TY - JOUR
AU - Marescaux, J
AB - Abstract Background This prospective study evaluated the technical aspects and microbiological consequences of laparoscopic resection with transanal specimen extraction and per ano transcolonic stapler anvil insertion in patients requiring elective operation for previous diverticulitis. Methods Laparoscopic sigmoid colectomy was performed with three ports, and specimen extraction carried out transanally through a complete opening of the rectal stump. A triple-stapled anastomosis restored colonic continuity. Systematic intraoperative bacteriological sampling was performed. Intraoperative data as well as microbiological and postoperative outcomes were evaluated prospectively. Results Sixteen consecutive patients were studied over a 6-month period. All procedures were technically satisfactory, with a mean(s.d.) operating time of 120·9(41·9) min. No conversion or additional access was required. Four of the 16 patients developed complications, but none required intervention. Although polybacterial growth was present in all peritoneal culture samples, no infection-related complications were observed. Two patients had an extended course of perioperative antibiotic cover owing to overt peritoneal cavity contamination during surgery, and in two further patients antibiotics were instituted empirically following the development of postoperative fever alone. Conclusion Transanal specimen extraction in addition to per ano transcolonic stapler anvil insertion allows laparoscopic sigmoid resection to be performed with just three ports. Although intraperitoneal bacterial contamination occurs, this does not appear to translate into infectious morbidity. Introduction An aim of minimally invasive surgery is to reduce postoperative pain and minimize transparietal wounds. Natural-orifice transluminal endoscopic surgery (NOTES) may represent the ultimate expression of this concept, but there remains considerable potential for advancement in the current laparoscopic operative technique that may provide advantages in terms of reduced abdominal wall injury. In colorectal surgery, the main focus in this regard is the wound required for specimen extraction and preparation of the proximal colon for reanastomosis. This wound is more likely to result in morbidity and cosmetic distress than the port access sites and does not allow fully intracorporeal laparoscopic practice. Although transanal specimen extraction has long been described and performed by selected expert advocates1–5, general interest in this approach has been initiated more recently by moves towards reduced-port laparoscopic surgery (including single-port colorectal resection6,7), inventive natural-orifice surgical intervention and hybrid laparoendoscopic techniques. Improved instrumentation and optical visualization is also conducive to this endeavour, as well as the validation and improved technical standardization of laparoscopic colorectal surgical techniques. However, although recent reports have consisted mostly of individual case experiences of simple feasibility8–10, if this technique is to have widespread dissemination each of its technical aspects requires full and proper evaluation, including careful consideration of any potential iatrogenic effects and assessment of potential benefit to patients. As a start in addressing some of these issues, this article describes a new concept in the technique of transanal colorectal extraction after laparoscopic sigmoidectomy that includes per ano transcolonic anvil insertion and fully intracorporeal anastomosis. A prospective study of the efficacy of the technique in a cohort of patients over a 6-month period was also undertaken. In addition, the tendency of the technique to induce abdominopelvic peritoneal bacterial contamination, and the clinical significance of this, was examined. Methods With full departmental and institutional ethics committee approval, a prospective study of patients undergoing elective laparoscopic sigmoidectomy for previous diverticulitis was performed between October 2009 and March 2010. For inclusion, patients must have had diverticulitis confirmed by computed tomography (CT) at presentation and have required emergency in-patient hospital admission with intravenous antibiotics. The indications for subsequently considering surgical intervention, including quality-of-life assessment, have recently been published elsewhere11 and are consistent with common continental European practice as outlined in a recent international consensus proposal12,13. In addition, for this specific study protocol for transanal specimen extraction and per ano transcolonic stapler anvil insertion, patients had to be aged between 18 and 85 years with an American Society of Anesthesiologists (ASA) grade of I or II, and a body mass index (BMI) of less than 30 kg/m2, and be scheduled for elective surgery under the colorectal surgeon in charge of the protocol. Patients undergoing elective surgery for non-diverticular disease or emergency or urgent laparoscopic sigmoidectomy for diverticulitis were excluded, as were those having surgery as part of the trainee mentorship or live congress demonstration programmes. Patients with clinical or radiological evidence of a sigmoid mass or fistula formation were also excluded from the study. Preoperative preparation In line with the authors' routine practice, a preoperative bowel enema preparation was administered the evening before surgery, in addition to an enema 2 h before the procedure. A single dose of a second-generation cephalosporin and metronidazole was administered during anaesthetic induction and repeated when surgery took more than 3 h. Standardized operative technique Once anaesthetized, the patient was placed supine in the lithotomy position and the following standardized operative technique was performed. A three-trocar laparoscopic approach was employed, with one 12-mm trocar placed periumbilically, another 12-mm trocar situated in the right iliac fossa (RIF) and one 5-mm trocar in the right flank. After ensuring good exposure of the root of the sigmoid mesocolon, a medial to lateral approach to the sigmoid vessels was employed. A 5-mm LigaSure™ blunt tip long probe (Covidien, Boulder, Colorado, USA) device was used to divide the inferior mesenteric artery beyond its left colic branch after clear identification of the left ureter and left gonadal vein. The lateral attachments of the sigmoid and descending colon were then divided caudad as far as the colorectal junction and cephalad towards the splenic flexure as far as necessary to ensure an adequate length for a tension-free colorectal anastomosis; that is, complete splenic flexure mobilization was performed selectively. The technical steps for transanal specimen extraction and a fully laparoscopic intracorporeal anastomosis were then performed as described below. Step 1 (Figs 1 and 2) The distal sigmoid colon was ligated with an extracorporeal suture positioned just above the colorectal junction in order to allow washing out of the now isolated rectal stump. Minimal transanal lavage with 500 ml povidone–iodine and normal saline solution was performed. Fig. 1 Open in new tabDownload slide Suture ligation placed around the distal sigmoid colon allowing washout of the colorectal stump and control of the proximal luminal stream Fig. 2 Open in new tabDownload slide a After complete mobilization of the specimen to be excised (the sigmoid colon), a suture tie is placed laparoscopically at the colorectum. b This allows the distal colorectum to be washed out fully using transanal lavage and controls the proximal luminal stream Step 2 (Fig. 3) The colorectal junction was then half opened on its medial aspect laparoscopically. A second suture was introduced via the 12-mm RIF trocar and fixed on to the medial corner of the distal aspect of the opened colorectal junction. By means of traction via the RIF port, this suture suspended and kept open the rectal stump. Thereafter, division of the colorectal junction was completed. Fig. 3 Open in new tabDownload slide The top of the rectum is opened and held by sutures placed laparoscopically Step 3 (Figs 4–6) Transanal exteriorization of the sigmoid colon was facilitated by means of a 5-mm atraumatic laparoscopic forceps inserted per ano and through the open rectal stump into the peritoneum. This forceps was used to grasp the suture that had earlier been tied around the distal sigmoid colon. The sigmoid colon was then pulled into the anus and out to the exterior until the diseased segment was accessible at the anus. A longitudinal colotomy was then made in the descending colon (above the site of evident disease but still within the specimen) and the anvil of a 28-mm DST series EEA™ circular stapler (Autosuture™; Covidien, Norwalk, Connecticut, USA) connected to a 2/0 suture was introduced. The anvil was then pushed in the proximal colon under laparoscopic control to a site just proximal to the point of intended proximal division. Fig. 4 Open in new tabDownload slide The rectum is completely opened below the level of the suture. a The sigmoid colon is delivered into the rectum and out through the anus to the exterior (note that the holding sutures in the rectum and the forceps used to extract the specimen per ano are not shown here). b A colotomy is made within the exteriorized specimen and the anvil inserted into the colonic lumen (a suture is fixed to the anvil pike). c The anvil is then pushed retrogradely into the descending colon and left above the level of the intended proximal transection site Fig. 5 Open in new tabDownload slide The distal transection can then be completed and the specimen delivered into the rectal stump and out to the exterior per ano Fig. 6 Open in new tabDownload slide Once the proximal sigmoid is exteriorized, a colotomy is made within the specimen and the anvil is placed into the colon. Note the suture affixed to the anvil before the anvil is pushed retrogradely into the descending colon Step 4 (Figs 7 and 8) Proximal transection of the colon was performed with an Endo-GIA™ linear stapler (Autosuture™; Covidien), entrapping the suture connected to the anvil so as to maintain its position in the descending colon and allow its retrieval later in the procedure. The remnant of the sigmoid colonic specimen was exteriorized transanally. The open cuff of colorectum (the rectal stump) was stapled across with a new application of the Endo-GIA™ linear stapler. Fig. 7 Open in new tabDownload slide After the proximal colon is divided and the distal sigmoid extracted transanally, the rectal stump is cross-stapled to close it and the divided cuff is extracted through the 12-mm right iliac fossa port in a specimen retrieval bag Fig. 8 Open in new tabDownload slide a Proximal stapled transection is then performed and b the rest of the specimen delivered transanally. c The open rectal stump is then stapled to close it over and the cuff removed through the 12-mm abdominal port Step 5 (Figs 9 and 10) The anvil in the proximal colon was then exteriorized on the antimesenteric side of the staple line of the distal descending colon by means of a hook placed through a colotomy made adjacent to the staple line. This hook was used to snare the suture attached to the anvil and facilitate its withdrawal. A purse-string suture was fashioned around the shaft of the anvil to secure its position. After detachment of the removable spike of the anvil (and its extraction through the 12-mm RIF trocar), the anastomosis was created in the conventional end-to-end fashion. The mesenteric defect was closed with either clips or sutures to avoid the risk of postoperative internal herniation14. Fig. 9 Open in new tabDownload slide The anvil pike is delivered through a colotomy made adjacent to the proximal transection staple line (this is achieved by passing a hook instrument into the colotomy and pulling the suture which is attached to the anvil pike and also caught in the staple line). The anvil pike is secured in position by means of an endoloop Fig. 10 Open in new tabDownload slide a A small colotomy is made adjacent to the staple line of the proximal colon and a hook used to catch the suture fixed to the anvil and withdraw the anvil pike into the colotomy. b A purse-string suture is then applied. c A standard mechanical anastomosis is constructed Microbiological samples and analysis To evaluate the presence and extent of abdominopelvic intraperitoneal contamination during the procedure, a sample of pelvic fluid was taken at completion of the final laparoscopic step of the surgery. Both direct bacteriological examination and routine aerobe/anaerobe bacterial culture were performed on this sample. Because of the novel nature of the surgical technique, the surgical team was not blinded to the results of the analysis and a low threshold for empirical postoperative antibiotic usage was agreed before the study. Clinical data Specimen pathology as well as postoperative outcome and the length of hospital stay were recorded prospectively. Clinical and biochemical parameters were recorded sequentially, including daily white blood cell (WBC) count and C-reactive protein (CRP) measurements. Adverse events were classified using the Clavien–Dindo classification15. Statistical analysis Continuous variables are given as mean(s.d.) values. Factorial data were recorded on Microsoft® Excel (Microsoft, Redmond, Washington, USA) worksheets and SPSS® software version 16.0 (SPSS, Chicago, Illinois, USA) was used to calculate crude statistics regarding the study population. Results During the study period, 16 patients were included in this prospective study (Table 1). Each patient had radiologically confirmed previous diverticulitis with a mean time between last attack and admission for surgery of 43·3(7·1) days. The mean age of the study group was 61·2(10·1) years; 12 patients were women. Mean BMI was 24·7(3·4) kg/m2. Six patients had ASA grade I disease. Twelve patients had undergone at least one previous abdominal operation. Table 1 Patients presenting for laparoscopic sigmoidectomy over the 6-month period by inclusion or exclusion from the study protocol . No. of patients . Included patients 16  Diagnosis at initial presentation*   Hinchey I† 4   Hinchey II† 10    IIa 8    IIb 2   Chronic left iliac fossa pain after second episode† 2 Excluded patients 25  Reason for exclusion   Non-diverticular disease    Cancer 6    Postradiotherapy sigmoid stricture 1    Sigmoid polyp not amenable to endoscopic 1     resection   Emergency surgery for acute sigmoid 2    diverticulitis   Other elective operation for sigmoid diverticular 7    disease   Training including live congress demonstration of 4    conventional technique   Body mass index > 30 kg/m2 4 . No. of patients . Included patients 16  Diagnosis at initial presentation*   Hinchey I† 4   Hinchey II† 10    IIa 8    IIb 2   Chronic left iliac fossa pain after second episode† 2 Excluded patients 25  Reason for exclusion   Non-diverticular disease    Cancer 6    Postradiotherapy sigmoid stricture 1    Sigmoid polyp not amenable to endoscopic 1     resection   Emergency surgery for acute sigmoid 2    diverticulitis   Other elective operation for sigmoid diverticular 7    disease   Training including live congress demonstration of 4    conventional technique   Body mass index > 30 kg/m2 4 * All patients had diverticulitis documented by computed tomography at presentation16. † All patients underwent medical treatment alone at presentation; no radiological drainage procedures were performed. Open in new tab Table 1 Patients presenting for laparoscopic sigmoidectomy over the 6-month period by inclusion or exclusion from the study protocol . No. of patients . Included patients 16  Diagnosis at initial presentation*   Hinchey I† 4   Hinchey II† 10    IIa 8    IIb 2   Chronic left iliac fossa pain after second episode† 2 Excluded patients 25  Reason for exclusion   Non-diverticular disease    Cancer 6    Postradiotherapy sigmoid stricture 1    Sigmoid polyp not amenable to endoscopic 1     resection   Emergency surgery for acute sigmoid 2    diverticulitis   Other elective operation for sigmoid diverticular 7    disease   Training including live congress demonstration of 4    conventional technique   Body mass index > 30 kg/m2 4 . No. of patients . Included patients 16  Diagnosis at initial presentation*   Hinchey I† 4   Hinchey II† 10    IIa 8    IIb 2   Chronic left iliac fossa pain after second episode† 2 Excluded patients 25  Reason for exclusion   Non-diverticular disease    Cancer 6    Postradiotherapy sigmoid stricture 1    Sigmoid polyp not amenable to endoscopic 1     resection   Emergency surgery for acute sigmoid 2    diverticulitis   Other elective operation for sigmoid diverticular 7    disease   Training including live congress demonstration of 4    conventional technique   Body mass index > 30 kg/m2 4 * All patients had diverticulitis documented by computed tomography at presentation16. † All patients underwent medical treatment alone at presentation; no radiological drainage procedures were performed. Open in new tab The operative technique was followed as described in all patients, with no intraoperative complications, and no deviation or additional abdominal access being required. The mean operating time was 120·9(41·9) min, and the mean length of specimen excised was 27·7(7·0) cm. Two patients had macroscopically evident contamination of the peritoneal cavity owing to suboptimal preoperative bowel preparation, as was manifest by the anvil spike being coated with faecal content on its extraction in preparation for the anastomosis. Although no overt, direct faecal spillage into the abdomen was apparent, it was considered prudent to provide a further 3-day antibiotic course for these patients after the routine perioperative regimen. Direct bacterial examination of intraoperative samples was negative in all patients. Sample fluid culture, however, was positive for polybacterial growth in all 16 patients, and demonstrated the expected spectrum of microbial pathogens. Mixed aerobic/anaerobic bacteria were present in 13 patients, with Escherichia coli the most common aerobic pathogen (present in 11 patients) and Bacteroides fragilis the most frequent anaerobe (8 patients). Both E. coli and B. fragilis were found in pelvic intraoperative samples from six patients. All patients commenced oral diet on the first postoperative day, and the first postoperative bowel movement occurred a mean of 23·2(9·0) h after surgery. The mean hospital stay was 6·1(2·4) days. WBC counts were within normal limits in all patients on every postoperative day (mean count 7825(2326) cells/mm3), and CRP level followed the typical trend of an early postoperative increase with normalization by 5 days after surgery. No patient had clinically evident sepsis or an anastomotic complication. Although well, two patients spiked a fever on postoperative days 3 and 5 respectively. Radiological examinations including abdominal CT revealed no evidence of an intra-abdominal collection or complication. Because these patients were known to have positive peritoneal cultures, a course of antibiotics was considered prudent. No overt infectious sequelae were manifest, but one of these patients developed antibiotic-related Clostridium difficile colitis. This was treated with vancomycin and settled. One further patient developed transient epigastric pain with no apparent specific cause; the oral analgesia schedule was modified. Thus, according to the Clavien–Dindo classification, there were one grade I and three grade II complications in the 16 patients. Discussion Operative technique continues to evolve but there remains a clear requirement to balance innovative proposals with caution regarding potential indirect adverse sequelae. Although dramatic in its initial concept, if NOTES is to emerge as a distinct, useful, operative approach, it will probably do so best as a result of the gradual evolution of adapted laparoscopic (and endoscopic) practice. Similarly, the evolution of laparoscopic techniques is already benefiting from the NOTES endeavour, as it is increasingly clear that the contamination (as opposed to overt infection) that may result from controlled opening of the bowel has been well tolerated in both experimental and initial, limited, clinical experience1,8,17. One of the most enabling principles of laparoscopic colorectal surgery has been the development and validation of double-stapled anastomosis. This was initially described by Knight and Griffen18, who used a linear stapler to divide the rectum and a circular mechanical stapler introduced transanally to achieve an end-to-end colorectal anastomosis. Its worldwide adoption has resulted from its many advantages, including technical ease and speed as well as its associated increased distal margin resection and minor clinical and radiological leakage rates, compared with hand-sewn or single stapling techniques19–22. Theoretically, however, its major benefit over hand-sewn anastomosis is avoidance of the potential for intra-abdominal bacterial contamination by the absence of rectal stump opening during the procedure17,23,24. In this regard, in 1996 Miller and Moritz21 evaluated bacterial contamination resulting from the application of a single or double stapling technique for rectal cancer in open surgery (taking samples from drains). The single stapling technique resulted in significantly increased lysozyme enzyme activity compared with the double technique, indicating probable increased bacterial contamination20. Saida and co-workers17 also demonstrated bacterial contamination in the abdominal cavity for both open (49 per cent) and laparoscopic (28 per cent) procedures for non-obstructive colorectal cancer. Thus, leaving the rectal stump open to facilitate specimen extraction seems likely to counteract one of the benefits of mechanical stapling. Transanal extraction of laparoscopic colorectal specimens does have clear potential advantages. In particular, it reduces both the size and the length of associated abdominal incisions. This could further reduce the risk of wound dehiscence, herniation and superficial surgical-site infectious morbidity (which is reported to be as high as 11 per cent25) as well as potentially decreasing postoperative narcotic use and hospital stay26,27. Additionally, the minimization of skin scarring has been construed as a major cosmetic benefit. Such a route of specimen extraction has already been evaluated several times in both paediatric and colorectal surgery4–6,28 (including laparoscopic colectomy7,8,24). However, different authors have described considerably different methods of achieving their goal, with varying numbers of ports, lengths of colonic mobilization, use or non-use of multiple transanal endoscopic operating devices, and benign and malignant pathologies1,8,9,29. The present series has confirmed that the use of a standardized protocol can contribute to successful systematic procedures using transanal specimen extraction for benign diseases, and has demonstrated safety in a sequential experience of this technique for fully laparoscopic intracorporeal anastomosis. The present intraoperative and postoperative outcomes as well as morbidity rates were similar to those reported previously9,15,30. This experience also corroborates previous experience of bacterial contamination by showing the systematic growth of intestinal bacterial flora in all pelvic samples following transanal extraction. The authors assume that contamination is a direct result of colonic opening during the procedure. As no anastomotic leakage or overt pelvic infection was observed in the present series, it can be concluded that the presence of intestinal bacteria in the pelvis does not necessarily lead to infection-related complications. Clearly, however, prudence is required in the advancement of this technique, as is cautioned by the case of iatrogenic C. difficile, because extended perioperative antibiotic use cannot be seen as a panacea. Therefore, as well as perfecting the technique, other methods of protecting the abdominal cavity from contamination need to be considered as investigative work in this field continues. Acknowledgements The authors declare no conflict of interest. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Laparoscopic resection with transanal specimen extraction for sigmoid diverticulitis
JF - British Journal of Surgery
DO - 10.1002/bjs.7517
DA - 2011-07-25
UR - https://www.deepdyve.com/lp/oxford-university-press/laparoscopic-resection-with-transanal-specimen-extraction-for-sigmoid-UW4G4bAXNF
SP - 1327
EP - 1334
VL - 98
IS - 9
DP - DeepDyve
ER -