1. Laparoscopy for Ischemia Howard Ross, MD, FACS, FASCRS Chief, Colon and Rectal Surgery Director, Crohn’s and Colitis Management Center Riverview Medical Center Clinical Associate Professor of Surgery UMDNJ

2. Disclosures Consultant and Course Director: –Applied Medical –Covidien Poked fun at NJ my entire life….Now I live there!

3. Laparoscopy for Ischemia ?

4. Open Operation

5. Ischemia

7. Literature Results: Laparoscopic Surgery for Ischemic Colitis Nil

8. Second look laparoscopy after mesenteric infarct Second-look laparotomy is not always routinely performed after mesenteric infarction because of the high operative risk Authors developed a minimally invasive technique for second-look laparoscopy Aim to decrease the operative morbidity –old incision is opened at the umbilicus –suture lifted with a clamp and the incision line is gently reopened –trocar with a blunt tip inserted –It was possible to explore the entire small bowel and colon Glättli AGlättli A, Seiler C, Metzger A, Stirnemann P, Baer HU.Seiler CMetzger AStirnemann PBaer HU Universitätsklinik für Viszerale und Transplantationschirurgie, Inselspital, Bern, Schweiz Langenbecks Arch Chir. 1994;379(2):66-9.

9. Second look laparoscopy after mesenteric infarct Five patients after bowel resection performed for mesenteric infarction –Second-look laparoscopy was diagnostic in all but one –Laparoscopy failed due to massive small bowel dilatation Glättli AGlättli A, Seiler C, Metzger A, Stirnemann P, Baer HU.Seiler CMetzger AStirnemann PBaer HU Universitätsklinik für Viszerale und Transplantationschirurgie, Inselspital, Bern, Schweiz Langenbecks Arch Chir. 1994;379(2):66-9.

10. Laparoscopic Colon Resection in Emergent Situations Toxic Colitis Diverticultis Crohn’s Disease …One can to extrapolate to ischemia

11. Laparoscopy for Toxic Colitis Limited number of studies describing the role of minimally invasive colectomy for urgent or emergent conditions of the large bowel Single institution (Cornell) 2001-6 identified from a prospective database Urgent and emergent conditions were included 68 [open 32, MIS 36 [HALS 22, LAP 14)] Patients with toxic colitis were more often selected for MIS Patients with colon perforation or large bowel obstruction were more often selected for open surgery –No difference in morbidity –MIS group had a longer median operative time and fewer cases of prolonged hospitalization Colorectal Dis. 2010 May;12(5):480-4. Epub 2009 Mar 26. Minimally invasive surgery is safe and effective for urgent and emergent colectomy

12. Laparoscopic two-stage left colonic resection for patients with peritonitis caused by acute diverticulitis Emergent Open Hartmann's procedure is standard for complicated disease –abscess, peritonitis, and stenosis The advantages of laparoscopy could be combined with those of the primary resection Laparoscopic Hartmann's procedure seldom reported –technical difficulties –theoretic risk of poorly controlled sepsis Chouillard E, Maggiori L, Ata T, Jarbaoui S, Rivkine E, Benhaim L, Ghiles E, Etienne JC, Fingerhut A. Department of General and Minimally Invasive Surgery, Centre Hospitalier Intercommunal, 10, rue du Champ Gaillard, Poissy, France.Chouillard EMaggiori LAta TJarbaoui SRivkine EBenhaim LGhiles EEtienne JCFingerhut A

13. Laparoscopic two-stage left colonic resection for patients with peritonitis caused by acute diverticulitis Data were prospectively collected from 2003 -5 in a single center Laparoscopic Hartmann's procedure (Stage 1) was performed in selected patients with peritonitis complicating acute diverticulitis. Secondarily, Hartmann's reversal (Stage 2) also was performed laparoscopically. Thirty-one patients were studied –Median Mannheim Peritonitis Index score was 21 (+/-5; range, 12-32) –Conversion rate was 19 and 11 percent for Stage 1 and Stage 2, respectively –There was no perioperative uncontrolled sepsis –Overall operative 30-day mortality and morbidity rates were 3 and 23 percent for Stage 1, and 0 and 15 percent for Stage 2, respectively. –Stoma reversal was possible in 90 percent of patients. Chouillard E, Maggiori L, Ata T, Jarbaoui S, Rivkine E, Benhaim L, Ghiles E, Etienne JC, Fingerhut A.Chouillard EMaggiori LAta TJarbaoui SRivkine EBenhaim LGhiles E Etienne JCFingerhut A

14. Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis laparoscopic peritoneal lavage, inspection of the colon, and intraoperative drain placement of the peritoneal cavity for complicated acute diverticulitis and peritonitis without gross fecal contamination Texas Endosurgery Institute from 1991 - 2006 retrospectively reviewed 40 patients, average age was 60, (many with associated co-morbidities) –average operating time was 62 minutes –no conversions to an open procedure. –paralytic ileus in six patients and chest infections in two Just over 50% underwent elective interval laparoscopic sigmoid colectomy During the mean follow-up of 96 months, none of the other patients required further surgical intervention. Franklin ME Jr, Portillo G, Treviño JM, Gonzalez JJ, Glass JL.Franklin ME JrPortillo GTreviño JMGonzalez JJGlass JL World J Surg. 2008 Jul;32(7):1507-11.

15. Franklin Conclusions decrease in the overall cost of treatment colostomy is avoided reduction in mortality and morbidity as definitive laparoscopic resection can be performed in a nonemergent fashion fewer wound complications such as dehiscence, wound infection, and the high risk of hernia formation Laparoscopic lavage and drainage should be considered in all patients in whom medical and/or percutaneous treatment is not feasible...should be considered the standard of care. Franklin ME JrFranklin ME Jr, Portillo G, Treviño JM, Gonzalez JJ, Glass JL.Portillo GTreviño JMGonzalez JJGlass JL World J Surg. 2008 Jul;32(7):1507-11.

16. Laparoscopic Colectomy for Crohn’s Disease

17. National Trends and Outcomes for the Surgical Therapy of Ileocolonic Crohn’s Disease: A Population-Based Analysis of Laparoscopic vs. Open Approaches All admissions with a dx of Crohn’s selected from Nationwide Inpatient Sample 2000–4 396,911 patients admitted for Crohn’s disease 49,609 (12%) required surgical treatment Laparoscopic resection in 2,826 cases (6%) J Gastrointest Surg (2009) 13:1251–1259

18. Meta-analysis Lap vs. Open Ileocolic Resection H. S. Tilney, V. A. Constantinides, A. G. Heriot, M. Nicolaou, T. Athanasiou, P. Ziprin, A. W. Darzi, P. P. Tekkis 20 studies identified by review of Medline, Ovid, Embase, and Cochrane databases 15 satisfied inclusion criteria, 783 patients 338 (43.2%) had laparoscopic resection Conversion rate 6.8% Operative time 29.6 min longer in laparoscopic group (p = 0.002) Blood loss and complications similar Laparoscopic patients –significantly shorter time for recovery of their enteric function –shorter hospital stay, by 2.7 days (p < 0.001) The contraindications to laparoscopic approaches for Crohn’s disease remain undefined Surg Endosc (2006) 20: 1036–1044

19. Laparoscopic resection for Crohn’s disease: an experience with 335 cases Pts identified since 1993 117 patients with fistula, 45% multiple 80 enteroenteric, 51 ileosigmoid, 33 enteroabdominal wall, 22 ileovesical fistulas Eight conversions occurred (2%), primarily because of large inflammatory masses involving the intestinal mesentery We believe all operations should initially be approached laparoscopically and that no cases should be considered for an open operation, not even a tertiary or quaternary resection Salky Surg Endoscopy Published Online 05 March 2009

20. Emergency Laparoscopic Colectomy: Does it Measure Up to Open? Patients from prospective database who underwent an emergency colectomy 2005-8 Laparoscopic operations in 42 compared to 25 suitable for laparoscopy but received open colectomy Blood loss was lower (118ml vs. 205ml, p <0.01) Postoperative stay shorter (8 vs.11 days, p = 0.02) Perioperative mortality rates were similar between the two groups (1 vs. 3, p = 0.29) laparoscopic colectomy is a feasible option in certain emergency situations… Jonah J. Stulberg, M.P.H.1,2, Brad J. Champagne, M.D.1, Zhen Fan, M.D.1, Mike Horan, DDS, PhD3, Vincent Obias, M.D.1, Eric Marderstein, M.D., M.P.H.1, Harry Reynolds, M.D.1, and Conor P. Delaney, M.D., Ph.D., M.Ch.11 University Hospitals Case Medical Center, Department of Surgery Am J Surg. 2009 March ; 197(3): 296–301

21. Emergency Laparoscopic Colectomy: Does it Measure Up to Open? Diagnoses: –bowel obstruction –perforated viscus –fulminant colitis –ischemia –uncontrollable gastrointestinal hemorrhage Excluded: –severe hemodynamic lability on inotropes –toxic megacolon –peritonitis in the setting of morbid obesity –prior colectomy –body mass index > 55

22. Guidelines Not possible in all patients –Unstable patient –Massively distended bowel –? Morbidly obese, Prior Laparotomy Patient Safety is Paramount Rapid, Efficient Operation Must Occur Careful handling of fragile tissue

23. Laparoscopy is a tool

24. Emergency Laparoscopic Colectomy: Does it Measure Up to Open? No patient received a preoperative bowel preparation. Conversion was defined as an incision over eight centimeters or operating through the extraction incision. Age, gender, body mass index, admission date, admission status, operative date, operation, time to flatus, time to first bowel movement, intra-operative complications, postoperative complications, discharge date, and discharge status were collected prospectively. Previous abdominal operations, comorbidities, indication for surgery, operative time, estimated blood loss, time to resuming diet, time to full ambulation, post-operative diagnosis, and 30 day readmission rate were collected retrospectively.

25. Surg Laparosc Endosc Percutan Tech. 2011 Oct;21(5):340-3. Laparoscopic colorectal surgery in urgent and emergent settings. Catani M, De Milito R, Romagnoli F, Romeo V, Modini C.Catani MDe Milito RRomagnoli FRomeo VModini C Source Division of Emergency Surgery and Trauma, DEAII Emergency Department, Umberto I Policlinico di Roma, La Sapienza Università di Roma, Rome, Italy. Abstract Laparoscopic colectomy (LC) is slowly becoming the standard of care for elective resections. The use of LC in the emergency setting is relatively unstudied. Authors describe their experience with a series of 34 emergent and urgent LC cases for a variety of benign and neoplastic colorectal diseases, admitted from 2007 to 2009 at Emergency Department of a tertiary level hospital, comparing laparoscopic group with matched control open group. Twenty-one LC was performed for benign complicated disease, 12 for malignant disease and 1 for iatrogenic perforation during colonoscopy. Two cases were converted to open procedure (5.8%), the average operative time was 188 minutes (SD 61.84). The average postoperative length of hospital stay was 6.57 days (SD 1.75), with no postoperative mortality and no major morbidity. Results of laparoscopic group compared with 61 patients treated with open colorectal procedure confirm the advantages of laparoscopic approach similar to those established in elective colorectal surgery. With increasing experience, LC would be a feasible and an effective option in nonelective situations lowering complication rate and length of hospital stay.