1. 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

2. 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

4. 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

5. 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

6. 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

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

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

9. Intracorporeal anastomosis

10. Postoperative colonoscopy
Anastomosis integrity
Bleeding
Air-leak test

11. Transanal Removal of Specimen

12. TEI Experience Transanal extraction
Procedures Case # Percentage
Laparoscopic Left %
Hemicolectomy
Laparoscopic %
Sigmoidectomy
Laparoscopic Low
Anterior Resection %
Total Case Number %

13. TEI Experience Transanal extraction
Pathologies Case # Percentage
Cancer %
Diverticulitis %
Other %
Total Case Number %

14. TEI Experience Transanal extraction
Postop complications Case # Percentage
Minor POC’s
Wound infection %
Ileus %
UTI %
Total %

15. TEI Experience Transanal extraction
Postop complications Case # Percentage
Major POC’s
Bowel obstruction %
Fecal incontinence %
Anastomotic leak %
Tumor implant %
Total %
Follow-up of 2 years

16. Texas Endosurgery Institute

17. 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

18. Old or new ???

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