Extraperitoneal Colorectal Surgery.
It has been an immensely privileged experience, like a time travel journey, to get from a distant idea to an established practice with huge potential for patients and surgeons alike. It is never too late to take a fresh perspective even on the most enshrined and established dogmas in any field including my own -surgical practice.
The more you look the more you find. There is a chain of events or reactions that happen every time you explore something. I just needed to know more about myself.
I, like you, have many merits and demerits. But most of the time most of us are not aware of our strengths or weaknesses. For instance, it turned out that new and subtle ideas come to me easily. But it also turned out that I was not aware of them, discounted them and did not really pursue them to any length to see if any is workable.
It was not until the “consultant stretch programme” which is pioneered at my Trust (Lancashire Hospitals NHS Foundation Trust) where the organisers, pointed this out to me. After a mock exercise during the first day of the course called the “development centre”, I remember two, three or even four of the observing team almost all at once yelling at me “YOU HAD A GOOD IDEA BUT YOU DID NOT PUSH FOR IT!”
This was an absolute eye opener for me on that day. In fact, it is the only thing I remember about this course, and it was just enough.
I then developed this resilience and persistence in me rather than just running hot and cold. I have run several marathons since then, 18 at the time of this writing, and every project or idea has since become like a marathon; you start, you grit, you finish.
EXPERTS on frozen windscreen February 2019. The S is a late edit.
I don’t know exactly when the idea of extraperitoneal surgery was triggered in my head. Although we started cadaveric studies in 2018, I remember the idea was there in my mind even 10 or more years earlier.
I might have been looking for something different, new or even spectacular. The transperitoneal (TP) approach to colorectal surgery - both laparoscopic and robotic surgery has never made sense to me even after many years of performing both techniques. From a colorectal perspective, every important anatomical structure is a retroperitoneal structure. The peritoneum itself is an under-appreciated, under-utilised organ. When trespassing the peritoneal cavity, the small bowel/omentum present significant unnecessary challenges especially in the obese and those with previous surgery. The whole experience could feel like eating with knife and fork for the first time
Patients really don’t know anything about what we are doing except that they will have keyhole surgery or open surgery depending on the discussion with the surgeon. They are consented for many potential complications, but it is rarely if any when a surgeon explains to them, they will be in almost halfway upside down - the so-called head down position. They are not consented for complications of head down position which despite understandably rare, could be devastating.
Surgeons, on the other hand, do not know anything else other than the transperitoneal approach. They would never have imagined laparoscopic or robotic surgery without head down position. Many would tell you that laparoscopic/robotic surgery through the transperitoneal route is working so why change? The answer to this is twofold; it is true that some 75-90% of operations could be completed without much struggle through the TP route. But it is also important that it is the remaining 10-25% who roughly cause 75-90% of the pain and difficulty for patients, surgeons, assistants and anaesthetists. Secondly, in the UK, only 61% of operations are performed laparoscopically. The reason cited are usually technical difficulty, bleeding or tumour characteristics. Once could perceive that the 10-25% challenging cases could be at least double this figure had there been more uptake of keyhole surgery of more than the current 61% figure.
Laparoscopic surgery by straight instruments is awkward and non- ergonomic. Multiport wristed robotic instruments have just made an awkward laparoscopic TP procedure less so. While instrument design is important, it is the design fault with TP access that also needs to be addressed. In fact open surgery is the most ergonomic but it is the one that causes the most damage to patients in term of wound trauma and rough handling of tissues.
I wondered whether an XP approach in colorectal surgery could help improve further on the drawbacks of TP surgery. I got used to the XP space while performing TEP hernia repair
The first challenge was to find and test the concept on cadavers. This has taken a long time, but we were fortunate enough to get initial support from Intuitive Surgical to use their Xi robot to perform, XP dissections in cadavers. We received further support from Lancashire Teaching Hospitals’ Trustee Bursary Award to develop our own dissections using laparoscopic instruments during 2018 and 2019. In my opinion, the most important aspect of an innovation is to have a supportive team, governance structure and medical leadership without which it is almost impossible for any innovation to develop further. We were not successful using the multiport robot in the narrow XP space, the first team that I gathered considered this as a failure and their support stopped at this stage. Pivoting to standard laparoscopic instruments and getting further support from my current team and co-authors have taken the technique further and we were able to perform a whole low anterior resection using XP approach in cadavers using standard laparoscopic instruments.
A specific challenge came up when the local ethics committee asked for external opinion on the technique (image below). This was a long and frustrating journey as I was essentially asking – in vain- those who never heard of the concept for validation.
The journey was not easy but having a clear vision, personal characteristics (passion, acting and resilience) and the right relationships have all helped navigate many challenges. We are all naturally sceptic about change and high standards of safety need to be achieved before we could start to appreciate positive change.
We have so far completed some 70 live cases. We have published and presented data on cadaveric and clinical experience including the latest original article in the prestigious BJS. We continue to develop the technique to achieve it is maximum potential.
3D animation of XP versus TP approach - the model could be rotated.
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