CHALLENGING SCENERIOS in Laparoscopic Colo rectal surgery

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Advanced colorectal surgery - Challenges

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CHALLENGING SCENERIOS in Lap Colorectal Surgery:

CHALLENGING SCENERIOS in Lap Colorectal Surgery Dr John AC Thanakumar MS, MNAMS, FRCS, FRCS, Dip MIS Dr Pravin John MS, FIBC,FIAGES, FALS ANURAG HOSPITAL, Coimbatore Disclosure s None

Slide 2:

Patient Factors Pathology Factors Surgeon Factors Miscellaneous Factors Advantage Adverse factors Cost Obstruction Good Oncology Small vs Big Cancer Medial or Lateral approach Contraindications Manual skills to tone up Personal variables

MAS ADVANTAGES:

MAS ADVANTAGES Less trauma Less immune suppression Better lungs Shorter stay Less complications Better cosmesis Patient Factors Pathology Factors Surgeon Factors Miscellaneous Patient Factors Pathology Factors Surgeon Factors Miscellaneous High Risk Elderly Obese Transplanted pts Cirrhotics May take longer Still less trauma

Benign Pathology:

Benign Pathology Diverticulitis Inflammatory bowel disease Familial Adenomatous Polyposis Rectal prolapse Crohn’s disease Patient Factors Pathology Factors Surgeon Factors Miscellaneous Well accepted 75% CD>1operation Repeated surgeries Abscess Phlegmon Perforation

Benign Pathology:

Benign Pathology +/- Minimal incision Crohn’s Disease – Use lower, cosmetic incisions UC, FAP – Ileo anal pouch can be staged or single sitting. Patient Factors Pathology Factors Surgeon Factors Miscellaneous

Malignant Pathology:

Malignant Pathology Port site metastasis (0.6 -0.68%) vs Open(-1%) Specimen extraction Patient Factors Pathology Factors Surgeon Factors Miscellaneous CO2 increase pressure Flow towards the ports Ischemia at edges Direct handling of tumor Exfoliated cancer cells deposit Immuno -suppression due to surgery Endobag Hand made plastic bags with purse string - cost

Malignant Pathology:

Malignant Pathology Lower surgical trauma Less immuno suppression Less complications Faster recovery Less wound metastasis Comparable wound margins Comparable LN harvesting Comparable survival ( St III Better 91% vs 74% Open ) Patient Factors Pathology Factors Surgeon Factors Miscellaneous (Lacy, Garcia et al Lancet

Malignant Pathology:

Malignant Pathology St III , lap better due to better preservation of immunological Better physiological status after less stress surgery COST(USA), COLOR(European), CLASSIC(UK Trial) Lap surgery comparable to open surgery ?Robotics, Intra op Enhanced imaging +/- help Patient Factors Pathology Factors Surgeon Factors Miscellaneous

Surgeon Factors:

Surgeon Factors General , Lap, GI, Colorectal Surgeons Well organized protocol Oncological steps Open and Lap experience (wet lab) Proctor Credentialing Patient Factors Pathology Factors Surgeon Factors Miscellaneous

Adverse factors:

Adverse factors Operating time in lap is longer ( Bg and Malignant) Cost in lap is higher Patient selection is the key- smaller, earlier ca Ports, camera, see tumor, vascular pedicle origin, proximal and distal margins to be seen If not, conversion to open surgery Surgeon’s skill and experience Patient Factors Pathology Factors Surgeon Factors Miscellaneous

Cost of MAS:

Cost of MAS Early bowel return Less pain Early return to work Short hospital stay - Hence less cost Cost of MAS higher in theater Longer surgery Reoperations More equipment – heat sources, staplers, hemostatic agents Efficacy of SILS, Robotics to be established Patient Factors Pathology Factors Surgeon Factors Miscellaneous Swedish sub-protocol to COLOR trial

Large Gut Obstruction Rectosigmoid:

Large Gut Obstruction Rectosigmoid Endo-luminal stent , dilatation, NdYag Laser , Cryo , Photo Dynamic Therapy(PDT) Laparoscopic Colostomy – Patient Factors Pathology Factors Surgeon Factors Miscellaneou s Better staging if no liver, local nodules, Less manipulation , Allows hemostasis Allows biopsy Allows surgery later Perforation Migration Bleeding Pain Occlusion Lap better >>> Open

Lap Asst Right Colectomy:

Lap Asst Right Colectomy Good Oncology High ligation of vessels Adequate resection-5 cm Clear proximal &distal margins Radical LN >12 Patient Factors Pathology Factors Surgeon Factors Miscellaneous LAC is safe and efficacious as open surgery Port recurrences (0.5%) Wound sepsis, ileus less Death <1% Complications less (20% vs 21% in open) Raza et al, Multicentric RCT

With malignancy, MAS:

With malignancy, MAS Patient Factors Pathology Factors Surgeon Factors Miscellaneous Shorter stay Early bowel Less blood loss Better Qty of Life 1.Conversion rate 20-26% 2.Stepwise, protocols 3.Surgeon 20 cases, with videos 4.Polyp Colonoscopy-India Ink 5.Intra operative colonoscopy-CO2 6.Vessel ligation before handling 7.Small incision to deliver tumor 8.Tumor protection 9.Mesenteric defect closure/or not 10.LAC vs OS Tactile sensation Syncronous tumors ? Of course pain is there Pneumo can spread ca More time More money

Approaches:

Approaches Lateral to Medial Babcocks on colon Medial retraction White line of Toldt to be incised Dissect upto the ureters Isolate the vessels Windows for ligation of vessels Divide mesentery to colonic margin Patient Factors Pathology Factors Surgeon Factors Miscellaneous Medial to Lateral Easier in slender patients Hold up the bowel Stretch the mesentery Look at medial aspect Vascular isolation, division Mark Mesentery, divide

Lap colectomy-Contraindications :

Lap colectomy -Contraindications Severe adhesions Advanced malignancy Ascitis Uncorrected coagulopathy Contra indication for GA Patient Factors Pathology Factors Surgeon Factors Miscellaneous

Develop Manual Skills :

Develop Manual Skills Redo surgery entries, dissection Intra corporeal knotting and suturing Post op leaks – localize early, and suture Hand Assisted Laparoscopic Surgery – HALS makes it easy prior to conversion Workshop on Lap linear and circular staplers Patient Factors Pathology Factors Surgeon Factors Miscellaneous

HALS:

HALS Patient Factors Pathology Factors Surgeon Factors Miscellaneous Positives Allows tactile sensation Allows specimen extraction Allows extra corporeal anastamosis Efficient control of bleeding if any Easy learning curve Less surgery time Negatives Hand delves into operating space Large incision may not help lap Device can cause air leak Shoulder, arm pain Increased cost

Personal Variables:

Personal Variables Ports – no , site, size, transparent Position of patient – Electronic/hydraulic table Heat sources – Bi, Mono, Ligasure , Ultrasound, thunder-beat, force triad Visualize ureters – stents, Stryker 1588 TEMS ( Trans-anal endoscopic micro surgery) Single incision /Robotics – boon or bane Patient Factors Pathology Factors Surgeon Factors Miscellaneous

Slide 20:

Patient Factors Pathology Factors Surgeon Factors Miscellaneous ANURAG HOSPITAL, 8, Krishna Nagar Sowripalayam Main Road, Sowripalayam Coimbatore -641028 Tel:0422-6587871 Web: www.anuraghospital.com

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