Combined Laparoscopic–Endoscopic Procedures

Fig. 10.1

a Hourglass-shaped gastrointestinal stromal tumor located in the gastric fundus that appears by endoscopic assessment to be endoluminally growing. b Endosonographic finding that obviously supports endoscopic assessment. c Intraoperative laparoscopic vision showing the large extraluminal aspect

Nevertheless, even in these complex lesions, flexible endoscopy is of great value, as it has already been possible to show during conventional surgical interventions, for example, to ease precise tumor localization (Sakanoue 1993). While flexible endoscopy appears supportive but only «nice to have» in open surgery, it becomes a «conditio sine qua non» in laparoscopic surgery. This inalienability of flexible endoscopy, at least for the mentioned indications, is explained by procedural limitations of minimally invasive surgery that are brought about by reduced degrees of freedom (only a few but fixed trocar sites), by the small size of the instruments, and if nothing else by the loss of tactile sensation. Due to these limitations, local laparoscopic resection of benign and early malignant pathologies of the gastrointestinal tract is hindered significantly (◘ Table 10.1). Even in the case of a large protruding mass, the precise extent of a tumor and its defined borders are estimated by laparoscopy only at a quality level that allows for an extended but not for a tissue-sparing local resection.

Table 10.1

Known limitations of laparoscopy and endoscopy. By combining both techniques these limitations can be overcome

Laparoscopy	Endoscopy
Imprecise localization of endoluminal lesions	Only amenable to superficial, circumscript lesions
Reduced degrees of freedom	Limited hemostasis
No evaluation of suture lines from outside	Highly limited viscerosynthesis, no suturing
Inferior and limited exposure techniques	Only applicable endoluminally
Difficulties in accessing subcardial and prepyloric lesions	Restricted maximum lesion size (2–3 cm)

In most cases, preoperative marking of the tumor prior to laparoscopic resection seems indispensable. However, available techniques for preoperative tumor marking (endoscopic tattoo, clip, etc.) are evaluated as unreliable and too imprecise (Cho et al. 2007; D’Annibale et al. 2004) and, identically, allow only for gross tumor resection. In particular, adhesive pigments available do not remain at the site and show diffusion effects soon after injection, resulting in staining of a much larger area than intended and thus requiring extended surgery (◘ Fig. 10.2). If at all, we recommend Indian ink for endoscopic tattoo.

Fig. 10.2

Preoperative endoluminal–endoscopic color staining of a tumor. Already 3 h after injection, the pigment diffuses beyond the area of interest. Precise localization and demarcation of the tumor borders become impossible. In this specific case, unreliable marking of the tumor resulted in an unnecessarily gross and tubular resection

The marking of a tumor by endoscopic clips might become even more critical. Although placement of clips can be achieved easily and with acceptable precision, identification of the clips turns out to be difficult and cumbersome even if intraoperative fluoroscopy is available (◘ Fig. 10.3). In some rare cases, mislocalization of endoscopic clips during surgery has resulted in resection of the wrong colon segment and in medicolegal conflicts.

Fig. 10.3

a Marking of a lesion by endoscopic clip placement. b Intraoperative fluoroscopic visualization. Although identification of the clip seems easy and unequivocal, precise tumor resection without intraoperative endoscopic support becomes difficult in the majority of interventions

As compared to the insufficient marking by tattoo and clips, intraoperative endoscopy is capable of precisely describing the endoluminal aspect of a lesion that can be demonstrated to the surgeon and that finally facilitates true local resection. Demonstration of the tumor borders can be achieved by manipulating the intestinal wall from the outside while observing from the inside or via transillumination (diaphanoscopy), which means illustrating the endoluminal lesion by spot lighting (◘ Fig. 10.4). Intraoperative endoscopy is second to none for the abovementioned marking techniques and, accordingly, the modality of choice for intraoperative tumor localization.

Fig. 10.4.

Invagination of a small prepyloric lesion through external manipulation by a laparoscopic grasper. Although the stomach is extended to its maximum, the palpating instrument is easily identified from inside

It is important to note that the contribution of intraoperative endoscopy is not only confined to localizing a lesion but is extended over the entire intervention with the idea of a combined laparoscopic–endoscopic intervention. This additional contribution is extremely valuable and was realized even several years ago.

Potential Advantages of Intraoperative Endoscopy

Highly precise tumor localization
Endoluminal tumor resection
Prevention of stenosis
Test for leakproofness after resection
Endoluminal specimen extraction

The first reports on combined hybrid interventions date back to the early 1990s and deal with the therapy of benign and early malignant tumors of the stomach and the colon. In this context, Ohgami first reported on the «lesion-lifting method» that he applied in 1994 for the therapy of gastric leiomyosarcomas and T1 cancer (◘ Fig. 10.5). For this technique, the tumor-bearing aspect of the anterior gastric wall was exposed by anchors that were inserted into the lumen under endoscopic vision. Tumor resection is then easily performed by stapler application and wedge resection of the affected gastric aspect. Intraoperative gastroscopy is maintained throughout the resection to assure correct exposure of the tumor and to verify complete and secure tumor resection (Ohgami et al. 1994, 1996). Alternatively, tumor resection is also possible by a transgastric approach, which was introduced by Ohashi et al. (1995). For a transgastric resection, laparoscopic trocars are advanced via the abdominal wall and under flexible endoscopic guidance into the gastric lumen; thus endoluminal tumor resection is performed inside the gastric lumen with standard laparoscopic instruments (◘ Fig. 10.6). Visualization during the intervention is possible without application of a laparoscopy only on the basis of the gastroscope.

Fig. 10.5

The so-called lesion-lifting method was first published by Ohgami in 1992 for resection of a T1 cancer that was located at the anterior gastric aspect. Tumor resection was eased by exposure with anchors that helped to elevate the inflicted part of the stomach and was finally completed by stapler application (Ohgami et al. 1999)

Fig. 10.6

Tumors located at the posterior side of the stomach that cannot be accessed by a lesion lift can be treated by a transgastric resection. Transgastric resection can be done both by performing an anterior gastrostomy and by inserting the trocars into the gastric lumen as described by Ohashi. The latter technique avoids spillage of gastric content and is less traumatic (Ohashi et al. 1995)

As for gastric lesions, combined interventions are also applicable to colonic lesions. Depending on the exact localization of the tumor in respect to the colonic circumference, resection might be possible without opening of the lumen in form of a wedge resection (Shallman et al. 1993) or with a transluminal approach after incision (Champault 1994; Zuro et al. 1992). Identical to the technique which has been described for gastric pathologies, simultaneous endoscopy supports laparoscopic resection by tumor localization, endoluminal control during the resection, and reduction of the postoperative complication rate by testing the suture lines for leakproofness. In some favorable lesions, endoluminal endoscopic resection can be performed secondarily and by means of laparoscopic assistance and manipulation, even though it appeared impossible at initial endoscopic evaluation (Beck and Karulf 1993; Smedh et al. 1997). As compared to a combined transluminal or wedge resection as described above, laparoscopically assisted endoscopic resection further reduces the interventional trauma, as it avoids opening/resection of the intestinal wall. If the risk of secondary perforation is estimated as too high after endoscopic tumor resection, oversewing of the resection site from the outside by laparoscopy is easily achieved. Two approaches are conceivable: preemptive suturing before endoscopic resection as described by Back and Karulf in 1993 or according to Sarker in 2014, by prior application of a mega-clip (the so-called endoscopic full-thickness resection (EFTR)), and securing of the resection site secondary to endoscopic resection, if a local burn or pending perforation is visualized by laparoscopy.

The modality of «combined endoscopic–laparoscopic interventions» developed only slowly in the beginning, although this terminology was already used in 1995 by Payne et al. (1995). In the original phase, one did not refer to the consequent application of intraoperative endoscopy but to the simultaneous therapy of gastrointestinal lesions by accessing them via different routes and by different technologies. Subsequently, it was possible to show that combined interventions were not restricted only to colonic or gastric lesions but could also be applied for the treatment of tumors of different origin and location (Feussner et al. 2003). A systematic classification of the different forms of combined endoscopic–laparoscopic interventions is also part of this latter publication. According to this classification, one can distinguish laparoscopically assisted endoscopic resections from endoscopy-assisted laparoscopic resection—depending on which of the involved partners is resecting the tumor. For endoscopy-assisted laparoscopic interventions, further differentiation and subclassification are offered, and this distinguishes resection with intended opening of the gastrointestinal lumen to gain access to the tumor (endoscopy-assisted transluminal resection (EATR)) and resection without the need to open the intestinal integrity from tumor therapy by wedge resection (endoscopy-assisted wedge resection (EAWR)). Not to be forgotten and infrequently required for treatment of large tumors, the endoscopy-assisted segmental resection has to be mentioned (EASR) that is also part of this classification, although it is, due to the fact of extended resection, not in the primary focus of a combined tumor therapy. In EASR, the contribution of intraoperative endoscopy is reduced to a minimum and is more an intraoperative endoscopy than a hybrid intervention. Only in tumors that do not allow for local tumor resection (planned EASR) preoperative marking of the tumor site by tattoo is permissible.

Over the past decades, we were successful in optimizing the initially published techniques and further reducing the trauma, e.g., by using percutaneously placed suspension sutures to support exposure or by manipulation sutures that are inserted assisted by endoscopy close to the tumor to ease resection. But simultaneously, therapeutic flexible endoscopy also significantly evolved in the meantime, facilitating even resection of larger lesions and tumors located in the submucosa. For example, endoscopic submucosal dissection (ESD) techniques allow for resection of flat spreading adenomas that cannot be treated by snare polypectomy (Hotta et al. 2012). Obviously, these advanced endoscopic techniques can easily be incorporated to combined interventions and now can be applied to local endoluminal tumor therapy that is supported by laparoscopic assistance (e.g., exposure of a lesion by neutralization of bends and haustrations). Thanks to that, the rate of laparoscopically assisted endoscopic resections has dramatically increased in recent years, while we can identify a reduction of laparoscopic resection and especially of segmental resections (◘ Fig. 10.7).

Fig. 10.7

Regression analysis of intervention frequencies of different types of combined interventions. It should be noted that while a reduction of EASR and less frequently of EAWR was observed, one could observe a slight increase in transluminal resections (EATR) and a strong increase in endoscopic resections (LAER)

10.2 Technical Considerations

Combined laparoscopic–endoscopic interventions are performed in the operation theater and with the patient under general anesthesia. Obviously, for hybrid interventions, the operating room must be fully equipped with both state-of-the-art laparoscopic and endoscopic equipment, so the personnel must be trained in both techniques. To ease cooperative work at a high-quality standard, enough room must be given to the laparoscopic and the endoscopic team, and visualization must be optimized not only as far as one’s own working monitor is concerned but must further include access to the visual field of the respective partner. Accordingly, placement of the working towers, the patient, and the monitors has to be adapted and optimized. Therefore and as the ideal solution, the hybrid intervention room should be equipped with double monitors for both actors to ergonomically visualize the operative field of both modalities simultaneously. Since flat screen monitors have long been available, mounting of the panels on the ceiling is no longer a problem. If a double-screen solution is unachievable, picture-in-picture mode is used to integrate the different video sources into one monitor.

In ◘ Fig. 10.8 , a typical OR configuration for hybrid interventions is shown. For interventions in the upper gastrointestinal tract, the endoscopist is situated beside the anesthesiologist at the head of the patient and outside the sterile operating field.

Fig. 10.8

a For interventions in the upper gastrointestinal tract, the endoscopist has to find his place alongside the anesthesiologist at the patient’s head. In most cases, the surgeon and the camera assistant are positioned on the right side of the patient, with good vision to the monitors on the opposite side that visualize both the laparoscopic and the endoscopic field of view. b If a hybrid intervention deals with colonic lesions, the patient is placed in a lithotomy position. The endoscopist is asked to place himself in the confined region in between the legs for colonoscopy. Depending on the location of the lesion, the surgeon operates from the right (left hemicolon) or the left side (right hemicolon)

During hybrid colonic resections, the patient is positioned in a lithotomy position. It is inadvisable for the endoscopist to be positioned in close proximity to the sterile operative field. Only a sterile drape that is fixed to the patient’s legs prevents from contamination. As the endoscopic tower has to be placed besides the patient, it is sometimes difficult (if ceiling-mounted monitors are not available) to obtain a direct view of the monitor. In these cases, wearing a head-mounted display (HMD) has proved beneficial (◘ Fig. 10.9).

Fig. 10.9

Wearing a head-mounted display (HMD) was rated ergonomically superior if the endoscopic tower had to be placed in an unfavorable position

Colonoscopic examination turned out to be highly demanding inside the operating theater, when the patient cannot be maneuvered laterally and when general anesthesia neutralizes abdominal guarding. Additionally, the endoscopist should avoid over-insufflation and distension of the bowel loops during endoscopy in order not to hinder later laparoscopy. For the same reason, we have the impression that it is better to use CO² instead of room air for insufflation, as it is absorbed much faster. However, even with CO², insufflation should be reduced to a minimum. If insufflation is unavoidable, bowel distension can be controlled by clamping the intestine outside the region of interest by application of a soft grasper.

Irrespective of the abovementioned aspects, some additional issues have to be considered. Intubation of the esophagus with the endoscope can be impossible due to the tracheal tube being air blocked. If so, reducing the cuff pressure or deblocking of the cuff is helpful, but this must be done in close cooperation with the anesthesiologist and with care. In addition, an inserted gastric tube can interfere with gastroscopy. However, we recommend removal of the tube anyway before commencing the intervention. It should be noted that any intraoperative manipulation at the patient’s head, e.g., for placement of the bite-protecting ring, might lead to dislocation of the tube, airway problems, or some other severe dangers to the patient, so it must be done with the highest accuracy possible and always side-by-side with the anesthesiologist. This holds true even more if a hybrid procedure aims to resect an esophageal lesion with the need for single-lung ventilation and double-lumen intubation and with the patient in an awkward position.

Air insufflation during endoscopy in the course of hybrid interventions should always be kept to a minimum not to hinder laparoscopic vision by distended bowel loops.

As soon as the endoscope is advanced into the stomach, one should remove all fluids by suction to prevent spillage and peritoneal contamination during transluminal manipulation.

As already mentioned, if a hybrid procedure requires colonoscopy, special attention has to be paid to maintain hygienic requirements and to preserve the sterile operative field, as the endoscopist is situated close to the surgeon. Therefore, and as a basic prerequisite, the endoscopist is asked to wear sterile scrubs just like anybody else during a surgical intervention. A relevant problem for efficient colonoscopy arises from the confined space between the patient’s legs, not only for manipulating the endoscope but also in order to be supported by any assistance, e.g., for scope stabilization or to navigate a snare. As hybrid interventions are done under general anesthesia and with the patient relaxed, a supportive effect from the tensed abdominal wall for guidance of the endoscope is not to be expected. This is not only problematic in terms of technical feasibility of intraoperative colonoscopy but can result in iatrogenic colon perforation, as in addition typical warning signs such as pain and abdominal overdistension will not be noticed. For this reason, assistance from the operating surgeon, either by transabdominal or laparoscopic guidance, is extremely helpful. Nevertheless, we prefer colonoscopy to be done with a desufflated abdomen and with no laparoscopic instruments introduced, as we suppose the risk of violation is minimal with this technique. In practice, we start the operation with a diagnostic laparoscopy to desufflate soon thereafter, to advance the colonoscope to the lesion of interest. Not until then is laparoscopy restarted, unless endoscopy is impossible due to anatomical alterations that require laparoscopic support. Finally, both partners can start the hybrid resection, as soon as the lesion is visible with the colonoscope.

Obviously, and not only for the mentioned reasons, an effective combined laparoscopic–endoscopic intervention is only successful when both actors work together closely and with adequate comprehension of the working process of the partner. Ideally, both partners are trained in both laparoscopic surgery and flexible endoscopy.

Laparoscopy is not only supportive to endoscopy but can also complicate colonoscopy by inadequate manipulation from the outside and because of the laparoscopic light that interferes with intraluminal vision. Accordingly, close cooperation and helpful coordination between the partners are of utmost importance.

In daily praxis, however, not only technical problems but even more organizational issues interfere with effective collaboration. In particular, timing of an intervention that takes place in the surgical OR is challenging when the endoscopist is working in another department and has to integrate the intervention into his timetable. Additional work arises if all instruments and the endoscopic tower have to be brought to the OR as well.

With the formation of viscero-medical centers and thanks to an improved interdisciplinary cooperation, we strongly believe these obstacles can be overcome.

10.3 Safety Laparoscopy

In risky and complex endoscopic interventions (e.g., full-thickness resections or interventions with a high risk for perforation), a priori laparoscopic support and surveillance might be reasonable.

Safety laparoscopy needs to be performed under general anesthesia but can be reduced to a minimum, thus a single trocar access with introduction of a needlescope only (2 mm optical system). Although the endoscope can only be identified indirectly and by its transluminating light, the laparoscopist can easily follow the endoscopic intervention. If a perforation occurs, it can immediately be identified by vision or secondarily by gas bubbles or spillage of intraluminal fluids. If full-thickness resection with immediate endoscopic closure of the intestinal defect is intended, the laparoscopist can test for a leakproof closure of the defect.

Sometimes, when the lesion is located averted from the laparoscope or toward the mesentery or the lesser sac, laparoscopic exposure requires the introduction of additional instruments and dissection of the dedicated resection site. Fortunately, even then mini-laparoscopic instruments can be used to keep the interventional trauma as low as possible.

10.4 Laparoscopy-Assisted Endoscopic Resection (LAER)

In some rare lesions, when primary endoscopic resection appears impossible due to disadvantageous aspects and after failure of typical facilitating measures such as repositioning of the patient, exposure by submucosal injection, or re-endoscopy, endoscopy treatment can succeed in some case if supported by laparoscopy laparoscopy-assisted endoscopic resection (LAER)). As opposed to the abovementioned «safety laparoscopy», in LAER, the laparoscopic assistance and extraluminal manipulation are planned from the beginning, or it turns out during intraoperative assessment that in spite of the tumor having been scheduled for laparoscopic resection, an endoluminal resection is feasible (◘ Fig. 10.10). For example, this can be achieved by protruding the lesion to the luminal side by external manipulation, so it is amenable to snare resection or external dissection, and by stretching of the affected bowel segment to allow for endoscopic therapy (◘ Fig. 10.11).

Fig. 10.10

Sole endoscopic interventions that appear risky are sometimes better performed under laparoscopic surveillance (safety laparoscopy). In cases of perforation or any other adverse event, laparoscopic support is immediately available either for oversewing of the intestine or for hemostasis. Due to advances in interventional endoscopy and the ability to perform full-thickness closure, safety laparoscopy is only rarely indicated

Fig. 10.11

a Complete exposure and sufficient evaluation were never given during preoperative colonoscopy. b Intraoperative view, with the inflicted bowel segment stretched by external manipulation. c Finally, safe endoscopic resection was easily conducted under laparoscopic support

Moreover, laparoscopic hemostasis, irrespective of whether it is achieved by direct suturing or by control of the feeding artery, is helpful in the case of iatrogenic bleeding after endoscopic resection. Fortunately, and because of laparoscopic «rear cover», endoscopic tumor resection can be performed regardless of potential side effects and with maximum thoroughness. Accordingly, LAER can ensure complete and oncologically adequate endoluminal therapy (Tsujimoto et al. 2010).

For LAER, we usually insert three 5-mm trocars. The insertion points are carefully chosen according to the position of the lesions (◘ Fig. 10.12), as is done in all hybrid interventions.

Fig. 10.12

Placement of trocars for different hybrid interventions. a Interventions on the distal esophagus, cardia, and proximal aspect of the stomach. b Gastric hybrid interventions on the distal aspect of the stomach and antrum. c Interventions on the right hemicolon. d Interventions on the left hemicolon

Only gold members can continue reading. Log In or Register to continue