1. Extraction sites for colon resection: What’s out there right now? Extraction sites for colon resection: What’s out there right now? Morris E. Franklin Jr MD. F.A.C.S. Director Texas Endosurgery Institute Karla Russek, MD. Research Fellow Morris E. Franklin Jr MD. F.A.C.S. Director Texas Endosurgery Institute Karla Russek, MD. Research Fellow MISS meeting 2010

2. Industry relationships W.L. Gore & AssociatesW.L. Gore & Associates –Grant/research support, consultant and speaker bureau CovidienCovidien –Grant/research support, consultant and speaker bureau StrikerStriker –Consultant, advisory board EthiconEthicon –Consultant and speaker bureau AtriumAtrium –Consultant AesculapAesculap –Consultant KCIKCI –Consultant The Authors do not have financial interest with the above mentioned companies

3. A major advantage of laparoscopic surgery (small incisions) must be balanced with the need to remove and preserve specimens

4. Types of specimens Benign Malignant Infected Over size Hollow/solid Others Benign Malignant Infected Over size Hollow/solid Others Types of specimens Benign Malignant Infected Over size Hollow/solid Others Benign Malignant Infected Over size Hollow/solid Others

5. Should all laparoscopic specimens be extracted with a bag or protective sleeve ?

6. Wound protectors Plastic sheaths used to line a wound during surgery Camera sleeve Commercially available Avoid infection, port site metastasis. Plastic sheaths used to line a wound during surgery Camera sleeve Commercially available Avoid infection, port site metastasis.

7. Bags for specimen confinement and retrieval Commercially available Gloves Gloves’ fingers Condoms Others –Freezer bags –Orthopedic bags Commercially available Gloves Gloves’ fingers Condoms Others –Freezer bags –Orthopedic bags

8. Bag considerations Strength Size Aperture Maneuverability Easy of deployment Easy of retrieval Porosity Strength Size Aperture Maneuverability Easy of deployment Easy of retrieval Porosity

9. Bag Utilization Insertion –Roll and insert Bag deployment –Pull out –Use two graspers Insertion –Roll and insert Bag deployment –Pull out –Use two graspers

11. Specimen entrapment –Triangulate the opening –Allow sufficient working space –Grasp connective tissue at the organ appendages, no the organ itself –Use of gravity –Trendelenburg + reverse Trendelenburg Specimen entrapment –Triangulate the opening –Allow sufficient working space –Grasp connective tissue at the organ appendages, no the organ itself –Use of gravity –Trendelenburg + reverse Trendelenburg Bag Utilization

12. Bag retrieval Bag closure –Drawstring –Ligasure –Clips Bag extraction –Constant laparoscopic visual control –Avoid puncturing or tearing the bag Bag closure –Drawstring –Ligasure –Clips Bag extraction –Constant laparoscopic visual control –Avoid puncturing or tearing the bag

13. Colon

14. Complications of specimen extraction Specimen loss Specimen rupture Wound infection Tumor implantation Visceral injury Incisional hernia Specimen loss Specimen rupture Wound infection Tumor implantation Visceral injury Incisional hernia

15. The best method for removal depends on the size, location, and nature of the specimen

16. Routes for Specimen Removal Port site Midline incision Pfannestiel incision Muscle splitting incision Natural orifices Port site Midline incision Pfannestiel incision Muscle splitting incision Natural orifices

17. Port Site Removal Small specimens With or without a reducing sleeve Under direct laparoscopic visualization Small specimens With or without a reducing sleeve Under direct laparoscopic visualization

18. Port Site Removal

19. Midline incision Requires only a single layer fascia division Can remove large and very large specimens Hernia formation 20-20% incidence The longer the incision, the greater the incidence of hernia formation Used extensively in SILS surgery Requires only a single layer fascia division Can remove large and very large specimens Hernia formation 20-20% incidence The longer the incision, the greater the incidence of hernia formation Used extensively in SILS surgery

20. Does the extraction-site location in laparoscopic colorectal surgery have an impact on incisional hernia rates? Prospective study of 208 patients Hernia incidence of 7.8% Midline incision hernia incidence of 17.6 Prospective study of 208 patients Hernia incidence of 7.8% Midline incision hernia incidence of 17.6 Ravinder Singh, Alex Omiccioli, Susan Hegge, Craig McKinley. Surg Endosc 2006

21. A large Cochrane study which included 33 randomized control trials and 3346 patients reported: –Incidence of incisional hernias (different extraction sites): 7.9% vs. 10.9% (open colectomy) A large Cochrane study which included 33 randomized control trials and 3346 patients reported: –Incidence of incisional hernias (different extraction sites): 7.9% vs. 10.9% (open colectomy) Long-term results of laparoscopic colorectal cancer resection Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer HJ Long-term results of laparoscopic colorectal cancer resection Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer HJ

22. Muscle splitting incision Hernia formation reduced Lower Infection rate Less Pain ? Hernia formation reduced Lower Infection rate Less Pain ?

23. Pfannenstiel incision Used extensively by urologists as a kidney extraction site Less pain Cosmesis Used extensively by urologists as a kidney extraction site Less pain Cosmesis Matthew L. Steinway, M.D., Irma J. Lengu, M.D., Edward E. Cherullo, M.D., and Lee E. Ponsky, M.D. Laparoendoscopic Single-Site (LESS) Nephrectomy Through a Pfannenstiel Incision: Porcine Model. Journal of Endourology 2009

24. Pfannenstiel incision No studies as a colon extraction site Hand-assist technique Has been used as a liver extraction site for laparoscopic resections No studies as a colon extraction site Hand-assist technique Has been used as a liver extraction site for laparoscopic resections A Simple Technique for Large Tumor Removal During Laparoscopic Liver Resection Teixeira, Antonio Roberto F. MD; Pilla, Victor F. MD; Makdissi, Fábio F. MD; Machado, Marcel Autran C. MD. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques: December 2008 A Simple Technique for Large Tumor Removal During Laparoscopic Liver Resection Teixeira, Antonio Roberto F. MD; Pilla, Victor F. MD; Makdissi, Fábio F. MD; Machado, Marcel Autran C. MD. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques: December 2008

25. Natural Orifices Decrease body insult Avoid incisional hernias Lower infection rate NOTES approach

26. Natural Orifices Transgastric Transanal Transvaginal Others Transgastric Transanal Transvaginal Others

27. Selected cases

28. Texas Endosurgery Institute Experience Muscle splitting incision –Right lower quadrant 192 patients –Left lower quadrant210 patients –Midline incision137 patients Muscle splitting incision –Right lower quadrant 192 patients –Left lower quadrant210 patients –Midline incision137 patients

29. Texas Endosurgery Institute Experience NOTES –Transanal extraction227 patients –Transvaginal extraction25 patients NOTES –Transanal extraction227 patients –Transvaginal extraction25 patients

30. Muscle splitting extraction

31. Transanal benign disease

32. Transanal malignant disease

33. Transvaginal extraction

34. Morcellation of specimens Futuristic ? Specimen can be evaluated for histology but not for pathological staging Cosmetically desirable Futuristic ? Specimen can be evaluated for histology but not for pathological staging Cosmetically desirable

35. ConclusionsConclusions Determine extraction site by lesion localization and etiology Importance of wound protection Determine extraction site by lesion localization and etiology Importance of wound protection

36. ConclusionsConclusions Always use a bag for extraction!!!!

37. “Imagination is more important than knowledge. For knowledge is limited to all we now know and understand, while imagination embraces the entire world, and all there ever will be to know and understand.” Albert Einstein

38. www.texasendosurgery.com