bowel was transected by the diathermy wire and delivered through the anus. Results: One animal was killed before completion of the operation because of a ...
Surg Endosc (1998) 12: 1245–1248
© Springer-Verlag New York Inc. 1998
Aseptic laparoscopic colon resection with intraabdominal anastomosis An experimental study in pigs L. S. Jørgensen,1,3 N. C. Langkilde,1 P. K. Møller,1 F. V. Mortensen,1 T. M. Tei,1 N. O. Jacobsen2 1
Department of Surgical Gastroenterology, Aarhus Kommunehospital, Aarhus University Hospital, DK-8000 Aarhus C, Denmark Department of Pathology, Aarhus Kommunehospital, Aarhus University Hospital, DK-8000 Aarhus C, Denmark 3 Institute of Experimental Clinical Research, Skejby Hospital, University of Aarhus, DK-8200 Aarhus N, Denmark 2
Received: 3 December 1997/Accepted: 21 January 1998
Abstract Background: We evaluated a new aseptic method for laparoscopic left colon resection in terms of technical feasibility and outcome. Methods: Ten pigs were operated on under general anesthesia. Pre- and postoperative body weight, stools, behavior, and need for analgesics were recorded. Fourteen days later, the animals were killed. At autopsy, the degree of intraabdominal adhesions was noted. The anastomoses were sent for histological examination. The entire procedure was performed intracorporeally, and no antibiotics were given. After division of the mesocolon, the segment to be resected was invaginated down through the colon. This was facilitated by a custom-made instrument that was introduced into the bowel via the anus; it consisted of a pull-out device and a modified diathermy wire. The anastomosis was completed at the invagination fold by a row of hernia staples that were covered by an interrupted suture. Then the invaginated bowel was transected by the diathermy wire and delivered through the anus. Results: One animal was killed before completion of the operation because of a colonic perforation. The remaining nine animals had an uneventful and rapid recovery. They ate from the 1st postoperative day and gained weight rapidly. Stools were normal after 2 days (median), and normal behaviour was noted in all animals from the 1st postoperative day. At the postmortem examination, intraabdominal adhesions were observed in two animals. In one case, the adhesions extended from a hematoma in the mesentery to the abdominal wall. There were no adhesions to the anastomosis or the colon. In the other case, the anastomosis adhered to the right uterine tube and a loop of small intestines. Conclusions: The method is technically feasible, but a modification is suggested for cases where the invagination is impossible. Recovery after the operation is rapid.
Correspondence to: L. S. Jørgensen
Key words: Colon — Laparoscopic colectomy — Surgical technique — Aseptic colon resection — Animal study
Conventional open operations on the colon present a number of problems. These include septic complications and long convalescence due to gastrointestinal paralysis and surgical stress. Septic complications are reduced to ∼5% with modern prophylactic antibiotic regimens and bowel preparation, but the drawbacks include complications caused by development of resistant bacterial strains and the risk of enteritis caused by overgrowth of pathogenic microorganisms. Aseptic surgical techniques might abolish the need for antibiotics and reduce the rate of infection. Laparoscopical techniques combined with modern pain-reducing modalities and early nutrition could also reduce the time of recovery [1]. We have previously described an aseptic technique for colon resection [5]. Here we report on our experience with a laparoscopic modification of this technique performed on pigs.
Materials and methods The operations were performed under general anesthesia. Twenty-seven female pigs weighing 35–40 kg were used. Sixteen pigs were used to establish the surgical technique. Subsequently, the final procedure was performed on eleven pigs. Because of technical problems encountered during insertion of the Veress needle, intestinal damage was suspected in one pig, which was killed without further operation. No serious damage, however, was seen at postmortem examination. The series then consisted of 10 female pigs. They were fasted for 2 days with free access to water, and the bowel was prepared with two bisacodyl tablets in the morning and afternoon the day before surgery. Two bisacodyl suppositories were administered together with the last tablets. No antibiotics were given before or after surgery. At the termination of the operation, one indomethacin suppository (50 mg) was placed in the rectum. Written instructions ordered 1 ml of buprenorphine up to a maximum of
1246 four times per day if pain was suspected during the early postoperative days. Standard food mixed with water was given from the day after the operation until normal stools were passed. Body weight, food intake, consistency of stools, administration of analgesics, and behavior were recorded every day, and the animals were killed with potassium chloride under general anesthesia after 14 days. At the postmortem examination, any abnormalities in the abdomen (including adhesions) were recorded, and photographic documentation was obtained.
adhesions to the colon or anastomosis were observed. The hematoma was probably induced by the Veress needle. In pig 4, thick adhesions were observed extending from the anastomosis to the right uterine tube and light adhesions from an intestinal loop to the anastomosis and abdominal wall.
Histopathology
Histopathology
Approximately 10 cm of colon containing the anastomosis was excised, opened, and sent for histopathologic examination. It was pinned on cork, macroscopically examined, and fixed in buffered formalin. Tissue specimens were taken for histology from the line of anastomosis (three samples) and a few cm on each side of the anastomosis (two samples). Hematoxylinand-eoxin–stained paraffin sections were prepared from each specimen. The study was approved by the Danish Committee for Animal Experiments.
At gross examination, all nine anastomoses could easily be passed by an index finger. A ridge with a median height of 8 mm (range, 2–25 mm) was seen at the line of anastomosis. Five animals had a slight dilatation proximal to the anastomosis. The median inner circumference at the anastomosis was 6.4 cm (range, 4.5–9.0 cm). At 3–5 cm proximal and distal to the anastomosis, median inner circumference were 8.5 and 8.0 cm, respectively. Microscopic examination revealed a healed anastomosis in all cases except for small superficial defects at the top of the ridges. One animal (pig 2) had an abscess measuring 0.5 × 1.5 cm in relation to sutures in the intestinal wall. In another animal (pig 4) fibrous adhesions containing food remnants were found between the anastomosis and the uterine tube and uterus, but no other signs of leakage were observed. Thus, this animal had a small, healed, subclinical anastomotic leakage.
Operative procedure The basic principle of this laparoscopic colon resection is identical with that previously described for open surgery [5]. However, a two-layered anastomosis consisting of an inner stapled seromuscular layer (Multifire Endo-Hernia 4.0 mm; Auto-Suture, Copenhagen, Denmark) covered by an outer layer of interrupted absorbable suture (Polysorb 3–0; Auto-Suture) was used instead of one sutured layer. Pneumoperitoneum was established through a Veress needle. Trocar placement is illustrated in Fig. 1. The 10-cm segment of the descending colon to be resected was determined, and the pull-out device of a custommade combined diathermy instrument was advanced via the anus to the middle of this segment and fixed by a ligature (Fig. 2), tied extracorporeally. The mesocolon was divided by diathermy, and the bowel was then invaginated down through the diathermy wire by applying traction on the pull-out device while pushing the diathermy instrument (Fig. 3). Stay sutures were placed at the mesenteric and antimesenteric borders, tied intracorporeally, and kept by graspers placed via two laterally positioned trochars. The first layer of the anastomosis was accomplished by placing ∼10 hernia staples at the anterior side of the invagination fold. The staples were covered by a second layer of about five interrupted sutures (Fig. 4). The bowel was turned by means of the stay sutures, and the posterior side of the anastomosis was accomplished. The hernia stapler was introduced through a 12-mm port placed in the midline a few cm cephally to the anastomotic line. After completion of the anastomosis, the invaginated bowel was divided by the diathermy and delivered through the anus.
Results The operation was completed in nine of the 10 pigs. In one animal (pig 9) the colon was inadvertently perforated, so the animal was sacrificed. Table 1 summarizes the clinical data for each animal. In five animals, the median weight gain from 2 days before to 1 day after surgery was 0.3 kg (range, –1–1.1 kg). One was weighed 1 day before surgery for the first time, and two were weighed just before surgery. None of these three animals lost weight after the operation. Most of the clinical postoperative data for one animal (pig 8) were lost at the animal farm. After a median of 2 days, stool consistency was normal (range, 1–6 days). No analgesics were needed after the operation. At the postmortem examination 14 days after the operation, intraabdominal adhesions were seen in two animals. In pig 1, adhesions extended from a hematoma in the mesentery to the abdominal wall and loops of small intestines. No
Discussion Quicker recovery after laparoscopic colon surgery than usually seen after open surgery has been reported [1, 4], but no randomized trials have been published. Many surgeons do only part of the operation laparoscopically, leaving the rest of the operation to be done through a laparotomy, but entirely intracorporeal techniques have been reported [2, 4]. The preliminary series presented here includes only a small number of pigs, but it shows that this entirely intracorporeal and aseptic surgical technique is technically feasible. All animals started to eat the 1st day after surgery, six of eight had higher body weight 2 days after surgery than before, and recovery was in all ways uneventful in spite of the absence of prophylactic antibiotic treatment. The insertion of the combined diathermy–pull-out instrument through the anus was easily accomplished, and on bleeding or thermal injuries after the transection of the invaginated bowel was encountered. The transection was effected with a blend of cut and coagulation mode of the diathermy apparatus. One operation in the series failed because of a perforation in the midpoint of the bowel segment to be resected. There was no contamination; with the administration of a single dose of antibiotics, the operation could probably have been completed safely. The placement of hernia staples was easy to accomplish with the stapler inserted almost right above the middle of the invagination fold. The second layer of interrupted sutures was placed in order to reduce the risk of leakage caused by inappropriately placed staples. These sutures were placed so that the staple line was just covered. Only one case of adhesions to the anastomosis and one
1247
Fig. 1. Trocar placement. Numbers 1, 2, and 5 are 10-mm trocars. Number 3 is a 5-mm, and number 4 a 12-mm trocar (for the hernia stapler). Fig. 2. The diathermy instrument (D) and pull-out device (P) have been advanced via the anus to the segment of colon to be resected. The pull-out device is fixed to the middle of this segment by a ligature (L). Fig. 3. The segment of colon to be resected has been invaginated by traction on the pull-out device while at the same time pushing the diathermy instrument. Stay sutures have been placed at the mesenteric and antimesenteric borders. Fig. 4. The anastomosis has been completed in two layers with hernia staples innermost. The invaginate has been divided by the diathermy and removed through the anus by the pull-out device.
case of a small abscess around a suture were recorded at the autopsy 2 weeks after the operation. The recovery of both animals was entirely uncomplicated without any loss of weight, and stools were normal from the 2nd postoperative day. Sometimes, the invagination of the entire bowel segment is not possible, either because of a large tumor or because of a stiff bowel wall. In these cases, a modification of the technique, as described previously [5], may be used.
With this technique, the bowel segment is divided between cable ties in both ends and delivered through an expansion of a port site. After reuniting the ends with a ligature, a short length of bowel is invaginated and the anastomosis accomplished with hernia staples and sutures. When performing the aseptic colon resection without transection between cable ties, cultures from the anastomosis and subcutis show only a few or no bacteria in the majority of cases when the operation is performed on dogs at open laparotomy. The
1248 Table 1. Data for each individual pig Weight (kg) No.
Day–2
Day–1
1 2 3 4 5 6 7 8 9a 10
37.5 36.9 — 37.0 40.0 36.0 — 45.1
37.3 36.5 39.0 36.5 39.5 35.0 — —
—
—
a
Day 0
40.5 35.5
Stools
Behavior
Adhesions
Day 1
Day 2
Last measurement/(day)
1st stool at day
Normal at day
Normal at day
At autopsy
37.0 38.0 39.8 38.0 39.0 36.3 41.0 —
36.5 38.0 40.5 38.2 39.5 38.0 42.5 —
27.3/(6) 39.5/(4) 42.6/(5) 38.5/(4) 41.3/(4) 38.5/(3) 42.5/(2) —
2 2 4 1 3 3 2 —
3 2 5 2 6 — 2 —
1 1 1 — 1 1 1 1
+ 0 0 + 0 0 0 0
35.5
36.5
38.5/(3)
2
2
1
0
Sacrificed before completion of the operation due to perforation of the colon
transection between cable ties does not increase the bacterial count [5]. In humans, traditional open resection of the large bowel without the administration of antibiotics results in a 45–51% infection rate, even when maximal efforts are carried out to empty the bowel mechanically [3, 6]. In the present laparoscopic series using the invagination technique, no clinical suspected infections were encountered, even though bowel emptying was insufficient in five of the pigs. Similarly, in another study of laparoscopic sigmoid resection in pigs without prophylactic antibiotics, no clinical signs of sepsis was encountered. The bowel was transected between cable ties and delivered through a rectoscope. The anastomosis was accomplished intracorporeally using a circular stapler [7]. Acknowledgment. We thank Auto-Suture, Copenhagen, Denmark, for supplying us with disposable instruments.
References 1. Bardram L, Funch-Jensen P, Crawford ME, Kehlet H (1995) Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 345: 763–764 2. Darzi A, Guillou PJ, Monson JRT (1994) Laparoscopic sigmoid colectomy: total laparoscopic approach. Dis Colon Rectum 37: 268–271 3. Eykyn SJ, Jackson BT, Lockhart-Mummery HE, Philips I (1979) Prophylactic peroperative intravenous metronidazole in elective colorectal surgery. Lancet 2: 761–764. 4. Franklin ME, Ramos R, Rosenthal D, Schuessler W (1993) Laparoscopic colonic procedures. World J Surg 17: 51–56 5. Jørgensen LS, Raundahl U, Knudsen LL, Aksglaede K, Søgaard P (1991) Aseptic colon resection by an invagination technique: experimental study on dogs. Dis Colon Rectum 34: 594–599 6. Keighley MRB, Crapp AR, Burdon DW, Cooke WT, AlexanderWilliams J (1976) Prophylaxis against anaerobic sepsis in bowel surgery. Br J Surg 63: 538–541 7. Lirici MM, Buess G, Melzer A, Weinreich S, Wehrmann M, Becker HD (1993) New technique for sigmoid colectomy. Br J Surg 80: 1606–1609
