Evolution of minimally invasive

Colorectal surgery
EVOLUTION OF COLORECTAL SURGERY

CONVENTIONAL OPEN SURGERY

LAPAROSCOPIC SURGERY

Single incision/NOTES/NOSE
ROBOTICS
 Milestones in colorectal surgery

 Sir Ernest Miles published his seminal

contribution, “A method of performing abdomino-
perineal excision for carcinoma of the rectum” in
1908.

1948-Claude Dixon, who propagated “anterior resection” with

anastomosis gave support to the idea of sparing part of the rectum
 TME impact

 In1980
–Prof Richard Heald developed a resection technique based on the
embryologic development of the hindgut. He excised the tumor and
mesorectum en bloc. He termed his technique "total mesorectal excision".

 Heald'stechnique resulted in decreased positive lateral margins and local

recurrence rates - the lowest ever at 3.6%.
 The next challenge after TME
 2005-Nagtegaal et al ascribed the poor
prognosis of APR patients to the resection
plane leading to a “waist” easily recognized in
the specimens.

 An alternative approach using a wide perineal

resection was proposed -“extralevator
abdominoperineal excision (ELAPE), or “Holm
cylindrical APR”
ADVENT of laparoscopy
Milestones in laparoscopy
Initial reactions to laparoscopy

DON’T DON’T
DON’T TALK
HEAR SEE LAP
LAP LAP
 Past concerns

 Delayed penetration of laparoscopy in colorectal surgery?

– Feasiblity
– Steep learning curve
– Increased complications
– Higher conversions
– Prolonged time
– Oncological clearance
– Port site metastases

Schlachta CM et al , Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum 2001;44: 217–22.
Slim K et al, Highmorbidity rate after converted laparoscopic colorectal surgery.Br J Surg 1995; 82: 1406–8.
 Technological Improvements

 HD digital cameras with improved clarity, visualization

 Better instrumentation

 Energy sources

 Harmonic scalpel
 Ligasure

 Staplers
 Endo-flex & circular
 Advantages of laparoscopy

 Less immune disturbance

 Favorable short-term outcomes

 ERAS facilitated.(fast track recovery)

– Diminished pain
– Earlier return of bowel function
– Better preserved pulmonary function
– Decreased abdominal wound infection rate
– Reduced incidence of postoperative adhesions
– Shorter hospitalization
 Better cosmesis & patient satisfaction
Bessler M, et al Is immune function better preserved after laparoscopic versus open colon resection? Surg Endosc 1994; 8:881–3.
Teoh TA et al , Enhancing cosmesis in laparoscopic colon and rectal surgery. Dis Colon Rectum 1995; 38: 213–4.
 Expansion of Indications

 Laparoscopic stoma creation

 Laparoscopic resection in benign conditions

– Diverticular disease
– Inflammatory bowel disease
– Tuberculosis
 Laparoscopic rectopexy
 Laparoscopic resection in malignancy

 Lap assisted colonoscopic procedure

 Lap colorectal surgeries

 Lap hemicolectomy
 Lap subtotal colectomy

 Lap anterior resection

 Lap abdominoperineal resection

 Lap total proctocolectomy/ ileal pouch anal anastomosis

 Lap rectopexy
LAPAROSCOPY IN COLORECTAL MALIGNANCY
 Laparoscopy for colonic cancer


 Level1 evidence from 4 large RCTs.

–Colon Cancer Laparoscopic or Open (COLOR),
–Conventional versus Laparoscopic Assisted Surgery in Colorectal
Cancer (CLASICC),
–Clinical Outcomes of Surgical Therapy Study Group (COSTSG),
–Barcelona RCT.
 Laparoscopy for rectal cancer
 Conclusionof CLASSICC trial: “Long-term results continue to support the use
of laparoscopic surgery for both colonic and rectal cancer.”

 Conclusionof COREAN trial: “Laparoscopic surgery after preoperative

chemoradiotherapy for mid or low rectal cancer is safe and has short-term
benefits compared with open surgery; the quality of oncological resection was
equivalent.”

Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically
assisted resection in colorectal cancer. British Journal of Surgery 2013; 100:75–82.

Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN
trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncology (Jul 2010): 637-45.
 Lap. Oncosurgical Principles

 Early vascular pedicle ligation

 Minimal growth handling

 En-bloc lympho-fatty tissue clearance with lymph node clearance

 Adequate tumor free margin in resectable growth

 Retrieval of en-bloc specimen without port contamination

Surgical clinics Of North America-MAS-Aug,2000

 Medial-to-lateral VS lateral-to-medial dissection
sequences

Liang JT et al. National Taiwan University Hospital, Taiwan

Comparison of medial - to - lateral versus traditional lateral-to-medial

laparoscopic dissection sequences for resection of rectosigmoid cancers:
randomized controlled clinical trial.

World J Surg. 2003 Feb;27(2):190-6.

 Advantages of Medial to lateral approach

 Easy to perform
 Takes lesser time

 Less invasive

– Protection of ureter
– Other structures : Duodenum & IVC
Laparoscopic colorectal cancer surgeries


– Right Hemicolectomy
– Lap AR
– Lap APR
– Subtotal Colectomy
– Total Proctocolectomy
 IRETA - Initial Retrocolic Endoscopic Tunnel Approach

– Initially Applied for Benign Disease – Early 1990s

– Transferred to Surgical Oncology
– Adheres to Oncological Principles!
– Technical Advantages-
1. Early Intra-Corporeal Identification of Ureter and Duodenum
2. Excellent Intra-corporeal Vascular Control
3. Excellent Specimen Control!
 I.R.E.T.A.
Operative Technique–
– Dissection Start-up
– Two Handed Tunnel Dissection
 Identification of Ureter and Right Gonadal Vs.
 Identification of Duodenum
– Control of Vascular Pedicle Roots
 Ileo-colic, Right colic and Right branch of/ Middle Colic A.
– Mobilisation – Gastro-colic & Hepato-colic ligaments
– Lateral Peritoneal Release
– Extra-Corporeal Resection & Anastomosis
COMPLETED DISSECTION

KIDNEY

DUODENUM

PSOAS

URETER
 MIS - Right Hemicolectomy
Post-Operative Care – FAST TRACKING!

–Ryle’s Tube (Optional)

–Analgesia
–VTE Prophylaxis
–Ambulate – 1st POD
–Urinary Catheter Removed – 1st POD
–Liquid diet ad libitum > 48 hours
–Early Discharge
 Our Experience in Right Hemicolectomy

 Total LRHC - 650

 Male - 57.14%
 Female - 42.66%
 Age range (yr) - 18 to 83
 Our Experience in Right Hemicolectomy

Before 2000 From 2001

 Ileocaecal TB - 28.44% <3%

 Adeno carcinoma - 57.14% >90%
 Lymphoma - 11.85% >5%
 Carcinoid - 2.37% <2%
 Conversion rate - 1.37% nil
 Mean operative time - 82mts 90mts
 Mean blood loss - 55 ml 50ml
 Laparoscopy in Ca rectum

 Malignancies of Lower rectum

 Difficult dissection and reconstruction
 Total mesorectal excision
 Increased rates of anastamotic leaks when compared to
other anastamosis
 Total Mesorectal excisiom

 Principles
Radical resection
Sphincter and Autonomic nerve preservation
 Class 1 Evidence

 Laparoscopic approach was associated with earlier return of

intestinal function, less overall morbidity and shorter
hospitalization

Lacy AM et al, Lap assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized
trial. Lancet 2002; 359: 2224–9.
Braga M et al , Laparoscopic versus open colorectal surgery. A randomized trial on short-term outcome. Ann Surg 2002;
236: 759–67.
 Ca Rectum : Lap resection

 403 patients with rectosigmoid carcinoma

 Randomised to (n=203) or open (n=200) resection
 End points :
– Survival
– disease-free interval
 Probabilities of survival at 5 years
– 76.1% (lap) and 72.9% (open)
 Probabilities of being disease free at 5 years
– 75.3% (lap) and 78.3% (open)

Leung KL et al, Lancet. 2004 Apr 10;363(9416):1187-92.

 Ca Rectum : Lap resection

 No difference in
 Distal margin
 Number of lymph nodes found in the resected specimen
 Overall morbidity
 Operative mortality

Leung KL et al, Lancet. 2004 Apr 10;363(9416):1187-92.

 Ca Rectum : Lap resection

 Laparoscopic resection of rectosigmoid carcinoma does not

jeopardise survival and disease control of patients

Leung KL et al, Lancet. 2004 Apr 10;363(9416):1187-92.

 Surgeries

 High Anterior Resection

 Anastomosis above the peritoneal reflection

 Low Anterior Resection –

 Anastomosis below the peritoneal reflection

 Ultra low Anterior Resection

 Anastomosis within 2cm of dentate line

 Coloanal anastomosis
 Anastomosis at or below the level of dentate line
LAPAROSCOPY IN BENIGN DISEASES
 Lap Total proctocolectomy with
ileal pouch-anal anastomosis

Peters et al, J Laparoendosc Surg 1992;2:175–8.

Wexner SD et al, Dis Colon Rectum 1992;35:651–5.
Lui CD et al, Am Surg 1995;61:1054–6.
Reissman P et al, Am J Surg 1996;171:47–51.
Santoro E et al, Hepatogastroenterology 1999;46:894–9.
Marcello et al, Dis Colon Rectum 2000;43:604–8.
Georgeson KE et al, Semin Pediatr Surg. 2002 ;11(4):233-6.
Ky AJ et al, Dis Colon Rectum. 2002;45(2):207-10.
Kienle P et al, Surg Endosc. 2003;17(5):716-20.
 Indications - TPC IPAA

• Inflammatory Bowel Disease

• Familial Adenomatous Polyposis
Laparoscopic Total Proctocolectomy with Ileo Anal
Pouch Anastomosis

 - technically feasible operation with low

morbidity

Ky AJ et al, One-stage laparoscopic restorative proctocolectomy: an alternative to the conventional approach? Dis Colon Rectum
2002;45:207–211.
Theatre setup
Theatre setup
 41

PORTS
 Procedure

• Surgeon on Rt side of patient

– Mobilisation of Sigmoid colon, splenic flexure and distal transverse colon

• Surgeon on Lt side of patient

– Mobilisation of terminal ileum, ascending colon, hepatic flexure and proximal transverse
colon

• Surgeon on Rt side of patient

– Division of Inferior mesenteric vessels, rectal mobilization and division with linear stapler
 Procedure -Contd

• Minilaparotomy
• Exteriorisation , Division of terminal ileum
• Creation of ileal pouch
• Pneumoperitoneum
• Ileal pouch anastamosis with circular stapler
• Protective ileostomy
Ileo Anal Pouch Anastomosis

Pouch formation – Endo GIA

Side to side anastomosis
Pouch anal anastomosis - Circular
EEA stapler
 45

GEM Experience

 Number of Patients - 73
 Mean Blood Loss - 170 ML
 Mean Operating Time - 210 MINS
 Average hospital stay - 8days
 SILS -5
 Single Incision vs NOTES
Ø No visceral injury
Ø Safer
Ø Similar cosmetic outcome
Ø Allows advanced laparoscopic procedures

SIMPS
 Innovations used
 Single incision multiport technique
 Conventional instruments and reusable trocars
 Overcoming loss of triangulation
– Mini triangulation externally
– Creating triangulation internally – curved tip instruments
 Advantages
 No added cost
 Less postoperative pain
 Reduced hospital stay
 High patient acceptability
 Ease of specimen extraction
 Combined procedures possible
 Excellent cosmesis
 SILS colorectal surgery

Review of Literature - at Present

Diagnostic and Therapeutic Endoscopy Volume 2010, Article ID 913216,
doi:10.1155/2010/913216
Review of single incision laparoscopic colectomy:
results.
 Systematic review of the literature using Pubmed, Medline, SCOPUS and Web of
Science databases.
 29 articles on colorectal MISS surgery have been published from July 2008 to July
2010, presenting data on 149 patients
 Conclusions: MISS colorectal surgery is a challenging procedure that seems to be
safe and feasible
 Retrospective review of 14 patients who underwent SILC at Siriraj Hospital(Thailand)from
May to December 2010

 Conclusion: SILC can successfully and safely be performed with standard laparoscopic
instruments. This technique might be an alternative procedure to conventional
laparoscopic colectomy with better cosmetic result.
 Ann Surg. 2012 Jan;255(1):66-9.
 Single-incision versus standard multiport laparoscopic colectomy: a
multicenter, case-controlled comparison.
 Champagne BJ, Papaconstantinou HT, Parmar SS, Nagle DA, Young-Fadok TM, Lee EC,
Delaney CP.
 CONCLUSIONS:
 SILC is feasible when performed on select patients by surgeons with extensive
laparoscopic experience. Outcomes were similar to MLC, except for a
reduction in peak pain score on the first postoperative day. Prospective
randomized trials should be performed before incorporation of this technology
into routine surgical care.
 Ann Surg. 2012 Apr;255(4):667-76
 Feasibility and safety of single-incision laparoscopic colectomy: a
systematic review.Makino T, Milsom JW, Lee SW.
 CONCLUSIONS:
 In early series of highly selected patients, SILC appears to be feasible and safe
when performed by surgeons who are highly skilled in laparoscopy. Despite
technical difficulties, there may be potential benefits associated with SILC over
MLC/HALC but it is yet to be proven objectively .
 SILS surgeries Gem Experiance
 Right hemicolectomy 18
 Extended right hemicolectomy 5
 Left hemicolectomy 3
 Anterior resection 10
 Abdominoperenial resection 3
 Total proctocolectomy 5
 Mesh Rectopexy 4
 Total 48
 SIMS
 Placement of incision
Ø Transumblical

Ø Ileostomy site

 Types of ports
Ø Single multiport trocar

Ø Multiple individual trocars

 Our Technique
Ø Single transumblical/right iliac fossa incision
Ø Raising skin flaps for adequate space
Ø Multiple conventional trocars
Ø Endoeye scope
Ø Conventional/long instruments
Ø Retraction using gravity/endoloop
Ø Stapled anastomosis
SILS TPC through ileostomy site
 SIMS- where are we now?

Single Incision lap colorectal surgery is feasible and

effective.

 Comparative studies are needed to determine its

benefits, cost analysis, oncologic outcomes.
 63

TPC IPAA with Natural orifice specimen extraction(N.O.S.E)

Ileal pouch made intracorporeally

Specimen extracted pervagina in female patients

 Ileal pouch anal anastomosis is done with a circular stapler

Covering loop ileostomy is then performed.

 Current indications
 Currently, there are no clear-cut indications for a robotic approach.
 Reported use of robotics for more common indications such as
diverticulitis, colon cancer, and inflammatory bowel disease.
 The major benefits robotics provide in the management of rectal
cancer & pelvic disorders (ie proctectomy) where the articulation of
the robotic arms and heightened visualization provide an enhanced
experience.
 Ongoing trials of robotic surgery
2 multicenter colorectal trials designed to assess the true
benefits for rectal cancer surgery:
ACOSOG 6051 (compared with open)
ROLLAR (compared with laparoscopy)
 Transanal Endoscopic Microsurgery
TEMS involves
– specialized 40-mm-diameter rectoscope,
– stereoscope 10-mm optical instrument with a 50° downward viewing
angle, and two eyepieces for 3D vision.
– instruments with downward-angled tips to facilitate access to the
operative field.
TEMS expands the transanal approach to mid- and upper-
rectum lesions that require more invasive low anterior
resections.
TEMS SET-UP
 CURRENT ROLE OF TEMS

 Benign rectal masses, mucosal advancement flaps for high

rectovaginal fistulas, high extrasphincteric fistulas and for transrectal
drainage of pelvic collections.
 T1 lesions ideal for TEMS, T2 lesions can also be resected, but
require additional chemoradiotherapy

SSAT/SAGES Joint Symposium. Indications and Techniques of Transanal Endoscopic Microsurgery (TEMS). Journal of
Gastrointestinal Surgery. Published online: June 2011
 TAMIS

Hybrid of TEM and SILS termed TransAnal Minimally

Invasive Surgery (TAMIS).
TAMIS provides a cost-effective alternative to TEM,
particularly using existing laparoscopic instruments
TAMIS
 TAMIS applications, beyond local excision.
 Repair of Recto-urethral fistula

 Completionproctectomy completely via the transanal approach, including

specimen extraction.

 Themost useful aspect is ‘reverse’ proctectomy, or TAMIS-TME for obese

male patient with a narrow pelvis.

 Furthermore, the distal margin is established first, in an approach to

rectal resection.
 The future

Minimally Invasive
Surgery
Remote Surgery

Pre-operative planning Simulation & Training

Intra-operative navigation
 Conclusion

 Minimally invasive colorectal surgeries are becoming standard

 SILCRS has the potential advantage of scarless surgery

 Robotic surgery may be useful in difficult rectal cancer surgery

 Future of colorectal MIS is promising

 75

Post Doctoral fellowship in Colorectal

Surgery in GEM Hospital

Affiliatedto The Tamilnadu Dr MGR Medical

University
Thank You