Cutting it fine
Mary Chay, 61, was uneasy when she regularly found blood in her stools, and went to see her doctor, who advised her to have a colonoscopy.
Although the idea of having a thin, tube-like instrument inserted into her colon was unsettling, Chay (name changed for patient confidentiality reasons) was even more disturbed by the potential causes of bloody stools, one of which was colon cancer.
She was referred to the Hong Kong Sanatorium and Hospital for the procedure. During the colonoscopy, doctors found a suspicious looking polyp in her sigmoid colon, which is the lower part of the large intestine close to the rectum.
Using the endoscope, the doctor immediately removed the polyp and sent it for further tests. Results confirmed that the polyp was a malignant tumour and that Chay had early stage colon cancer. Happily, the cancer was localised and contained within the polyp. But the oncologist wanted to remove the part of the sigmoid colon where the lesion was found to ensure that any remaining cancer cells were completely removed.
For this operation, called a colectomy, the oncologist enlisted the help of Dr Li Ka-wah, director of the Minimally Invasive and Robotic Surgery Development programme and a specialist in general surgery.
Conventional colectomies require a long incision down the abdomen to give surgeons access to the colon. But this method increases the patient's surgical and infection risks, post-operative pain, and recovery time.
However, advancements in minimally invasive surgery have given patients such as Chay a much less risky and painful option called laparoscopic colectomy.
With laparoscopy, a large incision is unnecessary as surgeons are able to look inside the abdominal cavity and operate on the organs using only thin instruments measuring 5mm to 12mm wide, which leave small wounds that heal fast and with much less pain.
But in laparoscopies such as Chay's, in which part of the colon had to be removed, an incision 5cm long still had to be made into the abdomen so that the resected tissue can be taken out. This would then add to her pain and slow the recovery process.
Li, though, had developed a unique technique that would do away with even that small incision and its related drawbacks. He intended to remove the resected tissue via the anus using equipment from an established procedure called a transanal endoscopic operation (TEO), in which lesions are removed from the rectum.
This hybrid method of TEO and laparoscopy, called Endo-Laparoscopic Colectomy, allows Li to view the area of concern from above and below, as well as to remove the affected section of the colon without creating an exit wound.
During Chay's procedure, a hollow needle was first inserted into her abdomen to pump carbon dioxide into the abdominal cavity to inflate the skin away from the organs and create more room in which Li could work.
A thin, lighted tube with a camera on the end (the laparoscope) was then inserted so that Li had a clear view of the organs within the abdomen. Other specialised instruments were then inserted into the abdomen to manipulate the colon and to clamp down on either side of the section of colon to be removed.
The TEO equipment, inserted through the anus, was then put in place. A camera gave Li a clear internal view of the intestinal tract. Once the carbon dioxide was introduced, Li was able to access the affected part of the colon from below, and - using the laparoscopic equipment - even pass surgical tools up the tract so that they could be manipulated and then removed.
Working in tandem with another surgeon operating the laparoscopic equipment, Li was able to cut away the targeted part of the colon, remove it via the natural orifice, and then staple the two ends of the colon back together without creating any significant wound.
Within 24 hours, Chay was up and walking about with 16.5cm of colon missing, and had only five tiny holes in her abdomen to show for it. Because of the minimally invasive procedure, Chay suffered very little pain and was discharged one to two days earlier than if she had undergone only the laparoscopic colectomy.