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General Surgery
Laparoscopic Colorectal Procedures
Built from Maingot's Abdominal Operations
What’s inside
12 sections · 163 slides
Overview
- Scope of this presentation
Overview and advantages
How minimally invasive surgery reached the colon and rectum
- Minimally invasive colorectal surgery
- Adoption and drivers of uptake
- Advantages of laparoscopy
- Patient benefits of the laparoscopic approach
- Range of procedures covered
Patient selection
Indications, contraindications and the limits of the approach
- Who can be offered a laparoscopic operation
- Matching case difficulty to experience
- Indications in colon and rectal diseases
- Indications for laparoscopic colorectal surgery
- Indications in inflammatory bowel disease
- Diverticular disease, polyps and colon cancer
- Rectal prolapse and rectal cancer
- Categories of contraindication
- Absolute and relative contraindications to laparoscopy
- Pneumoperitoneum and organ failure
- Renal, hepatic and bleeding limits
- Relative contraindications: adhesions and obesity
- Disease-specific contraindications in colon and rectal disease
- Disease-specific contraindications
- Bowel dilation and fixed tumours
Evaluation and conversion
Working up the patient when the surgeon cannot feel the disease
- Preoperative workup and staging
- Localizing the tumour and confirming the specimen
- Localization in benign disease
- Reasons for conversion to open surgery
- Conversion: judgement and timing
- Frail tissue and ureteral stents
- Key points in patient preparation
- Key points in oncologic resection
Oncologic considerations
What the randomized trials settled for colon cancer, and what rectal cancer still asks
- The port-site recurrence controversy
- Concerns after the 1991 introduction
- The four randomized trials
- Trial programme and short-term results
- Long-term survival and its consequences
- Rectal cancer and the chimney effect hypothesis
- Margins and instrumentation in rectal cancer
- ACOSOG Z6051 trial design and endpoints
- Z6051 eligibility criteria
- Z6051 credentialing and accrual
Equipment, position and access
The kit, the theatre layout and getting safely into the abdomen
- Commonly used laparoscopic instruments
- Laparoscopic instruments
- The 30-degree laparoscope
- Trocars, cautery and mobile equipment
- Bowel handling graspers
- Access to the peritoneal cavity
- Instrument length requirements
- Energy and stapling devices for the mesentery
- Position of equipment and the surgical team
- Securing the patient on the table
- Protecting nerves and decompressing hollow organs
- Port placement technique
- Wound closure after laparoscopy
Right hemicolectomy
Seven steps from positioning to anastomosis
- Sequence of laparoscopic right hemicolectomy
- Position of laparoscopic ports for right hemicolectomy
- Exploration of the abdomen
- Mobilization of the cecum
- Identifying the right ureter
- Entering the retroperitoneal plane
- Completing the medial mobilization
- Mobilization of the hepatic flexure
- Completing the flexure dissection
- Intracorporeal division of the right colon vasculature
- Technique of vessel ligation
- Exteriorization of the right colon
- Anastomosis after exteriorization
- Irrigation, inspection and wound closure
- Medial-to-lateral dissection for right hemicolectomy
- Completing the medial-to-lateral approach
Left hemicolectomy and hand-assisted surgery
Mirror-image technique, the spleen, and putting a hand back in the abdomen
- Position of laparoscopic ports for left hemicolectomy
- Mobilization of the left colon
- Mobilization of the splenic flexure
- Completing the left hemicolectomy
- Position of the hand inside the abdomen through a hand port
- Position of the hand port incision and laparoscopic ports
- Hand-assisted mobilization of the left colon
- Hand-assisted mobilization of the splenic flexure: omental attachments
- Hand-assisted mobilization of the splenic flexure
Sigmoid and transverse colectomy
Working down toward the pelvis, and the short middle colic pedicle
- Position of laparoscopic ports for sigmoid colectomy and anterior resection
- Mobilizing proximal sigmoid and descending colon
- Mobilization of the upper rectum
- Why the hypogastric nerves matter
- Intracorporeal division of the superior hemorrhoidal and sigmoidal vessels
- Division of the upper rectum with a linear stapler
- Stapled colorectal anastomosis
- Alternative hand-sewn anastomosis
- Hand-assisted laparoscopic sigmoidectomy
- Leak testing after sigmoid resection
- Transverse colectomy: position and ports
- Transverse colectomy: mobilization
- The middle colic pedicle
Rectal procedures
Anterior resection, low anterior resection, rectopexy and abdominoperineal resection
- Levels of resection in rectal surgery
- Levels of rectal resection
- Anterior resection and low anterior resection
- Abdominoperineal resection and rectopexy
- Anterior resection: position and ports
- Anterior resection: vascular ligation
- Anterior resection: mobilizing the rectum
- Anterior resection: oncological principles
- Anterior resection: excision and anastomosis
- Low anterior resection: position and ports
- Low anterior resection: mobilizing the left colon
- Low anterior resection: vascular pedicle
- Low anterior resection: the presacral plane
- Low anterior resection: achieving distal clearance
- Low anterior resection: lateral stalks and level check
- Division of the lower rectum with a transverse stapler
- Colorectal anastomosis
- Low anterior resection: leak testing
- Hand-assisted low anterior resection
- Position of laparoscopic ports for abdominoperineal resection
- Abdominoperineal resection: theatre set-up
- Abdominoperineal resection: vessels and abdominal mobilization
- Abdominoperineal resection: the perineal dissection
- Abdominoperineal resection: specimen delivery and the urethra
- Abdominoperineal resection: closure and colostomy
- Resection rectopexy: principle and set-up
- Resection rectopexy: vessels and mobilization
- Resection rectopexy: rectal dissection
- The lateral stalk question in rectopexy
- Resection rectopexy: judging the resection length
- Resection rectopexy: division and anastomosis
- The rectopexy fixation itself
Total colectomy and pouch surgery
Removing the whole colon and building an ileal reservoir
- Subtotal colectomy: position and ports
- Subtotal colectomy: mobilization and exteriorization
- Ileorectal anastomosis
- Technique of side-to-end ileorectal anastomosis
- Position of laparoscopic ports for total proctocolectomy
- Pouch surgery: colon and rectal mobilization
- Reaching the pelvic floor with the stapler
- Transanal mucosectomy
- Pouch surgery: exteriorization
- Preparing the ileum to reach the anus
- Lengthening manoeuvres and pouch construction
- Ileal J-pouch-anal anastomosis
- Hand-sewn pouch-anal anastomosis
- Defunctioning loop ileostomy
- Hand-assisted ileal J-pouch procedure
- Completing the hand-assisted pouch procedure
Complications, training and future directions
What can go wrong, how to prevent it, and where the field was heading
- Intraoperative complications related to patient position
- Intraoperative complications of access, gas and technique
- Complications related to patient position
- Complications of access, gas and technique
- Management of intraoperative complications
- Managing intraoperative injury
- Prevention of technique-related complications
- Prevention of anastomotic and wound complications
- Preventing perforation and organ injury
- Preventing bleeding, leak and wound problems
- Learning curve in laparoscopic colectomy
- Credentialing and progression of skills
- Advantages and disadvantages of robotic surgery
- Early experience with robotic colorectal surgery
- Advantages of robotic-assisted surgery
- Drawbacks and future role of robotics
- Natural orifice specimen extraction and NOTES
- Governance and appeal of NOTES
- Take-home points on selection and safety
- Take-home points on technique and evidence
- References
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition