Very large size is a relative contraindication for endoscopic removal (the skill set of the endoscopist is also a factor); polyps that involve the great majority of the cecum are best dealt with via bowel resection.

Regarding large sessile polyps for which prior biopsies show high grade dysplasia and where the majority of the polyp remains in place; the two largest series suggest that there is a 30–41% chance of there being invasive cancer on final pathology [23, 24]. Given the present inability of the vast majority of Western endoscopists to make the distinction between a highly dysplastic polyp and a cancer based on the surface appearance or other means, the authors recommend a standard oncologic right colectomy for patients with large sessile adenomas with high grade dysplasia.

Polyps that do not fully “lift” with submucosal injection also pose a problem. Failure to lift may signify either the presence of cancer invading into the muscularis propria or a scar that is the residua of prior polypectomy attempts. The treatment options in this situation are: EMR via snare, wedge partial circumference full thickness resection, or ileocolectomy (vs right hemicolectomy).

ESD and complete EMR are not options for lesions involving the ileocecal valve or appendix base since the inner polyp edge and margin may not be visible or accessible. The appropriate treatment for the former is an ileocolic bowel resection (vs right colectomy) whereas for the latter a wedge resection may be possible vs. an ileocolectomy.

As stated, an assumption has been made that surgical endoscopists would perform these advanced colonoscopic procedures in the operating room in conjunction with laparoscopy. Since there are multiple advanced colonoscopic methods that can be used and because the preference and experience of each surgeon will largely determine the method chosen, the algorithm includes all 3 methods.

The ESD and EMR methods are listed side by side in the table since the algorithm for each is the same. After successful polypectomy, laparoscopy is done to interrogate the bowel for perforations and to repair the bowel wall with seromuscular sutures, if necessary. If the polypectomy is not successful, a wedge resection would be carried out, if feasible. Laparoscopic-assisted colectomy is reserved for failed polypectomy patients for whom wedge resection is not an option or if the bowel has been injured beyond repair during endoscopic polyp removal.

Proponents of the laparoscopic-facilitated colonoscopic method (Milsom, Franklin) would follow the right most track on Table 15.2; in these cases, the laparoscopy would be done simultaneously so that the polyp can be presented to endoscopist during the polypectomy. After successful colonoscopic polypectomy the bowel wall is inspected and laparoscopically repaired if need be. A laparoscopic wedge resection or ileocolectomy is reserved for patients in whom the colonoscopic removal attempt fails.

It is appropriate to utilize advanced colonoscopic methods to remove large benign polyps in order to avoid colectomy and its attendant morbidity. Numerous methods are available, however, in the authors opinion, ESD is the current gold standard. Since ESD has not yet been widely embraced by gastroenterologists in the U.S., the combined colonoscopic and laparoscopic methods discussed in this chapter have been devised and employed by surgeons in the West. Use of these methods holds the promise of organ preservation in patients in whom the current alternative is a segmental colectomy. Having said this, it is likely that in a decade or so these lesions will be excised endoscopically in the endoscopy suite without the need for concomitant laparoscopy.