Gentler, Kinder Cut

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13 Νοε 2013 (πριν από 3 χρόνια και 6 μήνες)

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Gentler, Kinder Cut

What’s New in Minimally invasive Colorectal
Surgery?

Samuel C.
Oommen
, MD, FACS, FASCRS

Bay Area Colon and Rectal Surgeons

Walnut Creek, Ca

Topics To be Covered


Trans anal Endoscopic Microsurgery
(TEM)


Laparoscopic
Colectomy


Total
Mesorectal

Excision & Autonomic
Nerve Preservation (TME & ANP)


Hand Assisted Laparoscopic Surgery
(HALS)


Robotic Colorectal Surgery

Trans anal Endoscopic Microsurgery

(TEM)

Transanal

Endoscopic Microsurgery


Introduced by
Gerhard
Buess

in 1983
for
excision of proximal rectal lesions not
amenable to a standard
Transanal

excision(TAE)


Operating
Proctoscope

with ports for CO2
insufflation

and instrumentation


Six fold stereoscopic view


Facilitates negative surgical margins
when
direct visualization of the radial extent of
the tumor is visible

TRANSANAL ENDSCOPIC

MICROSURGERY

(TEM)

Indications For TEM


Adenocarcinoma


T1 lesion (Confined to
Submucosa
)


Well or Moderately differentiated


Without
Lympho

vascular invasion


T2 lesion (Muscle Invasion)following
preop

chemo radiation under ACOSOG Z 6041 protocol


Carcinoid
(< 2 cm)


Adenoma unable or incompletely excised by
endoscopy


Residual neoplasm or uncertain margin after
endoscopic resection


Excision of benign rectal
stenoses


Palliation of advanced cancer in high risk patients


TEM

Technique


Proctoscopic exam


Isolate tumor in lower
half of field of view


Secure scope in place
with
Martin Arm

Courtesy Peter Cataldo, MD


TEM

Technique

Direct view through
stereoscope

or on
monitor

Courtesy Peter Cataldo, MD


Technique



Inject lesion with
lidocaine

w/
epinephrine

Courtesy Peter
Cataldo
, MD


ENDOSCOPIC VIEW

Multifocal Dysplastic Adenoma (TEM Specimen)

T1 Polypoid Cancer


TEM specimen

T2 Adenocarcinoma of Mid Rectum

TEM VIDEO

TEM for Rectal Cancer?

Oncologic Results

TEM vs. Radical Resection

Winde et. al. Munster, Germany


Prospective, randomized trial


uT1N0


52 patients


TEM vs. Ant. Resection


Morbidity / mortality


Recurrence


Survival

TEM vs. Radical Resection

Winde et. al. Munster, Germany


Complications


TEM 20.8% vs. LAR 34.5%

Local recurrence


TEM 2/24(8%) vs. LAR (?)

Survival



TEM 23/24 (96%) vs. LAR 25/26 (96%)

TEM

Oncologic Results


LeZoche et al


Rome, Italy


40 patients, 3 yr f/u


prospective, randomized trial


T2N0


Preop chemoradiotherapy


TEM vs LAR







TEM vs Lap LAR

T2N0





TEM



LAR


OR time 95 min



165 min

LOS



4.5 days 7.5 days

Compl


15%



15%

Local rec.


5%



5%

3 yr.
Surv
.


90%



83%



Laparoscopic Colorectal Surgery

Historical Perspectives


1990: Laparoscopic Right
Colectomy
-

Jacobs, Miami, Florida



2004: COST Study



*Jacobs M. et al Minimally Invasive Colon Resection,
Surg

Laparosc

Endosc

1991; 1:
144
-
50



Recurrence


&

Survival

Benefits of Laparoscopic Surgery


Smaller incisions


Reduced postoperative pain


Earlier return of bowel function


Reduced hospital stay


Earlier return to work and activities of

daily living


Reduced operative trauma and stress


Reduced adhesions

Endoscopic Tattoo

Right
Colectomy

Right Colon Anatomy

Adequate Lymph Node Harvest

Total
Mesorectal

Excision

(TME)

What is Total
Mesorectal

Excision?



TME is defined as the resection of the rectum with
its surrounding fatty and lymphatic tissue contained
within the visceral sheet (Fascia
Propria
) of the
endopelvic

fascia. The dissection in this almost
avascular

cleavage allows the complete removal of
the
mesorectal

tissue, as well as good protection of
the
hypogastric

nerves and the inferior
hypogastric

plexus, resulting in less disturbance to bladder and
sexual functions
.”




Faerden AE et al, Dis Colon Rectum , 2005; 48: 2224
-
2231

Adapted from Heald, RJ et al, Br. J. Surg Vol 69(1982)613
-
616

Total
Mesorectal

Excision (TME
)

Total
Mesorectal

Excision (TME)

Shiny Fascia Propria covering
the Mesorectum

TME Grading


COMPLETE:


Intact bulky
mesorectum

with a smooth surface


Only minor irregularities
of
mesorectal

surface


No coning towards the
distal margin of the
specimen


After transverse
sectioning, the
circumferential margin
appears smooth


TME Grading


NEARLY COMPLETE:


Moderate bulk to the
mesorectum


Irregularity of the
mesorectal

surface with
defects greater than 5
mm, but none extending
to the
muscularis

propria


No areas of visibility of
muscularis

propria


TME Grading


INCOMPLETE




Little bulk to the
mesorectum


Defects in the
mesorectum

down to
muscularis

propria


After transverse
sectiong
, the
circumferential margin
appears very irregular


Mesorectal grade vs. local and overall r
ecurrence


Grade of
Mesorectum

Total
Patients

(n)

Local
Recurrence

n (%)

Overall
Recurrence

n (%)

1

17

7 (41)

10 (59)

2

52

3 (5.7)

9 (17)

3

61

1 (1.6)

1 (1.6)

P
value


0.0001

0.0001


From Maslekar
et al.

2006 “Mesorectal grades predict recurrences after curative
resection for rectal cancer.”
Dis Colon Rectum
50:168
-
175.

Hand Assisted laparoscopic Surgery


Still the best Surgical
instrument


Tactile feedback for
retraction and dissection


May reduce operative
times and need for
conversion


Bridge between open and
laparoscopic surgery


Two Commandments


Adapted from
Michael McCue, MD

Two Commandments of laparoscopic
surgery.


“Thou Shall not change your operation to
fit the equipment”


“Thou shall K. I. S. S. (keep it simple
surgeons)”



HALS is ideal in meeting above criteria.



Adapted from
Michael McCue, MD

Benefits of HALS


Maintains Tactile Feedback


Improves Eye Hand coordination and Depth
perception


Better exposure due to improved traction


Facilitates rapid hemorrhage control



No Laparoscopic instrument is as
versatile, educated and safe as the
experienced Surgeon’s Hand


Lap Disc Ethicon Endosurgery

Hand Assisted Right
Colectomy

for Hepatic Flexure
Cancer

HALS

Robotic Colorectal Surgery


Disadvantages of

Laparoscopic surgery


Unstable video camera
imaging



Dependency on assistant’s
skills



Disadvantages of

Laparoscopic surgery


Limited motion of instruments



The Surgical instruments are Rod
-
like having no
wrist movement at the tip which required from
the surgeon to move his arms in large scale
movements outside the patients body for the
instrument tip (internally) to get to the desired
location.



The movement of the instruments/scope were
awkward (counter
-
intuitive) meaning that if the
surgeon wants to move the instrument/scope to
the left, he has to move to the right from outside.




Related loss of dexterity

Disadvantages of

Laparoscopic surgery

(
Contd
)


The scope displays only a 2D image on
the display which has no depth
perception. The surgeon needed to
over/under shoot the target anatomy to
be able to allocate it properly.




The Surgeon gets tired


Awkward position such as twisting his neck
to be able to follow up the surgical site
displayed on the monitor.


Longer hours standing

Advantages of Robotic Surgery


Tridimensional(3D) imaging under
the surgeon’s direct control


Provides instruments with seven
degrees of freedom


Enhances dexterity, precision, and
control during surgical procedures.

Advantages of Robotic Surgery

(
Contd
)

.


Scales down hand movements,
and eliminates hand tremors


Facilitates
handsewn

sutures.


Cuts down the surgeon’s
fatigue

OR Setup and Patient Preparation

Patient Positioning


Docking The Patient Cart


Surgical Steps
-

Surgical Overview

Robotic Colorectal Surgery

Disadvantages of Robotic Surgery


Cost.

With a price tag of 1.6 million
dollars, and nearly 100k in maintenance
costs annually.


the
size
of these systems.


lack of compatible instruments
like
energy sources and staplers.


Lack of tactile feedback

Conclusion


Generally, the maximum benefit seems to be
achieved whenever a complex and precise dissection
in a confined space is required.


Still in infancy, and many advances are expected in
the near future (smaller and operative
-
room
integrated systems, tactile feedback technology,
specifically designed instruments, reduced costs)


Robotic laparoscopic colon surgery is feasible and
safe.


Operating time is longer than in standard
laparoscopic surgery.


Results from long term studies
studies

regarding
cancer survival and recurrence are awaited