Long-term wound advantages of the laparoscopic approach in rectal cancer

Occurrence and prevention of incisional hernia following laparoscopic colorectal surgery

Among minimally invasive surgical procedures, colorectal surgery is associated with a notably higher incidence of incisional hernia (IH), ranging from 1.7% to 24.3%. This complication poses a significant burden on the healthcare system annually, necessitating urgent attention from surgeons. In a study published in the World Journal of Gastrointestinal Surgery, Fan et al compared the incidence of IH among 1614 patients who underwent laparoscopic colorectal surgery with different extraction site locations and evaluated the risk factors associated with its occurrence. This editorial analyzes the current risk factors for IH after laparoscopic colorectal surgery, emphasizing the impact of obesity, surgical site infection, and the choice of incision location on its development. Furthermore, we summarize the currently available preventive measures for IH. Given the low surgical repair rate and high recurrence rate associated with IH, prevention deserves greater research and attention compared to treatment.

Evaluating short-term and survival outcomes of natural orifice specimen extraction surgery for colorectal cancer: A single-centre retrospective study

Background

Natural orifice specimen extraction surgery (NOSES) has been confirmed as an alternative approach without auxiliary incisions. The purpose of this study was to investigate the short-term and survival outcomes of NOSES versus conventional laparoscopic surgery (LAP) in treatment of sigmoid and high rectal cancer.

Method

The retrospective study was conducted at single centers between January 2017 to December 2021. Relevant data included clinical demographics, pathological features, operative parameters, postoperative complications and survival outcomes were collected and analyzed. All procedures were performed using either a NOSES or a conventional LAP approach. Propensity score matching (PSM) was conducted to balance clinical and pathological features between the two groups.

Results

After PSM, a total of 288 patients were eventually included in this study, 144 in each group. Patients in the NOSES group experienced faster recovery of gastrointestinal function (2.6 ± 0.8 vs. 3.6 ± 0.9 day, P = 0.037), less pain and less analgesia required (12.5% vs. 33.3%, P < 0.001). In addition, the incidence of surgical site infection in the LAP group was significantly higher than that in the NOSES group (12.5% vs. 4.2%, P = 0.011), especially incision-related complications (8.3% vs. 2.1%, P = 0.017). After a median follow-up of 32 (range, 3-75) months, the two groups had similar 3-year overall survival rates (88.4% vs. 88.6%; P = 0.850) and disease-free survival rates (82.9% vs. 77.2%; P = 0.494).

Conclusion

The transrectal NOSES procedure is a well-established strategy with advantages in reducing postoperative pain, faster recovery of gastrointestinal function, and less incision-related complications. In addition, the long-term survival is similar between NOSES and conventional laparoscopic surgery.

Choice of specimen's extraction site affects wound morbidity in laparoscopic colorectal cancer surgery

BACKGROUND

The choice for an ideal site of specimen extraction following laparoscopic colorectal surgery remains debatable. However, midline incision (MI) is usually employed for right and left-sided colonic resections while left iliac fossa or suprapubic transverse incision (STI) were reserved for sigmoid and rectal cancer resections.

OBJECTIVE

To compare the incidence of surgical site infection (SSI) and incisional hernia (IH) in elective laparoscopic colorectal surgery for cancer and specimen extraction via MI or STI.

METHOD

Prospectively collected data of elective laparoscopic colorectal cancer resections between January 2017 and December 2019 were retrospectively reviewed. MI was employed for right and left-sided colonic resections while STI was used for sigmoid and rectal resections. SSI is defined according to the US CDC criteria. IH was diagnosed clinically and confirmed by CT scan at 1 year.

RESULTS

A total of 168 patients underwent elective laparoscopic colorectal resections. MI was used in 90 patients while 78 patients had STI as an extraction site. Demographic and preoperative data is similar for two groups. The rate of IH was 13.3% for MI and 0% in the STI (p = 0.001). SSI was seen in 16.7% of MI vs 11.5% of STI (p = 0.34). Univariate and multivariate analysis showed that the choice of extraction site is associated with statistically significant higher incisional hernia rate.

CONCLUSION

MI for specimen extraction is associated with higher incidence of both SSI and IH. The choice of incision for extraction site is an independent predicative factor for significantly higher IH and increased SSI rates.

Incidence and risk factors for umbilical incisional hernia after reduced port colorectal surgery (SIL + 1 additional port)-is an umbilical midline approach really a problem?

PURPOSE

Umbilical midline incisions for single incision- or reduced port laparoscopic surgery are still discussed controversially because of a higher rate of incisional hernia compared to conventional laparoscopic techniques. The aim of this study was to evaluate incidence and risk factors for incisional hernia after reduced port colorectal surgery.

METHODS

A total 241 patients underwent elective reduced port colorectal surgery between 2014 and 2020. Follow-up was achieved through telephone interview or clinical examination. The study collective was examined using univariate and multivariate analysis.

RESULTS

A total of 150 patients with complete follow-up were included into this study. Mean follow-up time was 36 (IQR 24-50) months. The study collective consists of 77 (51.3%) female and 73 (48.7%) male patients with an average BMI of 26 kg/m² (IQR 23-28) and an average age of 61 (± 14). Indication for surgery was diverticulitis in 55 (36.6%) cases, colorectal cancer in 65 (43.3%) patients, and other benign reasons in 30 (20.0%) cases. An incisional hernia was observed 9 times (6.0%). Obesity (OR 5.8, 95% CI 1.5-23.1, p = 0.02) and pre-existent umbilical hernia (OR 161.0, 95% CI 23.1-1124.5, p < 0.01) were significant risk factors for incisional hernia in the univariate analysis. Furthermore, pre-existent hernia is shown to be a risk factor also in multivariate analysis.

CONCLUSION

We could demonstrate that reduced port colorectal surgery using an umbilical single port access is feasible and safe with a low rate of incisional hernia. Obesity and pre-existing umbilical hernia are significant risk factors for incisional hernia.

Botulinum Toxin A Facilitated Laparoscopic Repair of Complex Ventral Hernia

Background: Complex ventral hernia repair can be challenging despite the recent advances in surgical techniques. Here, we aimed to examine the effectiveness of preoperative combined use of botulinum toxin A (BTA) and preoperative progressive pneumoperitoneum (PPP) for surgical preparation of patients with complex ventral hernia.

Methods: In this prospective, observational study, we included 22 patients with complex ventral hernia between January 2018 and May 2021. All patients were treated with BTA injections into the lateral abdominal muscles and PPP before hernia repair. The lengths of abdominal wall muscles, the volumes of the incisional hernia (VIH), the volumes of the abdominal cavity (VAC), and the VIH/VAC ratio were measured before and after BTA and PPP using abdominal CT scan. All Hernias were repaired using laparoscopic intra-peritoneal onlay mesh (IPOM) or laparoscopic-open-laparoscopic (LOL) techniques.

Results: Imaging showed a significant increase in the mean lateral abdominal muscle length from 13.1 to 17.2 cm/side (p < 0.01). Before and after BTA and PPP, the mean VIH was 894 cc and 1209 cc (P < 0.01), and the mean VAC was 6,692 cc and 9,183 cc (P < 0.01). The VAC increased by 2,491 cc (P < 0.01) and was greater than the mean VIH before PPP. An average reduction of 0.9% of the VIH/VAC ratio after BTA and PPP was obtained (p > 0.05). All hernias were surgically reduced with mesh, hernia recurrence occurred in only two patients.

Conclusions: The preoperative combined use of PPP and BTA increased the abdominal volume, lengthened the laterally retracted abdominal muscles, and facilitated laparoscopic closure of large complex ventral hernia.

Potential considerations in decision making on laparoscopic colorectal resections in Hungary based on administrative data

Background

Laparoscopic colorectal surgeries offer numerous advantages over their open counterparts. To compare these measurable short-time outcomes of open and laparoscopic resections in Hungary, data of colorectal surgeries were collected and analysed. The study focused on identifying patients’ characteristics that can influence the decision on laparoscopic colorectal resections and on comparing efficiency of Hungarian colorectal operations with international data.

Methods

Using patients’ data of laparoscopic and open colorectal surgery performed in 2015 and 2016 from the National Health Insurance Fund of Hungary, a countrywide retrospective comparative analysis was done. Logistic regression was used to explore main influencing factors for laparoscopic colorectal surgery.

Results

A total of 17,876 colorectal surgical cases, including 14,876 open and 3,000 laparoscopic resections were selected and analysed. Laparoscopy was used only in 16.78% of all cases. Comparison of age groups showed that odds ratio (OR) of laparoscopic colorectal resections was significantly lower in over 40 years than in younger patients (18–39 years). In university institutes patients had higher odds (OR: 2.23 p<0.0001) for laparoscopic colorectal resections. Presence of comorbidity codes and preoperative treatment in internal medicine department decreased odds for laparoscopic colorectal operations.

Conclusions

Patients’ age, comorbidities and hospital type influenced the likelihood of decision on laparoscopic colorectal resection. Selection of patients contributed to improved laparoscopic outcomes.

A Comparison of Colectomy Outcomes Utilizing Open, Laparoscopic, and Robotic Techniques

INTRODUCTION

Robotic colectomy could reduce morbidity and postoperative recovery over laparoscopic and open procedures. This comparative review evaluates colectomy outcomes based on surgical approach at a single community institution.

METHODS

A retrospective review of all patients who underwent colectomy by a fellowship-trained colon and rectal surgeon at a single institution from 2015 through 2019 was performed, and a cohort developed for each approach (open, laparoscopic, and robotic). 30-day outcomes were evaluated. For dichotomous outcomes, univariate logistic regression models were used to quantify the individual effect of each predictor of interest on the odds of each outcome. Continuous outcomes received a similar approach; however, linear and Poisson regression modeling were used, as appropriate.

RESULTS

115 patients were evaluated: 14% (n = 16) open, 44% (n = 51) laparoscopic, and 42% (n = 48) robotic. Among the cohorts, there was no statistically significant difference in operative time, rate of reoperation, readmission, or major complications. Robotic colectomies resulted in the shortest length of stay (LOS) (Kruskal-Wallis P < .0001) and decreased estimated blood loss (EBL) (Kruskal-Wallis P = .0012). Median age was 63 years (interquartile range [IQR] 53-72). 54% (n = 62) were female. Median American Society of Anesthesiologists physical status classification was 3 (IQR 2-3). Median body mass index was 28.67 (IQR 25.03-33.47). A malignant diagnosis was noted on final pathology in 44% (n = 51).

CONCLUSION

Among the 3 approaches, there was no statistically significant difference in 30-day morbidity or mortality. There was a statistically significant decreased LOS and EBL for robotic colectomies.

Homogeneously Emitting, Mechanically Stable, and Efficient fs-Laser-Machined Fiber Diffusers for Medical Applications

BACKGROUND AND OBJECTIVES

Light delivery is an essential part of therapy forms like photodynamic therapy (PDT), laser-induced thermotherapy, and endovenous laser therapy. While there are approaches to the light application for all three therapies, there is no diffuser that can be used for all three approaches. This diffuser must meet the following criteria: Homogeneous radiation profile over a length of 40 mm, efficient light extraction in the diffuser area, mechanical breakage resistance as well as thermal stability when applying high power.

STUDY DESIGN/MATERIALS AND METHODS

An ultrashort pulse laser was used to inscribe inhomogeneities into the core of a fused-silica fiber core while scanning the laser focus within a linear arrangement of cuboids centered around the fiber axis. The manufactured diffuser was optically and mechanically characterized and examined to determine the maximum power that can be applied in a tissue environment.

RESULTS

Based on the analysis of all examined diffusers, the manufactured diffuser exhibits an emission efficiency ε = (81.5 ± 5.9)%, an intensity variability of (19 ± 5)% between distal and proximal diffuser end, and a minimum bending radius R_b = (15.4 ± 1.5) mm. It was taken advantage of the fact that the outer areas of the fiber core do not undergo any structural changes due to the machining and therefore do not suffer a major loss of stability. Tissue experiments revealed that a maximal power of 15 W was deliverable from the diffuser without harming the diffuser itself.

CONCLUSIONS

It could be shown that a diffuser manufactured by ultrafast-laser processing can be used for low power applications as well as for high power applications. Further tests have to show whether the mechanical stability is still maintained after the application of high power in a tissue environment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Minimally invasive right colectomy with transrectal natural orifice extraction: could this be the next step forward?

Background

The transvaginal natural orifice specimen extraction (NOSE) approach for right-side colon surgery has been proven to exhibit favorable short-term outcomes. However, thus far, no study has reported the advantages of transrectal NOSE for right-side colon surgery. The aim of this study was to compare the technical feasibility, safety, and short-term outcomes of minimally invasive right hemicolectomy using the transrectal NOSE method and those of conventional mini-laparotomy specimen extraction.

Methods

A study was conducted on consecutive patients who had minimally invasive right hemicolectomy either for malignancy or benign disease at Chang Gung Memorial Hospital, Linkou, Taiwan, between January 2017 and December 2018. The patients were divided into two groups: conventional surgery with specimen extraction using mini-laparotomy and NOSE surgery. Surgical outcomes, including complications, postoperative short-term recovery, and pain intensity, were analyzed.

Results

We enrolled 297 patients (151 males, mean age 64.9 ± 12.8 years) who had minimally invasive right hemicolectomy. Of these 297 patients, 272 patients had conventional surgery with specimen extraction through mini-laparotomy and 25 patients had NOSE surgery (23 transrectal, 2 transvaginal). The diagnosis of colon disease did not differ significantly between the conventional and NOSE groups. Postoperative morbidity and mortality rates were comparable. The postoperative hospital stay was significantly (p = 0.004) shorter in the NOSE group (median 5 days, range 3–17 days) than in the conventional group (median 7 days, range 3–45 days). Postoperative pain was significantly (p = 0.026 on postoperative day 1 and p = 0.002 on postoperative day 2) greater in the conventional group than in the NOSE group.

Conclusions

NOSE was associated with acceptable short-term surgical outcomes that were comparable to those of conventional surgery. NOSE results in less postoperative wound pain and a shorter hospital stay than conventional surgery. Larger studies are needed

Hernia incidence following a randomized clinical trial of single-incision versus multi-port laparoscopic colectomy

BACKGROUND

The short-term results of single-incision laparoscopic colectomy (SILC) showed the safety, feasibility, and effectiveness when performed by skilled laparoscopic surgeons. However, the long-term complications, such as SILC-associated incisional hernia, have not been evaluated. The aim of this study was to determine the incidence of incisional hernia after SILC compared with multi-port laparoscopic colectomy (MPC) for colon cancer.

METHODS

From March 2012, to March 2015, a total of 200 patients were enrolled in this study. The patients were randomized to the MPC arm and SILC arm. A total of 200 patients (MPC arm; 100 patients, SILC arm; 100 patients) were therefore analyzed. In all cases the specimen was extracted through the umbilical port, which was extended according to the size of the specimen. A diagnosis of incisional hernia was made either based on a physical examination or computed tomography.

RESULTS

The baseline factors were well balanced between the arms. The median follow-up period was 42.4 (range 9.4-70.0) months. Twenty-one patients were diagnosed with incisional hernia, giving an incidence rate of 12.1% in the MPC arm and 9.0% in the SILC arm at 36 months (P = 0.451). In the multivariate analysis, the body mass index (≥ 25 kg/m²) (hazard ratio [HR] 3.03; 95% confidence interval [CI] 1.03-8.92; P = 0.044), umbilical incision (≥ 5.0 cm) (HR 3.22; 95% CI 1.16-8.93; P = 0.025), and history of umbilical hernia (HR 3.16; 95% CI 1.02-9.77; P = 0.045) were shown to be correlated with incisional hernia.

CONCLUSIONS

We found no significant difference in the incidence of incisional hernia after SILC arm versus MPC arm with a long-term follow-up. However, this result may be biased because all specimens were harvested through the umbilical port. The study was registered with the Japanese Clinical Trials Registry as UMIN000007220.

Totally Laparoscopic Resection for Low Sigmoid and Rectal Cancer Using Natural Orifice Specimen Extraction Techniques

BACKGROUND

A minilaparotomy for specimen extraction during laparoscopy occasionally results in postoperative wound complications. We have performed a totally laparoscopic resection for early colorectal cancer using the natural orifice specimen extraction technique.

METHODS

From 2008 to 2013, we have performed a totally laparoscopic resection for clinical stage I and IIA low sigmoid colon and rectal cancers. A prospectively maintained database was reviewed to assess the outcomes after surgery.

RESULTS

In total, 40 patients had high anterior resections using transanal specimen extraction, and 32 patients had low anterior resections with transanal pull-through. Eight patients (11%) reported conversion to conventional laparoscopic colorectal resections; anastomotic leakages occurred in 4 patients (5.6%). No mortality or cancer recurrence was observed during 42.5±16.2 months of follow-up.

CONCLUSIONS

One natural orifice specimen extraction technique, known as transanal specimen extraction, has emerged as a promising form of totally laparoscopic surgical intervention for early-stage cancers of the low sigmoid colon and rectum.

Minimally Invasive versus Open Approach for Right-Sided Colectomy: A Study in 12,006 Patients from the Dutch Surgical Colorectal Audit

BACKGROUND

There is ongoing debate whether laparoscopic right colectomy is superior to open surgery. The purpose of this study was to address this issue and arrive at a consensus using data from a national database.

METHODS

Patients who underwent elective open or laparoscopic right colectomy for colorectal cancer during the period 2009-2013 were identified from the Dutch Surgical Colorectal Audit. Complications that occurred within 30 days after surgery and 30-day mortality rates were calculated and compared between open and laparoscopic resection.

RESULTS

In total, 12,006 patients underwent elective open or laparoscopic surgery for right-sided colorectal cancer. Of these, 6,683 (55.7%) underwent open resection and 5,323 (44.3%) underwent laparoscopic resection. Complications occurred within 30 days after surgery in the laparoscopic group in 26.1% of patients and in 32.1% of patients in the open group (p < 0.001). Thirty-day mortality was also significantly lower in the laparoscopic group (2.2 vs. 3.6% p < 0.001).

CONCLUSION

In this non-randomized, descriptive study conducted in the Netherlands, open right colectomy seems to have a higher risk for complications and mortality as compared to laparoscopic right colectomy, even after correction for confounding factors.

Learning curve in robotic rectal cancer surgery: current state of affairs

INTRODUCTION

Robotic-assisted rectal cancer surgery offers multiple advantages for surgeons, and it seems to yield the same clinical outcomes as regards the short-time follow-up of patients compared to conventional laparoscopy. This surgical approach emerges as a technique aiming at overcoming the limitations posed by rectal cancer and other surgical fields of difficult access, in order to obtain better outcomes and a shorter learning curve.

MATERIAL AND METHODS

A systematic review of the literature of robot-assisted rectal surgery was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted in October 2015 in PubMed, MEDLINE and the Cochrane Central Register of Controlled Trials, for articles published in the last 10 years and pertaining the learning curve of robotic surgery for colorectal cancer. It consisted of the following key words: "rectal cancer/learning curve/robotic-assisted laparoscopic surgery".

RESULTS

A total of 34 references were identified, but only 9 full texts specifically addressed the analysis of the learning curve in robot-assisted rectal cancer surgery, 7 were case series and 2 were non-randomised case-comparison series. Eight papers used the cumulative sum (CUSUM) method, and only one author divided the series into two groups to compare both. The mean number of cases for phase I of the learning curve was calculated to be 29.7 patients; phase II corresponds to a mean number 37.4 patients. The mean number of cases required for the surgeon to be classed as an expert in robotic surgery was calculated to be 39 patients.

CONCLUSION

Robotic advantages could have an impact on learning curve for rectal cancer and lower the number of cases that are necessary for rectal resections.

Ten-year outcomes following laparoscopic colorectal resection: results of a randomized controlled trial

PURPOSE

To evaluate the impact of laparoscopy compared to open surgery on long-term outcomes in a large series of patients who participated in a randomized controlled trial comparing short-term results of laparoscopic (LPS) versus open colorectal resection.

METHODS

This is a retrospective review of a prospective database including 662 patients with colorectal disease (526, 79 % cancer patients) who were randomly assigned to LPS or open colorectal resection and followed every 6 months by office visits. The primary endpoint of the study was long-term morbidity. Secondary outcomes included 10-year overall, cancer-specific, and disease-free survivals. All patients were analyzed on an intention-to-treat basis.

RESULTS

Fifty-eight (8.8 %) patients were lost to follow-up. Median follow-up was 131 (IQR 78-153) months in the LPS group and 126 (IQR 52-152) months in the open group (p = 0.121). Overall, long-term morbidity rate was 11.8 % (36/309) in the LPS versus 12.6 % (37/295) in the open group (p = 0.770). Incisional hernia rate was 5.8 % (18/309) in the LPS group versus 8.1 % (24/295) in the open group (p = 0.264). Adhesion-related small-bowel obstruction occurred in five (1.6 %) patients in the LPS versus four (1.4 %) patients in the open group (p = 1.000). In 497 cancer patients, 10-year overall survival was 45.3 % in the LPS group and 40.9 % in the open group (p = 0.160). No difference was found in cancer-specific and disease-free survivals, also when patients were stratified according to cancer stage.

CONCLUSION

In this series, LPS colorectal resection was not associated with a lower long-term morbidity rate when compared to open surgery. Overall, cancer-specific and disease-free survivals were similar in cancer patients who were treated with LPS and open surgeries.

Laparoscopic management of non-midline incisional hernia: A multicentric study

BACKGROUND

The laparoscopic repair of non-midline ventral hernia (LNM) has been debated. The aim of this study is to analyze our experience performing the laparoscopic approach to non-midline ventral hernias (NMVHs) in Northwest Italy for 6 years.

METHODS

A total of 78 patients who underwent LNM between March 2008 and March 2014 in the selected institutions were analyzed. We retrospectively analyzed the peri- and postoperative data and the recurrence rate of four subgroups of NMVHs: subcostal, suprapubic, lumbar, and epigastric. We also conducted a literature review.

RESULTS

No difference was found between the four subgroups in terms of demographic data, defect characteristics, admission data, and complications. Subcostal defects required a shorter operating time. Obesity was found to be a risk factor for recurrence.

CONCLUSIONS

In our experience, subcostal defects were easier to perform, with a lower recurrence rate, lesser chronic pain, and faster surgical performance. A more specific prospective randomized trial with a larger sample is awaited. Based on our experience, however, the laparoscopic approach is a safe treatment for NMVHs in specialized centers.

Laparoscopic incisional hernia repair after colorectal surgery. Is it possible to maintain a mini-invasive approach?

Several benefits have been described in laparoscopic surgery. However, there is a lack of evidence concerning laparoscopic repair of incisional hernia after laparoscopic colorectal surgery (LCRS). We aimed to evaluate the feasibility and the results of laparoscopic incisional hernia repair after LCRS. Between May 2001 and March 2014, all charts of consecutive patients who underwent LCRS and developed an incisional hernia were evaluated. Patients with parastomal hernias or those with less than 6 months of follow-up were excluded. Patients were assigned to laparoscopic repair group (LR) and open repair group (OR). Demographics, surgical factors, and 30-day postoperative complications were analyzed. The incisional ventral hernia rate was 7 % (90/1290), and 82 incisional hernia repairs were performed. In 49 patients (60 %) an open approach was performed, and there were 33 laparoscopic repairs (2 converted due to small bowel injury). Mean age was 62 years. Average body mass index was 27.4 ± 5.2 kg/m². The mean defect size was 56 (4-527) cm², and there were no differences between the groups (LR: 49 cm² vs OR: 63 cm²; p = NS). Average operative time was 107 (45-240) minutes (LR: 93 min vs OR: 116 min, p = 0.02). OR showed a higher rate of postoperative complications (OR: 51 % vs LR: 18 %, p = 0.003) and increased hospital stay (OR: 2.77 ± 4 days vs LR: 0.7 ± 0.4 days; p = 0.02). The recurrence rate was 15 % (12 patients, 6 each group; p = NS) after a follow-up of 48 (r: 6-141) months. Laparoscopic approach for incisional hernia repair after LCRS seems to be safe and feasible. Patients who received laparoscopic approach showed significantly less postoperative complications and shorter hospital staying. These observations suggest that mini-invasive surgery may be the initial approach in patients who develop an incisional hernia after LCRS.

Feasibility of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis and total colectomy with ileorectal anastomosis for familial adenomatous polyposis: results of a nationwide multicenter study

BACKGROUND

Data supporting the safety and feasibility of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) and total colectomy with ileorectal anastomosis (TC-IRA) for patients with familial adenomatous polyposis (FAP) are limited. The aim of this study was to clarify the feasibility and morbidity of laparoscopic TPC-IPAA and TC-IRA for patients with FAP, using a large Japanese multicenter dataset.

METHODS

Data on 256 patients with FAP who underwent TPC-IPAA (n = 171) or TC-IRA (n = 85) at 23 institutions between the years 2000 and 2012 were collected. Short- and long-term clinical outcomes were compared between laparoscopic and open approaches for each procedure.

RESULTS

Among the 256 patients with FAP, a total of 126 patients underwent laparoscopic surgery, consisting of 74 laparoscopic TPC-IPAAs and 52 laparoscopic TC-IRAs. The proportion of the FAP patients who underwent laparoscopic surgery increased during the study period, reaching 79 % of all TPC-IPAAs and 82 % of all TC-IRAs in the final two years covered by the data. In both TPC-IPAA and TC-IRA, the laparoscopic approach was associated with a longer operative duration but a similarly low postoperative morbidity and comparably adequate anal function compared with the open approach. The overall survival and the incidence of desmoid tumor were also comparable between the laparoscopic and open approaches in both procedures.

CONCLUSIONS

Laparoscopic TPC-IPAA and TC-IRA are both feasible options-with low rates of morbidity, good functional outcomes, and excellent overall survival rates-in patients with FAP. Since the data indicate that laparoscopic TPC-IPAA and TC-IRA are feasible, they also support the recent increase in laparoscopic surgery for patients with FAP in Japan.

Effect of Visceral Obesity on Surgical Outcomes of Patients Undergoing Laparoscopic Colorectal Surgery

BACKGROUND

Visceral obesity has been known to be more pathogenic than body mass index (BMI). There have been a few reports about the association between visceral obesity and surgical outcomes in laparoscopic surgery. The aim of this study was to evaluate the effect of visceral obesity on surgical outcomes undergoing laparoscopic colorectal surgery.

METHODS

Between January 2005 and December 2012, a total of 543 patients who underwent laparoscopic resection for colorectal cancer and had available computed tomography (CT) scans were included in this retrospective study. Visceral fat volumes (VFVs) were measured in preoperative CT scans from S1 to 12.5 cm above. Patients were divided into an obese group and a non-obese group according to VFV and BMI. Obesity was defined by VFV ≥1.92 dm(3) (75% value of VFV) or BMI ≥25 kg/m(2).

RESULTS

There were 136 (25.0%) and 150 (27.6%) obese patients according to VFV and BMI, respectively. The high VFV group had a longer operative times (165.2 ± 84.4 vs. 146.1 ± 58.9 min; P = 0.016), higher blood loss during surgery (132.5 ± 144.8 vs. 98.3 ± 109.6 ml; P = 0.012), more frequent conversion to laparotomy (5.9 vs. 1.5%; P = 0.010), and more frequent major complications (Dindo score ≥3; 11.0 vs. 4.7%; P = 0.008), whereas there was no significant difference between the high and low BMI groups. High VFV was a significant independent risk factor for open conversion (odds ratio 4.964, 95% confidence interval 1.336-18.438, P = 0.017).

CONCLUSIONS

Visceral obesity can be a more clinically useful predictor than BMI in predicting surgical outcomes for laparoscopic colorectal cancer surgery.

Incisional and port-site hernias following robotic colorectal surgery

BACKGROUND

The association between extraction site location, robotic trocar size, and the incidence of incisional hernias in robotic colorectal surgery remain unclear. Laparoscopic literature reports variable rates of incisional hernias versus open surgery, and variable rates of trocar site hernias. However, conclusions from these studies are confusing due to heterogeneity in closure techniques and may not be generalized to robotic cases. This study evaluates the effect of extraction site location on incisional hernia rates, as well as trocar hernia rates in robotic colorectal surgery.

MATERIALS AND METHODS

A retrospective review of multiport and single incision robotic colorectal surgeries from a single institution was performed. Patients underwent subtotal, segmental, or proctocolectomies, and were compared based on the extraction site through either a muscle-splitting (MS) or midline (ML) incision. Hernias were identified by imaging and/or physical exam. Demographics and risk factors for hernias were assessed. Groups were compared using a multivariate logistic regression analysis.

RESULTS

The study included 259 colorectal surgery patients comprising 146 with MS and 113 with ML extraction sites. Postoperative computed tomograms were performed on 155 patients (59.8 %) with a mean follow-up of 16.5 months. The overall incisional hernia rate was 5.8 %. A significantly higher hernia rate was found among the ML group compared to the MS group (12.4 vs. 0.68 %, p < 0.0001). Of the known risk factors assessed, only increased BMI was associated with incisional hernias (OR 1.18). No trocar site hernias were found.

CONCLUSION

Midline extraction sites are associated with a significantly increased rate of incisional hernias compared to muscle-splitting extraction sites. There is little evidence to recommend fascia closure of 8-mm trocar sites.

Systematic Review and Meta-Regression of Factors Affecting Midline Incisional Hernia Rates: Analysis of 14,618 Patients

BACKGROUND

The incidence of incisional hernias (IHs) following midline abdominal incisions is difficult to estimate. Furthermore recent analyses have reported inconsistent findings on the superiority of absorbable versus non-absorbable sutures.

OBJECTIVE

To estimate the mean IH rate following midline laparotomy from the published literature, to identify variables that predict IH rates and to analyse whether the type of suture (absorbable versus non-absorbable) affects IH rates.

METHODS

We undertook a systematic review according to PRISMA guidelines. We sought randomised trials and observational studies including patients undergoing midline incisions with standard suture closure. Papers describing two or more arms suitable for inclusion had data abstracted independently for each arm.

RESULTS

Fifty-six papers, describing 83 separate groups comprising 14,618 patients, met the inclusion criteria. The prevalence of IHs after midline incision was 12.8% (range: 0 to 35.6%) at a weighted mean of 23.7 months. The estimated risk of undergoing IH repair after midline laparotomy was 5.2%. Two meta-regression analyses (A and B) each identified seven characteristics associated with increased IH rate: one patient variable (higher age), two surgical variables (surgery for AAA and either surgery for obesity surgery (model A) or using an upper midline incision (model B)), two inclusion criteria (including patients with previous laparotomies and those with previous IHs), and two circumstantial variables (later year of publication and specifying an exact significance level). There was no significant difference in IH rate between absorbable and non-absorbable sutures either alone or in conjunction with either regression analysis.

CONCLUSIONS

The IH rate estimated by pooling the published literature is 12.8% after about two years. Seven factors account for the large variation in IH rates across groups. However there is no evidence that suture type has an intrinsic effect on IH rates.

Laparoscopic versus open surgery for complicated appendicitis in adults: a randomized controlled trial

BACKGROUND

The aim of this study was to assess whether laparoscopic appendectomy (LA) for complicated appendicitis (CA) effectively reduces the incidence of postoperative complications and improves various measurements of postoperative recovery in adults compared with open appendectomy (OA).

METHODS

This single-center, randomized controlled trial was performed in the Nagoya Daini Red Cross Hospital. Patients diagnosed as having CA with peritonitis or abscess formation were eligible to participate and were randomly assigned to an LA group or an OA group. The primary study outcome was development of infectious complications, especially surgical site infection (SSI), within 30 days of surgery.

RESULTS

Between October 2008 and August 2014, 81 patients were enrolled and randomly assigned with a 1:1 allocation ratio (42, LA; 39, OA). All were eligible for study of the primary endpoint. Groups were well balanced in terms of patient characteristics and preoperative levels of C-reactive protein. SSI occurred in 14 LA group patients (33.3 %) and in 10 OA group patients (25.6 %) (OR 1.450, 95 % CI 0.553-3.800; p = 0.476). Overall, the rate of postoperative complications, including incisional or organ/space SSI and stump leakage, did not differ significantly between groups. No significant differences between groups were found in hospital stay, duration of drainage, analgesic use, or parameters for postoperative recovery except days to walking.

CONCLUSION

These results suggested that LA for CA is safe and feasible, while the distinguishing benefit of LA was not validated in this clinical trial.

Risk factors for incisional hernia after hepatic resection for hepatocellular carcinoma in patients with liver cirrhosis

BACKGROUND

The risk factors for incisional hernia (IH) and the association between liver fibrosis and IH after hepatic resection in patients with hepatocellular carcinoma (HCC) with liver cirrhosis (LC) are still unclear. We aimed to evaluate the rate of IH and to assess the effect of perioperative factors, including serum markers for liver fibrosis, on the risk of IH.

METHODS

A total of 192 patients with HCC with LC who received hepatectomy were retrospectively analyzed. The primary end point was the incidence rate of IH and the secondary end points were associations between IH and 22 clinical factors.

RESULTS

IH was diagnosed in 60 (31.3%) patients. The estimated incidence rates were 19.8% at 12 months, 32.5% at 36 months, and 38.8% at 60 months. In multivariable analysis, the presence of postoperative intractable ascites (odds ratio 24.83, P = .0003), abdominal wall closure by a single-layer mass closure with a continuous running suture (odds ratio 4.59, P = .0143), preoperative body mass index ≥ 25 kg/m(2) (odds ratio 3.36, P = .0025), and preoperative serum N-terminal pro-peptide of type IV collagen 7S domain (P4NP 7S) levels ≥ 5 ng/mL (odds ratio 3.13, P = .0234) were independent risk factors.

CONCLUSION

There are several risk factors for IH after hepatic resection in HCC patients with LC. Preoperative serum P4NP 7S levels ≥ 5 ng/mL are a useful predictive marker, and abdominal wall closure with a continuous running suture by a single-layer mass closure should be avoided.

How do patients score cosmesis after laparoscopic natural orifice specimen extraction colectomy?

AIM

Laparoscopic colorectal resection results in improved cosmetic outcome and better presumed body image. Laparoscopic NOSE colectomy omits an incision for specimen extraction and is supposed to further improve postoperative cosmesis. This study aimed to assess the cosmetic benefit.

METHOD

Forty-nine patients who underwent a NOSE colectomy for bowel endometriosis from September 2009 to September 2013 were matched for age, American Society of Anesthesiologists (ASA) grade and body mass index (BMI) with patients who underwent a conventional laparoscopic colectomy for the same indication. Patients were asked to complete a questionnaire consisting of a body scale and a cosmetic scale and the Patient Scar Assessment Questionnaire (PSAQ) including five subscales (appearance, symptoms, scar consciousness, satisfaction with appearance and satisfaction with symptoms).

RESULTS

Patient demographics were similar between both groups. Patients were assessed at a median postoperative follow-up of 41 months in the NOSE colectomy group and 35 months in the conventional resection group. The median body image questionnaire score was 15 for NOSE colectomy and 18 for conventional resection (P = 0.027). The respective median PSAQ scores were 56 and 71 (P = 0.002). There was a good relationship between the PSAQ score and the body image questionnaire (Spearman correlation coefficient 0.82).

CONCLUSION

Depending on the scoring system used, the cosmetic outcome may be better after NOSE colectomy than conventional laparoscopy in patients having surgery for endometriosis. The comprehensive body image questionnaire, being shorter and easier to use, could be a valid tool for assessing cosmesis after NOSE procedures.

Laparoscopic right hemicolectomy with intracorporeal versus extracorporeal anastamosis: a comparison of short-term outcomes

BACKGROUND

There is wide variation among laparoscopic colon resection techniques, including the approach for mobilization and the extent of intracorporal vessel ligation, bowel division or anastamosis. We compared the short-term outcomes of laparoscopic right hemicolectomy (LRHC) with intracorporeal (IA) versus extracorporeal (EA) anastamosis.

METHODS

We retrospectively reviewed all elective laparoscopic right hemicolectomies performed at St. Joseph's Hospital between January 2008 and September 2009 and compared the demographic, pathologic, operative and outcome data.

RESULTS

Fifty LRHCs were completed during the study period: 21 IA and 29 EA. The groups were similar in age, sex, body mass index, American Society of Anesthesiologists score, previous laparotomy and preoperative invasive pathology. There was no difference between IA and EA in mean duration of surgery (170 v. 181 min, p = 0.78), estimated blood loss (14 v. 42 mL, p = 0.15), perioperative blood transfusions (5% v. 14%, p = 0.29), in-hospital morbidity (33% v. 41%, p = 0.56), out-of-hospital morbidity (19% v. 31% p = 0.34), emergency department visits (10% v. 17%, p = 0.16) or 30-day readmissions (5% v. 7%, p = 0.75). There was 1 anastamotic leak in each group and no perioperative deaths. Median length of stay was significantly shorter for IA (4 v. 5 d, p = 0.05). There were 6 extraction site hernias with EA and none with IA (p = 0.026).

CONCLUSION

Laparoscopic right hemicolectomy with IA has the advantage of a less hernia-prone Pfannenstiel extraction site, faster recovery and shorter stay in hospital EA.

Laparoscopic IPAA is not associated with decreased rates of incisional hernia and small-bowel obstruction when compared with open technique: long-term follow-up of a case-matched study

BACKGROUND

There are scant data on the presumed reduction of small-bowel obstruction and incisional hernia rates associated with laparoscopic IPAA.

OBJECTIVE

The aim of this study was to compare long-term outcomes after open vs laparoscopic IPAA based on a previous study from our institution.

DESIGN

This was a retrospective cohort study (from January 1992 through December 2007).

SETTINGS

The study was conducted in a high-volume, specialized colorectal surgery department.

PATIENTS

Patients included those who were enrolled in a previous institutional case-matched (2:1) study that examined 238 open and 119 laparoscopic IPAAs.

MAIN OUTCOME MEASURES

Long-term complications, including incisional hernia clinically detected by physician, adhesive small-bowel obstruction requiring hospital admission and surgery, pouch excision, and pouchitis rates, were collected. Laparoscopic abdominal colectomy followed by rectal dissection under direct vision (lower midline or Pfannenstiel incision) and converted cases were analyzed within the laparoscopic group.

RESULTS

Groups were comparable with respect to age, sex, BMI, and extent of resection (completion proctectomy vs proctocolectomy), consistent with the original case matching. Mean follow-up was significantly longer in the open group (9.6 vs 8.1 years; p = 0.008). Open and laparoscopic operations were associated with similar incidences of incisional hernia (8.4% vs 5.9%; p = 0.40), small-bowel obstruction requiring hospital admission (26.1% vs 29.4%; p = 0.50), and small-bowel obstruction requiring surgery (8.4% vs 11.8%; p = 0.31). A subgroup analysis comparing 50 patients with laparoscopic rectal dissection versus 69 patients with rectal dissection under direct vision confirmed statistically similar incidences of incisional hernia, hospital admission, and surgery for small-bowel obstruction.

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSIONS

Some of the anticipated long-term benefits of laparoscopic IPAA could not be demonstrated in this cohort. The lack of such long-term benefits should be discussed with patients when proposing a laparoscopic approach.

Single port laparoscopy in gastroenterology and hepatology: A fine step forward

Single incision laparoscopy (SIL) has become an emerging technology aiming at a further reduction of abdominal wall trauma in minimally invasive surgery. Available data is encouraging for the safe application of standardized SIL in a wide range of procedures in gastroenterology and hepatology. Compared to technically simple SIL procedures, the merit of SIL in advanced surgeries, such as liver or colorectal interventions, compared to conventional laparsocopy is self-evident without any doubt. SIL has already passed the learning curve and is routinely utilized in expert centers. This minimized approach has allowed to enter a new era of surgical management that can not be acceded without a fruitful combination of prudent training, consistent day-to-day work and enthusiastic motivation for technical innovations. Both, basic and novel technical specifics as well as particular procedures are described herein. The focus is on the most important surgical interventions in gastroenterology and aims at reviewing the current literature and shares our experience in a high volume center.

Laparoscopic natural orifice specimen extraction-colectomy: A systematic review

Over the last 20 years, laparoscopic colorectal surgery has shown equal efficacy for benign and malignant colorectal diseases when compared to open surgery. However, a laparoscopic approach reduces postoperative morbidity and shortens hospital stay. In the quest to optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma could be a way to improve recovery. To date, one method to reduce access trauma is natural orifice specimen extraction (NOSE). NOSE aims to reduce access trauma in laparoscopic colorectal surgery. The specimen is delivered via a natural orifice and the anastomosis is created intracorporeally. Different methods are used to extract the specimen and to create a bowel anastomosis. Currently, specimens are delivered transcolonically, transrectally, transanally, or transvaginally. Each of these NOSE-procedures raises specific issues with regard to operative technique and application. The presumed benefits of NOSE-procedures are less pain, lower analgesia requirements, faster recovery, shorter hospital stay, better cosmetic results, and lower incisional hernia rates. Avoidance of extraction site laparotomy is the most important characteristic of NOSE. Concerns associated with the NOSE-technique include bacterial contamination of the peritoneal cavity, inflammatory response, and postoperative outcomes, including postoperative pain and the functional and oncologic outcomes. These issues need to be studied in prospective randomized controlled trials. The aim of this systematic review is to describe the role of NOSE in minimally invasive colorectal surgery.

Incidence of and risk factors for incisional hernia after abdominal surgery

BACKGROUND

Few larger studies have estimated the incidence of incisional hernia (IH) after abdominal surgery.

METHODS

Patients who had abdominal surgery between November 2009 and February 2011 were included in the study. The incidence rate and risk factors for IH were monitored for at least 180  days.

RESULTS

A total of 4305 consecutive patients were registered. Of these, 378 were excluded because of failure to complete follow-up and 3927 patients were analysed. IH was diagnosed in 318 patients. The estimated incidence rates for IH were 5·2 per cent at 12  months and 10·3 per cent at 24 months. In multivariable analysis, wound classification III and IV (hazard ratio (HR) 2·26, 95 per cent confidence interval 1·52 to 3·35), body mass index of 25 kg/m(2) or higher (HR 1·76, 1·35 to 2·30), midline incision (HR 1·74, 1·28 to 2·38), incisional surgical-site infection (I-SSI) (HR 1·68, 1·24 to 2·28), preoperative chemotherapy (HR 1·61, 1·08 to 2·37), blood transfusion (HR 1·46, 1·04 to 2·05), increasing age by 10-year interval (HR 1·30, 1·16 to 1·45), female sex (HR 1·26, 1·01 to 1·59) and thickness of subcutaneous tissue for every 1-cm increase (HR 1·18, 1·03 to 1·35) were identified as independent risk factors. Compared with superficial I-SSI, deep I-SSI was more strongly associated with the development of IH.

CONCLUSION

Although there are several risk factors for IH, reducing I-SSI is an important step in the prevention of IH.

REGISTRATION NUMBER

UMIN000004723 (University Hospital Medical Information Network, http://www.umin.ac.jp/ctr/index.htm).

Small bowel obstruction, incisional hernia and survival after laparoscopic and open colonic resection (LAFA study)

BACKGROUND

Short-term advantages to laparoscopic surgery are well described. This study compared medium- to long-term outcomes of a randomized clinical trial comparing laparoscopic and open colonic resection for cancer.

METHODS

The case notes of patients included in the LAFA study (perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care) were reviewed 2-5 years after randomization for incisional hernia, adhesional small bowel obstruction (SBO), overall survival, cancer recurrence and quality of life (QoL). The laparoscopic and open groups were compared irrespective of fast-track or standard perioperative care.

RESULTS

Data on incisional hernias, SBO, survival and recurrence were available for 399 of 400 patients: 208 laparoscopic and 191 open resections. These outcomes were corrected for duration of follow-up. Median follow-up was 3·4 (i.q.r. 2·6-4·4) years. Multivariable regression analysis showed that open resection was a risk factor for incisional hernia (odds ratio (OR) 2·44, 95 per cent confidence interval (c.i.) 1·12 to 5·26; P = 0·022) and SBO (OR 3·70, 1·07 to 12·50; P = 0·039). There were no differences in overall survival (hazard ratio 1·10, 95 per cent c.i. 0·67 to 1·80; P = 0·730) or in cumulative incidence of recurrence (P = 0·514) between the laparoscopic and open groups. There were no measured differences in QoL in 281 respondents (P > 0·350 for all scales).

CONCLUSION

Laparoscopic colonic surgery led to fewer incisional hernia and adhesional SBO events.

REGISTRATION NUMBER

NTR222 (http://www.trialregister.nl).

Incisional hernia after laparoscopic colorectal surgery. Is there any factor associated?

BACKGROUND

Laparoscopic approach is related to, among others, educing abdominal wall complications such as incisional hernia (IH). However, there are scarce data concerning laparoscopic colorectal surgery (LCRS). The aim of this study was to evaluate related factors and incidence of IH following this approach.

METHODS

A retrospective analysis of consecutive patients who underwent colorectal surgery with laparoscopic approach in a single center was performed. Patients with a minimum follow-up of 6 months, and also converted to open surgery were included. Uni- and multi-variate analyses were performed using the following variables: age; gender; type of surgery (left, right, total, or segmental colectomy); comorbidities [diabetes and chronic pulmonary obstructive disease (COPD)]; previous surgery; colorectal disease (benign and malignant); operative time; surgical site infection (SSI); and body mass index (BMI). Midline incisions (right colectomy) and off-midline incisions (left colectomies and rectal resections) were also compared.

RESULTS

During a period of 12 years, 1051 laparoscopic colorectal surgeries were performed. The incidence of IH was 6% (n = 63). Univariate analysis showed that BMI > 30 kg/m(2) [p < 0.01, OR: 2.3 (1.3-4.7)], SSI [p < 0.01, OR: 6.5 (3.4-12.5)], operative time >180 min [p < 0.01, OR: 2.1 (1.2-3.6)] and conversion to open surgery (p = 0.01, OR: 2.4 [1.1-5.0]) were related to incisional hernias. BMI and SSI have a statistically significant relation with the incidence of IH in multivariate analysis (p < 0.01). No statistical difference between right and left colectomy was observed (6.6 vs. 6.4%, respectively).

CONCLUSION

The incidence of IH after LCRS seems to be acceptable. BMI over 30 kg/m(2) and SSI are strongly associated to this complication.

Outcomes of laparoscopic and open restorative proctocolectomy

Background

The literature on laparoscopic restorative proctectomy (RP) and proctocolectomy (RPC) is limited. This study compared clinical outcomes of laparoscopic RP and RPC with those of conventional open surgery at one centre.

Methods

Data were analysed from consecutive patients undergoing RPC and RP between November 2006 and November 2011. A standard laparoscopic technique was developed during the first 2 years, performed by two laparoscopic surgeons, with selection of patients who had not previously undergone open colectomy. Study endpoints included postoperative length of stay, 30-day morbidity, readmission, reoperation, pouch function and failure.

Results

A total of 207 patients were included; open surgery was performed in 131 (63·3 per cent) and a laparoscopic procedure in 76 (36·7 per cent). There were no significant differences in patient demographics. The conversion rate was 9 per cent (7 of 76). The median (i.q.r.) duration of operation was shorter for open than for laparoscopic procedures: 208 (178–255) versus 285 (255–325) min respectively (P &lt; 0·001). Laparoscopic RPC had a shorter length of stay: median (i.q.r.) 6 (4–8) versus 8 (7–12) days (P &lt; 0·001). The rate of minor complications was lower in the laparoscopic group (33 versus 50·4 per cent; odds ratio (OR) 0·48, 95 per cent confidence interval 0·27 to 0·87). There were no significant differences in total complications (51 per cent after laparoscopy versus 61·5 per cent after open surgery; OR 0·66, 0·37 to 1·17), anastomotic leakage, major morbidity, 30-day readmission, reoperation and stoma closure rates. Pouch failure (including permanent stoma) occurred in 14 (7·7 per cent) of 181 patients. Three patients died, all in the open surgery group.

Conclusion

Laparoscopic RPC is feasible with some short-term advantages.

Transvaginal specimen extraction versus conventional minilaparotomy after laparoscopic anterior resection for colorectal cancer: mid-term results of a case-matched study

BACKGROUND

Although the vagina is considered a viable route during laparoscopic surgery, a number of concerns have led to a need to demonstrate the safety of a transvaginal approach in colorectal surgery. However, the data for transvaginal access in left-sided colorectal cancer are extremely limited, and no study has compared the clinical outcomes with a conventional laparoscopic procedure.

OBJECTIVE

We compared the clinical outcomes of totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) with those of the conventional laparoscopic approach with minilaparotomy (LAP) for anastomosis construction and specimen retrieval in left-sided colorectal cancer.

METHODS

Fifty-eight patients underwent TVSE between October 2006 and July 2011 and were matched by age, surgery date, tumor location, and tumor stage with patients who underwent conventional LAP for left-sided colorectal cancer.

RESULTS

Operative time was significantly longer in the TVSE group (149.3 ± 39.8 vs. 131.9 ± 41.4 min; p = 0.023). Patients in the TVSE group experienced less pain (pain score 4.9 ± 1.6 vs. 5.8 ± 1.9; p = 0.008), shorter time to passage of flatus (2.2 ± 1.1 vs. 2.7 ± 1.2 days; p = 0.026), and higher satisfaction with the cosmetic results (cosmetic score 8.0 ± 1.4 vs. 6.3 ± 1.5; p = 0.001). More endolinear staplers for rectal transection were used in the LAP group (1.2 ± 0.5 vs. 1.1 ± 0.2; p = 0.021). Overall morbidities were similar in both groups; however, three wound infections only occurred in the LAP group. After a median follow-up of 34.4 (range 11-60) months, no transvaginal access-site recurrence occurred. The 3-year disease-free survival was similar between groups (91.5 vs. 90.8%; p = 0.746).

CONCLUSIONS

Transvaginal access after totally laparoscopic anterior resection is safe and feasible for left-sided colorectal cancer in selected patients with better short-term outcomes.

Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES)

The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survival rates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.

Short and long-term outcomes of laparoscopic colectomy in obese patients

AIM: To investigate the impact of laparoscopic colectomy on short and long-term outcomes in obese patients with colorectal diseases.

METHODS: A total of 98 obese (body mass index > 30 kg/m²) patients who underwent laparoscopic (LPS) right or left colectomy over a 10 year period were identified from a prospective institutionally approved database and manually matched to obese patients who underwent open colectomy. Controls were selected to match for body mass index, site of primary disease, American Society of Anesthesiologists score, and year of surgery (± 3 year). The parameters analyzed included age, gender, comorbid conditions, American Society of Anaesthesiologists class, diagnosis, procedure, and duration of operation, operative blood loss, and amount of homologous blood transfused. Conversion rate, intra and postoperative complications as were as reoperation rate, 30 d and long-term morbidity rate were also analyzed. For continuous variables, the Student’s t test was used for normally distributed data the Mann-Whitney U test for non-normally distributed data. The Pearson’s χ² tests, or the Fisher exact test as appropriate, were used for proportions.

RESULTS: Conversion to open surgery was necessary in 13 of 98 patients (13.3%). In the LPS group, operative time was 29 min longer and blood loss was 78 mL lower when compared to open colectomy (P = 0.03, P = 0.0001, respectively). Overall morbidity, anastomotic leak and readmission rate did not significantly differ between the two groups. A trend toward a reduction of wound complications was observed in the LPS when compared to open group (P = 0.09). In the LPS group, an earlier recovery of bowel function (P = 0.001) and a shorter length of stay (P = 0.03) were observed. After a median follow-up of 62 (range 12-132) mo 23 patients in the LPS group and 38 in the open group experienced long-term complications (LPS vs open, P = 0.03). Incisional hernia resulted to be the most frequent long-term complication with a significantly higher occurrence in the open group when compared to the laparoscopic one (P = 0.03).

CONCLUSION: Laparoscopic colectomy in obese patients is safe, does not jeopardize postoperative complications and resulted in lower incidence of long-term complications when compared with open cases.

Early learning effect of residents for laparoscopic sigmoid resection

OBJECTIVE

To evaluate the effect of learning the laparoscopic sigmoid resection procedure on resident surgeons; establish a minimum number of cases before a resident surgeon could be expected to achieve proficiency with the procedure; and examine if an analysis could be used to measure and support the clinical evaluation of the surgeon's competence with the procedure.

DESIGN

Retrospective analysis of data which was prospective entered in the database.

PARTICIPANTS

From 2003 to 2007 all patients who underwent a laparoscopic sigmoid resection carried out by senior residents, who completed the procedure as the primary surgeon proctored by an experienced surgeon, were included in the study. A cumulative sum control chart (CUSUM) analysis was used evaluate performance. The procedure was defined as a failure if major intra-operative complications occurred such as intra abdominal organ injury, bleeding, or anastomotic leakage; if an inadequate number of lymph nodes (<12 nodes) were removed; or if conversion to an open surgical procedure was required.

RESULTS

Thirteen residents performed 169 laparoscopic sigmoid resections in the period evaluated. A significant majority of the resident surgeons were able to consistently perform the procedure without failure after 11 cases and determined to be competent. One resident was not determined to be competent and the CUSUM score supported these findings.

CONCLUSIONS

We concluded that at least 11 cases are required for most residents to obtain necessary competence with the laparoscopic sigmoid resection procedure. Evaluation with the CUSUM analysis can be used to measure and support the clinical evaluation of the resident surgeon's competence with the procedure.

Management of the perineal wound after abdominoperineal resection

Although many options are available for the management of perineal wounds after abdominoperineal resection, ranging from direct closure to flap reconstruction, treatment remains challenging. A better understanding of the aims, drawbacks and progress in perineal wound management after abdominoperineal rectal resection can help the surgeon make better choices for each patient, but it is very difficult to propose a single, optimal, evidence-based procedure for the management of pelvic exenteration. Recent progress provided by the extralevator abdominoperineal resection technique and perforator flap concepts have changed our conception of reconstruction leading to the different technical options highlighted in this review.

Extraction site location and incisional hernias after laparoscopic colorectal surgery: should we be avoiding the midline?

BACKGROUND

Laparoscopic colorectal procedures require specimen extraction. It is unclear whether extraction site affects the incidence of incisional hernia (IH).

METHODS

Patients undergoing laparoscopic colectomy over a 6-year period were identified. Outcomes were compared between patients to evaluate the incidence of hernia.

RESULTS

Among 480 laparoscopic colorectal procedures, extraction sites were midline (n = 305), muscle splitting (n = 128), Pfannenstiel (n = 26), and ostomy (n = 21). Average follow-up was 3.5 years. Age, gender, diagnosis, extraction incision length, and hospital stay were similar. The mean body mass index for all patients was 28 kg/m(2) and for those with IHs was 31 kg/m(2) (P = .008). The overall IH rate was 7%. Midline IHs accounted for 84% of all hernias, occurring in 8.9% of midline extractions (P < .05 vs nonmidline extractions). Hernia rates for muscle-splitting, Pfannenstiel, and ostomy site extractions were 2.3%, 3.8%, and 4.8%, respectively.

CONCLUSIONS

Although midline hernia rates were lower than traditionally reported with open surgery, midline extraction sites have a higher chance of IH than nonmidline sites.