LAPAROSCOPIC SIGMOID COLECTOMY SHAWNEE MISSION MEDICAL CENTER SHAWNEE MISSION KANSAS June 21, 2006

Transcription

1 LAPAROSCOPIC SIGMOID COLECTOMY SHAWNEE MISSION MEDICAL CENTER SHAWNEE MISSION KANSAS June 21, :00:14 Announcer: Internationally recognized surgeon Dr. Joseph Petelin is pioneering new techniques for the treatment of colon disease. 00:00:21 Dr. Petelin: About 15 years ago, we developed the techniques that allow us to do the same operation laparoscopically with little ports, small incisions, same operation on the inside. So when you give the patient a chance of having three of four small, halfinch incisions versus a 12-inch incision, the choice is pretty easy for the patient. 00:00:42 Announcer: Today, live from Shawnee Mission Medical Center in Shawnee Mission, Kansas, Dr. Petelin will perform a laparoscopic sigmoid colectomy, a procedure used to treat cancer and other colo-rectal diseases. With the aid of a tiny camera and special surgical instruments, Dr. Petelin will operation through ports that are no larger than a few centimeters in diameter. 00:01:04 Dr. Petelin: If we can do the same operation with the same technical quality for the patient, if we can do all that, then a laparoscopic approach, in my opinion, is better, and I think we ve been able to show that over the last 15 years. With our results in terms of how fast the patient is able to eat, how fast they get up and ambulate after the surgery, and how fast they re able to get out of the hospital. 00:01:25 Announcer: During the webcast, Dr. Petelin and colleagues will answer question from the viewing audience. You may send your questions to the OR by clicking the MDirectAccess button at any time. 00:01:40 Dr. Gecelter: Good afternoon, everyone. Thank you for joining us at Shawnee Mission Medical Center. We are coming to you live from Shawnee Mission, Kansas, for Kansas City metropolitan area s very first live surgical webcast. Today, we will be performing a laparoscopic sigmoid colectomy. My name is Dr. Gary Gecelter:. I m joined by my colleague and friend Dr. Joseph Petelin, who will be performing the surgery today. Two housekeeping matters before we turn over to Dr. Petelin. Firstly, we welcome you ing questions to us, and this can be done at any time during the live webcast by clicking on the MDiretAccess button in the top right-hand corner of your screen. We welcome all your questions, and we will try to answer all of them during this webcast. In addition, for those of you who are interested in CME credits, if you re interested, at the end of the procedure, you ll be able to take the quick CME test at the conclusion of the procedure. I d now like to turn over to Dr. Petelin so he can tell us where he is in the stages of the laparoscopic sigmoid colectomy. 00:02:58 Dr. Petelin: Thank you, Dr. Gecelter. I m Joe Petelin, and I m joined by my staff in the operating room here in Room 9 at Shawnee Mission Medical Center in Shawnee

2 Mission, Kansas, where we re performing a laparoscopic sigmoid coletomy on a gentleman who has a very common problem in the colon called diverticulits. This gentleman has had a number of attacks of diverticulitis over the past 10 years, and he was sent to us for consideration of removal of this part of his colon. I m joined in the operating room by my team, with Dr., my first assistant here in the operating room. Mrs. Sherry Vitali, my scrub nurse. Miss Tisha Funk, who is one of the circulators. Mrs. Karen Wells, who is one of the other circulators, and by one of the finest we have here at Shawnee Mission, Marlene Bailey. What we ve done is start the procedure so that we could show you the most important parts of it. So we ve done a little bit of preliminary dissection. What you can see here in the front, we re looking toward the patient s pelvis. So the patient s pelvis is down on this end of the table, and the patient s head is here. We have the patient tipped somewhat headdown. We re looking into the pelvis through these ports. We ve put in three ports in the abdomen. These tubes are called ports for the non-medical people. And through these ports through the center port, we have CO2 that is inflating the abdomen. So as you can see, we have a place to work. Through the other ports, we have instruments that allow us to manipulate the tissues inside. Now, what you see right here is actually what the problem is in this gentleman. These little outpouchings on the colon are actually what we call diverticuli. You can see a number of them here, and once like this, obviously, have been inflamed in the past. Now, this is not the worst case of diverticulits, but it does emphasize what the problem is. So this part of the colon is abnormal, and if we look up in the other part of the colon and this young man has a significant amount of colon - -this part of the colon up here looks more normal. This part of the colon does not have any tics. So we re going to we ve started the dissection, and what we ve done is mark the proximal end of what we re going to take out with a few clips up on the one these pieces of fat that we call the appendices epiploica. So we put these clips on here so when we take the colon out, we know where to stop the dissection. We ve also looked here laterally and have freed the colon up from where it was attached laterally on the abdominal wall so that we can manipulate it and bring it up to the surface. This is one of the patient s arteries that leads down to the lower extremities. This little white tubular structure here is actually the ureter, and that takes the for the non-medical folks, that takes the urine from the kidney from the left kidney down to the bladder. So this is the left side of the patient. One of the questions that sometimes comes up from physicians not familiar with the procedure is Can you see the anatomy adequately when you do this? And the most important thing to see is the ureter, and so we always like to know exactly where the ureter is, and you can see it move. That s what helps bring the urine from the kidney down to the bladder. Now, if you look at typical pictures of the anatomy, the colon comes from the rectum in anatomy pictures, and it looks like it just ascends from the anus down below here up through the rectum and then the sigmoid colon, and it s supposed to just go up the left side of the abdomen, but in this gentleman, you can see that he has a significant amount of redundant colon, which is not an uncommon finding in people with diverticular disease. So we re going to take out this part of the colon that s bad, and the other thing that we ve done is marked the area that we want to dissect. We ve used a small cautery device to actually mark the path where we re going to cut this fatty tissue, and then the fatty tissue are the blood vessels that lead to the colon. So that s what we re going to be about doing here for the next 4 or 5 minutes, and after we get that part done, then we re just going to divide the colon distally. We have a number of devices that have been developed over the past years. This is a cauterytype device. It s called a bipolar-type device, and with that, we re able to grab the tissues and actually cauterize the blood vessels inside those tissues. And then with a small trigger, we re actually able to divide the tissue. Now, as I mentioned earlier,

3 we have these clips on here so we know where to go, and I think those clips are right up here somewhere. It s important to put the clips on so that you don t get lost during the procedure, and there they are right there. So we re going to start by taking off this part of the fatty tissue and dividing it. And that s what we do with this device. Obviously, we don t want to injure the large vessels that we see leading to the lower extremities, and at the same time, we don t want to injure the ureter as well. You can see for those who haven t seen laparoscopic surgery before, you can see what a good view we have in the abdomen, and both Dr. Meth, my assistant and Dr. Gecelter would attest to the fact that the view that we have laparoscopically is actually much better than we have in open surgery because all the tissues are magnified. So this part of the surgery involves dividing what we call the blood supply to the colon. In the past, before we had this device that cauterizes the tissue, we had to put clips or staples or even ties on the tissue to be able to divide it. So we ve gotten that far enough up to the colon. We re going to divide this part of the colon later in the case when we actually bring the colon out through the abdominal wall, and we ll show you that in a bit, how we go about doing that. The rest of this right now, we have to divide the remainder of the mesentery. I should also let you all know that in the room in addition to all the personnel that I talked about and the personnel that are bringing you this broadcast, in the room, we also have a remote presence device called the RP&. This device works just like the wireless it works on the same wireless network that your laptop notebooks work on when you re in a hotel or a coffee shop. So this device allows a surgeon or anyone, for that matter, from a distant location to actually move the robot around, see what they re doing in the operating room and actually take pictures and telestrate, just like you ve seen the football commentators do at various events. At some point during the case, we ll have Dr. Gecelter lead the operating. He s actually here in the OR with us, but we ll have him demonstrate how this has been useful for us. With it should also be important to note that Dr has taken a year out of his life to come and learn these techniques during a laparoscopic fellowship. The importance of that is that although this is looks like a straightforward case, many of the colon operations that we do are not nearly as straightforward as this. And it s almost impossible to learn how to do this operation on a weekend, and a lot of the courses in laparoscopy in the early 1990s were actually weekend courses. But we realized that teaching the colon operations was just a little bit too much to expect surgeons to pick up in a weekend. So people like Dr take a year out of their lives to actually go after their surgical residency to learn how to do these advanced techniques. As it turns out, Dr. Gecelter, my friend from New York City, our moderator, has a fellowship similar to the one that we have here at Shawnee Mission Medical Center and teaches fellows in much the same manner that we do here in the Kansas City area. So it s in my opinion and Dr. Gecelter might want to comment on this in my opinion, it s very important for people to have enough training in this, and we think that it s almost necessary for many of those people to actually do a fellowship. Dr. Gecelter, do you have, maybe, a comment about that? 00:12:10 Dr. Gecelter: Yeah, sure, Joe. There is very good evidence that the learning curve is not a very steep one, and to get familiar with all the nuances of laparoscopic colon and rectal surgery, it takes about 40 cases. And this has been looked at, we know, research into learning-curve parameters from published in Surgical Endoscopy in 1995 that showed that it took significantly more colon and rectal laparoscopic cases for the operating time to come down to appreciable levels that were comparable to the time it took an open colectomy, and sometimes as long as five years. So it is a complex process. Clearly, the more experience one gains, the more rapidly one gains that experience, the safer it is for the patient, and I strongly endorse the concept of

4 of advanced training in laparoscopic colon and rectal surgery, as Dr is getting right here. 00:13:35 Dr. Petelin: The other issue that arises sometimes is what happens to the people who, for whatever reason, didn t have the opportunity to take a full year off? And that s especially true for colo-rectal surgeons who have did not have, basically, a gall bladder to practice their techniques on. General surgeons have had a lot of experience with laparoscopic gall bladder surgery, and it allowed us to improve our techniques. The problem is more difficult for colo-rectal surgeons who do the same operation. So what actually, what one of our colo-rectal surgeons at Shawnee- Mission has done -- Dr. Bruce Graham actually went and did a mini fellowship. He too ka three-month period of time to learn these techniques. Other colo-rectal surgeons here have had experience in laparoscopic colectomy as well, but I think the important thing for the public to know is that to make sure that the surgeon who s doing this, whether it s a general surgeon or a colo-rectal surgeon has had enough training. And I can overemphasize that for the safety of the public. That s a very important issue. So what we re doing here is what we call taking down the mesentery. We re dividing all the blood supply to the colon, and we re just about reaching the end of where we re going to divide it here. For the non-surgical medical people who may be watching this, this is a such a much better view of the pelvis the inside of the pelvis than we ever get in open surgery. It s just an absolutely beautiful view of the pelvis. The other nice thing about this for the patient is that the patient develops many fewer adhesions than they would otherwise develop if they had a 10- or 12-inch incision to do the same operation. What that does for the patient is it actually causes them less problems post-operatively, down the road. So as soon as we get the rest of this mesentery divided, we have a special stapling device that we ll show you that allows us to both staple the colon and divide it. So that allows us to to make sure there s no spillage of any intestinal contents in the abdomen. So this part of the colon that we re removing is actually being devasturized, and that s one of the reasons that we can move it around so easily. When we first started doing laparoscopic colestomies, literally, over 15 years ago, many of the tools we have now were just not available. These tools make it so much easier for the surgeon to be able to actually do the operation. It was safe back then in experienced hands, but the instrumentation that we have now is just phenomenal. Dr. Gecelter is actually going to leave the operating room for a moment, and he ll actually log onto the RP7 and demonstrate for you all how we re able to use this. What I ve been able to do with this robot, in addition to making rounds on patients in the hospital and we have five of these robots here at Shawnee Mission I ve actually been able to be in the operating room with Dr when I m not physically present at Shawnee Mission. If for some reason I m out of town and he has a case, I can actually consult with him right in the operating room while he s operating via the RP7. And with that technology, which Dr. Gecelter will probably demonstrate here in a few minutes, we ll you can actually take a picture of the screen and telestrate on it. So we really would like to show you that technology. What all this translates into is not just, you know, toys or gadgets. It actually translates into more safety for the patient, because in theory, what can happen is that the surgeon doing a case, for example, that may need an expert opinion, if there s an expert that has access to the robot, they can actually log into the robot, see what s going on the operating room, and advise the surgeon to any tips that they might have as to how to do the case more efficiently. So we ve just about gotten the colon the mesentery divided enough. We re going to come across this part of the colon with a stapler, and Sherry is now handing me the stapling device, and you ll see that enter the abdomen here in a minute. With this stapling device, we re able to divide the colon and actually put

5 staples in it to secure it. He has just a tremendous amount of colon here. So we want to show you this. We like to make sure when we re doing this that we ve got just colon and not ureter, and that looks, actually, pretty good. I m going to advance this just a little bit more. Now, as I manipulate this handle, this will fire a series of staples through the colon and divide it all at the same time. So what you see here is the divided bottom end of colo-rectum as well as okay. As well as this part here. So I m going to fire once more and then we re going to have Dr. Gecelter we ll demonstrate how much we ve taken out and we ll have Dr. Gelcelter show you what he can see on the other end. Okay, Gary, what I m going to do is push the colon back down into the pelvis, and you could maybe grab a picture of this and show the folks how we do this, or if you d like to see the ureter, I could do that as well. Okay. Gary, I ll tell you Dr. Gecelter, let s do this: why don t we I ll push the colon out of the way, and if you could take a picture of this screen and demonstrate the distal rectum, the artery, and the and the ureter for the people watching. Yes. 00:22:08 Dr. Gecelter: Good, so, this here is the distal rectal stump that you ve transected already. In this are over is the of the left common iliac artery, which is the main artery in the left lower extremity. And tracking down this area is the left urter which you had so aptly dissected for everybody to see. 00:22:41 Dr. Petelin: Great, well, thank for that, Gary. What we re going to do now is eviscerate the colon, and I m sure a question on a lot of non-surgical minds is how are you going to get this thing out through these little ports? Well, the way that we do that is to actually make one of these ports just a little bit longer. So Dr.will be holding this part of the colon. This is the part that s going to come out, and we re actually going to make an incision here about two inches in length to take the colon out, and during that time, the abdomen will deflate. I have to stand on a stool because I m not as tall as Dr So, Dr. And Mrs. Vitali are retracting for me so I can actually make an opening in the muscle to bring the colon out. One of the concerns that we always have in doing colon surgery is infection, and so before the surgery today, the patient actually prepared his colon with what we call a bowel prep. And in addition to that, we use a plastic sleeve through the abdominal wall so that okay. So that we don t contaminate at all. I m going to make just a little more of an opening here. So what we ve got here is about a 2-inch opening in the abdomen versus what would otherwise be a 12-inch opening. This is a plastic sleeve that we ll put through the abdominal wall that will protect it from from contamination. So now what you ll see is the colon come out, and you ll actually see quite a long segment of colon. This is the area that has the diverticular disease. You remember we put the clips on what we call the proximal part of the colon, and I don t know if you can see that or not, but the clips that we placed laparoscopically are right up here. So this is where we re going to divide the colon itself. I have a few more vessles to take down here. And the next question that may be on a number of the viewers minds is okay, so you got the colon out, and you can get it out through this opening. How are you ever going to ever get those two ends back together? Well, there s a number of things that we could do. We could sew it back together, which has been done, but that takes a considerable amount of effort. We also have specialized staplers that will allow us to do the same thing, and we ll show you one of those staplers here in just a minute. The okay. I understand that we have some e- mail questions, and if Dr. Gecelter will be the one to sort of sift through those so whenever Dr. Gecelter is ready, we can try to answer those. 00:27:05 Dr. Gecelter: Sure, Joe. I have an here from Walter who asks a very pertinent question. The question is: if a patient is young and is already experiencing severe

6 symptoms of diverticulitis, is it possible that the wall of the colon has become so weakened that the risk of recurrence could predict that this could perforate and that the patient should, in fact, have surgery sooner rather than later. The key, really, is that diverticulitis is a condition that becomes more common as one gets older. The commonest incidents of diverticulitis is in the 70s and sometimes in the 80. So in a young person and when you say young with regard to diverticulitis, we usually mean somebody under the age of 50 who develops diverticulitis the risk of them having longstanding problems over the next 30 years, which is their life expectancy, would be a very good indication for them to consider surgery. So if you are, really, under the age of 50 and some people under the age of 40 and have experienced diverticulitis, then you really should consult with the your gastroenterologist and a surgeon to discuss the options. There has also, however, been some evidence that mild episodes of diverticulitis in young people, we predict that over the course of their life, they would never have a severe complication. But that is still something that is being evaluated by the medical community. So if you think that you are having recurring bouts of diverticulitis and you feel that it s affecting your life and your quality of life, then you should really be considering discussing this with your gastroenterologist and a surgeon who s familiar with the kind of surgery that Dr. Petelin is doing today. 00:29:15 Dr. Petelin: Dr. Gecelter, I m just going to break in for a second here. What we ve done is put a purse string in the top part of the colon, and we ve placed this anvil, which is like the base of what you would have on a stapler on your desk. This anvil will go back into the abdomen. We ll take out the plastic sleeve. And then we ll change gloves, and we re going to close this small incision back up, and we ll reinflate the abdomen so that we can then do the anastomosis, or the reconnection of the colon to the rectum. So right now, what we re doing is closing the muscle, and we put a number of sutures in this so that we can reinflate the abdomen without any problem. And so that it ll be airtight. And this just takes two or three minutes to close back up. Then we ll reinflate the abdomen. Dr. Gecelter, you might tell the audience a little bit about the history of laparoscopic colectomy if you have a chance to do that. 00:31:00 Dr. Gecelter: Sure, John. I have a slide that we can demonstrate the history of laparoscopy. The very first laparoscopic colectomy was described in Very familiar name: Joeseph Petelin, Doug Olsen, and very soon thereafter, by 1991, some 15 years ago, Dennis Fowler and were the first people to describe laparoscopic colectomy. Interestingly, they were operating on colo-rectal cancer laparoscopically as far back as And then looking at this slide I don t know if the audience can see the slide, but numerous advances in advanced laparoscopy were described, many of them by you. Upper gastrointestinal anastomosis, the gastrojejunostomy, operating on the consequences of pancreatitis, gastrostomy, and then even solid-organ surgery like adrenalectomy, removal of the adrenal glands, splenectomy, removal of the spleen, and anti-reflux surgery for people with severe gastro-esophageal reflux disease all very rapidly followed suit. So 1991 was a very active year, and laparoscopic colectomy was right up there with with all of these seminal laparoscopic procedures. The the forefathers of laparoscopy that took took the envelope to the edge after laparoscopic colisistectomy have one and half decades of experience in minimally invasive colon surgery. So this is really nothing new, and we ve learned a lot of lessons. And you can see from the efficiency and the exquisite detail that you have demonstrated in this webcast how how simple you make it look. Clearly it s not always this simple, and I ve really enjoyed watching you

7 perform an operation that sometimes can take as much as three hours in less than a third of that time. 00:33:46 Dr. Petelin: So what we ve done is reinflate the abdomen here, and we re going to perform the anastomosis or connect the two parts of the colon back together. And you can turn off the spotlights here. So we ve reinflated the abdomen. I ll clean my scope off. And our job is going to be to connect this back to the colon up here. So I m sure some of the younger people that may be watching may be thinking, gosh, did he lose that upper part of the colon? Well, it turns out there s only so many places it can be, and we ll be able to displace that back down into the pelvis here very shortly. As soon as I find it. Also, the blue coloring on the anvil allows us to see that a little better. I ll clear your view up here a little bit so you all can see this. This blood that you see here is actually the blood that came from the abdominal wall. So you can see when we do open surgery and things in an open fashion, it actually generates more blood loss than it does laparoscopically. And that s one of the nice things that we ve found with laparoscopy is that we were able to decrease the problems. So those two pieces are going to come together quite nicely. I m going to free u pa few more attachments here on the on the lateral border to facilitate that. 00:36:02 Dr. Gecelter: While you re doing that 00:36:04 Dr. Petelin: We don t want to have any tension on the area that we reconnect. So what we re doing is making making the colon slightly more mobile. 00:36:28 Dr. Gecelter: Joe, we ve had a very, very strong response, and I just selected one question from Kurt, who asks: in one of our indication screens, we showed that carcinoma was preceded by a question mark. The question is does that mean that this is not recommended as successful with colon-cancer patients? This is a very timely question because early after the 1991 experience with Jacobs and Fowler, some surgeons reported the incidence of complications associated with the validity of the cancer part of the operation in that cancer was seen to recur in the port sites on the skin with an increased incidence. And that led us to look very closely at whether this was a sporadic phenomenon or whether it was just whether it was really a consequence of laparoscopy. And after reviewing many of the largest experiences with an amalgamated 2,000 patients, the incidence of port-site recurrence of carcinoma was less than 1%, which is, in fact, better than seeing cancer occur in the incision in patients who had open colon-cancer surgery. That led to a multi-center study that was abbreviated to the COST trial, C-O-S-T by Heidi Nelson that initially evaluated the quality of life parameters comparing people who d had laparoscopic versus open colon surgery for cancer and found that in general, patients were more comfortable and recovered more quickly. And then at the end of 2004, that same group reported the outcome of the risk of recurrent cancer and the quality of the cancer operation itself and found that there was no statistical difference in outcome between those patients who had colon cancer surgery done laparoscopically versus those patients who had colon cancer performed open. The kind of parameters that we use to to evaluate the quality of a cancer operation are the margins of resection on either side of the cancer as well as the number of lymph nodes yielded, the amount of lymph nodes that are received in the specimen, both of which were equivalent in both operations. Therefore, it really is based upon the patient s choice and the experience of the surgeon that they choose as to how they want to have this operation performed. 00:39:38

8 Dr. Petelin: Thank you, Dr. Gecelter. That was an excellent explanation. What we ve done now is insert the bottom part or the handle, as we call it, of the stapling device through the anus, and we re now docking the top part of the colon, the proximal part of the colon, and I m going to just rotate this in the camera just a little bit the other way just a little so that we don t have the colon twisted upon itself, and that looks like it s in pretty good position. Now, by reaching over here, I can actually close this this handle, and I ll show you what the result is after I finish this. I m going to go ahead and fire this. We hold it for about 10 seconds to make sure that all the staples fire, and inside of this device, there s actually a cookie-cutter type portion that actually cuts a hole between the bottom part of the colon and the upper part of the colon. So we then remove this, and you ll see as I pull this out that there will be two rings of tissue on this. This is the ring from the top part of the colon that had the anvil. This is the ring from the other part of the colon. So we ve connected the colon back together. Now, what I m going to do to check that to make sure is to go to the foot of the table and actually look inside the colon with a colonoscope to show that we ve actually created an anastomsis, as we use the medical term. So laparoscopically, you can see the sigmoidoscope coming in. And as we go up further, you ll start to see the inside of the staple line if I can get the screen cleared here. So that s the inside of the staple line. It looks a little bit blurry because of the fluid that I m inserting, but we always like to check to make sure that we ve got a good solid anastomosis. So you can see that ring of tissue there. We like to make sure that it s nice and secure, and that just looks great. So that s the top part of the colon up there, the bottom part of the colon down here, and they ve been connected back together by that fantastic device. So that s how we check to make sure that we ve gotten a good anastomosis. Now I ll change gown and gloves and come back to the table, and we re actually going to close that mesentery that we divided. We want to sew those two ends back together so that the patient doesn t develop an internal hernia. 00:42:34 Dr. Gecelter: Why are you changing gloves? 00:42:36 Dr. Petelin: Basically, for the non-medical people, everything I just did down below the patient is considered a contaminated area, not a sterile field. So we don t to bring any contamination into the field, so I change gown and gloves and do this. The alternative would be to have your assistant do it, but Dr is letting me do that business today. So what I m going to do is to sew this mesentery back together. You can see where we ve divided it here. We want to sew he has a very this mesentery. We want to sew this part here back to the other side. So this is all going to get sewn to this so that small intestine doesn t get stuck in there and become tangled. So we re actually going to put a suture inside the abdomen. So we re going to close this, and then after we do this, this is pretty much the completion of the operation with the exception of removing the ports. So as Dr. Gecelter mentioned, many time, this operation can take two or three hours. Especially in a surgeon s learning curve, it takes that, and for cases where there s a lot more inflammation than this case, it can take quite a bit of effort to dissect back to healthy-appearing tissue. It usually takes us about 5 to 10 minutes to close this depending on how tough it is to get the tissues back together. These sorts of tying and sewing techniques are things that -- in open surgery, every surgeon practices tying knots during his residency and internship, and it s the same thing the fellows do when they come to a laparoscopic fellowship. They practice tying, literally, thousands of knots during their training so that this part doesn t take forever to get done and so it can be done accurately. Obviously, we don t want to hit that big blood vessel there, the left iliac artery. This suture that we use is an absorbable suture, and actually, on some o the patients that we ve done

9 and we ve done close to 1,000 of these here now over the past 15 years just at Shawnee Mission Medical Center, we ve signoidis we ve laparoscoped these patients for other reasons, and there are absolutely no adhesions in the pelvis when we go back after this sort of procedure. So it s a pretty phenomenal result for the patient. I think, Dr. Gecelter, the thing that amazed me when I first started doing laparoscopic colectomies was the was the view that I had laparoscopically as compared with an open case. So that s not uncommon to have that same sort of same sort of response. 00:46:33 Dr. Gecelter: Joe, you mentioned earlier your ability to see things magnified. You can get the camera as close to the region of interest as one centimeter. So your ability to see the ureter and the ability to go down to the base of the true pelvis is much better than if you re in an open case, where there s a limit to how deeply you can actually see. I also want to address a couple of questions. There have been an enormous number of s, a lot from surgeon colleagues. One of the questions for you, Joe, is do you like the ligature to divide the mesenteric vessels? I presume they re talking about the inferior mesenteric artery and vein. Do you have to divide the artery and vein and ligate them separately to assure hemostasis? And this is from Jamie. 00:47:36 Dr. Petelin: The that s a very good question. I grew up at the time when we had to actually tie these vessels off laparoscopically or use clips, and so when the ligature device, which is the device we use to work on the mesentery, when that device first came out, I really had reservation as to whether or not it could control those vessels. But you re looking at a true believer now. It just makes the operation so much easier. We ve not as far as dividing the vessels individually, if we re going to tie them off or clip them off, then many times we ll do that individually, but we ve not run into any problems taking them just as we showed you here during that part of the dissection as one. And we have had absolutely no bleeding problems with the ligature. There are other devices available that use harmonic energy, and there are many companies that make devices like that that are just as good, although I ve not felt quite as comfortable taking the root vessels with the harmonic energy as with this device. So fortunately nowadays, we ve just got so many tools that we can use, so many tremendous tools. It makes this just a joy to do. 00:49:06 Dr. Gecelter: Can I ask you another insightful question? 00:49:11 Dr. Petelin: Sure. 00:49:12 Dr. Gecelter: From Samuel: during laparoscopic colectomy, you find a previously undiagnosed fairly large hernia. Do you place an extra peritoneal mesh? What is your experience? Very good question, Samuel. 00:49:27 Dr. Petelin: That is a good question. Some surgeons might do that. Although in general, when we work on the colon, it s considered a clean, contaminated operation. In other words, we re crossing the GI tract. And I think most of us prefer not to put in a prosthetic material such as a mesh when we do that. So I don t do those at the same time. If I found a small defect that I can sew closed, I would probably consider doing that. Otherwise, I would not put any peritoneal mesh in at that time. 00:50:03 Dr. Gecelter: I completely agree. 00:50:09

10 Dr. Petelin: So we re I m sure if there are non-medical seamstresses watching, they re thinking, gosh, I could have had this sewn up in no time. What s taking him so long? But these techniques are a little bit more difficult. But you can see, again, with the magnification, you just have such great accuracy in in being able to pull these tissues back together. So once we get this completed, you can see that the small intestine is not going to be able to sneak in there and get stuck and obstructed and necessitate another operation. So this is just a great way for the patient to get this done. 00:51:03 Dr. Gecelter: A lot of us who perform laparoscopic colon surgery would not go to the trouble of closing the mesentery the way you have, and I m not sure whether you re doing it just to show off how good you are with the laparoscopic needle and thread, but I can tell you, for those of you who are familiar with the complexities of of intra-abdominal suturing or laparoscopic suturing, you really make it look extremely easy, and I m envious of that. 00:51:35 Dr. Petelin: Well, Dr. Gecelter is actually being quite humble. I close the mesentery because I was taught to that in open surgery, and one of the rules that as you know, Dr. Gecelter that we ve all had is if we can t do the operation just as well and with the same technique as we did in open surgery, then it shouldn t be done. And so I do it the way I was taught to do in open surgery, and we don t change the rules just to say it s laparoscopic. At the end of the day, the most important thing, as you know, is what s the best thing for the patient? And doing the same operation or better than you did open is what s the essence of this. So we ve come a long way in 15 years. You know, at first people thought, gosh, we can get the gall bladder out, but that s going to be the end of what laparoscopy can do. But look what s happened in 15 years. This patient, for example, won t be in the hospital the seven days that an open patient might be in the hospital. He ll actually go home by his third post-op morning. He won t have an NG tube in his nose. He ll be able to eat actually, he ll be able to eat tomorrow, and it doesn t get any better than that for colon surgery. So we ll cut this, take another look around, and irrigate some of the tissues, and then the rest of our job is just to close up these little port sites and this incision in the lower abdomen and we re done. One of the other issues and that s another thing that we could probably mention is the effect on the immune system of laparoscopy versus open surgery. 00:53:28 Dr. Gecelter: Yes, I think you re alluding to one of the interesting findings from Antonio Lacey s study from Barcelona. Dr. Lacey did a randomized trial comparing open versus laparoscopic colectomy for colon cancer, and one of the unusual findings was that in patients who had advanced locally advanced colon cancer, the threeyear actuarial survival was in fact better in the patients done laparoscopically than in the patients done open, and clearly because there was no vested interest between different groups of surgeons they were all Dr. Lacey s hospital patients this sparked some important basic science into the immune response following the laparoscopic surgery. And translation data -- that is, taking information acquired in the clinical setting and trying to validate it using basic science has demonstrated that the immune response to laparoscopy and in particular to laparoscopic colon resection, is less. The consequence of that is that the ability of the patient to resist cancer spreading is probably better. So this is one of the previously unsuspected byproducts of minimally invasive surgical oncology and is particularly pertinent to patients having laparoscopic colectomy for cancer. 00:55:13

11 Dr. Petelin: Thank you, Dr. Gecelter. We re in the process of just closing up these wounds, and after I get this wound closed, I ll take one quick look back inside the abdomen, and then we ll close these wounds. I think I ll take a moist Okay. And so this this is what we ve done. We ve taken out the bad part of the colon. What his colon looks like now is more of a normal looking colon. All the diverticular disease has been removed. So we re now going to remove the score and this last port and then close the close the incisions. You can see that it takes a number of people to make this operation look easy. If I didn t have the kind of assistants that I have, it would be much more difficult to do this procedure, so it really takes a good team, and I have to tell you that Shawnee Mission has gone to great lengths to try to help provide that because a surgeon, even if he s a technical wizard has a difficult time doing this if he doesn t have the support. And that includes the people at the head of the table, the anesthesia department. Dr the anesthesiologist, just walked in recently. He s been here during the case. We ve had great support from what the anesthesia department s been able to help us do here. So you can bring him back up to almost close to normal. So we ve got these three small incisions that we re going to close, and just for the non-medical folks do we have a ruler? We can show you how big the wounds look. That s great, thanks, Marlene. We re injecting local anesthesia to help decrease the initial amount of post-operative pain. The postoperative course of these patients is just absolutely no less than phenomenal. There s no NG tube in the nose. They re able to take liquids within usually within 8 hours or so, and they re usually eating solids within 24 hours, at least by the protocol that I use. This we ll show you the size of these wounds. This is a centimeter scale here. So the one at the umbilicus is one centimeter. The one in the lower abdomen is actually a 12-millimeter port, about 15 millimeters, and the one over here in the left-lower quadrant is about 4 ½ centimeters or, as you can see, slightly less than 2 inches versus a zyphoid to pubic incision. So it doesn t take a rocket scientist to figure out that that s going to hurt a lot less for the patient. The we ve enjoyed having you join us in operating room 9 at Shawnee Mission Medical Center. We hope that this has been something educational for you all and something that will help bridge the gap between the mysteries of the operating room and the public. 00:59:00 Dr. Gecelter: I would also like to take this opportunity to thank Dr. Petelin and his staff. That s about all we have time for. I d like to also remind you, for those of you who are taking the CME credits, you can now click on the Take the CME test and complete the post test. This has been a live demonstration of a laparoscopic sigmoid colectomy from Shawnee Mission Medical Center. I would like to thank everybody for joining us this evening. It s been a great privilege and pleasure for me to be associated with you. Good night, everybody. 00:59:43 Announcer: This has been a surgical webcast of a laparoscopic sigmoid colectomy live from Shawnee Mission Medical Center in Shawnee Mission, Kansas. For more information, to make a referral, or to make an appointment, click the buttons on your screen.