Colonoscopically Assisted Laparoscopic Polypectomy–An Alternative to Right Hemicolectomy for Large Right-Sided Benign Polyps

doi:10.4236/ss.2013.48069

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Surgical Science, 2013, 4, 350-353

http://dx.doi.org/10.4236/ss.2013.48069 Published Online August 2013 (http://www.scirp.org/journal/ss)

Colonoscopically Assisted Laparoscopic Polypectomy—An

Alternative to Right Hemi colectomy for Large Right-Sided

Benign Polyps*

A. Z. Kaleem#, C. Strachan, L. Whittaker, S. M. Ahmad

Department of Colorectal Surgery, Northern Lincolnshire and Goole Hospital NHS Foundation Trust,

Scunthorpe General Hospital, Scunthorpe, UK

Email: #[email protected]

Received April 28, 2013; revised May 30, 2013; accepted June 8, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: Laparoscopic assisted colonoscopic polypectomies have been well described in the literature and are

well established in surgical practice, for removal of large, inaccessible, or flat based polyps. Laparoscope allows the

endoscopist a serosal viewpoint and thus clear indication of perforation, in addition to enhancing endoscopic position-

ing through colonic mobilisation, facilitating polypectomy. We describe a previously rarely published technique, in

which the colonoscope directs the surgeon to polyps and laparoscopy enables wedge resection of benign polyps using

Endo GIA staplers. Using this method, the colonoscope provides an intra-luminal view ensuring adequate excision with

margins whilst the laparoscope provides intra-peritoneal access for the wedge resection. Methods: This is a case series

of 12 patients with large tubulovillous adenomas, found and biopsied at colonoscopy. Under a general anaesthetic, an

on table colonoscopy was performed to identify and reassess the polyp, whilst a laparoscopy was performed to excise

the polyp via wedge resection, using the endoscopic view as guidance. Results: The polyp was identified and com-

pletely resected in our 12 patients. All patients were discharged on the first post-operative day. Of the polyps excised, a

focus of adenocarcinoma was detected in one and an adjacent endocrine tumour was found in another patient in histol-

ogy along with tubulovillous adenoma. Rest were all tubulovillous adenomas only. Conclusion: We propose that this

technique should be regarded as an alternative to Right hemicolectomies and difficult endoscopic mucosal resections for

large adenomas, and be regarded as a definitive and safe procedure in its own right.

Keywords: Colonoscopically Assisted Laparoscopic Polypectomy

1. Introduction

Colonoscopic polypectomies are the treatment of choice

for most benign colonic polyps, and are the most com-

monly performed therapeutic intervention in colonoscopy.

Polypectomy techniques and established practice has

evolved considerably in the last 10 years; providing

many options for the varying morphology of colonic

polyps.

Snare polypectomies (cold/hot) are performed com-

monly and routinely for most accessible, pedunculated

and small polyps. If a broad based polyp is found, more

advanced procedures such as endoscopic mucosal resec-

tions (EMR), endoscopic sub mucosal dissections or

formal operative colonic resections are performed to re-

move them. EMR techniques are growing in popularity

given the improved accuracy and safety profiles associ-

ated with raising a lesion via injection to facilitate ease of

removal and thus identification of an invading lesion.

EMR is now recommended by the British Society of

Gastroenterology guidelines for flat and depressed le-

sions. The risk of perforation of the colon during colono-

scopic polypectomies varies between 0.1% and 3%, in

some studies [1] and between 0% - 0.19% for therapeutic

interventions, according to the British society of gastro-

enterology guidelines [2]. A recent Japanese study has

reported figures of 0.91% perforation risk associated

with EMR, compared with 0.17% with simple Polypec-

tomy and 3.3% with Endoscopic Mucosal resection [3].

Such figures rise with the size and location of the polyp.

*Source of funding: N/A (Department of Colorectal Surgery, Scunthorpe).

Disclosure Statement: Mr Ahmed Zaman Kaleem, Miss Caroline Stra-

chan, Miss Laura Whittaker and Mr Syed Muzaffar Ahmad have no

conflicts of interest or financial ties to disclose.

#Corresponding author.

A. Z. KALEEM ET AL. 351

Perforation risk is greater with polyps > 3 cm and when

located in the thin walled caecum or ascending colon.

This is due to the high wall tension in the caecum. In

addition there is a risk of thermal transmural damage to

the colonic mucosal surface in coagulating the polyp

during snare removal.

The well documented and established method of com-

bining laparoscopy with colonoscopy to perform colono-

scopic polypectomies, allows the direct visualization of

the polyp and the extra-luminal surface with the laparo-

scope [4,5]. Thus if perforation were to occur, the laparo-

scope allows this to be viewed and immediately repaired,

or indeed proceed to laparoscopic resection.

We describe an alternative technique of polypectomy,

for benign colonic polyps, utilizing the principles of si-

multaneous laparoscopy and colonoscopy. We propose

the colonoscopically assisted laparoscopic polypectomy

as a scarcely described technique and improved method

of polypectomy using a laparoscopic wedge resection of

the segment of colon containing the benign polyp.

2. Materials and Methods

Thus far, we have successfully carried out this procedure

on 12 patients, 7 male and 5 female, with an age range

between 66 and 92. Pathological examination from initial

biopsies showed tubulovillous adenoma in all 12 patients.

7 of the 12 polyps were located in the caecum, and 5

polyps were located in the ascending colon and the pa-

tients were referred for this procedure, as the polyps were

deemed unsuitable for colonoscopic resection.

The resected polyps ranged in size from 15 mm in

maximum diameter to 50 mm from colonoscopic assisted

laparoscopic polypectomy. The pathology of the wedge

resections of the polyps showed tubulovillous adenoma

in 11 of the 12 patients and a focus of adenocarcinoma in

1 patient, where the tumour had been completely excised

at all margins. This case was taken to the multi-disciple-

nary team meeting (MDT) where the decision to perform

a laparoscopic Right hemicolectomy was taken. In one

patient, the appendix was removed in the wedge resec-

tion given the proximity of the appendiceal opening to

the polyp. The pathological analysis of the polyp was a

completely excised TVA; however, the pathological

analysis of the appendix was that of a well differentiated

endocrine tumour, confined to the sub mucosa, and a

pathological staging of pT1, completely excised. Thus,

histological analysis confirms complete excision of ade-

noma in all performed polypectomies.

3. Technique

The patient receives full bowel preparation for colono-

scopy. The patients are admitted the day before surgery

and are consented and counselled for colonoscopically

assisted laparoscopic polypectomy, +/− R hemicolec-

tomy (laparoscopic/ open), with all the potential risks

involved in such a procedure for example; leak, need for

further surgery if malignancy is suspected or confirmed

on histology, incomplete resection, further polyps, an-

aesthetic risks. It is explained to the patient that this is a

novel procedure in this country, and permission is taken

for publication and photography during laparoscopy/

colonoscopy.

The patient is positioned in the lithotomy position on

the operating table, after a general anaesthetic is admin-

istered, prepped and draped for a laparoscopic procedure.

A colonoscopy is performed and the polyp is identified

with the colonoscope. A tattoo may also be used to fa-

cilitate polyp identification at laparoscopy. At this point,

laparoscopy is performed, via a 10 mm umbilical port. A

further 2 ports are inserted under vision, one 12 mm port

in the hypo gastric and another 5 mm port in the paraum-

blical region as shown in Figure 1.

Tattoo on bowel or light of colonoscope is used to find

polyp from abdominal side (Figures 2(a) and 3). If visu-

alization from abdominal side via laparoscope is difficult

or polyp is located posteriorly then caecum and ascend-

ing colon are mobilized from lateral aspect. When polyp

is identified both endoscopically and laparoscopically

then by using an endoscopic GIA linear stapler, the seg-

ment of bowel containing the polyp is stapled off (Fig-

ures 2(b), 4 and 5). Before firing the stapler using

colonoscope, it is made sure that polyp is completely

excised. Once divided it is removed in a Burt bag

through the umbilical port (Figure 6). The role of the

colonoscopy here is to directly visualize the lumen to

identify that the polyp is being completely enveloped by

the stapler along with good margins. The stapler will not

be closed and fired before the surgeon is satisfied with

the colonoscopic image demonstrating the complete

Figure 1. Port positioning.

A. Z. KALEEM ET AL.

352

(a) (b)

Figure 2. (a) Demonstration of the right sided polyp; (b)

Demonstration of the wedge resection.

Figure 3. Double view of linear stapler and colonoscopic

view.

Figure 4. Firing of the stapler and the colonoscopic view.

Figure 5. Post wedge stapling of the polyp.

Figure 6. Retrieval of the wedge of caecum in a Burt bag.

involvement of the polyp in the stapler. The right colon

has, in 11 out of our 12 cases not required mobilization

in order to carry out the segmental resection. In one case,

the polyp was located on the posterior wall and thus the

right colon had to be laparoscopically mobilized in order

to angle the laparoscopic stapler to achieve polypectomy.

The colonoscope is then withdrawn with intermittent

suction to deflate the colon, and the ports are removed

under direct vision and the wounds are closed in the

usual manner. Patients remain in hospital overnight for

monitoring and are discharged the following day if well.

All patients were discharged the following day.

Colonoscopically assisted laparoscopic polypectomy

was successfully achieved in 12 cases. All patients were

able to tolerate oral intake following the procedure and

there were no complications. The pathological analysis

has been detailed above. Of the excised polyps, 11 were

confirmed as benign adenomatous polyps and 1 polyp

showed a focus of moderately differentiated adenocarci-

noma arising from Tubulovillous adenomatous lesion.

This patient went on to have a laparoscopically assisted

R hemicolectomy.

4. Discussion

Adenomatous colonic polyps are amongst the most

A. Z. KALEEM ET AL.

353

common disorders of the colon and regarded as pre-ma-

lignant conditions. The majority of colonic polyps are

amenable to endoscopic snare excision. Large flat or in-

accessible right sided polyps pose a problem to safe en-

doscopic excision. The danger of incomplete excision or

perforation of the colon is significant, particularly in thin

walled caecum and ascending colon, and varies amongst

reports to as much as 3% [2]. Laparoscopic assisted colono-

scopic polypectomies are now well established for the

removal of such polyps and provide the extra security of

an intra-abdominal, serosal view of the colon whilst the

endoscopist is removing the polyp via snare [5]. Thus in

the case of perforation, it may be identified and treated

immediately. In addition, the use of the colonoscope al-

lows for accurate location of the polyp and thus mini-

mizing the need for colonic mobilization, with the excep-

tion of posterior/lateral wall located polyp. In this ap-

proach, the polyp is removed piecemeal and without sur-

rounding margins and thus histological comments on the

complete excision are difficult. There is also the consid-

eration of a late perforation due to diathermy injury

which may not be evident at the time of laparoscopy/

colonoscopy. We describe an alternative technique to

ensure complete polyp and margin removal, as a simple

wedge resection with the combination of laparoscopy and

colonoscopy. This technique has previously been de-

scribed, in association with the laparoscopic assisted

EMR, but not as a definitive procedure in its own right

[6,7]. Using an endoscopic GIA stapler, guided by the

colonoscope, a wedge of the affected part of colon is

removed with adequate margins. Laparoscopic tools are

used to lift up the colon to achieve appropriate stapler

angle, and the colonoscope provides simultaneous view

of the polyp to the laparoscopic surgeon, thus ensuring

complete removal of the polyp. This procedure for be-

nign colonic polyps eliminates the risk of perforation in

difficult polypectomies whilst also providing complete

excision with margins. This procedure has been de-

scribed previously in the literature as an alternative to

laparoscopically assisted colonoscopic excision, depend-

ing upon the location of the polyp. Due to the fragility of

this caecal walls, we believe that the endoscopic wedge

resection of tubulovillous adenomas in the caecum or

ascending colon should be considered as a safer and

more definitive procedure within its own right.

The negative caveat to the combined laparoscopic and

colonoscopic polyp removals is the potential need for

definitive resection if histology shows malignant change.

1 of the 12 patients in our experience thus far has had a

focus of adenocarcinoma in the resected polyp and has

thus required formal laparoscopic hemicolectomy. Thus,

the patient undergoes 2 general anaesthetics and laparo-

scopic abdominal surgeries within a short time frame.

However, given the common place nature of colonic

polyps, and the advent of bowel screening, a large num-

ber of benign polyps are being identified that are not

amenable to endoscopic resection. We feel that in such

circumstances colonoscopic assisted laparoscopic poly-

pectomies provide an excellent, safe and definitive exci-

sion method, particularly for right sided lesions. Patients

may go home the following day, and may eat and drink

once recovered from the anaesthetic.

5. Conclusion

Colonoscopically assisted laparoscopic polypectomies

provide an alternative and safe method of colonic poly-

pectomy for benign polyps, which are not amenable to

endoscopic resection. Laparoscopic wedge resection en-

sures complete polypectomy with margins, and avoids

formal laparoscopic colonic resection and the risk of

perforation in difficult inaccessible polyps with endo-

scopic mucosal resection. We recommend this should be

considered as a definitive procedure for benign polyps,

with no histological evidence of malignant transforma-

tion, and propose this technique as an alternative to right

hemicolectomies for benign lesions.

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