Preoperative evaluation Indication and contraindication Positioning OR setup Ass. Prof. Zdravko Perko

OPEN APPROACH Colonoscopy, rectoscopy (surgeon!) –Precise measurement –Anocutaneus distance –biopsy! Barium enema –Op strategy MSCT, NMR, EUS

preoperative work-up the same prior to both laparoscopic and conventional colectomies Colonoscopic biopsy is done in most patients to confirm presence of cancer –Colonoscopy does not accurately localize the lesion Metastatic spread –commonly investigated by ultrasonography of the liver and plain radiography of the chest. –Abdominal CT imaging to assess the size of the tumor and possible invasion of adjacent tissues performed selectively in some European centres and more extensively in the USA accuracy of preoperative staging of colonic cancer by CT varies from 40 to 77 % almost 40 % of conversions were due to a bulky or adherent tumor Laparoscopy has the potential for assessing tumor invasion of adjacent organs –there are no published reports with respect to the value of laparoscopic staging in the workup

Indication and contraindication Disease –Malignant TNM, stage –Benign Crohn, diverticular disease, polyps, UC Patient –Condition (BMI) –Respiratory / cardiac function –Previous operations Surgeon –Op team –Equipement

± Ind. / CI ~ Learning curve Objective Position Patient Disease (Malignant, TNM/stage) Subjective Skills (surgeon / team) Equipement Time / OR availability Learning curve Patient selection!?

Patient positioning Lithotomy position –Hip abduction, legs apart, knee slightly bent up to 15º –Crural position Elastic socks Trendelenburg / Antitrendelenburg Tilting –Safe fasten!

Op room setup Commodious (endoscopic?) op room –Sufficient space around the table Two / three monitors (endoscopic equipement!) –Disease localisation –Trocar position Diamond shape Two-hand technique Devices –Behind the surgeon Integrated op room Experienced team –Scrub / “flying” nurse

Trocar positioning based on the experience and preference of the individual surgeon RIGHT HEMICOLECTOMIES 50% of experts use four trocars, 30% use 3 trocars and 20% 5 trocars. The majority extracts the specimen through an incision made at the site of the umbilical trocar –At the umbilicus 10-12mm trocar is placed –A 10mm trocar is placed suprapubically and in the epigastric region by 70% of authors –Some experts place a 5mm trocar at the left iliac fossa or at the right subcostal space.

RIGHT HEMICOLECTOMIES

LEFT HEMICOLECTOMIES For left hemicolectomy and for sigmoid resection almost at the same sites Thirty percent of experts perform these procedures using the hand-assisted technique Five trocars are used by over 70% of experts –A 10-12mm trocar is placed at the umbilicus –two 10mm trocars are placed by 80% of experts in the right iliac fossa and in the right suprapubic region The incision for specimen extraction –the left iliac fossa –suprapubic incision

LEFT HEMICOLECTOMIES

Type of procedure? Preop planning

Right colon procedures

Right colon patient position - op setup

Right colon - trocars

Right / Transverse colon patient position - op setup

Right / Transverse colon trocar placement

Transverse colon

Left colon / rectum patient position / OR setup

Left colon / rectum trocar position

Conclusions Indication / Contraindication –Open approach? –Objective / subjective / learning curve Positioning / OR setup / trocar placement –Based on the experience and preference of the individual surgeon –Good preop work-up and planning –Avoid surprises and keep flexibility