LAPAROSCOPY
| HOW TO ACQUIRE AND MASTER ADVANCED LAPAROSCOPIC TECHNIQUES—Lee L. Swanstrom, MD, Clinical
Professor of Surgery, Oregon Health Sciences University, and Director, Minimally Invasive Surgery, Legacy Health System,
Portland, OR
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| Laparoscopic cholecystectomy paradigm: advantages—stimulated innovation; rapid introduction into general
practice; enabled surgeon to control own practice; marketing tool for hospitals and surgeons; disadvantages—short-course
model unvalidated for how effectively it taught surgeons; no quality control over educational content; tended to shortcut
cognitive foundation; inadequate time to build manual skills; resident education took back seat
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| Learning curves: minimize or avoid; stress on surgeon—leads to rejection of new; stress on system—loss of efficiency;
increased cost; stress on patient—leads to complications
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| Clinical outcomes: related to volume; to achieve competence, need experience and to achieve experience, need volume
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| New technology: mastery becoming more difficult; for advanced skills, need good foundation in cognitive basics,
breadth of experience, plenty of practice, and ongoing volume of cases to maintain competency; new teaching techniques
and tools—mentorships, internet-based teaching and learning tools, and development of performance and knowledge
benchmarks; virtual reality and simulation important
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| THE ROLE OF THE HAND—James W. Fleshman, MD, Professor of Surgery and Chief of Colorectal Surgery, Washington
University School of Medicine, St. Louis, MO
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| Hand-assisted laparoscopic surgery (HALS): advantages—potential to decrease operating room (OR) time; ability
to overcome intraoperative difficulties without converting to open operation; may shorten learning curve for surgeons starting
laparoscopic experience; facilitates teaching in residency training program; disadvantages—pure laparoscopic approach
lost; may lead to inappropriate use of laparoscopic approach for condition better treated with open operation; study
(Litwin 2000)—compared laparoscopic and open surgery of colon; flawed; found increased hospitalization time for hand-
assisted group; wound complications and remainder of outcomes same
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| Procedure: use standard trocar site pattern with camera above umbilicus; 2 ports on patient’s right side and port on left
side; hand-access incision above pubis (vertical midline suprapubic or Pfannenstiel); suffices for all patients with left colon
disease or total abdominal colectomy; setup in OR same as for laparoscopic procedure; patient placed in lithotomy
position (bean bag used); trocar sites placed under direct vision or with hand as guidance; advantages with hand—ability
to feel ureter when looking for it at pelvic brim and to dissect inflammatory masses off pelvis, using pinching-type dissection;
easier operation to take down splenic flexure; mobilization of splenic flexure integral part of left colectomy procedures;
dissecting at base of mesentery of left colon in patients with inflammatory bowel, isolation of inferior
mesenteric artery with finger, rather than relying on instrument; helping guide instrument used to divide vessel; managing
torn vessel in abdomen easier than using another instrument to grab vessel; obtaining hemostasis and clearing retroperitoneum
easier; better exposure of field; if difficult to find mass lesion for resection, can feel it
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| Hand vs laparoscopic: some data suggest outcomes with HALS as good as with laparoscopic; Tarragona—looked at left
colectomy mostly (some right lesions); concluded that extraction site of laparoscopic group almost same as hand-access incision;
conversion rate less for HALS group; complication rates and hospital stay almost same; in 9 patients, felt that unable to
perform operation without hand access; 4 patients in laparoscopic group converted to HALS; increase in inflammatory response
with hand-access; study—compared HALS with straight laparoscopic total abdominal colectomy and pouch procedure;
conversion rate higher in laparoscopic group; operative time 1 hr shorter for hand-access group; blood loss, length of
stay, and morbidity same; Sang Lee et al—looked at complicated and uncomplicated diverticulitis; little difference in operating
time; incision length slightly larger for HALS group; in complicated cases, conversion rate extremely high for laparoscopic
group, reasonable for HALS group; difference in operating time ≈1.5 hr; study—looked at whether HALS facilitates
adoption of laparoscopic procedure by 3 inexperienced surgeons and 1 experienced surgeon attempting to perform conventional
operations for diverticulitis; in HALS group, times “tighter” and more patients completed; study—interim results
showed median time 210 min for left colectomy group using standard laparoscopic approach and 163 min in HALS group; for
total abdominal colectomy group, even larger difference ( ≈90 min); no difference in length of stay, bowel recovery, and pain
score; conclusion—HALS used in circumstances where laparoscopic surgery not good idea or if unable to complete operation
laparoscopically; HALS means of increasing adoption of laparoscopic technique
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| CHALLENGES IN LAPAROSCOPIC COLORECTAL SURGERY—Charles P. Heise, MD, Assistant Professor of Surgery,
University of Wisconsin School of Medicine and Public Health, Madison
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| Teaching advanced laparoscopic techniques: several standardized approaches; as yet, no good way to measure or
test competence; important to have experienced mentor during training period
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| Evaluation of learning curve: cumulative sum model (CUSUM)—heavily based on conversion rates and allows consideration
of other outcome measures (eg, operative times, postoperative complications, readmission rates); allows for
risk adjustment for other confounding factors affecting learning curve, eg, case-mix variables, procedural risk factors; for
right-sided resections, learning curve ≈55 cases, 62 cases for left-sided resections; variability in learning curves; individual
surgeons and number of surgeons involved play role in determining learning curve; range 15 to 80 cases; learning
curve steep and more prolonged than initially thought
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| Bleeding issues: most important to maintain adequate visualization during dissection; grasp bleeding vessel gently; suction
irrigation device good tool for clean field; place extra ports if necessary; options to control bleeding include clips,
stapling devices, and ligature loops; avoid rapid placement of clips or ligature when unsure of problem
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| Identification of ureter: perform gentle dissection in area; avoid use of cautery or harmonic scalpel initially; check and
recheck ureter throughout procedure; lighted ureteral stents option but add time; in many instances, medial-to-lateral approach
has definite advantage (starting dissection away from inflammatory process based on surgical principle of starting
from known plane of dissection and working toward unknown area); consider converting from laparoscopic to hand-assisted
approach (useful in breaking up inflammatory adhesions)
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| Patient selection: as surgeon becomes more comfortable with laparoscopic surgery techniques, patient selection becomes
more liberal; obesity—more obese patients expected; because of differences in fat distribution between obese
men and women, procedures more likely to be completed in women than in men; studies comparing laparoscopic colorectal
surgery in obese vs nonobese patients show that in most cases, operative times prolonged and conversion and
complication rates higher in obese; obesity not absolute contraindication, but requires increased level of expertise; ideal
situation to consider hand port or additional ports, as major obstacle often good visualization, and optimal retraction
needed; previous abdominal surgery—not absolute contraindication; important to use safe abdominal entry and open
approach, and alter placement of ports in more difficult cases if necessary
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| LAPAROSCOPY FOR RECTAL PROLAPSE: TECHNIQUE AND RESULTS—Anthony J. Senagore, MD, Professor and
Chair, Department of Surgery, University of Toledo, College of Medicine, Toledo, OH
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| Goals for treatment of rectal prolapse: ideally, anorectal and bowel function not worsened, recurrence rate zero,
and few complications; elderly patients often affected, so must consider existing medical conditions and lifespan of patient;
if projected lifespan short, durability of operation less of issue and morbidity of operative procedure main decision-
making factor; for patients with longer projected lifespan, recurrence rates and bowel and anorectal function important in
decision making
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| Procedures: >100; data show that recurrence rates and morbidity and mortality fall within same range, but if followed
long enough, recurrence rates all increase; Ripstein repair—abandoned because of high rate of constipation; rather than
putting mesh around anteriorly, perform Wells rectopexy, where mesh placed along sacrum in posterior 40% or 50% of
circumference (lower rate of constipation); Delorme repair—associated with incontinence because essentially performed
coloanal anastomosis and if followed longer, has highest recurrence rate of any perineal operation; Altmeier
repair—full thickness or perineal proctosigmoidectomy; higher recurrence rate overall than with abdominal approaches
and incontinence (removing reservoir function of rectum and performing coloanal anastomosis); comparing abdominal
to perineal approaches—different patterns in overall morbidity, with higher rate of small-bowel obstruction in abdominal
approach (none with perineal approach); leaks typically few and easily managed transanally; advantage of perineal
approach shorter length of stay at expense of slightly higher recurrence rate
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| Laparoscopy: better visualization of operative field through smaller hole; should provide same benefits as open surgery;
access-related complications—in United States, vertical midline incision associated with ventral hernia rate of 10%;
surgical management of ventral hernia costs ≈$10,000; small bowel obstruction—significant reason for readmission after
laparotomy; both complications markedly reduced with laparoscopy because of smaller incision and less trauma; risk
for adhesion formation markedly reduced
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| Options for rectal prolapse: stapled rectopexy—posterior rectal mobilization; early in laparoscopic approach to
bowel surgery, so instrumentation limited; mobilized rectum up and used tacking device to tack mesorectum to sacrum; no
mortality; low complication rate; Solomon et al—compared laparoscopic to open approach; mobilization and tacking procedure;
significant increase in operative time, compared to open; with laparoscopic approach, able to feed patients earlier;
lower morbidity because of reduced cardiopulmonary complications; reduction in length of stay; rectopexy—from Germany;
involved full rectal mobilization with resection and complete suture reperitonealization of pelvic floor; significant
operative time; length of stay ≈6 days; morbidity low; conversion rate low; Orr-Loygue repair—mesh fixation with 2
strips; operative time similar to open operation; less ileus and earlier rehabilitation and discharge; Solomon et al—40 patients
with complete prolapse; performed Wells’ repair with full rectal mobilization; longer time than with open; 3 days
shorter stay; less cardiopulmonary morbidity and wound complications; speaker’s method—mechanical bowel preparation
and preoperative intravenous (IV) antibiotics (no oral antibiotics); key to place patients in “yellow fin” stirrups to get
hips flat and knees flexed to secure them on table; bean bag used to maintain position; full posterior mobilization with sigmoid
colectomy and anastomosis to peritonealized rectum; then suture fixation or hernia stapling tacking devices to fix
mesorectum to sacrum; study—compared 25 Well’s rectopexies laparoscopically with 13 resection rectopexies; median
hospital stay 2 days; operative time ≈103 min; no conversions; longer follow-up for open approach than laparoscopic; median
follow-up 63 mo; no significant difference in recurrence rate; looking at matched pairs of laparoscopic and open, no
difference in constipation, but slight advantage with laparoscopic approach for better results through better selection of patients
for resection rectopexy vs Well’s rectopexy; for incontinence, slightly better functional result in laparoscopic group
(possibly selection bias); operative time longer with laparoscopic group (partly due to learning curve), but advantage in
length of stay; similar recurrence rate
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| Algorithm: overall bowel and rectal function assessed based on history; if patient primarily constipated and has good anal
sphincter tone, perform resection rectopexy; if patient incontinent or has poor anal sphincter function, perform Well’s rectopexy;
if patient has diarrhea, avoid resection; if patient normal in both components, rectopexy safer option to avoid anastomosis;
meta-analysis—shows no difference in disease management when done laparoscopically; learning curve in beginning, but
once curve ascended, operative times approximate open procedure; overall reduction in short-term morbidity and mortality because
wound and cardiopulmonary complications reduced; long term, ventral hernia and small bowel obstruction rates reduced;
if performed correctly, significantly lower cost due to shortened length of stay and more appropriate resource utilization in OR
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| LAPAROSCOPY FOR COLON CANCER—Heidi Nelson, MD, Professor of Surgery, Mayo Clinic College of Medicine,
Rochester, MN
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| Randomized controlled trials (RCTs): include Barcelona, Clinical Outcomes of Surgical Therapy study group
(COST), Conventional vs Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC) trial, and Colon Cancer Laparoscopic
or Open Resection (COLOR) trial; ≈3000 patients; randomized groups similar in age, sex, prior abdominal surgery,
body mass index (BMI), and health status using American Society of Anesthesiologists classification; rates of
conversion 11% to 29%; laparoscopic cases longer (by 30-60 min), but incisions shorter; open incision 2 to 3 times that
of laparoscopic; within each trial, no significant difference in morbidity and mortality rates; no complication or mortality
advantage for laparoscopy; recovery benefits for 3 multi-institutional trials essentially same, using slightly different recovery
parameters; COST trial—length of time of narcotic or oral analgesic usage and length of hospital stay reduced by
20% to 50%; COLOR trial—fluid intake, first bowel motion, and length of stay all reduced in laparoscopic group; P values
significant; CLASICC trial—first bowel motion, resumption of regular diet, and length of stay all reduced significantly
in laparoscopic arm; recovery benefits irrefutable
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| Cancer results from RCTs: Barcelona trial—P value not significant for overall survival, but statistically significant
for disease-free survival; attributed differences in survival favoring laparoscopy to patients with stage 3 disease (no difference
between open surgery and laparoscopic in stages 1 and 2); COST trial—median follow-up 4.4 yr; large sample
size; incidence of recurrence essentially same; did not find benefit reported in Barcelona trial; meta-analysis for trials ongoing;
for laparoscopic colectomy, evidence solid for faster recovery and cosmesis benefit, but no advantage for morbidity
and mortality; at present, cancer outcomes for laparoscopic surgery same, although results from Barcelona trial need
confirmation; implications for practice—consideration of patient selection variables; obstructed and perforated cancers,
large T4 cancers where adherence present, and high-risk patients should have open surgery; need thorough staging and
localization of tumor before surgery; tattooing performed during endoscopy to ensure visualization of lesion during surgery;
if, eg, large number of adhesions, unanticipated findings, T4 lesion, resectable liver metastasis encountered, convert
early; rectal cancer resection—data not as solid as with laparoscopic colon surgery; CLASICC only prospective RCT
that included 253 patients; concern with CLASICC trial that positive margins in open resection 6% but 12% for laparoscopic
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Suggested Reading
Darzi A et al: Stapled laparoscopic rectopexy for rectal prolapse. Surg Endosc 9:301, 1995; Delaney CP et al: Case-
matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery. Ann Surg 238:67, 2003;
Delaney CP et al: Is laparoscopic colectomy applicable to patients with body mass index >30? A case-matched comparative
study with open colectomy. Dis Colon Rectum 48:975, 2005; Duepree HJ et al: Does means of access affect the incidence
of small bowel obstruction and ventral hernia after bowel resection? Laparoscopy versus laparotomy. J Am Coll Surg
197:177, 2003; Hazebroek EJ: Color Study Group. COLOR: a randomized clinical trial comparing laparoscopic and open
resection for colon cancer. Surg Endosc 16:949, 2002; Jacobs LK et al: The best operation for rectal prolapse. Surg Clin
North Am 77:49, 1997; Kariv Y et al: Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-
control study. Surg Endosc 20:35, 2006; Kenyon TA et al: Cost and benefit of the trained laparoscopic team. A comparative
study of a designated nursing team vs a nontrained team. Surg Endosc 11:812, 1997; Kim DS et al: Complete rectal
prolapse: evolution of management and results. Dis Colon Rectum 42:460, 1999; Kiran RP et al: Operative blood loss and
use of blood products after laparoscopic and conventional open colorectal operations. Arch Surg 139:39, 2004; Lacy AM et
al: Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer. Surg Endosc
9:1101, 1995; Madbouly KM et al: Clinically based management of rectal prolapse. Surg Endosc 17:99, 2003;
Schwandner O et al: Laparoscopic colectomy for diverticulitis is not associated with increased morbidity when compared
with non-diverticular disease. Int J Colorectal Dis 20:165, 2005; Slim K: MRC CLASICC trial. Lancet 366:712, 2005; Solomon
MJ et al: Laparoscopic rectopexy using mesh fixation with a spiked chromium staple. Dis Colon Rectum 39:279,
1996; Solomon MJ et al: Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse.
Br J Surg 89:35, 2002; Stevenson AR et al: Laparoscopic-assisted resection-rectopexy for rectal prolapse: early and medium
follow-up. Dis Colon Rectum 41:46, 1998; Tekkis PP et al: Evaluation of the learning curve in laparoscopic colorectal
surgery: comparison of right-sided and left-sided resections. Ann Surg 242:83, 2005
Educational Objectives
| The goal of this program is to improve laparoscopic techniques for colorectal surgery. After hearing and assimilating this
program, the clinician will be better able to:
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 | 1. Describe the problems of teaching and learning advanced laparoscopic techniques and possible solutions.
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| 2. Compare hand-assisted laparascopic surgery to the completely laparoscopic approach in colorectal surgery.
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| 3. Discuss the challenges involved in laparoscopic colorectal surgery.
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| 4. Assess the various options for management of rectal prolapse.
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| 5. Discuss the results of the major randomized controlled trials of laparoscopic surgery for colon cancer.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the following has been disclosed: Dr. Fleshman has received research funds from
NiTi Medical Technologies and LifeCell.
Acknowledgements
Dr. Swanstrom was recorded at The Postgraduate Course in General Surgery, held March 22-24, 2007, in San Francisco,
CA, and sponsored by the University of California, San Francisco, School of Medicine, Department of Surgery. Dr. Fleshman
was recorded at the 18th Annual International Colorectal Disease Symposium, held February 15-17, 2007, in Fort Lauderdale,
FL, and sponsored by the Cleveland Clinic, Florida. Drs. Heise, Senagore, and Nelson were recorded at the 69th Annual
Colon and Rectal Surgery, held September 7-9, 2006, in Minneapolis, MN, and sponsored by the Division of Colon and Rectal
Surgery, Department of Surgery, Continuing Medical Education, University of Minnesota Medical School, Colon and Rectal
Surgery Associates, Ltd., and the Minnesota Colon and Rectal Foundation. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
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