Simultaneous Laparoscopy and Co2 Colonoscopy for Full-thickness Excision of a Submucosal Cecal Lesion

INTRODUCTION: Insufflation with carbon dioxide (CO2) instead of air during colonoscopy minimizes bowel distension therefore better enabling simultaneous colonoscopic and laparoscopic procedures. Precise localization of intestinal lesions permits more limited, safer resections. In the case presented, a benign-appearing submucosal lesion may have required a segmental colectomy with anastomosis, but use of a combined procedure allowed a wedge resection with wide, grossly negative margins.

METHODS: A 66 year old male presented with a cecal nodule on screening colonoscopy. The lesion was submucosal and was not amenable to endoscopic mucosal resection (EMR). The lesion was precisely localized and completely removed utilizing a combined laparoscopic andCO2 colonoscopic approach.

RESULTS: The lesion was completely resected by excising a full thickness portion of the colonic wall using a laparoscopic stapler. The staple line closure of the wall was tested to be intact with pneumatic insufflation. Postoperatively, the patient had no complications or complaints and was discharged home on postoperative day 1. Pathology showed a benign mural lesion (parasite, consistent with pinworm).

CONCLUSION: Combined laparoscopy with CO2 colonoscopy is a safe and effective method to remove benign colonic lesions that are otherwise not amenable to EMR. The combined approach appears to offer several distinct advantages:

1) Precise localization of the lesion
2) Wide local excision with negative margins observed endoscopically and confirmed ex vivo. This avoids both impingment of adjacent viscus, such as the lumen of the terminal ileum.
3) Avoidance of bowel resection and anastomosis, which is associated with higher complication rates such as infection, hemorrhage, and intestinal dysmotility
4) Early hospital discharge

Use of combined CO2 colonoscopy with laparoscopy can reduce bowel resection and enhance recovery in selected patients with localized benign lesions.

Session: Video Channel

Program Number: V049