Laparoscopic-assisted colonoscopic polypectomy

Laparoscopic-Assisted Colonoscopic Polypectomy The Texas Endosurgery Institute Experience Morris E. Franklin Jr., M.D,*t Josd Antonio Dfaz-E., M.D.,~ Daniel Abrego, M.D.,~ Eduardo Parra-D~ivila, M.D.,I] Jeffrey L. Glass, M.D.g From the *Texas Endosurgery Institute and Surgery Department, University of Texas At San Antonio, San Antonio, Texas, ~Surgery Department and ~Texas Endosurgery Institute, Hospital San Josd-Tec de Monterrey, Nuevo Ledn, Mexico, ~Texas Endosurgery Institute, Southeast Baptist Hospital, San Antonio, Texas, and IITexas Endosurgery Institute, Jackson Memorial Hospital,, Miamg Florida PURPOSE: The advent of laparoscopic surgery has altered the manner by which surgical specialties address pathologies of the abdominal cavity. This advance in technology has also changed colorectal surgery. One of the more common procedures of colorectal surgery is segmental resection for polyps that are large, broad based, or inaccessible for colonoseopic removal. We present a technique combining colonoscopy and laparoscopy to remove troublesome polyps without the need for segmental resections. METHODS: From May 1990 to September 1999 laparoscopicmonitored colonic polypectomies were performed in 47 patients, with a total of 60 polyps being removed. After taparoscopie mobilization of the involved segment of the colon, the proximal bowel is cross-clamped and the colonoscope passed to the involved portion of the colon. The polyp is then presented to the colonoscopist by the laparoscopist facilitating removal. The serosal surface is monitored for any indications of transluminal injury, and the area is repaired if needed. All polyps undergo immediate frozen section analysis. If the pathologic evaluation indicates malignancy then a segmental resection may be performed, otherwise the patients are decompressed and fed within a short time before discharge. RESULTS: The polyps were located most commonly in the ascending colon (18 polyps), transverse colon (12 polyps), and cecum (12 polyps). The most common histopathologic diagnosis was tubtdovillous adenoma in 28 polyps followed by villous adenoma in 11 polyps. In three cases histopathologic diagnosis revealed malignancy necessitating segmental resection (t low anterior resection and 2 fight hemicolectomies), which were performed laparoscopically. Patients received a liquid diet within 6 hours, were discharged in an average of 21 hours, and returned to full activity, usually within days. The only complication presented in this group of patients was an umbilical port seroma. Virtually all patients (97 percent) behaved as if only a colonoscopy had been performed. Pain at the trocar sites was managed with acetaminophen 600 mg by mouth as needed. CONCLUSION: Laparoscopic-monitored colonoseopie polypectomy allows patients to undergo removal of colonic polyps without a segmental resection. This less invasive procedure yields recovery times similar to that of colonoscopy alone, and the potential complications of a segmental resection are avoided. All polyps are examined by frozen section, and if a malignancy is encountered, a laparoscopic resection can be performed. Address reprint requests to Dr. Franklin: Texas Endosurgery Institute, 4242 East Southcross, Suite 1, San Antonio, Texas, 78222.

[Key words: Polypectomy; Colonoscopy; Laparoscopy; Management of difficult polyps] Franklin ME Jr, Diaz-E JA, Abrego D, Parra-D~ivlla E, Glass JL. Laparoscopic-assisted colonoscopic polypectomy: the Texas Endosurgery Institute experience. Dis Colon Rectum 2000;43:1246-1249. aparoscopic a p p r o a c h e s to intra-abdominal disease processes have forever c h a n g e d the face o f surgery. Although laparoscopic c o l o n surgery has b e e n slow to evolve, a variety of p r o c e d u r e s are being p e r f o r m e d in lieu o f standard o p e n operations. The c o t o n o s c o p e has evolved t h r o u g h the years to b e c o m e an instrument w h i c h is increasingly v a l u e d for its flexibility and visual accuracy, allowing widespread use to r e m o v e most polyps in the colon. 1 Despite all the advantages of the c o l o n o s c o p e , there is a g r o u p of patients with colonic polyps in w h o m c o l o n o s c o p i c p o l y p e c t o m y is unsafe or inaccessible b e c a u s e of location, size, tortuosity of the colon, adhesions, or complexity o f the lesion (sessile vs. pedunculated). 2 In the past these patients usually required surgery (segmental colectomy). With traditional c o t o n o s c o p i c p o l y p e c t o m y , intraluminal inspection o f the b o w e l wall can b e performed; h o w ever, the extent of the thermal effect over the seromuscular p o l y p e c t o m y site and the immediate surr o u n d i n g tissue limits the size, number, and the extent o f the excision. W h e n the integrity of the b o w e l wall is in doubt, abdominal x-ray films in upright position t o detect extraluminal air are performed, and multiple serial a b d o m i n a l examinations are required to follow up the patient, sometimes including admission o f the patient to the hospital for observation a n d possible surgical exploration. The p u r p o s e o f this article is to describe a c o m b i n e d technique using the l a p a r o s c o p e and the c o l o n o s c o p e for c o t o n o s c o p i c removal o f these difficult polyps, while laparoscopically facilitat-

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ing the procedure and observing potential full-thickness injuries.

PATIENTS AND METHODS There is a group of patients with inaccessible polyps which cannot be removed conveniently with the colonoscope because they cannot be seen, their base cannot be visualized, they are too large, or the location is poor for snare removal even with submucosal infiltration. This situation can be present because of a tortuous colon resulting in difficult angles giving poor visualization and decreasing the ability to advance or retract the colonoscope without completely losing visualization. Patients with polyps located behind coIonic folds are also included in this group. Additional indications are those patients with large sessile polyps that could not be removed satisfactorily without risk of full-thickness thermal injury or leaving a portion of the polyp behind or both. Contraindications to the procedure include the usual contraindications for laparoscopy related to comorbidities and intolerance of general anesthesia. Noncorrectable bleeding dyscrasias are also considered a contraindication to this approach. However, the presence of multiple prior operations or adhesions is not necessarily a contraindication but is certainly dependent on the surgeon and and the surgeon's experience for successful completion of the procedure. Additionally, we think that many patients with severe chronic obstructive puhnonary disease or cardiopulmonary disease are better served by these techniques than open surgery and therefore do not consider these comorbidities to be contraindications.

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neum is established via a Veress needle and C O 2 pressure set to 14 mmHg. A 5-mm port and 5-mm laparoscope are placed to the contralateral side of the lesion, and additional ports are placed, under direct visualization, as needed to visualize the colon and to lyse any adhesions. After inspecting the abdominal cavity and lysing any adhesions which may be present, a 10-mm 0 ° laparoscope is introduced through an umbilical port. The portion of the bowel containing the polyp is thoroughly mobilized, as if for a resection, but the vascular supply is preserved. The bowel is clamped proximally with laparoscopic bulldog Glassman clamps to prevent distention of the proximal bowel. Colonoscopy is performed with a minimum of insufflation by either another surgeon or a gastroenterologist. Frequently, laparoscopic instruments are used to straighten the sigmoid colon, which facilitates passage of the colonoscope. The polyp is located intraluminally, and its position is noted under laparoscopic control with direct visualization, transluminal shadowing, or by intense illumination ("X-I,UM" setting) by the colonoscope. The ideal situation is to have the serosa of the bowel at the base of the lesion exposed so that direct visualization by laparoscopy is present during the colonoscopic polypectomy. Mobilization and pushing of the colon wall with 5-mm graspers is frequently used to present the base of the lesion for easier

Technique Patients undergo mechanical and antibiotic bowel preparation at home and are admitted as outpatients to the hospital on the day of surgery. General anesthesia is administered, and subsequently, a nasogastric tube and Foley catheter are placed. Patients are placed in a modified lithotomy position allowing anal access, The laparoscopic monitors must be placed in accordance with standard position for the given segment of colon where the polyp is known to be present. The monitor for the cotonoscope is placed in a location viewable by both the colonoscopist and laparoscopist during the colonoscopic portion of the procedure. The abdomen and perinemn are prepared and draped in the usual fashion and pneumoperito-

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Figure 1. Trocar location and instrument placement for laparoscopic-assisted colonoscopic polypectomy, Note presenting polyp for colonoscopic placement of snare.

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snaring by the colonoscopist. Figure 1 graphically" demonstrates the technique as seen through the abdominal wall. When the exposure of the bowel wall is complete, we observe the colonoscopic polypectomy for changes on the serosal surface, such as dimpling, blanching, or perforation. The snare is tugged slightly once it has surrounded the polyp and before the electrocautery resection is initiated; this ensures that the exact location of the lesion is visualized extraluminally. Decreasing the light source of the laparoscope allows transillumination from the colonoscope's light source to produce the effect of backlighting the lesion, which often allows clear visualization and localization by" the laparoscope. After resection the bowel wall is irrigated and intraluminal pressure is increased by insufflating air through the colonoscope to verify absence of leakage. If there are signs of transmural involvement of the bowel wall by either cautery or perforation, 3-0 VicrylT M (Ethicon Inc, Sommerville, NJ) seromuscular sutures are placed laparoscopically to repair the affected area. A full-thickness excision is made if the involvement of the polyp requires it. A subsequent closure of the colotomy is performed with sutures or on a less frequent basis with a iaparoscopic linear stapler. Initially seromuscular sutures using 3-0 VicrylT M were placed only when an obvious perforation or fullthickness burn was present. Rethinking this, we have recently placed seromuscular sutures in all patients as a preventative measure because of the fear of nearfull-thickness injuries that may go unrecognized. All polyps are removed and have immediate frozen section analysis. In the event that the polyp is determined to be malignant, an immediate laparoscopic resection of that segment of bowel is completed, observing oncologic surgical principles.

RESULTS The group consisted of 47 patients, 24 males, with a median age (+ standard deviation) of 72 - 18 years. A total of 60 polyps were removed with the number of polyps per patient ranging from 1 to 11. Most of the polyps were located in the ascending colon (18 polyps), transverse colon (12 polyps), and cecum (12 polyps; Table 1). The most common hystopathologic diagnosis was tubulovillous adenoma (28 polyps) and villous adenoma (11 polyps; Table 2). The median diameter of the polyps was 2.8 (range, 0.3-6) cm.

Dis Colon Rectum, September 2000 Table 1. Location of Colonic Polyps Location

No. of Polyps

Rectosigmoid junction Sigmoid Splenic Flexure Transverse Hepatic Flexure Ascending

3

Cecum

8 1 12 6 18 12

Table 2. Histopathologic Diagnosis of Polyps Pathology

No.

Tubulovillous adenoma

28

Villous adenoma Tubular adenoma Adenomatous

11

Submucosal lipoma

Adenoma with cancer in situ* Villous adenoma with Adenocarcinoma

8 8 1 1 2

Tubulovillous adenoma with intramucosal carcinoma1* Pedunculated.

1 Sessile.

Margins were dear on all polyps not only by colonic visualization but also by pathologic examination. A total of three patients underwent a laparoscopic segmental resection for malignancy that had not been diagnosed previously (1 low anterior resection and 2 right hemicolectomies). Two patients with benign histopathologic diagnosis underwent a colotomy for specimen extraction (cecum and transverse colon) because of the size of the base of the polyps (6 cm and 11 cm). Two patients with benign polyps had circumferential involvement requiring a laparoscopic segmental resection (2 sigmoidectomies). Postoperative hospitalization time averaged 21 hours, with a range of 8 hours to five days, and a liquid diet was started at six hours postoperatively. Return to full activity was usually within two days, with a range of one to ten days. The only complication presented was a seroma in the umbilical port site, which was drained at an office follow-up. No cardiopulmonary complications were seen, and there were no delayed perforations caused by thermal lesions. Despite mobilization of the colon, none of patients experienced an ileus, and surprisingly, 97 percent of the patients reacted to the procedure as if they had undergone a colonoscopy alone,

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with the exception of umbilical and trocar site pain, which was usually managed with oral analgesics (acetaminophen 600 mg). The follow-up on these patients consisted of office visits at one week, one and six months, and then on an annual basis. A colonoscopy was performed six months postoperatively and yearly thereafter. To date, only one patient has had a recurrent polyp (at a different location), and n o patient has progressed to carcinoma. DISCUSSION Colonic polyps are thought to be premalignant lesions, and before the introduction of the colonoscope, they were discovered only when a diagnosis could be made by contrast studies or by proctosigmoidoscopy The advent of colonoscopy allowed accurate identification of the presence of polyps, and with modification, not only to biopsy but also to remove many of the newly diagnosed polyps. Polyps that were large or located in a difficult position were traditionally removed by a segmental resection or more rarely a colotomy. Each of these procedures carried its own morbidity. The location of the polyp obviously dictated the type and extent of resection, and frequently an extensive resection (right hemicolectomy or subtotal colectomy) was performed for as few as two to three polyps located in difficult positions. Many surgeons, including those in our group, have questioned the need for such extensive resections when perhaps simple maneuvers could improve the margin of safety of colonoscopic removal. After careful thought and multiple efforts in our lab, we felt that laparoscopically monitored colonoscopic polypectomy could prevent many of the patients from having to undergo segmental resections, thus enhancing patient care and reducing costs of the procedure (Franklin ME Jr, Dfaz-E. JA, Abrego D, et al., unpublished data). The primary fear of aggressive colonoscopic polypectomy is that of a full-thickness cautery burn during snare polypectomy, which is especially of concern in large and sessile polyps. Other concerns include inadvertent perforations, inadequate margins in poorly situated polyps, and uncontrollable bleeding, especially with large, sessile polyps. Thus, if the serosal surface of the colon at the exact site of the polypectomy could be visualized and potentially re-

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paired in the case of a perforation or suspected fullthickness burns, then perhaps a segmental resection could be avoided. We have shown during the past eight years that this can be done safely, efficiently, and with minimal morbidity. CONCLUSION Laparoscopic-assisted colonoscopic polypectomy uses advanced technology and minimally invasive techniques to remove difficult colonic polyps that otherwise would require a formal segmental resection. 3 The use of these combined technologies eliminates the morbidity of segmental resection and seems to be safe and effective. When the histopathologic report reveals carcinoma, a formal resection can easily be performed laparoscopically. We think that use of these techniques greatly enhances the margin of safety for colonoscopic removal of difficult polyps, 4-7 resulting in shorter hospital stays, quicker recovery, and equal long term results, i,e., no recurrence of the polyps. The margin of safety for difficult polypectomies has apparently increased tremendously with the aid of laparoscopy.

REFERENCES 1. Greene FL. Colonoscopic polypectomy: indication, technique and therapeutic implications. Semin Surg Oncol 1995;11:416-22. 2. Nivatvongs S. Complications in colonoscopic polypectomy. An experience with 1555 polypectomies. Dis Colon Rectum 1986;29:825-30. 3. Franklin ME, Abrego D, Balli J. Combined laparoscopic and flexible endoscopic techniques in the management of malignant gastrointestinal lesions. Semin Surg Oncol 1998;15:183-8. 4. Beck DE, Karulf RE. Laparoscopically-assisted fullthickness endoscopic polypectomy. Dis Colon Rectum 1993;36:693-5. 5. Averbach M, Cohen RV, de Barros M, et al. Laparoscopically-assisted colonoscopic polypectomy. Surg Laparosc Endosc Percutaneous Tech 1995;5:137-8. 6. Smedh K, Skullman S, Kald A, Anderberg B, Nystrom P. Laparoscopic bowel mobilization combined with intraoperative colonoscopic polypectomy in patients with an accessible polyp of the colon. Surg Endosc 1997;1: 643-4. 7. Hensman C, Luck AJ, Hewett PJ. Laparoscopic-assisted colonoscopic polypectomy. Technique and preliminary experience. Surg Endosc 1999;13:231-2.