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Minimally Invasive Surgery Conduct of the Operation

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									Minimally Invasive Surgery
There are two major types of minimally invasive surgery: laparoscopic and robotic.
Minimally invasive laparoscopic and robotic colon and rectal surgery allows the same
surgical operations to be performed through small incisions rather than one large incision.
This advance in technology may allow many patients to have less pain after surgery, to
have quicker return of bowel function, to leave the hospital sooner, and return to normal
activities more quickly than patients having the same operation through a standard long
open incision.

Laparoscopic surgery is now available for a wide variety of colorectal diseases including
inflammatory bowel disease, diverticulitis, and colorectal cancer. We participated in a
large national randomized controlled trial that was published in the New England Journal
of Medicine (COST Study 2004). This study included 872 patients from 48 institutions
and concluded that the rate of cancer recurrence and survival is the same after open and
laparoscopic techniques for colon cancer (1). This has led to the increased utilization of
laparoscopic surgery for this and other diseases.




Conduct of the Operation
Laparoscopic surgery is done with standard laparoscopic video equipment which includes
a lighted camera, television monitor, and instruments designed to work in small incisions.
Instead of one long incision, several small incisions are made through which devices
called trocars are placed that enable the abdomen to be filled with carbon dioxide. This
provides an environment which enables the liver, spleen, stomach, intestines, and other
organs to be clearly visualized by way of a television monitor. Instruments are then
placed through these trocars which allow the operation to be performed in a similar
fashion as a standard open operation. The affected segment of bowel is then removed
through one of the incisions after it is enlarged to a length of 4-8 centimeters.

There are times when adhesions from previous surgeries, body habitus, or other technical
difficulties make laparoscopic surgery difficult or impossible resulting in the need to
convert the procedure to a standard open operation. This happens between 5-20% of the
time.
Potential Benefits

1) Pain After Surgery
        The need for narcotic pain medication may be reduced by laparoscopic surgery. In
the COST trial cited above, patients needed narcotic pain medication for 1 day less than
those who had open surgery (3.2 days vs 4.0 days). Other studies have shown an even
greater reduction in the need for narcotic pain medications (2)

2) Return of Bowel Function
       Patients who have laparoscopic surgery may pass gas (flatus) and may be able to
eat sooner than those who have standard open procedures (3, 4)

3) Hospital Stay
       Patients who have laparoscopic surgery may have shorter hospital stays after
surgery by a mean of 1-2.7 days (1, 4)

4) Other Potential Benefits
       a) decreased blood loss during surgery
       b) decreased wound infections
       c) quicker return of lung function to normal after surgery
       d) less suppression of the immune system
       e) quicker return to normal activity after surgery
       f) better cosmetic results

Complications
       There is the potential to injure bowel, blood vessels, and other organs (ureter,
bladder) with the instruments placed into the abdomen. This is very rare. Those who have
had previous surgeries may be at increased risk for this complication. Other rare risks
include hernias at incision sites, bleeding at instrument insertion sites, heart rhythm and
lung problems associated with the gas inserted into the abdomen. Risks for open
procedures also apply to laparoscopic surgery. There is a possibility that because of
previous surgeries or other technical factors, the laparoscopic operation may need to be
converted to a standard open incision.
Robot Surgery




Like, laparoscopic surgery, robotic surgery is performed through small incisions. All of
the benefits listed above for laparoscopic surgery also apply to robotic surgery, including
decreased blood loss, decreased pain after surgery, quicker return of bowel function,
decreased wound infections, shorter hospital stay, and better cosmetic results.

The robots arms are connected to trocars which are inserted into the abdomen in the same
fashion as with laparoscopic surgery. Very fine instruments are attached to the robot. The
surgeon controls these very fine instruments in a console attached to the robot. The
advantages of robotic surgery include 1) a high quality 3D imaging system which allows
for the best possible view of the surgical site, 2) surgical movements which more closely
mimic human wrist movements, and 3) potentially fewer conversions to open surgery.
The high tech computerized robot allows movements through greater range of motion
than laparoscopic instruments. In addition, tremors are filtered by the robot and suture
and knot tying are more easily performed.

Any Questions ?
For more information regarding minimally invasive surgery, talk to your Colon and
Rectal Surgeon and see the references and websites below.




References
1) The Clinical Outcomes of Surgical Therapy Study Group. N Engl J Med
2004;350:2050-2059

2) Hasegawa H, et al Surg Endosc 2003;17:636-640

3) Milsom JW, et al J Am Coll Surg 1998;187:46-55

4) Lacy AM, et al Lancet 2002;359:2224-2229

5) Hellan M, Pigazzi A, et al Ann Surg Oncol 14:3168, 2007

6) Baik SH, et al Ann Surg Oncol March 2009

7) Spinoglio G, et al Dis Colon Rectum 51:1627, 2009


Websites
     1) www.fascrs.org
     2) www.askasge.org
     3) www.google.com
     4) www.sages.org
     5) www.cancer.org
     6) www.intuitivesurgical.com
     7) www.davincisurgery.com

								
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