FLEXIBLE ENDOSCOPY AS AN ADJUNCT TO LAPAROSCOPIC SURGERY

LAPAROSCOPIC SURGERY

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FLEXIBLE ENDOSCOPY AS AN ADJUNCT TO LAPAROSCOPIC SURGERY Thomas A. Stellato, MD, FACS

The marriage of intraluminal endoscopy (usually flexible endoscopy) and laparoscopy has allowed a creative approach to the management of both benign and malignant gastrointestinal diseases. For convenience, this combination is called EndoLap. Combining these endoscopic modalities may provide a number of advantages, including improved localization of lesions, elimination of complementary procedures, and cost savings. Since by definition EndoLap mandates expertise, equipment, and technical support for both endoscopy and laparoscopy, the successful accomplishment of an EndoLap procedure mandates a "high tech mindset" and rethinking of problems that would usually be managed by conventional surgery alone or by multiple separate procedures of open surgery, laparoscopy, and endoscopy. The following narrative gives a description of early attempts at combining laparoscopy and intraluminal endoscopy, the present status, and some possible future applications. EARLY AlTEMPTS AT ENDOLAP

A study of the historical evolution of laparoscopy since its inception in 1901 (Fig. 1) reveals that attempts to incorporate intraluminal endoscopy with laparoscopy were made early in the development of laparoscopy.I0Two reports, both published in 1937, clearly describe the seminal efforts to produce an EndoLap procedure. John C. Ruddock authored a publication in Surgery, Gynecology, and Obstetrics which was a landmark paper.8 This report entitled "Peritoneoscopy" detailed a personal experience of 500 laparoscopic procedures over a 4-year period. It represented one of the most important publications on laparoscopy in the United States up to that time. In addition to detailing 39 From the Department of Surgery, Case Western Reserve University; and the Division of General Surgery, University Hospitals of Cleveland, Cleveland, Ohio

SURGICAL CLINICS OF NORTH AMERICA VOLUME 76 * NUMBER 3 * JUNE 1996

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Figure 1. Some of the major personalities and technologic milestones that have shaped laparoscopy from its origins in 1901. Although Georg Kelling first performed a successful laparoscopic examination in a canine in 1901 and later in human beings, the first major series in human beings is attributed to Hans Jacobaeus. (from Stellato TA: History of laparoscopic surgery. Surg Clin North Am 72:997-1002, 1992.)

laparoscopic biopsies, Ruddock describes the technique of using laparoscopy and endoluminal intubation with a special tube fitted with a light (Fig. 2). This allowed both inflation and transillumination of the stomach or colon during the laparoscopy. The description by Ruddock clearly presents the technique. "The technique for the examination of a known case of gastric malignancy is not difficult . . . The special stomach tube, fitted with an electric light at its tip, is placed in the stomach through the mouth prior to the examination. The peritoneoscope is inserted . . . The stomach is now distended with air under vision and examined while it unfolds. Good stomach wall distends, whereas infiltrated stomach wall is rigid. When the stomach has been distended with air, the globe at the tip of the tube is lighted and the stomach wall is transilluminated. The stomach appears to the observer like a 'Chinese lantern' and any infiltrations in the gastric mucosa can be outlined." Ruddock indicated that the sigmoid colon could be examined in a similar manner. In the same year as Ruddock (1937) E. T. Anderson authored a report also entitled "Peritoneoscopy," which was published in the American Journal of Surgery.' Anderson described a special gastrodiaphane, which was an instrument with an air passageway and a light for transillumination. Similar to Ruddock, he indicates that this instrument, when combined with laparoscopy, could allow study of the "transilluminated anterior wall and greater curvature (of the stomach). It could also be used to balloon and transilluminate the sigmoid. This has proved of value in the diagnosis of gastric ulcer on the anterior surface near the lesser curvature and in gastric carcinoma and has helped to decide operability or non-operability of cases." Anderson expanded the application with examination of the urinary bladder by the same technique. Although these examples by Ruddock and Anderson do not in their strictest sense fulfill the definition of EndoLap, that is, a combined intraluminal endoscopy and laparoscopy, they show an obvious similarity to EndoLap and their importance as the forerunner to this technique. MODERN ERA

EndoLap, which is only in its infancy even today, awaited the introduction of laparoscopic cholecystectomy in the late 1980s before it could develop. Al-

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Figure 2. Operability of gastric malignancy. A, Visualization of stomach, liver, and adjacent tissues and localization of malignancy. 6, Unfolding of stomach under vision with air. C, Transillumination of inflated stomach. (From Ruddock JC: Peritoneoscopy. Surg Gynecol Obstet 65:623-639, 1937; with permission of Surgery, Gynecology & Obstetrics, now known as the Journal of the American College of Surgeons.)

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though laparoscopy was firmly established by this time, its application was limited to use by gynecologists and a minority of general surgeons. The extent of therapeutic laparoscopy prior to laparoscopic cholecystectomy encompassed tuba1 ligation and appendectomy, although the latter was limited to the noninflamed appendix. Concomitant with the development of laparoscopic cholecystectomy was the introduction of video laparoscopy, which allowed the entire surgical team to view the procedure, a demand and development of instrumentation for more complex procedures, and a need to address common bile duct stones during laparoscopic cholecystectomy. All of these factors contributed to the most commonly performed EndoLap procedure-laparoscopic cholecystectomy and flexible choledochoscopy with stone extraction. This combination illustrates the demands of an EndoLap procedure-expertise in both laparoscopy and flexible endoscopy; a high level of technical equipment and support, such as multiple video monitors and mixers to produce simultaneous images; and coordination of both the laparoscopic and endoscopic procedure. As these demands have been met, a variety of other creative EndoLap procedures have followed. LOCALIZATION OF TUMORS AND LESIONS

The tattooing of colonic polyps (injection to cause staining of the tissues) has been used with open colon surgery. This application as a part of EndoLap surgery is obvious. Because digital palpation is eliminated by laparoscopy, preoperative marking at the time of colonoscopy or gastroscopy can then allow the identification during laparoscopy. Actual management would depend on the pathology present. With a benign lesion or carcinoma-in-situ, a lift and resect technique using laparoscopic staplers may allow excisional biopsy with simultaneous closure of the viscus. A modification of this technique can be simultaneous flexible endoscopy and laparoscopy. Transillumination with the endoscope allows identification of the lesion. We have used this technique to avoid formal right colectomy for benign sessile cecal polyps. A recent report has described a similar technique for local excision of a proximal rectal carcinoid tumor.4 Intraoperative colonoscopy was used for localization; laparoscopic technique then allowed mobilization of the rectum; and finally, a laparoscopic stapler permitted full-thickness excision of the rectal wall containing the carcinoid tumor. Colonoscopy also allowed evaluation of the rectal lumen to ensure that it was not compromised during the procedure. CONTROL OF UPPER GASTROINTESTINAL BLEEDING

Control of difficult upper gastrointestinal bleeding has been reported using two different EndoLap approaches. In one patient with a vascular malformation of the proximal stomach, upper endoscopy was combined with laparoscopy6 (Fig. 3). Endoscopy allowed identification of the lesion, and then transillumination allowed the laparoscopic identification of the feeding vessel. The vessel was clipped proximally and distally with laparoscopic clips. A second report describes the creative technique of transgastric insertion of the laparoscope for direct intragastric control of the bleeding site3 (Fig. 4). The lesion is initially viewed with the gastroscope and if it is posterior in location, laparoscopic cannulas are introduced directly into the stomach. This allows laparoscopic suturing and clipping of the bleeding vessel.

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Figure 3. Laparoscopic guided ligation of feeding vessel in a patient with massive hemorrhage from a Dieulafoy's ulcer. (From Mixter CG 111, Sullivan CA: Control of proximal gastric bleeding: Combined laparoscopic and endoscopic approach. J Laparoendosc Surg 2:105-109, 1992; with permission.)

GASTRIC TUMOR EXCISION

Introduction of the laparoscope directly into the stomach percutaneously has been used for excision of posterior gastric wall tumors7 (Fig. 5 ) . In two patients, the gastric lesions were identified by upper endoscopy, and then three trocars were inserted directly into the stomach percutaneously through the anterior gastric wall. The lesions were then excised using laparoscopic techniques. The authors suggest that this may be safe and feasible for the management of mucosal and submucosal gastric tumors. LAPAROSCOPIC HEPATICOGASTROSTOMY

Attempts to decompress the biliary tree when malignant obstruction encases the porta hepatis have been accomplished via laparoscopic left hepaticogastrostomy* (Fig. 6). Segment I11 bile duct is intubated using percutaneous techniques, and the guide wire is allowed to perforate the undersurface of the liver. This is then guided laparoscopically into the lesser curve of the stomach. Using intraoperative gastroscopy, the wire is withdrawn through the mouth. This allows the percutaneous endoscopic gastrostomy tube to be placed into the stomach and biliary tree in a retrograde fashion. Fibrin glue is used to seal the hepaticogastric surface.

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Figure 4. Suture ligation of bleeding gastric ulcer. A, Laparoscopic view of the bleeding ulcer located in the posterior wall of the stomach. B, Suturing of the bleeding ulcer was done under laparoscopic guidance. C, The suture was pulled outside and an Endoclip was placed, under endoscopic guidance. 0,Bleeding from the gastric ulcer ceased. (From Kitano S, Kawanaka H, Tomikawa M, et al: Bleeding from gastric ulcer halted by laparoscopic suture ligation. Surg Endosc 8:405407, 0 1994, Springer-Verlag; with permission.)

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Figure 5. Laparoscopic intragastric surgery. GF = gastrofiberscope; Th = thorax; L = liver; TC = transverse colon; TV = television monitor. (From Ohashi S: Laparoscopic intraluminal (intragastric) surgery for early gastric cancer: A new concept in laparoscopic surgery. Surg Endosc 9:169-171, 1995; with permission.)

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Figure 6. Technique of peripheral biliary diversion. A, A 0.38-gauge flexible needle is introduced through a 5-F catheter to perforate the stomach. B, Snare is then introduced through a catheter into the stomach. C,Snare is grasped by the endoscopist and pulled out through the patient’s mouth. D,Snare is bound to a 20-F percutaneous endoscopic gastrostomy tube. The radiologist then pulls the wire previously positioned across the transhepatic tract, and the gastrostomy tube is gently drawn into the stomach by the surgeon. €, Stomach and inferior surface of the left hepatic lobe are coated with fibrin glue by the surgeon. F, Anastomosis is maintained by tight traction on the tube, which is affixed to the skin to prevent bile leakage. 1 = 8.5-F catheter; 2 = 5-F catheter; 3 = 0.38-gauge flexible needle; 4 = endoscope; 5 = laparoscope; 6 = percutaneous snare; 7 = endoscopic snare; 8 = 20-F silicone percutaneous endoscopic gastrostomy tube; 9 = flexible catheter for application of fibrin glue; 10 = fibrin glue. (From Soulez G, Gagner M, Therasse E, et al: Malignant biliary obstruction: Preliminary results of palliative treatment with hepaticogastrostomy under fluoroscopic, endoscopic, and laparoscopic guidance. Radiology 192:241-246, 1994; with permission.)

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LAPAROSCOPIC BOWEL RESECTION

Attempts to perform total laparoscopic bowel resection with intracorporeal anastomosis have been hindered by the difficulty of suturing the anastomosis laparoscopically. Efforts are thus being directed to develop the endoscopic (flexible or rigid) means to deliver stapling anvils and the biofragmentable anastomosis ring intraluminally to allow a total laparoscopic bowel re~ection.~, Much of this has been performed in the laboratory, and clinical data are sparse. THE FUTURE

From the above it is obvious that creativity and ingenuity are valuable allies in expanding the growth of EndoLap. The combination of endoscopy and laparoscopy will not only allow resection, vessel ligation, and bowel and bile decompression but also may permit the introduction of agents such as chemotherapy, radiation, photodynamic therapy, and cryosurgery. With imagination guided by sound surgical principles, the combined use of laparoscopy and intraluminal endoscopy should expand the boundaries of general surgery. References 1. Anderson ET: Peritoneoscopy. Am J Surg 35:136-139, 1937 2. Gagner M, Soulez G, Deslandres E, et al: Laparoscopic left hepaticogastrostomy for malignant biliary obstruction [abstract]. Surg Endosc 8:232, 1994 3. Kitano S, Kawanaka H, Tomikawa M, et al: Bleeding from gastric ulcer halted by laparoscopic suture ligation. Surg Endosc 8:405407, 1994 4. Leach SD, Modlin IM, Goldstein L, et al: Laparoscopic local excision of a proximal rectal carcinoid. J Laparoendosc Surg 4:65-70, 1994 5. Lirici MM, Bueb G, Melzer A, et al: New technique for sigmoid colectomy. Br J Surg 80:1606-1609, 1993 6. Mixter CG 111, Sullivan CA: Control of proximal gastric bleeding: Combined laparoscopic and endoscopic approach. J Laparoendosc Surg 2:105-109, 1992 7. Ohashi S Laparoscopic intraluminal (intragastric) surgery for early gastric cancer: A new concept in laparoscopic surgery. Surg Endosc 9:169-171, 1995 8. Ruddock JC: Peritoneoscopy. Surg Gynecol Obstet 65:623-639, 1937 9. Sackier JM, Krens H, Allen JM: Totally intracorporeal laparoscopic anastomoses with the biofragmentable anastomosis ring (BAR) [abstract]. Surg Endosc 8:260, 1994 10. Stellato TA: History of laparoscopic surgery. Surg Clin North Am 72:997-1002, 1992 Address reprint requests to Thomas A. Stellato, MD, FACS Division of General Surgery University Hospitals of Cleveland 11100 Euclid Avenue Cleveland, OH 44106-5047