Perioperative Care

All patients receive a mechanical bowel preparation consisting of a clear liquid diet for 24 hours preoperatively and 3 oz of Fleets Phosphosoda™ administered the afternoon prior to surgery. Intravenous prophylactic cefuroxime 1 g and metronidazole 500 mg one hour prior to the procedure is administered to all nonallergic patients. A urinary catheter is inserted at surgery and removed the following morning. Theperioperative care plan includes the following: preemptive analgesia with oral Voltaren®a 50 mg the day before surgery; nasogastric tubes and drains are not employed routinely; and analgesia consisting of patient-controlled epidural (bupivacaine/fentanyl) or intravenous morphine for 12 to 18 hours. All patients are offered a full liquid diet as the first meal following surgery. Thereafter, dietary intake is ad libitum with no specific restrictions. Patients are encouraged to ambulate as soon as possible after the procedure, with a minimum of five walks outside the room the first postoperative day. The first postoperative morning patients are converted to oral analgesics that include hydroxycodone (one or two tablets every 6 hours) and Voltaren 50 mg TID. The intravenous catheters are removed the first postoperative morning unless the patient is nauseated or distended. Discharge criteria include the tolerance of three general meals without nausea or vomiting, absence of abdominal distention, adequate oral analgesia, and passage of flatus.

It appears that the combination of a lesser degree of trauma with laparoscopy, early feeding, and aggressive ambulation dramatically reduces the risk of postoperative ileus and allows for early discharge after laparoscopic colectomy.

OPERATIVE TECHNIQUES Right Colectomy

The operative steps (Table 1) for laparoscopic right colectomy and recommended time for completion are as follows: (5) (i) open insertion of the umbilical port for establishment of pneumoperitoneum and peritoneal inspection (two to five minutes); (ii) placement of a 12 mm port 2 cm medial to the left anterior superior iliac spine, a 5 mm port 2 cm medial to the right anterior superior iliac spine, and a 5 mm port laterally on the left side just rostral to the umbilicus, all under direct vision with pneumoperitoneum (2-10 minutes, if adhesions from prior surgeries require lysis prior to port insertion); (iii) elevation of the right colic pedicle allows dissection beneath the vessels with identification of the origin of the right colic artery and the duodenum (15-20 minutes); (iv) elevation of the right colon and proximal transverse colon off the retroperitoneum (5-10 minutes); (v) release of the hepatic flexure to mid transverse colon (15-20 minutes); (vi) division of the lateral peritoneal reflection and ligament of Treitz (10-15 minutes); (vii) exteriorization of the specimen through a 4 to 6 cm umbilical incision with use of a wound protector (Protractor™b) (two to five minutes); and (viii) extracorporeal bowel division and ileocolic anastomosis (5-10 minutes).

If the intended procedure is to mobilize the right colon rather than resect bowel then the following step modifications are used; division of the peritoneum lateral to the colon and medial mobilization of the right colon without ligation of the vessels. The remainder of the procedure is similar as bowel transection and construction of an ileo-colic anastomosis is performed extracorporeally in the interest of cost-effectiveness.

Sigmoid/Left Colectomy

The operative steps (Table 2) for laparoscopic colectomy for the sigmoid or left colon and recommended times for completion are: (i) open insertion of the umbilical port for

TABLE 1 ■ Steps for Laparoscopic Right Colectomy

Open insertion of the umbilical port for establishment of pneumoperitoneum Placement of a 12-mm port 2 cm medial to the left anterior superior iliac spine; a 5-mm port 2 cm medial to the right anterior superior iliac spine; and a 5-mm port laterally on the left side just rostral to the umbilicus

Elevation of the right colic pedicle from the retroperitoneum with ligation of the right colic artery

Elevation of the right colon and proximal transverse colon off the retroperitoneum

Release of the hepatic flexure to mid transverse colon

Division of the lateral peritoneal reflection and ligament of Treitz

Exteriorization of the specimen through a 4 to 6 cm umbilical midline incision

Extracorporeal bowel division and ileocolic anastomosis

It appears that the combination of a lesser degree of trauma with laparoscopy, early feeding, and aggressive ambulation dramatically reduces the risk of postoperative ileus and allows for early discharge after laparo-scopic colectomy.

aNovartis, East Hanover, NJ.

bWeck Closure Systems, Research Triangle Park, NC.

TABLE 2 ■ Steps for Laparoscopic Sigmoid/Left Colectomy

Open insertion of the umbilical port for establishment of pneumoperitoneum

Placement of a 12-mm port 2 cm medial to the right anterior superior iliac spine; a 5-mm port 2 cm medial to the left anterior superior iliac spine; and a 5-mm port laterally on the right side just rostral to the umbilicus

Mobilization of the mesosigmoid and mesorectum from the right side for identification of the left ureter and subsequent intracorporeal division of the vessels

Mobilization of the sigmoid and descending colon laterally up to the splenic flexure and medially off Gerota's fascia

Mobilization of the proximal rectum with division of the rectosigmoid junction with a linear endoscopic stapler

Division of the mesorectum at the distal resection site with control of vessels via bipolar cautery or vascular clips

Exteriorization of the specimen through a left lower quadrant muscle splitting incision for specimen resection and anvil placement within the proximal colon

Reestablishment of pneumoperitoneum and circular-stapled colorectal anastomosis establishment of pneumoperitoneum and peritoneal inspection (two to five minutes); (ii) placement of a 12 mm port 2 cm medial to the right anterior superior iliac spine, a 5 mm port 2 cm medial to the left anterior superior iliac spine, and a 5 mm port laterally on the right side just rostral to the umbilicus, all under direct vision with pneumoperitoneum (two to five minutes); (iii) mobilization of the mesosigmoid and mesorectum from the right side for identification of the left ureter and subsequent intracorporeal division of the vessels (10-20 minutes); (iv) mobilization of the sigmoid and descending colon laterally up to the splenic flexure and medially off Gerota's fascia (10-20 minutes); (v) mobilization of the proximal rectum with division of the rectosigmoid junction with a linear endoscopic stapler (10-12 minutes); (vi) division of the mesorectum at the distal resection site with control of vessels via bipolar cautery or vascular clips (15-25 minutes); (vii) exteriorization of the specimen through a left lower quadrant muscle splitting incision for specimen resection and anvil placement within the proximal colon (15-20 minutes); and (viii) reestablishment of pneumoperitoneum and circular-stapled anastomosis (10-15 minutes). This approach allows the patient to be placed head up for dissection of the flexure at a time when pelvic visualization has already been sacrificed, rather than changing the patient's position during the earlier dissection and losing time with each loss of exposure. If a left colectomy is required then the head up position can be used prior to making the exteriorizing incision that will generally be a short midline at the umbilicus as used for right colectomy (see above). If the sigmoid colon will be used for bladder augmentation or reservoir construction then Step 3 is modified by not dividing the vascular pedicle. The mesenteric mobilization will allow easy reach of the bowel to the pelvis.

Instrumentation for the procedure has been standardized. Reusable ports, graspers, laparoscopic scissors, and cautery (monopolar and bipolar) are used. The fascia at the umbilical port site is approximated around the port via a pursestring suture of 0-polygly-colic acid suture to prevent air leaks. This suture is tied at the end of the case to close the fascial defect. The 12 mm port site is closed with 0-polyglycolic acid suture at the end of the case using a reusable fascial closure instrument. The wound is closed in layers with running 0-polyglycolic acid suture prior to reestablishing pneumoperitoneum. All skin incisions are closed with running subcuticular 4-0 polyglycolic acid suture.

TECHNICAL CAVEAT/TIP

The major pitfalls associated with laparoscopic colectomy are prolonged attempts at performing laparoscopic colectomy despite failure to progress, failure to identify key retroperitoneal structures (particularly the ureter and duodenum), and iatrogenic injuries to viscera.

The steps described above are meant to serve as guidelines for the surgeon to ensure that progress is indeed being made. Failure to identify key structures or to mobilize the bowel safely is an indication that the procedure should be converted to open. The typical conversion rate for major colon resection should be approximately 10%. It is better to err on the side of safety. Iatrogenic damage to viscera should be a rare event indeed in the hands of an experienced laparoscopic surgeon. Even adherent viscera that must be incised can be repaired laparoscopically; however it is key to observe the operative field at all times to avoid unrecognized damage that then falls out of the visual field. It is also important that the bowel be completely mobilized to allow performance of a tension free anastomosis and to allow the bowel to reach into the pelvis if required for urologic reconstruction.

SUMMARY

■ Modified use of colorectal laparoscopic techniques can be employed by urologists for bowel work and reservoir construction.

■ Bowel division and reanastomosis is typically performed extracorporeal^ through a 4 to 6 cm umbilical incision.

■ A standardized protocol of preemptive and perigesative analgesia, early feeding, and aggressive ambulation minimizes the risk of postoperative ileus.

■ Early in the urologist's experience, teaming up with a laparoscopic colorectal surgeon could allow smooth incorporation of urologic bowel work.

REFERENCES

1. Young-Fadok TM, HallLong K, McConnell EJ, Gomez Rey G, Cabanela RL. Advantages of laparoscopic resection for ileocolic Crohn's disease. Improved outcomes and reduced costs. Surg Endosc 2001; 15(5):450-454.

2. Senagore AJ, Duepree HJ, Delaney CP, Dissanaike S, Brady KM, Fazio VW. Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: similarities and differences. Dis Colon Rectum 2002; 45(4):485-490.

3. Delaney CP, Kiran RP, Senagore AJ, Brady K, Fazio VW. Case-matched comparison and financial outcome after laparoscopic or open colorectal sugery. Ann Surg 2003; 238(l):67-72.

4. Franklin ME Jr, Rosenthal D, Abrego-Medina D, et al. Prospective comparison of open vs. laparo-scopic colon surgery for carcinoma. Five-year results. Dis Colon Rectum 1996; 39(10 suppl):S35-S46.

5. Young-Fadok TM, Nelson H. Laparoscopic right colectomy: five-step procedure. Dis Colon Rectum 2000; 43(2):267-271; discussion 271-3.

6. Goh YC, Eu KW, Seow-Choen F. Early postoperative results of a prospective series of laparoscopic vs. Open anterior resections for rectosigmoid cancers. Dis Colon Rectum 1997; 40(7):776-780.

7. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy vs. open colectomy for treatment of non-metastatic cancer: a randomized trial. Lancet 2002; 359(9325):2224-2229.

8. Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL, Remzi FH. 'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 2001; 88(l1):1533-1538.

9. Chapman AE, Levitt MD, Hewett P, Woods R, Sheiner H, Maddern GJ. Laparoscopic-assisted resection of colorectal malignancies: a systematic review. Ann Surg 2001; 234(5):590-606.

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