الفهرس 
The Surgical Anatomy of the ColonOnly 14 pages are availabe for public view
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Abstract
Since the development of laparoscopic surgery for the management of colorectal diseases in the beginning of 1990s, where the first planned laparoscopic colon operation were performed by Fowler, Franklin and Jacobs in 1990, there is a greet argument between the surgeons about the indications, contraindications, advantages, disadvantages and complications of that technique in applications for the management of colorectal diseases instead conventional surgery.
On reviewing various studies about the application of the laparoscopic surgery for the management of colorectal diseases and obstacles which delay wide spread of that technique, it was demonstrated that the laparoscopic approach can be safely and effectively applied to a wide range of operations.
The introduction of the minimally invasive approach is one the most important advances in modern surgery. Global benefits to patients include; decreased post operative pain, short hospital stays and earlier resumption to normal activities. This approach has applied to colorectal surgery and the same advantages have been demonstrated.
Laparoscopic colorectal surgery is more demanding than open colonic surgery and high-lights the difficulties common to all laparoscopic surgery. The laparoscopic surgeon must view the operative field on a distant video monitor leading to a change in the normal hand –eye-target axis.
In addition, this image is two dimensional with the resultant loss of stereoscopic depth perception, requiring the surgeon to learn new compensatory strategies.
These changes in operative view are compounded by the camera being held by an assistant and not under the direct control the primary surgeon. With the extended operative times of laparoscopic colorectal surgery, fatigue may cause the assistant to present the surgeon with a wandering image.
Standard laparoscopic surgery requires the use of long rigid instrumentation which leads to a substantial reduction in the dexterity.
Additionally the surgeon’s movements are reversed by the fulcrum effect of the abdominal wall. The most important effect on the dexterity is the loss degrees of freedom with standard laparoscopic instruments limited to four while there are seven degrees of freedom available to the surgeon during open surgery. This makes tasks such as ligation and suturing which are routine in open colectomy, relatively complex in laparoscopic surgery and almost impossible unless performed in the most optimal part of the operative field.
All of these factors lead to laparoscopic colorectal surgery having a substantial learning curve, which has meant that despite many surgeons have attempted this technique few have incorporated it as a part of their regular practice.
Some of the inherent technical difficulties with standard laparoscopic surgery may be alleviated by the use of robots designed for minimally invasive surgery. Although, referred to as ‘robots’ these machines do not perform pre-program asks automatically as the name might suggest, but under the control of the surgeon.
This study focuses on advanced laparoscopic colorectal surgery and its new recent trends of minimally invasive techniques.
The shortening of the hospitalization period has led to increasing use of out-patient laparoscopic and endoscopic surgery, clinical research has also focused on the topic of expanding the indications for laparoscopic and other minimally invasive approaches in the elderly and in high risk patients, to take the advantage of the little pulmonary complications, the shorter hospital stays and reduced surgical trauma that are possible.
A considerable amount of basic research has been carried out on the stress response during and after such laparoscopic and minimally invasive procedures and an improved immune response with such approach has been observed, leading to better results after extensive oncological procedures.
Robotic surgery and tele surgery involve new computer-aided methods that allow greater precision in surgical technique, as well as providing an opportunity to improve surgical skill and expertise remotely, over long distances.
Laparoscopic and minimally invasive surgical techniques are thus now fully established in routine use and the indications continuing to extend.
Intestinal surgery is a challenge; it requires dissection in multiple parts of the abdomen, isolation and ligation of major vessels, division of colonic attachments, identification and preservation of critical retroperitoneal structures, intestinal division and reconstruction of bowel continuity.
The indications for the laparoscopic approach to colon surgery are broad, ranging from inflammatory to malignant diseases. Laparoscopic colorectal surgery is now being performed routinely for benign lesions such as inflammatory bowel disease, rectal prolapse, ulcerative colitis and diverticular disease.
Cancer operations can be performed just as in open surgery, however in the setting of cancer colon there has been more caution in using these newer surgical techniques. The extent of lymph node dissection, concerns over the adequacy of tumour resection, tumour spillage is dependent on the skill of the operator and his determination to widely resect the mesentery. Inflammatory lesions also can be excised, but active inflammation and induration in the mesentery increase the possibility of conversion.
The most important benefit of the laparoscopic approach to colon surgery was the decrease in post- operative ileus. Most of studies of open bowel surgery demonstrated the inability to pass flatus or to tolerate oral fluids for 4 to 5 days after surgery. On reviewing the results of the studies high percentage of patients undergoing laparoscopic approach was taking oral fluids at the first post-operative day, this benefit may be due to: less manipulations of the bowel, preservation of intraperitoneal humidity temperature, less stress hormonal response to surgery and less post-operative administration of narcotics. The early return of bowel function is one of the greatest benefits of the laparoscopic approach and is responsible for the early hospital discharge of this group of patients. Other advantages include; less pain, lower narcotic requirements, a shorter duration of disability and much better cosmetic result. The surgery is less disruptive and more accurate.
Because there is less incisional pain, there are fewer post-operative pulmonary problems, also; in laparoscopic approach there is less chance for abdominal adhesions to form due to little intra-operative manipulations in comparison to open surgery of the colon, however; this benefit is under reported.
Do these benefits offset the potential complication rate, the major disadvantage of laparoscopic approach which is increased operative time and the increased technical difficulty of the laparoscopic approach? This question can not be answered until a great number of procedures are performed and performed by a large number of surgeons so the true complication rate is known. A recent reports notes that the operative time decreases significantly, the greater the number of procedures performed by the operating surgeon.
Unless there are specific contraindications most patients can be considered candidates for a laparoscopic approach. Apart from perforating and obstructing carcinoma, there are no uniformly accepted specific contraindications. The laparoscopic approach is intolerant of cases that are difficult due to extensive adhesions, obesity or bulky or fixed tumours. There is increased tendency for conversion in these patients.
Inability to identify the ureters, doubtful resectability and equipment failure are other reasons consider conversion.
Several studies have confirmed the inverse relation between experience and complication rates, with a decline in the percentage of complications.
Laparoscopy for colorectal cancer has shown to be superior to laparotomy in regard to short term benefits including pain, length of ileus, length of hospitalization, cosmesis, morbidity and disability when performed by an appropriately skilled surgeon in properly selected patients, these short- term benefits are almost always demonstrated. Recent studies demonstrated that laparoscopic colectomy and open colectomy have similar long-term outcomes.