|Year : 2016 | Volume
| Issue : 2 | Page : 179-186
Laparoscopic colectomy with intracorporeal anastomosis using endostaplers: Surgical technique description
Marilee Carballo1, Ellyn Smith1, WT Hillman Terzian1, Samuel Schadt2, Stanislaw P Stawicki1, Anthony Dippolito1
1 Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
2 Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
|Date of Submission||16-Jul-2016|
|Date of Acceptance||01-Aug-2016|
|Date of Web Publication||28-Dec-2016|
Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania 18015
Source of Support: None, Conflict of Interest: None
Background and Objectives: Published evidence suggests that colorectal laparoscopic surgery is similar to conventional open surgery in terms of oncological safety. Here, we describe our experience performing a laparoscopic right hemicolectomy with an intracorporeal anastomosis using endostaplers (LRH-IAE).
Methods: A retrospective review of patients who underwent LRH-IAE from February 2008 to May 2012 was performed. Demographic, intraoperative, and postoperative data were collected. Key end-points included open conversion rates, adequacy of oncologic resection, and 30-day morbidity and mortality.
Results: A total of 27 LRH-IAE procedures were performed during the study period. Median patient age was 74 years, with 12 females and 15 males. Most common indications for surgery included colonic mass (74.1%, n = 20) and incomplete polypectomy (14.8%, n = 4). The median American Society of Anesthesiologists score was 3 (interquartile range [IQR]: 2–3) and median operative time was 312 min (IQR: 200–420 min). There were no conversions to open laparotomy. Surgical margins were negative in all patients, with a median of 17 lymph nodes examined per specimen. Nine patients experienced postoperative morbidity, including cardiac (7.4%, n = 2), pulmonary (18.5%, n = 5), and abdominal (22.2%, n = 6) complications. Abdominal complications included ileus (3.7%, n = 1), perforated viscus/leak (7.4%, n = 2), anastomotic stricture (3.8%, n = 1), and an incisional hernia (7.4%, n = 2). All-cause 30-day mortality was 11.1% (3/27). The median length of stay was 5 days (range: 3–42 days).
Conclusion: This report shows that LRH-IAE in high-risk surgical population is characterized by an acceptable risk-benefit profile. LRH-IAE offers the advantages of less tissue manipulation and adheres to established oncological principles.
The following core competencies are addressed in this article: Medical knowledge and patient care.
Keywords: Colectomy, colonic mass, colorectal surgery, laparoscopy, minimally-invasive surgery
|How to cite this article:|
Carballo M, Smith E, Hillman Terzian W T, Schadt S, Stawicki SP, Dippolito A. Laparoscopic colectomy with intracorporeal anastomosis using endostaplers: Surgical technique description. Int J Acad Med 2016;2:179-86
|How to cite this URL:|
Carballo M, Smith E, Hillman Terzian W T, Schadt S, Stawicki SP, Dippolito A. Laparoscopic colectomy with intracorporeal anastomosis using endostaplers: Surgical technique description. Int J Acad Med [serial online] 2016 [cited 2022 Jan 19];2:179-86. Available from: https://www.ijam-web.org/text.asp?2016/2/2/179/196878
| Introduction|| |
The goal of reducing surgical complications prompted the development of less invasive techniques in colorectal surgery. Potential advantages of laparoscopy over open surgery have been well-documented, including better visualization with surgical field magnification, more precise hemostasis, the ability to operate in challenging anatomic areas without the need for extensive abdominal wall incision(s), as well as less severe immune and physiologic disruption.,,,,,, Many right hemicolectomies are performed using hybrid approaches where the affected bowel segment is resected intracorporeally, often using a hand-port device, followed by an extracorporeal anastomosis creation., A refinement of this approach employs endostaplers to perform a completely intracorporeal anastomosis., In addition to a smaller incision and associated clinical benefits (e.g., lower risk of surgical wound infection and better postoperative pain profile), potential advantages of such intracorporeal anastomosis include the reduction of intestinal kinking, the flexibility of choosing different routes for specimen extraction, and less tissue trauma compared to an extracorporeal anastomosis.,, Laparoscopic surgery is similar to conventional open approaches in terms of oncological safety., 7, ,, However, many questions remain in this important area, especially regarding complication rates related to intracorporeal versus extracorporeal anastomotic approaches.,, The aim of the study is to describe both technical aspects and clinical outcomes of our single-institution experience performing an entirely laparoscopic right hemicolectomy with an intracorporeal anastomosis using endostaplers (LRH-IAE) alone. This preliminary report focuses on the safety, efficacy, and technical feasibility of LRH-IAE.
| Methods|| |
Settings and participants
A retrospective medical record review of patients who underwent LRH-IAE from February 2008 to May 2012 was performed. All reported LRH-IAE procedures took place at three teaching hospitals in the Greater Lehigh Valley region, and all operations were performed by a single surgeon (AD) with the aid of a general surgery resident, a surgical fellow, or a surgical physician assistant. Indications for hemicolectomy included colonic mass, incomplete polypectomy during colonoscopy, and inflammatory bowel disease/other. Clinical sources of data included hospital charts and outpatient office medical records.
Collected variables include age, gender, body mass index, comorbid medical conditions, the American Society of Anesthesiologists (ASA) score, indication for hemicolectomy, and information regarding any previous abdominal surgery. Intraoperative data collected included operative time (in minutes), estimated blood loss (mL), conversion to open laparotomy, and intraoperative complications. Collected postoperative data included: time to resumption of oral intake, time to first flatus or bowel movement, length of hospital stay, 30-day operative morbidity and mortality, surgical pathology findings, number of lymph nodes harvested, readmissions within 30 days, and reoperation rates.
Preoperative preparation and procedures
Before surgery, all patients included in this series underwent standardized bowel preparation using polyglycolic acid. For surgical planning purposes, all patients in our series had a preprocedure colonoscopy with India ink applied to any surgically relevant colonic site(s), as appropriate. Before incision, all patients were given prophylactic antibiotics (cefazolin and metronidazole, with levofloxacin used in patients allergic to cefazolin). Bilateral lower extremity sequential compression devices were placed before induction of anesthesia. Postoperatively, pain control was achieved primarily using a combination of intravenous opioids, with or without patient controlled analgesia devices (e.g., pain management was not standardized across the study group).
Schematic representation of the entire surgical process is shown in [Figure 1]. A synopsis of key procedural steps now follows.
|Figure 1: Step-wise depiction of the operative technique employed by our surgical team: (a) Trocar placement; (b) resection of involved bowel; (c) stapled ends of the bowel are shown, with resected specimen placed above the liver for later retrieval (not shown); (d and e) suspending sutures are placed in both proximal and distal anastomotic bowel segments; (f and g) both proximal and distal bowel ends are held in place using suspending sutures; (h and i) after enterotomies are made in both proximal and distal bowel, two consecutive intraluminal staplings are performed to secure adequate anastomotic segment length; (j) side-to-side stapled anastomosis is created; (k) transverse stapling is performed to complete the anastomosis; (l and m) horizontal and vertical side views of newly created anastomosis; (n) terminal ends of the postanastomotic bowel suspended against the anterior abdominal wall; (o-q) sequential removal of both the terminal ends of the postanastomotic bowel and the surgical specimen (shown above the liver) via the umbilical 15-mm port|
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Placement of ports: The patient is placed in the Lloyd-Davies position using a bean bag. Once the abdomen is prepped and draped, four ports are placed: A 15-mm port at the umbilicus using the open Hasson Technique, a 12-mm port in the right upper quadrant, a 12-mm port in the left lower quadrant, and a 5-mm port in the left upper quadrant.
Isolation of Ileocolic Pedicle via “medial to lateral technique:” The patient is placed in Trendelenburg position and rotated toward the left to assist in retraction of the small bowel; the right colon is taken down in a medial-to-lateral fashion. A window is made in the mesentery of the right colon at the ileocolic pedicle, and the right ureter is visualized. The duodenum is identified and retracted down and away from the operative field. The ileocolic vessels are then circumferentially mobilized and ligated.
Dissection of middle colic vessels: The hepatocolic and gastrocolic ligaments are subsequently mobilized and separated from their attachments to the antimesenteric colonic wall. The right branch of the middle colic artery is then identified within the mesocolon, isolated, and divided.
Mobilization and resection of ileum and right colon: The lateral peritoneal colonic attachments are divided. At this point, the terminal ileum and the proximal transverse colon are each transected using the endoscopic stapler, completion of mesenteric division is also performed, and the specimen is placed above the liver for retrieval at a later time.
Creation of the anastomosis: The transverse staple lines of the distal ileum and proximal end of the remaining colon are secured and stabilized using suspensory sutures placed through the anterior abdominal wall. Using an introducer needle, a 2-0 nylon or prolene suture is passed through the abdominal wall in the right upper quadrant inferior to the right upper quadrant trocar. The suspensory suture is then passed through this staple line of the ileum and then back out through the abdominal wall. The suture loop is then secured externally with a hemostat. Similarly, the second suture is placed superior to the right upper quadrant trocar to secure the proximal end of the remaining colon. Next, enterotomies are made through the staple lines of the ileum and transverse colon. An endoscopic stapler is then passed through the right upper quadrant port site, and a side-to-side anastomosis is constructed while the bowel is steadied using the suspensory sutures. If needed, the endoscopic stapler is then reloaded and fired for the second time to ensure sufficient anastomotic length. The stapler is reloaded and passed through the left lower quadrant port and fired transversely to complete the anastomosis. The mesenteric defect is usually not closed. The resected bowel is placed in an endoscopic retrieval device and removed through the umbilical site. The anastomotic fragments (i.e., the transected “peripheral tails” of the excised anastomotic staple line) are then similarly removed.
Completion of the operative procedure: The abdomen is thoroughly inspected and irrigated as appropriate. This is followed by the removal of any surgical instruments and suture materials. All anatomic structures are returned to their natural configuration. Finally, laparoscopic ports are removed under direct vision, and all fascial incisions >10 mm in length formally closed with suture.
Continuous data were reported as medians with associated range and interquartile range (IQR). Categorical data were reported as frequencies. Descriptive statistics were obtained using MedCalc for Windows, version 184.108.40.206 (MedCalc Software, Mariakerke, Belgium). Comparisons of operative duration, intravenous fluid administration, intraoperative urine output, and blood loss between “early” (e.g., initial 14) and “later” (e.g., final 13) cases in this series utilized Mann–Whitney U-test, with statistical significance set at alpha < 0.05. This study was approved by our Institutional Review Board.
| Results|| |
At total of 27 LRH-IAE procedures were performed at three hospitals during the study period. Median patient age was 74 years (IQR: 63–83 years). There were 12 females (44.4%) and 15 males (55.6%). The median ASA score was 3 (IQR 2–3), and the median number of preexisting conditions was 8 (IQR: 4–10), highlighting the presence of severe systemic disease and significant comorbidity burden in this sample of patients. Fifteen patients (55.6%) had prior abdominal surgery. Three patients (11.1%) received blood products either intraoperatively or in the initial 24 h postoperative period. [Table 1] lists demographic information and surgical indications for study group. Most patients (20/27 or 74.1%) underwent LRH-IAE for removal of a colonic mass.
Summary of key intraoperative parameters is provided in [Table 2]. Median operative time was 312 min (IQR: 200–420 min). Of note, there was a statistically significant difference between the initial 14 cases (median 387 min, IQR: 295–473 min) and the final 13 cases (median 302 min, IQR: 278–387 min) in terms of total operative time (P< 0.04). Median intraoperative blood loss was 100 mL (IQR: 50–220 mL), intravenous fluid administered was 3053 mL (IQR: 1980–4200 mL), and median urine output was 300 mL (IQR: 170–450 mL). There were no differences between the initial 14 cases and the final 13 cases in terms of blood loss, intravenous fluid use, or median urine output. No conversions to open laparotomy were required. Likewise, no intraoperative complications were recorded during index resection procedures in this series.
Median time to oral intake resumption (either clear liquids or regular diet) was postoperative day (POD) #1 [IQR: 1–2 days, [Table 3]. Seven patients (25.9%) required return to “nothing by mouth” status by POD #2 (IQR: 1–4 days; range: 1–6 days). Median time to return of bowel function was POD #2 (IQR: 2–3 days). The median length of stay was 5 days (IQR: 2–8; range 3–42 days).
Pathology and oncologic considerations
When evaluating pathology findings, the median number of lymph nodes per specimen was 17 (range: 12–22). Final pathology revealed malignancy in 16/27 (59%) of cases and benign disease in the remaining 11/27 (41%) of cases. The summary of general pathology findings is provided in [Table 3]. Proximal and distal surgical margins were negative in all instances involving malignancy.
Morbidity and mortality
There were 17 postoperative complications involving 9 (33.3%) patients [Table 4]. Atrial fibrillation occurred in 2 cases (7.4%). Pulmonary complications included pulmonary embolism (7.4%, n = 2) and respiratory failure (7.4%, n = 2). Abdominal complications included ileus (3.7%, n = 1), perforated viscus/leak (7.4%, n = 2), anastomotic stricture (3.7%, n = 1), nonhealing infected wound (3.7%, n = 1), and an incisional hernia (7.4%, n = 2). Acute kidney injury was seen in 4 patients (14.8%). A total of 5 (18.5%) patients required readmission, 1 for postoperative dehydration and an acute kidney injury, and 4 for reoperation (1 anastomotic leak on POD #17, 1 bowel obstruction, and 2 for incisional hernia). There were three deaths, resulting in all-cause 30-day mortality of 11.1% (3/27). Two deaths were due to sepsis, whereas one mortality occurred after withdrawal of care was instituted based on advance directives.
| Discussion|| |
The most commonly utilized technique for the creation of an anastomosis during a laparoscopic right hemicolectomy (LRH) remains the extracorporeal, stapled ileocolic anastomosis. However, the intracorporeal approach may produce equivalent or superior results. Our early experience corroborates previous reports showing that LRH-IAE produces clinical outcomes comparable to those of LRH with extracorporeal anastomosis.,, We also demonstrate the oncologic safety of this technique, including transumbilical removal of the resected bowel, adequate lymph node extraction, and the achievement of negative margins in all cases involving malignancy.
There is a paucity of published experience regarding intracorporeal ileocolic anastomoses. One of the largest series by Franklin et al. suggested that the intracorporeal technique avoids trauma related to retraction and/or undue tension on the mesentery. Both of the above problems can complicate extracorporeal anastomosis creation, especially in the morbidly obese surgical population. In fact, some surgeons exclude morbidly obese patients as candidates for laparoscopic-assisted surgery for that reason. Our experience is consistent with that of Jansen, where the entirely intracorporeal anastomotic approach eliminates the need to exteriorize a foreshortened or bulky mesentery through a small incision in a thick abdominal wall. One can also speculate that this approach may help reduce postoperative pain and surgical wound complications (e.g., infection or hernia).
The relative lack of published experience documenting the efficacy of the intracorporeal laparoscopic anastomotic technique, combined with the presence of a learning curve, deters some colorectal surgeons from adopting this approach.,, From a technical perspective, the main differentiating point of the LRH-IAE approach is the requirement for rudimentary laparoscopic suturing expertise and attaining technical comfort levels sufficient for the performance of the anastomosis using endoscopic stapling device(s). Our median operative time was 312 min – a number closer to the upper time limit reported in the literature (range: 130–340 min) and likely a reflection of the technical learning curve, for both the attending surgeon and the trainees.,,,,,, Although the current series are insufficient to establish how many operations are needed to master surgical skills required for proficiency in performing LRH-IAE, it is important to note that the median time required to complete the initial 14 cases was nearly 90 min longer than the median time required for the final 13 cases. Furthermore, none of the cases in this series required conversion to open colectomy. This compares favorably to other series, with reported conversion rates between 2% and 9%.,,,,
The technique of LRH-IAE requires opening the bowel within the peritoneal cavity. It has been shown that the intracorporeal enterotomy for anastomosis creation does not increase infectious surgical risk in both bariatric surgery (involving small bowel) and colorectal procedures (involving right- and left-sided colonic resections)., In the current LRH-IAE technique, using suspensory sutures to secure and elevate the bowel as the enterotomies are made provides good control of anastomotic segments and decreases the chance of spillage of intestinal contents. A similar approach was described during single-incision laparoscopic gastrojejunostomy creation. Others suggest occluding the enterotomies with straight laparoscopic clamps. The currently described method also provides a clear anatomic view and may enhance the safety of the procedure during the anastomotic construction phase – something that may not be feasible with the extracorporeal technique.
There has been some controversy around stapling techniques, mainly due to the possible stricture formation, potential for tumor recurrence, and some concern for anastomotic leakage. Regarding tumor recurrence, a reduced incidence was demonstrated among patients in whom a stapling anastomotic technique was used, as compared to conventional suturing techniques for large bowel surgery. Bergamaschi and Arnaud  reported that a “double-stapled” intracorporeal colorectal anastomosis is both feasible and safe. Others also found that intersecting staple lines in small bowel and colonic anastomoses did not reduce anastomotic blood flow sufficiently to substantiate anecdotal concerns to the contrary. In our experience, a double-stapled side-to-side anastomosis did not result in unanticipated adverse effects, with only one patient experiencing an anastomotic leak. An important consideration while constructing the anastomosis is the meticulous inspection of the transverse staple line to ensure that the posterior bowel wall is completely incorporated. Finally, perfect hemostasis must be ensured to optimize the technical outcome.,,,,
A comprehensive review of minimally invasive surgery for colon cancer showed that laparoscopic resection is as safe and effective as the conventional open approach. The LRH-IAE technique described here conforms to the general oncologic principles, including proximal vascular ligation, complete lymphadenectomy, en bloc resection with adequate resection margins, “no touch” isolation technique, and wound protection [Figure 1]. This is corroborated by Scatizzi et al. In our series, a median of 17 lymph nodes were retrieved per specimen – a reflection of adequate oncological assessment of resected colonic segments.,, The ability to obtain a sufficient number of lymph nodes using the LRH-IAE approach is likely due to the ability to perform a high ligation without the impediments associated with the extracorporeal mesenteric ligation as previously mentioned. The LRH-IAE technique also does not extrude the bowel through the subcutaneous tissue, which may reduce the occurrence of wound infections and decrease the risk of tumor seeding. The intracorporeal procedure does reduce the ability to perform tactile identification of the lesion. To circumvent this limitation, it is important that the colonic site in question be endoscopically tattooed with India ink preoperatively, which was done in all patients with an identifiable mass/polyp in this series.
The LRH-IAE technique with specimen extraction using a retrieval bag via the umbilical port site requires a small extension of the corresponding incision. In this setting, the use of a retrieval bag has been shown to decrease the incidence of wound infections at the extended incision site and to diminish the risk of seeding of tumor cells into the abdominal cavity and/or the wound during specimen manipulation – a potential risk with an extracorporeal anastomosis., Another alternative, reported for both right hemicolectomy  and for more distal (e.g., sigmoid) resections, is the retrieval of the resected colonic segment using a natural orifice (e.g., transanal or transvaginal) route. An important consideration with the intracorporeal technique is to avoid detaching the marginal anastomotic fragments (e.g., residual bowel amputated during the stapled transverse closure of the anastomosis) from the right upper quadrant retaining sutures when placing resected tissue into the specimen bag. Because these fragments can be easily misplaced if the retrieval bag ruptures, the retaining sutures should be kept intact until the specimen is already extracorporeal.
Among other important aspects of the LRH-IAE technique are the approaches to the mesenteric defect and laparoscopic port incision closure. Given published clinical evidence,, we felt that it is relatively safe to leave the mesenteric defect open. Regarding the approach to port site closure, we routinely perform fascial closure of every laparoscopic incision >10 mm in length. Ultimately, careful patient selection, familiarity with pervious history of abdominal surgeries, adherence to surgical safety checklists, and inspecting the abdominal wall intraoperatively are all important maneuvers to minimize postoperative complications and optimize patient outcomes.,
Limitations of this report include its retrospective nature, with biases inherent to such study design. Due to the low volume of LRH-IAE procedures in our geographic area, the sample size of this study was small. However, the latter limitation was partly offset by the fact that this study only reports clinical data from one attending surgeon who is an expert in LRH-IAE, with the added benefit of uniform technical approach in all cases.
Because of the pilot nature of this report and the presence of learning curve during the early parts of our experience, we chose not to include a control group consisting of more established operative procedures. Mortality in this report (7.4% when excluding one case associated with advance directive) was higher than that reported by others (2–5%)., However, our study population was both older (74 years vs. 67–69 years) and had higher comorbidity burden compared to previous literature reports., Finally, the lack of long-term follow-up precludes accurate determination of long-term malignancy recurrences and other (surgical and nonsurgical) outcomes and complications.
| Conclusion|| |
Laparoscopic right hemicolectomy with stapled intracorporeal anastomosis can be performed safely and effectively. Benefits of this approach include smaller total incision size, with potential for improved cosmetic and postoperative pain outcomes. Of importance, LRH-IAE also provides an advantage in morbidly obese patients in whom extracorporeal anastomosis may not be feasible. Finally, the LRH-IAE approach is consistent with established oncological principles of colonic tumor resection.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]