Medical Device Daily Contributing Writer

Colorectal surgery has undergone rapid advancement in recent years, and the benefits of the laparoscopic approach (vs. open surgery) — presented in a recent live webcast by surgeons at University Hospitals Case Medical Center (Cleveland) — suggest that the procedure is a bonanza for device makers, given the large number of instruments employed. These range from standard surgical clamps to electrical devices to advanced imaging, with surgeon Conor Delaney comparing some parts of the procedure to operating a Play Station game.

Delaney, MD, is chief of colorectal surgery at the hospital. Bradley Champagne, MD, assistant professor at Case Western Reserve University (Cleveland), served as web cast moderator.

"The benefits [of the laparoscopic approach] are so great for the patient," said Delaney. "Cancer outcomes are as good as open surgery, but short-term recovery is hugely improved. Two recently published clinical trials have shown improved survival after the laparoscopic procedure."

In the U.S. in 2004 150,000 new cases of colon cancer were diagnosed, with 560,000 deaths from the disease, and healthcare providers increasingly recommend screening, from age 50, using flexible colonoscopy.

Delaney described the procedure as a right hemicolectomy, or partial removal of the colon, for a right-sided colon cancer, the patient a woman in her 50s.

"We will remove the entire right colon, then join the small intestine to the middle or transverse colon," he said. "We are using a miniature telescope, video camera and monitors to guide us through this minimally invasive procedure."

Delaney stood at the patient's left shoulder, the assistant at her left hip. Four small Incisions were made starting with a 10 mm incision at the umbilicus area for entry of the laparoscope.

Delaney said the patient had "a cancer of her right colon. She is now under general anesthetic and we have draped the operative field. You can see here the ports we have in place. Our instruments are about 5 mm in diameter, with jaws or scissors or graspers for cutting, positioning or for use of electric current for dissection."

"Here you can visualize the patient's anatomy with us," Delaney said. "You can see the right colon, then the appendix, which is distended due to the tumor blocking the cecum. Here you can see the hepatic flexure of the colon and the transverse colon over the stomach. This lady is very thin so the anatomy is easily demonstrated."

Champagne emphasized that the surgical team's technique as both routine and teachable for such cases.

He explained: "Dr. Delaney is starting the procedure by addressing the vasculature of the right colon. He has attached electric current to his scissors in preparation for dissection and control of the small amount of bleeding expected.

An Internet question came: "What is the preoperative workup for such patients?"

"Our first objective," Delaney replied, is "an accurate diagnosis . . . usually done through colonoscopy with tissue biopsy. The referring physician may also do a CT [computed tomography] scan of the abdomen, checking for spread or metastasis of the tumor, looking particularly at the liver. These patients also have a routine workup by anesthesia and cardiology teams.

"We now see the Ileocolic artery and vein. I'm using my scissors and cautery to lift vessels off the peritoneum, and now I'm working under these delicate vessels."

Delaney described his armamentarium as follows: "In my right hand I have a 5 mm bowel grasper. I will also use ligatures, scissors, clips, staplers and Maryland clamps during this surgery. Every surgeon will use slightly different instruments, depending on his training.

"Now I'm taking some lymph glands as specimen for the pathologist and introducing a ligature to suture the blood vessels around those glands." He said he was working "carefully, but rapidly as we try to accomplish this procedure within a one-hour window."

Delaney next divided vessels, freeing the right colon off the retroperiotoneum. The duodenum, behind the ascending colon was visualized.

"Most surgeons are able to do this procedure with very little blood loss, usually 10 cc or less," Champagne said.

Another question: Does this approach have any disadvantages?

"No," Delaney answered, "not after enough practice. In the worst case you'd have to convert to an open operation and that's not a disaster."

Delaney went on to say that the best chance for cure of this cancer is to do "a complete resection of the affected portion of the bowel — in this case, the entire right colon. The goal of this surgery is to leave the pathologist with enough specimens to evaluate for prognosis and determine the need, if any, for chemotherapy. So we take at least 12 lymph nodes along with the colonic section."

"Now," Champagne continued, "Dr. Delaney is moving to the right side of the patient and changing the instrument placement through the ports."

Delaney said, "This always feels a little like an advanced Play Station game. I can almost keep up with my son on his Play Station.

"Now I've freed up behind the hepatic flexure and can see the liver. I am examining it carefully . . . for evidence of metastasis at the surface of the liver. I see nothing out of the ordinary here.

"Now we free up the hepatic flexure and grasp the transverse colon. We use gravity to shift contents a little out of the field, and this lets us see the gallbladder and the liver. Now I am dividing the peritoneum and bringing the colon to the midline. Here we can see the right ureter, and it is functioning properly.

"We've dissected the colon free from its attachments now and are bringing the tissue out through the umbilical port onto the exterior of the wound. Go to the external cameras, please. Turn the operating room lights back on, please. At this stage we bring the specimen out through a small incision and let the gas out of the abdomen.

"We've closed the left lower port site with suture and enlarged the umbilical incision slightly. A wound protector has been placed to eliminate the possibility of cellular spread of the tumor."

Champagne said, "Now we examine the transverse colon and prepare it for re-anastamosis — reattachment of the bowel. Here we use the GIA [a surgical stapler, from USSC [Norwalk, Connecticut]). We've divided the colon with the stapling device, leaving two rows of titanium staples on each side and firing a cutting blade up the middle. When we open up the remaining tissue, we can complete closure of the bowel. Now we examine the remaining, complete bowel specimen. We are now changing gloves before completing the procedure. This is another technique to prevent cancer spread."

Staples are used to connect the small bowel to the transverse colon. "This gives us a side-to-side, stapled anastamosis. We save five to 10 minutes with the staplers. After closing with an end-on stapler we drop the anastamosis back into the abdomen and remove the wound protector."

Champagne added: "As with all major surgery, complications can include wound infection and deep vein thrombosis so antibiotics are administered pre-op and patients get a shot of heparin to thin the blood a little, to reduce the possibility of thrombosis or clot in the leg. This patient also has pneumatic stockings in place to keep blood flow during the procedure. No surgery is complication-free, but we do all we can to prevent problems."

Delaney then closed the small wounds with sutures, small dressings were applied and the patient recovered from anesthesia and was moved to the recovery area.

An Internet question: "How soon do these patients return to work?"

Champagne said that the hospital stay for Medicare patients is about 10.5 days, adding: "Open surgery with fast-track techniques can reduce this to less than five days. With laparoscopy our patients stay two to three days. It takes six to eight weeks for return to work with open surgery and three to four weeks with laparoscopy. Some patients will return to work in just three days."