Laparoscopic surgery has steadily gained acceptance over the past two decades, and now it has replaced open surgery for many abdominal procedures (such as appendectomy and cholecystectomy); it is also becoming the preferred approach to many colorectal procedures (such as colectomy).1 The reasons for the widespread adaptation of laparoscopic techniques are multiple, as listed in Table 50-1. Laparoscopic techniques, when coupled with enhanced recovery pathways, also allow patients to enjoy a speedier recovery, and are associated with fewer complication rates.2
TABLE 50-1ADVANTAGES OF LAPAROSCOPY |Favorite Table|Download (.pdf) TABLE 50-1 ADVANTAGES OF LAPAROSCOPY
|1. Smaller incision |
|2. Less post-op pain |
|3. Shorter hospitalization |
|4. Improved quality of life |
|5. Shorter posthospital recovery |
|6. Better cosmetic result |
|7. Reduction in post-op adhesions |
The introduction of hand-assisted laparoscopic surgery (HALS) and the early exposure of trainees to diverse laparoscopic techniques have increased the availability of laparoscopic surgery to more practitioners and patients.3 Knowledge and experience gained from the evolving laparoscopic 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, focusing on providing a contemporary description of the 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 natural orifice specimen extraction (NOSE), natural orifice transluminal endoscopic surgery (NOTES), and the growing practice of robotic surgery is offered at the conclusion of this chapter.
Indications, Contraindications, Evaluations
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 are 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 along with pre- and intraoperative evaluations ...