Laparoscopy for Ischemia

Howard Ross, MD, FACS, FASCRS

Chief, Colon and Rectal Surgery

Director, Crohn’s and Colitis Management Center

Riverview Medical Center

Clinical Associate Professor of Surgery UMDNJ

Disclosures• Consultant and Course Director:

– Applied Medical– Covidien

•Poked fun at NJ my entire life….Now I live there!

Laparoscopy for Ischemia

?

Open Operation

Ischemia

Ischemia

Literature Results: Laparoscopic Surgery for Ischemic Colitis

• Nil

Second look laparoscopy after mesenteric infarct

Second-look laparotomy is not always routinely performed after mesenteric infarction because of the high operative risk

• Authors developed a minimally invasive technique for second-look laparoscopy

• Aim to decrease the operative morbidity– old incision is opened at the umbilicus– suture lifted with a clamp and the incision line is gently

reopened – trocar with a blunt tip inserted – It was possible to explore the entire small bowel and

colonGlättli A, Seiler C, Metzger A, Stirnemann P, Baer HU. Universitätsklinik für Viszerale und Transplantationschirurgie, Inselspital, Bern, Schweiz

Langenbecks Arch Chir. 1994;379(2):66-9.

Second look laparoscopy after mesenteric infarct

• Five patients after bowel resection performed for mesenteric infarction – Second-look laparoscopy was diagnostic in all

but one– Laparoscopy failed due to massive small

bowel dilatation

Glättli A, Seiler C, Metzger A, Stirnemann P, Baer HU. Universitätsklinik für Viszerale und Transplantationschirurgie, Inselspital, Bern, SchweizLangenbecks Arch Chir. 1994;379(2):66-9.

Laparoscopic Colon Resection in Emergent Situations

• Toxic Colitis

• Diverticultis

• Crohn’s Disease

…One can to extrapolate to ischemia

Laparoscopy for Toxic Colitis• Limited number of studies describing the role of minimally invasive

colectomy for urgent or emergent conditions of the large bowel

• Single institution (Cornell) 2001-6 identified from a prospective database

• Urgent and emergent conditions were included

• 68 [open 32, MIS 36 [HALS 22, LAP 14)]

• Patients with toxic colitis were more often selected for MIS

• Patients with colon perforation or large bowel obstruction were more often selected for open surgery

– No difference in morbidity

– MIS group had a longer median operative time and fewer cases of prolonged hospitalization

Colorectal Dis. 2010 May;12(5):480-4. Epub 2009 Mar 26.

•Minimally invasive surgery is safe and effective for urgent and emergent colectomy

Laparoscopic two-stage left colonic resection for patients with peritonitis

caused by acute diverticulitis

• Emergent Open Hartmann's procedure is standard for complicated disease– abscess, peritonitis, and stenosis

• The advantages of laparoscopy could be combined with

those of the primary resection

• Laparoscopic Hartmann's procedure seldom reported– technical difficulties – theoretic risk of poorly controlled sepsis

•Chouillard E, Maggiori L, Ata T, Jarbaoui S, Rivkine E, Benhaim L, Ghiles E, Etienne JC, Fingerhut A. Department of General and Minimally Invasive Surgery, Centre Hospitalier Intercommunal, 10, rue du Champ Gaillard, Poissy, France.

Laparoscopic two-stage left colonic resection for patients with peritonitis

caused by acute diverticulitis

• Data were prospectively collected from 2003 -5 in a single center • Laparoscopic Hartmann's procedure (Stage 1) was performed in

selected patients with peritonitis complicating acute diverticulitis. • Secondarily, Hartmann's reversal (Stage 2) also was performed

laparoscopically.• Thirty-one patients were studied

– Median Mannheim Peritonitis Index score was 21 (+/-5; range, 12-32)

– Conversion rate was 19 and 11 percent for Stage 1 and Stage 2, respectively

– There was no perioperative uncontrolled sepsis

– Overall operative 30-day mortality and morbidity rates were 3 and 23 percent for Stage 1, and 0 and 15 percent for Stage 2, respectively.

– Stoma reversal was possible in 90 percent of patients.

•Chouillard E, Maggiori L, Ata T, Jarbaoui S, Rivkine E, Benhaim L, Ghiles E, Etienne JC, Fingerhut A.

Long-term experience with the laparoscopic approach to perforated diverticulitis plus

generalized peritonitis

• laparoscopic peritoneal lavage, inspection of the colon, and intraoperative drain placement of the peritoneal cavity for complicated acute diverticulitis and peritonitis without gross fecal contamination

• Texas Endosurgery Institute from 1991 - 2006 retrospectively reviewed• 40 patients, average age was 60, (many with associated co-morbidities)

– average operating time was 62 minutes– no conversions to an open procedure. – paralytic ileus in six patients and chest infections in two

• Just over 50% underwent elective interval laparoscopic sigmoid colectomy• During the mean follow-up of 96 months, none of the other patients required

further surgical intervention.

•Franklin ME Jr, Portillo G, Treviño JM, Gonzalez JJ, Glass JL. World J Surg. 2008 Jul;32(7):1507-11.

Franklin Conclusions

• decrease in the overall cost of treatment• colostomy is avoided • reduction in mortality and morbidity as definitive

laparoscopic resection can be performed in a nonemergent fashion

• fewer wound complications such as dehiscence, wound infection, and the high risk of hernia formation

• Laparoscopic lavage and drainage should be considered in all patients in whom medical and/or percutaneous treatment is not feasible...should be considered the standard of care.

Franklin ME Jr, Portillo G, Treviño JM, Gonzalez JJ, Glass JL. World J Surg. 2008 Jul;32(7):1507-11.

Laparoscopic Colectomy for Crohn’s Disease

National Trends and Outcomes for the Surgical Therapy of Ileocolonic Crohn’s Disease:A Population-Based Analysis of Laparoscopic vs. Open Approaches

•All admissions with a dx of Crohn’s selected

from Nationwide Inpatient Sample 2000–4

•396,911 patients admitted for Crohn’s disease

•49,609 (12%) required surgical treatment

•Laparoscopic resection in 2,826 cases (6%)

J Gastrointest Surg (2009) 13:1251–1259

Meta-analysis Lap vs. Open Ileocolic Resection

• H. S. Tilney, V. A. Constantinides, A. G. Heriot, M. Nicolaou, T. Athanasiou, P. Ziprin, A. W. Darzi, P. P. Tekkis

• 20 studies identified by review of Medline, Ovid, Embase, and Cochrane databases

• 15 satisfied inclusion criteria, 783 patients • 338 (43.2%) had laparoscopic resection• Conversion rate 6.8%• Operative time 29.6 min longer in laparoscopic group (p = 0.002)• Blood loss and complications similar• Laparoscopic patients

– significantly shorter time for recovery of their enteric function – shorter hospital stay, by 2.7 days (p < 0.001)

The contraindications to laparoscopic approaches for Crohn’s disease remain undefined

Surg Endosc (2006) 20: 1036–1044

Laparoscopic resection for Crohn’s disease: an experience with 335 cases

• Pts identified since 1993• 117 patients with fistula, 45% multiple• 80 enteroenteric, 51 ileosigmoid, 33 enteroabdominal

wall, 22 ileovesical fistulas• Eight conversions occurred (2%), primarily because of

large inflammatory masses involving the intestinal mesentery

We believe all operations should initially be approached laparoscopically and that no cases should be considered for an open operation, not even a tertiary or quaternary resection

Salky Surg Endoscopy Published Online 05 March 2009

Emergency Laparoscopic Colectomy: Does it Measure Up to Open?

• Patients from prospective database who underwent an emergency colectomy 2005-8

• Laparoscopic operations in 42 compared to 25 suitable for laparoscopy but received open colectomy

• Blood loss was lower (118ml vs. 205ml, p <0.01) • Postoperative stay shorter (8 vs.11 days, p = 0.02) • Perioperative mortality rates were similar between the

two groups (1 vs. 3, p = 0.29)

• laparoscopic colectomy is a feasible option in certain emergency situations…

Jonah J. Stulberg, M.P.H.1,2, Brad J. Champagne, M.D.1, Zhen Fan, M.D.1, Mike Horan, DDS,PhD3, Vincent Obias, M.D.1, Eric Marderstein, M.D., M.P.H.1, Harry Reynolds, M.D.1, andConor P. Delaney, M.D., Ph.D., M.Ch.11 University Hospitals Case Medical Center, Department of Surgery

Am J Surg. 2009 March ; 197(3): 296–301

Emergency Laparoscopic Colectomy: Does it Measure Up to Open?

• Diagnoses:– bowel obstruction– perforated viscus – fulminant colitis– ischemia – uncontrollable gastrointestinal hemorrhage

• Excluded: – severe hemodynamic lability on inotropes – toxic megacolon – peritonitis in the setting of morbid obesity– prior colectomy – body mass index > 55

Guidelines

• Not possible in all patients– Unstable patient – Massively distended bowel– ? Morbidly obese, Prior Laparotomy

• Patient Safety is Paramount

• Rapid, Efficient Operation Must Occur

• Careful handling of fragile tissue

Laparoscopy is a tool