Basics Skills for Laparoscopic Colon Surgery

1. Basics Skills for Laparoscopic Colon Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery University of Cincinnati Program Director Residency in General Surgery Director of Minimally Invasive Colorectal Surgery, University Hospital

2. Laparoscopic Colectomy:You’ve Come a Long Way Baby! • Improved instrumentation • Improved techniques • Standardized approach • Large experience by a few surgeons • Still not routine

3. Barriers to Implementation • Access to cases • Technique often differs from open approach • Medial vs. lateral • Comfort in major pedicle ligation (aortic branches) • Requirements for more than one skilled surgeon • Time

4. Skill Sets • Multi quadrant surgery • Skilled camera operator • Ability to work against the camera • Colon not always fixed • Tension created by two operators – both skilled • Knowledge of energy devices and endo staplers

6. Other Considerations • Loss of tactile feedback • Diverticulitis • Crohn’s disease • Location of tumor/polyp • Learning curve • Surgeon • Surgical Team • Referring Docs

9. Preparation - The Patient • Preoperative evaluation • few additional studies necessary • additional invasive monitoring unusual • Flexibility of hips and legs

10. Room Setup What we get… What we hope for…

11. Set Up: The Bed • Electric bed • Bean bag • Velcro bag to bed • Bottom of bag at break

12. Set Up: The Patient • Modified lithotomy • Minimize hip flexure • Arms tucked • Padding for shoulder

13. Set Up: The Patient • Minimize hip flexion • 10o at most • More flexion may limit access to transverse colon

14. Even Better

15. Set Up: The Patient • Padding for neck and shoulder • 3” silk around chest to prevent lateral slippage

16. Set Up: The Room

17. Preparation - Surgeon: General Recommendations • Be prepared for the day • Don’t book too many cases • Keep your cool • Pick the easy lay-up • Find some good help

18. Preparation - Surgeon: Learning Curve • Steep (20-50 cases) • Depth perception • Multiple quadrants • Reverse angles • Coordination of team Operative times Conversion rates

19. Convert Alternate

20. Conversions – Does it matter • Conversion – an ugly word • Increased operative times • Increase length of stay • Increase 30 day readmission/morbidity • Increase cost

21. Conversions

22. Conversions • No difference in outcomes when compared to an open cohort of similar patient • KEY is to make a decision to ALTERNATE the approach early Dis Colon Rectum. 2004 Oct;47(10):1680-5

23. Alternatives to Conversion • Pfannenstiel incision after: • mobilization of splenic flexure • division of vascular pedicle • Hand-assisted laparoscopy • allows tactile sensation • blunt separation

24. Preparation - Surgeon: Developing a Systematic Approach • Develop an approach and stick with it • Initial survey • Port placement • Vascular ligation and medial mobilization • Lateral mobilization • Extraction and anastomosis

25. Laparoscopes • 10mm 0o • Easy orientation • May be inadequate at the flexures • 10mm 30o • Better visualization at flexure and pelvis • Disorientation • Flexible tip lens

26. Instrumentation

27. Conclusion • Don’t wait for the perfect case • Be prepared • If you are going to alternate – do it quickly • Have fun

28. Thanks