Hand-assisted laparoscopic low anterior resection: initial experience with a new procedure

"Peek port": avoiding conversion during laparoscopic colectomy-an update

PURPOSE

To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Patients considered being at high risk for conversion to formal laparotomy were initially approached via a small midline incision ("peek port") with the laparoscopic equipment readily available but unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy (HALS); if intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy.

METHODS

Data from 664 patients from a single surgeon brought to the operating room with the intention of proceeding with laparoscopic colectomy (either via straight laparoscopy or HALS) were retrieved from a prospective database. Comparison of conversion rates between groups was performed using χ² analysis.

RESULTS

The study population consisted of 361 men and 303 women with a mean age of 61 years. Inflammatory conditions accounted for 40% of the diagnoses and enteric fistulas were present in 12%. Of the 79 patients who underwent initial "peek port" exploration, 38 (48%) underwent immediate extension to formal laparotomy, whereas 41 (52%) underwent HALS colectomy, with one subsequent conversion from HALS to formal laparotomy. Of the 585 patients initially approached laparoscopically, 14 (2%) required conversion to laparotomy. Of the 626 patients from both groups who underwent laparoscopy, the overall conversion to laparotomy rate was 15/626 (2%).

DISCUSSION

The "peek port" approach to the patients with a potentially hostile abdomen allows for prompt assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy during colectomy. This technique may reduce expense and morbidity for patients who ultimately require laparotomy, while allowing some patients with complex disease to be managed laparoscopically who would not normally be considered for a minimally invasive procedure.

Robotic pancreatoduodenectomy with vascular resection

PURPOSE

This study aims to define the current status of robotic pancreatoduodenectomy (RPD) with resection and reconstruction of the superior mesenteric/portal vein (RPD-SMV/PV).

METHODS

Our experience on RPD, including RPD-SMV/PV, is presented along with a description of the surgical technique and a systematic review of the literature on RPD-SMV/PV.

RESULTS

We have performed 116 RPD and 14 RPD-SMV/PV. Seven additional cases of RPD-SMV/PV were identified in the literature. In our experience, RPD and RPD-SMV/PV were similar in all baseline variables, but lower mean body mass and higher prevalence of pancreatic cancer in RPD-SMV/PV. Regarding the type of vein resection, there were one type 2 (7.1 %), five type 3 (35.7 %) and eight type 4 (57.2 %) resections. As compared to RPD, RPD-SMV/PV required longer operative time, had higher median estimated blood loss, and blood transfusions were required more frequently. Incidence and severity of post-operative complications were not increased in RPD-SMV/PV, but post-pancreatectomy hemorrhage occurred more frequently after this procedure. In pancreatic cancer, RPD-SMV/PV was associated with a higher mean number of examined lymph nodes (60.0 ± 13.9 vs 44.6 ± 11.0; p = 0.02) and with the same rate of microscopic margin positivity (25.0 % vs 26.1 %). Mean length or resected vein was 23.1 ± 8.08 mm. Actual tumour infiltration was discovered in ten patients (71.4 %), reaching the adventitia in four patients (40.0 %), the media in two patients (20.0 %), and the intima in four patients (40.0 %). Literature review identified seven additional cases, all reported to have successful outcome.

CONCLUSIONS

RPD-SMV/PV is feasible in carefully selected patients. The generalization of these results remains to be demonstrated.

Hand-assisted laparoscopic versus open approach in colorectal surgery: a systematic review

AIM

This systematic review was performed to answer the question whether hand-assisted laparoscopic surgery (HALS) can preserve the advantages of laparoscopic compared with open surgery in colorectal disease.

METHOD

Eligible studies were identified from electronic databases (Medline, Embase Cochrane) and cross-reference search. The database search, quality assessment and data extraction were independently performed by two reviewers. Outcome criteria were operative time, number of trocars used, conversion rate, incision length, blood loss, time to passage of flatus, use of analgesia, postoperative morbidity, in-hospital mortality, length of hospital stay, number of lymph nodes and costs.

RESULTS

Out of 162 publications seven publications were selected for comprehensive review. Three randomized controlled trials (RCT) and four non-RCTs, comprising 571 patients, met the inclusion criteria. Because of heterogeneity, the data could not be pooled. The operative time was significantly longer in HALS in four of the seven studies (addition in median operative time of 13-81 min). The conversion rate varied from 0 to 10%. Two of the four reporting studies demonstrated a significantly shorter time to passage of flatus in HALS (averagely one day in advance). Length of hospital stay was significantly shorter in HALS in four of the seven studies (average gain between 2 and 4 days).

CONCLUSIONS

Hand-assisted laparoscopic surgery has the advantages of laparoscopic surgery over open surgery while reducing some of the disadvantages of laparoscopic surgery (shorter operative time, lower conversion rates). Especially for indications in which an incision to extract the resection specimen is required, HALS provides an excellent treatment option.

Hand-assisted laparoscopic surgery may be a useful tool for surgeons early in the learning curve performing total abdominal colectomy

OBJECTIVE

We evaluated outcomes after hand-assisted (HALC) and straight laparoscopic (LC) techniques for the initial laparoscopic total abdominal colectomy (TAC) procedures performed by surgeons starting their laparoscopic careers.

METHOD

The first eight HALC cases of two surgeons performing TAC by this technique (Group A) were compared with the first (Group B) and last eight (Group C) TAC cases of three surgeons performing LC. Groups A and B were compared with a matched group of open total colectomy cases (Group D) and to the eight cases performed by an experienced surgeon (Group E). Demographics, intra-operative and postoperative outcomes including operation time, morbidity, conversion and readmission rates and length of hospital stay (LOS) were compared using Wilcoxon or Chi-squared tests.

RESULTS

Demographics of the patients were similar. Groups A, B C and E had similar operating time (P = 0.10) which was significantly longer than Group D (P < 0.0001). Morbidity (P = 0.75) and readmission rates were similar (P = 0.89). Conversion rate was significantly higher for Group B (Group B: 41.7%vs Group A: 0%, P = 0.008), in the early period. LOS was comparable between minimally invasive groups but significantly shorter than open surgery group (P = 0.0005). For Groups A and C, operating time (P = 0.55), conversion rate (P = 0.11), morbidity (P = 0.83) and LOS (P = 0.12) were similar.

CONCLUSIONS

Hand-assisted laparoscopic colectomy may be associated with a significantly shorter learning curve for TAC as results are better than early LC and comparable with LC performed by experienced laparoscopic surgeons. It may be a better option for surgeons early in their laparoscopic career.

Risk factors for anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique

BACKGROUND

Laparoscopic rectal transection carries the risk of anastomotic leakage because of its technical difficulty and long staple line with an inadequate cutting angle. Our objective was to investigate the risk factors affecting anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique.

STUDY DESIGN

Between November 2006 and September 2008, 270 consecutive patients underwent laparoscopic sigmoidectomy and anterior resection with double stapling technique for distal sigmoid and rectal cancer. Data were collected prospectively. Univariate and multivariate analyses were performed to determine risk factors for anastomotic leakage. Additionally, we evaluated the relationship between the number of stapler firings and clinical parameters.

RESULTS

Anastomotic leakage was noted in 17 (6.3%) of 270 patients. In univariate analyses, tumor location (p = 0.021), operation time (p = 0.025), number of stapler firings (p = 0.040), and diameter of the circular stapler (p = 0.022) were significant risk factors for anastomotic leakage. Multivariate analyses showed that middle or lower rectal cancer was an independent factor affecting anastomotic leakage (p = 0.013). The number of stapler firings increased significantly in men (p = 0.023), in patients with a tumor at a lower level (p = 0.034), and in those with longer operation times (p < 0.001).

CONCLUSIONS

A reduction in the number of linear stapler firings is necessary to avoid anastomotic leakage after laparoscopic colorectal anastomosis with a double stapling technique. We recommend that a diverting ileostomy is mandatory in patients with middle and lower rectal cancer where multiple linear staplers were used.

Hand-assisted laparoscopic colectomy: benefits of laparoscopic colectomy at no extra cost

BACKGROUND

Comparison studies of hand-assisted and laparoscopic-assisted colectomy have indicated that short-term outcomes are similar. Although a few of these studies have compared costs, none has reported on the costs of hand-assisted colectomy performed in the US. Our aim was to determine the short-term outcomes and direct costs associated with hand-assisted and laparoscopic-assisted colectomy performed in the US.

STUDY DESIGN

One hundred hand-assisted laparoscopic colectomies were matched to 100 laparoscopic-assisted colectomies performed concurrently. Matching criteria were age (+/- 10 years), gender, diagnosis, American Society of Anesthesiologists score, earlier abdominal operation, colectomy type, and conversion. Operative time, morbidity, length of stay, reoperation, and readmission were assessed. Direct costs for the operating room, nursing care, intensive care, anesthesia, laboratory, pharmacy, radiology, emergency services and consultations, and professional and ancillary services related to the initial hospitalization and readmissions were compared.

RESULTS

From June 2005 to August 2008, 176 hand-assisted and 845 laparoscopic-assisted segmental and total colectomies were performed. Of 100 matched hand-assisted and laparoscopic-assisted patients, there were no differences in body mass index (29 and 28, respectively), operating time (168 and 163 minutes, respectively), length of stay (4 days), readmission (6% and 11%, respectively), or reoperation rates (5% and 9%, respectively). Overall morbidity was 16% and 32% for hand-assisted and laparoscopic-assisted colectomy, respectively (p = 0.009). Major morbidity, including abscess, hemorrhage, and anastomotic leak, were similar. Operating room costs were increased for hand-assisted colectomy (3,476 versus 3,167 US dollars); total costs were similar (8,521 versus 8,373 US dollars).

CONCLUSIONS

Short-term outcomes and total costs of hand-assisted and laparoscopic-assisted colectomy are similar.

Laparoscopic proctectomy for rectal adenocarcinoma

During the past 15 years, there has been increasing enthusiasm for the use of laparoscopic techniques in the operative treatment of patients suffering from colorectal disease. Laparoscopic colectomy has been demonstrated to be safe for patients suffering from adenocarcinoma of the intraperitoneal colon. Attention is now being focused on the treatment of patients with rectal adenocarcinoma using laparoscopic methods. Prospective data analysis will be crucial in determining whether laparoscopic proctectomy provides equivalent results to open procedures.

Current Status of Hand-Assisted Laparoscopic Colorectal Surgery: A Review

PURPOSE

Hand-assisted laparoscopic colorectal surgery has continued to develop since the mid-1990s. There have been a number of publications regarding its use and efficacy as a technique. We studied these reports to assess the current status of hand-assisted laparoscopic colorectal surgery.

MATERIALS AND METHODS

We searched for articles on hand-assisted laparoscopic colorectal surgery archived in MEDLINE, PubMed, and the Cochrane database of systematic reviews.

RESULTS

We found a total of 36 papers. These included nine descriptive studies, three nonrandomized trials, and four randomized trials.

CONCLUSION

Most authors found hand-assisted laparoscopic colorectal surgery to be a very useful and promising technique. Suitable hand-insertion ports and laparoscopic instruments are crucial. Controlled trials demonstrate that the early benefits of the laparoscopic approach are realized and there may be a shorter learning curve.

The learning curve for hand-assisted laparoscopic colectomy: a single surgeon’s experience

BACKGROUND

Surgical experience and outcomes for hand-assisted laparoscopic colectomy were evaluated to define a learning curve.

METHODS

This study included 60 patients who underwent hand-assisted laparoscopic colectomies performed by a single surgeon. They were analyzed as three consecutive equal groups: A, B, and C. Pearson's chi-square test and one-way analysis of variance (ANOVA) were used to compare differences in demographics and perioperative parameters. Operative times were analyzed to document the learning curve for the procedure.

RESULTS

There were no significant differences between the three groups in terms of age, sex, operative procedure, or comorbidity. Groups B and C showed significantly shorter operative times, significantly earlier recoveries of gastrointestinal function, less blood loss, and shorter hospital stays than group A. The incidence of operative complications was not significantly different among the three groups (35% vs 5% vs 15%; p = 0.07).

CONCLUSIONS

Approximately 21 to 25 cases were needed to achieve proficiency in this series.

Laparoscopic rectal surgery: rectal cancer, pelvic pouch surgery, and rectal prolapse

With the increasing popularity of minimally invasive approaches to surgery, laparoscopic techniques are being applied increasingly to more complex procedures. Surgeons who are interested in gaining skill and confidence with the techniques of rectal mobilization and resection initially should consider attempting procedures for benign disease. Patients who have rectal prolapse, who often have wide, accommodating pelvic anatomy, are the logical choice with whom to begin the laparoscopic rectal experience. Laparoscopic restorative proctocolectomy is more technically challenging. Laparoscopic proctectomy for rectal cancer probably should remain in the hands of well-trained, high-volume, experienced surgeons who have built a dedicated team for treatment of these patients, and who track their outcomes prospectively.

Laparoscopic versus open total mesorectal excision for rectal cancer

BACKGROUND

Because definitive long-term results are not yet available, the oncological safety of laparoscopic surgery for treatment of rectal cancer remains controversial. However, laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME).

OBJECTIVES

To evaluate whether there are any relevant differences in safety and efficacy after elective LTME, for the resection of rectal cancer, compared with OTME.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Cochrane Central register of Controlled Trials (CENTRAL), and Current Contents from 1990 to December 2005. Searches were conducted using MESH terms: "laparoscopy", "minimally invasive","colorectal neoplasms". Furthermore we used the following text words: laparoscopy, surgical procedures, minimally invasive, rectal cancer, rectal carcinoma, rectal adenocarcinoma, rectal neoplasms, anterior resection, abdominoperineal resection, total mesorectal excision.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled clinical trials and case series comparing LTME versus OTME. Furthermore case reports which describe LTME were also included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality. All relevant studies have been categorized according to the evidence they provide according to the guidelines for "Levels of Evidence and Grades of Recommendation" supplied by the "Oxford Centre for Evidence-based Medicine". Disagreements were solved by discussion.

MAIN RESULTS

80 studies were identified of which 48 studies, representing 4224 patients, met the inclusion criteria. Methodological quality of most of the included studies was poor; three studies were grade 1b (individual randomised trial), 12 grade 2b (individual cohort study), 5 grade 3b (individual case-control study) and 28 grade 4 (case-series). As only one RCT described primary outcome, 3-year and 5-year disease-free survival rates, no meta-analyses could be performed. No significant differences in terms of disease-free survival rate, local recurrence rate, mortality, morbidity, anastomotic leakage, resection margins, or recovered lymph nodes were found. There is evidence that LTME results in less blood loss, quicker return to normal diet, less pain, less narcotic use and less immune response. It seems likely that LTME is associated with longer operative time and higher costs. No results of quality of life were reported.

AUTHORS' CONCLUSIONS

Based on evidence mainly from non-randomized studies, LTME appears to have clinically measurable short-term advantages in patients with primary resectable rectal cancer. The long-term impact on oncological endpoints awaits the findings from large on-going randomized trials.

Hand-assisted laparoscopic low anterior resection for rectal carcinoma

Laparoscopic low anterior resection for rectal carcinoma has never been widely accepted among general surgeons because of the technical difficulties encountered during pelvic dissection. We describe our technique of hand-assisted laparoscopic low anterior resection (HAL-LAR) for rectal carcinoma using the Lapdisc abdominal wall sealing device (Hakko Medical, Tokyo, Japan, and Ethicon Endo- Surgery, New Brunswick, New Jersey) which results in pelvic dissection almost equivalent to the laparotomic operation. Thirteen patients with rectal adenocarcinoma (lower edge less than 15 cm from the anal verge) underwent laparoscopic low anterior resection, including 8 standard laparoscopic low anterior resections (SL-LAR) and 5 HAL-LAR. The mean operative time in the HAL-LAR group (211 +/- 48 min) was significantly shorter than in the SL-LAR group (311 +/- 78 min) (P = 0.0268). The mean intraoperative blood loss in the HAL-LAR group (37 +/- 45 g) was less than that in the SL-LAR group (198 +/- 177 g) (P = 0.075). The mean distal margin in the HAL-LAR group (23 +/- 4.5 mm) was longer than in the SL-LAR group (15 +/- 13.1 mm) (P = 0.2199). One patient in the SL-LAR group was found to have anastomotic recurrence in the staple suture line 10 months after surgery and died from cancer 24 months after surgery. One patient in the SL-LAR group was converted to open surgery because the distal margin was insufficient. In the HAL-LAR group, there were no intra- or postoperative complications, no conversion to open surgery, and no recurrence after surgery.

Ressecção laparoscópica pós terapia neo-adjuvante no tratamento do câncer no reto médio e baixo

Desde o início da década de 90, diversas publicações têm reportado equivalência de resultados entre as ressecções colorretais laparoscópicas e convencionais de neoplasias, seja quanto ao número de linfonodos, extensão da ressecção, margens e implantes parietais. Quanto às neoplasias colônicas, séries recentes demonstraram não haver alteração dos índices de recidiva e sobrevida. Entretanto, a avaliação dos resultados oncológicos nas ressecções retais ainda suscita controvérsias. Este trabalho visou apresentar a experiência do Hospital de Câncer de Barretos no tratamento vídeo-laparoscópico do câncer do reto e discutir o impacto do tratamento neo-adjuvante nos resultados intra e pós-operatórios imediatos. PACIENTES E MÉTODOS: a presente casuística é constituída por série de pacientes operados consecutivamente no período de janeiro de 2000 a janeiro de 2003, submetidos a ressecções pretensamente curativas para tumores T3 ou T4 no reto médio e baixo. Esses pacientes receberam tratamento neoadjuvante e foram operados por videolaparoscopia (LAP) ou laparotomia (CONV) 4 a 6 semanas após. Analisaram-se dados clínicos, cirúrgicos, patológicos, recidiva e sobrevida após seguimento mínimo de 24 meses. RESULTADOS: foram computados 43 pacientes (20 LAP, 23 CONV), que não apresentaram diferença em relação ao gênero, IMC, estadio clínico, tipo de procedimento, tempo de internação, morbidade pós-operatória, linfonodos, tamanho de espécime e margens. A recidiva global foi semelhante entre os grupos (35% LAP vs. 26% CONV, p = 0,43). A curva de sobrevida avaliada pelo método de Kaplan Meier para um período de seguimento médio de 45,6 meses no grupo LAP e 39,8 meses no grupo CONV (p = 0,86) mostrou sobrevida global de 76,7% (85% LAP e 70% CONV; p = 0,761) sem diferença entre os grupos. CONCLUSÕES: Os dados apresentados indicam equivalência nos índices de recidiva e sobrevida de pacientes portadores de câncer no reto médio e distal, tratados pelas vias de acesso laparoscópica e convencional. A realização de terapia neoadjuvante parece não dificultar a dissecação laparoscópica do reto extra-peritonial, favorecendo a obtenção de resultados oncológicos adequados.

Laparoscopy for rectal cancer: the need for randomized trials

The adoption of laparoscopic proctectomy for rectal cancer has been relatively slow, primarily because of the technical difficulty of the procedure. The wide surgeon-to-surgeon variability in disease-free survival and local pelvic recurrence noted after open proctectomy is probably due to differences in surgical technique, and these differences are likely to be magnified when the additional challenge of laparoscopy is added to the procedure. At present, oncologic and functional outcomes data are limited. Although the adoption of laparoscopic techniques to perform curative proctectomy is likely to expand as technical challenges are overcome and experience and training improve, the results of prospective multicenter trials are necessary to ensure that the procedures provide an oncologic and functional outcome equivalent to that of conventional surgery.

Laparoscopic resection of low rectal cancer with a mean follow-up of seven years

The role of laparoscopic surgery in the management of cancer of the rectum remains controversial. The main concern is the risk of port-site metastasis and neoplastic dissemination. The aim of this study was to evaluate prospectively 29 patients who underwent laparoscopic resection with total mesorectum excision for lower rectal carcinoma with a mean follow-up of 7 years. From January 1993 to December 1998, 29 patients with proven low (<10 cm from the anal verge) rectal cancer were operated by a laparoscopic approach. They were followed up at 1-, 3-, and then every 6-month intervals, postoperatively for an average of 7 years. Mean operative time was 157 +/- 46 minutes. The conversion rate was 13.7% (4 cases): 1 for tumor invasion of adjacent structures, 2 for inadequate margins of resection, and 1 for locally advanced cancer. First flatus occurred after 37.3 +/- 11.5 hours, and oral feeding started at 48.3 +/- 23 hours postoperatively. The length of the suprapubic incision for extraction of the specimen was 5.6 +/- 1.7 cm. Hospital stay was 7.2 +/- 3.0 days. There were no deaths. The morbidity rate was 14.8%. Length of the specimen, lateral and distal margins, and the number of lymph nodes resected were comparable to those of an open surgical approach. The average postoperative follow-up was 7 years (5-10 years). The late complication rate was 3.7%. There were no port-site metastases. Five-year recurrence rates were 0%, 22%, and 37% for Duke's A, B, and C cancers, respectively. The 5-year survival rate was 100% for Duke's A, 89% for B, and 50% for C. Laparoscopic resection for low rectal cancer with total mesorectum excision can be performed with the same oncologic principles, low morbidity, and long-term complications. Five-year survival and recurrence rates are comparable to those of open surgery.

Anterior resection of rectal cancer through a one hand-size incision with or without laparoscopy: proposal of one hand-size incision surgery (OHaSIS)

BACKGROUND

One hand-size incision surgery (OHaSIS) is a surgery that is carried out through one hand-size incision with or without laparoscopy. Safety, feasibility and recovery advantage of the anterior resection of rectal cancer by the OHaSIS were studied.

STUDY DESIGN

Nineteen consecutive patients with rectal cancer, consisting of seven rectosigmoid, six upper rectal, and six lower rectal cancers, were treated with anterior resection, including seven high, six low, three super-low, and three partial intersphincteric resections, through a suprapubic longitudinal one hand-size incision. The initial 11 patients were treated in combination with laparoscopy and the following eight patients were treated without laparoscopy.

RESULTS

All anterior resections with mesorectal excision were completed in a safe manner with acceptable operative time (average 245 min), blood loss (average 280 g), and postoperative complications without any elongation of the initial incision. When compared with 12 previous high and low anterior resections by conventional open surgery (OS), the 13 high and low anterior resections by the OHaSIS showed equivalent operative time, blood loss, anastomotic procedures of single stapling, lymph node numbers dissected, surgical margin of the anal side of the tumor, and complications. Moreover, analysis of perioperative parameters for surgical invasiveness, including a body temperature >37 degrees C, days of bed rest, and days of use of parenteral narcotics, revealed a recovery advantage in the OHaSIS group compared with that in the OS group.

CONCLUSIONS

These results suggest that anterior resection for patients with rectal cancer by the OHaSIS is safe, feasible, and less invasive than conventional OS, and has sufficient operative performance. Although the survival benefit and recurrence rate by this approach must be ensured in a future trial, we would like to propose the new concept of OHaSIS for treating rectal cancer.

Laparoscopic resection for rectal cancer: outcomes in 194 patients and review of the literature

BACKGROUND

There are few reports on laparoscopic rectum resection demonstrating its feasibility and efficacy in patients with rectal cancer. Most patient series are small, and results must be considered preliminary and medium-term. Our large prospective conducted study aimed to assess the effectiveness of a totally laparoscopic resection for rectum carcinoma with emphasis on perioperative and long-term oncological outcomes.

METHODS

Between November 1992 and July 2003, 194 unselected patients were resected laparoscopically for rectal carcinoma. Patients with locally advanced rectum carcinoma (uT3/uT4) and no evidence of distant metastases were candidates for neoadjuvant chemoradiation. Adjuvant treatment was administered to patients with UICC stage II/III disease. All patients were followed up prospectively to evaluate complications and late outcomes. Survival probability analysis was performed using the Kaplan-Meier method. Study selection was made by Medline search using the following key words: rectal cancer, rectal neoplasms, laparoscopy, and resection. Single case reports and abstracts were excluded. When surgical series were reported more than once, only the most recent reports were considered and listed.

RESULTS

The most common procedures were low anterior resection with total mesorectum excision in 65.5% of patients and high anterior resection in 25.3%. Average operative time was 174 min. Average number of lymph nodes removed was 25.4 and length of specimen resected was 27.6 cm. Resection was curative in 145 patients and palliative in 49 cases. UICC tumor stages were as follows: stage I: 25.2%, stage II: 27.3%, stage III: 30.4%, and stage IV: 17%. Intraoperative complications were <1% for lesions of the ureter, urinary bladder, and deferent duct. Conversion to conventional surgery was necessary in two cases (1%). The most common postoperative complication was anastomotic leakage in 13.5% of patients. There was no postoperative mortality. Follow-up evaluation ranged from 1 to 128 months with a mean of 46.1 months. The most common late complication was incisional hernia in 3.6% of patients. Port-site metastases occurred in one patient (0.5%). Tumor recurrence developed in 23 of the 145 curative resected patients (11.7% distant metastases and 4.1% local recurrence). Overall local recurrence rate was 6.7% (4.1% after curative resection and 14.3% after palliative resection). Overall survival rate was 90.6% at 1 year, 74.5% at 3 years, and 66.3% at 5 years. Overall 5-year survival rate was 76.9% after curative resection and 31.8% after palliative resection. Cancer-related survival rate was 94% at 1 year, 82.4% at 3 years, and 78.9% at 5 years. At 5 years it was 87.7% after curative resection and 48.5% after palliative resection. At 5 years, the survival rate was 100% for stage I, 94.4% for stage II, 66.6% for stage III, and 44.6% for stage IV.

CONCLUSIONS

Our results and the literature review clearly demonstrate that laparoscopic resection for rectal cancer is not associated with higher morbidity and mortality. Established oncological and surgical principles are respected and long-term outcomes are at least as good as those after open surgery.

Safety of Laparoscopic Intracorporeal Rectal Transection With Double-Stapling Technique Anastomosis

To assess the feasibility and analyze the short-term outcomes of laparoscopic intracorporeal rectal transection with double-stapling technique anastomosis, a review was performed of a prospective registry of 67 patients who underwent laparoscopic sigmoidectomy and anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis between July 2001 and January 2004. Patients were divided into 3 groups: sigmoid colon/rectosigmoid carcinoma, upper rectal carcinoma, and middle/lower rectal carcinoma. A comparison was made of the short-term outcomes among the groups. The number of cartridges required in bowel transection was significantly increased in patients with middle/lower rectal carcinoma, and significant differences were observed in the length of the first stapler cartridge fired for rectal transection. Furthermore, mean operative time and blood loss were also significantly greater in the middle/lower rectum group; however, complication rates and postoperative course were similar among the 3 groups. No anastomotic leakage was observed. Laparoscopic intracorporeal rectal transection with double-stapling technique anastomosis can be performed safely without increased morbidity or mortality.

Laparoscopic surgery for colon cancer

Acceptance of laparoscopy for the management of oncological disease has been slow due to the increased complexity of the technique, requirement of technological advances, and fears for the oncological safety of the approach. Laparoscopic oncological surgery has a role in the management of oncological patients at all stages of disease. Good evidence exists for the laparoscopic approach being a viable option for colon cancer patients. Current large multicenter trials will report the true outcomes of laparoscopic colon cancer surgery and how it compares with open surgery. This article examines some of the parameters by which laparoscopic colectomy will be judged.

Laparoscopic surgery for colorectal cancer: the state of the art

Laparoscopic techniques have expanded since their introduction 15 years ago. The laparoscopic approach for colorectal surgery has been slower to develop than other fields of surgery. However, this approach does provide significant benefits for colorectal resection, although concerns regarding the ability to satisfy oncological criteria have restricted its use in the past. This review studies the published data on the use of laparoscopic surgery for colorectal cancer including the short- and long-term outcomes. New long-term outcome data is now available which is likely to encourage the use of this technique for colon cancer resection. Laparoscopic rectal cancer resection is also discussed including the more limited outcome data that is available.

Hand-assisted laparoscopic colectomy vs open colectomy: a prospective randomized study

BACKGROUND

We compared the perioperative parameters and outcomes achieved with hand-assisted laparoscopic colectomy (HALC) vs open colectomy (OC) for the management of benign and malignant colorectal disease, including cancer patients treated with curative intent.

METHODS

Sixty eligible patients were randomized to either HALC (n = 30) or OC (n = 30) treatment groups. We used Pearson's chi-square and two-sample t-tests to compare the differences in demographics and perioperative parameters.

RESULTS

There were no significant differences in age, gender distribution, disease pattern, operative procedure, comorbidity, or history of abdominal surgery. The HALC patients had significantly shorter hospital stays and incision lengths, faster recovery of gastrointestinal function, less analgesic use and blood loss, and lower pain scores on postoperative days 1, 3, and 14. There were no significant differences in operative time, complications, or time to return to normal activity.

CONCLUSION

Hand-assisted laparoscopic colectomy (HALC) is safe and produces better therapeutic results in terms of perioperative parameters than OC.

Laparoscopic total colectomy: hand-assisted vs standard technique

BACKGROUND

Although hand-assisted laparoscopic surgery (HALS) has been proposed as an alternative to laparoscopically assisted surgery (LAP), little is known about its role in total colectomy. The objectives of the study were to compare the outcomes in patients undergoing total colectomy via either HALS or LAP and to determine what benefits HALS might have in extensive colorectal procedures.

METHODS

We reviewed the data for 23 patients who underwent total proctocolectomy (TPC) or total abdominal colectomy (TAC) using either a HALS or LAP technique.

RESULTS

There were 12 HALS (five TPC, seven TAC) and 11 LAP (seven TPC, four TAC) for ulcerative colitis (n = 17), familial polyposis (n = 5), and colonic inertia (n = 1). One LAP was converted (9.1%). The operative time was shorter for HALS than for LAP (210 vs 273 min; p = 0.03). Blood loss and incision length were similar. Postoperative recovery and morbidity rates were comparable.

CONCLUSION

HALS reduces the operative time but patient morbidity rates and recovery are similar to LAP. HALS may be preferable for extensive colorectal procedures such as TPC and TAC.

Hand-assisted laparoscopic colorectal surgery using GelPort

BACKGROUND

An easily usable hand access device will optimize success in hand-assisted laparoscopic surgery (HALS). The authors describe their initial series of HALS colorectal resections using GelPort to evaluate their current technique and results with this new device.

METHODS

A retrospective study investigated 33 HALS colorectal procedures including total colectomy ( n = 16) and low anterior resection ( n = 10). All operative data, including intraoperative GelPort performance, were prospectively recorded and retrospectively analyzed.

RESULTS

In this study, 3 (9.1%) of 33 HALS procedures were converted to open surgery, and 4 (13.3%) of 30 HALS procedures required minimal enlargement of incisions to facilitate extracorporeal procedures. The operative time was 263 +/- 85 min, and the blood loss was 282 +/- 148 ml. There were no device malfunctions. Three major complications (9.1%) and 7 minor wound infections (21%) were noted postoperatively. The mean hospital stay was 7.9 +/- 3.8 days.

CONCLUSION

When performed with GelPort, HALS is safely and reliably applicable for various colorectal procedures.

Laparoscopy and its current role in the management of colorectal disease

OBJECTIVE

To evaluate the current place of laparoscopy in the management of colorectal disease.

METHOD

A literature search was undertaken on Medline between the period 1991 and 2002.

RESULTS

From the literature there is good evidence that the laparoscopic approach is associated with at least some short-term advantages. Improved cosmesis and better patient's satisfaction are also evident. Because of this laparoscopy has been widely employed in various benign conditions. Among others, laparoscopic stoma formation, laparoscopic resection for diverticular disease and Crohn's disease, laparoscopic rectopexy, as well as laparoscopic assisted reversal of Hartmann's procedure were commonly reported. As port site recurrence and oncological safety are of less concern, there have been increasing reports on laparoscopic resection for colorectal cancer. Although long-term follow up data is still limited, results of large prospective studies as well as various randomized trials show that recurrence and survival rates of the laparoscopic approach were at least comparable to open surgery. As experience and confidence accumulates, there are also increasing reports on technically demanding, laparoscopic sphincter-saving rectal excision. Articles on functional aspects following this type of resection also start to appear, which might be one of the future directions.

CONCLUSION

The applicability of laparoscopy to colorectal disease continues to expand. Laparoscopic approach should be considered for patients with benign conditions. For colorectal cancer, results from randomized trials so far have been favourable. Hence, the authors suggest the utility of laparoscopy in potentially curable cancer can also be judiciously relaxed.

Laparoscopic total mesorectal excision: a consecutive series of 100 patients

OBJECTIVE

To analyze total mesorectal excision (TME) for rectal cancer by the laparoscopic approach during a prospective nonrandomized trial.

SUMMARY BACKGROUND DATA

Improved local control and survival rates in the treatment of rectal cancer have been reported after TME.

METHODS

The authors conducted a prospective consecutive series of 100 laparoscopic TMEs for low and mid-rectal tumors. All patients had a sphincter-saving procedure. Case selection, surgical technique, and clinical and oncologic results were reviewed.

RESULTS

The distal limit of rectal neoplasm was on average 6.1 (range 3-12) cm from the anal verge. The mean operative time was 250 (range 110-540) minutes. The conversion rate was 12%. Excluding the patient who stayed 104 days after a severe fistula and reoperation, the mean postoperative stay was 12.05 (range 5-53) days. The 30-day mortality was 2% and the overall postoperative morbidity was 36%, including 17 anastomotic leaks. Of 87 malignant cases, 70 (80.4%) had a minimum follow-up of 12 months, with a median follow-up of 45.7 (range 12-72) months. During this period 18.5% (13/70) died of cancer and 8.5% (6/70) are alive with metastatic disease. The port-site metastasis rate was 1.4% (1/70): a rectal cancer stage IV presented with a parietal recurrence at 17 months after surgery. The locoregional pelvic recurrence rate was 4.2% (3/70): three rectal cancers stage III at 19, 13, and 7 postoperative months.

CONCLUSIONS

Laparoscopic TME is a feasible but technically demanding procedure (12% conversion rate). This series confirms the safety of the procedure, while oncologic results are at present comparable to the open published series with the limitation of a short follow-up period. Further studies and possibly randomized series will be necessary to evaluate long-term clinical outcome in cancer patients.