1. Gentler, Kinder Cut What’s New in Minimally invasive Colorectal Surgery? Samuel C. Oommen, MD, FACS, FASCRS Bay Area Colon and Rectal Surgeons Walnut Creek, Ca

2. Topics To be Covered Trans anal Endoscopic Microsurgery (TEM) Laparoscopic Colectomy Total Mesorectal Excision & Autonomic Nerve Preservation (TME & ANP) Hand Assisted Laparoscopic Surgery (HALS) Robotic Colorectal Surgery

3. Trans anal Endoscopic Microsurgery (TEM)

4. Transanal Endoscopic Microsurgery  Introduced by Gerhard Buess in 1983 for excision of proximal rectal lesions not amenable to a standard Transanal excision(TAE)  Operating Proctoscope with ports for CO2 insufflation and instrumentation  Six fold stereoscopic view  Facilitates negative surgical margins when direct visualization of the radial extent of the tumor is visible

5. TRANSANAL ENDSCOPIC MICROSURGERY (TEM)

6. Indications For TEM  Adenocarcinoma T1 lesion (Confined to Submucosa) Well or Moderately differentiated Without Lympho vascular invasion T2 lesion (Muscle Invasion)following preop chemo radiation under ACOSOG Z 6041 protocol  Carcinoid(< 2 cm)  Adenoma unable or incompletely excised by endoscopy  Residual neoplasm or uncertain margin after endoscopic resection  Excision of benign rectal stenoses  Palliation of advanced cancer in high risk patients

7. TEM Technique Proctoscopic exam Isolate tumor in lower half of field of view Secure scope in place with Martin Arm Courtesy Peter Cataldo, MD

8. TEM Technique Direct view through stereoscope or on monitor Courtesy Peter Cataldo, MD

9. Technique Inject lesion with lidocaine w/ epinephrine Courtesy Peter Cataldo, MD

10. ENDOSCOPIC VIEW

11. Multifocal Dysplastic Adenoma (TEM Specimen)

12. T1 Polypoid Cancer TEM specimen

13. T2 Adenocarcinoma of Mid Rectum

14. TEM VIDEO

15. TEM for Rectal Cancer? Oncologic Results

16. TEM vs. Radical Resection Winde et. al. Munster, Germany Prospective, randomized trial uT1N0 52 patients TEM vs. Ant. Resection Morbidity / mortality Recurrence Survival

17. TEM vs. Radical Resection Winde et. al. Munster, Germany Complications TEM 20.8% vs. LAR 34.5% Local recurrence TEM 2/24(8%) vs. LAR (?) Survival TEM 23/24 (96%) vs. LAR 25/26 (96%)

18. TEM Oncologic Results LeZoche et al Rome, Italy 40 patients, 3 yr f/u prospective, randomized trial T2N0 Preop chemoradiotherapy TEM vs LAR

19. TEM vs Lap LAR T2N0 TEM LAR OR time 95 min 165 min LOS 4.5 days 7.5 days Compl 15% 15% Local rec. 5% 5% 3 yr. Surv. 90% 83%

20. Laparoscopic Colorectal Surgery

21. Historical Perspectives  1990: Laparoscopic Right Colectomy- Jacobs, Miami, Florida  2004: COST Study *Jacobs M. et al Minimally Invasive Colon Resection, Surg Laparosc Endosc 1991; 1: 144-50 Recurrence & Survival

22. Benefits of Laparoscopic Surgery Smaller incisions Reduced postoperative pain Earlier return of bowel function Reduced hospital stay Earlier return to work and activities of daily living Reduced operative trauma and stress Reduced adhesions

23. Endoscopic Tattoo

24. Right Colectomy

25. Right Colon Anatomy

26. Adequate Lymph Node Harvest

28. Total Mesorectal Excision (TME)

29. What is Total Mesorectal Excision? “ TME is defined as the resection of the rectum with its surrounding fatty and lymphatic tissue contained within the visceral sheet (Fascia Propria) of the endopelvic fascia. The dissection in this almost avascular cleavage allows the complete removal of the mesorectal tissue, as well as good protection of the hypogastric nerves and the inferior hypogastric plexus, resulting in less disturbance to bladder and sexual functions.” Faerden AE et al, Dis Colon Rectum, 2005; 48: 2224-2231

30. Adapted from Heald, RJ et al, Br. J. Surg Vol 69(1982)613-616

31. Total Mesorectal Excision (TME) Shiny Fascia Propria covering the Mesorectum

32. Mesorectal Integrity and Survival Adapted from Dutch Colorectal Cancer Group, 2002; J Clin Oncol, 20: 1729

33. TME Grading COMPLETE: – Intact bulky mesorectum with a smooth surface – Only minor irregularities of mesorectal surface – No coning towards the distal margin of the specimen – After transverse sectioning, the circumferential margin appears smooth

34. TME Grading NEARLY COMPLETE: – Moderate bulk to the mesorectum – Irregularity of the mesorectal surface with defects greater than 5 mm, but none extending to the muscularis propria – No areas of visibility of muscularis propria

35. TME Grading INCOMPLETE – – Little bulk to the mesorectum – Defects in the mesorectum down to muscularis propria – After transverse sectiong, the circumferential margin appears very irregular

36. From Maslekar et al. 2006 “Mesorectal grades predict recurrences after curative resection for rectal cancer.” Dis Colon Rectum 50:168-175.

38. Hand Assisted laparoscopic Surgery Still the best Surgical instrument Tactile feedback for retraction and dissection May reduce operative times and need for conversion Bridge between open and laparoscopic surgery Two Commandments Adapted from Michael McCue, MD

39. Two Commandments of laparoscopic surgery. “Thou Shall not change your operation to fit the equipment” “Thou shall K. I. S. S. (keep it simple surgeons)” HALS is ideal in meeting above criteria. Adapted from Michael McCue, MD

40. Benefits of HALS Maintains Tactile Feedback Improves Eye Hand coordination and Depth perception Better exposure due to improved traction Facilitates rapid hemorrhage control No Laparoscopic instrument is as versatile, educated and safe as the experienced Surgeon’s Hand

41. Lap Disc Ethicon Endosurgery

43. Hand Assisted Right Colectomy for Hepatic Flexure Cancer HALS

44. Robotic Colorectal Surgery

45. Disadvantages of Laparoscopic surgery Unstable video camera imaging Dependency on assistant’s skills

46. Disadvantages of Laparoscopic surgery Limited motion of instruments  The Surgical instruments are Rod-like having no wrist movement at the tip which required from the surgeon to move his arms in large scale movements outside the patients body for the instrument tip (internally) to get to the desired location.  The movement of the instruments/scope were awkward (counter-intuitive) meaning that if the surgeon wants to move the instrument/scope to the left, he has to move to the right from outside.  Related loss of dexterity

47. Disadvantages of Laparoscopic surgery (Contd) The scope displays only a 2D image on the display which has no depth perception. The surgeon needed to over/under shoot the target anatomy to be able to allocate it properly. The Surgeon gets tired Awkward position such as twisting his neck to be able to follow up the surgical site displayed on the monitor. Longer hours standing

48. Advantages of Robotic Surgery Tridimensional(3D) imaging under the surgeon’s direct control Provides instruments with seven degrees of freedom Enhances dexterity, precision, and control during surgical procedures.

49. Advantages of Robotic Surgery (Contd). Scales down hand movements, and eliminates hand tremors Facilitates handsewn sutures. Cuts down the surgeon’s fatigue

50. OR Setup and Patient Preparation

51. Patient Positioning

52. Docking The Patient Cart

53. Surgical Steps - Surgical Overview

54. Robotic Colorectal Surgery

55. Disadvantages of Robotic Surgery Cost. With a price tag of 1.6 million dollars, and nearly 100k in maintenance costs annually. the size of these systems. lack of compatible instruments like energy sources and staplers. Lack of tactile feedback

56. Conclusion Generally, the maximum benefit seems to be achieved whenever a complex and precise dissection in a confined space is required. Still in infancy, and many advances are expected in the near future (smaller and operative-room integrated systems, tactile feedback technology, specifically designed instruments, reduced costs) Robotic laparoscopic colon surgery is feasible and safe. Operating time is longer than in standard laparoscopic surgery. Results from long term studies studies regarding cancer survival and recurrence are awaited