Treatments offered: Minimally Invasive Surgery: Colon Cancer Surgery Rectal Cancer Surgery Anal sphincter preservation, Transanal

excision of polyps and cancers Proctectomy, coloanal anastomosis, colonic J pouch Restorative procotocolectomy (ileal pouch anal anastomosis) Anorectal treatments Hemorrhoids: Sclerotherapy /rubber band ligation, hemorrhoidectomy Fistulas/Abscesses: Seton, Fistulotomy/ectomy, Endorectal advancement flaps for rectal fistulas Fissure: Topical therapy, Sphincterotomy Prolapse/Intussusception: Transabdominal mesh rectopexy, Sigmoidectomy and sutured rectopexy Incontinence: Anal sphincteroplasty for anal sphincter disruption Gracilis Muscle Flap

Minimally Invasive Surgery Minimally Invasive Surgery (MIS): not just small incisions but a true revolution in the management of patients through surgical interventions. The introduction of laparoscopic cholecystectomy in the late 1980s has become a new landmark in the history of surgery. Since then, we have embarked in the quest for techniques and materials to carry out all forms of surgery through smaller and smaller incisions. MIS is performed with long instruments and video cameras placed through small port sites in different parts of the body. This can be accomplished by direct manipulation of the instruments and the camera by the surgeon or even remotely through robotic arms directed from a console within the operating room. In 10 years MIS not only has changed techniques quite radically but also has made surgery much safer. Safety has been accomplished by better exposure through perfected optics, better hemostasis through various techniques and a high degree of versatility in the possible tactics to be applied to handle the variants often encountered at surgery. One early objection to MIS has been the potential of making surgery riskier by lengthening the operating time. Long before MIS the risk of surgery was significantly reduced by improved anesthesia techniques. The safety of anesthesia reached a point where there was no longer a need to hurry through an operation. In fact, nowadays, the morbidity of an operation can potentially increase if hurrying results in increased blood loss. As independent variables, blood loss is a much stronger predictor of postoperative complications than operating time. Furthermore, blood loss usually extends the operating

time and this defeats the purpose of hurrying in the first place. As long as blood loss is kept to a minimum lengthening of an operation does not add risk to the patient. On the other hand the field magnification used in MIS has lowered the threshold for tolerance of bleeding. As small a bleeding source may seem it is always controlled before it can interfere with proper visualization of the field. Consequently, blood loss has been significantly reduced for every MIS procedure in comparison to the open counterpart. Along with smaller incisions we have observed patients recover much faster and with much less pain. In doing so, we also realized that other interventions we did around surgery were as invasive, and painful, as the incision itself. Tubes places in the bladder (Foley catheters) and stomach (nasogastric or NGT) have been used routinely in most forms of surgery. Nowadays, they are used very selectively, placed only after the patient is under anesthesia and often removed before the anesthesia is reversed. With the reduced blood loss there is less of a need for blood transfusion and blood work to monitor red cell counts. Less incisional pain results in less need for narcotic analgesics which in turn allows for earlier mobilization of the patient and earlier return to full function of all body systems: respiratory, urinary, musculoskeletal and, in particular, gastrointestinal; thus eliminating the need for multiple tubes in the postoperative period, such as urinary catheters (Foley), nasogastric (NGT), drains (Jackson-Pratt and alike). In the pre-MIS era the anxiety of the surgeon waiting for the return of bowel function often led to obtaining imaging and laboratory studies which added more invasiveness and risk to the patient. The post-MIS area is also anxiety-producing for the nurses and surgeons caring for the patient: we have lost some indicators for monitoring possible, albeit unlikely, complications during recovery: hourly urinary output (measured through a urinary catheter), nasogastric output, and various measurements in blood. We are also breaking some dogmas: patients go home before consuming a solid meal or having a bowel movement after bowel surgery. MIS has lead to a reduction in the length of stay in the hospital and of the length of recovery at home. We are still informing patients that there is always the possibility of having to resort to the traditional open approach and that by doing so the hospital stay and recovery time can be extended. A very interesting observation we are now making is that when MIS is not feasible, or is not even tried at all, and the patient receives the same minimalist postoperative management the hospital stay and recovery time is similar to that of patients undergoing MIS. Therefore, incision and postoperative management can independently reduce length of stay and recovery time if applied under the minimalist concept. One dilemma for patients after MIS is the return to work. Those who work independently are happy to be back in a week or less. Some of those who are entitled to medical leave are disappointed when they realize that they cannot take as much time off as some workers who had surgery for the same disease through the conventional, open method. The minimalism in incision, and invasiveness before and after surgery, should not be misinterpreted as a minimization of the risks of surgery. Under elective circumstances, modern diagnostics allow us to detect, and correct, many disturbances of

the functioning of vital organs prior to surgery, thus reducing risk. We can optimize heart function through medications and even interventions on the coronary arteries. In most cases, we can also ensure that lungs and kidneys are able to sustain the stress of surgery. However, there is a limit to the sensitivity of these diagnostic modalities and to the efficacy of all these preoperative interventions, especially when we are performing surgery in patients who are reaching unprecedented ages for surgery. In addition, there are many factors that are still out of our control as surgeons: we can make a plan based on experience and all the studies on a particular patient and find during surgery that such plan is not executable. For instance there are many variants in the anatomy of blood vessels; an operation, which is ordinarily very safe in the typical configuration of blood vessels. Due to anatomic variations, unexpected or additional findings, or incidents that occur with surgery (unusual bleeding, spillage of infectious material), the scope of surgery may escalate beyond MIS. While patients have always being informed about these possibilities it seems that in this MIS era it comes as a surprise when surgery has been extended due to intraoperative findings or occurrences. Recent studies have given the green light for surgeons to apply MIS for cancer surgery in the abdomen and chest. Earlier studies had raised concerns about the completeness of cancer surgery through small incisions and the risk of implanting tumor cells in the incision through which the specimen is extracted. Neither one of these concerns has proven valid; in fact preliminary data is showing better outcome in patients with cancer who undergo MIS versus traditional open approach. Scientists are now trying to explain this opposite and beneficial effect of MIS on cancer surgery. One possible explanation is that proportional to the invasiveness of the surgery there is a immunosuppressive response by the body, as if all the immune system is devoted to healing and establishing a barrier against infection losing its natural ability for cancer surveillance. One problem we still struggle with when using MIS is the loss of tactile function. This has heightened the need for gathering as much information as possible before surgery. Imaging studies, such as CT scan and MRI, can give us precision in location and characteristics of the problem. Endoscopies with tattooing of the lesion are essential in the gastrointestinal tract. One solution already in the works is bringing to the operating room with imaging and endoscopic equipment to further minimize the invasiveness to the patient by doing this assessment in the same setting where surgery is to be done. Another solution currently applied for bowel surgery is the ability to introduce a hand in the abdomen while maintaining the incision sealed from gas leakage. In the case of bowel surgery this has come as solution to various problems: in addition to affording tactile function it allows extracting bulky specimens while protecting the incision from implantation of cancer cells. Early on, MIS brought about a great interest in Ambulatory Surgery Centers. Many procedures that before MIS required hospitalization could be done at these centers without getting the patient admitted to the hospital. As MIS expands into greater applications, the utilization of resources becomes very intense during surgery and in preparing the patient to go home. Some of the newer applications of MIS only afford a small margin for error; if the MIS approach is aborted then the magnitude of the surgery

exceeds the capability of any ambulatory surgery center. The recovery at home from these advanced MIS procedures also requires hospital resources brought to the home. Colon Cancer Surgery Over the past two decades surveillance colonoscopy has given surgeons the possibility of curing most patients with colon cancer, since the majority of patients are now diagnosed at very early stages of this disease. In addition, modern forms of chemotherapy significantly prolong the life and minimize the symptoms of even the most advanced forms of colon cancer. Surgery remains the mainstay of treatment not only because it is the only way of effectively removing the tumor but also because it permits staging of the disease by sampling of the lymph nodes around the colon. This is the reason why the standard operations are done including a margin of colon and blood vessels extending beyond the tumor itself. Based on the anatomy of the colon we divided it in three major segments: the right colon, the transverse colon and the left colon. The right side of the colon extends from the cecum in the right lower quadrant of the abdomen to the hepatic flexure which is located in the right upper quadrant (below the rib cage). The transverse colon takes a horizontal direction across the upper abdomen into the left upper quadrant abutting the spleen, hence the name of splenic flexure. The left colon begins at the splenic flexure and ends at the inlet of the pelvis where the rectum begins. The sigmoid colon is part of the left colon at its lower aspect in the left lower quadrant of the abdomen. Tumors anywhere in the right side are treated with a right colectomy which involves removing the cecum and its connection to the small bowel (ileocecal valve), the ascending colon and the hepatic flexure along with the ileocolic vessels and at least the right colic artery. In tumors of the transverse colon the right colectomy is extended to the splenic flexure including another set of blood vessels called the middle colic vessels. Tumors any where in the left side are treated with a left colectomy which extends from the splenic flexure to the rectum along with the inferior mesenteric vessels. As long as the bowel has been well prepared before surgery the goal is to reconnect both ends. If the colon was obstructed precluding a good preparation, then a colostomy or ileostomy may be necessary. Right colectomies are performed with the patient lying supine on the operating table, meaning with the legs down. Left colectomies require to elevate the legs during surgery in lithotomy position to access the anus and rectum for the reconnection of colon to rectum. The specimen of colon and blood vessels removed at surgery is submitted to pathology for microscopic examination. This examination is most accurate when done over a period of 3 to 4 days. The pathologist will report on the depth of penetration of the tumor across the wall of the colon and on the number of lymph nodes found and the presence of tumor cells inside of them. Pathologists are constantly advancing in their field to provide more information for the staging of the tumor. They report of presence of tumor cells within blood and lymphatic vessels as well as some genetic markers that may render the disease more or less favorable. If the tumor is contained within the muscle layer of the bowel wall and all other parameters are favorable surgery results in the cure of the disease and no other therapy is needed. Conversely, if the tumor penetrates deeper or tumor cells are found in lymph nodes or tumor markers are unfavorable then chemotherapy is necessary. Chemotherapy is done through intravenous infusions

delivered either in the hospital or, more often these days, outside of the hospital. In most cases patients can return to work or their usual activities even while receiving chemotherapy. Newer forms of chemotherapy are being developed to take by mouth. s