Gentler, Kinder CutWhat’s New in Minimally invasive Colorectal

Surgery?

Samuel C. Oommen, MD, FACS, FASCRSBay Area Colon and Rectal Surgeons

Walnut Creek, Ca

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

Trans anal Endoscopic Microsurgery(TEM)

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 viewFacilitates negative surgical margins when

direct visualization of the radial extent of the tumor is visible

TRANSANAL ENDSCOPICMICROSURGERY

(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

TEMTechnique

•Proctoscopic exam•Isolate tumor in lower half of field of view•Secure scope in place with Martin Arm

Courtesy Peter Cataldo, MD

TEMTechnique

Direct view through stereoscope or on monitor

Courtesy Peter Cataldo, MD

Technique

Inject lesion with lidocaine w/ epinephrine

Courtesy Peter Cataldo, MD

ENDOSCOPIC VIEW

Multifocal Dysplastic Adenoma (TEM Specimen)

T1 Polypoid Cancer

TEM specimen

T2 Adenocarcinoma of Mid Rectum

TEM VIDEO

TEM for Rectal Cancer?Oncologic Results

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 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%)

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 LART2N0

TEM LAR

OR time 95 min 165 minLOS 4.5 days 7.5 daysCompl 15% 15%Local rec. 5% 5%3 yr. Surv. 90% 83%

Laparoscopic Colorectal Surgery

Historical Perspectives 1990: Laparoscopic Right Colectomy-

Jacobs, Miami, Florida

2004: COST Study

*Jacobs M. et al Minimally Invasive Colon Resection, Surg Laparosc Endosc 1991; 1: 144-50

Recurrence &Survival

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

Endoscopic Tattoo

Right Colectomy

Right Colon Anatomy

Adequate Lymph Node Harvest

Total Mesorectal Excision(TME)

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

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

Total Mesorectal Excision (TME)

Total Mesorectal Excision (TME)

Shiny Fascia Propria covering the Mesorectum

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

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 muscularis propria

– No areas of visibility of muscularis propria

TME Grading

• INCOMPLETE – – Little bulk to the

mesorectum– Defects in the

mesorectum down to muscularis propria

– After transverse sectiong, the circumferential margin appears very irregular

Mesorectal grade vs. local and overall recurrence Grade of Mesorectum

Total Patients

(n)

Local Recurrence

n (%)

Overall Recurrence

n (%)

1 17 7 (41) 10 (59)

2 52 3 (5.7) 9 (17)

3 61 1 (1.6) 1 (1.6)

P value 0.0001 0.0001

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

• 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.

• “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 HALSMaintains Tactile FeedbackImproves Eye Hand coordination and Depth

perceptionBetter exposure due to improved traction Facilitates rapid hemorrhage control

No Laparoscopic instrument is as versatile, educated and safe as the experienced Surgeon’s Hand

Lap Disc Ethicon Endosurgery

Hand Assisted Right Colectomy for Hepatic Flexure CancerHALS

Robotic Colorectal Surgery

Disadvantages of Laparoscopic surgery

• Unstable video camera imaging

• Dependency on assistant’s skills

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)

• 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

• 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)

.

• Scales down hand movements, and eliminates hand tremors

• Facilitates handsewn sutures.• Cuts down the surgeon’s

fatigue

OR Setup and Patient Preparation

Patient Positioning

Docking The Patient Cart

Surgical Steps - Surgical Overview

Robotic Colorectal 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

Conclusion• 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