Ulf Kressner Kolorektalsektionen Kirurgkliniken Södersjukhuset

En presentation över ämnet: "Ulf Kressner Kolorektalsektionen Kirurgkliniken Södersjukhuset"— Presentationens avskrift:

1 Laparoskopi vid akut och elektiv tarmkirurgi Kirubdagarna i Södertälje maj 2014
Ulf Kressner Kolorektalsektionen Kirurgkliniken Södersjukhuset Stockholm

2 LAPAROSKOPISK KOLOREKTAL KIRURGI
I SVERIGE 2010–2012

3 Lap kolonresektion för cancer
andel lap konv (%) (%) ,0 17 ,0 21 ,2 19

4 Sverige kolon %

5 Lap kolon regioner 2012 Södra 4% (19/517) 26%
Andel Konv. Södra % (19/517) 26% Sydöstra % (37/333) 19% Västra % (62/524) 24% Stockholm/Gotland 23% (109/479) 19% Uppsala/Örebro 18% (99/563) 14% Norra % (0/246) -

6 2012

7 >30% lap kolon 2012 Torsby 90% (9/10) Hudiksvall 57% (12/21)
Lindesberg 55% (6/11) Danderyd 53% (50/95) Ersta 46% (41/89) Örebro 33% (21/63) Skövde 31% (19/61) Uppsala 30% (19/64)

8 Lap rektumresektion för cancer
andel lap konv (%) (%) ,5 17 ,9 22 ,4 19

9 Sverige rektum %

10 Lap rektum regioner 2012 Södra 3% (7/255) 29%
andel konv Södra 3% (7/255) % Sydöstra % (25/150) 28% Västra % (73/278) 16% Stockholm/Gotland 12% (30/250) 13% Uppsala/Örebro 7% (22/313) 23% Norra % (0/128) -

11 >30% lap rektum 2012 Trollhättan(NÄL) 75% (36/48)
Skövde 58% (19/33) Örebro 42% (20/48) Danderyd 35% (13/37) Linköping 32% (15/47)

12 Sammanfattning Andelen lap kolon & rektum är låg men ökar
Skillnader mellan regionerna Acceptabel konverteringsfrekvens

13 Sammanfattning Andelen lap kolon & rektum är låg men ökar
Skillnader mellan regionerna Acceptabel konverteringsfrekvens

14 Laparoskopi vid akut tarmkirurgi
Appendicit Cholecystit Perforerat ulcus Adherensileus

15 Laparoskopi vid akut tarmkirurgi
1/3 av akut kirurgi kolorektal kirurgi Akut divertikulit – lavage + drän Komplikationer till elektiv kirurgi Akut IBD kirurgi Myers et al, BJS 2008 Kirsthein et al, JGS 2008

16 Systematic review of emergency laparoscopic colorectal resection
Flow chart of studies retrieved from literature search IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. British Journal of Surgery Volume 101, Issue 1, pages e126-e133, 28 NOV 2013

17 Systematic review of emergency laparoscopic colorectal resection
11 case series 11 comparative studies comparing emergency LS versus OS. No randomized clinical trials were identified. All comparative series were retrospective case-matched series, with matching based on age and sex. Flow chart of studies retrieved from literature search IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. British Journal of Surgery Volume 101, Issue 1, pages e126-e133, 28 NOV 2013

18 Systematic review of emergency laparoscopic colorectal resection
Eligibility criteria outcomes of laparoscopic colorectal resections in the acute or emergency setting in adults. Exclusion laparoscopic management of acute small bowel obstruction laparoscopy and peritoneal lavage alone for colorectal pathology diagnostic laparoscopy Flow chart of studies retrieved from literature search IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. British Journal of Surgery Volume 101, Issue 1, pages e126-e133, 28 NOV 2013

19 Systematic review of emergency laparoscopic colorectal resection
5557 pt 932 laparoscopic 4625 open Flow chart of studies retrieved from literature search IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. British Journal of Surgery Volume 101, Issue 1, pages e126-e133, 28 NOV 2013

20 Systematic review of emergency laparoscopic colorectal resection
Diagnoser Divertikulit UC Crohn Kolorektal cancer Sigmoideum Volvulus Flow chart of studies retrieved from literature search IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. British Journal of Surgery Volume 101, Issue 1, pages e126-e133, 28 NOV 2013

21 Systematic review of emergency laparoscopic colorectal resection
Results LS OS Op time(min) (63–444) (61–231) Length of stay 10 (3–23) (6–33) Coversion (%) 3(0-13) Complication rate(%) Flow chart of studies retrieved from literature search IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.

22 Systematic review of emergency laparoscopic colorectal resection
Conclusion Emergency laparoscopic colorectal resection, where technically feasible, has better short-term outcomes than open resection. Flow chart of studies retrieved from literature search IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. British Journal of Surgery Volme 101, Issue 1, pages e126-e133, 28 NOV 2013

23 Laparoskopisk kolorektal kirurgi
How to start the operation 7 april 2017

24 Laparoscopic surgery for colon and rectal cancer - current evidence
COLOR I and II Colon and rectal cancer EUROPE CLASICC Colon and rectal cancer UK COST Colon cancer USA Cohrane 2005, 2008

25 Laparoskopisk kolorektal kirurgi
Snabbare normalisering av tarmfunktion Snabbare återhämtning Mindre analgetikabehov Kortare vårdtid Flow chart of studies retrieved from literature search IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.

26 Anatomiska landmärken vid dissektion av vänster kolon
Inferior mesenteric vein – IMV Inferior mesenteric artery - IMA Vänster uretär Eagle sign

27 Medial to lateral view in left-sided resections
15-25 Trendelenburg 5-10 right tilt Trocars: Optical Operating Retractors 2nd ass, camera Monitor First assistant Surgeon Team setup Nurse Monitor

28

29 Hur man på ett bra sätt kommer igång….
Tippa patienten samt rotera vänster sida upp För omentet uppåt Lyft tunntarmen med försiktighet Lyft upp sigmoideum uppåt - lateralt Ev sut uterus och kolon mot bukväggen

30 Laparoskopisk teknik – vä kolon mobilisering
7 april 2017

31 Hur man på ett bra sätt kommer igång….(2)
Inscidera peritoneum alldeles vid promontorium Dissekera nära kärlet Obs! nerverna vid promontorium Dissekera mellan fascieplanen Visualisera vänster uretär

32 Eagle sign

33 Medial to lateral view in right-sided resections
Trocars: Optical Operating Retractors Monitor Surgeon 2nd ass, camera Nurse Monitor

34

35 Vascular anatomy right hemicolectomy
Ileocolic artery - constant vessel Right colic artery - rare! 13% Middle colic artery - complex system of different vessels

36

37 Exposure The assistent pull on caecum
Incise peritoneal sheet just under the ileocolic artery Dissect close to the artery Be aware of the duodenum and the pancreatic head

38 7 april 2017

39 7 april 2017

40 Sammanfattning Standardisering av stegen
Medial till lateral dissektion Starta med enkla fall – selektera noggrannt Konvertera tidigt!

41 Tack! Ulf Kressner Kolorektalsektionen Kirurgkliniken Södersjukhuset
Stockholm