Combined Endoscopic and Laparoscopic Surgery
Emre Gorgun
Perioperative Considerations
Combined endoscopic and laparoscopic surgery (CELS) enables mobilization of the colon to provide ease in colonoscopic dissection and removal of colon lesions, and synchronized visualization of the colonic wall after lesion removal and prompt closure of full-thickness defects, when necessary.
CELS can be used for large benign lesions or lesions that are located in areas that make the endoscopic resection difficult (ie, flexures and folds).
CELS can also be preferred in lesions where endoscopic resection was attempted multiple times and scarred. These lesions have a higher risk of full-thickness defect during removal and may require minimally invasive approaches for repair.
Benign lesions and lesions with high-grade dysplasia can also be removed using CELS (Fig. 5-1).
FIGURE 5-1 ▪ Operating room setup for combined endoscopic laparoscopic surgery. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
The operating room should be equipped with a colonoscope, most importantly with CO2 insufflation for the colonoscopy unit.
Two monitors should be placed depending on the surgeon’s position to allow for visualization of the endoscopic portion and abdominal portion.
An experienced assistant or an attending physician should be present to perform either the laparoscopic or the colonoscopic part of the procedure and aid the primary surgeon accordingly (Fig. 5-2).
 FIGURE 5-2 ▪ Two monitors are placed depending on the surgeon’s position. It is important that both the colonoscopy and laparoscopy monitor are visible by the operating team. |
Equipment
Adult colonoscope
CO2 insufflation unit
Assorted snares, baskets, and irrigation for the colonoscope
Bipolar and monopolar endoscopic energy unit
10- and 5-mm abdominal trocars
Standard laparoscopic abdominal colectomy set with bowel graspers (atraumatic)
Endovascular gastrointestinal anastomosis or other mechanical staplers
Technique
Under general anesthesia, stabilize the patient on the operating table and place orogastric tube and Foley catheter.
Choose a pediatric or adult colonoscope to use.
Start by introducing the colonoscope to locate the lesion. If lesion is amenable to endoscopic removal, it can be removed at this stage without further need for laparoscopy.
If the lesion shows nonlifting sign or displays signs of malignancy, the lesion can biopsied intraoperatively for frozen sections, and CELS or formal oncological resection should be performed.Related posts:
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