Extraction sites for colon resection: What’s out there right now?

1. Extraction sites for colon resection: What’s out there right now? Morris E. Franklin Jr MD. F.A.C.S. Director Texas Endosurgery Institute Karla Russek, MD. ResearchFellow MISS meeting 2010

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. A major advantage of laparoscopic surgery (small incisions) must be balanced with the need to remove and preserve specimens

4. Types of specimens Types of specimens • Benign • Malignant • Infected • Over size • Hollow/solid • Others • Benign • Malignant • Infected • Over size • Hollow/solid • Others

5. Should all laparoscopic specimens be extracted with a bag or protective sleeve ?

6. Wound protectors • Plastic sheaths used to line a wound during surgery • Camera sleeve • Commercially available • Avoid infection, port site metastasis.

7. Bags for specimen confinement and retrieval • Commercially available • Gloves • Gloves’ fingers • Condoms • Others • Freezer bags • Orthopedic bags

8. Bag considerations • Strength • Size • Aperture • Maneuverability • Easy of deployment • Easy of retrieval • Porosity

9. Bag Utilization • Insertion • Roll and insert • Bag deployment • Pull out • Use two graspers

11. Bag Utilization • Specimen entrapment • Triangulate the opening • Allow sufficient working space • Grasp connective tissue at the organ appendages, no the organ itself • Use of gravity • Trendelenburg + reverse Trendelenburg

12. Bag retrieval • Bag closure • Drawstring • Ligasure • Clips • Bag extraction • Constant laparoscopic visual control • Avoid puncturing or tearing the bag

13. Colon

14. Complications of specimen extraction • Specimen loss • Specimen rupture • Wound infection • Tumor implantation • Visceral injury • Incisional hernia

15. The best method for removal depends on the size, location, and nature of the specimen

16. Routes for Specimen Removal • Port site • Midline incision • Pfannestiel incision • Muscle splitting incision • Natural orifices

17. Port Site Removal • Small specimens • With or without a reducing sleeve • Under direct laparoscopic visualization

18. Port Site Removal

19. Midline incision • Requires only a single layer fascia division • Can remove large and very large specimens • Hernia formation 20-20% incidence • The longer the incision, the greater the incidence of hernia formation • Used extensively in SILS surgery

20. Does the extraction-site location in laparoscopic colorectal surgeryhave an impact on incisional hernia rates? • Prospective study of 208 patients • Hernia incidence of 7.8% • Midline incision hernia incidence of 17.6 Ravinder Singh, Alex Omiccioli, Susan Hegge, Craig McKinley. SurgEndosc 2006

21. A large Cochrane study which included 33 randomized control trials and 3346 patients reported: • Incidence of incisional hernias (different extraction sites): 7.9% vs. 10.9% (open colectomy) Long-term results of laparoscopic colorectal cancer resection Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer HJ

22. Muscle splitting incision • Hernia formation reduced • Lower Infection rate • Less Pain ?

23. Pfannenstiel incision • Used extensively by urologists as a kidney extraction site • Less pain • Cosmesis Matthew L. Steinway, M.D., Irma J. Lengu, M.D., Edward E. Cherullo, M.D., and Lee E. Ponsky, M.D. Laparoendoscopic Single-Site (LESS) Nephrectomy Through a Pfannenstiel Incision: Porcine Model. Journal of Endourology 2009

24. Pfannenstiel incision • No studies as a colon extraction site • Hand-assist technique • Has been used as a liver extraction site for laparoscopic resections A Simple Technique for Large Tumor Removal During Laparoscopic Liver Resection Teixeira, Antonio Roberto F. MD; Pilla, Victor F. MD; Makdissi, Fábio F. MD; Machado, Marcel Autran C. MD. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques: December 2008

25. Natural Orifices • Decrease body insult • Avoid incisional hernias • Lower infection rate • NOTES approach

26. Natural Orifices • Transgastric • Transanal • Transvaginal • Others

27. Selected cases

28. Texas Endosurgery InstituteExperience • Muscle splitting incision • Right lower quadrant 192 patients • Left lower quadrant 210 patients • Midline incision 137 patients

29. Texas Endosurgery InstituteExperience • NOTES • Transanal extraction 227 patients • Transvaginal extraction 25 patients

30. Muscle splitting extraction

31. Transanal benign disease

32. Transanal malignant disease

33. Transvaginal extraction

34. Morcellation of specimens • Futuristic ? • Specimen can be evaluated for histology but not for pathological staging • Cosmetically desirable

35. Determine extraction site by lesion localization and etiology • Importance of wound protection Conclusions

36. Always use a bag for extraction!!!! Conclusions

37. “Imagination is more important than knowledge. For knowledge is limited to all we now know and understand, while imagination embraces the entire world, and all there ever will be to know and understand.” Albert Einstein

38. www.texasendosurgery.com