more difficult to operate on than women due to a greater preponderance of fat in the mesentery regardless of overall body weight.
"With any surgery the patient takes a hit. The question is, do you want the patient to get hit by
a Mack truck or by a bicycle? What laparoscopy does is offer the patient a lesser hit."
-Dr. Morris Franklin
In a report in the journal Surgical Endoscopy (1994;8:12), Dr. Karl Zucker et al concluded that the only contraindications that led them to exclude patients were obstruction and preoperative evidence of fixation of the lesion to an adjacent visceral structure such as the bladder or abdominal wall. "It's the rare case that cannot be done laparoscopically," said Dr. Uddo. "The extent of potential intraabdominal adhesions cannot be appreciated preoperatively; consequently, I will approach almost everyone laparoscopically. I am careful to not spend too much time struggling laparoscopically. I try to make an assessment early on as to whether or not the patient needs to be converted. Even with this approach, our conversion rate is less than 5%."
Once the laparoscopic procedure has been initiated, problems may prompt the surgeon to convert to a laparotomy. Indeed, the highest costs associated with colon resections occur when patients undergo a prolonged laparoscopic resection who are then converted to an open operation. The high cost is generated by the laparoscopic and open charges, the long OR time, and the increased hospitalization. Thus, converting to open is most economical when it is done as soon as the need arises, not after minutes of further laparoscopic exploration. Most of the literature indicates that conversions to open procedures are more frequent early in the surgeon's experience with laparoscopy and the conversion rate decreases considerably as experience mounts. Dr. Ballantyne, for example, had a conversion rate of 77% in his first 20 procedures. That number is now down to less than 10%. "If you have difficulty identifying the ureters you should convert to open right away," said Dr. Hoffman. "There is really nothing I can think of in the way of 'surprises' that would make me convert once the procedure was underway. You always have a lot more conversions when you are just starting out." Dr. Ballantyne added that the one thing that might cause him to convert a procedure to open is a sigmoid cancer extending near the ureter. "In that case I would probably feel more comfortable assessing it in an open situation because I'm more experienced with open procedures. It becomes a question of preserving the ureter at that point."
"Im coming in under open charges and I think that is directly related to experience and proper use of instrumentation. Probably the single most important factor in lowering average total cost for laparoscopic colectomy is decreased O.R. time."
-Dr. Joseph Uddo, Jr.
In a recent study reported in Diseases of the Colon and Rectum (1994;37:215-8), Dr. Jeffrey Milsom, a colorectal surgeon at The Cleveland Clinic Foundation, used the following criteria to determine whether conversion to an open procedure was necessary: 1) Time: if the laparoscopic procedure came within 30 minutes of twice the usual time for the procedure using conventional techniques; 2) Operative complications: if any inadvertent enterotomy was made, or if uncontrolled hemorrhage occurred; 3) Adhesions: if adhesions could not be safely lysed using laparoscopic techniques; and 4) Miscellaneous: if any intraoperative instability of the patient's vital signs occurred. Dr. Uddo added that advanced laparoscopic surgeons doing these procedures must keep in mind the basic principles of colon surgery. "These principles should not be violated. Laparoscopy should improve upon the traditional open operation and be of lasting benefit to the patient," he said.
Use in Malignancy
Perhaps the greatest controversy in the debate over laparoscopic colon procedures is the fear that, with the techniques still in their infancy, it is impossible to assert their safety for curative cancer operations. Some surgeons who feel comfortable with the idea of laparoscopic surgery for palliative resection avoid removing tumors in this manner. Still others feel comfortable enough with their experience levels and their techniques to forge ahead.
"I think that laparoscopic palliative resection for colon cancer is a fine approach," Dr. Uddo said. "It seems that detractors of this approach and those who question it are mostly concerned with early cancers. My main concern is with patients with transmural disease and patients with limited node-positive disease. In particular, we are concerned about port-site recurrence and what happens to the tumor biology following laparoscopic intervention. We just don't know the answer to that right now. However, I feel that proper technique and experience will minimize these potential problems." Recurrences of tumors at laparoscopic port sites have been reported following removal of gastric, pancreatic, gallbladder and ovarian tumors.
Most recently, a number of case reports have suggested that laparoscopic assisted techniques for resection of colon cancer may increase the probability of tumor implantation in the site of specimen extraction or at other trocar sites. But in a review of the literature published last spring in The Gastroenterologist (1995;3:75-89), Dr. Ballantyne found just three incidences of wound implantations following 498 laparoscopic resections, for a rate of 0.6%. These data were culled from the Laparoscopy Registry of the American Society of Colon and Rectal Surgeons.
"There has never been, and continues not to be, any data supporting the idea that wound implantation is more common with laparoscopic surgery than with open techniques," Dr. Ballantyne said.
"We believe that laparoscopic colectomy is definitely here to stay. It is a technique that is difficult to learn, but once mastered, it will have a major role to play in the way colon surgery is done in the future."
-Dr. Richard Whelan
One of the controversies that surrounds the issue of port-site recurrence is whether the surgeon's skill, the elusive "learning curve," is responsible for a higher rate of recurrence. As Dr. Franklin noted, "Colorectal surgeons have a disadvantage when it comes to laparoscopy, because they don't have the cholecystectomy or appendectomy to practice on. They are forced to do complicated laparoscopic colon resections with much less laparoscopic experience and training. Just going to a weekend course is not enough," he said. "What's the solution? The solution is for them to get with a gynecologist or a general surgeon and put in their time. These doctors all did a lot of laparoscopy before they started on colons, because colon surgery is the hardest to do. I don't care how great a surgeon you are, you just can't do this surgery laparoscopically without going and learning the tricks from people who have been there already and made the mistakes."
The anvil-shaft assembly is advanced into the colon, and the purse-string suture is tied. The bowel is then dropped back into the abdomen.
Most surgeons, like Dr. Whelan, believe technique and experience have an important role to play. What are some techniques suggested by the experts? Dr. Franklin, who has never had a patient experience a port-site recurrence, mentioned a few. "First, you never want to chip the tumor or mishandle it in any way. Be careful to avoid touching it. You want to bag the specimen and not pull it out through a tight incision. This is where most of the trocar site implantations that I am aware of worldwide have come from," he said. "You do not want to have ... an instrument that has been contaminated with tumor cells come through the abdominal wall unprotected."
An article in The British Journal of Surgery (1995;82:295-8) this spring examined 33 cases of port-site recurrence. The majority of these cases occurred during what would be considered the early part of the surgeon's learning curve-his first 20 or so procedures.
Dr. Whelan said that because of evidence like this, he believes it is wrong for surgeons who are just starting out in laparoscopic techniques to operate for cure in cases of malignancy. "Under no circumstances should this kind of surgery be attempted by people who don't have enough experience," he stressed. Last year, in a published review of 353 colon cancers treated laparoscopically, Dr. Whelan found only one case of port-site recurrence. "There were 20 surgeons together who had performed these cases, and when we looked at them individually, it was a much less experienced surgeon who had had the recurrence."
He added that at least two studies in the past decade that examined recurrence at the wound site in open colectomy found incidences of 0.45% and 0.6%. "The point is, it happens after open cases too. It's not common, but it happens," he said. "We don't have any hard data on the incidence of wound recurrence in laparoscopic surgery right now, but I don't believe that the numbers will be drastically higher."
Dr. Hoffman added, "I can tell you that it's not easy learning to do these techniques laparoscopically. It's certainly a lot harder than cholecystectomy. The learning curve remains a big issue, but we really don't know if it is related to port-site recurrence. It would be a leap at this point to say that it is."
As Dr. Uddo noted, when removing large cancerous specimens from the abdomen, "caution would be prudent. Intracorporeal division of proximal and distal bowel and intracorporeal mesenteric division can combat this problem. Placing the bowel containing a malignancy in a retrieval sack like the ENDO CATCH* specimen removal device can only be accomplished following intracorporeal division of the bowel and mesentery."
Closure of the anastomosis: The anvil shaft is grasped and coupled to the locking mechanism on the PREMIUM CEEA* or PREMIUM PLUS CEEA* stapler.
While debate surely will continue over the appropriateness of laparoscopic techniques for malignancies in bowel procedures, the research efforts underway by individuals and organizations like the NCI and the ASCRS should contribute much to the understanding of these relatively new methods. In the meantime, surgeons like Dr. Uddo are convinced that they are performing as good a cancer operation laparoscopically as they are open. "Certainly it needs to be done in a setting in which the patients are followed carefully and the results are reported," Dr. Uddo said. "We need to assess recurrence rates and disease-free survival." But who will be doing those surgeries in the future? Many older surgeons who have become accustomed to the open techniques are reluctant to learn the newer approaches. "It's true," said Dr. Hoffman. "People who have been doing open surgery all their lives are not happy about having to get used to all the different types of equipment and surgical instruments. I found it difficult myself at first. But I think that as the newer generations start getting into the field, that is where you are going to see more willingness to learn new techniques."
One explanation for that willingness to learn may be an artifact of growing up in an age of information superhighways and portable computers. "I think in the future it's likely that the young people coming out of residencies who grew up with computers, computer games and every other kind of technology will enjoy learning how to do laparoscopy and want to continue doing it throughout their careers," said Dr. Ballantyne. And yet it is important to underscore the fact that many older surgeons have invested the time to learn minimally invasive techniques, becoming converts in the process. Laparoscopic colectomy is far from being the exclusive domain of the young. In the meantime, research continues using animal models to determine the effect of small incisions versus large incisions on the immune system. Dr. Whelan and others have shown less immunosuppression, as measured by degree of delayed hypersensitivity response, in animals treated laparoscopically as opposed to animals who undergo an open procedure. If future studies confirm these results in humans, it would present a strong case for creating the smallest incision possible or even no incision at all, as exemplified by the method of transanal removal. Dr. Whelan stressed that at this point cautious optimism is the best attitude. "We believe that laparoscopic colectomy is definitely here to stay," he said. "It is a technique that is difficult to learn, but once mastered, it will have a major role to play in the way colon surgery is done in the future."
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