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Home , Anoscopy, Enteroscopy, Proctoscopy

WHE18 6/16/2005 2:22 PM Page 225

18. Intraoperative Upper and Lower Considerations

Keith P. Meslin, M.D. John M. Cosgrove, M.D.

A. Introduction

There is a growing list of reasonable indications for intraoperative endoscopy. Although this modality may be required for both open and minimally invasive procedures, it will be utilized more often in the laparoscopic setting, excepting hand-assisted procedures, due to the inability to palpate the bowel. In either case, the endoscope can provide information that is not otherwise avail- able to the surgeon which may impact the choice of surgical procedure. Present indications include (1) nonpalpable and nonlocalizable intestinal neoplasms, (2) polypectomy site localization, (3) nonlocalized upper and lower gastrointestinal (GI) bleeding site(s), (4) assessment of the status of the intestinal mucosal lining (for ischemia, colitis, or inflammation) or the bowel lumen (looking for stric- tures), and (5) searching for other intestinal pathology. Endoscopy may also be used as a technical aid to facilitate the successful completion of a chosen oper- ation. Examples of this type of indication include (1) during low anterior resec- tion to check for an anastomotic leak or bleeding, (2) during , (3) during fundoplication to assess the diameter of the esophageal lumen, and (4) during laparoscopic with positive cholan- giogram to retrieve stones or perform sphincterotomy via intraoperative endo- scopic retrograde cholangiopancreatography (ERCP). When booking and planning an intestinal operation, the surgeon should consider whether intraoperative endoscopy may be required or useful. If there is even a reasonable chance that an intraoperative endoscopic examination may be necessary, the required endoscopy equipment should be specifically requested when the operation is booked, to provide the operating room with ample time to gather the appropriate scope and other equipment. A well-equipped endoscopic cart is required (a single cart can be used for both upper and lower endoscopy). It should have a full array of equipment including forceps, snare, and some means of coagulation (bipolar cautery, heater probe, or laser). Endoscopic sclerotherapy catheters should also be available. When intraoperative endoscopy is anticipated, the surgeon should choose the body and table positions that best facilitate the examination and operation. Because unanticipated situations and indications do arise, the operating room should have one or several fully equipped endoscopy carts ready for use as well as clean upper and lower endoscopes. WHE18 6/16/2005 2:22 PM Page 226

226 K P Meslin and J M Cosgrove B. Lower Gastrointestinal Endoscopy

This category includes , rigid , flexible , and . Each is discussed separately. 1. Anoscopy a. Anoscopy permits evaluation of the anorectal sphincter and the distal portion of the . b. Outside the setting of an anorectal or perineal procedure, anoscopy should be done preoperatively. The indications for intra- operative anoscopy include: 1. To rule out neoplasms 2. To evaluate the or the distal rectum c. Patient position that will permit anoscopy (Figure 18.1) 1. Modified lithotomy (Figure 18.1A) 2. Prone (transverse buttock roll and chest rolls are often used) (Figure 18.1B) 3. Lateral decubitus (Figure 18.1C) d. Equipment 1. Beveled anoscope with obturator (either disposable or reusable)

A-(1) Figure 18.1. (A) Modified lithotomy position (side view and front from foot of bed). (B) Prone position (will roll under pelvis). (C) Sim’s position (modified left lateral). WHE18 6/16/2005 2:22 PM Page 227

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A-(2)

B

C

Figure 18.1. Continued WHE18 6/16/2005 2:22 PM Page 228

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Figure 18.2. Rigid proctoscopy: reusable metal scope.

2. Light source a. Some anoscopes have attached light sources b. Headlight or other directed light source otherwise needed 2. Rigid proctoscopy (Figure 18.2) a. Indications 1. To localize a rectal , polypectomy site, cancer, or other lesion 2. To check for anastomotic integrity or bleeding 3. To assess for , inflammation, etc. 4. Measurement of the distance between the dentate line (or anal verge) and a neoplasm or anastomosis b. Patient position 1. Modified lithotomy 2. Prone 3. Lateral decubitus c. Equipment 1. Length a. 25cm b. 15 cm 2. Scope diameters range from 1.1 to 2.7cm 3. Types of scopes a. Disposable b. Metal, reusable c. Plastic, reusable (operating anoscopes) 4. A working light source with power source in close proxim- ity to table (setting up a rectal cart with all the necessary equipment is advised) 5. Proper instrumentation includes a proximal magnifying lens and an attachment for the insufflation of air WHE18 6/16/2005 2:22 PM Page 229

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3. Colonoscopy and sigmoidoscopy (Figure 18.3A,B) Intraoperative colonoscopy and flexible sigmoidoscopy in both the emer- gency and the elective situation provide much useful information that is other- wise difficult to obtain. a. Indications: as per the introduction b. Equipment 1. A flexible endoscopy cart with light source, processor, image printer, and monitor (the latter three for videoscopes). An irrigation and air insufflation device (usually part of the light source) and water bottle (with connecting cable) are also needed. a. The video monitor may be fixed to the top of the cart (this necessitates that the endoscopist look toward the cart to view the endoscopic image) b. The monitor may be kept on a separate mobile stand that can be placed in the ideal position, which is often opposite the endoscopy cart

A

B Figure 18.3. (A) Flexible endoscope. (B) Close-up of scope tip showing biopsy forceps from the instrument channel of the scope. WHE18 6/16/2005 2:22 PM Page 230

230 K P Meslin and J M Cosgrove

2. The cart should also be stocked with biopsy forceps, snares, sclerotherapy catheters, cleaning brushes, and suction tubing. 3. An appropriate flexible scope (sigmoidoscope or colono- scope) with all the needed detachable components. a. Suction and irrigation/insufflation buttons (with appro- priate washers) b. Instrument channel fenestrated caps (through which biopsy forceps or snare is passed) 4. A dedicated high-volume pump for irrigation is advised for the evaluation of GI bleeders and those patients with incom- plete colonic preparations. 5. The flexible endoscopy cart is usually placed at the level of the feet on the patient’s right or left if the modified lithotomy position is used. If the patient is left supine with the right mid- and lower leg elevated on one or several pillows, then the endoscopist stands on the patient’s right side and the video monitor is placed on the patient’s left side. 6. Equipment hookup: It is important that the endoscopist be well acquainted with the operating room (OR) endoscopic equipment to allow rapidly resolving problems that arise. The following steps must be followed before the examination: a. Turn on all electronic equipment b. Connect the umbilical cable of the endoscope to the light source c. Connect the cable/hose of the three-fourths-filled water bottle to the umbilical cable d. Connect the suction to the appropriate site on the umbilical cable e. Test the insufflation, irrigation, and suction before com- mencing the procedure f. Turn on the light source (ignition) g. Check the scopes flexion controls before insertion h. Check that the cables from the image processor to the video monitor are connected (for video exams)

C. Patient Position

1. Modified lithotomy position. This is the best position for laparoscopic- assisted because it facilitates both the colonoscopy and the performance of the colectomy. The endoscopist can either stand or sit on a stool. The patient’s thighs should be parallel to the surface of the if a laparoscopic procedure is planned, because if the thighs are flexed (angled toward the ceiling) they will limit the use of the lower abdominal ports when working in the cephalad direction. 2. Modified supine position: The left leg is elevated by placing several pillows under the lower extremity from just above the knee to the foot. WHE18 6/16/2005 2:22 PM Page 231

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At the time of the colonoscopy, an additional drape is placed between the legs and the abdomen so as to create a nonsterile working space for the endoscopist. The endoscopist stands on the patient’s right side and inserts the scope into the anus from underneath the elevated right upper leg. This can be done from either a sitting or a standing position. 3. Modified left lateral position a. Particularly useful for office exams and inspection in the emer- gency room b. Positioning of the legs i. The thighs and knees both flexed ii. The left leg is kept straight and the right leg is flexed at both the hip and knee c. Position particularly suited to the pregnant patient, patients with severe chronic obstructive pulmonary disease (COPD), and patients with severe neurologic impairments d. The endoscopist usually stands for the examination

D. Surgeon’s Responsibilities (Remains Scrubbed at the Operative Field During the Endoscopy)

1. Must place noncrushing clamp on the terminal to prevent insuf- flation of the small bowel. 2. Must mark the site of the lesion once it is located with suture, clip, or other means. 3. During laparoscopic case, may be necessary to desufflate abdomen to limit loop formation and to permit application of external pressure to facilitate scope insertion. 4. If intraoperative colonoscopy done with abdomen open, then the surgeon can stent the bowel and facilitate insertion (Figure 18.4). Also, the surgeon and assistant should limit loop size by manually applying pressure to the loops as they form; otherwise, they can enlarge unchecked.

E. Esophagogastroduodenoscopy (EGD)

1. Indications: a. Massive suspected upper GI hemorrhage that requires surgery. All upper GI bleeds should undergo endsocopy before surgery; however, if definitive localization was not possible on the preop- erative examination(s), then an intraoperative exam for localiza- tion may be needed. b. Foreign-body removal when the OR is the chosen site for the examination. WHE18 6/16/2005 2:22 PM Page 232

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Figure 18.4. Intraoperative colonoscopy during open procedure: manual stent- ing of the colon to facilitate exam.

c. During gastric bypass. d. During fundoplication to assess the diameter of the esophageal lumen. e. To localize a small lesion or ulcer and to inspect the or for other reasons. 2. Equipment: a. As stated in the introduction. b. Flexible upper endoscope. 3. Positioning a. The patient is usually lying supine with an endotracheal tube in place. This differs from the most commonly used elective posi- tion (left lateral decubitis) for examinations performed outside the OR setting. b. The endoscopist usually stands on the left side of the patient’s head. The video monitor can be positioned close to the head of the table on either the right or left side. c. Despite the fact that the patient is under general anesthesia, it is advised that a bite block be used to protect the scope and to facil- itate insertion. 4. Surgeon’s (at the operative field) responsibilities i. The placement of a noncrushing clamp on the proximal will prevent insufflation of the more distal small bowel. ii. If the endoscopy is being done for the purposes of iden- tifying the location of a lesion or of a bleeding site, then the surgeon must mark the site with a suture or clip WHE18 6/16/2005 2:22 PM Page 233

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Figure 18.5. Intraoperative endoscopy during open surgical procedure: manual stenting of greater curvature of the stomach and the duodenal “C” loop to facil- itate small bowel intubation.

once the site is identified via transillumination or via palpation of the scope tip with an instrument. iii. If the intraoperative upper endoscopy is being done with the abdomen open, then the surgeon can facilitate the exam and limit loop formation by eternally sup- porting the greater curve of the stomach and the “C” loop of the duodenum manually (Figure 18.5).

F. Percutaneous Endoscopic

1. The majority of percutaneous endoscopic gastrostomies (PEGs) are performed in the endoscopy suite; a PEG can also be placed in the intensive care unit, provided the necessary equipment and support are WHE18 6/16/2005 2:22 PM Page 234

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available. The OR may be chosen as the setting for PEG placement in high-risk patients with multiple medical problems to enlist the assis- tance of an anesthesiologist. In the majority of patients in whom the PEG insertion is the only procedure to be carried out, intravenous sedation and local anesthesia under the anesthesiologist’s guidance and monitoring, so-called monitored anesthesia care (MAC), will suffice. In rare cases, general anesthesia may be required. Uncommonly, PEG insertion may be called for during a lower abdominal operation being carried out under general anesthesia. Rather than extend the lower incision or make a separate upper abdominal incision, a PEG can be placed. 2. The patient should be positioned supine with the head slightly elevated to prevent aspiration. If necessary, in situations where MAC is being given, the left lateral position can be used to intubate the , after which the patient is rolled to the supine position. 3. Well-functioning suction should be available for oropharyngeal secretions. 4. Please refer to the EGD section above (E, 3) in regard to intubat- ing the esophagus in patients in whom general anesthesia is being used. 5. As for EGD, the endoscopist stands on the patient’s left with the video cart on the patient’s right. 6. The assistant may stand on either side of the patient depending upon the endoscopist’s preference and the patient’s body habitus. 7. Once the stomach is intubated and a thorough examination completed, the endoscope is used to transilluminate the anterior abdominal wall and a suitable site for tube insertion chosen. 8. The surgeon then administers the local anesthesia and makes a small skin incision. With the stomach fully insufflated, a long needle is inserted through the abdominal wall toward the light. Once the endo- scopist verifies that the needle is in the stomach, a long wire is passed through it from the outside. The endoscopist grasps the wire with a snare and then removes the scope, thus pulling the wire out through the mouth. 9. At this point either the pull or push PEG insertion technique may be used to position the tube. (Please see a standard endoscopy text for details of the procedure.) 10. If a PEG is to be placed in conjunction with a laparoscopic procedure, it will be necessary to desufflate the abdomen completely (after occluding the proximal small bowel) to transilluminate the abdominal wall and choose the best site for the PEG. 11. Standard OR “minor” tray instruments may be used to make the skin incision at the site chosen for the PEG and for the suturing of the tube. Alternately, almost all PEG tubes come in kits that provide adequate disposable instruments for the tube placement. WHE18 6/16/2005 2:22 PM Page 235

18. Intraoperative Upper and Lower Endoscopy Considerations 235 G.

Endoscopy of the small bowel is especially useful in the evaluation and treat- ment of patients with obscure bleeding where prior diagnostic procedures, including upper and lower endoscopy, have failed to determine the bleeding site. Enteroscopy can also be used to locate a small bowel neoplasm, or a lesion, or to investigate a radiologic abnormality. There are four different ways to endo- scopically evaluate the small bowel: (1) push enteroscopy, (2) sonde enteroscopy, (3) capsule enteroscopy, and (4) intraoperative enteroscopy. Enteroscopy done during an open abdominal operation allows the surgeon to guide the endoscope through the small bowel as well as to mark the site of important endoscopic findings. 1. Either a pediatric or adult colonoscope should be used because a stan- dard upper scope is not long enough to permit a thorough small bowel examination. The pediatric colonoscope is needed, at times, because it can be difficult to traverse the cricopharynx with a standard diameter colonoscope. However, if the anesthesiologist deflates the endotracheal cuff, passage of the adult scope is usually possible. 2. The endoscopist usually stands to the left of the patient’s head above the sterile drapes. The video cart is usually placed on the left side near or above the head. 3. If possible, the endoscopic procedure should be initiated before making the skin incision to facilitate passage of the scope to the level of the proximal jejunum. The intact abdominal wall limits the size of the intragastric loop that forms during insertion through the stomach. If the endoscope is inserted after the abdomen is open, the surgeon can limit the gastric loop by grasping and anchoring the duodenal bulb with one hand while compressing the greater curvature of the stomach with the other hand (Figure 18.5). 4. Concomitant passage of a nasogastric tube is recommended to decrease inflation of the stomach and to limit the development of mucosal lacerations. 5. It is not recommended that the endoscope be passed into the small bowel via an enterotomy because of the increased risk of intraabdom- inal or wound infections. 6. The surgeon assists the endoscopist in inserting and examining as much of the as possible. 7. It is not always possible to examine the entire small bowel via an upper approach. 8. Retrograde enteroscopic examination of the terminal ileum and, often, the middle portion of the ileum can be accomplished using a transanally placed colonoscope via the ileocecal valve. In this situa- tion, the upper enteroscopy would be performed first followed by colonoscopy and retrograde distal enteroscopy. WHE18 6/16/2005 2:22 PM Page 236

236 K P Meslin and J M Cosgrove H. Endoscopic Retrograde Cholangiopancreatography

In patients suspected of having common stones in whom a chole- cystectomy is indicated, it is the author’s experience that intraoperative ERCP can be quite helpful. During laparoscopic cholecystectomy, an intraoperative cholangiogram is often performed. If the cholangiogram is positive or sugges- tive of common bile duct stones, an ERCP can be carried out in the OR during the same procedure. This allows the patient to have both procedures under the same anesthesia. Further, if in the midst of intraoperative ERCP large stones (>15mm) are encountered that cannot be removed by ERCP, the surgeon can next carry out a surgical common bile duct exploration. This approach has not only decreased the percentage of negative ERCPs, it has also decreased the overall length of stay by obviating the need for preoperative or postoperative ERCP and the attendant logistic problems associated with scheduling multiple procedures during a single admission. The method used for intraoperative ERCP is very similar to that used when the procedure is performed in the endoscopy or radiology suite. 1. Patients are placed on a table that permits fluoroscopy in the supine position under general anesthesia. 2. The laparoscopic cholecystectomy is completed, the abdomen desuf- flated, and all port sites closed and dressed. 3. The endoscopist stands to the left of the patient. 4. The video cart is placed to the right of the patient. 5. The OR needs to be prepared for fluoroscopy. In addition to having the patient on a fluoroscopy capable table, a fluoroscopy machine with a C-arm, a monitor, and a radiology technician must be available. The operating room requirements are similar to those required for opera- tive placement of a long-term central venous access line. 6. A standard ERCP endoscope is required. The scope is connected to the video cart as for other endoscopic procedures. 7. A variety of different endoscopic catheters are used to cannulate the ampulla. 8. Standard ERCP methods are used to carry out the procedure (please consult an endoscopy text for the details). 9. Sphincterotomes, stone retrieval baskets, and balloon catheters are used to facilitate removal of common bile duct (CBD) stones.

I. Selected References

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Cave DR, Cooley JS. Intraoperative enteroscopy. Indications and techniques. Gastro Endosc Clin N Am 1996;6(4):793–802. Geenen JE. Techniques in Therapeutic Endoscopy. New York: Gower, 1992. Kalimi R, Cosgrove JM, Marini C, et al. Combined intraoperative laparoscopic cholecys- tectomy and endoscopic retrograde cholangiopancreatography: lessons from 29 cases. Surg Endosc 2000;14(3):232–234. Keighley MR. Surgery of the Anus, Rectum and Colon. London: Saunders, 1999. Kim SH, Milsom JW, Church JM, et al. Perioperative tumor localization for laparoscopic . Surg Endosc 1997;11(10):1013–1016. Kuramoto S, Ihara O, Sakai S, et al. Intraoperative colonoscopy in the detection of non- palpable colonic lesions: how to identify the affected bowel segment. Surg Endosc 1988;2(2):76–80. Martinez SA, Hellinger MD, Martini M, et al. Intraoperative endoscopy during colorectal surgery. Surg Laparosc Endosc 1998;8(2):123–126. Ponsky JL, Dunkin BJ. Percutaneous endoscopic gastrostomy. In: Yamada T (ed) Textbook of . Philadelphia: Lippincott, 1999. Sakanoue Y, Nakao K, Shoji Y, et al. Intraoperative colonoscopy. Surg Endosc 1993; 7(2):84–87. Soderman C, Uribe A. Enteroscopy as a tool for diagnosing gastrointestinal bleeding requiring blood transfusion. Surg Laparosc Endosc 2001;11(2):97–102. Stellato TA. Flexible endoscopy as an adjunct to laparoscopic surgery. Surg Clin N Am 1996;76(3):595–602. Thorson AG, Blatchford GJ. Operative and anesthetic techniques. In: Beck DE (ed) Fun- damentals of Anorectal Surgery. Philadelphia: Saunders, 1998. Tytgat GN. Upper gastrointestinal endoscopy. In: Yamada T (ed) Textbook of Gastroen- terology. Philadelphia: Lippincott, 1999. Vamosi-Nagy I, Koves I, Szanto I, et al. Intraoperative colonoscopy. Eur J Surg Oncol 1993;19(6):615–618.