Colorectal surgery repairs damage to the colon, rectum, and anus through a variety of procedures that may have little or great long-term consequence to the patient. It may also involve surgery to the pelvic floor to repair hernias.
Gastro-intestinal surgery in general and colonic surgery in particular is considered as very demanding and requires – high degree of operative skill. In the discovery of the last decade is an attempt to minimize these injuries for patients benefit Laparoscopic colonic surgery is being accepted by many centres as primary line of treatment for carcinoma colon. It is no more considered an experimental work. Centres specialised in this field have conducted double blind randomised trial (DBRT) in large number of cases and have shown that the basic principles of oncosurgery are not compromised and long term follow-up results are comparable to conventional surgery. In India because of limited work load of colonic cancer, it has not made the progress unlike laparoscopic cholecystectomy. There are no large published series. We have carried out 32 colonic surgeries, out of which only six are for malignancy, the rest being inflammatory colonic diseases.
It makes great sense to offer the benefits : –
* Less post operative pain and analgesics.
* Shorter hospital stay.
* Less wound related and post-op pulmonary complication.
* Early return to work or family.
* Better cosmesis.
Port site implantation was a concern in early period but it has been shown now that it can be prevented by
* Proper protection of port site while delivering the specimen
* Avoid squeezing of the specimen by taking a liberal incision.
* Thorough wash to the wound, 5FU solution irrigation of all ports.
* Slow release of pneumo-peritoneum.
* Lap-lift technique etc.
Cost can be brought down by either doing a hand sewn anastomosis through the specimen delivery site or use of conventional stapler for extra – corporeal stapled anastomosis.
Harmonic disposable hand pieces are reused by us multiple times to cut down the cost. Tremendous amount of time and blood loss is saved particularly in obese patient by use of ultrasonic generator. We have observed that the same can be achieved to a great extent by use of bipolar diathermy endo-scissors, dissectors and hooks etc. The sealing capacity for vessels is comparable and no lateral thermal damage takes place when bipolar electric energy source is used. Haemostasis in our initial cases was carried out by use of bipolar diathermy and of late we carry out these procedure with much ease by Harmonic scalpel ultracision (L.C.S. of Ethicon). In fact we are the first to acquire this in Mumbai’s private setup.
The two burning issues are port site metastasis in malignancies and cost factor due to use of endostaplers. As mentioned earlier for benign condition like rectal prolapse, adenomas, rectal polyposis and inflammatory condition like tuberculosis, ulcerative colitis, simple diverticulitis, laparoscopic surgery offers a patient friendly technique. Crohn’s though not very common in our country, but laparoscopy can be offered for diagnosis, lymph node sampling and curative resection. Ileo-caecal tuberculosis is commonly seen in our country and its a good option to offer the benefits of M.I.S. to these patients whenever surgery is indicated. Incidental colonic resection is unlikely to help the laparoscopic surgeon team in mastering the techniques. Reduction of O.T. time due to better co-ordination and cost benefit to patients can only be offered by repetitive performances. Details of various procedures is beyond the scope of this article, but I will give a broad overview of various procedures.
Diagnostic laparoscopy in india
a. This is offered to stage a malignant condition, take tissue for biopsy and have relook (second look) operation by laparoscopy.
b. To obtain specimen and lymph nodes in inflammatory large bowel diseases.
Laparoscopic colostomy in india
Laparoscopy is mainly used to achieve faecal diversion in unresectable malignant growth, severe perianal infections, trauma faecal incontinence and complex fistula in ano. If indicated even a loop iliostomy can be offered to patient.
Laparoscopic colonic resection in india
Rt and Lt hemicolectomy, total colonic resection, abdomino-perineal resection (APR), anterior resection (AR), lap assisted resection are various procedures that can be offered to patients. Out of these the most difficult technique is a transverse colonic resection in an obese patient. Large malignant and inflammatory masses also are relative contraindication for surgery. Obstructed lesions are absolute contraindication for Lap surgery. To resect the bowel Endo-staplers can be used. Now we have even smaller stapler in the form to endo G.I.A.
Smaller length is easy to handle and manoeuvre. If larger lumen needs to be divided, it’s better to fire smaller endo G.I.A. 30 twice. Variable staple height of 2 mm, 2.5 mm, 3 mm colour coded cartridges are used according to bowel thickness. Vascular pedicles can also be divided by using 2 mm height stapler. We prefer to tie the vessels individually at the root of mesocolon is gives better nodal clearance and cuts down the cost. For anterior and low anterior resection EEA cured staple became very handy.
Showing staple height, staple line of 3 rows on each side with line of cutting and closure of staple in letter B format
It has been seen that the basic principles of oncosurgery are not compromised. The procedure done is same as open surgery. The five year survival rate are comparable.