Gentler, Kinder Cut What’s New in Minimally invasive Colorectal Surgery?

1. Gentler, Kinder CutWhat’s New in Minimally invasive Colorectal Surgery? Samuel C. Oommen, MD, FACS, FASCRS Bay Area Colon and Rectal Surgeons Walnut Creek, Ca

2. Topics To be Covered • Trans anal Endoscopic Microsurgery (TEM) • Laparoscopic Colectomy • Total Mesorectal Excision & Autonomic Nerve Preservation (TME & ANP) • Hand Assisted Laparoscopic Surgery (HALS) • Robotic Colorectal Surgery

3. Trans anal Endoscopic Microsurgery(TEM)

4. Transanal Endoscopic Microsurgery • Introduced by Gerhard Buess in 1983 for excision of proximal rectal lesions not amenable to a standard Transanal excision(TAE) • Operating Proctoscope with ports for CO2 insufflation and instrumentation • Six fold stereoscopic view • Facilitates negative surgical margins when direct visualization of the radial extent of the tumor is visible

5. TRANSANAL ENDSCOPICMICROSURGERY(TEM)

6. Indications For TEM • Adenocarcinoma T1 lesion (Confined to Submucosa) Well or Moderately differentiated Without Lympho vascular invasion T2 lesion (Muscle Invasion)following preop chemo radiation under ACOSOG Z 6041 protocol • Carcinoid(< 2 cm) • Adenoma unable or incompletely excised by endoscopy • Residual neoplasm or uncertain margin after endoscopic resection • Excision of benign rectal stenoses • Palliation of advanced cancer in high risk patients

7. TEMTechnique • Proctoscopic exam • Isolate tumor in lower half of field of view • Secure scope in place with Martin Arm Courtesy Peter Cataldo, MD

8. TEMTechnique Direct view through stereoscope or on monitor Courtesy Peter Cataldo, MD

9. Inject lesion with lidocaine w/ epinephrine Technique Courtesy Peter Cataldo, MD

10. ENDOSCOPIC VIEW

11. Multifocal Dysplastic Adenoma (TEM Specimen)

12. T1 Polypoid Cancer TEM specimen

13. T2 Adenocarcinoma of Mid Rectum

14. TEM VIDEO

15. TEM for Rectal Cancer?Oncologic Results

16. TEM vs. Radical ResectionWinde et. al. Munster, Germany • Prospective, randomized trial • uT1N0 • 52 patients • TEM vs. Ant. Resection • Morbidity / mortality • Recurrence • Survival

17. TEM vs. Radical ResectionWinde et. al. Munster, Germany Complications TEM 20.8% vs. LAR 34.5% Local recurrence TEM 2/24(8%) vs. LAR (?) Survival TEM 23/24 (96%) vs. LAR 25/26 (96%)

18. TEMOncologic Results • LeZoche et al • Rome, Italy • 40 patients, 3 yr f/u • prospective, randomized trial • T2N0 • Preop chemoradiotherapy • TEM vs LAR

19. TEM vs Lap LART2N0 TEMLAR OR time 95 min 165 min LOS 4.5 days 7.5 days Compl 15% 15% Local rec. 5% 5% 3 yr. Surv. 90% 83%

20. Laparoscopic Colorectal Surgery

21. Historical Perspectives • 1990: Laparoscopic Right Colectomy- Jacobs, Miami, Florida • 2004: COST Study *Jacobs M. et al Minimally Invasive Colon Resection, SurgLaparoscEndosc 1991; 1: 144-50 Recurrence & Survival

22. Benefits of Laparoscopic Surgery • Smaller incisions • Reduced postoperative pain • Earlier return of bowel function • Reduced hospital stay • Earlier return to work and activities of daily living • Reduced operative trauma and stress • Reduced adhesions

23. Endoscopic Tattoo

24. Right Colectomy

25. Right Colon Anatomy

26. Adequate Lymph Node Harvest

28. Total Mesorectal Excision(TME)

29. What is Total Mesorectal Excision? “TME is defined as the resection of the rectum with its surrounding fatty and lymphatic tissue contained within the visceral sheet (Fascia Propria) of the endopelvic fascia. The dissection in this almost avascular cleavage allows the complete removal of the mesorectal tissue, as well as good protection of the hypogastric nerves and the inferior hypogastric plexus, resulting in less disturbance to bladder and sexual functions.” Faerden AE et al, Dis Colon Rectum , 2005; 48: 2224-2231

30. Adapted from Heald, RJ et al, Br. J. Surg Vol 69(1982)613-616

31. Total Mesorectal Excision (TME) Shiny Fascia Propria covering the Mesorectum Total Mesorectal Excision (TME)

32. TME Grading • COMPLETE: • Intact bulky mesorectum with a smooth surface • Only minor irregularities of mesorectal surface • No coning towards the distal margin of the specimen • After transverse sectioning, the circumferential margin appears smooth

33. TME Grading • NEARLY COMPLETE: • Moderate bulk to the mesorectum • Irregularity of the mesorectal surface with defects greater than 5 mm, but none extending to the muscularispropria • No areas of visibility of muscularispropria

34. TME Grading • INCOMPLETE – • Little bulk to the mesorectum • Defects in the mesorectum down to muscularispropria • After transverse sectiong, the circumferential margin appears very irregular

35. From Maslekar et al. 2006 “Mesorectal grades predict recurrences after curative resection for rectal cancer.” Dis Colon Rectum 50:168-175.

37. Hand Assisted laparoscopic Surgery • Still the best Surgical instrument • Tactile feedback for retraction and dissection • May reduce operative times and need for conversion • Bridge between open and laparoscopic surgery • Two Commandments Adapted from Michael McCue, MD

38. Two Commandments of laparoscopic surgery. • “Thou Shall not change your operation to fit the equipment” • “Thou shall K. I. S. S. (keep it simple surgeons)” • HALS is ideal in meeting above criteria. Adapted from Michael McCue, MD

39. Benefits of HALS • Maintains Tactile Feedback • Improves Eye Hand coordination and Depth perception • Better exposure due to improved traction • Facilitates rapid hemorrhage control No Laparoscopic instrument is as versatile, educated and safe as the experienced Surgeon’s Hand

40. Lap Disc Ethicon Endosurgery

42. Hand Assisted Right Colectomy for Hepatic Flexure CancerHALS

43. Robotic Colorectal Surgery

44. Disadvantages of Laparoscopic surgery • Unstable video camera imaging • Dependency on assistant’s skills

45. Disadvantages of Laparoscopic surgery • Limited motion of instruments • The Surgical instruments are Rod-like having no wrist movement at the tip which required from the surgeon to move his arms in large scale movements outside the patients body for the instrument tip (internally) to get to the desired location. • The movement of the instruments/scope were awkward (counter-intuitive) meaning that if the surgeon wants to move the instrument/scope to the left, he has to move to the right from outside. • Related loss of dexterity

46. Disadvantages of Laparoscopic surgery(Contd) • The scope displays only a 2D image on the display which has no depth perception. The surgeon needed to over/under shoot the target anatomy to be able to allocate it properly. • The Surgeon gets tired • Awkward position such as twisting his neck to be able to follow up the surgical site displayed on the monitor. • Longer hours standing

47. Advantages of Robotic Surgery • Tridimensional(3D) imaging under the surgeon’s direct control • Provides instruments with seven degrees of freedom • Enhances dexterity, precision, and control during surgical procedures.

48. Advantages of Robotic Surgery(Contd) . • Scales down hand movements, and eliminates hand tremors • Facilitates handsewn sutures. • Cuts down the surgeon’s fatigue

49. OR Setup and Patient Preparation

50. Patient Positioning