Long-term follow-up of intracorporeal anastomosis

1. Long-term follow-up of intracorporeal anastomosis Morris E. Franklin Jr., M.D., FACS Director, Texas Endosurgery Institute Karla Russek, M.D. Research Fellow MISS, 2011

2. Industry relationships • W.L. Gore & Associates • Grant/research support, consultant and speaker bureau • Covidien • Grant/research support, consultant and speaker bureau • Striker • Consultant, advisory board • Ethicon • Consultant and speaker bureau • Atrium • Consultant • Aesculap • Consultant • KCI • Consultant The Authors do not have financial interest with the above mentioned companies

3. There is controversy regarding the feasibility and usefulness of a totally intracorporeal anastomosis

4. Intracorporeal vs laparoscopic-assistedresectionforuncomplicated diverticulitis of thesigmoid • 40 intracorporeal anastomosis Vs 34 diagnosis-matched, lap-assisted controls • Significant differences in: • Incision length, specimen length, complication rates, OR time, hospital stay, ward costs • Conclusion: • “The (…) advantages surmised from this study need further evaluation. LICR remains a procedure of considerable technical difficulty” • Bergamaschi R, Tuetch JJ, Pessaux P, Arnaud JP. Surg Endosc 2000 Jun;14(6):520-3

5. Standardized Laparoscopic Intracorporeal Right Colectomy for Cancer: Short-Term Outcome in 111 Unselected Patients. • 111 laparoscopic intracorporeal right colectomies • 5.4 percent conversion rate. • Operative time was 120 (range, 80-185) minutes. EBL 69 (range, 50-600) ml. • Skin incisions was 66 (range, 60-66) mm • Length of stay was four (range, 2-30) days CONCLUSIONS: A standardized laparoscopic intracorporeal right colectomy resulted in a favorable short-term outcome in unselected patients with neoplasia of the right colon. • Bergamaschi R, Schochet E, Haughn C et al,Dis Colon Rectum. 2008 May 14

6. Should completely intracorporeal anastomosis be considered in obese patients who undergo laparoscopic colectomy for benign or malignant disease of the colon? • Obesity had no effect on: • operative time: obese 232 min Vs 213 minutes • incision length (obese 4 cm Vs 4 cm) • estimated blood loss (obese 100 mL Vs 76 mL), • complications (obese 15% Vs 19% • duration of stay (obese 5 days Vs 5 days) • lymph nodes (obese 11 Vs 11 lymph nodes). CONCLUSIONS: LCIA can offer smaller incisions, improved cosmesis, and low conversion rates while oncologic principles are preserved. LCIA is a feasible and safe technique with equally successful outcomes in thin and obese patients. • Raftopoulos I, Courcoulas AP, BlumbergD.Surgery. 2006 Oct;140(4):675-82; discussion 682-3. Epub 2006 Sep 6.

7. Extracorporeal versus intracorporeal anastomosis for laparoscopic right hemicolectomy • Prospective study on 80 patients. • No significant difference in length of stay, number of lymph nodes removed, EBL, operative time, postoperative ileus. • Incision length was shorter in ICA ( 4 CM vs 5 cm) • Major complication rates were similar • (4.3 in ICA vs 5.3% in ECA) CONCLUSIONS: The type of anastomosis does not influence short-term outcomes after laparoscopic right hemicolectomy. An intracorporeal anastomosis results in shorter incision length and may decrease wound-related complications. • Pigazzi et al. JSLS, Sep 2009

8. These studies did not address postoperative pain, wound infection, incisional hernia and immunologic aspects

9. What is the rationale of intracorporeal anastomosis for laparoscopic colon resection?

10. Intracorporeal anastomosis • Applicable to all patients, regardless of their body habitus • No need to modify incision sites for short mesentery • Allows routine bagging of specimen • Less likelihood of malignant cell spillage and abdominal wound infection • Comfortable anastomosis • Less post-op pain

11. Intracorporeal anastomosis • Less impact on immunologic state of patient • Opportunity for use of natural orifices for specimen extraction • Represents a truly minimally invasive procedure (Patients expect and demand MIS) • While technically more demanding, it is the concept of MIS that is desired

12. Intracorporealanastomosis with Natural Orifices Extraction • Hernia elimination • Precursor to Morcellation • Choose site of extraction rather than having site mandated by need of anastomosis on completion of procedures • Allows lesser mobilization of transverse colon on RHC • Avoids mal alignment of anastomosis compared to extracorporeal anastomosis

13. Intracorporeal anastomosis: How do we approach the process?

14. A totally intracorporeal procedure with anastomosis involves the following steps: • Identification of disease and mobilization of the colon • Identification of anatomical landmarks • Duodenum in RHC • Left ureter in LHC/LAR • Isolation and division of colic vessels

15. A totally intracorporeal procedure with anastomosis involves the following steps: • Hepatic/Splenic flexure mobilization • Division of the omentum • Division of the bowel • Creation of an anastomosis • Specimen removal

16. Intracorporeal Anastomosis For Right Colon :

17. Right Hemicolectomy Duodenal localization

18. Right Hemicolectomy Omentum takedown

19. Right Hemicolectomy Resection

20. Right Hemicolectomy Anastomosis

21. Right Hemicolectomy Bagging

22. Colonoscopy and anastomosis leak test • Intestinal clamps • Liberal use of colonoscope • Anastomosis • Air leak test • ID • Bleeding • Integrity

23. Specimen extractionRLQ • Counter Incision • RLQ • Wound Protector • Natural orifices

24. Specimen extractionTransvaginal

25. Comparison of totally laparoscopic RHC with intracorporeal anastomosis Vs laparoscopical assisted RHC with extracorporeal anastomosis

26. Laparoscopic Right Colon Resection N=486 P>0.005 P<0.005

27. Laparoscopic Right Colon Resection

28. Laparoscopic Right Colon Resection N=486 COMPLICATIONS

29. Standardized Laparoscopic Intracorporeal Right Colectomy for Cancer: Short-Term Outcome in 111 Unselected Patients Bergamaschi R, Schochet E, HaughnC,et al Dis Colon Rectum. 2008 May 14

30. Intracorporeal Anastomosis For Left Colon :

31. Margins determinationProximal and distal resection

32. Transanal Extraction

33. Anastomosis

34. Tumor spillage of a colotomy ? With 1600 plus cases we have seen none.

35. Totally Lapaparoscopic Vs Laparoscopically Assisted LAR and Left Colectomy

36. Demographics Patients=957

37. Demographics Patients=957 P = 0.01

38. Demographics Patients=957 P = 0.01 P + 0.05 P = 0.01 P = 0.01 P = 0.01 * All resolved within 6 weeks

39. “You were right, intracorporeal anastomosis is better for the patient “ Barry Salky (2008)

40. We are trying it more and more (intracorporeal anastomosis) because it lessens the immunological impact on the patient. AlessioPigazzi (2008)

41. Conclusion • Laparoscopic colectomy with intracorporeal anastomosis can be performed safely and effectively for managing a variety of colonic diseases, including malignant colonic neoplasia.

42. Conclusion • It has been shown that the extent of the immunological response is directly proportional to the magnitude of trauma involved (length of incisions) • Wichmann, MW; Huttl, TP; Winter, H. Immunologicaleffects of laparoscopic vs open colorectalsurgery: a prospectiveclinicalstudy. ArchSurg, 2005

43. Conclusion • Intracorporeal anastomosis for right colon resulted in (Inhouse study): • Shorter operation time • Less intraoperative blood loss • Lower intraoperative and postoperative complications rates • Lower hospital stay

44. Conclusion • Extracorporeal anastomosis proved to have more (Inhouse study): • Post-operative anastomotic leaks • Incisional hernias • Abdominal abscesses • Wound infections

45. Conclusion • It is almost impossible to perform Natural Orifice Surgery without the skills necessary to perform an Intracorporeal Anastomosis

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