Minimally invasive techniques are becoming more and more common in surgery, and with the use of laparoscopy, it is no longer conceivable that surgeons cannot perform gallbladder removal using this technique. Colorectal surgery will face the same problem.
What is minimally invasive? Minimally invasive is not laparoscopic! It is a procedure that is less invasive.
It includes.
Total laparoscopy, hand-assisted laparoscopicsurgery (HALS) and laparoscopic-assisted small incision surgery.
Current status of laparoscopic colorectal resection
Laparoscopic surgery has been widely used in abdominal surgery with the advantages of small trauma and quick recovery, but since Fowler and Jacobs completed laparoscopic sigmoid resection in 1990, laparoscopic radical colorectal cancer resection has progressed slowly both at home and abroad, and it is difficult to be as popularly used as laparoscopic cholecystectomy (LC).
The reasons for this are mainly the following.
(1) Loss of tactile feedback of the hand, surgery under two-dimensional images, inability to accurately judge the infiltrating tumor, especially the metastasis of lymph nodes;
(2) Expensive special instruments and increased surgical time and cost;
(3) The specimen needs to be crushed and taken out of the body, which is not conducive to the judgment of tumor pathological staging and cutting edge condition;
(4) The learning curve is long, about 50 cases. The operation is more difficult, the technique is more complicated, and the requirement for doctors is high;
(5) It cannot resect advanced tumors, and the tumors of T4 cannot be resected in colorectal surgery, and mostly need to be resected in transit;
(6) More afraid of bleeding, often because of the bleeding to divert surgery;
(7) Lack of bulk prospective randomized studies and retrospective analysis, doubts and controversies about whether laparoscopic can achieve radical resection, thoroughness of lymph node dissection, intraoperative tumor-free operation techniques, tumor implantation in the incision and postoperative recurrence, etc. The selection of cases is also limited to resection of benign colorectal lesions outside the rectum or early colorectal cancer. However, with the improvement of surgical techniques, the development of new laparoscopic instruments, especially the application of ultrasonic knife, laparoscopic colorectal resection has gradually become one of the clinically promoted complex surgeries after LC, and the indications have been gradually expanded.
The radical treatment of tumor depends on the degree of tumor differentiation, pathological stage, scope of surgical resection, intraoperative tumor-free operation technique, postoperative comprehensive treatment and other factors. As far as laparoscopic surgery is concerned, the good irradiation, magnification effect and accurate operation for deep tissues are even better than traditional surgery, which can ensure complete resection of lesions and lymph node dissection. It has been shown that the length of resected specimens, extent of resection, and number of lymph nodes cleared in laparoscopic surgery do not differ significantly from those in conventional surgery.
et al follow-up studies have shown no significant differences in postoperative recurrence rates, incisional or Trocar implant metastases, and survival rates compared to conventional surgery. A multicenter prospective randomized clinical study comparing laparoscopic versus open surgery is currently underway in Europe and the United States [3], and conclusions regarding the place of laparoscopic techniques in colorectal resection will be available soon, and work in this area is underway in China.
Advantages of hand-assisted laparoscopy (HALS): In the mid-1990s, the advent of HALS [5], while retaining the advantages of minimally invasive surgery, greatly reduced the difficulty of some standard laparoscopic procedures, allowing complex procedures that were previously difficult to perform laparoscopically to be completed. Moreover, it has improved surgical safety, reduced operative time, saved costs, shortened the learning process for surgeons, and rapidly promoted the development of laparoscopic techniques in abdominal surgery.
Preliminary results of the FDA study showed that HALS colorectal resection is as safe as standard laparoscopic colorectal resection, with the same postoperative recovery time and no difference in the rate of intermediate openings, but requires fewer instruments and less time, arguing that HALS retains the advantages of minimal invasiveness and facilitates the surgeon’s ability to complete more complex procedures.
The HALS procedure restores the sense of touch to the hand, allowing the surgeon to return to operating in the familiar three-dimensional space. The dexterity of the hand can be used to quickly pull the organ and assist in exposure; it can be used to bluntly separate or guide the ultrasonic knife or scissors to accurately position the sharp separation; it can determine the location of the root of the vessel based on the vascular pulsation; it can assist in lymph node dissection by touching the lymph nodes; it can be used to accurately remove the diseased intestine by touching and positioning the small tumors that do not break through the plasma membrane layer intraoperatively; it can easily control intraoperative bleeding and avoid blind clamping It can easily control intraoperative bleeding, avoid blind clamping and damage to other organs, reduce intermediate open abdomen, and improve surgical safety.
In summary, the advantages are as follows.
1, with minimally invasive technology, only a about 5cm incision (about three fingers wide), full laparoscopy to take the specimen incision of about 3cm.
2, Trocar opening is less, 2-3 poke holes, usually 2. Total laparoscopy is 3-4.
3, The transit rate is lower than that of total laparoscopy.
4, The operation time is shorter than that of total laparoscopy.
5, can effectively control bleeding, bleeding volume is less than that of total laparoscopy.
6, Complications are comparable to total laparoscopy.
7, Accelerate the speed of complex surgery and can remove more advanced tumors, such as T4 colorectal cancer.
8.Short learning curve, about 5-10 cases.
9, Tactile feedback, with irreplaceable touch sensation in oncologic surgery.
10.The cost is lower than that of total laparoscopy.
11.It can move the organ quickly and pull the tissue, which helps to expose the operation field and blunt separation. It also has other advantages of total laparoscopy, such as fast turnaround, fast patient recovery, and less trauma.