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Evolution of minimally invasive Colorectal surgery

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1 Evolution of minimally invasive Colorectal surgery

2 EVOLUTION OF COLORECTAL SURGERY
CONVENTIONAL OPEN SURGERY LAPAROSCOPIC SURGERY Single incision/NOTES/NOSE ROBOTICS

3 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

4 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's technique resulted in decreased positive lateral margins and local recurrence rates - the lowest ever at 3.6%.

5 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”

6 ADVENT of laparoscopy

7 Milestones in laparoscopy

8 Initial reactions to laparoscopy
DON’T TALK LAP DON’T HEAR LAP DON’T SEE LAP

9 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.

10 Technological Improvements
HD digital cameras with improved clarity, visualization Better instrumentation Energy sources Harmonic scalpel Ligasure Staplers Endo-flex & circular

11 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.

12 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

13 Lap colorectal surgeries
Lap hemicolectomy Lap subtotal colectomy Lap anterior resection Lap abdominoperineal resection Lap total proctocolectomy/ ileal pouch anal anastomosis Lap rectopexy

14 LAPAROSCOPY IN COLORECTAL MALIGNANCY

15 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.

16

17 Laparoscopy for rectal cancer
Conclusion of CLASSICC trial: “Long-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer.” Conclusion of 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):

18 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

19 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 Feb;27(2):190-6.

20 Advantages of Medial to lateral approach
Easy to perform Takes lesser time Less invasive Protection of ureter Other structures : Duodenum & IVC

21 Laparoscopic colorectal cancer surgeries
Right Hemicolectomy Lap AR Lap APR Subtotal Colectomy Total Proctocolectomy

22 IRETA - Initial Retrocolic Endoscopic Tunnel Approach
Initially Applied for Benign Disease – Early 1990s Transferred to Surgical Oncology Adheres to Oncological Principles! Technical Advantages- Early Intra-Corporeal Identification of Ureter and Duodenum Excellent Intra-corporeal Vascular Control Excellent Specimen Control!

23 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

24 COMPLETED DISSECTION KIDNEY DUODENUM PSOAS URETER

25 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

26 Our Experience in Right Hemicolectomy
Total LRHC Male % Female % Age range (yr) to 83

27 Our Experience in Right Hemicolectomy
Before 2000 From 2001 Ileocaecal TB % <3% Adeno carcinoma % >90% Lymphoma % >5% Carcinoid % <2% Conversion rate % nil Mean operative time mts 90mts Mean blood loss ml 50ml

28 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

29 Total Mesorectal excisiom
Principles Radical resection Sphincter and Autonomic nerve preservation

30 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.

31 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 Apr 10;363(9416):

32 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 Apr 10;363(9416):

33 Ca Rectum : Lap resection
Laparoscopic resection of rectosigmoid carcinoma does not jeopardise survival and disease control of patients Leung KL et al, Lancet Apr 10;363(9416):

34 Surgeries High Anterior Resection Low 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

35 LAPAROSCOPY IN BENIGN DISEASES

36 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 ;11(4):233-6. Ky AJ et al, Dis Colon Rectum. 2002;45(2): Kienle P et al, Surg Endosc. 2003;17(5):

37 Indications - TPC IPAA Inflammatory Bowel Disease
Familial Adenomatous Polyposis

38 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.

39 Theatre setup

40 Theatre setup

41 PORTS

42 Procedure Surgeon on Rt side of patient Surgeon on Lt 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 Division of Inferior mesenteric vessels, rectal mobilization and division with linear stapler

43 Procedure -Contd Minilaparotomy
Exteriorisation , Division of terminal ileum Creation of ileal pouch Pneumoperitoneum Ileal pouch anastamosis with circular stapler Protective ileostomy

44 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 MINS Average hospital stay days SILS

46 Single Incision vs NOTES
No visceral injury Safer Similar cosmetic outcome Allows advanced laparoscopic procedures SIMPS

47 Innovations used Single incision multiport technique
Conventional instruments and reusable trocars Overcoming loss of triangulation Mini triangulation externally Creating triangulation internally – curved tip instruments

48 Advantages No added cost Less postoperative pain Reduced hospital stay
High patient acceptability Ease of specimen extraction Combined procedures possible Excellent cosmesis

49 SILS colorectal surgery
Review of Literature - at Present

50 Diagnostic and Therapeutic Endoscopy Volume 2010, Article ID 913216, doi:10.1155/2010/913216

51 Review of single incision laparoscopic colectomy: results.

52 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

53 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.

54 Ann Surg 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.

55 Ann Surg 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.

56 SILS surgeries Gem Experiance
Right hemicolectomy Extended right hemicolectomy 5 Left hemicolectomy Anterior resection Abdominoperenial resection Total proctocolectomy Mesh Rectopexy Total

57 SIMS Placement of incision Transumblical Ileostomy site Types of ports
Single multiport trocar Multiple individual trocars

58 Our Technique Single transumblical/right iliac fossa incision
Raising skin flaps for adequate space Multiple conventional trocars Endoeye scope Conventional/long instruments Retraction using gravity/endoloop Stapled anastomosis

59 SILS TPC through ileostomy site

60 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.

61 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.

62 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.

63 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)

64 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.

65 TEMS SET-UP

66 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

67 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

68 TAMIS

69 TAMIS applications, beyond local excision.
Repair of Recto-urethral fistula Completion proctectomy completely via the transanal approach, including specimen extraction. The most 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.

70 The future Minimally Invasive Surgery Remote Surgery
Pre-operative planning Simulation & Training Intra-operative navigation

71 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

72 Post Doctoral fellowship in Colorectal Surgery in GEM Hospital
Affiliated to The Tamilnadu Dr MGR Medical University

73 Thank You


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