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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?

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gentler kinder cut what s new in minimally invasive colorectal surgery

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

topics to be covered
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
transanal endoscopic microsurgery
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
indications for tem
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
tem technique
  • Proctoscopic exam
  • Isolate tumor in lower half of field of view
  • Secure scope in place with Martin Arm

Courtesy Peter Cataldo, MD

tem technique8

Direct view through stereoscope or on monitor

Courtesy Peter Cataldo, MD


T1 Polypoid Cancer

TEM specimen

tem vs radical resection winde et al munster germany
TEM vs. Radical ResectionWinde et. al. Munster, Germany
  • Prospective, randomized trial
  • uT1N0
  • 52 patients
  • TEM vs. Ant. Resection
  • Morbidity / mortality
  • Recurrence
  • Survival
tem vs radical resection winde et al munster germany17
TEM vs. Radical ResectionWinde et. al. Munster, Germany


TEM 20.8% vs. LAR 34.5%

Local recurrence

TEM 2/24(8%) vs. LAR (?)


TEM 23/24 (96%) vs. LAR 25/26 (96%)

tem oncologic results
TEMOncologic Results
  • LeZoche et al
  • Rome, Italy
  • 40 patients, 3 yr f/u
  • prospective, randomized trial
  • T2N0
  • Preop chemoradiotherapy
  • TEM vs LAR
tem vs lap lar t2n0
TEM vs Lap LART2N0


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%

historical perspectives
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




benefits of laparoscopic surgery
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
what is total mesorectal excision
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

total mesorectal excision tme31
Total Mesorectal Excision (TME)

Shiny Fascia Propria covering the Mesorectum

Total Mesorectal Excision (TME)

tme grading
TME Grading
    • 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
tme grading33
TME Grading
    • 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
tme grading34
TME Grading
    • Little bulk to the mesorectum
    • Defects in the mesorectum down to muscularispropria
    • After transverse sectiong, the circumferential margin appears very irregular

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

hand assisted laparoscopic surgery
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

two commandments of laparoscopic surgery
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

benefits of hals
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

disadvantages of laparoscopic surgery
Disadvantages of Laparoscopic surgery
  • Unstable video camera imaging
  • Dependency on assistant’s skills
disadvantages of laparoscopic surgery45
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
disadvantages of laparoscopic surgery contd
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
advantages of robotic surgery
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.
advantages of robotic surgery contd
Advantages of Robotic Surgery(Contd)


  • Scales down hand movements, and eliminates hand tremors
  • Facilitates handsewn sutures.
  • Cuts down the surgeon’s fatigue
disadvantages of robotic surgery
Disadvantages of Robotic Surgery
  • 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
  • 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