UW CVES: Laparoscopic Cholectomy


		LAPAROSCOPIC COLECTOMY The colon or large bowel is part of the intestine. It transfers waste material from the small bowel to the rectum and functions to store the waste and to absorb water from waste material. The colon is also responsible for bacterial production and absorption of certain vitamins. On occasion, removal or resection of a portion of the colon (or the entire organ) becomes necessary. Reasons for partial removal include infectious or inflammatory problems such as complications of diverticulitis and ulcerative colitis, poor blood supply, bleeding lesions, polyps, and cancers. The exact indications for removal of a portion of the colon in any given patient may be complex and should be carefully discussed with a surgeon. Laparoscopic colectomy is the technique of using the laparoscope for surgical removal of a portion of the colon. This is a relatively new addition to the range of procedures that are carried out using videoendoscopic techniques, in part because it requires skills and techniques that have only recently been developed. While a totally laparoscopic procedure is reasonable for some diseases, in many cases, the laparoscope is used as an adjunct to a more traditional open procedure. Laparoscopic dissection of the colon and mesentery followed by a small open incision for the actual tissue removal and reanastomosis or reconnection of the bowel is a technique more properly termed laparoscopically-assisted colectomy. In both cases, laparoscopic techniques have proven useful for dissection of the mesentery (blood supply) of the colon, and mobilization of the diseased portion. Preoperative localization of the diseased or abnormal section of the colon is essential for the laparoscopic approach. Sometimes, disease processes are clearly visible with a laparoscope but many diseases predominately involve the mucosa or lining of the colon. Polyps and many early tumors have this characteristic. For accurate removal of the right part of the colon, it is imperative that the surgeon have accurate preoperative localization. With this information, a plan for removal can be made. In preparation for laparoscopic colectomy, the patient is asked to completely clean the bowel. This is a crucial step if the bowel is to be opened safely within the peritoneal cavity, or even manipulated safely through small incisions. Following adequate bowel preparation, the patient is placed under general anesthesia and positioned for the operation. Since the effects of gravity to displace tissues and organs away from the site of operation are very important, patients are carefully positioned, padded, and strapped to the operating table to prevent slippage or movement when the patient is tilted to an extreme degree. Following this preparation, an initial injection of carbon dioxide, the gas used to create a working space in the abdomen, is achieved through the umbilicus. An initial port is usually placed here also. Next, the site of disease is considered and a plan generated to place ports, valved conduits that traverse the abdominal wall, in strategic positions through the abdominal wall. These ports allow the videoendoscope and necessary instruments to be brought to the site of the disease without losing the gas that holds the abdominal cavity open. Additional ports (either 5 or 12 mm in diameter) may inserted to allow all the necessary instruments to be brought into the operative field. For colectomy, up to 5 or 6 ports may be necessary depending on the extent of the dissection. Once an adequate view of the operative field is obtained, the actual dissection of the colon may begin. In all colon surgery, there are only three maneuvers though they may vary in difficulty depending on the region of the bowel and the nature of the disease. These three maneuvers are: 1) retraction of the colon, 2) division of the attachments to the colon, and 3) dissection of the mesentery. In the diagram, one instrument holds the hepatic flexure of the colon up while additional instruments are used for dissecting the mesentery. Prior to this maneuver, attachments to the liver and the small bowel were divided. Once the mesenteric vessels have been dissected and divided, the colon is divided with specially designed stapling devices that close off the bowel while simultaneously cutting between the staple lines. Alternatively, in a laparoscopically-assisted procedure, a small abdominal wall incision is made at this point to bring the bowel outside of the abdomen, allowing open bowel resection and reconnection using standard instruments. This technique is preferred by many surgeons since an incision must be made to remove the bowel specimen from the abdomen and the most time consuming and risky parts of the procedure (from a standpoint of infection risk), are done outside the body with better control of the bowel and more familiar instruments. The advantages of laparoscopic colectomy and laparoscopically-assisted colectomy are similar to those claimed for most other videoendoscopic procedures: smaller incisions, less pain, and a shorter recovery. Less exposed bowel means earlier bowel function, earlier diet, and a potentially earlier discharge from the hospital. However, the technical demands of the procedure require a high level of training and expertise. These operations commonly take longer and require a significant expenditure for equipment in the operating room, partially offsetting the financial benefits of a shorter hospital stay. Further, there is an as yet unresolved debate regarding the risk of cancer spread during curative laparoscopic colectomy for colon cancer. This concern is based on a number of reports of unexpected recurrence of cancer in abdominal wall port sites, an experience shared by many but not all groups who have performed these procedures. A large US study is currently being carried out to discover what aspects of laparoscopic technique or colectomy (and it does appear to be technique related) may predispose to cancer recurrence.


This page last updated 07/28/98 Comments to CVESWebmaster@u.washington.edu ©1996, 1997 University of Washington Department of Surgery Center for Videoendoscopic Surgery Home Page University of Washington Department of Surgery Home Page University of Washington Home Page