Page 56 - WJOLS

Ashok K Mathur et al

evaluation and distance of tumor from anal verge. In case of quadrant, descending colon transected extracorporeally and
ultra low rectal tumors (< 3 cm from anal verge), APR was end colostomy created. Conventional perineal dissection and
performed. For tumors > 3 cm from anal verge, sphincter delivery of specimen through perineal wound. Perineal drains
preserving TME was routinely attempted unless there was routinely used. Throughout the surgery meticulous hemostatis
clinical involvement of anal sphincter muscles. was maintained to prevent light absorption by hemoglobin
which reduces picture quality. 3
Exclusion Criteria Occurrence of general and surgical complications recorded.

1. Presence of distant metastasis General complications were defined as pleural effusion,
2. Locally advanced disease with invasion into adjacent pelvic pneumonia, infection of central line, DVT.
organs Surgical complications were defined as intraoperative
3. Acute bowel obstruction or perforation from cancer complication as injuries to neighboring organ, and preoperative
4. Severe medical illness. surgical problems as bleeding, wound infection and ileus.
a. All patients provided written informed consent.
b. All patients were evaluated before operation by RESULTS
colonoscopy/Ba Enema and abdominal USG. CT abdo- During 30 month period, 20 patients were operated for tumors
men was routinely done to rule out metastatic disease of rectosigmoid and rectum. Of these 20 patients, 17 had
and to look for evidence of local infiltration, gauge the adenocarcinoma, 2 showed malignant melanoma and 1 patient
size of tumor and regional lymph node involvement.
c. CEA levels were routinely noted preoperatively had GIST. In all patients intervention was done with curative
d. Preoperative biopsy were routinely taken intent.
e. All patients received mechanical bowel preparation day Average operative time for LAPR was 296 minutes with a
before the operation. Systematic prophylactic antibiotics range of 180-600 minutes. Initial 7 cases took an average of 368
were given i.v. few hours before surgery. minutes while subsequent 7 cases took 232.5 minutes which
f. Urinary catheter and nasogastric tube were routinely compares favorably with the operating time of any high volume
used. Neoadjuvant treatment was not routinely offered. center. Average operating time for LAR was 356 minutes with
range of 330-540 minutes. First 4 cases took 400 minutes while
OPERATIVE TECHNIQUE last 2 cases took 300 minutes on an average.
Thus there was a significant reduction in operating time
Operation time was taken as time from first incision to completion with increase in cumulative experience and refinement in surgical
of last stitch. Most of laparoscopic procedures were performed technique, in latter half of the observation period. Average
by a surgical team consisting of one surgeon and two assistants. blood loss was 200 ml (50-400) (Table 2).
Patient was placed in head down Lloyd-Davies Trendelenburg There was no intraoperative complication in any patient.
position with surgeon and camera assistant on patient’s right One patient of LAPR needed conversion to open surgery
side. 5 ports were routinely used with subumbilical port used because of advanced disease. Extent of bowel resection (Avg =
for 30° angled telescope. No deviation from basic principles of 19 cm) was comparable to extent of resection given in literature
open oncologic colorectal surgery was permitted and performed
as follows: Laparoscopic abdominal exploration, preliminary with no incidence of positive resection margins. Average lymph
identification and transaction of IMA and IMV with clips, node harvest examined per specimen was 5.
mobilization of left hemicolon and splenic flexure, identification Perioperative recovery was remarkable with only
of ureters and hypogastric nerves bilaterally, rectal mobilization 7 patients out of 20 needed to be shifted to ICU, 7 patients
(for higher lesion mesorectal tissue down to 5 cm below tumor requiring perioperative blood transfusion. All patients were
routinely excised and TME in tumors of middle and distal third) mobilized by POD 1, average analgesic requirement was
and intracorporeal transection of rectum with an endoluminal 2 injections. There were no complaints of postoperative nausea
stapler in case of restorative resection. Abdomen opened by and vomiting, usually started taking oral sips by POD 2/3 and
extension of umbilical port wound (max 5 cm length) and normal diet was usually by POD 5.
resection completed extracorporeally, delivering tumor bearing Incidence of wound infection was also significantly less
bowel under protection of plastic bag. Anvil of circular stapler (2/20). There was no 30 day postoperative mortality and no
inserted into proximal bowel, gut put back in peritoneal cavity, significant early postoperative complications. Over median
pneumoperitoneum reestablished and intracorporeal 20 months period of follow up, 1 patient of LAPR reported back
anastomosis done with stapler (CDH 29). For ultra low AR, with prolapsed and obstructed colostomy for which he under-
temporary diverting loop ileostomy used. went revision colostomy. One patient of LAR had iatrogenic
In patients with APR, pelvic dissection done as far distally colonic perforation during routine postoperative colonoscopy
as possible abdomen opened by extension of port in left lower for which re-laparotomy was done.

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