Traditional surgical treatment for many intestinal disorder has required a long midline abdominal incision and a long and difficult recovery period of between four and eight weeks because traditional “open” procedures are highly invasive. Today, more Cleveland Clinic colorectal surgeons are highly experienced in minimally invasive laparoscopic techniques for intestinal surgery.
The benefits of laparoscopic surgery include less postoperative pain, shorter hospitalization, faster return to a regular diet with quicker return on bowel function, quicker return to full health and less scarring with improved cosmetic results. Experience with more than 2,500 laparoscopic intestinal resections, and an average of five additional cases each week, has shown that the approach can be at least as safe as traditional surgical methods, when performed by a surgical team with special training and extensive experience. Our surgeons can now offer a laparoscopic approach to nearly 95% of all patients requiring a resective procedure while conversion rates and a need for a larger incision is needed in as few as 5% of patients.
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Graft Form
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2000
|
155
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|
|
2001
|
~160
|
|
|
2002
|
~175
|
|
|
2003
|
~200
|
|
|
2004
|
~310
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|
|
2005
|
180
|
|
|
2006
|
>400
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FIGURE 1: Laparoscopic Colorectal Procedure
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Suitable conditions for laparoscopic colectomy include cancer of the colon and rectum, diverticular disease and its complications, Crohn’s disease, ulcerative colitis, familial polyposis, polyps unamenable to colonoscopic polypectomy and rectal prolapse. In each case the bowel is mobilized using laparoscopic instruments, and the vascular pedicles divided using special stapling techniques. The bowel can then be removed and an anastamosis fashioned. Patients with rectal prolapse generally do not need any incision, and the rectum is repositioned and fixed to the sacrum, allowing the patient to be discharged the next day.
Many of the “relative” contraindications for a laparoscopic approach (obesity, other comorbidities, increased age, and history of previous surgery or radiation to the pelvis) have been dispelled and are not associated with an increased possibility of choosing or converting to an “open” procedure. Our surgeons have been involved in landmark studies since the development of laparoscopic colorectal surgery and are helping to redefine the way that colorectal surgery is performed.
Both causes of the colon and rectum are suitable for a laparoscopic approach when performed by a skilled surgical team trained in advanced laparoscopy. With adherence to the same strict oncologic principles that pertain to open surgery, minimally invasive approach allows for a true “hands-off”approach with the potential for less chance of spread of cancer cells. With the same operation being performed (same length of colon, same number of lymph nodes) but through a smaller incision, the patient’s immune response is not as strained as it is with a large incision, and the patient is afforded the opportunity to better combat the cancer. While the oncologic ramifications of a laparoscopic approach have now been proven at least equal to that of an open operation, we are now evaluating the possibility that a laparoscopic approach may actually help protectcolorectal cancer patients against recurrence.
A registry of all patients undergoing laparascopic colorectal surgery is maintained prospectively. Our surgeons continue to examine their results and perform a prospective of laparoscopy, leading to multiple recent publications that continue to set the benchmark of laparoscopic colorectal surgery.
A new and even less invasive modality for the treatment of most polyps and select cancers of the rectum and distal colon is now being offered at the Cleveland Clinic. For more on Transanal Endoscopic Microsurgery (T.E.M.), please see the innovations section.
Laparoscopy offers the patient an identical operation, performed through three or four small openings (about 1 cm in size) utilizing a small camera while watching an enlarged image of the patients internal organs on a television monitor. In mot cases one of the small openings is lengthened to approximately 5 cm in length to complete the operation. Patients are offered diet and oral medications the day after surgery, and in many cases, are well enough to be discharged on the second day after surgery.
FIGURE 3: Incisions
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Abdominal Perineal Resection
An abdominal perineal resection is the removal of the anus, rectum, and sigmoid colon, and the creation of a permanent colostomy. This procedure is usually performed to treat cancer located very low in the rectum or in the anus, close to the anal sphincter (control) muscles. If surgery is the form of treatment your doctor recommends, physicians at the Cleveland Clinic who specialize in this procedure can determine if laparoscopic surgery is appropriate for you.
How is laparoscopic abdominal perineal resection performed
Laparoscopic surgery uses a thin, telescope-like instrument called a laparoscope, which is inserted through a small incision at the umbilicus (belly button). The laparoscope is connected to a tiny video camera – smaller than a dime – which projects a view of the operative site onto video monitors located in the operating room. The abdomen is inflated with carbon dioxide, a gas, to allow your surgeon a better view of the operative area. Two or three additional small incisions are made on the abdomen through which the surgeon inserts specialized surgical instruments. The surgeon uses these instruments to perform the operation. The small incisions are closed with sutures and covered with surgical tape. A permanent colostomy is made on the abdominal wall.
What are the benefits?
• Three or four tiny scars instead of one large abdominal scar
• Shorter hospital stay
• Shorter recovery time and quicker return to daily activities, including work
What can I expect after surgery?
It is important to follow your doctor’s instructions after surgery. You will need to take it easy for a few weeks.
How safe is laparoscopic abdominal perineal resection?
If performed by experts in this field, laparoscopic abdominal perineal resection is as safe as “open” surgery.
Appointment
To schedule an appointment, please call the Digestive Disease Institute at 216-444-5404.
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Intestinal Surgery
Traditional surgical treatment for many intestinal disorders requires a long abdominal incision and a lengthy recovery period. Laparoscopic surgery has been used for several years to treat gallbladder and gynecologic problems. Cleveland Clinic colorectal surgeons are now using laparoscopic techniques to perform intestinal surgery for many patients.
Who is a candidate for laparoscopic intestinal surgery?
Anyone with a condition that requires removal of a large part of the intestine, including diverticulitis, Crohn’s disease, ulcerative colitis, cancers of the colon and rectum, and rectal prolapse may be a candidate for laparoscopic intestinal surgery. If surgery is the form of treatment your doctor recommends, physicians at the Cleveland Clinic who specialize in this procedure can determine if laparoscopic surgery is appropriate for you.
How is laparoscopic intestinal surgery performed?
Laparoscopic surgery uses a thin, telescope-like instrument called a laparoscope, which is inserted through a small incision at the umbilicus (belly button). The laparoscope is connected to a tiny video camera – smaller than a dime – which projects a view of the operative site onto video monitors located in the operating room. The abdomen is inflated with carbon dioxide, a gas, to allow your surgeon a better view of the operative area. Two or three additional small incisions are made near the laparoscope through which the surgeon inserts specialized surgical instruments. The surgeon manipulates these instruments to perform the operation. Following the procedure, the small incisions are closed with sutures and covered with surgical tape.
What are the benefits of laparoscopic intestinal surgery?
• Three or four tiny scars instead of one large abdominal scar
• Shorter hospital stay – many patients leave are discharged two to three days after surgery
• Reduced postoperative pain
• Shorter recovery time and a quicker return to daily activities, including work
What can I expect after surgery?
It is important to follow your doctor’s instructions after surgery. You will need to take it easy for two to four weeks.
How safe is laparoscopic intestinal surgery?
More than 2500 patients have undergone laparoscopic intestinal surgery at the Cleveland Clinic. Our experience indicates that laparoscopic intestinal surgery is as safe as traditional “open” intestinal surgery if performed by experts in this field.
Appointment
To schedule an appointment, please call the Digestive Disease Institute at 216-444-5404.
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Left Colectomy/Proctosigmoidectomy
A left colectomy is the removal of part or all of the left colon. A proctosigmoidectomy is the removal of the sigmoid colon and at least part of the rectum. These operations are performed for the removal of cancers, certain non-cancerous growths, or complicated diverticulitis. If surgery is the form of treatment your doctor recommends, physicians at the Cleveland Clinic who specialize in this procedure can determine if laparoscopic surgery is appropriate for you.
How are laparoscopic left colectomy and proctosigmoidectomy performed?
Laparoscopic surgery uses a thin, telescope-like instrument called a laparoscope, which is inserted through a small incision at the umbilicus (belly button). The laparoscope is connected to a tiny video camera – smaller than a dime – which projects a view of the operative site onto video monitors located in the operating room. The abdomen is inflated with carbon dioxide, a gas, to allow your surgeon a better view of the operative area. Additional small incisions are made in the abdomen through which the surgeon inserts specialized surgical instruments.
The surgeon uses these instruments to perform the operation. Following the procedure, the small incisions are closed with sutures or surgical tape.
What are the benefits?
• Three or four tiny scars instead of one large abdominal scar
• Shorter hospital stay
• Reduced postoperative pain
• Shorter recovery time and quicker return to daily activities, including work
What can I expect after surgery?
You will receive instructions on post-operative activity and suggestions for your diet. It is important to follow your doctor’s instructions after surgery. You will need to take it easy for four to six weeks.
How safe is laparoscopic surgery?
If performed by experts in this field, laparoscopic left colectomy and proctosigmoidectomy are as safe as “open” surgery in carefully selected cases.
Appointment
To schedule an appointment, please call the Digestive Disease Institute at 216-444-5404.
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Rectal Prolapse
Rectal prolapse is a condition in which the rectum loses its internal support and completely falls outside the body. Rectopexy is the surgical placement of internal sutures to position and secure the rectum correctly. If surgery is the form of treatment your doctor recommends, physicians at the Cleveland Clinic who specialize in this procedure can determine if laparoscopic surgery is appropriate for you.
How is laparoscopic rectopexy performed?
Laparoscopic surgery uses a thin, telescope-like instrument called a laparoscope, which is inserted through a small incision at the umbilicus (belly button). The laparoscope is connected to a tiny video camera – smaller than a dime – which projects a view of the operative site onto video monitors located in the operating room. The abdomen is inflated with carbon dioxide, a gas, to allow your surgeon a better view of the operative area. Three or four additional small incisions are made near the laparoscope through which the surgeon inserts specialized surgical instruments. The surgeon uses these instruments to correct the rectal prolapse. Following the procedure, the small incisions are closed with sutures and covered with surgical tape.
What are the benefits?
• Three or four tiny scars instead of one large abdominal scar
• Shorter hospital stay – you may leave the hospital in three to four days
• Reduced postoperative pain
• Shorter recovery time and quicker return to daily activities, including work
What can I expect after surgery?
It is important to follow your doctor’s instructions after surgery. You will need to take it easy for one or two weeks.
How safe is laparoscopic rectopexy?
If performed by experts in this field, laparoscopic rectopexy is as safe as “open” surgery in carefully selected cases.
Appointment
To schedule an appointment, please call the Digestive Disease Institute at 216-444-5404.
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Right Colectomy
A right colectomy is performed to remove cancers, certain non-cancerous growths, or areas of inflammation which occur in Crohn’s Disease and other disorders. A section of the colon that lies next to the small intestine is removed. If surgery is the form of treatment your doctor recommends, physicians at the Cleveland Clinic who specialize in this procedure can determine if laparoscopic surgery is appropriate for you.
How is laparoscopic right colectomy performed?
Laparoscopic surgery uses a thin, telescope-like instrument called a laparoscope, which is inserted through a small incision at the umbilicus (belly button). The laparoscope is connected to a tiny video camera – smaller than a dime – which projects a view of the operative site onto video monitors located in the operating room. The abdomen is inflated with carbon dioxide, a gas, to allow your surgeon a better view of the operative area. Two or three additional small incisions are made through which the surgeon inserts specialized surgical instruments. The surgeon uses these instruments to remove the right colon. Following the procedure, the small incisions are closed.
What are the benefits of laparoscopic right colectomy?
• Three or four tiny scars instead of one large abdominal scar
• Shorter hospital stay – you may leave the hospital in two or three days
• Reduced postoperative pain
• Shorter recovery time and quicker return to daily activities, including work
What can I expect after surgery?
It is important to follow your doctor’s instructions after surgery. You will need to take it easy for one or two weeks.
How safe is laparoscopic right colectomy?
If performed by experts in this field, laparoscopic right colectomy is as safe as “open” surgery in carefully selected cases.
Appointment
To schedule an appointment, please call the Digestive Disease Institute at 216-444-5404.
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Small Bowel Resection
Inflammatory conditions of the small intestine, including Crohn’s disease, or the formation of strictures – narrowed areas of the small intestine – may require the removal of that portion of the small intestine which is affected. A small bowel resection is the removal of one or more segments of the small intestine. If surgery is the form of treatment your doctor recommends, physicians at the Cleveland Clinic who specialize in this procedure can determine if laparoscopic surgery is appropriate for you.
How is laparoscopic small bowel resection performed?
Laparoscopic surgery uses a thin, telescope-like instrument called a laparoscope, which is inserted through a small incision at the umbilicus (belly button). The laparoscope is connected to a tiny video camera – smaller than a dime – which projects a view of the operative site onto video monitors located in the operating room. The abdomen is inflated with carbon dioxide, a gas, to allow your surgeon a better view of the operative area. Additional small incisions are made in the abdomen through which the surgeon inserts specialized surgical instruments. The surgeon uses these instruments to perform the operation. Following the procedure, the small incisions are closed with sutures or surgical tape.
What are the benefits?
• Three or four tiny scars instead of one large abdominal scar
• Shorter hospital stay
• Reduced postoperative pain
• Shorter recovery time and quicker return to daily activities, including work
What can I expect after surgery?
You will receive instructions on post-operative activity and suggestions for your diet. You will need to take it easy for four to six weeks.
How safe is laparoscopic small bowel resection?
If performed by experts in this field, laparoscopic small bowel resection is as safe as “open” surgery in carefully selected cases.
Appointment
To schedule an appointment, please call the Digestive Disease Institute at 216-444-5404.
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Stoma Creation for Fecal Diversion
Complex rectal or anal conditions, particularly those resulting from infection or permanent incontinence (poor control of the bowels) may require surgery. Fecal diversion is the surgical creation of an ileostomy – an opening (stoma) between the surface of the skin and the small intestine – or a colostomy – an opening between the surface of the skin and the colon. If surgery is the form of treatment your doctor recommends, physicians at the Cleveland Clinic who specialize in this procedure can determine if laparoscopic surgery is appropriate for you.
How is laparoscopic fecal diversion performed?
Laparoscopic surgery uses a thin, telescope-like instrument called a laparoscope, which is inserted through a small incision at the umbilicus (belly button). The laparoscope is connected to a tiny video camera – smaller than a dime – which projects a view of the operative site onto video monitors located in the operating room. The abdomen is inflated with carbon dioxide, a gas, to allow your surgeon a better view of the operative area.
Additional small incisions are made in the abdomen through which the surgeon inserts specialized surgical instruments. The surgeon uses these instruments to perform the operation. Following the procedure, the small incisions are closed with sutures or surgical tape.
What are the benefits?
• One or two tiny scars instead of one large abdominal scar
• Shorter hospital stay
• Reduced postoperative pain
• Shorter recovery time and quicker return to daily activities, including work
What can I expect after surgery?
You will receive instructions on the care of your stoma, post-operative activity, and suggestions for your diet. You will need to take it easy for one or two weeks.
How safe is laparoscopic fecal diversion?
If performed by experts in this field, laparoscopic fecal diversion is as safe as “open” surgery in carefully selected cases.
Appointment
To schedule an appointment, please call the Digestive Disease Institute at 216-444-5404.
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Innovations - TEM
FIGURE 5: Transanal Endoscopic Microsurgery (T.E.M.) device
Transanal Endoscopic Microsurgery (TEM)
Our institution introduced a new procedure called trananal endoscopic microscopic this year. This involves the use of stereoscopic endoscopes to fully respect lesions of the rectum and distal colon without making any abdominal incisions or splitting the sphincter. It is used for treatment of benign lesions up to 20 cm level and early rectal cancers. Cleveland clinic is one of the few centers in Midwest who has this technology
TEM Device
Transanal Endoscopic Microsurgery (T.E.M.)
T.E.M. Outcomes
LEAST INVASIVE WAY TO REMOVE ALL POLYPS AND SELECT CANCERS OF THE RECTUM AND DISTAL COLON
NO ABDOMINAL INCISION
Uses a closed airtight system that provides constant rectal distension, improved visibility, and longer reach than conventional instrumentation.
Virtually any rectal adenoma and select rectal cancers can be removed
Safe
Associated with minimal complications
Outpatient or single night hospital stay
Transanal excision of rectal
Lower recurrence rates than conventional methods
1. All polyps
2. Select T1 cancers
3. Select T2 cancers with Neoadjuvant therapy
4. T3 cancers in medical compromised patients
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