Surgical Innovation

Laparoscopic surgery has gained in popularity in the last few years. As the technology for minimally invasive surgery improves and surgeons' laparoscopic skills progress, more advanced surgical procedures are being attempted with the laparoscope. The role of the laparoscope in the field of colon and rectal surgery is still being defined. Of particular controversy is the issue of laparoscopic colon resection for malignancy. The long-term effect of laparoscopic colectomy on either local or distant recurrence is not obvious in the immediate postoperative period, and how the use of the laparoscope for resection of colorectal malignancy will affect survival is unknown. This chapter reviews the published "USA Experience" with laparoscopic resection for colorectal cancer.

The increasing use of laparoscopic techniques in colorectal surgery is controversial. The technical feasibility of such methods is now beyond doubt; however, their clinical evaluation is at an early stage. The expectation that the laparoscopic approach would confer benefit to patients in terms of reduced postoperative pain and other morbidity has been questioned. The safety of these methods in neoplasia is unproven. This article presents those laparoscopic resectional techniques available to the colorectal surgeon. The authors' personal experience with these procedures is reviewed and those issues of controversy are discussed, with particular reference to the question of the suitability of these techniques for the treatment of malignancy.

Laparoscopic colectomy for both benign and malignant conditions has been performed in many institutions worldwide. Because of its recent inception, there has been little data available about follow-up in cancer patients. This prospective study assesses the operating statistics, postoperative complications, and long-term outcomes for 128 patients with colorectal cancer who were treated selectively with laparoscopic surgery. Median operating times for right hemicolectomy, anterior resection, and abdominoperineal resection were 3 hours, 3.3 hours, and 3.5 hours, respectively. For right hemicolectomy and anterior resection patients, the median postoperative stay was 6 days. This stay was 9 days for abdominoperineal patients. Open conversion occurred in 9 patients (7%). 30 patients suffered from some postoperative morbidity (23%). Of 102 potentially curative procedures, there have been 9 recurrences (8.8%) to date. Fifteen patients have died. There is a low incidence of intestinal ileus (3%) and wound infection (1.8%).

Laparoscopic skills and perceptions are an increasing part of the "surgical commonsense" of the younger surgeon. The part played by the laparoscope in colorectal surgery will thus increase gradually over the coming years, and this process is unlikely to be prevented by widespread doubts and scepticism, which are quite properly applied at this time to cancer surgey. Nevertheless, permanent cure and the absence of a stoma-thus, the avoidance of autonomic nerve damage—remain far more important to the patient than any of the advantages so far conferred by the laparoscopic approach. However, there is a possibility that improved visualization low in the pelvis, particularly with the development of newer and better instruments, will actually facilitate better dissection and more accurate deep pelvic surgery than has been possible by open surgery in the past. Copyright © 1995 by W. B. Saunders Company

Very little has been written concerning the use of laparoscopic techniques in inflammatory bowel disease. Its most useful indications appear to be in Crohn's disease, especially for intestinal diversions when severe perineal/ perianal sepsis occurs. In this instance, avoidance of a laparotomy is a major advantage, and the simplicity of a laparoscopic stoma formation makes this a procedure that most surgeons may perform, even with minimal laparoscopic experience. Laparoscopic techniques may also be used for the limited resections required in Crohn's ileal or ileocolonic disease and for diagnostic purposes when indicated. The laparoscopic approach to the surgical treatment of ulcerative colitis (total abdominal colectomy, possibly with proctectomy and ileoanal pouch formation) remains to be evaluated before it can be contemplated as an alternative to conventional procedures.

Acute appendicitis is a common condition, accounting for a substantial number of hospital days in all institutions and giving rise to considerable adverse economic and social consequences in the postoperative period. Laparoscopic appendicectomy offers several advantages over the open procedure. Diagnostic accuracy is improved. Postoperative morbidity, in particular wound infection, is reduced, as is postoperative pain, and cosmesis is improved. Discharge from hospital is hastened, as is return to normal activity and work. Surgical technique is detailed, including the approach to specific clinical scenarios such as perforated and retrocaecal appendicitis. The utilization of ultrasonically activated dissection for laparoscopic removal of the appendix is explained. The implications of laparoscopic appendicectomy for surgical training are discussed.

Rectal prolapse is a distressing condition often affecting elderly patients. Open rectopexy has a proven track record in the treatment of this condition but may be complicated by significant morbidity. The benign nature of the disease and reduced pain and pulmonary complications of the laparoscopic approach makes this an attractive operation in this patient group. Laparoscopic prosthesis fixation rectopexy and lateral ligament suspension with and without colectomy have been described with low recurrence rates, good patient acceptance, improvement in symptoms, and both radiological and physiological assessments, although these initial findings require further evaluation with prospective controlled trials.

The increasing use of the laparascopic approach in colorectal surgery depends not only on the indications but also on technological development. Better visualization of the operative field is available using a three-chip camera or three-dimensional system. Alternative port positionings together with curved instruments increase the degree of freedom during operation. Complex laparoscopic procedures need highly specific instruments. We have developed atraumatic bowel graspers, different types of retractors, and innovative combination instruments. OREST II, a new multipurpose system that assists the organization of laparascopic surgery is described.