The practice of minimally invasive surgery has rapidly grown over the past two decades to the point that laparoscopic surgery has replaced open surgery for several abdominal procedures (such as cholecystectomy) and gained acceptance and implementation for many other procedures (such as colectomy).1 For many surgical practices laparoscopic techniques have become common place for the patient-related advantages they offer (Table 37-1). In part, the introduction of hand-assisted laparoscopic surgery (HALS) and the early exposure of trainees to diverse laparoscopic techniques have facilitated the availability of laparoscopic surgery to more practitioners and patients.2 Knowledge and experience gained from the evolving practice over the past nearly two decades has provided clarity on indications, contraindications, and technical advancements. This chapter provides a review of the principles behind the practice of laparoscopic colon and rectal surgery. It also provides a brief review of the special considerations for cancer of the colon and the rectum and focuses on providing a contemporary description of the technical approaches to laparoscopic and HALS approaches to segmental resections of the colon and the rectum, and the combined resections of the colon and rectum with creation of pelvic pouches. Finally, a perspective on NOSE (natural orifice specimen extraction), NOTES (natural orifice transluminal endoscopic surgery), and robotic surgery is offered at the conclusion of this chapter.
Table 37-1: Advantages of Laparoscopy |Favorite Table|Download (.pdf)
Table 37-1: Advantages of Laparoscopy
Less post-op pain
Improved quality of life
Shorter posthospital recovery
Better cosmetic result
Reduction in post-op adhesions
Indications, Contraindications, Evaluations
With the exception of rectal cancer cases, laparoscopic surgery can be considered an option for virtually any patient with a colon or rectal condition requiring surgery. With that said, not all patients will be ideal candidates and not all procedures can be performed by all surgeons. All surgeons must find their comfort zone with laparoscopic cases. The initiate to laparoscopy should consider limiting their early practice to right colectomies in patients who are thin and have limited risks of adhesions as well as benign disease process such as polyps or ileocolonic Crohn's strictures. Surgeons with advanced skills may be comfortable doing an entire total proctocolectomy and ileal pouch-anal anastomosis. All of these procedures have been technically described in this chapter to provide a range of procedures that are feasible. In addition to the technical range of possibilities, there is a range with respect to which patients will do well with the laparoscopic approach. As with any laparoscopic approach, for example, there would be some cases where a pneumoperitoneum is contraindicated and others where the disease or technical considerations represent contraindications. Indications and contraindications and pre- and intraoperative evaluations specific to the colon and rectal diseases and patient conditions are provided, followed by focused discussion on oncologic issues relevant to colon and rectal cancer and key points.