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Gentler, Kinder Cut What’s New in Minimally invasive Colorectal Surgery?. Samuel C. Oommen , MD, FACS, FASCRS Bay Area Colon and Rectal Surgeons Walnut Creek, Ca. Topics To be Covered. Trans anal Endoscopic Microsurgery (TEM) Laparoscopic Colectomy

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Gentler kinder cut what s new in minimally invasive colorectal surgery l.jpg

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


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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



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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


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TRANSANAL ENDSCOPICMICROSURGERY(TEM)


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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


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TEMTechnique

  • Proctoscopic exam

  • Isolate tumor in lower half of field of view

  • Secure scope in place with Martin Arm

Courtesy Peter Cataldo, MD


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TEMTechnique

Direct view through stereoscope or on monitor

Courtesy Peter Cataldo, MD


Technique l.jpg

Inject lesion with lidocaine w/ epinephrine

Technique

Courtesy Peter Cataldo, MD




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T1 Polypoid Cancer

TEM specimen




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TEM for Rectal Cancer?Oncologic Results


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TEM vs. Radical ResectionWinde et. al. Munster, Germany

  • Prospective, randomized trial

  • uT1N0

  • 52 patients

  • TEM vs. Ant. Resection

  • Morbidity / mortality

  • Recurrence

  • Survival


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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%)


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TEMOncologic Results

  • LeZoche et al

  • Rome, Italy

  • 40 patients, 3 yr f/u

  • prospective, randomized trial

  • T2N0

  • Preop chemoradiotherapy

  • TEM vs LAR


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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%



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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


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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



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Right Colectomy




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Total Mesorectal Excision(TME)


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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



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Total 69(1982)613-616Mesorectal Excision (TME)

Shiny Fascia Propria covering the Mesorectum

Total Mesorectal Excision (TME)


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TME Grading 69(1982)613-616

  • 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


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TME Grading 69(1982)613-616

  • 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


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TME Grading 69(1982)613-616

  • INCOMPLETE –

    • Little bulk to the mesorectum

    • Defects in the mesorectum down to muscularispropria

    • After transverse sectiong, the circumferential margin appears very irregular


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From Maslekar 69(1982)613-616et al. 2006 “Mesorectal grades predict recurrences after curative resection for rectal cancer.” Dis Colon Rectum 50:168-175.


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Hand Assisted laparoscopic Surgery 69(1982)613-616

  • 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


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Two Commandments of laparoscopic surgery. 69(1982)613-616

  • “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


Benefits of hals l.jpg
Benefits of HALS 69(1982)613-616

  • 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



Hand assisted right colectomy for hepatic flexure cancer hals l.jpg
Hand Assisted Right 69(1982)613-616Colectomy for Hepatic Flexure CancerHALS



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Disadvantages of 69(1982)613-616 Laparoscopic surgery

  • Unstable video camera imaging

  • Dependency on assistant’s skills


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Disadvantages of 69(1982)613-616 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


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Disadvantages of 69(1982)613-616 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


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Advantages of Robotic Surgery 69(1982)613-616

  • Tridimensional(3D) imaging under the surgeon’s direct control

  • Provides instruments with seven degrees of freedom

  • Enhances dexterity, precision, and control during surgical procedures.


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Advantages of Robotic Surgery 69(1982)613-616(Contd)

.

  • Scales down hand movements, and eliminates hand tremors

  • Facilitates handsewn sutures.

  • Cuts down the surgeon’s fatigue



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Patient Positioning 69(1982)613-616


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Docking The Patient Cart 69(1982)613-616




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Disadvantages of Robotic Surgery 69(1982)613-616

  • Cost. With a price tag of 1.6 million dollars, and nearly 100k in maintenance costs annually.

  • the size of these systems.

  • lack of compatible instruments like energy sources and staplers.

  • Lack of tactile feedback


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Conclusion 69(1982)613-616

  • Generally, the maximum benefit seems to be achieved whenever a complex and precise dissection in a confined space is required.

  • Still in infancy, and many advances are expected in the near future (smaller and operative-room integrated systems, tactile feedback technology, specifically designed instruments, reduced costs)

  • Robotic laparoscopic colon surgery is feasible and safe.

  • Operating time is longer than in standard laparoscopic surgery.

  • Results from long term studies studies regarding cancer survival and recurrence are awaited


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