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

LAPAROSKOPISK KOLOREKTAL KIRURGI I SVERIGE 2010–2012

Lap kolonresektion för cancer andel lap konv (%) (%) 2010 6,0 17 2011 9,0 21 2012 12,2 19

Sverige kolon 2010-2012 %

Lap kolon regioner 2012 Södra 4% (19/517) 26% Andel Konv. Södra 4% (19/517) 26% Sydöstra 11% (37/333) 19% Västra 12% (62/524) 24% Stockholm/Gotland 23% (109/479) 19% Uppsala/Örebro 18% (99/563) 14% Norra 0% (0/246) -

2012

>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)

Lap rektumresektion för cancer andel lap konv (%) (%) 2010 5,5 17 2011 7,9 22 2012 11,4 19

Sverige rektum 2010-2012 %

Lap rektum regioner 2012 Södra 3% (7/255) 29% andel konv Södra 3% (7/255) 29% Sydöstra 17% (25/150) 28% Västra 26% (73/278) 16% Stockholm/Gotland 12% (30/250) 13% Uppsala/Örebro 7% (22/313) 23% Norra 0% (0/128) -

>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)

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

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

Laparoskopi vid akut tarmkirurgi Appendicit Cholecystit Perforerat ulcus Adherensileus

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

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 PERMISSIONS@WILEY.COM 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

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 PERMISSIONS@WILEY.COM 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

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 PERMISSIONS@WILEY.COM 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

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 PERMISSIONS@WILEY.COM 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

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 PERMISSIONS@WILEY.COM 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

Systematic review of emergency laparoscopic colorectal resection Results LS OS Op time(min) 184 (63–444) 148 (61–231) Length of stay 10 (3–23) 15 (6–33) Coversion (%) 3(0-13) Complication rate(%) 29 48 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 PERMISSIONS@WILEY.COM 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.

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 PERMISSIONS@WILEY.COM 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

Laparoskopisk kolorektal kirurgi How to start the operation 7 april 2017

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

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 PERMISSIONS@WILEY.COM 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.

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

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

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

Laparoskopisk teknik – vä kolon mobilisering 7 april 2017

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

Eagle sign

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

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

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

7 april 2017

7 april 2017

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

Tack! Ulf Kressner Kolorektalsektionen Kirurgkliniken Södersjukhuset Stockholm