The equipment available for laparoscopic colectomy continues to evolve and improve. Equipment in the early laparoscopic era was basic [2], and mesenteric vessels were divided with clips, ENDOLOOPS™ (Ethicon, Cincinnati, OH), or ligatures. The advent of advanced energy devices has made intracorporeal vessel division safe, rapid, and reliable. Surgeons now have at their disposal ultrasonic, bipolar, and combination devices that can seal vessels up to 7 mm in diameter [13]. Endoscopic stapling devices come in a variety of lengths, staple heights, and degree of articulation. Powered staplers have been introduced to reduce surgeon effort and provide uniform compression when stapling. This is not to say that everything is perfect. Rectal division after low anterior resection remains a challenge, as no available stapling device has true 90° articulation. While high-definition imaging has certainly provided a huge upgrade, cameras continue to fog up, and visualization can always be improved.

Needlescopic instrumentation is another promising area. Also referred to as minilaparoscopy, it involves the use of instruments 3 mm or less in diameter. These instruments have been used for multiple procedures including cholecystectomy, appendectomy, among others [14]. While they can obviate the need for standard 5 mm transfascial access ports and potentially result in reduced scarring and postoperative pain, their lack of rigidity results in durability issues, as well as poor control and tissue manipulation, especially in obese patients. Despite these disadvantages, needlescopic instruments continue to evolve. The percutaneous surgical set (Ethicon, Cincinnati, OH) allows for standard-size instrument heads to be placed on needlescopic shafts that can be assembled within the abdominal cavity. Although this is FDA approved, it is not yet commercially available, and generalized use will provide more insight into their ultimate utility [15].

As yesterday’s laparoscopic pioneers pushed minimally invasive techniques over traditional open surgery, limited access laparoscopy and natural orifice transluminal surgery are being developed by tomorrow’s generation of minimally invasive surgeons. Limited access laparoscopic surgery involves reducing the number of access sites used for a procedure. In theory, this reduces a patient’s pain and discomfort postoperatively. Reduction in the number of incisions provides the potential for improved cosmesis. Single-incision laparoscopic surgery (SILS) has been successfully used for a variety of colorectal procedures, including segmental colectomy, total colectomy, and even proctocolectomy [16–18]. The incision site is often chosen in the umbilicus or at a site of planned ostomy formation to minimize visible scar. Multiple trocars can be placed through a single fascial incision or one of the commercially available single-incision ports can be used. One of the difficulties with SILS colectomy is the loss of triangulation with traditional laparoscopy. Rather, in-line dissection and visualization must be performed. Various innovative technologies have been introduced to try and overcome some of these difficulties, including flexible tip cameras and curved instruments. Extracorporeal magnetic retraction has been used to make up for the lack of triangulation in retraction [19]. Despite the purported benefits of reducing the number of laparoscopic incisions, no randomized trial has shown any benefit of SILS colectomy over traditional laparoscopic colectomy, with the one notable exception of patient perceived cosmesis [20].

Unlike the appendix or gallbladder, one of the limiting factors in minimizing the invasiveness of laparoscopic colectomy is the need for specimen removal. Even when a true intracorporeal anastomosis is performed, often a bulky, diseased colon, mesentery, or tumor must be extracted through the abdominal wall, requiring an incision of several centimeters in length. Alternate anatomical sites have been described for specimen extraction, sometimes referred to as natural orifice specimen extraction (NOSE). These include the vagina, stomach, and anus [21–23]. Transvaginal access to the abdominal cavity has been performed for the longest period of time and is relatively safe. Transgastric access is a developing field and has been used successfully for “incision-less” cholecystectomy [24]. Concerns still remain regarding the safety of the gastrotomy closure and the potential consequences with a leak at the site. Transanal abdominal cavity access is interesting in that it is more easily achieved when performing low or left-sided colorectal anastomosis. Specimen extraction can then be performed via the rectal stump, obviating the need for abdominal extraction excisions. Yet, adding a colotomy for more proximal resections, similar to gastric extraction, provides an additional source of morbidity and risk to the procedure for an, as yet, unknown benefit.

Other more established techniques are witnessing expanded use in attempt to push the “scarless” surgery envelope. Transanal endoscopic microsurgery (TEM) was introduced by Buess in 1988 [25]. TEM allows for full-thickness rectal resections in locations more proximal than would be amenable to traditional transanal excision. Recently, transanal oncologic proctectomy using this same equipment, but accessing the presacral plane from below, has been reported [26]. While this is promising, challenges remain. Difficulties have been encountered dissecting proximal to the sacral promontory. Furthermore, mobilization of the splenic flexure to allow for a low-rectal anastomosis using current technology remains a significant challenge. Therefore, while the anus and rectum can be used as an extraction site in NOSE procedures and TEM used for rectal closure, technical and technological modifications are required to allow for more widespread adaption.

Furthermore, TEM setups consist of a rigid, operating proctoscope, binocular optics, insufflation, and multiple laparoscopic working ports. This specialized equipment comes with a high startup cost. Recently, commercially available, disposal laparoscopic transanal ports have become available. These devices allow for TEM procedures to be completed with standard laparoscopic equipment, at a fraction of the cost, which may increase its utilization more than any other factor.

Flexible endoscopy has been an indispensable tool for the colorectal surgeon for many years. Colonoscopy allows for diagnosis and treatment of a large number of colorectal diseases. Investigators have increasingly pushed the envelope on what types of colon lesions can be resected with an endoscope. Endoscopic polypectomy has evolved significantly from simple snare techniques [27]. More recently, large polyps can be removed en bloc with endoscopic mucosal resection techniques. Furthermore, borrowing techniques first developed from the upper GI tract, even larger masses and early cancers can be removed with endoscopic submucosal dissection. Hybrid laparo-endoscopic procedures have also been performed, where an abdominal surgeon assists an endoscopic surgeon in the removal of large polyps or performs wall closure after full-thickness colon resection. Newer techniques are being developed allowing for colonic wall closure after full-thickness resection using only the colonoscope [28]. Refinement in NOTES technology has included large, multichannel, operating endoscopes [29] that presumably could also be deployed for intracolonic dissections.

Another important potential influence on the future of minimally invasive colectomy is the emergence of robotic-assisted surgery (Fig. 36.2). Originally developed as voice-guided camera assistants for laparoscopy [30], modern surgical robotic platforms provide multiple surgeon-controlled arms with binocular vision [31]. They allow for wrist-like degrees of freedom during dissection and neutralize physiologic tremor. Robotic assistance has been applied to all areas of traditionally laparoscopic or open colon surgery, including segmental colectomy, single-incision colectomy, and even proctectomy [32–34], the latter of which may be the procedure that benefits the most from robotic assistance. The narrow confines of the pelvis magnify the benefits of improved visualization and precise dissection that robotic surgery allows. Some reports have suggested decreased rates of circumferential radial margin positivity with robotic-assisted proctectomy for cancer [35, 36]. In addition, technology to estimate the adequacy of perfusion to the bowel is available on the robotic platform (Video 36.1).

One of the major drawbacks of robotic-assisted surgery is the cost. A surgical robotics platform costs seven figures to obtain and has ongoing maintenance service contract costs. Dedicated, specially trained staff is needed to set up and assist in cases. Robots have space requirements and may necessitate OR facility modifications to allow for optimal deployment. The increased cost of robotic colectomy would be acceptable if associated increases in value were realized. However, no reports have yet to identify any consistent benefits of robotic-assisted colectomy over conventional laparoscopic colectomy. Multiple studies have confirmed the equivalence of robotic surgery to laparoscopic surgery, with respect to short-term complications and length of stay metrics, but at the expense of greater costs [37–40]. There is some data suggesting improved sexual function with robotic rectal surgery [35]; however, randomized clinical trials for confirmation are awaited. The ACOSOG Z6051 trial is including robotic proctectomy in its minimally invasive arm, and the ROLARR (robotic vs. laparoscopic resection for rectal cancer) trial [41] also aims to determine any potential advantages of robotic over laparoscopic surgery. Regardless, looking ahead, the robotic platforms of today likely are not the platforms of tomorrow. Transanal use, single-incision approaches, and smaller equipment profiles all will likely expand its horizons, along with increased use during residency training.

Postoperative ileus (POI) is a major source of morbidity for patients undergoing laparoscopic colectomy. Ileus, although variably defined in clinical studies, is a delay in the return of gastrointestinal function after abdominal surgery. It has been estimated that managing prolonged ileus accounts for $1.46 billion in national healthcare costs for abdominal surgery. The incidence of prolonged ileus in laparoscopic colectomy patients is roughly 10 % [42, 43], and its development alone after colectomy increases hospitalization costs up to 15 % [44].

First proposed by Kehlet [45], fast-track, or enhanced recovery, protocols were developed to minimize ileus, decrease length of stay, and reduce complications. They encompass a wide range of preoperative, perioperative, and postoperative care measures with the focused goal of improving patient outcomes. Most protocols incorporate avoiding nasogastric tubes and drains, early feeding, and minimizing narcotics use, to name just a few components of care. Novel pharmaceutical agents have been developed to counteract the effects of narcotics on increasing POI [42, 46]. Fast-track protocols have been shown to reduce length of stay in the setting of laparoscopic colectomy [47]. Despite the technological advances in minimally invasive colectomy techniques, reduced incisions, and NOSE, POI will likely continue to cause morbidity and increase length of stay. Surgeons will have to continue to refine and improve their care protocols to maximize patient outcomes. When judged from the administrative perspective of cost and length of stay, even the most innovative surgical techniques will fail if the other important factors contributing to recovery are ignored.

The US healthcare system is currently in a period of great uncertainty. The Patient Protection and Affordable Care Act (PPACA) [48] signed into law by President Obama in 2010 is arguably the greatest change to our healthcare system since the origination of Medicare in 1965. While political brinkmanship and debate over the law continues, the Supreme Court has upheld the constitutionality of the individual mandate, so the numerous provisions of the PPACA seem likely to shape the face of medicine and surgery in the years to come. One of the major effects of the PPACA is expanding the availability of healthcare services to Americans. The law will accomplish this in various ways, including insurance exchanges, extended benefits for dependents, expansion of the Medicaid program, and financial disincentives for those to choose not to carry health insurance. With an aging population, and now with more patients eligible for healthcare benefits, one could expect the demand for minimally invasive treatments for colon and rectal diseases to dramatically increase.

A move away from traditional fee-for-service reimbursement will also affect the future of minimally invasive surgery. Accountable care organizations (ACOs) are groups, concentrated around primary care physicians, that assume responsibility for the total care of a cohort of patients [49]. In theory, costs savings are obtained through better integration and coordination of care within the ACO. Any potential cost savings are shared between the ACO and Medicare. This incentivizes high-quality healthcare delivery, over volume for profit. However, these cost savings may not be as relevant to inpatient services as they are to ambulatory ones [50]. The impact of ACOs on surgical care remains to be seen.

The expansion of minimally invasive colon surgery should fit well into the ideals of a high-quality procedure. Although there are slightly increased costs upfront, due to increased equipment cost, savings are realized by decreased hospital length of stay and infectious complications. ACOs could favor and promote the use of minimally invasive colectomy over open surgery in their networks, but only for properly selected patients.

Finally, as previously noted, implementation of laparoscopic colectomy in rural and smaller hospitals still lags behind larger or more urban institutions. Much of this is likely related to the practice preferences of surgical specialists trained in minimally invasive colectomy. There is clearly an opportunity for the role of minimally invasive colectomy to expand in these areas. As the next generation of surgeons enters the workforce, more experienced in a wide variety of minimally invasive surgery than their predecessors, there will likely be more practitioners offering laparoscopic colon surgery. Further measures have been implemented to increase the number of general surgeons in practice and direct them to geographic areas in need. The PPCA enacted a 10 % bonus payment to general surgeons in health provider shortage areas. Persistently unfilled residency training positions will be reallocated to primary care and general surgery positions.