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.

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