DIFFICULT SITUATIONS

Clinical Training TeamBEWARE!!

Shark-infested Waters

The Next Era in GI Surgery BioDynamixTM

AnastomosisThe Colon Ring

2

Appropriate Use of ColonRingTM

Check w/ surgeon before case to see if ColonRingTM is appropriate to use—

Ileostomy closure (above ileocecal valve)—

Right hemicolectomy (not initial case)—

Bowel prep—

Patient co-morbid conditions—

3

Appropriate Use of ColonRingTM

Check w/ surgeon before case to see if ColonRingTM is appropriate to use—

• Ileostomy closure (above ileocecal valve)—What is the problem?

• Ring may not pass ileocecal valve.

4

Appropriate Use of ColonRingTM

Check w/ surgeon before case to see if ColonRingTM is appropriate to use—

Right hemicolectomy (not initial case)— Why not?

Usually requires significant change in technique. Relatively higher incidence of adverse events??

5

Appropriate Use of ColonRingTM

Check w/ surgeon before case to see if ColonRingTM is appropriate to use—

Bowel prep— What may happen?

Hard stool proximally may force premature evacuation of the ring complex. What should be should be suggested?

Minimum required: 1-2 Fleets enemas preop, stool softeners 2 days preop & 7 days

postop.

6

Appropriate Use of ColonRingTM

In OR you find lack of or ineffectual bowel prep:

Hard stool present in right colon at time of OR—

• Don’t use ColonRingTM—“skip!”

• Colonic lavage

• Proximal diversion

7

Appropriate Use of ColonRingTM

Check w/ surgeon before case to see if ColonRingTM is appropriate to use—

Patient co-morbid conditions—

Ischemia,Severe inflammation,Uncontrolled diabetes,High ASA score,Immunosuppression.

Any disease process resulting in delay of

healing may increase the risk of an adverse event.

8

Appropriate Use of ColonRingTM

The ring complex is “smart” regarding the necrotic process, but it is unaware of the stage of the surrounding healing process!

9

Appropriate Use of ColonRingTM

But, what if the surgeon advises you that the patient has requested confidentiality of diagnosis?

Ask if there is any history or evidence of delayed healing.

10

Appropriate Use of ColonRingTM

In the presence of delayed healing—

Emphasize benefit of proximal diversion.

“When in doubt, skip out!”

11

To Divert or Not to Divert…That is the Question!

Why to divert?—

Diversion definitely decreases the severity of anastomotic leaks!

Why not to divert?—

Consequences of unnecessary stomas— – Second surgery required– Necrosis or retraction of stoma– Prolapse or peristomal herniation– Social implications

• Difficulties in care: leakage, appliance application• Odor• Appearance under clothing

17

Ring Loading Problems

Ring loads improperly on the applier—

Often due to excessive pressure applied during loading, especially if the ring is rotated excessively, stripping the plastic locking tabs.

May result from too little or unequal pressure on loader.

Accommodation:

Demonstrate proper loading techniques before procedure to involved individuals.

18

Anvil Retention Problems

The anvil will not remain secured to the trocar—

Usually due to excessive tissue present between the anvil and ring.Most often seen with reversal of Hartmann.May result with use of double purse-strings.

Accommodation:

Resect excessive tissue around purse-strings.Resect fibrotic distal staple line in Hartmann reversal.Perform side-to-side, end-to-side, or side-to-end anastomosis.Assist closure of device with gentle pressure on anvil head.

19

Improper Mating of Anvil & Trocar

When is the anvil seated properly?

When does the anvil lock in place?

Can the device be fired without the anvil properly attached to the trocar?

Can the cutting handles be fired?Will the anastomosis be formed?Can the device be opened?Will the ring remain attached to the applier?When does the mechanism actually push the ring off the device handle?When you notice the anvil and trocar fail to mate and separate, at what

point would you need to take the device out to be sure the ring is still firmly seated before reconnecting the trocar and anvil and

continuing?

20

Improper Cutting of Anvil Head

Blade won’t cut anvil head after ColonRingTM and anvil head are mated—

What may have happened?

Incomplete closure of device.

Lack of depression of cutting trigger.

Incomplete firing of cutting handle.

Instrument failure.

21

Proper Cutting of Anvil Head – No Anastomosis!

Blade cut anvil head after firing ColonRingTM handles but no anastomosis is formed—

What may have happened?

Most likely ColonRingTM was not loaded on applier!!!

Accommodation:

Assure that surgeon always checks to make sure that the ColonRingTM has been properly loaded before attempting to insert the applier.

22

Cross-Utilization of Parts

Cross-utilization of parts of two separate ColonRing units—

What may happen?

Potential for improper result is higher.

Devices are tested as a complete unit.

23

Difficulty in Withdrawing Applier

If withdrawal of the applier appears to place traction on the anastomosis—– Consider possibility of “vacuum” in rectal segment—

• Support distal side of anastomosis.

24

Difficulty in Withdrawing Applier

If withdrawal of the applier appears to place traction on the anastomosis—– Applier remains attached to ring complex—

• Attempt repeat cutting with cutting handle;– If success—

» Additional testing.» Visualization of anastomosis??» Diversion??

– If no success—» Open applier proximal to warning “click”.» Remove anastomosis anvil/ring complex from trocar.» Close applier distal to warning “click”. » Remove applier.» Resect anastomosis and re-do.

27

Anastomoses Placed Above ? Strictured Area

If there is a potentially “strictured” area below the anastomotic site—

• There is higher likelihood of potential difficulty in passage of the ring complex.

• Manual or endoscopic removal is likely to be required.

• Surgical removal may be necessary.

Accommodation:

Consider end-to-side anastomosis (anterior) below “stricture”.

Resect close to stricture and complete anastomosis as desired.