1. 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

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

3. 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

4. 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

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

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

10. Room Setup
What we get…
What we hope for…

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

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

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

14. Even Better

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

16. Set Up: The Room

17. 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

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

19. Convert
Alternate

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

21. Conversions

22. 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 Oct;47(10):1680-5

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

24. 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

25. 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

26. Instrumentation

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

28. Thanks