Basics Skills for Laparoscopic Colon Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery University of Cincinnati Program Director Residency in General Surgery Director of Minimally Invasive Colorectal Surgery, University Hospital

Laparoscopic Colectomy: You’ve Come a Long Way Baby! Improved instrumentation Improved techniques Standardized approach Large experience by a few surgeons Still not routine

Barriers to Implementation Access to cases Technique often differs from open approach Medial vs. lateral Comfort in major pedicle ligation (aortic branches) Requirements for more than one skilled surgeon Time

Skill Sets Multi quadrant surgery Colon not always fixed Skilled camera operator Ability to work against the camera Colon not always fixed Tension created by two operators – both skilled Knowledge of energy devices and endo staplers

Other Considerations Loss of tactile feedback Learning curve Diverticulitis Crohn’s disease Location of tumor/polyp Learning curve Surgeon Surgical Team Referring Docs

Preparation - The Patient Preoperative evaluation few additional studies necessary additional invasive monitoring unusual Flexibility of hips and legs

Room Setup What we get… What we hope for…

Set Up: The Bed Electric bed Bean bag Velcro bag to bed Bottom of bag at break

Set Up: The Patient Modified lithotomy Minimize hip flexure Arms tucked Padding for shoulder

Set Up: The Patient Minimize hip flexion 10o at most More flexion may limit access to transverse colon

Even Better

Set Up: The Patient Padding for neck and shoulder 3” silk around chest to prevent lateral slippage

Set Up: The Room

Preparation - Surgeon: General Recommendations Be prepared for the day Don’t book too many cases Keep your cool Pick the easy lay-up Find some good help

Preparation - Surgeon: Learning Curve Steep (20-50 cases) Depth perception Multiple quadrants Reverse angles Coordination of team Operative times Conversion rates

Convert Alternate

Conversions – Does it matter Conversion – an ugly word Increased operative times Increase length of stay Increase 30 day readmission/morbidity Increase cost

Conversions

Conversions No difference in outcomes when compared to an open cohort of similar patient KEY is to make a decision to ALTERNATE the approach early Dis Colon Rectum. 2004 Oct;47(10):1680-5

Alternatives to Conversion Pfannenstiel incision after: mobilization of splenic flexure division of vascular pedicle Hand-assisted laparoscopy allows tactile sensation blunt separation

Preparation - Surgeon: Developing a Systematic Approach Develop an approach and stick with it Initial survey Port placement Vascular ligation and medial mobilization Lateral mobilization Extraction and anastomosis

Laparoscopes 10mm 0o 10mm 30o Flexible tip lens Easy orientation May be inadequate at the flexures 10mm 30o Better visualization at flexure and pelvis Disorientation Flexible tip lens

Instrumentation

Conclusion Don’t wait for the perfect case Be prepared If you are going to alternate – do it quickly Have fun

Thanks