Techniques in Gastrointestinal Endoscopy 15 (2013) 180–183

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Techniques in Gastrointestinal Endoscopy

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Intraoperative endoscopy to identify lesions☆

Benjamin K. Poulose, MD, MPH, FACSVanderbilt University Medical Center, D-5203 Medical Center North, 1161 Medical Center Drive, Nashville, Tennessee

a r t i c l e i n f o

Article history:Received 8 July 2013Received in revised form23 July 2013Accepted 8 August 2013

Keywords:PathologySurgeryOperationLocalization

72/$ - see front matter & 2013 Elsevier Inc. Ax.doi.org/10.1016/j.tgie.2013.08.006

author reports no direct financial interests tin connection with the submitted manuscripail address: benjamin.poulose@vanderbilt.edu

a b s t r a c t

Intraoperative endoscopy is an important adjunct to surgical therapeutics. Endoscopy can improve theefficiency of operative interventions by localizing lesions and defining the extent of pathology. Differenttechniques can be employed to facilitate intraoperative endoscopy including sterile scope and nonsterilescope methods. Lesion marking can be accomplished using endoscopic or endoscopically guided surgicalmeans. Air insufflation can often be utilized for easily accessible regions of the gastrointestinal tract(esophagus, stomach, rectum, and distal sigmoid colon). Carbon dioxide insufflation is most useful forextended procedures and accessing more difficult locations of the gastrointestinal tract. Commonlylesions identified endoscopically for surgical resection include gastric ulcers and tumors, small bowellesions, and colon pathology.

& 2013 Elsevier Inc. All rights reserved.

1. Introduction

The intraoperative localization of pathology can sometimespose a challenge to surgeons. Endoscopy provides a useful meansby which identification of lesions can be performed during anoperative procedure. Surgeons should develop an appropriateendoscopic skillset that allows them to perform endoscopyin the operating room to benefit their patient population.This enables a single proceduralist to manage a patient's needs,rather than occupying the time of 2 physicians. Although seem-ingly straightforward, actually performing intraoperative endos-copy can be challenging and frustrating for operative teams notfamiliar with the technique. The purpose of this review is toimpart practical knowledge for the efficient performance of intra-operative endoscopy to localize lesions requiring surgical inter-vention [1].

2. Techniques for intraoperative endoscopy

2.1. Access

The most proximal and most distal portions of the gastro-intestinal tract tend to be the most difficult to access surgically andthe easiest to access endoscopically. The converse holds true forthe midportions of the gastrointestinal tract such as the biliarytract and small bowel. In these areas, endoscopic access is oftenchallenging and surgical access is readily achieved.

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For most open surgical procedures where endoluminal access isrequired, the simplest method of access is usually achieved using asterile endoscope. In elective situations, most operating room teamsneed to be notified 24 hours in advance to prepare a standardgastroscope or other common endoscope for use within theoperative field. A 9-mm diagnostic gastroscope is usually sufficientfor nearly all small and large bowel applications where surgicalaccess to the bowel is required. Ergonomics should be maximizedby ensuring that the endoscopic monitor is directly facing theendoscopist to minimize fatigue (Figure 1). Two stay sutures areplaced on either side of the antimesenteric border of the bowel anda 10-mm full-thickness longitudinal incision is made to accommo-date the endoscope. Endoscopy is performed while maintainingtraction on the bowel manually to pass the endoscope. The entiresmall bowel can be inspected with a standard gastroscope using astrategically placed enterotomy in the distal jejunum. In situationswhere a sterilized diagnostic gastroscope is not available, a sterilecystoscope can be used with excellent results. Most operative teamsare more familiar with the setup of urologic equipment than withendoscopic equipment. A sterile cystoscope can be used to visualizethe mucosal surface of the bowel, taking into consideration that thisis facilitated by continued irrigation. As such, care must be taken tolimit the amount of fluid used during the procedure to avoidpotential electrolyte abnormalities during the operation. Onceendoscopy has been completed, the enterotomy is closed in atransverse fashion to minimize risk of stricture.

Laparoscopic access for intraoperative endoscopy can be per-formed successfully using either a sterile scope or nonsterile scopetechnique. With either technique, preoperative consideration shouldbe given to port size and placement, intended point of luminal entryinto the GI tract, and need to maintain laparoscopic visualization. Ingeneral, a 10-12 mm port is required to accommodate a 9-mm

Fig. 1. Ergonomics are important to ensure easy performance of intraoperativeendoscopy. If endoscopy is to be performed in the operative field itself, theendoscopist should face the patient and the endoscopic monitor beyond.

B.K. Poulose / Techniques in Gastrointestinal Endoscopy 15 (2013) 180–183 181

diagnostic gastroscope and a 15-mm port is required to accommo-date a 13-mm duodenoscope. Disposable ports are usually lesstraumatic to the endoscope, thereby reducing the chance of damageto the shaft of the instrument. The distance between the tip of theport and the point of entry into the gastrointestinal tract should beminimized to reduce the chance of alpha-loop formation within theperitoneal cavity. If maintenance of laparoscopic visualization isneeded during the endoscopic portion of the procedure, using asterile endoscope allows all equipment to be manipulated in theoperative field. If laparoscopic visualization can temporarily besuspended (eg, during laparoscopic transgastric endoscopic retro-grade cholangiography), a nonsterile scope technique can be used.The intended laparoscopic port for endoscopic access is excludedfrom the operative field using an extremity drape, leaving the hub ofthe port and the endoscope as nonsterile. The underlying operativefield remains sterile. The endoscope is inserted into the selectedport, and the lumen entered. A short amount of nonsterile (albeithaving undergone high-level disinfection) endoscope is exposed tothe peritoneal cavity. Hazey et al [2] did confirm peritonealcontamination with nonsterile gastroscopes, which did not lead toincreased infectious complications. After the endoscopy is com-pleted, the luminal access point is closed primarily using sutures,staples, or an enteral access tube.

2.2. Endoscope preparation

In general, 3 methods of endoscope preparation can be utilizedto facilitated intraoperative endoscopy. Sterilization removes allmicroorganisms from the endoscope with intent of using the

Fig. 2. Endoscopic localization assists the surgeon to resect a gastrointestinal stromallocalized endoscopically. (B) With the endoscope present in the gastric lumen, the resectfigure is available online.)

endoscope on the operative field. This is usually accomplished via100% ethylene oxide gas sterilization. Some endoscopes are ame-nable to this sterilization technique whereas others are not com-patible with gas sterilization. Each manufacture has specified whichmodels can undergo safe gas sterilization. To use a sterile endo-scope, preoperative preparation is wise as the process can take up to80 minutes. A sterile bag can also be used to facilitate endoscopywithin the operative field. The endoscope is placed within thesterile bag, which is used to exclude the nonsterile endoscope fromthe operative field. During open operations, the sterile bag can besutured to tissues surrounding the luminal access point. Withlaparoscopic procedures, the sterile bag can be taped around a port.All endoscopes should undergo thorough cleaning and high-leveldisinfection before use. High-level disinfection is defined as com-plete elimination of microorganisms in or on an instrument, exceptfor small numbers of bacterial spores [3].

2.3. Lesion marking

Identifying lesions during intraoperative endoscopy differsfrom the usual practice of endoscopic lesion marking in the timeframe involved between endoscopy and surgical intervention. Inthe traditional sequence of endoscopy performed before an oper-ation, lesions are marked using a permanent tattooing agent,which can then be identified surgically. With intraoperativeendoscopy, lesions can easily be marked on serosal surfaces byhaving the endoscopist pass a closed biopsy forceps in or around alesion. This technique can be used to identify the precise locationof the lesion itself or to identify the margins of a lesion. This can bealso useful to protect areas away from the resection site (Figure 2).An appropriate mark can be made from the serosal side of thelesion either using a sterile surgical marker or with light applica-tion of electrosurgical energy taking care not to injure thestructure of interest.

3. Maximizing endoscopic and surgical visualization

3.1. Insufflation

The most widely used gas for endoscopy is room air. Room airhas advantages of being readily available and being essentiallyfree; its disadvantages include bowel distension and combustibil-ity. For short intraoperative endoscopic procedures, room airinsufflation usually suffices without causing significant hollowviscous distension. Carbon dioxide (CO2) offers many advantagesover room air for endoscopy. With traditional endoscopic proce-dures, CO2 affords decreased pain and abdominal distension [4].CO2 is especially useful in intraoperative endoscopy as it is quicklyabsorbed, resulting in decreased bowel distension, thereby

tumor near the gastroesophageal junction. (A) The gastroesophageal junction ision is performed avoiding narrowing of the esophageal lumen. (Color version of the

Fig. 3. CO2 endoscopic insufflation allows for easy simultaneous laparoscopy andendoscopy. Here, an endoscope guides the laparoscopic resection of a large benigngastric polyp. (Color version of the figure is available online.)

Fig. 4. Intraoperative small bowel endoscopy is used to carefully evaluate themucosa for lesions. Note that endoscopic visualization in this image is provided bya sterile cystoscope using standard cystoscopy irrigation. (Color version of thefigure is available online.)

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preserving laparoscopic visualization (Figure 3). In addition, CO2 isavailable in most operative environments given the prevalence oflaparoscopy. The disadvantages of CO2 include the higher cost andpotential side effects of systemic absorption. No study has system-atically evaluated cost differences between room air and CO2 usedfor endoscopy. Presumably, CO2 imparts some cost increase forendoscopy, given the need for gas supply and additional equip-ment. Systematic absorption of CO2 has been shown to transientlyincrease dissolved and end tidal CO2 levels, with little physiolog-ical consequence [4]. Caution should be employed in utilizing CO2

insufflation in patients with severe chronic obstructive pulmonarydisease, as most studies have excluded this population fromanalysis owing to CO2 absorption.

3.2. Surgical adjuncts

To facilitate the performance of intraoperative endoscopy andmaintain operative visualization, surgical maneuvers to occludethe enteral tract distal to the area of endoscopic interest can bevery useful. For open operations, manual occlusion or gentleocclusion with a noncrushing Glassman clamp is suitable. A similartechnique can be used for laparoscopic procedures utilizinglaparoscopic DeBakey forceps or bowel graspers.

4. Identification and management of common pathologies

4.1. Gastric lesions

Confirmed benign gastric lesions that are untreatable endoscopi-cally are usually the most amenable to intraoperative endoscopiclocalization for surgical therapy. These include gastric ulcers, largepolyps, and small gastrointestinal stromal tumors. Endoscopy canbe performed either with room air and distal jejunal occlusion orCO2 insufflation. Upper endoscopy is performed in the typicalfashion and an endoscopic instrument is used to “palpate” themucosa while maintaining surgical visualization. It is helpful for theendoscopist to know anterior and posterior gastric relationshipsthat would dictate if posterior gastric mobilization is needed forexposure. If local resection is the goal, this can be often accom-plished endoscopically with laparoscopic assistance or laparoscopi-cally with endoscopic assistance. The choice of which approach touse depends on the location of the lesion and experience of therespective proceduralists.

4.2. Occult small bowel bleeding

Identification of the site of occult small bowel bleeding can beone of the most challenging tasks for general surgeons. Assuming

that more obvious locations are not contributing to bleeding, asystematic and thorough evaluation of the small bowel is under-taken. Before mucosal evaluation, a careful serosal examinationsupplemented by direct palpation can usually identify areas ofpathology. Performing this effectively laparoscopically is very userdependent and should be done by laparoscopic surgeons familiarwith the technique. If no obvious serosal evidence of disease isidentified and a high preoperative suspicion exists for small bowelpathology, mucosal evaluation can be initiated. All preoperativeinformation (ie, small bowel contrast study, pill camera, andballoon enteroscopy) should be taken into consideration to helplocalize pathology. In general, an enterotomy placed in the distaljejunum is sufficient to evaluate the entire small bowel using astandard gastroscope. The proximal small bowel is evaluated firstusing a retrograde technique until the duodenal sweep is reached.The small bowel distal to the enterotomy is then evaluated movingantegrade toward the cecum. Shorter segments of bowel can beevaluated using a sterile cystoscope (Figure 4). The surgeon canoften assist the endoscopist by “telescoping” the bowel over scopeas needed. Care should be taken to not create a complete trans-ection of the small bowel at the enterotomy site due to scopemovement. CO2 insufflation is usually required for this procedure,unless fluid-based visualization is used.

4.3. Colon lesions

Colon lesions that are not readily apparent on serosal exami-nation can be identified in a manner similar to that for gastriclesions. Traditional colonoscopy performed through the anus isusually sufficient to identify the lesion in question endoscopically.Perioperative CO2 insufflation is preferred as colonic distentiondissipates rapidly and minimizes operative interference. An endo-scopic instrument is used to “palpate” the lesion while examiningthe colon operatively (open or laparoscopic) to precisely identifyits location. In most instances, a typical colon resection is selectedthat encompasses the lesion while preserving blood supply forsubsequent anastomosis. In select cases, laparoscopically assistedfull-thickness polypectomy can be performed.

5. Conclusion

Intraoperative endoscopy is a useful tool to identify andpotentially treat lesions of the gastrointestinal tract. Surgical and

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endoscopic adjuncts can improve the ease by which intraoperativeendoscopy is performed to help improve its feasibility in clinicalsettings.

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