surgery repairs damage
to the colon, rectum, and anus through
a variety of procedures that may
have little or great long-term consequence
to the patient. It may also involve
surgery to the pelvic floor to repair
surgery in general and colonic surgery
in particular is considered as very demanding
and requires - high degree of operative
skill. Major breakthrough was achieved when
end to end anastomosis (E.E.A.®.) stapler
was introduced in the year 1979 by United
States surgical corporation (U.S.S.C.®).
In Indian set up the 1st use of staplers
was in the year 1981 and gradually it gained
All these years surgeons have been inflicting
injuries to abdominal wall to get access
to internal organs inorder to achieve cure.
Minimal invasive surgery (M.I.S.) in the
discovery of the last decade is an attempt
to minimise these injuries for patients
benefit. A breakthrough of last millennium.
Dr. Kurt Semm a gynaecologist from Germany
performed the first laparoscopic appendicectomy
in the year 1981. Another German surgeon
Dr. Eric Muhe in the year 1985 performed
the world's first laparoscopic cholecystectomy.
Big abdominal incision for majority of intraabdominal
diseases is a thing of the past.
colonic surgery is being accepted by many
centres as primary line of treatment for
carcinoma colon. It is no more considered
an experimental work. Centres specialised
in this field have conducted double blind
randomised trial (DBRT) in large number
of cases and have shown that the basic principles
of oncosurgery are not compromised and long
term follow-up results are comparable to
conventional surgery. In India because of
limited work load of colonic cancer, it
has not made the progress unlike laparoscopic
cholecystectomy. There are no large published
series. We have carried out 32 colonic surgeries,
out of which only six are for malignancy,
the rest being inflammatory colonic diseases.
makes great sense to offer the benefits
of M.I.S. to our patient in terms of :
Less post operative pain and analgesics.
Shorter hospital stay.
wound related and post-op pulmonary
return to work or family.
site implantation was a concern in early
period but it has been shown now that it
can be prevented by
Proper protection of port site while
delivering the specimen. (Endobags ®
squeezing of the specimen by taking
a liberal incision.
wash to the wound, 5FU solution irrigation
of all ports.
release of pneumo-peritoneum.
It has been reported that in conventional
surgery also scar metastasis rate is about
2.5 per cent and by above mentioned guidelines
the reported large series quite a port site
metastasis to the tune of 1 to 2.5% only.
Cost can be brought down by either doing
a hand sewn anastomosis through the specimen
delivery site or use of conventional stapler
for extra - corporeal stapled anastomosis.
Minimal use of disposable trocars and instruments
can further cut down the cost. Use of ultrasonic
energy source in form of harmonic shears
(Ethicon ® and U.S.S.C.®) has added
to the cost of lap surgery.
disposable hand pieces are reused by us
multiple times to cut down the cost. Tremendous
amount of time and blood loss is saved particularly
in obese patient by use of ultrasonic generator.
We have observed that the same can be achieved
to a great extent by use of bipolar diathermy
endo-scissors, dissectors and hooks etc.
The sealing capacity for vessels is comparable
and no lateral thermal damage takes place
when bipolar electric energy source is used.
Haemostasis in our initial cases was carried
out by use of bipolar diathermy and of late
we carry out these procedure with much ease
by Harmonic scalpel ultracision (L.C.S.
of Ethicon). In fact we are the first to
acquire this in Mumbai's private setup.
two burning issues are port site metastasis
in malignancies and cost factor due to use
of endostaplers. As mentioned earlier for
benign condition like rectal prolapse, adenomas,
rectal polyposis and inflammatory condition
like tuberculosis, ulcerative colitis, simple
diverticulitis, laparoscopic surgery offers
a patient friendly technique. Crohn's though
not very common in our country, but laparoscopy
can be offered for diagnosis, lymph node
sampling and curative resection. Ileo-caecal
tuberculosis is commonly seen in our country
and its a good option to offer the benefits
of M.I.S. to these patients whenever surgery
is indicated. Incidental colonic resection
is unlikely to help the laparoscopic surgeon
team in mastering the techniques. Reduction
of O.T. time due to better co-ordination
and cost benefit to patients can only be
offered by repetitive performances. A dedicated
team effort will surely bring this speciality
under the umbrella of M.I.S. as has happened
in western world. Details of various procedures
is beyond the scope of this article, but
I will give a broad overview of various
This is offered to stage a malignant condition,
take tissue for biopsy and have relook (second
look) operation by laparoscopy.
To obtain specimen and lymph nodes in inflammatory
large bowel diseases.
is mainly used to achieve faecal diversion
in unresectable malignant growth, severe
perianal infections, trauma faecal incontinence
and complex fistula in ano. If indicated
even a loop iliostomy can be offered to
and Lt hemicolectomy, total colonic resection,
abdomino-perineal resection (APR), anterior
resection (AR), lap assisted resection
are various procedures that can be offered
to patients. Out of these the most difficult
technique is a transverse colonic resection
in an obese patient. Large malignant and
inflammatory masses also are relative contraindication
for surgery. Obstructed lesions are absolute
contraindication for Lap surgery. To resect
the bowel Endo-staplers can be used. Now
we have even smaller stapler in the form
to endo G.I.A. 30 (Fig. 1). Smaller length
is easy to handle and manoeuvre. If larger
lumen needs to be divided, it's better to
fire smaller endo G.I.A. 30 twice. Variable
staple height of 2 mm, 2.5 mm, 3 mm colour
coded cartridges are used according to bowel
thickness (Fig. 2). Vascular pedicles can
also be divided by using 2 mm height stapler.
We prefer to tie the vessels individually
at the root of mesocolon is gives better
nodal clearance and cuts down the cost.
For anterior and low anterior resection
EEA® cured staple became very handy
(Fig. 3). Proper selection of size is very
essential to form a proper anastomosis.
Three sizes are available 25 mm, (28-29
mm), (32-33 mm) giving an inner stoma of
15 mm, 19 mm and 22 mm.
staple height, staple line of 3 rows on
each side with line of cutting and closure
of staple in letter B format
G.I.A. 30 (U.S.S.C. ®) being shown going
through abdominal wall
of lap colonic surgery are the same as conventional
- Anastomotic leak.
has been observed that bowel function returns
much earlier in lap surgery. Thus feeding
is started much earlier and hospital stay
is shorter. The reason for early return
of peristaltic activity is lack of handling
and non-exposure to outside atmospheric
air. Flatus, faeces and feeds (three F's)
of colonic surgery are much faster in M.I.S.
of specimen removed after laparoscopy have
been compared with conventional surgery
specimen in terms of
- Number of lymph
- Resected margin
has been seen that the basic principles
of oncosurgery are not compromised. The
procedure done is same as open surgery.
The five year survival rate are comparable.
Use of E.E.A.® (U.S.S.C.®) staple
with detachable anvil and handle lower down,
about to be locked with help of special
anvil (head) holding forcep in anterior
has been reported that laparoscopic surgery
offers less immuno - supression post operatively
as compared to conventional surgery. Surgeon
should not hesitate to convert in difficult
situation, keeping in mind the patient safety.
Average conversion rate is 10 to 12% in
malignancy and 18 to 20% in inflammatory
colonic condition. Procedures are not
to be compared but comparison of surgeons
philosophy and sound judgement gives different
Ileal pouch after total procto-colectomy
can easily be fashioned with G.I.A. 90 mm.
Harmonic scalpel if available reduces the
blood loss and O.T. time.
rectum requiring surgery is another condition
wherein the benefits of laparoscopic surgery
can be offered to the patient. Various types
of procedures are carried out.Surgeon has
to be proficient in the art of laparoscopic
knotting and suturing. In absence of that
various fixing decision like stapler and
Tacker ® can be used to fix the mesh
in place. We have one of the largest series
of laparoscopic rectopexy. We prefer Notora's
modification of Ripstein technique. So far
16 such procedures are carried out with
and anterior resection are other procedures
carried out. Proper selection of patients
and right procedure offered will give long
to "General & Endoscopy Surgery"