**3. Endoscopy during laparoscopy (combined laparoscopic endoscopic procedure)**

#### **3.1 Laparoscopic monitored colonoscopic polypectomy (LMCP) to avoid segmental colon resection**

The majority of large colonic polyps can be resected with colonoscopy. In few circumstances, patients are referred to laparascopic segmental colonic resection either because of the polyp size or because of the polyp location. Laparoscopic monitored colonoscopic polypectomy was suggested as a new technique which can reduce the number of segmental colonic resections. In this technique, the laparoscope can guide the endoscope to the site of the polyp and mobilize the colon to achieve easier polypectomy. This technique is particularly valuable in patients with angulated sigmoid colon from prior surgery and adhesion. This technique was evaluated in a study by Grunhagen et al in which 11 patients with difficult polypectomy were enrolled. Segmental colonic resection was avoided in 9 patients. No residual polyps were seen in the follow-up period [16]. Another trial included 47 patients who had LMCP and showed that 97% of the patients had a successful procedure

significance. There are a few case reports of peritonitis or peritoneal abscess as a result of

Preoperative endoscopic tattooing of pancreatic lesions prior to laparoscopic distal pancreatectomy has been recently reported [9]. This technique utilizes endoscopic ultrasound with the use of a fine needle for tattooing under endoscopic guidance. In a study of 36 patients who underwent laparoscopic distal pancreatictomy, 10 patients had preoperative endoscopic tattooing. Patients in the preoperative tattooing group had shorter operation times compared to the control group [10]. Figure 1 Illustrate tattooing of duodenal

Common bile duct stones are found in 10% of patients undergoing elective cholecystectomy [11]. In these patients, management of common bile duct stones includes endoscopic sphincterotomy (ES) prior to or after laparoscopic cholecystectomy (LC) or LC with intraoperative common bile duct exploration. Many studies evaluated both approaches with controversial outcomes. A meta-analysis of 12 studies did not find any difference in mortality, morbidity or in the need for an additional procedure between both approaches [12]. However, a decision analysis published in 2008 suggested that LC with intraoperative bile duct exploration is superior to ES with LC [13]. Most likely, these controversial results could be explained by the difference in expertise among surgeons in performing laparoscopic common bile duct exploration. Recently, Intraoperative Endoscopic sphicnterotomy by Endoscopic Retrograde Cholangiopancreatography (ERCP) during LC was introduced as an alternative technique for the management of Choledocholithiasis. Enochsson et al. evaluated this technique in 37 patients with a 93.5% success rate and none of the patients developed post ERCP pancreatitis [14]. Intraoperative ERCP was compared to preoperative ERCP in patients with choledocholithiasis in a study by ElGeidie et al. The study included 198 patients and it did not find any difference in the morbidity or in the procedure time between the two approaches [15]. However, Intraoperative ERCP during LC has the advantage of being able to perform the procedure and surgery in a single stage

**3. Endoscopy during laparoscopy (combined laparoscopic endoscopic** 

**3.1 Laparoscopic monitored colonoscopic polypectomy (LMCP) to avoid segmental** 

The majority of large colonic polyps can be resected with colonoscopy. In few circumstances, patients are referred to laparascopic segmental colonic resection either because of the polyp size or because of the polyp location. Laparoscopic monitored colonoscopic polypectomy was suggested as a new technique which can reduce the number of segmental colonic resections. In this technique, the laparoscope can guide the endoscope to the site of the polyp and mobilize the colon to achieve easier polypectomy. This technique is particularly valuable in patients with angulated sigmoid colon from prior surgery and adhesion. This technique was evaluated in a study by Grunhagen et al in which 11 patients with difficult polypectomy were enrolled. Segmental colonic resection was avoided in 9 patients. No residual polyps were seen in the follow-up period [16]. Another trial included 47 patients who had LMCP and showed that 97% of the patients had a successful procedure

**2.2 Endoscopic sphincterotomy prior to laparoscopic cholecystectomy** 

238

intraperitoneal spillage [8].

lesion prior to laparoscopic removal.

procedure, making it an attractive option.

**procedure)** 

**colon resection** 

without any complications[17]. In another trial from Germany that included 23 patients, LMCP was successful in 17 patients [18]. In all previously mentioned trials, there was minimal to no discomfort from the laparoscopic part of the procedure.

#### **3.2 Endoscopy assisted laparoscopic wedge resection**

Laparoscopic wedge resection is currently the standard of care for the removal of gastric submucosal tumor and in particular Gastrointestinal Stromal Tumor (GIST). Laparoscopic wedge resection is more feasible in tumors located at the anterior wall of the stomach Tumors located in the posterior wall of the stomach or the gastro-esophageal junctions were traditionally managed by surgery to ensure negative margins and to avoid excessive gastric resection. Endoscopy assisted laparoscopic wedge resection was successfully performed in gastric submucosal tumors located in the above mentioned area to spare open surgery. In this technique, endoscopy is used simultaneously during laparoscopy to localize the tumor and ensure negative margins. In a trial of 18 patients, this technique was proven successful with a single complication (perforation) in one case [19]. A new technique described by Hiki et al utilizes endoscopic submucosal dissection (ESD) of three–fourths of the circumference around the submucosal tumor followed by seromuscular dissection of the exact threefourths of the circumference by laparoscopy then the tumor is removed by a laparoscopic stapling device [20]. This technique is successful regardless of the tumor location and the initial ESD done by endoscopy to ensure the exact margins of the tumor.

#### **3.3 Combined colonoscopy and laparoscopy to close colonic perforation**

Iatrogenic colonic perforation can be treated with segmental laparoscopic resection or with laparoscopic suturing [21]. A new technique was proposed to close iatrogenic colonic perforation with combined endoscopy and laparoscopy approach. This technique involves mucosal closure using endoscopic clips, serosal closure using laparoscopy and a leak test with air insufflations and water irrigation [22].

#### **3.4 Combined laparoscopic-endoscopic approach for duodenal lesions**

Endoscopic mucosal resection and endoscopic mucosal dissection of duodenal lesions is feasible [23]. However, it is complicated with higher rates of bleeding, perforation and tumor recurrence compared to EMR and ESD of colonic and stomach lesions [24]. Sakon et al described a new technique utilizing ESD of the margins of the duodenal lesion followed by laparoscopic resection. This promising technique was associated with less procedure time and minimal bleeding [25].

#### **3.5 Laparoscopy assisted foreign body removal**

Most of ingested foreign body can be removed endoscopically. In few instances, sharp foreign body can invade through the gastrointestinal wall to other organ and require surgical assistance. Lanitis et al described a case in which a patient ingested two sharp needles, one of them migrated to the liver and another one invaded into the abdominal wall. Combined endoscopy and laparoscopy technique was successful in removing both lesions [26]. Another case report described the removal of large dental bridge by the combined approach. The foreign body was snared by the endoscopy in the stomach but it could not pass through the overtube in the esophagus. Gastrostomy was done using laparoscope then the snared foreign body was delivered to a laparoscopy grasper through the gastrostomy

Role of Endoscopy in Laparoscopic Procedures

time;, however, the lack of elevator could be problematic in gaining deep access of the CBD, especially in patients with naive papilla. Another novel technique utilizes the creation of a gastrostomy tube by an interventional radiologist in the excluded part of the stomach followed by the use of an ERCP endoscope through the gastrostomy[48]. Although this technique enables the use of an ERCP endoscope, it requires delaying the ERCP until maturation of the gastrostomy tube. A new technique of laparoscopic-assisted ERCP was proven to be successful in RYGBP patients [49]. Initially, a laparoscopic examination is done, followed by identification of the stomach remnant to create gastrostomy as an access for the ERCP endoscope. The endoscope is inserted through trochar from the abdominal wall to the gastrostomy opening and then to the biliary tract. This technique was successful in 9 out of 10 patients included in the study by Lopes et al. These impressive results were confirmed by Bertin et al, in which successful biliary cannulation was achieved in 94% of 21 RYGBP patients who underwent laparoscopic assisted ERCP [50]. In conclusion, bariatric surgeries are increasing due to the obesity epidemic. Endoscopists will have a major role in either

evaluating these patients prior to surgery or in treating post-surgical complications.

applications such as leaks, fistula and perforation are extremely encouraging [54-57].

scenarios where surgery is contraindicated or considered a more invasive approach.

The recent advances in therapeutic endoscopy opened a new frontier for endoscopists to manage complicated clinical scenarios that were only managed surgically in the past. In this section we are going to discuss a few examples of the use of endoscopy in these clinical

Cholecystectomy (mainly by laparoscopic approach) is the standard of care for management of acute cholecystitis. In high risk patients for surgery percutaneous cholecystostomy is advocated as a temporarizing measure [58]. However, this approach could be problematic in patients with coagulopathy or due to anatomical reasons. In addition, an indwelling catheter

**5. Endoscopy as an alternative to laparoscopy** 

**5.1 Endoscopic gallbladder drainage** 

Anastomotic leaks are one of the major complications after gastrointestinal surgery. After laparoscopic RYGBP, anastomotic leaks can develop in 0.3 to 8% of patients[51]. Traditionally these leaks were managed surgically. The introduction of self-expandable removable stents offered a less invasive approach for management of anastomotic leak. In a retrospective study that included 5 patients with anastomotic leak and one patient with chronic gastrocutaneous fistula; self-expandable plastic stent was successful in closing the leak in all 5 patients but not in the patient with the fistula [52]. In another retrospective study that included 11 patients with acute leak and 2 patients with chronic fistula as a complication of bariatric surgery, self-expandable removal stents (metal and plastic) were successful in healing the acute leak in 89% of patients and one of the two patients with chronic fistula [53]. A new endoscopic device named "over the scope clip(OSC)," which utilizes a combination of clip with grasper and large suction cap to ensure serosa to serosa closure, was recently introduced to clinical practice. The new system has been evaluated in 12 patients with post-operative leaks or fistula with successful closure in 10 patients [54]. Currently, this system is approved in Europe but is not yet available for clinical use in United States. The recently published experiences of the use of this new OSC in different

**4.2 Endoscopy in treatment of post-surgical leaks and fistulas** 

241

[27]. This technique has many advantages in difficult cases of foreign body removal. Endoscopy provides trans-illumination of the stomach and help to localize the foreign body for laparoscopic removal. In addition, laparoscopy provides the opportunity to clean the peritoneal spillage and ensure the closure of the abdominal wall [28].
