Advanced Techniques in Minimally Invasive and Robotic Colorectal Surgery

​The first edition laid out the foundation with laparoscopic and robotic surgery utilizing the Da Vinci SI platform. Since then, many new advances in equipment and surgical techniques are becoming more popular. This second edition expands upon laparoscopic and endoscopic techniques and robotic surgery with the use of the new Da Vinci XI platform.
This book bridges the gap between the practicing community of surgeons and the surgical innovators and provides a foundation for all classic and new techniques in minimally invasive colorectal surgery.  By enhancing the surgical toolbox, the surgeon is able to progress from the novice to the master. Rather than describing the entire operative procedure by an individual author, this book compares operative steps of various technical difficulties throughout different chapters, thereby allowing the surgeon to tailor surgery to patient and surgeon`s own comfort level and experience. Chapters are written by a myriad ofrenowned experts in the field and discuss the major advances in advanced laparoscopic and endoscopic, robotic, and transanal minimally invasive surgical techniques. Great emphasis is placed on transanal total mesorectal excision (TaTME), which is dramatically changing the surgical approach to rectal resections. 
The second edition of Advanced Techniques in Minimally Invasive and Robotic Colorectal Surgery serves as a valuable resource to general surgeons, colon and rectal surgeons, minimally invasive surgeons, as well as residents and fellows.

• Language: English
• Publisher: Springer
• Release date: Jul 29, 2019
• ISBN: 9783030152734

Book preview

© Springer Nature Switzerland AG 2019

O. Bardakcioglu (ed.)Advanced Techniques in Minimally Invasive and Robotic Colorectal Surgeryhttps://doi.org/10.1007/978-3-030-15273-4_1

1. Laparoscopic-Assisted Polypectomy

Erik R. Noren¹   and Sang W. Lee²  

(1)

Department of General Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA

(2)

Division of Colorectal Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA

Erik R. Noren

Email: [e-mail]

Sang W. Lee (Corresponding author)

Email: [e-mail]

Keywords

Laparoscopic-assisted polypectomyCELSCombined endoscopic and laparoscopic surgery

Introduction

This chapter presents a historical overview of laparoscopic-assisted polypectomy and detailed description of surgical technique. We will a additionally describe several variations and advanced maneuvers that extend the application of the technique to more difficult lesions. Tips and tricks will be highlighted to help navigate the procedure throughout the chapter. Finally, we will discuss special considerations in challenging cases and provide guidance for management of complications.

Background

Adoption of colorectal cancer screening has been effective in reducing the overall incidence and mortality from the disease. Concurrently, there has been an increase in the detection of large and complex polyps not amenable to simple endoscopic resection alone. Traditionally, these patients were referred for surgical management by segmental colon resection. In fact, surgery for benign colorectal polyps has increased significantly from 5.9 per 100,000 patients in 2000 to 9.4 per 100,000 patients in 2014, which represents more than 28,000 colectomies performed every year in the United States for benign lesions [1]. Although the development of laparoscopic colorectal surgery and deployment of enhanced recovery protocols has markedly reduced the surgical trauma, cost, and complication rate associated with colon resection, there remains significant morbidity for patients undergoing colectomy.

Innovative combined endoscopic and laparoscopic surgery (CELS) approaches have been developed that leverage the capabilities of each technology for removal of difficult polyps without colon resection [2–6]. Laparoscopic-assisted polypectomy was first described in 1993 as a method for complete excision of moderate-sized sessile polyps that avoided colon resection in select patients [3]. Subsequently described techniques include laparoscopic-assisted colon wall excision and full-thickness CELS [7]. In the following decades, several retrospective series have confirmed the safety and effectiveness of the procedures for management of such difficult lesions [8–11]. A systematic review of CELS experiences found low complication rates and high (74–91%) rates of successful resection with colon preservation [12]. In studies with long-term follow-up, there were no cases of malignant lesions developing in patients with completely resected histopathologically benign polyps [8, 10].

Cost analysis demonstrates that utilization of CELS benefits the healthcare system in addition to the benefits for patients. The majority of CELS patients will be discharged on the day of surgery or the following day, so while CELS has slightly higher equipment costs, this is more than surpassed by the savings from substantial reductions in inpatient hospital utilization. Sharma et al. identified the total cost per CELS procedure at $6554 compared with $12,585 per laparoscopic segmental resection and $18,216 per open resection [13].

Current indications for CELS encompass benign-appearing polyps not amenable to simple endoscopic resection. Often this is the result of polyp size or location on a luminal fold, colon flexure, proximity to the appendiceal orifice, or ileocecal valve. Eligible polyps may be pedunculated or sessile, appear soft with regular contours, have no central depression or ulceration, and lift with submucosal injection. Polyps with irregular vascular or pit pattern when viewed with narrow-band imaging are suspicious for invasive malignancy and may not be appropriate for CELS.

Preoperative Planning

Evaluation of the patient referred for an endoscopically unresectable polyp begins with a thorough history and physical exam with particular attention paid to the medical and surgical history as well as family history of colorectal cancer and inflammatory bowel disease. Patients should undergo appropriate preoperative cardiopulmonary evaluation for their age and existing comorbidities. Review of the colonoscopy report with relevant images and pathology report confirming a benign lesion is necessary to determine if a patient is indeed a candidate for CELS. In-office evaluation of left-sided lesions by flexible endoscopy allows verification of polyp location, size, and the absence of concerning characteristics.

It is necessary to counsel patients that, in the event that a lesion cannot be removed by CELS or if the lesion is found intraoperatively to have features concerning for malignancy, the operating surgeon will proceed with a laparoscopic colon resection. Additionally, patients should understand the possibility that a successfully removed polyp may be found on pathologic evaluation to contain malignancy which may necessitate a subsequent formal resection.

Full mechanical bowel preparation the day before surgery is necessary for utilization of the endoscope during the procedure. Subcutaneous heparin and prophylactic parenteral antibiotics are administered within 1 hour prior to surgical incision.

Room Setup and Positioning

After induction of general anesthesia, the patient is placed in a modified lithotomy position to allow simultaneous access to the anus and abdominal approach. Both arms are tucked at the patient’s side with care to ensure adequate padding of the hands, wrists, and all pressure points as the operating table position is often adjusted throughout the case. Nasogastric drainage tube and Foley catheter are placed and pneumatic compression devices are applied to the bilateral lower extremities.

Positioning of the laparoscopic viewing monitors is dependent on the anticipated lesion location. Right colon lesions will require the laparoscopic surgeon, often with an assistant, to stand on the patient’s left side with the monitor off the right side and slightly biased toward the shoulders and head (Fig. 1.1). The opposite for left colon lesions with monitors on the patients left biased toward the waist and feet. Monitors for transverse colon lesions should be positioned at the head of the bed. The endoscopist will work from between the patient’s legs. The endoscopy cart, including high-definition monitor and CO2 insufflator, is usually positioned on the same side of the patient as the laparoscopic monitor, though this is adjustable for strong surgeon preference or better comfort.

../images/302089_2_En_1_Chapter/302089_2_En_1_Fig1_HTML.jpg

Fig. 1.1

Operating room setup and positioning for excision of right colon lesion by laparoscopic-assisted polypectomy

It is important to have all equipment required for a laparoscopic colon resection available in the room in addition to that required for the CELS procedure in the event a formal resection is required.

Port Placement

Placement of abdominal trocars is typically deferred until the target lesion has been identified by intraoperative endoscopy and confirmed to be amenable to CELS resection. Trocar placement necessarily depends on the location of the lesion.

Abdominal access is achieved with placement of a 5 mm periumbilical trocar by standard technique and pneumoperitoneum established. Insertion of a laparoscope allows identification of the target lesion, either by tattoo identification or endoscopic transillumination of the colon wall. We recommend using a high-definition flexible-tip laparoscope for enhanced visualization and adaptability during mobilization. A pair of 5 mm working trocars is placed with intent to triangulate on the target lesion, though 3 mm microlaparoscopic trocars may be substituted if available. Place trocars in the right lower quadrant and suprapubic positions for left-sided lesions and in the left lower quadrant and suprapubic positions for right-sided lesions. Transverse colon lesions may be accessed by placement of bilateral 5 mm working trocars in the upper or lower quadrants.

Operative Steps

Colonoscopy

The use of CO2 insufflation is decidedly superior to room air when performing CELS procedures. More rapid absorption of CO2 minimizes unnecessary colon distention and allows for optimal simultaneous laparoscopic and endoscopic visualization [14].

The endoscopist begins the procedure with insertion of the colonoscope and advancement to identify the target lesion. It should be examined to confirm the location, size, and absence of concerning features such as hardness, fold convergence, expansile growth, and depression or ulceration. Having confirmed the lesion is amenable for CELS resection, the surgeon may proceed with incision and port placement as described in the previous section.

Mobilization

The great advantage CELS provides over solitary endoscopic approaches is the ability to externally manipulate the colon. The location of the polyp will dictate the degree of manipulation and in many cases mobilization of the colon that is required.

Polyps located along the edge or back side of folds are difficult to approach endoscopically. Directed laparoscopic manipulation repositions the colon wall exposing the lesion for endoscopic resection (Fig. 1.2). Polyps located behind flexures and kinks from scarring often will not respond to simple manipulation of the colon wall and will require mobilization of the corresponding segment of colon to straighten out the tissue and expose the polyp. Additionally, polyps located on the mesenteric or retroperitoneal side of the colon lumen require laparoscopic mobilization of that segment of the colon. This is performed with a similar technique as for a laparoscopic colon resection, utilizing an energy device to divide attachments along the embryologic tissue planes. It is helpful to have an assistant piloting the flexible-tip laparoscope to free the surgeon to work with both hands.

../images/302089_2_En_1_Chapter/302089_2_En_1_Fig2_HTML.png

Fig. 1.2

Laparoscopic instrument positions a difficult polyp for snare polypectomy

Polypectomy

Submucosal injection to lift the polyp is performed with an endoscopic injection needle through the working channel of the colonoscope. Dilute solution (50/50) of indigo carmine or methylene blue and either saline or albumin is used to both mark the location of the lesion and elevate the mucosal-based lesion. Injection into the submucosal space forms a broad smooth cushion barrier between the polyp and the underlying muscular layer. Failure to create this effect likely indicates injection into a deeper layer of the colon wall; slowly pull back the injection needle while slowly injecting to find the correct plane. It may be necessary to repeat injection later in the procedure if the elevated cushion has dissipated.

Be cautious with a lesion that does not elevate with submucosal injection as this may be an indication of an invasive tumor. Evaluate for additional concerning signs as mentioned previously. If there is concern for an invasive lesion, laparoscopic colectomy should be performed. If the polyp truly appears benign, the failure to lift may be the result of scarring from previous biopsies, and endoscopic removal may proceed. Overall the incidence of cancer found in benign-appearing lesions after CELS resection is low (~2%) [8], and those patients are able to undergo a subsequent resection as necessary.

The target polyp is removed by electrosurgical snare polypectomy . The laparoscopic instrument is utilized to position and deliver the polyp into the snare loop. Large or complex lesions may need to be removed in several piecemeal snare excisions. Do not lose track of the specimens prior to collection. Specimens removed by polypectomy are typically removed endoscopically with a Roth Net. However, specimens that are small (<5 mm) or excised in a piecemeal fashion can be removed by colonoscope suction with a specimen trap attached in line to the suction device.

The laparoscope is used to monitor the serosal side of the polypectomy site for any sign of thermal injury or weakness created by the procedure. Such areas can immediately be reinforced or repaired with a laparoscopic imbricating suture (Fig. 1.3).

../images/302089_2_En_1_Chapter/302089_2_En_1_Fig3_HTML.png

Fig. 1.3

Laparoscopic suture reinforcement for thermal colon injury

Full-Thickness CELS

An extension of the CELS technique allows for full-thickness excision of polyps that may be difficult to remove with snare polypectomy, particularly large serrated adenomas and polyps with significant scarring due to prior biopsies [15].

Submucosal dilute dye injection is utilized, as described in the prior section, to elevate and mark the polyp (Fig. 1.4). Once the entire area of the lesion is elevated with dye, the circumference of the resection area is marked on the serosal surface from the laparoscopic approach using monopolar cautery. The seromuscular layer is then divided along the circumference of the marked resection, taking particular care not to cause a full-thickness perforation by injuring the mucosal layer (Fig. 1.5). The dissected resection area can now be invaginated into the colon lumen with the assistance of a laparoscopic instrument. The formerly flat and adherent lesion is now visualized endoscopically protruding into the lumen and can be delivered into a polypectomy snare (Fig. 1.6). The snare is carefully closed, without dividing, pulling together the edges of the serosal dissection. The seromuscular defect is closed with a running 3-0 vicryl laparoscopic suture, an additional layer of imbricating sutures may additionally be placed (Fig. 1.7). Once the defect is closed, the snare polypectomy is completed and the lesion collected in a Roth net and removed from the colon (Fig. 1.8).

../images/302089_2_En_1_Chapter/302089_2_En_1_Fig4_HTML.png

Fig. 1.4

Submucosal dilute dye injection elevates the target polyp

../images/302089_2_En_1_Chapter/302089_2_En_1_Fig5_HTML.png

Fig. 1.5

Division of the seromuscular layer of the colon during full-thickness CELS technique

../images/302089_2_En_1_Chapter/302089_2_En_1_Fig6_HTML.png

Fig. 1.6

Laparoscopic instrument used to invaginate the polyp for endoscopic snare placement

../images/302089_2_En_1_Chapter/302089_2_En_1_Fig7_HTML.png

Fig. 1.7

Laparoscopic suture repair of the seromuscular defect prior to transection of the polyp

../images/302089_2_En_1_Chapter/302089_2_En_1_Fig8_HTML.png

Fig. 1.8

Energy is applied to the snare for full-thickness excision of the lesion. The repaired seromuscular defect

Colonoscopic-Assisted Laparoscopic Partial Cecectomy

Polyps located in the thin-walled cecum and proximal ascending colon are effectively managed with laparoscopic stapled wall excision or partial cecectomy performed under colonoscopic guidance. These polyps are often located within close proximity of the ileocecal valve or appendiceal orifice. This technique ensures complete full-thickness excision of even wide sessile polyps while protecting the aforementioned structures from damage [16].

The polyp is identified by colonoscopy as previously described. A 12 mm trocar is substituted for the usual 5 mm in the left lower quadrant to accommodate a laparoscopic linear cutting stapler. It may be necessary, in some cases, to mobilize the cecum and proximal ascending colon by dividing the peritoneum and lateral attachments using electrocautery. Placing the patient in Trendelenburg position with the right side elevated is also helpful. While positioning the stapler, the colonoscope is used to confirm the line of resection including the entire lesion. Intubation of the terminal ileum allows the colonoscope to function as a mechanical barrier, like a Bougie, when positioning the stapler for resection of a lesion in close proximity to the terminal ileum. The resected specimen is withdrawn from the abdomen in a laparoscopic Endo Catch bag.

Leak Test

An air leak test can be performed using CO2 colonoscope insufflation and laparoscopic irrigation. Adjust the operating table to place the tested colon in a dependent position, irrigate the abdomen and submerge. The absence of bubbles indicates a negative leak test.

Postoperative Care

The majority of patients who undergo CELS laparoscopic-assisted polypectomy can go home the same day as their procedure. Patients that undergo full-thickness excision, colonoscopic-assisted laparoscopic wall excision, or partial cecectomy or in cases in which a full- or partial-thickness injury was noted intraoperatively, patients will have a short hospital stay. The diet is advanced as tolerated, though we recommend monitoring until there is return of bowel function prior to discharge.

The importance of diligent surveillance colonoscopy must be emphasized, as there is a known incidence of polyp recurrence, reported at 10% over the course of a 10-year series [8]. We perform a follow-up colonoscopy at 3 months. The majority of detected recurrent polyps are managed endoscopically.

Special Considerations and Complications

The overall complication rate in multiple series reporting on CELS cases is low, 4–13% [2, 17, 18], and consists primarily of ileus and wound complications. Lee et al. report a complication rate of 4.2% over 10 years, most commonly consisting of urinary retention and wound hematoma [8].

Contraindications

Laparoscopic-assisted polypectomy should not be performed in patients with a known malignancy or for management of lesions with high risk features. Biopsied polyps demonstrating high-grade dysplasia but absent any other concerning features may be amenable to CELS. It is important to obtain tissue slides for review and diagnosis confirmation by your institution’s own pathologist. Patients with a known polyposis syndrome or patients with additional polyps that cannot be removed endoscopically or by CELS should not undergo this procedure. Adhesive disease in patients with a history of multiple prior abdominal operations makes manipulation and mobilization of the colon difficult and increases the likelihood that a patient will require a surgical resection.

Morbid Obesity

Morbid obesity is not a contraindication for CELS procedures. Placement of laparoscopic trocars may need to be adjusted nearer to the target lesion to maintain triangulation with increased abdominal girth, and in patients with super-morbid obesity, bariatric trocars and instruments may be required.

Perforation

The rate of iatrogenic colon perforation during purely endoscopic procedures is reported as less than 1% [19]. A primary advantage of CELS over totally endoscopic resection techniques is the continuous laparoscopic monitoring and leak testing during the procedure. This allows intraoperative detection of perforation or partial-thickness injury and immediate suture repair. Suture placement was reported in 10% of laparoscopic-assisted polypectomy cases by Franklin et al. [2] and in 43% of cases by Yan et al. [5]; however, in both series there were no reported incidences of full-thickness perforation. Rather, intraoperative suture placement in these cases represented detection of partial-thickness injury or colon wall weakness following polypectomy and prophylactic measures to reinforce the area.

Bleeding

Post-polypectomy bleeding has not been reported with significant incidence in the available series of CELS patients, likely because the majority of bleeds are detected and managed during the procedure. However, it is a known complication of polypectomy and endoscopic interventions, and thus the surgeon performing CELS procedures should be prepared to manage it.

Immediate bleeding from polypectomy sites can be controlled using the polypectomy snare to deliver electrocautery. In rare cases injection of epinephrine or placement of endoscopic clips may be required. Delayed bleeding may occur up to a month after the procedure. Management consists of resuscitation followed by repeat endoscopy with epinephrine injection or clipping in most cases [20].

Summary

Techniques for combined endoscopic and laparoscopic surgery (CELS) including laparoscopic-assisted polypectomy have demonstrated safety and effectiveness for management of benign polyps not otherwise amenable to endoscopic removal. Since initial description well over a decade ago, utilization of CELS has allowed a great number of patients to avoid the substantial morbidity of colectomy with faster recovery and lower cost.

References

1.

Peery AF, Cools KS, Strassle PD, McGill SK, Crockett S, Barker A, Koruda M, Grimm IS. Increasing rates of surgery for patients with nonmalignant colorectal polyps in the United States. Gastroenterology. 2018;154:1352–60.e3Crossref

2.

Franklin ME, JA D-E, Abrego D, Parra-Dávila E, Glass JL. Laparoscopic-assisted colonoscopic polypectomy: the Texas Endosurgery Institute experience. Dis Colon Rectum. 2000;43:1246–9.Crossref

3.

Beck DE, Karulf RE. Laparoscopic-assisted full-thickness endoscopic polypectomy. Dis Colon Rectum. 1993;36:693–5.Crossref

4.

Wood JJ, Lord AC, Wheeler JM, Borley NR. Laparo-endoscopic resection for extensive and inaccessible colorectal polyps: a feasible and safe procedure. Ann R Coll Surg Engl. 2011;93:241–5.Crossref

5.

Yan J, Trencheva K, Lee SW, Sonoda T, Shukla P, Milsom JW. Treatment for right colon polyps not removable using standard colonoscopy: combined laparoscopic-colonoscopic approach. Dis Colon Rectum. 2011;54:753–8.Crossref

6.

Lee MK, Chen F, Esrailian E, Russell MM, Sack J, Lin AY, Yoo J. Combined endoscopic and laparoscopic surgery may be an alternative to bowel resection for the management of colon polyps not removable by standard colonoscopy. Surg Endosc. 2013;27:2082–6.Crossref

7.

Garrett KA, Lee SW. Combined endoscopic and laparoscopic surgery. Clin Colon Rectal Surg. 2015;28:140–5.Crossref

8.

Lee SW, Garrett KA, Shin JH, Trencheva K, Sonoda T, Milsom JW. Dynamic article: long-term outcomes of patients undergoing combined endolaparoscopic surgery for benign colon polyps. Dis Colon Rectum. 2013;56:869–73.Crossref

9.

Wilhelm D, von Delius S, Weber L, Meining A, Schneider A, Friess H, Schmid RM, Frimberger E, Feussner H. Combined laparoscopic-endoscopic resections of colorectal polyps: 10-year experience and follow-up. Surg Endosc. 2009;23:688–93.Crossref

10.

Franklin ME, Portillo G. Laparoscopic monitored colonoscopic polypectomy: long-term follow-up. World J Surg. 2009;33:1306–9.Crossref

11.

Lascarides C, Buscaglia JM, Denoya PI, Nagula S, Bucobo JC, Bergamaschi R. Laparoscopic right colectomy vs laparoscopic-assisted colonoscopic polypectomy for endoscopically unresectable polyps: a randomized controlled trial. Colorectal Dis. 2016;18:1050–6.Crossref

12.

Nakajima K, Sharma SK, Lee SW, Milsom JW. Avoiding colorectal resection for polyps: is CELS the best method? Surg Endosc. 2016;30:807–18.Crossref

13.

Sharma S, Xing J, Nakajima K, Milsom J. Combined endo-laparoscopic surgery is significantly less costly than traditional surgery. J Am Coll Surg. 2015;221:S29.Crossref

14.

Nakajima K, Lee SW, Sonoda T, Milsom JW. Intraoperative carbon dioxide colonoscopy: a safe insufflation alternative for locating colonic lesions during laparoscopic surgery. Surg Endosc Other Interv Tech. 2005;19:321–5.Crossref

15.

Lin AY, O’Mahoney PR, Milsom JW, Lee SW. Dynamic article: full-thickness excision for benign colon polyps using combined endoscopic laparoscopic surgery. Dis Colon Rectum. 2016;59:16–21.Crossref

16.

Noren ER, Cologne KG, Lee SW. Endoscopically guided laparoscopic partial Cecectomy for management of benign cecal polyps. Dis Colon Rectum. 2018;61:e313–e4.

17.

Crawford AB, Yang I, Wu RC, Moloo H, Boushey RP. Dynamic article: combined endoscopic-laparoscopic surgery for complex colonic polyps: postoperative outcomes and video demonstration of 3 key operative techniques. Dis Colon Rectum. 2015;58:363–9.Crossref

18.

Goh C, Burke JP, McNamara DA, Cahill RA, Deasy J. Endolaparoscopic removal of colonic polyps. Color Dis. 2014;16:271–5.Crossref

19.

Lüning TH, Keemers-Gels ME, Barendregt WB, Tan ACITL, Rosman C. Colonoscopic perforations: a review of 30,366 patients. Surg Endosc. 2007;21:994–7.Crossref

20.

Lowenfeld L, Saur NM, Bleier JIS. How to avoid and treat endoscopic complications. Semin Colon Rectal Surg. 2017;28:41–6.Crossref

© Springer Nature Switzerland AG 2019

O. Bardakcioglu (ed.)Advanced Techniques in Minimally Invasive and Robotic Colorectal Surgeryhttps://doi.org/10.1007/978-3-030-15273-4_2

2. Endoscopic Submucosal Dissection

Ipek Sapci¹   and Emre Gorgun¹  

(1)

Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA

Ipek Sapci

Email: [e-mail]

Emre Gorgun (Corresponding author)

Email: [e-mail]

Electronic Supplementary Material

The online version of this chapter (https://​doi.​org/​10.​1007/​978-3-030-15273-4_​2) contains supplementary material, which is available to authorized users.

Keywords

Endoscopic submucosal dissectionColonoscopyLesion removalCost of endoscopic submucoal dissectionInjection material

Abbreviations

EMR

Endoscopic mucosal resection

ESD

Endoscopic submucosal dissection

HES

Hydroxyethyl starch

Introduction

This chapter will review the advanced endoscopic resection technique of endoscopic submucosal dissection . The steps of this novel method will be described in detail accompanying brief literature review on this approach. Equipment, tips, and key points for endoscopic submucosal dissection will be summarized with supplementary images and video clips.

Background

Colorectal cancer is the second most common cause of cancer death in the US population and was estimated to result in 50,260 deaths in 2017 [1]. Screening colonoscopy with polypectomy has been shown to decrease the incidence of colorectal cancer and its related mortality [2]. Most colorectal polyps are suitable for