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Laparoscopic anterior resection: Analysis of technique over 1000 cases
Senthil Kumar Ganapathi, Rajapandian Subbiah, Sathiyamoorthy Rudramurthy, Harish Kakkilaya, Parthasarathi Ramakrishnan, Palanivelu Chinnusamy
Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
|Date of Submission||21-Jul-2020|
|Date of Decision||06-Oct-2020|
|Date of Acceptance||28-Oct-2020|
|Date of Web Publication||03-Feb-2021|
Senthil Kumar Ganapathi,
Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Ramanathapuram, Coimbatore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Purpose: Laparoscopic rectal surgery has moved from being experimental to getting established as a mainstream procedure. We aimed at analysing how rectal cancer surgery has evolved at our institute.
Methods: A retrospective review of 1000 consecutive patients who underwent laparoscopic anterior resection for rectal adenocarcinoma over a period of 15 years (January 2005 to December 2019) was performed. Technical modifications were made with splenic flexure mobilisation, intersphincteric dissection and anastomotic technique. The data collected included type of surgery, duration of surgery, conversion to open, anastomotic leak, defunctioning stoma and duration of hospital stay. The first 500 and the next 500 cases were compared.
Results: The study patients were predominantly males comprising 68% (n = 680). The mean age of the patients was 58.3 years (range: 28–92 years). Majority of the procedures performed were high anterior resection (n = 402) and low anterior resection (LAR) (n = 341) followed by ultra-LAR (ULAR) (n = 208) and ULAR + colo-anal anastomosis (n = 49). A total of 42 patients who were planned for laparoscopic surgery needed conversion to open procedure. Forty-one patients (4.1%) had an anastomotic leak. The mean duration of stay was 5.3 + 2.8 days. The rate of conversion to open procedure had reduced from 5.4% to 3.0%. The rate of defunctioning stoma had reduced by >50% in the recent group. The anastomotic leak rate had reduced from 5.0% to 3.2%. The average duration of stay had reduced from 5.8 days to 4.9 days.
Conclusion: This is one of the largest single-centre experiences of laparoscopic anterior resection. We have shown the progressive benefits of an evolving approach to laparoscopic anterior resection.
Keywords: Anterior resection, colo-anal anastomosis, rectal cancer, ultra-low anterior resection
|How to cite this URL:|
Ganapathi SK, Subbiah R, Rudramurthy S, Kakkilaya H, Ramakrishnan P, Chinnusamy P. Laparoscopic anterior resection: Analysis of technique over 1000 cases. J Min Access Surg [Epub ahead of print] [cited 2021 Jun 15]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=308668
| ¤ Introduction|| |
Rectal cancer surgery with a radical intent was first performed by Sir William Ernest Miles in 1907. Miles presumed that cancer spread happens in both upward and downward directions. Hence, his procedure involved abdominal and perineal approaches to remove the rectum along with sphincter complex, thereby giving a permanent stoma. Considering the high rate of remissions, Miles' operation became the gold standard for rectal cancer in the first half of the 20th century. In order to reduce the morbidity and mortality due to abdominoperineal resection (APR), Hartmann in 1921 introduced the anterior resection of rectum by preserving the distal rectum and sphincters for proximal rectal tumours. However, this necessitated an end-sigmoid colostomy. Initial attempts at restoring bowel continuity after rectal resection were associated with significantly high leakage and mortality rates.
The first promising result of restorative anterior resection was presented by Claude Dixon in 1948, showing 64% 5-year survival. While initially a 5-cm margin was considered necessary, recent studies have shown that even with a safety margin of <1 cm, the oncological outcomes were similar. Mark Mitchell Ravitch introduced the technique of stapler suturing in gastrointestinal surgery., Another breakthrough was when circular staplers were introduced for low rectal anastomosis with a leakage rate similar to that of hand-sewn anastomoses, as reported by Fain et al. in 1975. Total mesorectal excision (TME), reported by Heald et al. in 1982, constituted the most important milestone in the modern rectal surgery.
Jacobs et al. reported the first series of laparoscopic colorectal resection in 1991. Initially, concerns were raised about the risk of port-site metastases, tumour exfoliation and pneumoperitoneum, stimulating tumour progression., Later, no difference in abdominal metastases was found between open and laparoscopic surgeries when wound protection devices were used. There was a concern of non-significant increased rate of circumferential margin positivity in the laparoscopic group in the MRC CLASSIC trial. A 5-year follow-up analysis has shown that the use of laparoscopic surgery to maximise short-term outcomes does not compromise the long-term oncological results. Both the COREAN and COLOR II trials compared laparoscopic to open rectal cancer resections and showed no difference in the quality of the oncologic resection, complication rates and long-term survival outcomes. As a result, laparoscopic rectal surgery has moved from being experimental to getting established as a mainstream procedure. At this juncture, having performed more than 1000 cases of laparoscopic rectal cancer surgery, we wanted to analyse how rectal surgery has evolved at our institute. The aim of this article is to provide a qualitative analysis of the surgical technique and put it in perspective with the available literature. Hence, a detailed analysis of oncological parameters and survival outcomes is outside the scope of this article.
| ¤ Methods|| |
A retrospective review of 1000 consecutive patients who underwent laparoscopic anterior resection for rectal adenocarcinoma over a period of 15 years (January 2005 to December 2019) was performed. Tumours involving the rectum and rectosigmoid junction were included in the study. Patients with acute obstruction who underwent laparotomy directly after a diagnostic laparoscopy were excluded from the study. The data collected included demographic details – age and gender. Operative data such as type of surgery, duration of surgery, conversion to open and whether a defunctioning stoma was constructed were collected. The operative data, duration of stay, anastomotic leak (clinical leak with radiological confirmation) and defunctioning stoma rates were compared between the first 500 and the next 500 patients. As this was a retrospective analysis, there was no definite cut-off in protocols between the first 500 and the next 500 patients, but it can be said that side-to-end anastomosis, and the usage of 4K technology, was done only in the majority of the second 500 patients. The study was approved by our institutional review board.
All patients had mechanical bowel preparation on the previous evening. The steps for our standard laparoscopic anterior resection were initial assessment (tumour location, peritoneal cavity and liver), peritoneal incision starting over the sacral promontory, vascular control, medial-to-lateral mobilisation of the sigmoid and descending colon, splenic flexure mobilisation, rectal mobilisation, resection, specimen removal and anastomosis. The detailed steps of the procedure are illustrated in the author's textbook of 'Laparoscopic Surgery Atlas'. The mobilisation and anastomotic techniques that have contributed to the evolution in our institute are explained below. Based on the extent of rectal resection, we classified the procedure into the following four types:
- High anterior resection (HAR) – Performed for distal sigmoid and rectosigmoid tumours and the final anastomosis was above the peritoneal reflection
- Low anterior resection (LAR) – Performed for upper rectal tumours and the final anastomosis was below the level of peritoneal reflection
- Ultra-LAR (ULAR) – Performed for mid and low rectal tumours. A resection is said to be ultra-low if the colorectal anastomosis was within 2 cm from the anorectal junction
- ULAR with Colo-Anal anastomosis (ULAR + CAA) – Performed for low rectal tumours where the level of division was either at the anorectal junction or below the anorectal junction (combined with partial intersphincteric resection [ISR]).
Splenic flexure mobilisation
A complete splenic flexure mobilisation involves a three-step approach. The patient is placed in reverse Trendelenburg position. First, medial mobilisation is performed extending up to the inferior border of the pancreas. Second, lateral mobilisation is performed by detaching the lateral peritoneal attachments up to the spleen and dividing the gastro-colic omentum. Third, the transverse mesocolon is detached from the inferior border of the pancreas and spleen [Figure 1]. A partial splenic flexure mobilisation (medial and lateral) is performed for HAR and LAR. However, in patients with ULAR and CAA, a complete splenic flexure mobilisation is performed. The extent of mobilisation needed for individual patients is assessed on table.
|Figure 1: Transverse mesocolon detached from the inferior border of the pancreas and spleen – third step of complete splenic flexure mobilisation|
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Side-to-end colorectal anastomosis
We performed an end-to-end anastomosis in our initial phase but changed to side-to-end anastomosis in the later phase for all patients where circular stapler anastomosis was done. The proximal cut end of the colon was opened and the anvil of the circular stapler was introduced into the lumen of the colon. The spike of the anvil was brought out about 7–8 cm proximal to the resected end on the ani-mesocolic side. The cut edge was closed with a linear stapler and reinforced with a continuous 2.0 PDS suture. Purse-string suture was taken using 1.0 polypropylene to fix the anvil. It was ensured that there is no twist in the mesocolon prior to the circular stapler anastomosis.
A circular stapler was used when the division was at the anorectal junction and when there was space in the anal canal to accommodate the stapler. However, in patients where an ISR [Figure 2]a and [Figure 2]b was needed, a sutured end-to-end CAA was performed. This was facilitated by exposure of the anal canal with a self-retaining Lone Star Retractor System™. Circumferential incision was made in the anal canal to allow at least 1-cm macroscopic margin. The end-to-end sutured anastomosis was performed only after a frozen section examination done by the pathologist reported the margins as negative for malignancy [Figure 3]a and [Figure 3]b.
|Figure 2: (a) Plane between the pelvic floor and the rectum showing the entry point into the intersphincteric space. (b) Intersphincteric dissection|
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|Figure 3: (a) Exposure to starting the resection from the anal canal. (b) Completion of colo-anal anastomosis|
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In our initial phase, we used the full high-definition (HD) imaging system which worked very well for laparoscopic surgery. However, recently, with the introduction of 4K ultra-HD (UHD) technology, we have achieved improved visibility, which further supports the accuracy and safety of laparoscopic surgery. We aimed at performing pelvic nerve-preserving surgery in all patients [Figure 4].
|Figure 4: Ultra-high-definition view clearly showing the hypogastric nerves in the pelvis|
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We follow an enhanced recovery programme in all our patients undergoing elective resection. The nasogastric tube was removed on the 1st post-operative day (POD) and allowed sips of clear liquids. The urinary catheter was removed on the 2nd day for all female and male patients with HAR and LAR and started on a clear liquid diet. In male patients who had ULAR/ULAR + CAA, urinary catheter was usually removed on the 4th day after 2 days of alpha-blockers. The patients were allowed a full liquid diet on the 3rd day and a soft solid diet on the 4th day. A drainage tube which was inserted into the pelvis in all the patients was removed on the 4th day after at least one satisfactory bowel movement. The patients were discharged on the 4th or 5th POD. If there was a clinical suspicion of anastomotic leak or the drainage tube showed any suspicious bowel contents, a computed tomography scan was performed. If an anastomotic leak was confirmed, the patient was taken to the theatre for a laparoscopic wash and defunctioning loop ileostomy. This possibility was explained to all patients prior to anterior resection and consent was obtained.
| ¤ Results|| |
A total of 1000 (680 males) consecutive patients who underwent laparoscopic anterior resection were included. The study patients were predominantly males comprising 68% (n = 680). The mean age of the patients was 58.3 years (range: 28–92 years). A large majority of the procedures performed were HAR (n = 402) and LAR (n = 341) followed by ULAR (n = 208) and ULAR + CAA (n = 49). The tumour-node-metastasis stage grouping was similar in both groups. A total of 42 patients who were planned for laparoscopic surgery needed conversion to open procedure. Subacute intestinal obstruction with bowel dilatation (n = 32) was the main cause for conversion, followed by locally advanced growth (n = 4), adhesions (n = 3), bleeding (n = 2) and obesity (n = 1). A total of 176 patients had a defunctioning stoma, which was predominantly in ULAR (n = 127) and ULAR + CAA (n = 49). Forty-one patients (4.1%) had an anastomotic leak. The mean duration of stay was 5.3 ± 2.8 days. A summary of all the results is presented in [Table 1].
Comparison of early (first 500) and recent (second 500) cases
The gender distribution was similar in both the groups. The mean age at presentation had reduced from 59.5 years to 57.1 years. The distribution of the HAR, LAR and ULAR was largely similar. However, of all the ULAR + CAA, 57% of the cases were performed in the recent group, indicating an increasing trend. The rate of conversion to open procedure had reduced from 5.4% to 3.0%. The rate of defunctioning stoma had reduced by >50% in the recent group compared to that of the early group. The anastomotic leak rate had reduced from 5.0% to 3.2%. The wound infection rate had reduced from 8.4% to 6.6%. The average duration of stay had reduced from 5.8 days initially to 4.9 days in the recent group.
| ¤ Discussion|| |
Data from major clinical trials,,, have shown that laparoscopic surgery for rectal cancer offers favourable short-term results without compromising the long-term oncological outcomes. Hence, it is currently considered a standard option for rectal cancer surgery. The successful evolution of a standard procedure relies on the modifications that can safely and effectively reduce the morbidity and can be adopted by a large number of surgeons.
Anastomotic leak is a common complication after anterior resection of rectal tumours occurring in 5%–19% of patients, according to various reports. While many clinical risk factors for anastomotic leak have been identified, anastomotic ischaemia has been considered a major cause of leak in LAR. Tension secondary to inadequate mobilisation of the splenic flexure can also lead to ischaemia and be a significant factor, but it is difficult to quantify the tension, hence this factor remains largely hypothetical. The need for splenic flexure mobilisation also depends on the available length of sigmoid colon, hence it will always be the surgeons' decision regarding the need for the extent of mobilisation. While a partial splenic flexure mobilisation may be adequate for HAR and LAR, a complete mobilisation is a safer option in ULAR and CAA. Hence, we follow a routine three-step mobilisation as described in the methods' section. Studies have shown that up to 28 cm can be gained by a complete splenic flexure mobilisation.,
Various reservoir techniques such as coloplasty and colonic pouch have been described to improve the colonic capacity to avoid post-operative LAR syndrome.,,, Obtaining adequate length of colon for a pouch may not be possible in all patients. A side-to-end anastomosis has been proposed as a more attractive technique with improved functional outcome., We believe that this technique also has the added benefit of better vascularity at the anastomotic site. A side-to-end anastomosis needs extra mobilisation of about 7–8 cm. We have found that a side-to-end anastomosis without any tension is possible in all patients when a complete three-step splenic flexure mobilisation is done. Very recently, indocyanine green-fluorescence angiography technology can identify poor perfusion at anastomotic site and is found to be associated with lower incidence of anastomotic leak. Currently, we have just started using this technology which may have the potential for further reducing the anastomotic leak rates.
Diverting stoma has been proposed as a safe and effective way to prevent anastomotic leak. However, there are also reports that a diverting stoma may not prevent anastomotic leak. An ileostomy can be associated with complications such as dehydration, electrolyte imbalance, skin excoriation and bowel obstruction. There can also be complications associated with closure of a diverting stoma with a reported morbidity of 17.3% and a mortality of 0.4%, with major complications being small bowel obstruction and wound sepsis. Considering this, we have a selective approach in giving the patients a diverting stoma. We construct a diverting stoma only when there is a combination of high-risk factors such as doubtful vascularity, positive air leak test, pre-operative chemoradiation and significant comorbidity. In spite of our reduced stoma rates, we did not encounter high anastomotic leak rates. Rather, our leak rate had reduced from 5% to 3.2%, probably due to improved surgical technique and appropriate case selection. There are also reports that have suggested the beneficial effects of a selective approach to a diverting stoma.,,
Our population characteristic is such that changes in body image and its influence on the physical, mental, emotional and social life are not well tolerated. On pre-operative counselling in low rectal cancers, it was found that there are people who refuse to undergo surgery if it is going to give them a permanent stoma. This has encouraged us to go further down to extend the resection to the intersphincteric space and perform the anastomosis at or even below the dentate line. Currently, a TME along with 1-cm clearance is considered to be adequate for low rectal cancers. The evolution of knowledge on minimum margins of safety and the development of ISR have considerably reduced the place of APR in patients with very low rectal cancer. With the enhanced, magnified and HD images deep within the pelvis, we feel that the low pelvic dissection along with ISR is better performed with laparoscopic surgery. The feasibility and effectiveness of laparoscopic ISR has been demonstrated with good oncological outcome. Reports have shown that about 50% of the patients have good functional result, 40% have minor faecal incontinence and 10% have major faecal incontinence, which seems like an acceptable trade-off for a permanent stoma. In our series, there has been an increase in the incidence of ULAR + CAA, thereby reducing the APR rates.
Recently, with the introduction of robotic surgery and 4K UHD technology in laparoscopic surgery, we have achieved improved visibility, which further supports the accuracy and safety of laparoscopic surgery. Autonomic nerve identification and preservation has improved with HD imaging systems and has further improved with UHD technology. Earlier trials had shown equivalent urinary function and worsening sexual function after laparoscopic surgery., Trials have reported lower incidence of urinary dysfunction and sexual dysfunction in laparoscopic surgery compared with that of open surgery.
This study was mainly performed to qualitatively assess the evolution of laparoscopic surgery at our institute and to discuss specific factors that may have contributed to the better results in the recent group compared to that of the early group. As this was a retrospective study of a large number of patients, data such as urinary and sexual dysfunction and long-term follow-up were not available for all patients.
| ¤ Conclusion|| |
This is one of the largest single-centre experiences of laparoscopic anterior resection. We have shown the progressive benefits of an evolving approach to laparoscopic anterior resection. While the initial aim is always to standardise a surgical technique, modifications that are safe, effective and reproducible are necessary in the evolution to reduce the morbidity further and further.
The authors would like to acknowledge Mr Pasupathy for retrieval of photographs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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