key: cord-1007567-ub4okzu8 authors: Serra‐Aracil, Xavier; Mora‐Lopez, Laura; Gomez‐Torres, Irene; Pallisera‐Lloveras, Anna; Serra‐Pla, Sheila; Serracant, Anna; Garcia‐Nalda, Albert; Pino‐Perez, Oriol; Navarro‐Soto, Salvador title: Minimal invasive surgery for left colectomy adapted to the COVID‐19 pandemic: laparoscopic intracorporeal resection and anastomosis, a ‘don’t touch the bowel’ technique date: 2021-02-22 journal: Colorectal Dis DOI: 10.1111/codi.15562 sha: 0bdb3cea6be53f989bec2d6b48bcdc7b624f43bb doc_id: 1007567 cord_uid: ub4okzu8 AIM: The COVID‐19 pandemic has forced surgeons to adapt their standard procedures. The modifications introduced are designed to favour minimally invasive surgery. The positive results obtained with intracorporeal resection and anastomosis in the right colon and rectum prompt us to adapt these procedures to the left colon. We describe a ‘don't touch the bowel’ technique and outline the benefits to patients of the use of less surgically aggressive techniques and also to surgeons in terms of the lower emission of aerosols that might transmit the COVID‐19 infection. METHODS: This was an observational study of intracorporeal resection and anastomosis in left colectomy. We describe the technical details of intracorporeal resection, end‐to‐end stapled anastomosis and extraction of the specimen through mini‐laparotomy in the ideal location. RESULTS: We present preliminary results of 17 patients with left‐sided colonic pathologies, 15 neoplasia and two diverticular disease, who underwent four left hemicolectomies, six sigmoidectomies and seven high anterior resections. Median operating time was 186 min (range 120–280). No patient required conversion to extracorporeal laparoscopy or open surgery. Median hospital stay was 4.7 days (range 3–12 days). There was one case of anastomotic leak managed with conservative treatment. CONCLUSION: Intracorporeal resection and end‐to‐end anastomosis with the possibility of extraction of the specimen by a mini‐laparotomy in the ideal location may present benefits and also adapts well to the conditions imposed by the COVID‐19 pandemic. Future comparative studies are needed to demonstrate these benefits with respect to extracorporeal anastomosis. The SARS-CoV-2 virus (COVID-19) pandemic in 2020 has forced surgeons to adapt and modify many of their procedures. Although there is no clear consensus at present regarding the measures to adopt, a variety of modifications have been suggested in order to prevent the generation of aerosols and subsequent exposure. Among the measures proposed are the use of minimally invasive approaches such as laparoscopy, central negative pressure systems, smoke filters in cannulas, and balloon trocars, as well as minimizing the size of surgical incisions [1] [2] [3] . One of these recommendations is the performance of laparoscopic procedures [4] with minimal evacuation of gas and exteriorization of the specimen, and intracorporeal intestinal anastomoses. Given the evidence of the benefits of intracorporeal resection and anastomosis in right hemicolectomy [5, 6] , and in view of our experience and that of other authors in transanal rectal and left colon surgery [7] [8] [9] , we propose to adapt these procedures The local Institutional Ethics Committee approved the use of the intracorporeal technique for the treatment of tumours and diverticular disease of the left colon, sigmoid and upper third of the rectum (LIEC 2020/679). Informed consent was obtained from the patients after an explanation of the risks and benefits of the procedure. Surgery was performed by our team of colorectal surgeons. Once the trocars are placed and pneumoperitoneum is created, tie of the inferior mesenteric vessels is performed and the splenic flexure is mobilized as necessary. The distal section is performed using an ECHELON FLEX™ ENDOPATH® stapler, 1.5 mm staple height and 60 mm blue reload. Intracorporeal resection (Video S1) Over the proximal mesocolon, the origin of the inferior mesenteric vessels is taken as a reference, and the mesocolon is marked and sectioned intracorporeally ( Figure 1A ). Next, we mark the area where the proximal section of the colon will be performed ( Figure 1B ). Preparation of the anvil of the circular stapled suture and its insertion in the proximal colon (Video S1) A 29 mm curved circular stapler (B. Braun, Melsungen, Germany) is used. The anvil-tip is mounted together with the anvil-head. On this device a 0 Prolene® monofilament suture is performed, with multiple knots to aid its manipulation (Figure 2A ), of about 7-10 cm in length so that it can be pulled through the staple line of the section of the colon. In order to introduce the anvil and to remove the specimen afterwards, a mini transverse laparotomy 3.5-4 cm long is performed in the better site of the abdomen, preferably a mini Pfannenstiel, although in obese patients in the left upper quadrant. To introduce the anvil in the proximal colon (Video S2), a colotomy is performed some 2-3 cm distal to the colon section mark. Seventeen patients underwent intracorporeal surgery of the left colon. The results for the demographic and preoperative variables of the patients are presented in Table 1 . The pathology location was splenic flexure (one), left colon (two), sigmoid (nine) and the rectosigmoid junction/upper rectum (five). Table 2 As for the pathological variables among the tumours, there was one gastrointestinal stromal tumour and the rest were adenocarcinoma (14) . With regard to 30-day postoperative morbidity, there was only one complication due to anastomotic leak which settled with conservative management (Table 3) Intracorporeal resection of the specimen and stapled colorectal anastomosis without the need for its extraction, a 'don't touch the bowel' technique, offers multiple advantages. These benefits include the avoidance of excessive manipulation, less bleeding, and reduction of the tension of the mesocolon caused by its exteriorization. We believe that these manoeuvres avoid the traction of the colon, which may compromise the blood supply to the segment of the staple line anastomosis, and can help to reduce the rate of anastomotic leaks due to ischaemia. In the case of obese patients with a short mesocolon, the manoeuvres of exteriorization of the colon may be difficult and may damage the remaining colon; therefore, intracorporeal techniques represent a major improvement. Circular stapled end-to-end colorectal anastomoses in the left colon appear to be the safest; the rate of anastomotic leak is around 7.5% [10] . The end-to-end anastomosis that we describe avoids the suture line and is similar to the standard colo-colonic or colorectal anastomosis that we habitually perform; it does not require an extra length of colon, and mobilization of the splenic flexure is avoided. An intracorporeal anastomosis in left colonic laparoscopic resections has already been described in an emergency colorectal surgery setting. In pre-COVID times this could easily be done via Pfannenstiel and extracorporeal insertion of the anvil, but with the currently described technique the anvil is inserted intracorporeally with its benefits [11, 12] [15] , and from the oncological point of view the resection is performed in the same way as in standard laparoscopic surgery. In all the patients included in the study, more than 12 lymph nodes were resected [16] . The new situation caused by the COVID-19 pandemic has obliged us to modify our approach to left colon surgery. Intracorporeal resection and end-to-end anastomosis with the possibility of extraction of the specimen by a mini-laparotomy in the ideal location may present benefits and also adapts well to the conditions imposed by the COVID-19 pandemic. Also, adequate precautions must be adopted, using ultrafiltration (smoke evacuators and/or filters) during the procedure and monitoring smoke/ gas evacuation and final exsufflation. Trocar incisions should be minimized, using trocars with balloon to avoid gas leakage around ports [17] . Future comparative studies are needed to demonstrate these benefits with respect to extracorporeal anastomosis. The study has been approved by the local ethics committee of our centre (CEIC 2020/679). All patients included in the study have been informed of the surgical technique used as well as its risks and possible complications. They signed a specific informed consent for the surgery performed. We thank all the members of the Coloproctology English. The authors have no conflicts of interest to declare. XSA, LML, IGT wrote and edited the paper. All authors (XSA, LML, IGT, APL, SSP, AS, AGN, OPP, SNS) have reviewed the paper, revising it critically for intellectual content. Each author has participated sufficiently in the work of reviewing and approving the study as written.. Xavier Serra-Aracil https://orcid.org/0000-0003-0291-1900 Anna Pallisera-Lloveras https://orcid.org/0000-0001-6572-7356 Albert Garcia-Nalda https://orcid.org/0000-0003-4060-8216 SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic What is the appropriate use of laparoscopy over open procedures in the current COVID-19 climate? COVID-19: impact on colorectal surgery International guidelines and recommendations for surgery during COVID-19 pandemic: a systematic review Does laparoscopic intracorporeal ileo-colic anastomosis decrease surgical site infection rate? A propensity scorematched cohort study Randomized clinical trial of intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy (IEA trial) Hybrid-NOTES: TEO for transanal total mesorectal excision. Intracorporeal resection and anastomosis Laparoscopic resection with intracorporeal anastomosis for colon carcinoma located in the splenic flexure Totally laparoscopic sigmoid colectomy: a simple and safe technique for intracorporeal anastomosis Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit Intracorporeal anastomoses in emergency laparoscopic colorectal surgery from a series of 59 cases: where and how to do it-a technical note and video Laparoscopic management of acute, severe colon ischaemia: demanding emergency extended left hemicolectomy with completely intracorporeal anastomosis-a video vignette Should completely intracorporeal anastomosis be considered in obese patients who undergo laparoscopic colectomy for benign or malignant disease of the colon? Laparoscopic colectomy performed using a completely intracorporeal technique is associated with similar outcome in obese and thin patients Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial National Comprehensive Cancer Network. Colon Cancer. Clinical Practice Guidelines in Oncology: National Comprehensive. Cancer Network How to manage smoke evacuation and filter pneumoperitoneum during laparoscopy to minimize potential viral spread: different methods from SoMe-a video vignette Minimal invasive surgery for left colectomy adapted to the COVID-19 pandemic: laparoscopic intracorporeal resection and anastomosis, a 'don't touch the bowel' technique