Combined Endoscopic and Laparoscopic Surgery (CELS)

Adult or pediatric colonoscope with monitor (CO₂ insufflation if available)

Methylene blue diluted with albumin

Endoscopic injector needle

Endoscopic snare

Endoscopic Roth net (US Endoscopy, Mentor, OH)

Suction trap

Bovie cautery

Laparoscopic monitors

High definition flexible tip laparoscope

Trocars: 5 mm × 4, 10 mm × 1, 12 mm × 1

Laparoscopic bowel graspers and scissors

Laparoscopic needle driver

Laparoscopic energy device (surgeon preference)

Micro-laparoscopic (3 mm) instruments if available

Laparoscopic linear stapler with appropriate loads

Endo-Catch bag (Covidien, Norwalk, CT)

Wound protector

Polysorb or vicryl sutures

Laparoscopic monitors will be placed depending on the location of the lesion. For right colon polyps, monitors are placed on the patient’s right side and toward the head of the bed. (Fig. 18.1) For left colon lesions, the monitors are placed at the patient’s left and toward the foot of the bed. For transverse colon or flexure lesions, the monitors are placed at the head of the bed as the endoscopist will stand between the patient’s legs.

Fig. 18.1

Suggested trocar and monitor placement for CELS technique for excision of a right colon polyp

Endoscopic equipment may vary. Surgeons may prefer to use a pediatric or an adult colonoscope. In addition, we feel it is a prerequisite to use CO₂ colonoscopy in the operating room. Simultaneous laparoscopy and colonoscopy with room air present technical challenges that can jeopardize the ability to perform CELS. Colonoscopy insufflation using room air can significantly obscure the laparoscopic view and compromise exposure. In institutions where CO₂ is not be available for endoscopy, a technique of laparoscopically clamping the terminal ileum to minimize small bowel distention during laparoscopy has been described, but we have found that the colonic distension is still a major impediment to CELS [3, 4]. Since 2003, our group has been performing colonoscopy with the use of CO₂ insufflation during laparoscopy. Because the bowel absorbs CO₂ gas approximately 150 times faster than room air, there is minimal unwanted dilation of the colon and excellent simultaneous endoscopic and laparoscopic visualization. We have previously demonstrated that intraoperative CO₂ colonoscopy is safe during laparoscopy and can be used to avoid excessive bowel dilation during CELS procedures [9, 17]. Therefore, if available, it is preferred to have CO₂ for insufflation during colonoscopy.

Procedure Steps (Videos 18.1 and 18.2)

Endoscopy

After the abdomen is prepped and draped in a sterile fashion, CO₂ colonoscopy is performed to locate the lesion (Fig. 18.2). We then use a mixture of 10 cm³ of 1% methylene blue mixed in 100 cm³ of 25% albumin to mark the location of the polyp. Submucosal injection is performed under the polyp in order to raise it up.

Fig. 18.2

Endoscopic visualization of a right colon polyp
If the polyp seems amenable to endoscopic removal alone, then this may be attempted at this point prior to port placement. If patient history suggests that there may be adhesions or a fixed loop of colon that previously prevented endoscopic excision, then pure snare polypectomy may not be feasible.

Port Placement

Initial access: A periumbilical 5 mm port is placed, per usual, and pneumoperitoneum is established. A 5 mm, high definition flexible tip laparoscope is preferred for enhanced visualization. The abdomen is explored and the polyp is localized using the previously placed tattoo.
Secondary trocars: Depending on the location of the lesion, typically two 5 mm trocars may be placed. For right colon lesions, trocars can be placed in the left lower quadrant and suprapubically. For left colon lesions, trocars can be placed in the right lower quadrant, and suprapubically. For transverse colon lesions, trocars can be placed bilaterally in both the lower and upper quadrants. If available, micro-laparoscopic (3 mm) instruments are used.
Optional trocars: A 12 mm port may be needed for a stapler if a colonoscopic-assisted laparoscopic wall excision is anticipated.

Mobilization

For laparoscopic-assisted colonoscopic polypectomy, the lesion is located by the endoscopist and its position is confirmed by laparoscopic visualization with the use of transillumination and/or by endoscopic visualization during laparoscopic manipulation of the colon (Fig. 18.3). This maneuver can also expose mucosal areas that were not previously visualized because of folds or segmental kinks of the colon. Appreciating the location of the polyp in relation to the peritoneum is important. Polyps located on the retroperitoneal side or mesenteric side requires mobilization of the colon for adequate exposure.

Fig. 18.3

Endoscopic visualization of a colon polyp with simultaneous laparoscopic manipulation of the colon wall
If the polyp is in a difficult location (i.e., at a flexure or near the mesenteric border of the colon) and this area cannot be manipulated, the colon will need to be mobilized as in any laparoscopic colectomy procedure. We prefer to use an energy device along the Line of Toldt and the embryonic tissue planes. Once the colon is mobilized adequately, the area of the polyp can then be manipulated.

Polypectomy

As stated previously, the polyp is lifted with a mixture of methylene blue and albumin. This aids in visualizing the polyp in comparison to the normal surrounding mucosa and also aids in seeing the location of the polyp laparoscopically. It also provides a “buffer” zone to facilitate endoscopic resection without causing a full-thickness injury.
If the polyp does not lift due to scarring from previous biopsy, either resection or full-thickness CELS can be considered. The possibility of malignancy also needs to be considered in this situation.
Polypectomy is performed using an electrosurgical snare. This can be done using a single pass or in piecemeal fashion. For polyps that are either flat or are situated in tough location, laparoscopic manipulation of the polyp during snare polypectomy can facilitate delivery of the polyp into the snare (Fig. 18.4).

Fig. 18.4

Laparoscopic manipulation of the polyp during a snare polypectomy with laparoscopic delivery of the polyp into the snare
During polypectomy, the serosal aspect of the colon should be monitored closely laparoscopically. If there is any subtle change to the area, this can be immediately recognized and then over sewn, if needed (Fig. 18.5). Full-thickness thermal injury or perforation is addressed with suture repair and imbrication. If there is some evidence of blanching or deterioration of muscle layers, the area can also be reinforced to avoid the evolution of partial-thickness to full-thickness injury and perforation in the postoperative period. The ability to laparoscopically repair potential damage allows for a more aggressive polypectomy .

Fig. 18.5

Suture reinforcement of the colon in an area of partial-thickness injury