World Journal of Colorectal Surgery

Transcription

1 World Journal of Colorectal Surgery Volume 3, Issue Article 3 Total Colectomy Hand-assisted Laparoscopy Benefits: A Single-Center 8-year Experience Marisa Domingues Santos Ana Cristina Silva Carlos Jorge Nogueira Hospital de Santo António, Porto, Portugal, marisadsantos@gmail.com Hospital de Santo António, Porto, Portugal, ana cris f silva@hotmail.com Hospital de Santo António, Porto, Portugal, carlosnogueira21@yahoo.com Copyright c 213 The Berkeley Electronic Press. All rights reserved.

2 Total Colectomy Hand-assisted Laparoscopy Benefits: A Single-Center 8-year Experience Marisa Domingues Santos, Ana Cristina Silva, and Carlos Jorge Nogueira Abstract INTRODUCTION: In our surgical unit, colorectal laparoscopic procedures are being performed since The hand assisted approach has been introduced more recently in selected patients. OBJECTIVE: To evaluate the results obtained for hand-assisted total colectomies in our surgical unit. MATERIAL AND METHODS: Prospective analysis of a series of patients undergoing hand-assisted total colectomies, between October 23 and September 211. All surgeries were performed by a single surgeon. Thirty-two patients underwent an hand-assisted total colectomy; of those, 4 were associated with partial/total proctectomy with J-pouch and protection ileostomy. Among the patients 13 were women and 19 men, with an average age of 46.8 years (between 17 and 78 years). The indications for surgery were: Attenuated Familial Adenomatous Polyposis; MYH-associated polyposis (2); Hereditary nonpolyposis colorectal cancer (Lynch syndrome); synchronous colorectal cancer (7); colonic inertia (4); and familial adenomatous polyposis (1). Results were compared to those obtained, during the same period of time, with the same type of elective surgery performed by laparoscopy and open surgery in our unit. Kruskal-Wallis nonparametric test and the chi-square test were applied with a significance level of.5. RESULTS: The hand-assisted total colectomy allowed a decrease of 11 min (p<.1) in surgery length when compared with its regular laparoscopic counterpart. On the other hand, hand-assisted total colectomy led to a reduction in hospital stay of 4 days (p<.1) when compared with the open approach. An average shorter hospital stay of 1 day was found on the hand-assisted surgery compared to classic laparoscopic procedure, however this difference had no statistical significance (p<.7).

3 No statistically valid differences were found regarding morbidity of the three routes of approach (p=.31). KEYWORDS: Hand-assisted laparoscopic surgery (HALS), hand-assisted total colectomy, minimally invasive colorectal surgery, total colectomy, colorectal surgery.

4 Santos et al.: Total Colectomy Hand-assisted Laparoscopy Benefits: A Single- 1 INTRODUCTION Hand-assisted surgery in colorectal surgery has been widely used in North American centers. It is used because it can provide advantages when compared to laparoscopic surgery: a lower learning curve, a shorter surgery length, and a lower rate of conversion [1, 2]. These aspects seem to be more evident when it comes to more complex colorectal surgery, in obese patients or in surgery performed on adverse grounds.[1, 3, 4] On the other hand, there are published studies in which this surgery provides similar results to the regular laparoscopic procedure regarding postoperative hospital stay, and also the morbidity and mortality in the short and medium terms.[5-7] In oncologic situations it s also not proven that this way is less effective than the regular laparoscopic colon surgery or the conventional way.[2, 8] In this perspective we intend to analyze the results obtained in our service using hand-assisted approach in total colectomy and restorative proctocolectomy. MATERIAL AND METHODS PATIENTS A prospective analysis of a series of patients undergoing hand- assisted surgery for total colectomy, between October 23 and September 211 was carried out. Thirty-two patients underwent hand-assisted total colectomy; of these, 4 were associated with partial/total proctectomy with J-pouch and protection ileostomy (in 2 of 4): 13 women and 19 men, with an average age of 46.8 years (between 17 and 78 years). Produced by The Berkeley Electronic Press, 213

5 2 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [213], Art. 3 The patients characteristics (sex, age, surgical indication, American Society of Anesthesiology score), surgical procedures and results were recorded prospectively in a database. Eight patients had a previous abdominal surgery: right colectomy (1), enterectomy (1), cesarean (3) and apendicetomy (3). Fifteen were classified as ASA I (anesthetic risk according to the score established by the American Society of Anesthesiology), and seventeen as ASA II. None of the patients were submitted to neoadjuvant radiochemotherapy. The indications for surgery are referred in table 1. The inclusion criteria were based on the complexity or malignancy of these pathologies. Selected patients for hand-assisted approach presented less complex benign disease and neoplasms with small dimensions. We included the following pathologies: familial adenomatous polyposis attenuated (18), MYH polyposis (2), familial adenomatous polyposis (1), synchronous colon cancer (2), colon cancer in Lynch syndrome (5), and colonic inertia (4). All hand-assisted surgical procedures were performed by a single surgeon. The surgeries performed electively are shown in table 2. In tables 1 and 3, are represented the patients characteristics and the intra-operative parameters in total colectomy or restorative proctocolectomy (open, laparoscopic and hand assisted ) in the same period of time. The total colo-rectal surgeries carried out during that period of time were 1458, of which 543 were laparoscopic, 51 "handassisted", and 964 by open surgery The non-parametric Kruskal-Wallis test was used in the comparative analysis between the various surgeries and when differences were found, the Mann-Whitney U test was used as post hoc test. It was adopted the value of.5 as the significance level. All analyses were performed using SPSS version 17.

6 Santos et al.: Total Colectomy Hand-assisted Laparoscopy Benefits: A Single- 3 Surgical Technique Under general anesthesia, patients are positioned in the modified lithotomy position with their legs apart. The abdominal cavity is accessed by means of a suprapubic incision or alternatively by a 6.5 cm incision in the lower right quadrant. In one of these possible assistance incisions we fit the hand device (LapDisc and more recently Dextrus Ethicon Endosurgery, Cincinnati). Two other trocars of 1 mm are also placed: one for the optics and the other for the right hand trocart (fig.1). Sometimes, especially when associated with a total colectomy a proctectomy may be necessary and an additional 1 mm trocart is placed in the patient s upper right quadrant (fig1 and 3). The pneumoperitoneum is achieved inflating carbon dioxide by one of the trocarts. To perform the procedure an average pressure of 12 mmhg and a laparoscope with 3º optics is used. The portion of the intra-abdominal procedure is performed by laparoscopic surgery with the help of the non-dominant hand through LapDisc (Fig 1-2). When a proctectomy is associated, we perform it with laparoscopic procedure using the additional port in the right quadrant and applying a support 1 mm trocart in Lapdisc (Fig 3). The vascular pedicles are ligated early in the procedure using vascular clips, the colon is mobilized and the Ultracision Harmonic scalpel (Ethicon Endosurgery, Cincinnati) is used for the dissection (retroperitoneal dissection from medial to lateral), and section of the mesentery and omentum. Once the colon is fully mobilized and exteriorized through the LapDisc, the next steps of the procedure including the proximal and distal intestine section, the eventual ileal pouch confection and the ileo-rectal or ileo-anal anastomosis - are performed under direct vision using the LapDisc as wound retractor and wall protector. Produced by The Berkeley Electronic Press, 213

7 4 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [213], Art. 3 The anastomosis and the ileal pouch (performed in 4 cases) are made either with hand or with the help of automatic suture machines, as usual when by open surgery approach. Once the anastomosis was completed, the wall and port incisions are closed with a traditional technique. Other details and technique illustration are discriminated in a previously published article.[9] Figures 1, 2 and 3 show some aspects of the surgical technique. RESULTS The results obtained with the different surgery techniques are presented in Table 2. With the "hand-assisted" surgery technique it was easy to maintain the pneumoperitoneum, and conversion wasn t needed. The average time of surgery was 236 min (15 to 33). There was no significant loss of blood and there were no intraoperative complications. The results in the immediate postoperative period are listed in table 3. In "handassisted" surgery, the return of bowel function took place, on average, in 2.9 days (1 to 6) and the resumption of oral intake occurred at 4.4 days (2 to 15). There were major post-operative complications in 5 patients (15.6 %): Three cases of transient ileus requiring the placement of nasogastric tube; a case of pelvic abscess treated with percutaneous drainage and antibiotics; and a case of intraabdominal infection leading to surgical reintervention with abdominal cavity washing by laparoscopy and antibiotic therapy. There was no mortality in this series. The median postoperative hospital stay was 6 days (3 to 19). In documented cases of colon cancer; the average number of dissected ganglia was 2.

8 Santos et al.: Total Colectomy Hand-assisted Laparoscopy Benefits: A Single- 5 The comparison of the results regarding total colectomy surgeries for the three types of approach, carried out in our unit during the same period of time, is shown in Tables 1-3. The "hand-assisted" surgery length is shorter in about 11 min (p<.1) when compared with the regular laparoscopic surgery duration times. No significant differences were found between the operative times of the "handassisted" surgery and open surgery (p=.49). Regarding the hospital stay in the postoperative period, and comparing the "hand-assisted" technique with open way surgery, there was a stay shortening on average of 4 days (p<.1). This difference is not significant when the comparison is made between the "handassisted" surgery and the conventional laparoscopic surgery DISCUSSION Laparoscopic colectomy isn t widely used yet, despite the numerous benefits for the patients 3. This approach is technically demanding and the learning curve is slow. The "hand-assisted" approach allows the introduction of the hand inside the abdomen giving a useful aid in exposure and dissection.[1] The maintenance of the tactile sensation and the possibility of allowing a delicate and effective large quantity tissue retraction, provide the general surgeons a way to perform a broad spectrum of colorectal surgeries with a minimally invasive approach, with security, and expected benefits.[11] These aspects are particularly attractive in the more complex colorectal procedures.[3, 4, 12, 13] Several studies have demonstrated the applicability of this technique in advanced laparoscopic surgery with promising results.[1, 14-16] Produced by The Berkeley Electronic Press, 213

9 6 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [213], Art. 3 The so called "pure" laparoscopic surgery is rarely performed. The colorectal laparoscopic surgery usually requires an abdominal incision to remove the surgical specimen. The parietal insult caused by an incision marginally higher in assistance "by hand" is within the same order of magnitude and the immunological changes caused by this type of approach are identical to those found on regular laparoscopic technique.[17] Differences in terms of ileum at the postoperative period were neglegtable when these two ways of approach are compared.[18-19] Parameters such as time of surgery, incision extension for the assistance, recovery of intestinal transit and the hospital stay time seem to be comparable between the colorectal "hand-assisted" approach and the regular laparoscopic surgery.[18-2] The conversion rate is lower with "hand-assisted" approach when compared to regular laparoscopy, and that fact, by itself, may provide morbidity and mortality decrease, with reduction in hospitalization time, lowering the procedure costs. The direct hand aid is particularly useful in situations with present inflammatory phenomena such as Crohn's disease and acute diverticulitis; the use of the hand gives tactile feeling allowing lightweight traction of the colon and mesentery, both with inflammatory signs and brittle in this cases.[12, 16, 2-21] It can also be of added value in the surgery of obese patients and in the more time consuming procedures. In these more complex situations the decrease in the operative time becomes particularly evident, as well as the conversion rate reduction.[13,18-19]. It should also be noted, that in recent studies, the oncologic results obtained in short and medium term are stackable with those obtained by laparoscopy or conventional surgeries.[2, 8].

10 Santos et al.: Total Colectomy Hand-assisted Laparoscopy Benefits: A Single- 7 However, and although the "hand-assisted" surgery presents several advantages, these can disappear in the presence of a small abdominal cavity and a surgeon s big hand. Also, in easier procedures, the advantages may not be obvious. For this reason and in order to be able to achieve the maximum yield of the technique, an appropriate selection of patients and a meticulous planning about the surgery technique is necessary. In our experience the use of the "hand-assisted" approach, can be a real alternative to regular laparoscopy and even preferable, particularly in long colon surgeries.[18-19] The "hand-assisted" approach makes extensive procedures possible, such as total colectomy and total reconstructive proctocolectomy with good results. In our series, the results obtained with this technique were shown to be safe and without intra-operative complications. There was no need for conversion. The operative time was identical to other series [12, 2]. The average time of recovery colonic transit, (2.9 versus 3.5 days) and the hospital stay after surgery, was also identical to those in laparoscopic surgeries (7.2 versus 8.9 days).[18-2] There seems to be enough statistical evidence capable of supporting the fact that the "hand-assisted" approach in total colectomy, may shorten the surgical time - usually a long one - and at the same time allow a shorter hospital stay than the classic laparoscopic approach. Nevertheless the design of this study could show a bias due to the fact that all the hand-assisted" surgeries have been performed by a single surgeon; unlike those performed by open or regular laparoscopic that were performed by several; also patients selection had a preponderant role in the results obtained. However the use of the "handassisted" approach can provide some advantages in more extensive colorectal procedures. Produced by The Berkeley Electronic Press, 213

11 8 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [213], Art. 3 CONCLUSIONS "Hand-assisted" total colectomy provides the advantages of the well known laparoscopic assisted surgery: in particular the shortest hospital stay when compared with open surgery. Also, when compared with classic laparoscopic surgery, it reduces the operation time while providing the additional benefit of the "hand" help at the surgical procedure.

12 Santos et al.: Total Colectomy Hand-assisted Laparoscopy Benefits: A Single- 9 REFERENCES: 1. Marcello, P W, Fleshman J W, Milsom J W, et al (28) Hand-assisted laparoscopic vs. laparoscopic colorectal surgery: a multicenter, prospective, randomized trial. Dis Colon Rectum 51(6): ; discussion Pendlimari R, Holubar S D, Pattan-Arun J, et al (21) Hand-assisted laparoscopic colon and rectal cancer surgery: feasibility, short-term, and oncological outcomes. Surgery 148(2): Cima, R R, Pattana-arun J, Larson D W,et al (28) Experience with 969 minimal access colectomies: the role of hand-assisted laparoscopy in expanding minimally invasive surgery for complex colectomies. J Am Coll Surg 26(5): 946-5; discussion Bordeianou L and R Hodin (29) Total proctocolectomy with ileoanal J-pouch reconstruction utilizing the hand-assisted laparoscopic approach. J Gastrointest Surg 13(12): Sonoda T, Pandey S, Trencheva K, et al., Longterm complications of handassisted versus laparoscopic colectomy. J Am Coll Surg, (1): Ozturk E, Kiran R P, Geisler D P, et al (29) Hand-assisted laparoscopic colectomy: benefits of laparoscopic colectomy at no extra cost. J Am Coll Surg 29(2): Martel G, Boushey R P, and Marcello P W (28) Hand-assisted laparoscopic colorectal surgery: an evidence-based review. Minerva Chir 63(5): Larson D W, Boostrom S Y, Cima R R, et al (21) Laparoscopic surgery for rectal cancer: short-term benefits and oncologic outcomes using more than one technique. Tech Coloproctol 14(2): Santos M D, Silva D and Nogueira C (29) Hand assisted total colectomy: a safe alternative. European Surgery 41/3: Marcello P W (24) Hand-assisted laparoscopic colectomy: a helping hand? Clin Colon Rectal Surg 17(2): Paraskeva P A, Aziz O, and Darzi A (25) Laparoscopic surgery for colon cancer. Surg Clin North Am 85(1): Lee S W, Yoo J, Dujovny N, et al (26) Laparoscopic vs. hand-assisted laparoscopic sigmoidectomy for diverticulitis. Dis Colon Rectum 49(4): Rivadeneira D E, Marcello P W, Roberts P L, et al (24) Benefits of handassisted laparoscopic restorative proctocolectomy: a comparative study. Dis Colon Rectum 47(8): Martel G and Boushey R P (26) Laparoscopic colon surgery: past, present and future. Surg Clin North Am 86(4): Pietrabissa A, Moretto C, Carobbi A, et al (22) Hand-assisted laparoscopic low anterior resection: initial experience with a new procedure. Surg Endosc 16(3): Chang Y J, Marcello P W, Rusin L C, et al (25) Hand-assisted laparoscopic sigmoid colectomy: helping hand or hindrance? Surg Endosc 19(5): Novitsky Y W, Czerniach D R, Kaban G K, et al (26) Immunologic effects of hand-assisted surgery on peritoneal macrophages: comparison to open and standard laparoscopic approaches. Surgery 139(1): Produced by The Berkeley Electronic Press, 213

13 1 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [213], Art Nakajima K, Lee S W, Cocilovo C, et al (24) Hand-assisted laparoscopic colorectal surgery using GelPort. Surg Endosc 18(1): Nakajima K, Lee S W, Cocilovo C, et al (24) Laparoscopic total colectomy: hand-assisted vs standard technique. Surg Endosc 18(4): Anderson J, Luchtefeld M, Dujovny N, et al (27) A comparison of laparoscopic, hand-assist and open sigmoid resection in the treatment of diverticular disease. Am J Surg 193(3): 4-3; discussion Wilhelm T J, Refeidi A, Palma P, et al (26) Hand-assisted laparoscopic sigmoid resection for diverticular disease: 1 consecutive cases. Surg Endosc 2(3):

14 Santos et al.: Total Colectomy Hand-assisted Laparoscopy Benefits: A Single- 11 Figure 1- total colectomy surgical technique ilustration (1) Produced by The Berkeley Electronic Press, 213

15 12 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [213], Art. 3 Figure 2 total colectomy surgical techique ilustration (2)

16 Santos et al.: Total Colectomy Hand-assisted Laparoscopy Benefits: A Single- 13 Figure 3 Restorative protocolectomy surgical technique ilustration Produced by The Berkeley Electronic Press, 213

17 14 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [213], Art. 3 Table 1 Patient characteristics Sex Male Female Hand assisted (n=32) Open (n=58) Laparoscopic (n=23) 1 13 Age Mean (min; max) 46.8 (17;78) 52.8 (17;86) 39.3 (17;77) Surgical indications Familial adenomatous polyposis Colon cancer in Lynch syndrome Colonic inertia Inflammatory bowel disease Synchronous colon cancer 1+2ª ª ASA I II III ªFamilial adenomatous polyposis with rectal sparing or attenuated familial adenomatous polyposis or MYH

18 Santos et al.: Total Colectomy Hand-assisted Laparoscopy Benefits: A Single- 15 Table 2 Intra-operative parameters Surgical procedures Total colectomy Total colectomy and partial protectomy with a ileal pouch Total colectomy with other procedures Restorative proctocolectomy Proctocolectomy with brooke ileostomy Hand assisted (n=32) Open (n=58) Laparoscopic (n=23) Anastomosis Manual Stapled Without (ileostomy) Duration of operation* Mean (minutes) Median (minutes) (min;max) Interquartile range (15:33) (15;34) (28;45) 49 Length of the incision for the placement of LapDisc Mean (cm) (min;max) 6.5 (6;7.5) 4.5 (4;6) Conversion (thecnical problems) 3 Intra-operative complications 1 * Statistical analysis on Duration of operation : - Kruskal Wallis test p<.1 -Mann-Whitney test: Hand assisted vs Open p =.49 Hand-assisted vs Laparoscopic p<.1 Produced by The Berkeley Electronic Press, 213

19 16 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [213], Art. 3 Table 3 Immediate clinical outcome Return of bowel function Mean (days) (min;max) Hand assisted (n=32) 2.9 (1;6) Open (n=58) 5.1 (2;8) Laparoscopic (n=23) 3.5 (1;6) Resumption of oral intake Mean (days) (min;max) 4.4 (2;15) 8.1 (3;22) 7.6 (3;25) Major post-operative complications Transient ileus Intra-abdominal infection Pelvic abscess Anastomotic leakage Total (n;%) Reoperation (n;%) Thirty-day post-operative mortality (15.6%) 1(3.1%) (22.4%) 5(8:6%) (17.3%) 2(8.6%) Hospital post-operative stay* Mean (days) Median (days) (min;max) Interquartile range (3;19) (3;28) (4;28) 3 TMN stages for the cancers (n) T1-2NM T3NM T3-4N1M * Statistical analysis on Hospital post-operative stay : - Kruskal Wallis test p<.1 -Mann-Whitney test: Hand assisted vs Laparoscopic p =.7 Hand-assisted vs Open p<.1

20 Santos et al.: Total Colectomy Hand-assisted Laparoscopy Benefits: A Single- 17 Produced by The Berkeley Electronic Press, 213