A technique for laparoscopic-assisted colectomy using two ports.

OBJECTIVES: Laparoscopic colon and rectal surgery requires advanced laparoscopic skills. The aim of this study was to describe a novel technique for laparoscopic-assisted colectomy using only 2 ports and to review our initial experience with this technique for patients with benign colonic pathologies.
METHODS: A retrospective chart review of all patients who had laparoscopic-assisted colon surgery using this technique was performed. The technique is described.
RESULTS: For right colectomy, a 10-mm trocar for the camera was placed just below the umbilicus and a 5-mm working port just above the umbilicus. The colon was mobilized using one instrument and gravity assistance. The incisions were then connected, and the mobilized colon was pulled through this incision. For left-sided colectomy, the 5-mm working port was placed at the left suprapubic hairline, which was then extended for removal of the specimen. Sixty patients with benign colonic pathologies had laparoscopic-assisted colon surgery using only 2 ports. Conversion to open surgery was required in 4 cases. The average length of the skin incision was 3.82 cm, and the mean length of hospital stay was 4.18 days. Postoperative complications occurred in 11 patients (18%) and included anastomotic leak in 1 patient and wound infection in 2.
CONCLUSIONS: Laparoscopic-assisted segmental colectomy using 2 ports is easy and feasible, with minimal skin incisions and fast recovery. Our initial experience suggests that it may be easier for the experienced colorectal surgeon to acquire the skills needed to perform this technique.

INTRODUCTION

The introduction of laparoscopic techniques is one of the most significant events in the evolution of surgery in the 20th century. In just a few years, advanced laparoscopic techniques have been developed for treating most surgical pathologies, including colorectal pathologies.[1] Advanced laparoscopic procedures require specific skills and expertise, which are only partially translatable from traditional surgical training. Advanced laparoscopic techniques have a steep learning curve[2-5] and require a dedicated operating room team for adequate assistance. This may limit the widespread application of advanced laparoscopic techniques, which may be performed mainly by dedicated, experienced laparoscopic teams based mainly in academic medical centers.

The aim of this study was to describe a novel “fast and easy” technique for laparoscopic-assisted colectomy using only 2 ports and to review our preliminary experience with this technique for patients with benign colonic pathologies. In this technique, the colon is mobilized intracorporeally using only one working port, and the resection and anastomosis are performed extracorporeally. Our preliminary experience may show that this technique is simple to acquire, has an easier learning curve, and thus may be more suitable for the experienced colorectal surgeons who are acquiring laparoscopic techniques.

METHODS

A retrospective chart review of all patients who underwent laparoscopically assisted colon surgery for benign conditions, using only 2 ports, was performed. This procedure is described in detail. Demographic and clinical characteristics, the surgical procedure, hospital course, and outcome were retrieved from the hospital and office medical records.

Conversion to an open procedure was defined as a laparotomy incision performed earlier than planned. When a laparotomy was performed after complete mobilization of the colon, the length of skin incisions was not considered as a parameter determining conversion.

RESULTS

Right Colectomy Technique

With patients in the supine position under general anesthesia, 2 vertical skin incisions are made, just above and below the umbilicus, and 2 ports are inserted (. The camera is inserted through the 10-mm infraumbilical trocar, whereas the supraumbilical, 5-mm port is used as the working port. The patient is then tilted with the left side down as much as possible, for gravity assistance. A grasper instrument with diathermy is then inserted through the working port, and the lateral peritoneal reflection is grasped, briefly cauterized, and gently pulled, to mobilize the colon (. The colon is bluntly and gently swept medially, and the lateral peritoneal reflection is repeatedly grasped and mobilized. Adequate tilt to the left is important at this point, to prevent the colon from falling back to the gutter. By using this tilt, it is usually possible to keep the colon in a medial position, without the need for a second instrument to grasp the colon itself. In this case, the operating surgeon can use the operating instrument with the right hand and hold the camera with the left hand. Care should be taken to keep the anatomic planes during the dissection, to prevent harm to the colon and adjacent structures, and to avoid excessive bleeding. After complete mobilization of the right colon, the cecum is grasped using a laparoscopic Babcock instrument. The skin incisions are then connected to the right of the umbilicus, and the right colon is brought out through this incision. The right colon is resected extracorporeally and a stapled side-to-side functional end-to-end anastomosis is performed.

Trocar placement for laparoscopically assisted right colectomy. The 2 skin incisions are made just above and just below the umbilicus. Arrows pointing to the skin incisions.

Laparoscopic mobilization of the lateral peritoneal reflection. Tilt to the patient's left side assists in medial mobilization of the colon.

Left and Sigmoid Colectomy Technique

For left-sided colonic resection, a 10-mm umbilical port is inserted for the camera. A 5-mm working port is inserted in the left lower quadrant just above the hairline (. The operating table is tilted to the right as much as possible, to allow gravity to help in keeping the colon in the medial position. The lateral peritoneal reflection is repeatedly grasped, briefly cauterized, and medially mobilized using gentle traction. Again, the mobilized colon is repeatedly swept medially. Because of gravity, it usually stays in this position without the need for an additional instrument. After adequate laparoscopic mobilization of the left and sigmoid colon, a left lower quadrant horizontal incision is made around the working port, and the mobilized colon is brought out for an extracorporeal resection and anastomosis.

Trocar placement for laparoscopically assisted left colectomy. The skin incisions are made just below the umbilicus and at the left lower quadrant above the pubic hairline.

Preliminary Experience

Sixty patients underwent laparoscopically assisted colectomy for benign colonic pathologies with this technique, with only 2 ports, between 1999 and 2001. Patients comprised 34 males and 26 females, at a mean age of 75.1 years (range, 44 to 91 years). Thirty patients underwent right colectomy, 14 had sigmoid colectomy, 8 had transverse colectomies, and 8 had colotomies with polypectomy and primary closure. All patients were operated on for benign colonic conditions, and the indications for surgery are detailed in .

In 56 (93%) of the cases, the colon was successfully mobilized laparoscopically; and in 4 cases, conversion to laparotomy was required. In 3 cases, conversion was performed due to technical difficulties owing to extensive adhesions. In 1 case surgery was converted to laparotomy after exploration, owing to complications related to the preoperative endoscopic tattoo of the lesion.

Mean operative time of the entire procedure, including the laparoscopic mobilization and extracorporeal resection and anastomosis, was 78.9 minutes. The laparoscopic mobilization time was specifically measured only in the last 10 cases, and ranged from 10 minutes to 25 minutes. The mean length of the skin incision was 3.82 cm (range, 1.5 to 10). Mean hospital stay was 4.18 days (range, 3 to 12). Postoperative complications occurred in 11 patients (18.3%) and are detailed in .

DISCUSSION

Laparoscopic colorectal surgery has the potential benefits of reduced postoperative pain, faster recovery, and improved cosmesis.[6, 7] Recent data suggest that laparoscopic surgery may also promote an attenuated response of the immune system following surgery,[8,9] further augmenting the benefits of this approach. Although the effect of these advantages on improved postoperative quality of life is yet to be determined in the ongoing multi-center prospective, randomized trails, it is the impression of most laparoscopic surgeons that patients undergoing laparoscopic surgery have at least an easier postoperative course.

Laparoscopic colon and rectal surgery requires advanced laparoscopic skills and has a steep learning curve. Whereas, Schlachta et al[2] considered 30 cases as the required learning curve, Bennett et al[4] drew the line at 40 cases, and Reissman et al[5] found that more than 66 cases were required to achieve a lower complication rate. This steep learning curve may be an even greater obstacle to surgeons who were not trained in laparoscopic surgery techniques during their general surgery education and are not engaged with dedicated laparoscopic colon and rectal surgery groups, which are often based in academic medical centers.

The novel, fast and easy technique for laparoscopic-assisted colectomy described here requires a limited number of instruments and maneuvers, with intracorporeal mobilization of the colon and extracorporeal resection and anastomosis. We believe that this technique is easier to acquire, requires a shorter learning curve, and thus may be suitable for the experienced colorectal surgeon who is acquiring laparoscopic techniques. The results of our preliminary experience show conversion and complication rates comparable to those in other series of laparoscopic[10] and open[11] colorectal surgery. These results may suggest that a less steep learning curve is necessary to acquire this technique.

A few technical aspects of this technique should be emphasized. A steep tilt, as much as the patient can tolerate, is critical to the success of this procedure, as the colon is not retracted with instruments. With adequate tilt, gravity prevents the colon from falling back into the gutter, and the weight of the colon itself provides gentle traction on the peritoneal reflection attachments, allowing dissection of these structures. A dissection along anatomic planes is extremely important for safe use of this method, as the control of excessive bleeding may be more difficult using only one working port. Although our preliminary experience suggests that this fast and easy technique for laparoscopic colectomy is feasible, one should be aware of the limitations of this technique. In case of technical difficulty, such as excessive adhesions or excessive bleeding, the insertion of additional working ports or prompt conversion to laparotomy should be performed. Sound surgical judgment should be used if one is to implement these additional methods before intraoperative complications occur.

As in other surgical methods, appropriate patient selection is integral to the success of this procedure. Patients expected to have excessive intraabdominal adhesions owing to multiple abdominal surgeries or intraabdominal inflammation may be more difficult to operate on with this technique. The use of laparoscopically assisted colectomy for malignant diseases is still controversial, owing to reports of port-site metastases in patients with otherwise potentially curable disease.[11-13] As it is the declared policy of the American Society of Colon and Rectal Surgeons to perform laparoscopic surgery for colon cancer only within prospective studies,[14] the current series included only patients with benign colonic conditions. When treating malignant diseases, colonic resection with the adequate lymph node clearance is essential. It may be more difficult to perform an extracorporeal colonic resection with deep mesenteric excision through a small incision, as in laparoscopically assisted colectomy, and a larger skin incision may be required.

CONCLUSION

Our preliminary experience suggests that laparoscopically assisted colon resection for benign conditions using only 2 ports is safe and feasible, with minimal skin incisions and fast recovery. This series also suggests that this technique may be easier to learn and perform, and thus may be more suitable for experienced colorectal surgeons who are acquiring laparoscopic techniques.

Table 1.

Indications for Laparoscopically Assisted Colon Surgery

Polyps	48 (80%)
Diverticular disease	6 (10%)
Angiodysplasia	3 (5%)
Sigmoid volvulus	2 (3%)
Post polypectomy bleeding	1 (2%)

Table 2.

Postoperative Complications

Anastomotic leak	1 (1.6%)
Anastomotic bleeding	1 (1.6%)
Wound infection	2 (3.3%)
Ileus	3 (3.3%)
Urinary retention	3 (3.3%)
Line sepsis	1 (1.6%)
Total	11 (18.3%)