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Laparoscopic Colorectal Resection (MIS)

The goal of minimally invasive colorectal surgery, which was introduced in 1991, is to minimize the trauma and injury to the abdominal wall during bowel resection. Traditionally, intestinal resections have been carried out through a lengthy incision made in the abdominal wall which provides the surgeon access to the abdominal cavity. It has been well shown that by avoiding the longer incision the patient experiences less pain and requires less pain medications. Other short term benefits include a more rapid resumption of diet, return of bowel function, and discharge home as well as the ability to walk sooner and farther than patients receiving a traditional or “open” operation. It has also been shown that laparoscopic operations cause less marked physiologic and immunologic changes than the equivalent big incision operation (see Research Section). Also, most often patients are able to return to work and full activity more rapidly. Cancer patients who require chemotherapy can also start those treatments sooner because of the faster recovery. A brief description of a laparoscopic operation follows.

After anesthesia is administered, a laparoscopic operation is begun by making a small incision (< 1 cm) near the belly button through which a hollow needle is inserted into the abdominal cavity. Carbon dioxide gas (CO2) is then pumped through the needle into the abdomen which lifts the abdominal wall off of the internal organs and creates a space in which the surgeon can work; this is called a pneumoperitoneum. A hollow tube (port) is then inserted into the abdomen through the small incision. A rigid telescope with a powerful light is then inserted into the abdomen through the port and attached to a camera which projects the image on several television monitors in the operating room. The camera provides the surgeon and his assistants with a magnified internal view of the abdominal organs. The images obtained with the high definition image systems that are used today are excellent. Additional 3 to 4 ports, with diameters ranging from a little more than a ¼ inch to ¾ inch are then placed. The ports have airtight valves on their exterior end which prevent gas leakage while allowing insertion of specially designed long surgical instruments into the abdomen. By using these instruments while watching the monitors the surgeons can work in all areas of the abdomen and can carry out the operation.

It is possible to mobilize the colon, to seal and divide blood vessels, and to divide the bowel using laparoscopic tools and without a large incision. In this way, a portion or all of the colon and rectum can be resected. Next, in order to remove the specimen it is necessary to either enlarge one of the port incisions or make a separate small incision (length is usually between 2 and 3 inches). In contrast, the standard “open” abdominal incisions usually range in size from 4 to 9 inches in length. Once the specimen has been removed, in the great majority of patients, the remaining bowel ends are rejoined and an anastomosis constructed. In some cases the rejoining of the bowel ends is done inside the abdomen laparoscopically whereas in other situations the reconnection is done externally, through the extraction incision. After completion of the anastomosis the ports and instruments are removed and the wounds carefully closed.

There are a number of different minimally invasive methods that can be used. In addition to the standard laparoscopic approach, described above, there are several other methods including; hand-assisted laparoscopic, hybrid laparoscopic/open, and the robotic laparoscopic approach. Dr. Whelan routinely uses the standard laparoscopic approach as well as the hand-assisted laparoscopic method. The latter calls for an incision large enough to accommodate the insertion of one hand into the abdomen (between 3 and 3 ½“). A special device is placed in the wound that allows the hand to be inserted yet doesn’t permit the CO2 gas in the abdomen from escaping. In this way a laparoscopic operation is carried out with one hand in the abdomen. It is then possible to palpate the bowel and to grasp and retract it which facilitates the carrying out and completion of the operation. This method is used when the segment of colon or rectum to be removed is large and bulkier than usual. It is also commonly used in obese patients in whom the standard laparoscopic operation may be more difficult. Although the final incision is usually a 2-4 cm larger than after a standard laparoscopic operation it is still at least 50% smaller than the incisions needed to do an open or big incision bowel resection.

Although at first controversial, it is now well accepted that laparoscopic colon resection is the gold standard. Laparoscopic methods have been used for almost 20 years and there are many studies and published reports attesting to the safety and presently, all parts of the colon and rectum can be removed laparoscopically; if necessary, the entire colon and rectum can be removed using minimally invasive methods. Surgeons of the Section of Colon and Rectal Surgery have done over 1,800 laparoscopic colorectal resections and have also been involved with one of the large multi-center randomized cancer trials mentioned above. In addition, Dr. Whelan has published over 85 peer reviewed publications concerning laparoscopy and the physiologic and immunologic changes associated with both laparoscopic and open bowel resection.

MIS Methods for Colon Cancer

As mentioned, during the 1990’s and up to about 2003 there was great concern and fear that laparoscopic methods might be associated with lower survival rates, higher tumor recurrence rates, and a higher rate of abdominal wall tumors. These fears led to at least 3 large randomized multicenter clinical trials which compared the traditional open (big incision) method to laparoscopic colon resection methods. Preliminary reports from these studies made it clear that there was no difference in the size of the surgical specimens removed, in the distance from the tumor to the ends of the colon specimen (called the margins), or in the number of lymph nodes removed per specimen when the open and laparoscopic pathology results were compared. Thus, it is possible to do a “radical” cancer resection laparoscopically given a skilled and experienced surgeon. Thankfully, the 3 and 5 year cancer follow up results have become available from several of these studies. The 5 year survival and local recurrence rates for the laparoscopic and open or traditional surgical methods are very similar. Also, there was no difference in the rate of abdominal wall tumors in the open and laparoscopic groups. Since the short term recovery results of the laparoscopic approach are significantly better than those of the big incision method and the long term cancer results are similar, the laparoscopic method is the surgical approach of choice.

What Our Patient’s Say…

Our family wishes to express our heartfelt appreciation for the kindness, excellent care and wisdom our mother, Jean Broussard, received during her hospitalization.

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