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Laparoscopic Sigmoid Colon Resection forDiverticular Disease
George Ferzli, MD, FACSProfessor of Surgery, SUNY Downstate Health Science Center, Brooklyn, NY
How is it done?
1. Lateral Approach2. Anterior Approach
Patient With Large Ventral Hernia
Lateral patient position
• Patient positioned on right side
• Hand rotated in semicircle over sigmoid for trocar placement (more like triangle)
Trocar placement : Lateral Position
Lateral positionSplenic Flexture Mobilization
Lateral ApproachInferior Mesenteric Artery
Lateral Position
Lateral trocar cuts sigmoid
Repair - Lateral Position
If proximal colon can be brought through lateral incision tension-free, the repair will be tension free
End to End Anastomosis
Lap. Sigmoidectomy - Lateral Position
Laparoscopic Sigmoidectomy – Lateral Position
Lateral Approach
Lateral ApproachAdvantages and Disadvantages
Advantages• Easy mobilization of
splenic flexture• Easier identification of
ureter• Small bowel out of the
way in case of ventral hernia
Disadvantages• Inability to evaluate
liver• Poor access to
adhesions or lesions on the right side of the recto-sigmoid
• In females, ovary may interfere
Anterior Approach
• Patient supine
• Position hand over sigmoid and rotate in semi-circle to place trocars (3)
Trocar Placement : Anterior Position
Anterior position
1
2
Trocar in inguinal crease cuts sigmoid
Repair - Anterior Position
If proximal colon can be brought through inguinal crease trocar incision, tension free repair will be successful
Anterior Approach
Anterior Approach
Laparoscopic Sigmoid ColectomyTotal (n) = 62 pts Lateral (24) Anterior (38)
Age 48 (32 - 70) 46 (27 - 86)
Sex, M:F 23:1 35:3
Indications:
• Diverticulitis 16 (2 abscess) 20 (4 abscess)
• Polyp 3 6
• Carcinoma 5 12
Complications 1 hematoma flank,
1 re-op for SBO,
1 leak (cut.drainage)
1 leak (re-op hartman)
Hospital Stay 2.2 (2 - 10) 2.4 (2 - 9)
OR Time 142 (98 – 216) 147 (110 – 279)Ferzli G et al. (2000 – 2001) Unpublished Data
Laparoscopic Sigmoid ColectomyTotal (n) = 62 pts Lateral (24) Anterior (38)
Age 48 (32 - 70) 46 (27 - 86)
Sex, M:F 23:1 35:3
Indications:
• Diverticulitis 16 (2 abscess) 20 (4 abscess)
• Polyp 3 6
• Carcinoma 5 12
Complications 1 hematoma flank,
1 re-op for SBO,
1 leak (cut.drainage)
1 leak (re-op hartman)
Hospital Stay 2.2 (2 - 10) 2.4 (2 - 9)
OR Time 142 (98 – 216) 147 (110 – 279)Ferzli G et al. (2000 – 2001) Unpublished Data
Laparoscopic Versus Open Colectomy for Cancer
Colorectal ResectionLaparoscopic vs. open resection for carcinoma
0
10
20
30
40
RHC Trans AR Sig LAR APR Total
Ave
. # ly
mp
h no
des
0
5
10
15
20
25
RHC Trans AR Sig LAR APR
Ave
. spe
cim
en le
ngth
, cm
0
4
8
12
16
20
RHC Trans AR Sig LAR APR
Ave
. dis
tal m
arg
in, c
m
LCR OCR
0
7
14
21
28
35
RHC Trans AR Sig LAR APR
Ave
. pro
xim
al m
arg
in, c
m
LCR OCR
RHC = Right hemicolectomy; Trans = Transverse; AR = Anterior resection; Sig = Sigmoid; LAR = Low anterior resection; APR = Abdominoperineal resection
Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46
Colorectal ResectionLaparoscopic vs. open resection for carcinoma
Laparoscopic
(n=192)
Open
(n=224)
Hospitalization, days 5.6 9
Blood loss, mL 150 450
Wound complications 0.5% 6%
Recurrence rates 12.2% 22%
Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III)
13% 19.1%
Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46
Colorectal ResectionLaparoscopic vs. open resection for carcinoma
Follow-up Lap. Open
No. of cases (n) 40 43
Overall metastases 8 (20%) 10 (23%)
Single site metastases 3 5
Liver 2 4
Regional 1 1
Multiple site metastases 5 5
Liver+ Peritoneum 4 4
Liver+Peritoneum+
Trocar-site or scar
1 1
Five-year overall survival
0
20
40
60
80
100
0 12 24 36 48 60
Follow-up (months)
Sur
viva
l (%
)
Five-year disease-free survival
0
20
40
60
80
100
0 12 24 36 48 60
Follow-up (months)
Sur
viva
l (%
)
Lap OpenSantoro E et al, Hepato-Gastroenterology 1999; 46:900-904
Colorectal ResectionLaparoscopic vs. open resection for carcinoma
Lap (n=18) Open (n=18) Converted (n=7)
Operating room time (min) 210 138 242
Blood loss (mL) 284 407 683
ICU stay (days) 3 4 6
Clear liquids (days) 2.7 4.4 5
Regular diet (days) 4.1 5.8 7
Length of stay (days) 5.2 7.3 8
Complications (n, %) 1, 5% 5, 28% 8, 100%
Length of specimen (cm) 26 26 32
Number of lymph nodes 11 10 12
Late death from cancer (mean follow-up 4.9 years)
4 6 1
Recurrence 0 1 1
Curet MJ et al, Surg Endosc (2000) 14: 1062-1066
Long-Term Survival After Laparoscopic Colon Resection For Cancer
• Aim: To evaluate long-term survival after curative, laparoscopic resection for colorectal cancer.
• Design: Retrospective review of 102 consecutive patients with laparoscopic colon resection between 1991 and 1996 with 5-year follow-up. Comparison made to open colectomy at the same institution and National Cancer Database during similar time period.
Lujan HJ et.al. Dis. of Colon and Rectum;45:491-405,April 2002
Long-Term Survival After Laparoscopic Colon Resection For Cancer
02040
6080
100
0 1 2 3 4 5
Time in years
% s
urv
iva
l
Lap
Open0
20406080
100
0 1 2 3 4 5
Time in years
% s
urvi
val
Stage I Stage II Stage III Stage IV
Long-Term Survival After Laparoscopic Colon Resection For Cancer
02040
6080
100
0 1 2 3 4 5
Time in years
% s
urv
iva
l
Lap
Open – Nat.Ca. Database
020406080
100
0 1 2 3 4 5
Time in years
% s
urvi
val
Stage I Stage II Stage III Stage IV
Long-Term Survival After Laparoscopic Colon Resection For Cancer - Conclusions
• Laparoscopic colectomy for cancer is safe and feasible
• 5-year survival after laparoscopic colon resection for cancer is similar to survival after conventional surgery
• Prospective randomized trials currently under way will likely confirm these results
Lujan HJ et.al. Dis. of Colon and Rectum;45:491-405,April 2002
Lap (LCR) Versus Open (OCR) ColectomyAuthor/Year Study Design N Mean
/Median Follow-up
Recurrence / Long-term
Survival
Lujan, 2002 Retrospective review 102 64.4 + 2.8 LCR=OCR
Poulin, 2002 Retrospective review
of prospective data
80 31 Stg I-III
15.5 Stg IV
LCR=OCR
Lechaux, 2002 Retrospective review 206 60 LCR=OCR
Champault, 2002 Prospective, Non-Randomized (NR)
157 60 LCR=OCR
Lezoche, 2002 Prospective, NR 248 42 LCR=OCR
Anderson, 2002 Prospective, NR 100 40.3 LCR=OCR
Feliciotti, 2002 Prospective, NR 197 48.9 LCR=OCR
Lacy, 2002 Prospective,Randomized 219 43 LCR>OCR
*Nelson, 2001 Prospective,Randomized 1200
*Hazebroek2002 Prospective,Randomized 1200
Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic
colon cancer: a randomized trial
End-point P Value And the winner is…….
Peristalsis detection 0.001 Laparoscopic colectomy
Oral-intake times 0.001 Laparoscopic colectomy
Hospital stay 0.005 Laparoscopic colectomy
Overall morbidity 0.001 Laparoscopic colectomy
Cancer-related survival
0.02 Laparoscopic colectomy
Overall survival NS
Antonio M. Lacy et al. The Lancet June 2002, Vol.359, Issue 9325, p.2224-9
Questions!