Extraction sites for colon resection: What’s out there right now?

Extraction sites for colon resection: What’s out there right now?

Morris E. Franklin Jr MD. F.A.C.S.

Director Texas Endosurgery Institute

Karla Russek, MD.

Research Fellow

Morris E. Franklin Jr MD. F.A.C.S.

Director Texas Endosurgery Institute

Karla Russek, MD.

Research Fellow

MISS meeting 2010MISS meeting 2010

Industry relationshipsIndustry relationships• W.L. Gore & AssociatesW.L. Gore & Associates

– Grant/research support, consultant and speaker bureauGrant/research support, consultant and speaker bureau• CovidienCovidien

– Grant/research support, consultant and speaker bureauGrant/research support, consultant and speaker bureau• StrikerStriker

– Consultant, advisory boardConsultant, advisory board• EthiconEthicon

– Consultant and speaker bureauConsultant and speaker bureau• AtriumAtrium

– ConsultantConsultant• AesculapAesculap

– ConsultantConsultant• KCIKCI

– ConsultantConsultantThe Authors do not have financial interestThe Authors do not have financial interestwith the above mentioned companieswith the above mentioned companies

A major advantage of laparoscopic surgery (small incisions) must be balanced with the need to remove and

preserve specimens

A major advantage of laparoscopic surgery (small incisions) must be balanced with the need to remove and

preserve specimens

Types of specimensTypes of specimensTypes of specimensTypes of specimens

• Benign• Malignant• Infected• Over size• Hollow/solid• Others

• Benign• Malignant• Infected• Over size• Hollow/solid• Others

Types of specimensTypes of specimensTypes of specimensTypes of specimens

• Benign

• Malignant

• Infected

• Over size

• Hollow/solid

• Others

• Benign

• Malignant

• Infected

• Over size

• Hollow/solid

• Others

Should all laparoscopic specimens be extracted with a bag or protective

sleeve ?

Wound protectorsWound protectorsWound protectorsWound protectors

• Plastic sheaths used to line a wound during surgery

• Camera sleeve• Commercially available• Avoid infection, port site metastasis.

• Plastic sheaths used to line a wound during surgery

• Camera sleeve• Commercially available• Avoid infection, port site metastasis.

Bags for specimen Bags for specimen confinement and retrieval confinement and retrieval

Bags for specimen Bags for specimen confinement and retrieval confinement and retrieval

• Commercially available

• Gloves

• Gloves’ fingers

• Condoms

• Others– Freezer bags

– Orthopedic bags

• Commercially available

• Gloves

• Gloves’ fingers

• Condoms

• Others– Freezer bags

– Orthopedic bags

Bag considerationsBag considerationsBag considerationsBag considerations• Strength

• Size

• Aperture

• Maneuverability

• Easy of deployment

• Easy of retrieval

• Porosity

• Strength

• Size

• Aperture

• Maneuverability

• Easy of deployment

• Easy of retrieval

• Porosity

Bag UtilizationBag UtilizationBag UtilizationBag Utilization

• Insertion– Roll and insert

• Bag deployment– Pull out

– Use two graspers

• Insertion– Roll and insert

• Bag deployment– Pull out

– Use two graspers

• Specimen entrapment– Triangulate the opening– Allow sufficient working space– Grasp connective tissue at the organ

appendages, no the organ itself– Use of gravity– Trendelenburg + reverse Trendelenburg

• Specimen entrapment– Triangulate the opening– Allow sufficient working space– Grasp connective tissue at the organ

appendages, no the organ itself– Use of gravity– Trendelenburg + reverse Trendelenburg

Bag UtilizationBag UtilizationBag UtilizationBag Utilization

Bag retrievalBag retrievalBag retrievalBag retrieval

• Bag closure– Drawstring– Ligasure– Clips

• Bag extraction– Constant laparoscopic visual control– Avoid puncturing or tearing the bag

• Bag closure– Drawstring– Ligasure– Clips

• Bag extraction– Constant laparoscopic visual control– Avoid puncturing or tearing the bag

ColonColon

Complications of specimen Complications of specimen extractionextraction

Complications of specimen Complications of specimen extractionextraction

• Specimen loss

• Specimen rupture

• Wound infection

• Tumor implantation

• Visceral injury

• Incisional hernia

• Specimen loss

• Specimen rupture

• Wound infection

• Tumor implantation

• Visceral injury

• Incisional hernia

The best method for removal depends on the size, location, and nature of the specimen

The best method for removal depends on the size, location, and nature of the specimen

Routes for Specimen RemovalRoutes for Specimen RemovalRoutes for Specimen RemovalRoutes for Specimen Removal

• Port site

• Midline incision

• Pfannestiel incision

• Muscle splitting incision

• Natural orifices

• Port site

• Midline incision

• Pfannestiel incision

• Muscle splitting incision

• Natural orifices

Port Site RemovalPort Site RemovalPort Site RemovalPort Site Removal

• Small specimens

• With or without a reducing sleeve

• Under direct laparoscopic visualization

• Small specimens

• With or without a reducing sleeve

• Under direct laparoscopic visualization

Port Site RemovalPort Site RemovalPort Site RemovalPort Site Removal

Midline incision Midline incision Midline incision Midline incision • Requires only a single layer fascia division• Can remove large and very large

specimens• Hernia formation 20-20% incidence• The longer the incision, the greater the

incidence of hernia formation• Used extensively in SILS surgery

• Requires only a single layer fascia division• Can remove large and very large

specimens• Hernia formation 20-20% incidence• The longer the incision, the greater the

incidence of hernia formation• Used extensively in SILS surgery

Does the extraction-site location in Does the extraction-site location in laparoscopic colorectal surgerylaparoscopic colorectal surgery

have an impact on incisional hernia rates?have an impact on incisional hernia rates?

Does the extraction-site location in Does the extraction-site location in laparoscopic colorectal surgerylaparoscopic colorectal surgery

have an impact on incisional hernia rates?have an impact on incisional hernia rates?

• Prospective study of 208 patients

• Hernia incidence of 7.8%

• Midline incision hernia incidence

of 17.6

• Prospective study of 208 patients

• Hernia incidence of 7.8%

• Midline incision hernia incidence

of 17.6

Ravinder Singh, Alex Omiccioli, Susan Hegge, Craig McKinley. Surg Endosc 2006Ravinder Singh, Alex Omiccioli, Susan Hegge, Craig McKinley. Surg Endosc 2006

• A large Cochrane study which included 33 randomized control trials and 3346 patients reported:

– Incidence of incisional hernias (different extraction sites): 7.9% vs. 10.9% (open colectomy)

• A large Cochrane study which included 33 randomized control trials and 3346 patients reported:

– Incidence of incisional hernias (different extraction sites): 7.9% vs. 10.9% (open colectomy)

Long-term results of laparoscopic colorectal cancer resectionKuhry E, Schwenk W, Gaupset R, Romild U, Bonjer HJLong-term results of laparoscopic colorectal cancer resectionKuhry E, Schwenk W, Gaupset R, Romild U, Bonjer HJ

Muscle splitting incisionMuscle splitting incisionMuscle splitting incisionMuscle splitting incision

• Hernia formation reduced

• Lower Infection rate

• Less Pain ?

• Hernia formation reduced

• Lower Infection rate

• Less Pain ?

Pfannenstiel incisionPfannenstiel incisionPfannenstiel incisionPfannenstiel incision

• Used extensively by urologists as a kidney extraction site

• Less pain

• Cosmesis

• Used extensively by urologists as a kidney extraction site

• Less pain

• Cosmesis

Matthew L. Steinway, M.D., Irma J. Lengu, M.D., Edward E. Cherullo, M.D., and Lee E. Ponsky, M.D. Laparoendoscopic Single-Site (LESS) Nephrectomy Through a Pfannenstiel Incision: Porcine Model. Journal of Endourology 2009

Matthew L. Steinway, M.D., Irma J. Lengu, M.D., Edward E. Cherullo, M.D., and Lee E. Ponsky, M.D. Laparoendoscopic Single-Site (LESS) Nephrectomy Through a Pfannenstiel Incision: Porcine Model. Journal of Endourology 2009

Pfannenstiel incisionPfannenstiel incisionPfannenstiel incisionPfannenstiel incision

• No studies as a colon extraction site

• Hand-assist technique

• Has been used as a liver extraction site for laparoscopic resections

• No studies as a colon extraction site

• Hand-assist technique

• Has been used as a liver extraction site for laparoscopic resections

A Simple Technique for Large Tumor Removal During Laparoscopic Liver ResectionTeixeira, Antonio Roberto F. MD; Pilla, Victor F. MD; Makdissi, Fábio F. MD; Machado, Marcel Autran C. MD. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques: December 2008

A Simple Technique for Large Tumor Removal During Laparoscopic Liver ResectionTeixeira, Antonio Roberto F. MD; Pilla, Victor F. MD; Makdissi, Fábio F. MD; Machado, Marcel Autran C. MD. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques: December 2008

Natural OrificesNatural OrificesNatural OrificesNatural Orifices

• Decrease body insult

• Avoid incisional hernias

• Lower infection rate

• NOTES approach

Natural OrificesNatural OrificesNatural OrificesNatural Orifices

• Transgastric

• Transanal

• Transvaginal

• Others

• Transgastric

• Transanal

• Transvaginal

• Others

Selected casesSelected casesSelected casesSelected cases

Texas Endosurgery InstituteTexas Endosurgery InstituteExperienceExperience

Texas Endosurgery InstituteTexas Endosurgery InstituteExperienceExperience

• Muscle splitting incision

– Right lower quadrant 192 patients

– Left lower quadrant 210 patients

– Midline incision 137 patients

• Muscle splitting incision

– Right lower quadrant 192 patients

– Left lower quadrant 210 patients

– Midline incision 137 patients

Texas Endosurgery InstituteTexas Endosurgery InstituteExperienceExperience

Texas Endosurgery InstituteTexas Endosurgery InstituteExperienceExperience

• NOTES

– Transanal extraction 227 patients

– Transvaginal extraction 25 patients

• NOTES

– Transanal extraction 227 patients

– Transvaginal extraction 25 patients

Muscle splitting extractionMuscle splitting extractionMuscle splitting extractionMuscle splitting extraction

Transanal benign diseaseTransanal benign diseaseTransanal benign diseaseTransanal benign disease

Transanal malignant Transanal malignant diseasedisease

Transanal malignant Transanal malignant diseasedisease

Transvaginal extractionTransvaginal extractionTransvaginal extractionTransvaginal extraction

Morcellation of specimensMorcellation of specimensMorcellation of specimensMorcellation of specimens

• Futuristic ?

• Specimen can be evaluated for

histology but not for pathological

staging

• Cosmetically desirable

• Futuristic ?

• Specimen can be evaluated for

histology but not for pathological

staging

• Cosmetically desirable

ConclusionsConclusionsConclusionsConclusions

•Determine extraction site by

lesion localization and etiology

•Importance of wound

protection

•Determine extraction site by

lesion localization and etiology

•Importance of wound

protection

ConclusionsConclusionsConclusionsConclusions

•Always use a bag for

extraction!!!!

•Always use a bag for

extraction!!!!

“Imagination is more important than knowledge. For knowledge is

limited to all we now know and understand, while imagination

embraces the entire world, and all there ever will be to know and

understand.”

“Imagination is more important than knowledge. For knowledge is

limited to all we now know and understand, while imagination

embraces the entire world, and all there ever will be to know and

understand.”

Albert Einstein

Albert Einstein

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