|SURGICAL TREATMENT FOR THE COLON DESEASES ROBOTIC AND LAPAROSCOPIC COLECTOMY
1. Where is the colon and what does it do?
Section of the colon
The procedure of digestion and adsorption of food is done in three sections of the small intestine: duodenum, jejunum and ileum.
The large intestine or colon is the lower part of the alimentary tract; it is responsible for water absorption and for conversion of indigestible food to feces.
The colon begins from the right side of the abdomen and ends left to the rectum, where the feces are transiently stored, before they are discarded from the body, through the anus. It consists from the blank, the ascending colon, the transverse colon, left colon, the sigmoid colon and the rectum that ends up at the anal canal.
2. What is colectomy?
Colectomy is the surgical removal of part (partial colectomy) or the entire colon (total colectomy).
Depending on the part to be removed, partial colectomy is divided into:
- Right colectomy (removal of the right portion of the colon)
- Left colectomy (removal of the left colon)
- Sigmoidectomy (removal of the sigmoid colon)
- Transverse colectomy (removal of the transverse colon)
- Lower anterior resection (removal of part of the rectum and sigmoid colon)
- Abdominoperineal rectal resection (removal of the rectum with the anus, part of the sigmoid and creating colostomy)
3. What are the symptoms of colon diseases?
Some colon diseases may not cause any symptoms and could appear accidentally. Never the less, if a patient shows any of these symptoms below should pay a visit to his doctor, in order to deal with any potential problem in an early stage.
- Persistent constipation
- Severe diarrhea
- Pain and tenderness lower in the abdomen, accompanied by chills, fever or vomiting and intense constipation
- Passing of mucous
Every blood loss from the lower digestive system needs investigation.
4. What kind of tests should be run in order to determine if there is a problem in the large intestine? Are they painful?
The main test is colonoscopy, which with the modern medical means is painless. Some other tests are CT and MRI abdomen scan, a barium enema and the endoscopic ultrasound for rectum diseases (the lower part of the colon). Undoubtedly, the latest technological achievement is the axial colonography (Virtual Colonoscopy), in which we can check the interior of the organ, without conventional colonoscopy and only for specific indications.
5. What are the most common conditions in order to perform a colectomy?
The colon can get infected by a multitude of diseases, such as:
- Obstructive ileus
- Diverticulosis – diverticulitis
- Inflammatory bowel diseases (Ulcerative colitis, Crohns’ disease)
- Malignant tumors (adenocarcinomas, carcinoid tumors, lemphomas, sarcomas)
- Καλοήθεις tumors (adenomatous polyps, papillary polyps, lipomas, leiomyomas)
- Rectum prolapse
- Stenosis or occlusion of mesenteric arteries or veins
- Congenital polyposis (Gardner syndrome, Peutz – Jeghers syndrome e.t.c.)
- Volvulus (rotation of intestine)
6. When a colectomy is necessary to de performed?
The decision for surgical treatment depends both from the type, and from the intensity of the problem that every individual patient is facing. The problems of the colon, depending on the type and intensity, can cause:
- Intestine perforation
- Severe bleeding from the anus
- Intestine obstruction
- Intestine stenosis
- Creation of abscess around the Intestine
- Creation of fistula between the intestine and other organs of the abdomen
- Increased possibility of cancer development
When the patient faces one of the conditions above, it is usually necessary to undergo to a colectomy
7. Is it some kind of preparation before surgery needed?
The night before surgery you should not drink or eat anything. Usually it is required the day prior to surgery to take oral laxatives in order to clean the colon. It is essential that we stop any oral anticoagulation (aspirin) at least one week before surgery, always in consultation with the attending physician.
8. How is a colectomy performed in our days?
Currently, surgical options for colectomy are open, laparoscopic and robotic colectomy.
9. What does “open” mean?
The typical “open” colectomies are especially traumatic procedures, because the surgeon is forced to make a large incision in the abdomen in order to intervene into the colon. The reason that a large incision is in need is because the intestine must be detached from the liver, spleen, stomach, etc. Thus, the “surgical trauma” is extensive and patients often have to deal with a long and difficult recovery period.
The postoperative pain is major and it is countered with powerful painkillers that often maintain the patient in a sedation state. Thus the patient can be mobilized quickly; this is resulting in uncommon infections of the respiratory and urinary, so this implies the prolongation of hospitalization.
Furthermore, when there is a large incision the probability of decay and suppuration of the surgical trauma is increased, the wound is left open and there are changes in daily bases for several weeks after the surgery is performed.
In many cases the patient remains intubated (mechanical ventilation) in the intensive care unit for days until the surgical stress is surpassed, this significantly prolongs hospitalization and increases the likelihood of hospital infections.
A significant complication of open colectomy is the development of a ventral hernia in the incision and the discomfort which will be caused to patient from the surgery he must undergo so the hernia could be repaired.
10. What laparoscopic colectomy is?
In laparoscopic colectomy, the surgeon makes 4 or 5 small incisions with a diameter of 0.5 cm and the entire operation is performed through narrow tubes; through these tubes the specialized laparoscopic surgical instruments are imported to the body. The laparoscope, a small telescope connected to a video camera, is inserted into a pipe of 1cm and allows the surgeon to see the internal organs of the patient magnified on a television screen. One of the small incisions grows 4-6 cm at the end of surgery in order to extract the part of the intestine is removed.
11. What are the benefits of the laparoscopic colectomy versus the open one?
The advantages of laparoscopic colectomy are many, such as:
- Bloodless surgery
- Measurable reduction in postoperative pain
- Faster recovery
- Minimizing postoperative complications associated with the trauma (suppuration, cleavage, hernia, chronic pain)
- Elimination of postoperative adhesions
- Fewer respiratory and cardiovascular complications
- Excellent cosmetic result
- Shorter hospitalization time
- Swift return to your commitments
12. Are there cases that a laparoscopic colectomy can’t be performed?
A very small number of patients may not be possible to undergo a laparoscopic colectomy. Factors that may increase your chances of choosing an open surgery are:
- History of multiple previous abdominal surgery, that may have created many adhesions
- Bleeding problems during surgery
- Inability to obtain clear pictures of organs
Dr. K.M. Konstantinidis clinic has a vast experience in laparoscopic colectomy with hundreds of surgeries performed since 1991. The conversion rate of laparoscopic surgery to an open is about 1-2% and it usually has to do with the anatomy problems of the patient.
Our experience, in laparoscopic and robotic surgery, is one of the largest internationally for bemign diseases and for colon cancer.
13. What robotic colectomy is? Is it something new and experimental?
The robotic surgical systems have been in use since the late ‘90s from the largest medical centers of the world, with excellent results demonstrated in international studies.
The robotic colectomy is the evolution of laparoscopic one and it is already applied in Greece for a 6 years’ time, from the surgeon Mr. M. Konstantinidis at “Athens Medical Center”. The vast experience of Dr. K. M. Konstantinidis in laparoscopic surgery (since 1991 he has performed over 14,000 procedures) led him to adopt robotics technology in colon surgery.
14. How is the robot that is used in surgery?
The system in use from Dr. Konstantinidis clinic and from the most important centers worldwide is the cutting edge technology robotic surgical system da Vinci HD, it consists of three interrelated parts:
Robotic surgical system da Vinci HD
- A central control that connects the two other parts of the system to each other
- A console where the surgeon sits and operates, moving a small lever on each hand and seeing inside the patient through special binoculars that offer high resolution and three-dimensional vision
- A mobile unit that has four arms and it is placed beside the patient. In each arm a robotic tool is placed that is controlled by the surgeon via the console lever.
One of the arms also has the camera, which offers three-dimensional, high-resolution display on the surgeon’s console via the central control unit
15. Does the robot acts on its own? What will it happen if there is a power failure or mechanical problem?
The robotic system is completely under control of the surgeon and does not act on its own in any case. The surgery is performed by the surgeon with better instruments for better safety. If there is any problem, the surgery can be converted to laparoscopic or even to open surgery, however this is extremely rare.
16. What more does the robotic surgery versus the laparoscopic one?
The robotic colectomy retains all the advantages of laparoscopic in comparison to the open colectomy and further provides:
- A minimum interference with the patient’s body with sections that do not exceed 0.8 cm. One of the small incisions extends to 4cm to extract the portion of the colon was removed. This incision is made in the lower abdomen to lessen the pain and to avoid affecting breathing.
- Ultimate flexibility with the tools and precise moves with accuracy of mm while the natural hand tremor is removed through electronic filter. The movements are stable and precise so the surgeon can avoid injuring significant intraventricular organs such as the spleen, liver, duodenum, etc. during the repair of the colon.
- Great convenience and accuracy at stapling the intestinal anastomoses (reuniting the intestines after the colectomy).
- Minimize physical fatigue of the surgeon (who is seated at the surgeon console), especially in long-lasting surgeries such as colectomy.
- Ability to operate even overly obese (BMI> 60) because of the stability that robotic tools have towards increased intra-abdominal and parietal pressure. In addition, the three dimensional robotic camera of the system gives us better insight into the abdomen, which at an obese patient is full of visceral fat.
- Extensive ability of unhooking the adhesions during colectomy in patients who formerly had open abdominal surgery. The precision of the movements of the robotic tools protects the integrity of the intestines that usually are stuck closely to the abdominal wall.
- Maintenance of low pressure of the pneumoperitoneum during surgery, resulting in the reduction of post-operative pain and the concentration of CO2 in the blood.
- Easy identification and preservation of pelvic nerves very important for the function of urination and sexual activity in low anterior colectomy.
- Avoidance of colostomy due to colectomy for cancer at the lower part of colon, since it’s easier to make the anastomosis a few inches from the anus.
- Complete and bloodless removal of the affected colon parts, along with all of the lymph nodes, especially when it comes to cancer.
- Completion of major surgeries that require colostomy such as abdominoperineal resection and total colectomy, through micro cuts of 10 and 8mm.
17. How does the patient feel after the surgery?
After a laparoscopic or robotic colectomy, the patient stands up and walks overnight. The postoperative pain is minimal, especially in the case of robotic surgery. The intestine starts functioning after a short while (2-4 days) and the patient begins feeding on soft food sooner and is discharged within few days. Patient is ready to return to daily activities within only couple of weeks without physically lifting weights.
18. After a colectomy at the lower part of the colon could there be problems with urination and with the patients’ sexual activity?
The robotic colectomy, with the three-dimensional and high-resolution imaging that offers, gives the possibility to all important pelvic nerves to be preserved.
Those nerves are responsible for urination and sexual activity functions. At present, nerve preservation is one of the most popular topics in all international conferences because in open surgery it’s almost impossible to recognize them, nor prevent their severity.
The robotic anterior lower robotic colectomy for rectal and sigmoidal cancer has changed facts to such extent, that our team recommends this as the 1st line of treatment.
19. Would I need a blood transfusion during surgery?
A transfusion is rarely needed because in laparoscopic and especially in robotic colectomy, operation is bloodless. However during preoperative preparation we always check the blood group of the patient.
20. After a colectomy operation, will my intestine work properly? What am I going to eat?
Yes! For a period of time of about 2 months after surgery you may experience some episodes of frequent stools but they will progressively minimize and the bowel will return to normal function. Initially patients’ diet should be rich in protein (meat) and low in fiber (avoidance of large amounts of raw vegetables), to avoid abdominal cramps.
21. Is there a chance that a hernia may appear due to surgery?
It’s extremely rare, because in both laparoscopic and robotic colectomies, no injury to the abdominal wall is done and the operation is performed through micro incisions that prevent postoperative hernias.
22. In case of malignancy, the operation can still be performed robotically?
Recent international studies have shown that the robotic colectomy is safe and offers excellent oncological outcomes in cases of malignancy. The extraction of tumor and lymph node cleansing has equivalent results to those of open surgery. Moreover, the possibility of spreading the cancer cells decreases because at the robotic colectomy the tumor stays untouched (no touch technique). Robotic colectomy is used routinely, at over fifty of the largest worldwide oncology centers with excellent results. In hospitals with extensive robotic surgery experience such as ours, surgeons invariably recommend this technique.
23. Which is the best method for colectomy?
Dr. Konstantinidis clinic already counts several hundred of colectomies and since 2006 has adopted robotic technology in colon surgery due to several important advantages that this approach offers.
24. Isn’t the cost of a robotic colectomy very high?
The use of the robotic system adds to the cost of operation with a decreasing trend as technology progress. However, total cost of the hospitalization for a robotic colectomy (which the patient has to pay), is proven by international studies that is equal if not less from that of an open surgery.
This is happening because of the large surgical trauma of open surgery, significantly prolongs the duration of hospitalization and increases the probability of admission in intensive care unit for a few days; as a result the total cost is highly raised in comparison to robotic or laparoscopic surgery.
Certainly, one thing that cannot be measured by economic criteria is the benefit for the patient who undergoes a robotic colectomy, who recovers quickly and with minimal postoperative complications.
Dr. Konstantinidis has a philosophy that aims to offer maximum to his patients and sets at his service the best available modern science and technology for healthcare.
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