morris e. franklin jr, m.d., f.a.c.s. director texas endosurgery institute karla russek, m.d....
TRANSCRIPT
Morris E. Franklin Jr, M.D., F.A.C.S.
Director Texas Endosurgery Institute
Karla Russek, M.D.
Research Fellow, Texas Endosurgery Institute
Morris E. Franklin Jr, M.D., F.A.C.S.
Director Texas Endosurgery Institute
Karla Russek, M.D.
Research Fellow, Texas Endosurgery Institute
MISS ,2012MISS ,2012
Transanal extraction:Is it worth it?
Transanal extraction:Is it worth it?
Industry relationshipsIndustry relationships• W.L. Gore & Associates
– Grant/research support, consultant and speaker bureau• Covidien
– Grant/research support, consultant and speaker bureau• Striker
– Consultant, advisory board• Ethicon
– Consultant and speaker bureau• Atrium
– Consultant• Aesculap
– Consultant• Encision
• Consultant• KCI
• Consultant• Cook
– Consultant
Indications / Contraindications for totally lap colon surgery
Indications / Contraindications for totally lap colon surgery
• Colon cancer• Crohn’s disease• Diverticulitis• Rectal prolapse• Ulcerative colitis• Intestinal ischemia• Familiar adenomatous
polyposis
• Colon cancer• Crohn’s disease• Diverticulitis• Rectal prolapse• Ulcerative colitis• Intestinal ischemia• Familiar adenomatous
polyposis
Indications ContraindicationsIndications Contraindications
• Lack or advanced laparoscopic skills
• Lack of colon preparation
• Fecal peritonitis
• Lack or advanced laparoscopic skills
• Lack of colon preparation
• Fecal peritonitis
Laparoscopic Technique for left colon resectionsLaparoscopic Technique for left colon resectionsPatient positioning
• Modified lithotomy
• Arms tucked at sides
• Shoulders taped to table
Patient positioning
• Modified lithotomy
• Arms tucked at sides
• Shoulders taped to table
AssistantCamera
Surgeon
Insufflation, trocar placementGenerally 5 trocars usedUmbilicus and outside of rectus sheath2 cm below Mc Burney’s pointFix trocars
Mobilization, nerves & ureter IDMobilization, nerves & ureter ID Same as building a house
• Lateral stalks taken down
• Dissection carried down to levator ani muscles
• Anterior dissection last
Same as building a house
• Lateral stalks taken down
• Dissection carried down to levator ani muscles
• Anterior dissection last
White line of Toldt Allows a tension-free
anastomosis Avoid laceration of
the spleen
White line of Toldt Allows a tension-free
anastomosis Avoid laceration of
the spleen
Clamps Placement and colonoscopyClamps Placement and colonoscopy Control gas
insufflation
Necessary with CO2???
Localize lesion
Lavage with Betadine
Determine margins of resection
Control gas insufflation
Necessary with CO2???
Localize lesion
Lavage with Betadine
Determine margins of resection
Colon transection & trim, orientation
Anvil placement
Colon transection & trim, orientation
Anvil placement Endoloop
placement on proximal segment
Easier and safer handling prior to extraction
Introduce all in bag
Endoloop placement on proximal segment
Easier and safer handling prior to extraction
Introduce all in bag
Intracorporeal anastomosisIntracorporeal anastomosis
Postoperative colonoscopyPostoperative colonoscopy
Anastomosis integrity
Bleeding
Air-leak test
Anastomosis integrity
Bleeding
Air-leak test
Transanal Removal of SpecimenTransanal Removal of Specimen
TEI ExperienceTransanal extraction
TEI ExperienceTransanal extraction
Procedures Case # Percentage
Laparoscopic Left 6 2.5%Hemicolectomy
Laparoscopic 83 34.9%Sigmoidectomy
Laparoscopic LowAnterior Resection 148 62.8%
Total Case Number 238 100%
Procedures Case # Percentage
Laparoscopic Left 6 2.5%Hemicolectomy
Laparoscopic 83 34.9%Sigmoidectomy
Laparoscopic LowAnterior Resection 148 62.8%
Total Case Number 238 100%
TEI ExperienceTransanal extraction
TEI ExperienceTransanal extraction
Pathologies Case # Percentage
Cancer 167 70.20%
Diverticulitis 69 29.00%
Other 2 0.80%
Total Case Number 238 100%
Pathologies Case # Percentage
Cancer 167 70.20%
Diverticulitis 69 29.00%
Other 2 0.80%
Total Case Number 238 100%
TEI ExperienceTransanal extraction
TEI ExperienceTransanal extraction
Postop complications Case # Percentage
Minor POC’s
Wound infection 2 0.84%
Ileus 7 2.9%
UTI 6 2.5%
Total 15 6.3%
Postop complications Case # Percentage
Minor POC’s
Wound infection 2 0.84%
Ileus 7 2.9%
UTI 6 2.5%
Total 15 6.3%
TEI ExperienceTransanal extraction
TEI ExperienceTransanal extraction
Postop complications Case # PercentageMajor POC’s
Bowel obstruction 1 0.42%
Fecal incontinence 3 2.3%
Anastomotic leak 1 0.42%
Tumor implant 0 0%
Total 5 2.1%
Postop complications Case # PercentageMajor POC’s
Bowel obstruction 1 0.42%
Fecal incontinence 3 2.3%
Anastomotic leak 1 0.42%
Tumor implant 0 0%
Total 5 2.1%
Follow-up of 2 years
Texas Endosurgery InstituteTexas Endosurgery Institute
Learning Curve for Low Anterior Resection with TME & TASE
0
50
100
150
200
250
300
1 2 3 4 5 6 7 8 9 10
Year
Ope
ratin
g Ti
me
(Min
utes
)
Conclusions Plan approach
Know anatomy and anatomic relations
Medial to lateral approach makes it easier
Visualize the ureter more than one time
Determine extraction site by lesion localization and etiology
Use wound protection
Beware of complications
Plan approach
Know anatomy and anatomic relations
Medial to lateral approach makes it easier
Visualize the ureter more than one time
Determine extraction site by lesion localization and etiology
Use wound protection
Beware of complications
Old or new ???
“If you do the same thing over and over again you cannot ever
expect a different outcome ”
“If you do the same thing over and over again you cannot ever
expect a different outcome ”
Albert Einstein
Albert Einstein
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