Laparoscopy assisted resection for colorectal cancer

Overview

  The advantages of laparoscopy assisted surgery have been well delineated and include reduced post-operative pain, reduced suppression of pulmonary function, fewer wound complications, expedited ileus resolution, fewer adhesions, shortened hospital stay, earlier recovery, improved cosmesis, and reduced costs than with laparotomy

Patient selection for laparoscopic resection of colorectal cancer

Despite increasing level of expertise, not every patient with colorectal cancer will be a good candidate for minimally invasive surgery. One of the limiting factors is previous abdominal surgery. Prior laparotomy is not an absolute contraindication, and the possibilities of getting safe access to the abdominal cavity and obtaining exposure with laparoscopic adhesiolysis should be determined on an individual basis. Other risk factors for a laparoscopic approach that have been suggested in literature are obesity, high patient age, high ASA score, advanced tumor stage and emergency setting. Clinical T4 stage and transverse colon localization will be common exclusion criteria in randomized trials. It becomes more and more clear that all these factors are relative contraindications depending on the level of expertise

Procedure

The patient will be placed in the lithotomy position under general anesthesia and fixed in position to tolerate deep Trendelenburg position. Four or Five ports will be usually placed, regardless of tumor location. CO₂ pneumoperitoneum of 12-15 mmHg will be maintained during the procedure. We routinely utilized the median approach for all procedures.

Right colectomy :

The medial side of mesentery, just caudal to the ileocolic vessels, is pulled up by the first assistant and incised. The incision is carried to the anterior surface of the duodenum, and lymphadenectomy around the root of the ileocolic vessels is performed, exposing the superior mesenteric vein. After transection of the ileocolic artery and vein, lymphadenectomy is extended cranially along the superior mesenteric vein, reaching the root of the middle colic artery. Mobilization of the hepatic flexure is required in almost all cases. When the retroperitoneum is divided at the hepatic flexure, the duodenum and Gerrotta’s fascia should be preserved behind the subperitoneal fascia. Told’s fusion fascia is incised as far cranially and caudally as possible. Finally, the ileocecal region is flipped up from the caudal side, preserving the right gonadal vessels and ureter, and the dissection is continued medially. The resection of the right colon and reconstruction are performed intra or extracorporeally. A small skin incision is made just around the umbilicus where the trocar for camera will be initially placed. An end-to-end or side to side ileocolonostomy is performed using hand sewn or stapling technique .

Sigmoidectomy :

The medial aspect of the rectosigmoid mesocolon is incised to mobilize the retroperitoneal space, preserving both hypogastric nerves. The inferior mesenteric artery (IMA) is divided at its origin from the aorta. The inferior mesenteric vein is divided at the same level as the IMA. Following retroperitoneal mobilization, with preservation of the left ureter and gonadal vessels, lateral peritoneal reflection is incised and continued to the median layer. The resection of the specimen and reconstruction is performed extracorporeally. When the anal side of the colon is too short to permit extracorporeal anastomosis, intracorporeal colorectal division and anastomosis with the double-stapling technique using a circular stapler is performed.

Lower anterior resection:

The pelvis is approached following the division of the main artery. The rectosigmoid colon is pulled cranially and dissection is continued laterally, providing excellent exposure of the pelvic space. The peritoneal reflection is incised on the anterior wall of the rectum, resecting Denonvillier’s fascia to expose the seminal vesicle in men or the vaginal wall in women, and the rectum is mobilized distally so that levator ani is exposed circumferentially. After determining the line of division on the anal side of the rectum, the mesorectum is incised circumferentially. A 5 cm midline wound incision is created, using a wound protector to maintain intra-abdominal pressure while introducing a linear stapler to use through the incision. The rectal stump is irrigated to avoid anastomotic recurrences. The continuity of the digestive tract is restored with a double-stapling technique using a circular stapler.

Transanal Total mesorectal excision (taTME)

After disinfecting and fully expanding the anus, a Lone Star Retractor™ will be positioned to better expose the anal canal. Depending on the tumor location, the transanal operation platform and surgical instruments will be directly inserted, or intersphincteric resection (ISR) will be initially performed transanally. Discontinuous annular pre-labeling of the intestinal wall will be performed on the mucosal surface of the intestinal wall 1–2 cm from the tumor’s lower edge. A 2–0 suture will be used to purse-string suture the muscular layer of the rectal wall at the labeled site and subsequently tighten the purse and tie the knot to close the rectal lumen. The mesorectum will be isolated through the anus in the “Holy Plane” of the TME until total mesorectal resection will be completed by meeting with the transabdominal operating plane.

Laparoscopic exploration, dissection of the inferior mesenteric artery or superior rectal artery root, and mesenteric-membrane dissection will be the same as in conventional laparoscopic-assisted TME surgery. Splenic flexure mobilization will be performed when necessary for tension-free anastomosis.

Notification

  Specific risks and complications of laparoscopic assisted resection is similar to those of open surgery. The long term oncology outcome is also the same as those of open surgery.

Estimated Cost:

  The surgical fee will be paid by National Healthy Insurance, Taiwan. The extra cost includes wound retractor, energy device, and 3-D scopy(optional) Gelport(for taTME). The range of cost is 50,000 to 150,000 NT according to what you use.