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Minimally Invasive Surgery

 

OVERVIEW

There are a variety of diseases and conditions of the colon and rectum for which surgery is recommended.  In addition to the decision to undergo surgery, patients are often faced with a choice of traditional or minimally invasive surgical techniques.  In order to participate fully in the decision-making process, patients need information about the following issues:

  • How is traditional “open” surgery performed?
  • What is “minimally invasive colon and rectal surgery”?
  • A description of the minimally invasive surgery techniques available
  • The benefits and risks of minimally invasive surgery
  • The types of operations and diseases for which minimally invasive surgery is appropriate
  • Individual patient factors that must be considered
  • Questions to discuss with the surgeon

Minimally invasive colon and rectal surgery is a continually changing field.  Every year brings new information based on further refinements and increasing use of these techniques.  The information and opinions in this material are based on the current state of the art in 2024.

HOW ARE TRADITIONAL OPEN COLON AND RECTAL OPERATIONS PERFORMED?

In order to perform operations inside the abdomen, surgeons must make an incision large enough to offer adequate visibility, provide access to the abdominal organs and allow the use of hand-held surgical instruments.  These incisions may be placed in different parts of the abdominal wall.  Depending on the size of the patient and the type of operation, the incision may be 6 to 12 inches in length.  There is a significant amount of discomfort associated with these incisions that can prolong the time spent in the hospital after surgery and can limit how quickly a patient can resume normal daily activities.  Because traditional techniques have long been used and taught to generations of surgeons, they are widely available and are considered the standard treatment to which newer techniques must be compared.

WHAT IS MINIMALLY INVASIVE SURGERY?

Minimally invasive procedures use advanced technologies to avoid the need for the large incisions used in traditional open surgery.  The development of these techniques has been an important advance for the benefit of patients and is useful for the treatment of many conditions.  Minimally invasive surgery can include laparoscopic surgery, robotic surgery, or even newer endoluminal surgical techniques. 
Minimally invasive surgical approaches have been developed to perform operations through smaller incisions, reducing the discomfort and healing complications associated with long incisions.  Minimally invasive surgery can be used to effectively treat a variety of common benign and malignant colon and rectal conditions. All minimally invasive techniques require advanced surgical skills and specialized equipment.  Many surgeons have had advanced training in minimally invasive surgery and can discuss the specific techniques they recommended for surgery.  All minimally invasive surgeries are performed with the patient asleep under a general anesthetic.  All the techniques listed below are considered “minimally invasive,” but may vary slightly in their overall advantages and disadvantages.   

HOW IS MINIMALLY INVASIVE SURGERY PERFORMED? 

  • Laparoscopic surgery refers to a technique where the surgeon makes several small incisions about ½” in size, instead of a single large incision.  For most colon and rectal operations, 3-5 incisions are needed.  Small tubes, called “trocars,” are placed through these incisions and into the abdomen.  Carbon dioxide gas is used to inflate the abdomen in order to give the surgeon room to work.  This allows the surgeon to use a camera attached to a thin metal telescope (called a laparoscope) to watch a magnified view of the inside the abdomen on operating room monitors.  Special instruments have been developed for the surgeon to pass through the trocars to take the place of the surgeon’s hands and traditional surgical instruments.  Surgical stapling devices to divide and reconnect intestine as well as energy devices to cut and cauterize tissues and blood vessels have also been adapted for laparoscopic use.  For most operations, one slightly larger incision (about 2-4 inches in length) must be made in order to remove tissue (sometimes called a “specimen”) from the abdomen.
  • Laparoscopic-assisted surgery is used to describe a procedure that is performed largely laparoscopically and then completed through a small abdominal incision.  Strictly speaking, many “laparoscopic” procedures are actually laparoscopic-assisted because some part of the operation may be performed through the specimen-removal incision. 
  • Hand-assisted laparoscopic surgery (HALS) refers to another variation of laparoscopic surgery in which a device is placed in a small (2-4 inch) incision that allows the surgeon to pass a hand into the abdomen to assist in performing the operation.  The surgeon still uses the laparoscope to view the operation on monitors and uses the same instruments, staplers and energy devices as in traditional laparoscopic surgery.  The specimen is removed through the device used by the surgeon to place a hand in the abdomen.  The main advantage of this procedure is that the ability to use the surgeon’s hand may be very helpful in performing the operation.  The disadvantage is that the incision required might be slightly larger than would otherwise be necessary. Studies have shown hand-assisted techniques to provide the same recovery benefits as purely laparoscopic procedures.
  • “Single incision surgery” or “single site surgery” is another minimally invasive option.  With this technique, both the laparoscopic camera and the operating instruments are passed through a single, small incision (about 2 inches in length) that can also be used to remove the specimen.  The primary advantage of this technique is less visible scarring since no additional small trocar incisions are necessary.  The disadvantage is that most surgeons find this technique more difficult than traditional laparoscopic surgery because the instruments are placed so closely together.
  • Robotic surgery or robotic-assisted surgery is a variation on minimally invasive colon and rectal surgery.  The technique is very similar to standard laparoscopic surgery in that instruments are passed into the abdomen through trocars.  Rather than manipulate the instruments manually, the surgeon sits at a console, or special computer desk, and manipulates small controllers while observing the inside of the abdomen with a 3-D monitor.  A sophisticated computer system translates the movements of the surgeon’s hands to the robot, which then moves the surgical instruments.  Robotic surgery has gained popularity in part because the robotic instruments are well suited to operating in narrow areas, such as the pelvis, where laparoscopic surgery is more difficult.  
  • Although many patients have heard the term “laser laparoscopic surgery,” this term is left over from the very early days of laparoscopic gallbladder surgery.  Lasers are not currently used in minimally invasive surgery.
  • Transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM) are two techniques that allow transanal surgical resection of polyps or lesions in the rectum. These utilize a transanal platform to allow laparoscopy or robotic surgery to be performed through the rectum, removing the need for any incisions.
  • Endoluminal surgery is a developing field that facilitates transanal surgical resection of polyps or lesions within the colon or rectum. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are advanced techniques done with colonoscopy to remove larger polyps or lesions that may otherwise have needed surgery with cuts through the abdomen. Further technology is being developed to help come up with even more ways to remove these polyps through transanal resection without abdominal incisions. 

BENEFITS OF MINIMALLY INVASIVE SURGERY

Incisions are much smaller than those used in traditional surgery. Potential benefits include: 

  • Decreased postoperative discomfort 
  • Shorter hospital stays 
  • Reduced requirement for prescription pain medications 
  • Earlier return to normal activities 
  • Less visible scarring 
It is important to note that long-term outcomes are similar between open and minimally invasive procedures. However, minimally invasive surgery offers potential benefits in the early post-surgery recovery period. 

IS MINIMALLY INVASIVE SURGERY SAFE?

Minimally invasive surgery has been well studied. The risk of complications is similar to that of traditional open surgery. Every surgical procedure, whether minimally invasive or traditional, carries some risk of complications.  Risks common to both open and minimally invasive colon and rectal surgery include bleeding, infection, post-operative bowel blockage and leakage from an intestinal anastomosis (reconnection).  Other risks, such as heart problems, pneumonia and blood clots exist with any major abdominal surgery requiring general anesthesia.  

Occasionally, a surgeon will encounter conditions during surgery that would make continuing with minimally invasive surgery unsafe.  In this situation, the incision is enlarged to allow traditional surgical techniques to be used to complete the operation.  This is referred to as a “conversion” to traditional or “open” surgery and should be considered utilization of surgical judgment rather than a complication.   

It is important to discuss your condition and surgical options with your colon and rectal surgeon. Together, you can weigh the risks and benefits of minimally invasive surgery versus traditional surgery. Minimally invasive surgery is not appropriate for all patients or conditions. 

WHEN IS MINIMALLY INVASIVE SURGERY AN OPTION?

Minimally invasive surgery can be successfully performed for a variety of common benign colon and rectal conditions including diverticulitis, colon polyps, inflammatory bowel diseases (Crohn’s Disease and Ulcerative Colitis,) and rectal prolapse.  It can be used to remove the entire colon and rectum or just a portion, or segment, of the colon. Multiple studies have shown when properly performed, minimally invasive surgery is an effective option for colon and rectal cancer. Minimally invasive surgery is suitable for colon and rectal cancer in the hands of well-trained surgeons following accepted cancer surgery principles. Minimally invasive techniques can be used to create an ostomy (surgically created opening between an internal organ and the body surface). They may be either a colostomy (connecting a part of the colon to the skin of the abdominal wall) or an ileostomy (connecting the last part of the small intestine, or ileum, to the skin of the abdominal wall). Also, minimally invasive techniques can be used to reconnect the intestine from a temporary ostomy.  Complex reconstructive surgeries, such as ileal pouch creation can be performed in a minimally invasive fashion.  There are very few traditional abdominal colon and rectal procedures that cannot be performed in a minimally invasive manner.
 
The following factors help determine if a minimally invasive procedure can be performed safely and effectively. 
  • Prior surgical history
  • Medical history
  • Characteristics of the disease (such as inflammation, tumor size). 

QUESTIONS FOR YOUR SURGEON:

  • Does minimally invasive surgery offer me any benefit? 
  • Am I an appropriate patient for minimally invasive surgery? 
  • Which minimally invasive technique(s) are you most comfortable with and why? 
  • What is the chance that you will have to convert to traditional surgery and what will happen if you do? 
  • What can I expect after surgery in terms of hospital stay, restrictions on my activities, help required at home and return to work? 
  • What options do I have for anesthesia with an operative procedure? 
  • How do you plan to address my pain after surgery? 
  • What will happen if I don’t want any treatment? 


WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.
 

DISCLAIMER

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention and management of disorders and diseases of the colon, rectum and anus. These brochures are inclusive but not prescriptive. Their purpose is to provide information on diseases and processes, rather than dictate a specific form of treatment. They are intended for the use of all practitioners, health care workers and patients who desire information about the management of the conditions addressed. It should be recognized that these brochures should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. 


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