Laparoscopic assisted proctosigmoidectomy with extracorporeal transanal anastomosis. A pilot study

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world, an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery. Thus, a certain sized skin incision is required to remove the resected colon. Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction. We present a case characterized by a laterally spreading type of tumor of the cecum. We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy. Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction. The patient was discharged without complications on postoperative day 4. Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique. Although our method is restricted to flat or small lesions, we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world, an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery. Thus, a certain sized skin incision is required to remove the resected colon. Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction. We present a case characterized by a laterally spreading type of tumor of the cecum. We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy. Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction. The patient was discharged without complications on postoperative day 4. Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique. Although our method is restricted to flat or small lesions, we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.

Triluminal hybrid NOS as a novel approach for colonic resection with colorectal anastomosis

BACKGROUND

Minimal invasive surgery has led to a significant decrease in surgical trauma, pain, recovery time and improved cosmesis compared with open surgery. However, scar development and the risk of hot spots for infections and hernias are still present. Natural orifice surgery (NOS) promises to offer even further reduction in invasiveness and thus may lead to even faster recovery. The goal of this study was to establish a NOS colonic resection by using commercially available standard surgical instruments avoiding major abdominal incisions.

METHODS AND RESULTS

This article reports a new triluminal hybrid NOS approach for sigmoid and colonic resection (Tri-Port-NOS-SIG), established using rigid laparoscopic instruments through the umbilicus, the vagina, and the rectum, without any major abdominal incision. The specimen was retrieved through the anus avoiding dilatation of the vagina. In an early series of 5 patients the first patient was a 37-year-old woman with a 10-year history of recurrent diverticulitis. She recovered quickly and was discharged on postoperative day 2. She returned to sports activity on day 12 postoperatively and to her heavy-duty job on day 16. The following 4 patients also recovered well and were discharged on postoperative days 7 (2 patients), 8, and 11, respectively. One patient experienced a temporary, mild paresthesia of the left lower dorsal leg, most likely because of intraoperative positioning. No major complications occurred.

CONCLUSION

Tri-Port-NOS-SIG offers a feasible scarless approach for abdominal resections using commercially available surgical instruments in experienced hands.

Laparoscopic-assisted sigmoidectomy with transanal specimen extraction: a bridge to NOTES?

The combination of standard laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound related complications. We describe the technical approach to laparoscopic sigmoidectomy in which the specimen is extracted transanally through a proctoscope. Laparoscopic-assisted sigmoidectomy with transanal specimen removal avoids an abdominal wall extraction incision and may be considered an alternative approach to conventional minimally invasive sigmoidectomy in patients with disease of the sigmoid or left colon.

Laparoscopic rectopexy using mesh fixation with a spiked chromium staple

Abdominal rectopexy for patients with rectal prolapse is well suited for performance laparoscopically because no resection or anastomosis is necessary, with potential benefits being a decrease in postoperative pain, better cosmesis, and an earlier return to normal activity.

PURPOSE

Objectives of this study were to determine the feasibility of laparoscopic abdominal rectopexy using a solitary spiked chromium staple to fix the mesh to the sacrum and to compare initial results with consecutive previous abdominal rectopexies (historical control study).

METHODS

Duration of operation (anesthetic plus surgery), the day a solid diet was first tolerated, day of discharge, and patient morphine requirements in the first 48 hours were documented prospectively for the laparoscopic group and retrospectively from medical records for an open abdominal rectopexy group.

RESULTS

Laparoscopic rectopexy group had lower morphine requirements when using patient-controlled analgesia (mean, 38.2 vs. 100.6 mg; P < 0.02), an earlier tolerance of solid diet (mean, 2.7 vs. 5.8 days; P < 0.001), and an earlier discharge from the hospital (mean, 6.3 vs. 11.0 days; P < 0.01). Operating time was longer for the laparoscopic group (mean, 198 vs. 130 minutes; P < 0.001).

CONCLUSIONS

Laparoscopic rectopexy is feasible, may have benefits in reducing postoperative pain, and may aid earlier return to normal diet and activity. Given the inherent bias of a historical control study, a randomized controlled study has commenced to confirm these results.

Laparoscopic surgery for colorectal neoplasms

Laparoscopy is being used to assist in an increasing number and variety of bowel procedures. However, when being used for neoplastic disease concerns of margins and adequacy of mesenteric dissection must be addressed. We've performed 110 laparoscopic-assisted bowel procedures, with 45 of these performed for neoplastic disease. Ninety-two bowel resections were performed including 24 subtotal, total, or proctocolectomies. In this chapter we review the results of our series, as well as other reported series, and discuss some of the controversies involved with laparoscopy for neoplastic disease.

Laparoscopic-assisted segmental colectomy: early Mayo Clinic experience

OBJECTIVE

To present a large initial series of patients who underwent laparoscopic-assisted segmental colectomy and to assess the feasibility and safety of this procedure.

DESIGN

We summarized the clinical outcome data for 122 Mayo Clinic patients selected for laparoscopic-assisted resection of the right, left, or sigmoid colon between 1991 and 1993.

MATERIAL AND METHODS

Preexisting factors (such as obesity and prior abdominal operations), indications for surgical treatment, and intraoperative and postoperative complications were analyzed statistically in two groups of patients--those in whom the laparoscopic procedure was completed and those in whom conversion to an open surgical technique was necessary.

RESULTS

Laparoscopic-assisted colectomy was successfully completed for a variety of colonic pathologic conditions, including polyps, cancer, and diverticulitis. No operative deaths occurred in this series, and the overall complication rate was low (11%). Patients in whom laparoscopic-assisted colectomy was completed had a more rapid return of bowel function and a briefer hospital stay than did those who required conversion to the traditional open surgical technique. Neither obesity nor previous abdominal surgical procedures precluded successful laparoscopic-assisted colectomy, although the conversion rate to open colectomy was 75% in patients whose weight exceeded 90 kg.

CONCLUSION

These findings indicate that laparoscopic-assisted segmental colectomy is safe and feasible, and the procedure may offer patient-related advantages. Oncologic concerns, including recent reports of trocar site recurrences, suggest a cautious approach to its application for resection of colonic cancer.

[Experimental studies of laparoscopically-assisted rectum resection with colo-anal or colorectal anastomosis]

A minimally invasive procedure for radical resection of tumors in the deep rectum without laparoscopic anastomosis was developed in seven domestic pigs. The length of resected rectosigmoid and mesenterium was adequate on all oncologic counts.

Animal models as educational tools in laparoscopic colorectal surgery

Laparoscopic colectomies have been shown to be feasible in patients with low morbidity. Thus, many surgeons, as they begin to perform laparoscopic surgery on other areas of the abdomen, may consider performing laparoscopic colectomies. Although certain basic skills like suturing and knot tying can be practiced in training models, the preclinical performance of intraperitoneal bowel mobilization and anastomosis, dissection of mesentery, and control of bleeding can only be practiced and perfected in live animal models. We describe several laparoscopic intestinal techniques in porcine and canine models. Through use of these procedures, the surgeon can learn to handle intraperitoneal organs atraumatically, to achieve hemostasis, to dissect mesentery with lymphadenectomy and high ligation of major vessels, and to accomplish a variety of intraperitoneal anastomoses. Acquisition of these skills is essential in the quest to perform successful laparoscopic intestinal surgery. These skills cannot be learned in inanimate training models.

Laparoscopic-assisted perineal rectosigmoidectomy with pullthrough

We report for the first time the treatment of an early rectal cancer by laparoscopically assisted rectosigmoidectomy with pullthrough. The low colorectal anastomosis was constructed using a double-stapling technique. We believe that this procedure might offer a promising new option for the treatment of midrectal cancer with sphincter saving. Further investigation is recommended.