Bowel Anastomoses For MIS Procedures

1. 2012 MISS Meeting, Salt Lake City Bowel Anastomoses For MIS Procedures Richard L. Whelan, MD St. Luke’s Roosevelt Hospital New York, N.Y.

2. Whelan Disclosures • Ethicon Endosurgery • Olympus Corporation • Atrium Corporation • Convatec • Hooters Restaurants • Coca Cola Corporation • Frito Lay • Hospital Vending Machine Corporate Council (who support lengthy operations)

3. What does “MIS” Mean? • Laparoscopic (no extraction incision) ? • Laparoscopic-assisted (extraction incision) ? • Hand-assisted ? • Hybrid (part laparoscopic, part open) ? • SILS ? • Robotic ? • NOTES ?

4. Number of Splinter MIS Methods is Growing • Each new method has a group of devoted proponents who have mastered the method • In their hands it works well • Each splinter method handles certain aspects of colorectal resection differently • It is now harder to give a general talk on some topics because what is said will not apply to all MIS methods

5. This Talks Comments Apply to the Following Methods: • Laparoscopic (no extraction incision) • Laparoscopic-assisted (extraction incision) • Hand-assisted

6. What Are You Comfortable Doing? • In the end, the surgeon must be comfortable with the method selected • If you want to learn a new method then: • Read about it, watch videos, talk/visit with surgeons who use the method • Consider doing the first few cases with someone in your area who has experience • What you hear at this conference must be considered in the context of your skill set and your MIS experience

7. Types of Bowel Anastomoses • Stomach to small bowel • Small bowel to small bowel • Small bowel to colon • Colon to colon • Colon to rectum • Colon to anus

8. Types of Anastomoses • End to End • Side to Side • Isoperistaltic vs Anti-peristaltic • End to Side • Pouch formation + anastomosis • Ileal • colonic

9. Means of Rejoining the Bowel • Staplers • Circular EEA, linear GIA stapler, TA-staplers • Hand-sewn • Combination • Stapled off bowel end & hand sewn side to side anastomosis • Stapled anastomosis reinforced with sutures • Pressure (seldom used) • Murphy button • Niti method

10. Colorectal Anastomoses After Laparoscopic Bowel Resection • Bariatric / Upper GI and MIS General surgeons: • Staplers • Hand-sewn methods • Colorectal surgeons • Rely on staplers predominately • In general, few intracorporeal hand-sewn ‘moses. • Need to be comfortable sewing intracoporeally

11. Sigmoid & Low Anterior Resection • Almost all distal L anastomoses done in the same manner (double stapled circular EEA): • Specimen exteriorized via lower abdominal extraction incision • Extracorporeal pursestring and anvil placement • Intracorporeal docking of anvil and firing of stapler

12. Laparoscopic-Assisted Sigmoid & Low Anterior Resection

13. Hand-assisted LAR

14. Exteriorization of Specimen

15. Placement of Anvil in Proximal Bowel

16. EEA Anastomosis

17. Stapled EEA Anastomosis

18. Leak Test After EEA Anastomosis • Alerts surgeon as to presence of leak • Choices: • Rigid procto with anastomosis submerged • Flexible sig + mosis submerged (CO2 for insufflation of bowel) • Bulb syringe injected air/betadine in rectum • If leak found suture reinforcement of anastomosis then retest • ? Need for proximal stoma if leak found or doughnuts incomplete (must check doughnuts)

19. Circular EEA Anastomosis • Proper stapler size • If too big, anvil won’t fit • If too small, then the “doughnut” may be too bulky • Must clear mesentery • Is anus strictured or narrowed? • Must consider colon & rectal diameters • Largest size possible

20. Factors That Impact Distal Left Anastomotic Healing • Level of the anastomosis (how low?) • Blood supply • Unusual anatomy (vessel origin, marginal art.) • Division IMA at origin or more distal • Tension  flexure takedown • Abnormal tissue • Neoadjuvant RT/chemo • Inflammatory bowel disease • Critical co-morbidities (cardiac, vascular)

21. How to Avoid Leaks For Sigmoid/LAR Anastomoses • Splenic flexure takedown in great majority • Carefully assess & understand the arterial anatomy • Carefully assess vascularity of proximal end when placing dougnut • Use sizers to make sure that stapler can be inserted to proximal end of Hartmann’s pouch

22. Sigmoid Resection for Diverticulitis • Preserve IMA (which improves blood supply) • Devascularize specimen in mid- mesentery • Preserves pelvic autonomic nerves • Danger here is leaving distal rectosigmoid colon and subsequent difficult stapler insertion (to reach proximal end of Hartmann’s) • Can partially mobilize in presacral plane (without detaching or dividing all attachments in order to preserve nerve supply)

23. Fully Laparoscopic Anastomosis • Transanal extraction of specimen • Transanal introduction of EEA Anvil • Placement of anvil in proximal bowel • Anvil into bowel end and then endoloop • Anvil spike exits side of proximal bowel and stapler used to close the bowel end • Close open end of Hartmann’s pouch • Insert stapler transanally • Docking of anvil and firing of stapler

24. Coloanal Anastomosis • Mucosectomy (Lone star retractor) • After TME to levators (breakthrough tricky) • TATA (done at start of case) • Need fully mobilized proximal colon • Flexure takedown • IMA at aorta and IMV proximal to L colic • Handsewn colon to anoderm anastomosis • +/- colonic J Pouch • Has clear functional implications

25. Ileocolic and Colo-colic AnastomosesIntracorporeal vs. Extracorporeal • Majority done extracorporeally • Can be safely done intracorporeally • Latter is harder to accomplish, may add time to operation • Is extraction incision size appreciably smaller for intracorporeal method? For most probably not. • Does it matter ? Not been well studied. There is little comparative data.

26. Ileal to Transverse Colon Anastomosis: The Problem • The length of the Middle Colic Artery is highly variable • In some patients it is very short and will not easily reach outside via small extraction incision • In obese patients with a thick abdominal wall this can be a big problem • Intracorporeal anastomosis makes most sense in the very obese population

27. Right Hemicolectomy: Standard Periumbilical Extraction Incision Takeoff of Middle colic vessels Extraction Incision

28. Right Hemicolectomy: Extraction Incision in Obese & Short Mesentery Patients Takeoff of Middle colic vessels

29. Right Hemicolectomy Epigastric Extraction Site Takeoff of Middle colic vessels

30. Extracorporeal Anastomosis • Two side to side stapling methods • Remove specimen first, then anastomose • Disadvantage: 3 crossing staple lines usually • Make anastomosis with bowel still in continuity (Barcelona Method) • Advantage: avoid 3 staple lines & fewer cartridges • Disadvantage: less sound oncologically ? • GIA 75 (or 80 mm) stapler used for both

31. Extracorporeal Ileocolic Anastomosis

32. Intracorporeal Anastomoses

33. Summary • Numerous ways to skin a cat • Before using new method fully investigate & learn about the technique (video/talk/observation). Mentor, if possible. • There are nuances to each method • Must be comfortable with method chosen • Good assistant and considerable colon experience prior to LAR / TME • Divert proximally if concerned about distal L anastomosis

34. Conditions Necessary for Anastomotic Healing • Adequate blood supply • Lack of tension • Technically “sound” anastomosis • Healthy, non-diseased bowel ends

38. Risk Factors for Anastomotic Leaks • Level of the anastomosis (< 6 cm) ** ++ • Neoadjuvant RT / chemo ** • Perioperative cardiac event * • Other co-morbidities (lung, liver, DM)+ • Male gender ? • Smoking, excessive ETOH ? • Double stapled method (vs handsewn) ^ ^^ *Lyall et al. Colorectal Dis 2003;9:801-7. **Heald RJ et al. Dis Col Rectum 1981;24:437-44. +Chessin et al. J Amer Coll Surg 1997;185:105-13. ++Vignali et al. J Amer Coll Surg 1997;185:105-13. ^ Mac Rae HM et al, Dis colon Rectum. 1998 ^^ Lustosa SA et al. , Sao Paulo Med J. 2002.

39. Cochrane Review of Literature 2005 Main findings regarding laparoscopic method: • Length of stay 1.5 days shorter • Incidence of wound infection lower (4.6% vs. open 8.7%, p=0.002) • No difference in anastomotic leak or abscess rate • Mortality similar • Quality of life better up until POD 30

40. How to Decrease Leak Rate: Blood Supply • Must determine each patient’s anatomy • Check for anatomic variations (common) • Vascular anatomy largely determines resection margins • When possible, palpate pulses, check for bleeding (extracorporeal anastomoses) • Does patient have atherosclerosis, DM ? • Prior Aortic aneurysm (is IMA open) ?

48. Anastomotic Leaks • The bane of the GI surgeons existence • They occur regardless of the construction method • Extraperitoneal bowel anastomoses have higher leak rates (no serosa) • Rectum • Esophagus • Types of leaks • Clinical • Radiologic (usually asymptomatic)

49. Anastomotic Morbidity: Not Just Leaks • Abscesses (without documented leak) • Fistulas can develop (abscess or leak related) • Rate of pelvic infection = leak + abscess • Abscess and collection rate not always given • Literature hard to assess for this reason • No uniform complication reporting system in place

50. Incidence of Clinical Leaks After Open LAR Series N No. Leaks % Karanjia et al ’94 219 24 11 Zaheer et al ’98 291 16 5 Enker et al ’99 681 8 1.2 Law et al ’00 196 20 10.2 Marijnen et al ’02 1861 214 11.5 Leester et al ’02 249 16 6.4 Wong NY et al ’05 1066 41 3.8 Gastinger et al ’05 2729 390 14.3 Chessin et al ’05 210 8 3.8 Lyall et al ’07 87 10 11.5