Transanal extraction: Is it worth it?

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Presentation transcript:

Transanal extraction: Is it worth it? Morris E. Franklin Jr, M.D., F.A.C.S. Director Texas Endosurgery Institute Karla Russek, M.D. Research Fellow, Texas Endosurgery Institute MISS ,2012

Industry relationships W.L. Gore & Associates Grant/research support, consultant and speaker bureau Covidien Striker Consultant, advisory board Ethicon Consultant and speaker bureau Atrium Consultant Aesculap Encision KCI Cook

Indications / Contraindications for totally lap colon surgery Colon cancer Crohn’s disease Diverticulitis Rectal prolapse Ulcerative colitis Intestinal ischemia Familiar adenomatous polyposis Lack or advanced laparoscopic skills Lack of colon preparation Fecal peritonitis

Laparoscopic Technique for left colon resections Patient positioning Modified lithotomy Arms tucked at sides Shoulders taped to table Insufflation, trocar placement Generally 5 trocars used Umbilicus and outside of rectus sheath 2 cm below Mc Burney’s point Fix trocars Assistant Camera Surgeon

Mobilization, nerves & ureter ID Same as building a house Lateral stalks taken down Dissection carried down to levator ani muscles Anterior dissection last White line of Toldt Allows a tension-free anastomosis Avoid laceration of the spleen

Clamps Placement and colonoscopy Control gas insufflation Necessary with CO2??? Localize lesion Lavage with Betadine Determine margins of resection

Colon transection & trim, orientation Anvil placement Endoloop placement on proximal segment Easier and safer handling prior to extraction Introduce all in bag

Intracorporeal anastomosis

Postoperative colonoscopy Anastomosis integrity Bleeding Air-leak test

Transanal Removal of Specimen

TEI Experience Transanal extraction Procedures Case # Percentage Laparoscopic Left 6 2.5% Hemicolectomy Laparoscopic 83 34.9% Sigmoidectomy Laparoscopic Low Anterior Resection 148 62.8% Total Case Number 238 100%

TEI Experience Transanal extraction Pathologies Case # Percentage Cancer 167 70.20% Diverticulitis 69 29.00% Other 2 0.80% Total Case Number 238 100%

TEI Experience Transanal extraction Postop complications Case # Percentage Minor POC’s Wound infection 2 0.84% Ileus 7 2.9% UTI 6 2.5% Total 15 6.3%

TEI Experience Transanal extraction Postop complications Case # Percentage Major POC’s Bowel obstruction 1 0.42% Fecal incontinence 3 2.3% Anastomotic leak 1 0.42% Tumor implant 0 0% Total 5 2.1% Follow-up of 2 years

Texas Endosurgery Institute

Conclusions Plan approach Know anatomy and anatomic relations Medial to lateral approach makes it easier Visualize the ureter more than one time Determine extraction site by lesion localization and etiology Use wound protection Beware of complications

Old or new ???

“If you do the same thing over and over again you cannot ever expect a different outcome ” Albert Einstein

www.texasendosurgery.com