Access the full text.
Sign up today, get DeepDyve free for 14 days.
Loading next page...
/lp/pubmed-central/lifting-of-the-colon-for-laparoscopic-assisted-colectomy-for-colon-and-b6GdBv07L4
References
References for this paper are not available at this time. We will be adding them shortly, thank you for your patience.
- Publisher
- Pubmed Central
- Copyright
- © 2004 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.
- ISSN
- 1086-8089
- eISSN
- 1938-3797
- Publisher site
- See Article on Publisher Site
Abstract
SCIENTIFIC PAPER Lifting of the Colon for Laparoscopic-Assisted Colectomy for Colon and Rectal Cancer Shoichi Fujii, MD, Hiroshi Shimada, MD, Hideyuki Ike, MD, Toshio Imada, MD, Shigeru Yamagishi, MD, Shuji Saito, MD ABSTRACT INTRODUCTION Background and Objectives: Laparoscopic-assisted co- Laparoscopic assisted colectomies (LAC) for colon and lectomy for colon and rectal cancer causes less surgical rectal cancer have recently become more common in trauma than does open colectomy. However, current Japan. This procedure minimizes surgical stress and has methods are more costly and require highly skilled staff. been recognized as acceptable treatment for colorectal In addition, the technique for lymphadenectomy has yet cancer based on long-term outcome studies and a low 1,2 to be standardized. We developed a technique that uses a complication rate. Long-term survival after LAC is simi- 3–6 nylon suture to elevate the colon. This method reduces lar to survival after conventional surgery, but it is more costs without compromising the completeness of the re- expensive in terms of surgical instruments and surgical section. staff. We have developed a colon-lifting method using a suture that requires only 2 operators and 3 trocars. This Methods: Three trocars are introduced and a 1–0 nylon technique can be performed without compromising cur- suture is passed into the abdominal cavity and through the ability. mesocolon. The colon is retracted anteriorly and is fixed by this suture to the abdominal wall. The main mesenteric vessels are under tension, and lymph node dissection is SURGICAL TECHNIQUE performed easily. This method requires only 2 surgeons, an operator, and a scopist, because the colon is fixed to The patient is placed in the lithotomy position at 15- the abdominal wall. In addition, the working space is degrees Trendelenburg. A 12-mm trocar is inserted below more stable because the colon is fixed to the abdominal the navel through a small incision and pneumoperito- wall. The procedure is relatively independent of the skill neum is created. Two additional trocars are placed of the first assistant. superior and inferior to the lesion and serve as the working ports (Figures 1 and 2). The mesocolon is Results: From April 2000 to August 2002, this method was pierced near the line of transection with dissecting performed in 52 patients. The mean number of dissected forceps. A 1– 0 nylon suture is introduced into the lower lymph nodes was 16.99.0 (range, 6 to 41). Nine patients abdominal cavity with a grasping needle (GraNee Nee- had lymph node metastases (17.3%). One patient devel- dle, R-Med, Inc., Oregon, OH, USA) and passed through oped hepatic recurrence; all patients are alive. No com- the mesocolon (Figure 3). The point of penetration of plication occurred that was related to lifting the colon. the mesocolon must be at least 10 cm from the edge of Conclusions: Using a suture to lift the colon is a useful the tumor to avoid tumor implantation (Figure 2). The method for performing laparoscopic-assisted colectomy colon is retracted anteriorly using the suture, exerting with lymphadenectomy. This method reduces the number slow and steady pressure to avoid injury to the vessels of surgical staff and the expense of the procedure. in the mesocolon. The suture is fixed to the abdominal wall by forceps. Then, traction is placed on the main Key Words: Laparoscopic-assisted colectomy, Lifting of nutrient artery (Figure 4). Lymph node dissection is colon, Trocar, Lymphadenectomy. performed easily because countertraction can be ap- plied at the point of incision. The stability of the work- Yokohama City University Medical Center Gastroenterological Center, Yokohama, ing space is achieved by fixing the colon to the abdom- Japan (Drs Fujii, Ike, Imada, Yamagishi).; Yokohama City University Medical Center, Second Department of Surgery, Yokohama, Japan (Drs Shimada, Saito). inal wall. The main nutrient vessels are divided at their Address reprint requests to: Shoichi Fujii, MD, Second Department of Surgery, origin to facilitate lymph node dissection (Figure 5). Yokohama City University School of Medicine, 3–9 Fukuura, Kanazawa-ku, Yoko- The mesocolon is dissected by medial approach. One hama 236-0004, Japan. Telephone: 81 45 787 2650, Fax: 81 45 782 9161, E-mail: port site for the trocars is enlarged, and the lesion is [email protected] removed through it. The reconstruction is intracorporal © 2004 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the Society of Laparoendoscopic Surgeons, Inc. for left-sided lesions and extracorporal for right-sided 352 JSLS (2004)8:352–355 Figure 1. Trocar sites. Right-sided lesion (A). Left-sided lesion (B). The arrow is a nylon suture. The closed circle is the lapa- roscopic port. The open circles are manipulation ports. Figure 3. The mesocolon is pierced near the line of transec- tion with dissecting forceps. A 1–0 nylon suture is inserted into the abdominal cavity and passed through the mesocolon. Arrow points to nylon suture. Figure 2. Schematic diagram showing technique for resecting a rectal cancer. The inferior mesenteric artery is divided. The autonomic nerve plexus is conserved. The sigmoid colon is lifted using the suture at least 10 cm from the edge of the tumor. RESULTS From April 2000 to August 2002, 52 laparoscopic colecto- mies were performed with this method. Thirty-one pa- lesions. This method requires only a scopist in addition tients had colon cancer in the following locations: cecum, to the operator. In some cases, an extra traction suture 2; ascending colon, 5; transverse colon, 3; descending is needed for lesions of the right colon or when the left colon, 1; and sigmoid colon, 21. Twenty-one patients had or sigmoid colon is redundant. rectal cancer, 17 in the upper rectum and 4 in the lower. One patient had rectal and sigmoid cancer. The mean INDICATIONS operative time was 27850 minutes (range, 115 to 380 LAC is indicated for colon and upper rectal cancer 5cm min). The mean blood loss was 137158 mL (range, 10 to in diameter. The documented existence of lymph node 800 mL). No operative complications were attributable to metastases preoperatively is an exclusion criterion. this technique. The disease stage of primary cancer was as JSLS (2004)8:352–355 353 Lifting of the Colon for Laparoscopic-Assisted Colectomy for Colon and Rectal Cancer, Fujii S et al. 12–15 most reports, LAC required 4 or 5 trocars. In our technique, only 3 trocar sites were needed, and one sur- geon was able to perform the laparoscopic procedure assisted only by a scopist. We selected nylon suture for the lifting tool because there are advantages in terms of med- ical costs and cosmesis; nylon is a very inexpensive tool, and wound to the abdomen is very slight. Our method saves 1 or 2 trocar implements, so the difference is 13,640 yen (about 114 US dollars) per operation. In Japan, the surgeon’s cost is inexpensive; it is about 3,500 yen (about 29 US dollars) per hour. The length of time for a laparo- scopic procedure is about 2.5 hours, so this method saves about 8,750 yen (about 73 US dollars) per operation. A similar method has been reported previously, but our method is different in that the colon is elevated using a ligature. This maneuver places the vessels in the mesoco- lon under tension and facilitates lymphadenectomy. This method allows the beginning LAC surgeon to easily un- derstand the operative anatomy. Because of suspension and fixation of the colon, the surgical field becomes sta- Figure 4. The colon is retracted anteriorly by pulling on the 1–0 ble, and the colon and mesocolon are on the same plane. nylon suture, placing traction on the main nutrient artery in the The nutritional vessel is stretched in the mesocolon. The mesocolon; lymph node dissection is easily performed near the inferior mesenteric artery (arrow). dissection line was easily placed under tension by using the grasping forceps because the colon was fixed to the abdominal wall. follows: Tis, 13; T1, 20; T2, 9; and T3, 10. The mean number of dissected lymph nodes was 16.99.0 (range, 5 Care must be taken to avoid injuring vessels when the to 41). Nine patients had lymph node metastases (17.3%). ligature is passed. The suture should be passed central to Thirty-three lesions were well-differentiated adenocarci- the mesenteric arcade. The suture should be drawn noma, 17 were moderately differentiated adenocarci- through slowly and gently to avoid vascular injury. noma, and 2 lesions were carcinoid. All patients are alive, Another concern is the risk of tumor implantation of and one patient has experienced a hepatic recurrence lymph node metastasis from the mesocolon to the abdom- during a mean follow-up of 16.08.4 months (range, 4 to inal wall. Therefore, the passed suture should be at least 33). 10 cm from the tumor. We have not encountered a lymph node metastasis that distance from the primary tumor. In DISCUSSION fact, this method seems to be more of a nontouch tech- Since LAC for colon cancer was first reported in 1991, its nique than other procedures because the colon is manip- use has increased worldwide. One long-term follow-up ulated only at points far from the cancer. study of LAC for stage 3 colon cancer reported results comparable to those of open colectomy (OC). The most Concerning the length of operation, the mean time was recent study was a randomized trial comparing LAC and 27850 minutes. It was slightly longer than open surgery. OC. This study found that LAC was superior to OC in But the learning curve has become shorter lately; it was terms of morbidity, length of hospital stay, incidence of about 180 minutes for colon cancer and 240 minutes for recurrence, and cancer-related survival. In economic rectal cancer in the last 10 cases. We performed 80 tradi- 9,10 11 studies of diverticular disease and cancer, the total tional laparoscopic procedures that required 4 or 5 ports hospital costs were similar to or less than those for LAC and 3 surgical personnel between 1993 and 2001. The than for OC, although the operating room charges were mean time of all cases was 33675 minutes. From 2000, it greater for LAC due to the need for many disposable has been 29041 minutes in the last 25 cases. So, the time items. Therefore, reducing the amount of instrumentation of our lifting method is the same as that of the traditional will increase LAC’s attractiveness as a surgical option. In laparoscopic method. 354 JSLS (2004)8:352–355 Figure 5. Lymphadenectomy. Exposure (A). Clipping (B). Division of the inferior mesenteric artery (C). 7. Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive co- A unique advantage of this method is that the operator is lon cancer (laparoscopic colectomy). Surg Laparosc Endosc. much less dependent on the assistant’s laparoscopic skills, 1991;1(3):144–150. giving the surgeon greater control over the operation. It is likely that the introduction of robotics to handle the lap- 8. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparo- aroscope will make it possible for a single operator to scopic assisted colectomy versus open colectomy for treatment perform this procedure in the future. of non-metastatic colon cancer: a randomized trial. Lancet. 2002; 359(29):2224–2229. CONCLUSION 9. Liberman MA, Phillips EH, Carroll BJ, Fallas M, Rosenthal R. Laparoscopic colectomy vs. traditional colectomy for diverticu- Lifting the colon using a ligature is a useful technique for litis. Outcome and costs. Surg Endosc. 1996;10(1):15–18. performing LAC with lymph node dissection. This method reduces the surgical staff and the amount of instrumentation. 10. Senagore AJ, Duepree HJ, Delaney CP, Dissanaike S, Brady KM, Fazio VW. Cost structure of laparoscopic and open sigmoid References: colectomy for diverticular disease: similarities and differences. Dis Colon Rectum. 2002;45(4):485–490. 1. Franklin ME, Kazantsec GB, Abrego D, Diaz-E JA, Balli J, Glass JL. Laparoscopic surgery for stage III colon cancer: long- 11. Bouvet M, Mansfield PF, Skibber JM, et al. Clinical, patho- term follow-up. Surg Endosc. 2000;14(7):312–316. logic, and economic parameters of laparoscopic colon resection for cancer. Am J Surg. 1998;176(6):554–558. 2. Lumley J, Stitz R, Stevenson A, Fielding G, Luck A. Laparo- scopic colorectal surgery for cancer: intermediate to long-term 12. Dennis L, Fowler MD, Sharon A, White RN. Laparoscopic- outcomes. Dis Colon Rectum. 2002;45(7):867–872. assisted sigmoid resection. Surg Laparosc Endosc. 1991;1(3): 183–188. 3. Hong D, Tabet J, Anvari M. Laparoscopic vs. open resection for colorectal adenocarcinoma. Dis Colon Rectum. 2001;44(1): 13. Pietrafitta JJ, Schultz LS, Graber JN, Hickok DF. An experi- 10–19. mental technique of laparoscopic bowel resection and reanas- tomosis. Surg Laparosc Endosc. 1992;2(3):205–211. 4. Champault GG, Barrat C, Raselli R, Elizalde A, Catheline JM. Laparoscopic versus open surgery for colorectal carcinoma: a 14. Wexter SD, Johansen OB. Laparoscopic bowel resection: prospective clinical trial involving 157 cases with a mean fol- Advantages and limitations. Ann Med. 1992;24:105–110. low-up of 5 years. Surg Laparosc Endosc Percutan Tech. 2002; 15. Zucker KA, Pitcher DE, Martin DT, Ford RS. Laparoscopic- 12(2):88–95. assisted colon resection. Surg Endosc. 1994;8(1):12–18. 5. Lezoche E, Feliciotti F, Paganini AM, et al. Laparoscopic vs 16. Allam M, Piskun G, Kothuru R, Fogler R. A three-trocar open hemicolectomy for colon cancer. Surg Endosc. 2002;16(4): midline approach to laparoscopic-assisted colectomy. J Lapa- 596–602. roendosc Adv Surg Tech. 1998;8(3):151–155. 6. Feliciotti F, Paganini AM, Guerrierri M, Sanctis A, Campag- nacci R, Lezoche E. Results of laparoscopic vs. open resection for colon cancer in patients with a minimum follow-up of 3 years. Surg Endosc. 2002;16(8):1158–1161. JSLS (2004)8:352–355 355
Journal
JSLS : Journal of the Society of Laparoendoscopic Surgeons – Pubmed Central
Published: Dec 1, 167