Intracorporeal anastomosis versus extracorporeal anastomosis for minimally invasive colectomy

Abstract

Outcomes advantages for the minimally invasive approach to colon and rectal surgery have been clearly described since the original report of a laparoscopic colectomy in 1991. Advancements in minimally invasive options for colon and rectal surgery have produced the need for critical evaluation of alternative and evolving techniques. The evolution and increased adoption of the minimally invasive robotic platform has allowed the intracorporeal anastomosis, previously described with the laparoscopic approach, to be more widely available to surgeon skill sets because of robotic articulating instruments and ergonomic advantages. Studies comparing intra- and extracorporeal techniques for laparoscopic right colectomy have demonstrated some outcomes advantages for the intracorporeal approach that include fewer conversions-to-open, fewer postoperative complications, and shorter hospital length of stay. Recent robotic-assisted comparisons have also shown an intracorporeal advantage and have extended the analysis to left-sided colorectal resections. Further upgrades in minimally invasive options and techniques warrant further evidence-based considerations for surgeons choosing between these options and techniques.

Keywords: Colectomy; anastomosis, surgical; laparoscopy; robotics.

Figure 1

Intracorporeal anastomosis for right hemicolectomy. The ileum and colon are aligned with a seromuscular stitch and retracted toward the right side of the abdomen (upper left). A colotomy and enterotomy are then made and the linear cutter stapler is placed (upper middle) and fired, creating the anastomosis (upper right). The common enterotomy (lower left) is then closed with suture in two layers (lower middle and right).

Figure 2

Intracorporeal anastomosis for left hemicolectomy. The rectum is divided using a linear cutter stapler (upper left). The anvil is then passed into the abdomen through the extraction site incision (upper middle). A 3–4 cm colotomy is made distal and a 6 mm colotomy is made proximal to the proposed point of transection (upper right). The anvil is passed through the long colotomy and the anvil shaft routed through the small colotomy (lower left). The colon is divided at the proposed transection site (lower middle). The circular stapler is passed per anum and coupled with the anvil to create a side-of-colon to end-of-rectum anastomosis (lower right).