We devised a new method for the safe introduction of the first trocar and induction of pneumoperitoneum for laparoscopic excision of the large intestine.
With this method, a small laparotomy is first conducted according to the size of the exposed affected intestinal tract or tumor size, prior to the application of a LAP DISC (LD) to the wound and introduction of a 12-mm trocar for the establishment of pneumoperitoneum. The method is advantageous in that organ injury and vessel injury are avoided when the small laparotomy is conducted first, and prompt transition to a conventional laparotomy is possible. The diaphragm of the iris bulb can be controlled in a non-stepwise manner. In addition, trocars, the stapler, and other instruments, can be inserted under the pneumoperitoneum. Furthermore, the use of a 5-mm flexible scope allows surgical maneuvers, except for application of LD, to be conducted via 5-mm trocars. In addition, the 5-mm scope can be inserted through any trocar, allowing multidirectional avoidance of dead space and intraperitoneal observation. When only 5-mm trocars are used, it is not necessary for the sites of trocar puncture to be closed by sutures, and this minimizes the risk of adhesions and port-site herniation. The method is also considered to be excellent from the point of view of esthetics.
We employed this surgical approach in 50 patients with colorectal cancer at our hospital. None of the patients developed any traumatic complications associated with the insertion of trocars, and none of the patients, even those with a past history of abdominal operation, required conversion to conventional laparotomy.
Based on these results, this method involving a small laparotomy prior to the application of an LD and introduction of a 12-mm trocar for establishing pneumoperitoneum, with the efficient use of a 5-mm flexible camera, is considered to be safe and useful for laparoscopic excision of the large intestine.
Laparoscopic excision of the large intestine allows reduction of postoperative wound pain, shortening of the duration of hospitalization, and early return to daily routine for patients, as compared to conventional laparotomy. Therefore, because of the less invasive nature of this approach, it has come to be widely adopted in recent years. Nevertheless, complications specific to laparoscopic surgeries have also been reported .
Great vessel injury and visceral injury as traumatic complications associated with trocar insertion have been reported in 0.09% of patients undergoing laparoscopic surgery [1, 3]; the incidence of such injury was reported to be 37.9% on insertion of the first trocar, and 22% on insertion of the second trocar . According to some reports, organs outside the visual field were injured during the operation because of the narrowness of the field, and there are even reports of death associated with severe complications such as massive postoperative hemorrhage [7, 9, 10, 11]. Hemorrhage related to removal of a trocar, postoperative port-site herniation, and adhesive intestinal obstruction occur most frequently around 1 week after the operation, at incidences ranging from 0.01% to 0.02% [6, 8].
We used a new method in which the first trocar is inserted after the application of a LAP DISC (LD), and a 5-mm flexible scope is used efficiently, for laparoscopic excision of the large intestine. The safety and usefulness of the method are discussed.
Patients and methods
The subjects were 50 patients in whom laparoscopic excision of the large intestine was conducted via an LD at our hospital during the period from December 2003 to December 2004. There were 32 men and 18 women, ranging in age from 38 to 90 years (mean, 67 ± 1.8 years). In terms of the site of the malignancy, there were 6 cases of cecal cancer, 12 of ascending colon cancer, 2 of transverse colon cancer, 14 of sigmoid colon cancer, and 16 of rectal cancer. There were 13 patients with a previous history of abdominal surgery, including 7 with a history of appendectomy, 3 with a history of gynecological surgery, and 3 with a history of gastrectomy.
For insertion of the first trocar, a skin incision of approximately 3–5 cm was made 2 fingerbreadths below the xiphoid process for lesions located in the right colon, and 2 fingerbreadths above the pubis for lesions located in the left colon or rectum. In cases requiring abdomino-perineal resection of the rectum, however, a round skin incision 2.5 cm in diameter was made immediately beneath the planned site of construction of the artificial anus. An LD ( Johnson and Johnson ) was applied at the site of the small incision, and a 12-mm trocar was inserted for induction of pneumoperitoneum (Fig. 1). Additional trocars, including one for introduction of the camera, were inserted into the infraumbilical region under direct observation with a 5-mm flexible scope (OLYMPUS) (Fig. 2).
After completion of the intraperitoneal maneuvers, the intestinal tract was exposed extracorporeally via the LD and excised. This method facilitates the repeat establishment of a pneumoperitoneum and allows prompt anastomosis with the double-stapling technique (DST), drain insertion, and confirmation of hemostasis. A transition to laparotomy is also facilitated, because a small incision is already made. The intestinal tract is repositioned before repeat establishment of pneumoperitoneum by insertion of a trocar via the LD. After confirming the absence of hemorrhage following removal of the trocar, the wound at the site of the LD was closed.
The surgical procedure conducted was excision of the colon in 34 patients 68%), anterior excision in 10 patients (20%), and abdominoperineal resection of the rectum in 6 patients (12%). The median intraoperative blood loss was 20 ml (10–440 ml), and the median operative time was 210 minutes (range, 130–360 minutes). None of the patients required transition from laparoscopic surgery to laparotomy. Histopathologically, the tumor was classified into stage 0 in 4 patients, stage I in 21 patients, stage II in 13 patients, and stage III in 12 patients. The median number of lymph nodes screened was 16 (range: 6–26). There was no case of surgical death and none of the patients required reoperation. Postoperative complications were recognized in 4 patients (8%), and wound infection was seen in 4 patients. There were no cases of ileus, rupture of sutures, postoperative hemorrhage, or port-site recurrence. Severe adhesions from previous abdominal operation were recognized in 13 patients (26%), and a trocar could be inserted safely under direct visualization at various angles with the 5-mm flexible scope. The median duration of postoperative hospitalization was 8 days (range: 4–21 days).
In recent years, laparoscopic surgeries have come to be widely performed. Unlike conventional laparotomy, laparoscopic operations are conducted after the induction of pneumoperitoneum, and they involve the use of specific surgical devices and manipulations within narrow spaces. Therefore, complications are bound to occur. It is particularly important for the safe performance of laparoscopic operations to avoid traumatic complications associated with the insertion of a trocar.
We sought to avoid such traumatic complications by safely inserting trocars through an LD, and by efficiently using a 5-mm flexible scope. The LD adheres to the abdominal wall, preventing the leakage of pneumoperitoneum gas. It protects the wound, preventing infection and port-site recurrence. It is easily applied, and the size of the iris bulb can be freely controlled. Accordingly, it is easy to establish pneumoperitoneum, repeatedly if required, under which condition various devices, including trocars are inserted. It is also possible to make a prompt transition to laparotomy, in the event of traumatic complications, such as intraoperative hemorrhage. The skin incision is closed after hemostasis as been confirmed at all sites of trocar insertion. Thus secondary hemorrhage from the sites of trocar insertion is avoided. Furthermore, a 5-mm flexible scope can be inserted through all trocars, leading to the avoidance of dead space, and the scope allows free visualization of the optimum visual field. Herniation and adhesive intestinal obstruction at the sites of trocar insertion have been reported to occur at incidences of 86.3%, 10.9%, and 2.7% for ≥ 10 mm, <10 mm and ≥ 8 mm, and <8 mm trocars, respectively . Based on these data, it can be surmised that the risk of herniation at sites of trocar insertion can be minimized by the use of 5-mm trocars. However, caution must also be exercised during the application of an LD, because tension is applied on the iris bulb, with ensuing risk of rupture, when the abdominal wall is thick as in very obese patients and muscularly well-developed patients.
The reported incidence of wound infection is 2.8% at the port site and 11% at the site of the wound from which the excised intestinal tract is extracted . In our hospital, wound infection has occurred only at the wound created for removal of the excised intestinal tract, at an incidence of 8%. Although the incidence of infection in our patients tended to be low, we emphasize that every effort should be made to prevent this complication by timely and appropriate antibiotic administration and lavage of the wound site.
From the above-described results and observations, our method of laparoscopic colectomy using safe insertion of the first trocar via an LD and efficient use of a 5-mm flexible scope is considered to be less invasive than other procedures, highly safe, and efficient.
We used a new method in which the first trocar is inserted after the application of a LAP DISC (LD), and a 5-mm flexible scope is used efficiently for laparoscopic excision of the large intestine. The safety and usefulness of the method are discussed.
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Nakamura, T., Kokuba, Y., Mitomi, H. et al. New technique of laparoscopic colectomy with the LAP DISC and a 5-mm flexible scope. Surg Endosc 20, 1501–1503 (2006). https://doi.org/10.1007/s00464-005-0619-2
- Laparoscopic colectomy
- LAP DISC
- 5-mm flexible scope