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Bayat Z, Guidolin K, Elsolh B, De Castro C, Kennedy E, Govindarajan A. Impact of surgeon and hospital factors on length of stay after colorectal surgery systematic review. BJS Open 2022; 6:6704875. [PMID: 36124901 PMCID: PMC9487584 DOI: 10.1093/bjsopen/zrac110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 11/22/2022] Open
Abstract
Background Although length of stay (LOS) after colorectal surgery (CRS) is associated with worse patient and system level outcomes, the impact of surgeon and hospital-level factors on LOS after CRS has not been well investigated. The aim of this study was to synthesize the evidence for the impact of surgeon and hospital-level factors on LOS after CRS. Methods A comprehensive database search was conducted using terms related to LOS and CRS. Studies were included if they reported the effect of surgeon or hospital factors on LOS after elective CRS. The evidence for the effect of each surgeon and hospital factor on LOS was synthesized using vote counting by direction of effect, taking risk of bias into consideration. Results A total of 13 946 unique titles and abstracts were screened, and 69 studies met the inclusion criteria. All studies were retrospective and assessed a total of eight factors. Surgeon factors such as increasing surgeon volume, colorectal surgical specialty, and progression along a learning curve were significantly associated with decreased LOS (effect seen in 87.5 per cent, 100 per cent, and 93.3 per cent of studies respectively). In contrast, hospital factors such as hospital volume and teaching hospital status were not significantly associated with LOS. Conclusion Provider-related factors were found to be significantly associated with LOS after elective CRS. In particular, surgeon-related factors related to experience specifically impacted LOS, whereas hospital-related factors did not. Understanding the mechanisms underlying these relationships may allow for tailoring of interventions to reduce LOS.
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Affiliation(s)
- Zubair Bayat
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto , Toronto, Ontario , Canada
- Sinai Health System , Toronto, Ontario , Canada
| | - Keegan Guidolin
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
| | - Basheer Elsolh
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
| | | | - Erin Kennedy
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto , Toronto, Ontario , Canada
- Sinai Health System , Toronto, Ontario , Canada
| | - Anand Govindarajan
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto , Toronto, Ontario , Canada
- Sinai Health System , Toronto, Ontario , Canada
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Zhang X, Zhang J, Ma P, Cao Y, Liu C, Li S, Li Z, Zhao Y. Tunnel versus medial approach in laparoscopic radical right hemicolectomy for right colon cancer: a retrospective cohort study. BMC Surg 2022; 22:27. [PMID: 35081941 PMCID: PMC8793186 DOI: 10.1186/s12893-022-01491-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 01/20/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE This study aimed to explore the feasibility and safety of the tunnel approach in laparoscopic radical right hemicolectomy for colon cancer. METHODS From July 2016 to October 2018, a total of 106 consecutive patients with colon cancer who underwent laparoscopic radical right hemicolectomy at the Affiliated Cancer Hospital of Zhengzhou University were enrolled. The patients were stratified into either a tunnel approach (TA) (n = 56) group or traditional medial approach (MA) (n = 50) group according to the surgical technique performed. The baseline demographics, perioperative outcomes and oncologic outcomes were compared between the two groups. RESULTS The baseline characteristics did not differ between groups. The TA group had significantly less blood loss [20.0 (10.0-40.0) vs. 100 (100.0-150.0) ml, p < 0.001] and a shorter operation time [128.4 ± 16.7 vs. 145.6 ± 20.3 min, p < 0.001] than the MA group. The time to first flatus and postoperative hospital stay were similar [3.0 (2.0-4.0) vs. 3.0 (3-4.0) days, p = 0.329; 10.4 ± 2.6 vs. 10.7 ± 3.0 days, p = 0.506] between the two groups. The conversion to laparotomy and complication rates were similar between groups (0 vs. 6.0%, p = 0.203; 14.3% vs. 18.0%, p = 0.603, respectively). No treatment-related deaths occurred in either group. The TA group did not have significantly better survival outcomes than the MA group (p = 0.372). CONCLUSIONS The TA seems to allow for more favourable results in terms of blood loss and operative time than the MA, with similar results regarding time to first flatus, hospital stay, postoperative complication rate, conversion rate and oncologic outcomes; moreover, the TA is easier for beginners to master.
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Affiliation(s)
- Xijie Zhang
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, 127 Dong Ming Road, Zhengzhou, 450008, Henan, China
| | - Junli Zhang
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, 127 Dong Ming Road, Zhengzhou, 450008, Henan, China
| | - Pengfei Ma
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, 127 Dong Ming Road, Zhengzhou, 450008, Henan, China
| | - Yanghui Cao
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, 127 Dong Ming Road, Zhengzhou, 450008, Henan, China
| | - Chenyu Liu
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, 127 Dong Ming Road, Zhengzhou, 450008, Henan, China
| | - Sen Li
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, 127 Dong Ming Road, Zhengzhou, 450008, Henan, China
| | - Zhi Li
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, 127 Dong Ming Road, Zhengzhou, 450008, Henan, China
| | - Yuzhou Zhao
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, 127 Dong Ming Road, Zhengzhou, 450008, Henan, China.
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Nepal P, Mori S, Kita Y, Tanabe K, Baba K, Sasaki K, Kurahara H, Arigami T, Ohtsuka T. Anatomical study of the inferior mesenteric vein using three-dimensional computed tomography angiography in laparoscopy-assisted surgery for left-sided colorectal cancer. Surg Today 2021; 51:1665-1670. [PMID: 33893527 DOI: 10.1007/s00595-021-02292-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/03/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the drainage patterns of the inferior mesenteric vein (IMV) and measure the distance from the root of the inferior mesenteric artery (IMA) to the IMV using preoperative three-dimensional computed tomography (3D-CT) angiography in patients undergoing surgery for left-sided colorectal cancer. METHODS In this retrospective study, we analyzed data collected prospectively on 167 consecutive patients who underwent laparoscopic left-sided colorectal cancer surgery between July, 2014 and August, 2019. The drainage pattern of the IMV and the distance from the root of the IMA to the IMV were evaluated using 3D-CT angiography. We also assessed intraoperative adverse events and postoperative outcomes. RESULTS The IMV drained into the superior mesenteric vein (SMV) in 44 patients, into the confluence point of the SMV and splenic vein (SV) in 38 patients, into the SV in 83 patients, and into the middle colic vein in the remaining three patients. The median length from the root of the IMA to the IMV was 22.1 mm (1.3-84.9). IMV injury occurred in only one patient during surgery, but resulted in colonic ischemia. CONCLUSION 3D-CT angiography is useful for the preoperative assessment of vascular anatomical variations of the IMV and IMA for safe intraoperative navigation and prevention of complications during laparoscopy-assisted left-sided colorectal surgery.
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Affiliation(s)
- Pramod Nepal
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima, 890-8520, Japan
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima, 890-8520, Japan.
| | - Yoshiaki Kita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima, 890-8520, Japan
| | - Kan Tanabe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima, 890-8520, Japan
| | - Kenji Baba
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima, 890-8520, Japan
| | - Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima, 890-8520, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima, 890-8520, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima, 890-8520, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima, 890-8520, Japan
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Nebbia M, Kotze PG, Spinelli A. Training on Minimally Invasive Colorectal Surgery during Surgical Residency: Integrating Surgical Education and Advanced Techniques. Clin Colon Rectal Surg 2021; 34:194-200. [PMID: 33815002 DOI: 10.1055/s-0041-1722843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Surgery is an ever-evolving discipline and continually incorporates new technologies that have improved the ability of the operating room surgeon to perform. The next generation of minimally invasive surgery includes laparoscopic and robotic-assisted procedures. Graduating residents may be expected to have the skills to perform common colorectal procedures using these technologies, and residency programs are developing curriculums to teach these skills. Minimally invasive techniques are challenging and learning only by observation and practice alone is difficult. This requires dedicated training and mentoring. New simulation methods have been conceived specifically for minimally invasive procedures, and these embrace a combination of virtual reality simulators and box trainers, with animal and human tissue, as well as synthetic materials. The aim of this review is to provide an overview of training in minimally invasive colorectal surgery with a focus on different types of simulators that build the basis to develop and include a multistep training approach in a structured training curriculum for minimally invasive colorectal procedures.
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Affiliation(s)
- Martina Nebbia
- Department of Surgery, Colon and Rectal Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, IBD Outpatient Clinics, Health Sciences Postgraduate Program, Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS Humanitas University, Department of Biomedical Sciences, Rozzano, Milan, Italy
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5
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LAP-VEGaS Practice Guidelines for Reporting of Educational Videos in Laparoscopic Surgery. Ann Surg 2018; 268:920-926. [DOI: 10.1097/sla.0000000000002725] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Wynn G, Lykoudis P, Berlingieri P. Development and implementation of a virtual reality laparoscopic colorectal training curriculum. Am J Surg 2017; 216:610-617. [PMID: 29268942 DOI: 10.1016/j.amjsurg.2017.11.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/20/2017] [Accepted: 11/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Contemporary surgical training can be compromised by fewer practical opportunities. Simulation can fill this gap to optimize skills' development and progress monitoring. A structured virtual reality (VR) laparoscopic sigmoid colectomy curriculum is constructed and its validity and outcomes assessed. METHODS Parameters and thresholds were defined by analysing the performance of six expert surgeons completing the relevant module on the LAP Mentor simulator. Fourteen surgical trainees followed the curriculum, performance being recorded and analysed. Evidence of validity was assessed. RESULTS Time to complete procedure, number of movements of right and left instrument, and total path length of right and left instrument movements demonstrated evidence of validity and clear learning curves, with a median of 14 attempts needed to complete the curriculum. CONCLUSIONS A structured curriculum is proposed for training in laparoscopic sigmoid colectomy in a VR environment based on objective metrics in addition to expert consensus. Validity has been demonstrated for some key metrics.
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Affiliation(s)
- Greg Wynn
- ICENI Centre for Minimally Invasive Surgery, Colchester, UK.
| | - Panagis Lykoudis
- Centre for Screen-Based Medical Simulation, Royal Free Hospital, London, UK; Division of Surgery & Interventional Science, Royal Free Campus, UCL, London, UK
| | - Pasquale Berlingieri
- Centre for Screen-Based Medical Simulation, Royal Free Hospital, London, UK; Division of Surgery & Interventional Science, Royal Free Campus, UCL, London, UK
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Training value of laparoscopic colorectal videos on the World Wide Web: a pilot study on the educational quality of laparoscopic right hemicolectomy videos. Surg Endosc 2017; 31:4496-4504. [PMID: 28378076 DOI: 10.1007/s00464-017-5504-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 03/08/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Instructive laparoscopy videos with appropriate exposition could be ideal for initial training in laparoscopic surgery, but unfortunately there are no guidelines for annotating these videos or agreed methods to measure the educational content and the safety of the procedure presented. Aim of this study is to systematically search the World Wide Web to determine the availability of laparoscopic colorectal surgery videos and to objectively establish their potential training value. METHODS A search for laparoscopic right hemicolectomy videos was performed on the three most used English language web search engines Google.com, Bing.com, and Yahoo.com; moreover, a survey among 25 local trainees was performed to identify additional websites for inclusion. All laparoscopic right hemicolectomy videos with an English language title were included. Videos of open surgery, single incision laparoscopic surgery, robotic, and hand-assisted surgery were excluded. The safety of the demonstrated procedure was assessed with a validated competency assessment tool specifically designed for laparoscopic colorectal surgery and data on the educational content of the video were extracted. RESULTS Thirty-one websites were identified and 182 surgical videos were included. One hundred and seventy-three videos (95%) detailed the year of publication; this demonstrated a significant increase in the number of videos published per year from 2009. Characteristics of the patient were rarely presented, only 10 videos (5.4%) reported operating time and only 6 videos (3.2%) reported 30-day morbidity; 34 videos (18.6%) underwent a peer-review process prior to publication. Formal case presentation, the presence of audio narration, the use of diagrams, and snapshots and a step-by-step approach are all characteristics of peer-reviewed videos but no significant difference was found in the safety of the procedure. CONCLUSIONS Laparoscopic videos can be a useful adjunct to operative training. There is a large and increasing amount of material available for free on the internet, but this is currently unregulated.
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8
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Beyer-Berjot L, Berdah S, Hashimoto DA, Darzi A, Aggarwal R. A Virtual Reality Training Curriculum for Laparoscopic Colorectal Surgery. JOURNAL OF SURGICAL EDUCATION 2016; 73:932-941. [PMID: 27342755 DOI: 10.1016/j.jsurg.2016.05.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/13/2016] [Accepted: 05/16/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Training within a competency-based curriculum (CBC) outside the operating room enhances performance during real basic surgical procedures. This study aimed to design and validate a virtual reality CBC for an advanced laparoscopic procedure: sigmoid colectomy. DESIGN This was a multicenter randomized study. Novice (surgeons who had performed <5 laparoscopic colorectal resections as primary operator), intermediate (between 10 and 20), and experienced surgeons (>50) were enrolled. Validity evidence for the metrics given by the virtual reality simulator, the LAP Mentor, was based on the second attempt of each task in between groups. The tasks assessed were 3 modules of a laparoscopic sigmoid colectomy (medial dissection [MD], lateral dissection [LD], and anastomosis) and a full procedure (FP). Novice surgeons were randomized to 1 of 2 groups to perform 8 further attempts of all 3 modules or FP, for learning curve analysis. SETTING Two academic tertiary care centers-division of surgery of St. Mary's campus, Imperial College Healthcare NHS Trust, London and Nord Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, were involved. PARTICIPANTS Novice surgeons were residents in digestive surgery at St. Mary's and Nord Hospitals. Intermediate and experienced surgeons were board-certified academic surgeons. RESULTS A total of 20 novice surgeons, 7 intermediate surgeons, and 6 experienced surgeons were enrolled. Evidence for validity based on experience was identified in MD, LD, and FP for time (p = 0.005, p = 0.003, and p = 0.001, respectively), number of movements (p = 0.013, p = 0.005, and p = 0.001, respectively), and path length (p = 0.03, p = 0.017, and p = 0.001, respectively), and only for time (p = 0.03) and path length (p = 0.013) in the anastomosis module. Novice surgeons' performance significantly improved through repetition for time, movements, and path length in MD, LD, and FP. Experienced surgeons' benchmark criteria were defined for all construct metrics showing validity evidence. CONCLUSIONS A CBC in laparoscopic colorectal surgery has been designed. Such training may reduce the learning curve during real colorectal resections in the operating room.
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Affiliation(s)
- Laura Beyer-Berjot
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, United Kingdom; Centre for Surgical Teaching and Research (CERC), Aix-Marseille Université, Marseille, France.
| | - Stéphane Berdah
- Centre for Surgical Teaching and Research (CERC), Aix-Marseille Université, Marseille, France
| | - Daniel A Hashimoto
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ara Darzi
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rajesh Aggarwal
- Arnold & Blema Steinberg Medical Simulation Centre, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Department of Surgery, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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Celentano V. Need for simulation in laparoscopic colorectal surgery training. World J Gastrointest Surg 2015; 7:185-189. [PMID: 26425266 PMCID: PMC4582235 DOI: 10.4240/wjgs.v7.i9.185] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 06/07/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023] Open
Abstract
The dissemination of laparoscopic colorectal surgery (LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Performing advanced laparoscopic procedures requires dedicated surgical skills and new simulation methods designed precisely for LCS have been established: These include virtual reality simulators, box trainers, animal and human tissue and synthetic materials. Studies have even demonstrated an improvement in trainees’ laparoscopic skills in the actual operating room and a staged approach to surgical simulation with a combination of various training methods should be mandatory in every colorectal training program. The learning curve for LCS could be reduced through practice and skills development in a riskfree setting.
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From anatomy to laparoscopic surgery, or how to reconcile surgeons to embryology. Surg Radiol Anat 2014; 37:393-8. [DOI: 10.1007/s00276-014-1373-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 09/04/2014] [Indexed: 11/25/2022]
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Chebbi F, Ayadi MS, Rhaiem R, Daghfous A, Makni A, Rebaϊ W, Ksantini R, Ftirich F, Jouini M, Kacem M, Ben Safta Z. Laparoscopic ileo-cecal resection: the total retro-mesenteric approach. Surg Endosc 2014; 29:245-51. [PMID: 25007973 DOI: 10.1007/s00464-014-3666-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ileo-cecal resection is the most performed procedure in Cohn's disease. In the last decades, the laparoscopic approach became the gold standard. The dissection can be lateral to median or median to lateral. In non-malignant diseases as it is the case for Crohn's disease, the most performed dissection approach is the lateral to median. Herein, we describe a technique performed in our department: the total retro-mesenteric approach. METHOD The procedure requires 4 trocars with a 10- to 12-mm median suprapubic trocar. The telescope is placed in this trocar. The dissection will begin with the opening of the mesentery root creating a retro-mesenteric tunnel. This dissection gives a direct visualization of the duodenum, of the ureter and the gonadic vessels which guarantees a safe procedure considering the importance of the inflammation in this disease. At the end of the retro-mesenteric step, the right colon is only attached to the Toldt's fascia. The transection of the mesentery is done next to the bowel wall leaving at the end the choice to the surgeon to perform an extra- or endocorporeal anastomosis. RESULTS This retro-mesenteric approach has been used in our department since 2004. Until May 2013, 89 patients underwent laparoscopic resection for Crohn's disease with a mean operative time of 130 min, a morbidity rate of 6 % and a laparoconversion rate of 13.6 %. CONCLUSION We describe the total retro-mesenteric approach in the ileo-cecal resection for Crohn's disease. The approach is considered to be safe allowing the surgeon to perform a dissection far from the inflammatory site and allowing a visual identification of the duodenum and the right ureter. The morbidity of the procedure is equivalent to the other dissection techniques.
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Affiliation(s)
- Faouzi Chebbi
- Service de chirurgie générale «A», CHU La Rabta, Jbel Lakdher, Bab Saadoun, 1007, Tunis, Tunisie,
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Beyer-Berjot L, Palter V, Grantcharov T, Aggarwal R. Advanced training in laparoscopic abdominal surgery: a systematic review. Surgery 2014; 156:676-88. [PMID: 24947643 DOI: 10.1016/j.surg.2014.04.044] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/18/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Simulation has spread widely this last decade, especially in laparoscopic surgery, and training out of the operating room has proven its positive impact on basic skills during real laparoscopic procedures. Few articles dealing with advanced training in laparoscopic abdominal surgery, however, have been published. Such training may decrease learning curves in the operating room for junior surgeons with limited access to complex laparoscopic procedures as a primary operator. METHODS Two reviewers, using MEDLINE, EMBASE, and The Cochrane Library conducted a systematic research with combinations of the following keywords: (teaching OR education OR computer simulation) AND laparoscopy AND (gastric OR stomach OR colorectal OR colon OR rectum OR small bowel OR liver OR spleen OR pancreas OR advanced surgery OR advanced procedure OR complex procedure). Additional studies were searched in the reference lists of all included articles. RESULTS Fifty-four original studies were retrieved. Their level of evidence was low: most of the studies were case series and one fifth were purely descriptive, but there were eight randomized trials. Pig models and video trainers as well as gastric and colorectal procedures were mainly assessed. The retrieved studies showed some encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly on the training tool itself. Some tools have been proven to be construct-valid. CONCLUSION Higher-quality studies are required to appraise educational value in this field.
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Affiliation(s)
- Laura Beyer-Berjot
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK; Center for Surgical Teaching and Research (CERC), Aix-Marseille Université, Marseille, France.
| | - Vanessa Palter
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Teodor Grantcharov
- Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rajesh Aggarwal
- Division of Surgery, Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Barrie J, Jayne DG, Wright J, Murray CJC, Collinson FJ, Pavitt SH. Attaining surgical competency and its implications in surgical clinical trial design: a systematic review of the learning curve in laparoscopic and robot-assisted laparoscopic colorectal cancer surgery. Ann Surg Oncol 2013; 21:829-40. [PMID: 24217787 DOI: 10.1245/s10434-013-3348-0] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic surgery is increasingly used in the treatment of colorectal cancer and more recently robotic assistance has been advocated. However, the learning curve to achieve surgical proficiency in laparoscopic surgery is ill-defined and subject to many influences. The aim of this review was to comprehensively appraise the literature on the learning curve for laparoscopic and robotic colorectal cancer surgery, and to quantify attainment of surgical proficiency and its implications in surgical clinical trial design. METHODS A systematic review using a defined search strategy was performed. Included studies had to state an explicit numerical value of the learning curve evaluated by a single parameter or multiple parameters. RESULTS Thirty-four studies were included, 28 laparoscopic and 6 robot assisted. Of the laparoscopic studies, nine defined the learning curve on the basis of a single parameter. Nine studies used more than one parameter to define learning, and 11 used a cumulative sum (CUSUM) analysis. One study used both a multiparameter and CUSUM analysis. The definition of proficiency was subjective, and the number of operations to achieve it ranged from 5 to 310 cases for laparoscopic and 15-30 cases for robotic surgery. CONCLUSIONS The learning curve in laparoscopic colorectal surgery is multifaceted and often ill-defined, with poor descriptions of mentorship/supervision. Further, the quantification to attain proficiency is variable. The use of a single parameter to quantify this is simplistic. Multidimensional assessment is recommended; as part of this, the CUSUM model, which assesses trends in multiple surgical outcomes, is useful and appropriate when assessing the learning curve in a clinical setting.
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Affiliation(s)
- Jenifer Barrie
- Division of Clinical Sciences, Leeds Institute of Molecular Medicine, The University of Leeds, Leeds, UK
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14
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Medial versus lateral approach in laparoscopic colorectal resection: a systematic review and meta-analysis. World J Surg 2013; 37:863-72. [PMID: 23254947 DOI: 10.1007/s00268-012-1888-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The aim of this study was to investigate the safety and efficacy of the medial approach (MA) and the lateral approach (LA) in the treatment of colorectal disease. METHODS Studies published since 1994 that compared MA versus LA in laparoscopic colorectal resection were collected. Data on conversion rate, operative time, blood loss, number of harvested lymph nodes, hospital stay, complications, mortality, rate of recurrence, and hospitalization costs for MA and LA were meta-analyzed using fixed-effect and random-effect models. RESULTS Five cohort studies (2 randomized controlled trials and 3 retrospective studies) that included 881 patients were studied. Of these patients, 475 and 582 had undergone laparoscopic colorectal resection via MA and LA, respectively. There were significant reductions in conversion rate and operative time and possible reductions in blood loss and hospitalization costs for MA compared to LA; however, there were fewer harvested lymph nodes for MA compared with LA, which remains to be further studied. Other outcome variables such as postoperative complications, postoperative immune function, mortality, and rate of recurrence were not found to be statistically significant for either group. Sensitivity analysis on the pooled data from randomized controlled trials showed that the conversion rates were not significantly different between MA and LA. CONCLUSIONS Compared with the lateral approach, the medial approach has the advantages of shorter operative time and possibly lower conversion rate; it also can be as safe as the lateral approach. Whether the MA has less blood loss and lower hospitalization costs remains to be confirmed, and its oncological safety and long-term prognosis are not clear. Due to insufficient data from a limited number of studies, inadequate assessment of the results may arise.
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Short Hospital Stay after Laparoscopic Colorectal Surgery without Fast Track. Minim Invasive Surg 2012; 2012:260273. [PMID: 23213498 PMCID: PMC3506894 DOI: 10.1155/2012/260273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 10/18/2012] [Indexed: 02/04/2023] Open
Abstract
Purpose. Short hospital stay and equal or reduced complication rates have been demonstrated after fast track open colonic surgery. However, fast track principles of perioperative care can be difficult to implement and often require increased nursing staff because of more concentrated nursing tasks during the shorter hospital stay. Specific data on nursing requirements after laparoscopic surgery are lacking. The purpose of the study was to evaluate the effect of operative technique (open versus laparoscopic operation), but without changing nurse staffing or principles for peri- or postoperative care, that is, without implementing fast track principles, on length of stay after colorectal resection for cancer. Methods. Records of all patients operated for colorectal cancer from November 2004 to December 2008 in our department were reviewed. No specific patients were selected for laparoscopic repair, which was solely dependent on the presence of two specific surgeons at the same time. Thus, the patients were not selected for laparoscopic repair based on patient-related factors, but only on the simultaneous presence of two specific surgeons on the day of the operation. Results. Of a total of 540 included patients, 213 (39%) were operated by a laparoscopic approach. The median hospital stay for patients with a primary anastomosis was significantly shorter after laparoscopic than after conventional open surgery (5 versus 8 days, P < 0.001) while there was no difference in patients receiving a stoma (10 versus 10 days, ns), with no changes in the perioperative care regimens. Furthermore there were significant lower blood loss (50 versus 200 mL, P < 0.001) and lower complication rate (21% versus 32%, P = 0.006) in the laparoscopic group. Conclusion. Implementing laparoscopic colorectal surgery in our department resulted in shorter hospital stay without using fast track principles for peri- and postoperative care in patients not receiving a stoma during the operation. Consequently, we aimed to reduce hospitalisation without increasing cost in nursing staff per hospital bed. Length of stay was not reduced in patients receiving a stoma pointing at this group for specific intervention in the future. Furthermore, the complication rate was reduced in the laparoscopic group.
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Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases. Dis Colon Rectum 2012; 55:1300-10. [PMID: 23135590 DOI: 10.1097/dcr.0b013e31826ab4dd] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The learning curve for laparoscopic colorectal surgery has not been conclusively analyzed. No reliable framework for case selection during training is available. OBJECTIVE The aim of this study was to analyze the length of the learning curve of laparoscopic colorectal surgeons and to recommend a case selection framework at the early stage of independent practice. DATA SOURCES Medline (1988-2010, October week 4) and Embase (1988-2010) were used for the literature review, databases were retrieved from the authors, and expert opinion was surveyed. STUDY SELECTION Studies describing the learning curve of laparoscopic or laparoscopically assisted colorectal surgery were selected. INTERVENTION No interventions were performed. MAIN OUTCOME MEASURES Learning curves were analyzed by using risk-adjusted, bootstrapped cumulative sum curves. Conversions and complications were independent variables in a multilevel random-effects regression model. Recommendations are based on analysis of ORs and a structured expert opinion gauging process. RESULTS Twenty-three studies were identified, showing great disparity on the length of the learning curve. Seven studies, representing 4852 cases (19 surgeons), were analyzed. Risk-adjusted cumulative sum charts demonstrated the length of the learning curves to be 152 cases for conversions, 143 for complications, 96 for operating time, 87 for blood loss, and 103 for length of stay. Body mass index and pelvic dissection (rectum), especially in male patients, independently increased the risk of complication and conversion. The expert survey revealed that increasing T stage and complicated inflammatory disease are likely to increase the complexity of the case. Based on this evidence, a framework for case selection in training was proposed. LIMITATIONS The generalizability of the study results maybe reduced because of inconsistent data quality and individual variations in the length of the learning curve CONCLUSIONS This multicenter database suggests a length of the learning curve of 88 to 152 cases. The use of the suggested framework may prevent high conversion and complication rates during the learning curve.
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A prospective study demonstrating the reliability and validity of two procedure-specific evaluation tools to assess operative competence in laparoscopic colorectal surgery. Surg Endosc 2012; 26:2489-503. [DOI: 10.1007/s00464-012-2220-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 10/16/2011] [Indexed: 10/28/2022]
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Palter VN, Graafland M, Schijven MP, Grantcharov TP. Designing a proficiency-based, content validated virtual reality curriculum for laparoscopic colorectal surgery: A Delphi approach. Surgery 2012; 151:391-7. [PMID: 22019340 DOI: 10.1016/j.surg.2011.08.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 08/04/2011] [Indexed: 11/24/2022]
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Laparoscopic colorectal cancer surgery by a colon lifting-up technique that decreases the number of access ports: comparison by propensity scoring of short-term and long-term outcomes with standard multiport laparoscopic surgery. Surg Laparosc Endosc Percutan Tech 2012; 22:38-45. [PMID: 22318058 DOI: 10.1097/sle.0b013e318242ec97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laparoscopic colectomy for colorectal cancer has become established as a minimally invasive surgical approach. However, many disposable instruments are required, and there is an associated disadvantage of cost. We have developed a new technique, which uses a suture string to lift up the colon. This method is expected to reduce the number of access ports required without compromising the radical cure. OPERATIVE PROCEDURE A suture string piercing the abdominal wall is passed through the mesocolon. The colon is retracted anteriorly and is fixed at the abdominal wall. The main mesenteric vessels are under tension, and lymph node dissection is performed easily by a medial approach. The working space is more stable because the colon is fixed to the abdominal wall. METHODS This study examined the short-term and long-term surgical outcomes of laparoscopic resection for colorectal cancer using our colon lifting-up technique (CLT), compared with the standard multiport technique. The study design was a case-matched control by propensity scoring. Analyzed variables were sex, age, American Society of Anesthesiologists score, cancer in a different organ, multiple colorectal cancer, operator, operative year, tumor location, operative procedure, adjuvant chemotherapy, and International Union Against Cancer TNM stage. RESULTS From 2000 to 2010, 301 patients underwent CLT and 436 standard multiport technique, 148 patients were matched by propensity score and analyzed. Regarding short-term outcomes, there was no difference between the 2 groups. The mean number of ports needed was 3.37±0.48 for CLT (93 with 3 ports, 55 with 4). There were no differences in recurrence-free survival and overall survival in long-term follow-up results for each stage. There were neither recurrences nor complications due to CLT. CONCLUSIONS The CLT facilitated laparoscopic colectomy without compromising cure rates. It is a useful method to keep a stable view and to conserve medical resources.
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Waters JA, Chihara R, Moreno J, Robb BW, Wiebke EA, George VV. Laparoscopic colectomy: does the learning curve extend beyond colorectal surgery fellowship? JSLS 2011; 14:325-31. [PMID: 21333183 PMCID: PMC3041026 DOI: 10.4293/108680810x12924466006800] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Colorectal fellowship training adequately surpasses the learning curve with regard to safety and outcome; however, the surgeon continues to increase operative efficiency during the first year of practice. Background and Objectives: As minimally invasive colon and rectal resection has become increasingly prevalent over the past decade, the role that fellowship training plays has become an important question. This analysis examines the learning curve of one fellowship-trained colorectal surgeon in his first 100 cases. Methods: This was a prospectively collected retrospective analysis of the first 100 laparoscopic colon and rectal resections performed between July 2007 and July 2008 by a colorectal (CRS) fellowship trained surgeon at a Veteran's Administration (VA) and county hospital. Included were all emergent and nonemergent laparoscopic cases. Results: Mean age was 63(range, 36 to 91). The 100 resections included 42 right, 6 left, 32 sigmoid, 13 rectal, and 7 total abdominal colectomies. Indications were 55% cancer, 20% unresectable polyp, 18% diverticular, 4% inflammatory, and 3% other. Overall mortality was 3%. Overall morbidity including wound infection was 24%. Early and late groups were similar in age, ASA score, and indication. Conversion rate was 4%. No statistical difference was seen in mortality, morbidity, EBL, LOS, margin, lymph nodes, or conversions between the first and second 50 cases (P<0.05). Right and sigmoid colectomy operative time decreased by 40.0% and 19.6%, respectively. Conclusion: Prior investigators have demonstrated a significant learning curve for laparoscopic colorectal surgery. In the first 100 cases, there is no difference in mortality or morbidity between early and late cases. Alternatively, operative times decreased with experience. Laparoscopic training during CRS fellowship surpasses the learning curve in regard to safety and outcome, whereas operative efficiency improves over the first year of practice.
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Affiliation(s)
- Joshua A Waters
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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Palter VN, MacRae HM, Grantcharov TP. Development of an objective evaluation tool to assess technical skill in laparoscopic colorectal surgery: a Delphi methodology. Am J Surg 2011; 201:251-9. [DOI: 10.1016/j.amjsurg.2010.01.031] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 01/19/2010] [Accepted: 01/19/2010] [Indexed: 10/19/2022]
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Abstract
OBJECTIVE To identify and evaluate the influence of mentoring and simulated training in laparoscopic colorectal surgery (LCS) and define the key components for learning advanced technical skills. BACKGROUND Laparoscopic colorectal surgery is a complex procedure, often being self-taught by senior surgeons. Educational issues such as inadequate training facilities or a shortfall of training fellowships may result in a slow uptake of LCS. The effectiveness of mentored and simulated training, however, remains unclear. METHODS We conducted a systematic search, using Ovid databases. Four study categories were identified: mentored versus nonmentored cases, training case selection, simulation, and assessment. We performed a meta-analysis and a mixed model regression on the difference of the main outcome measures (conversion rates, morbidity, and mortality) for mentored trainees and expert surgeons. We also compared conversion rates of mentored and nonmentored. Meta-analysis of risk factors for conversion was performed using published and unpublished data sets requested from various investigators. For studies on simulation, we compared scores of surveys on the perception of different training courses. RESULTS Thirty-seven studies were included. Pooled weighted outcomes of mentored cases (n = 751) showed a lower conversion rate (13.3% vs 20.5%, P = 0.0332) compared with nonmentored cases (n = 695). Compared to expert case series (n = 5313), there was no difference in conversion (P = 0.2835), anastomotic leak (P = 0.8342), or mortality (P = 0.5680). A meta-analysis of training case selection data (n = 4444) revealed male sex (P < 0.0001), previous abdominal surgery (P = 0.0200), a BMI greater than 30 (P = 0.0050), an ASA of less than 2 (P < 0.0001), colorectal cancer (P < 0.0001) and intra-abdominal fistula (P < 0.0001), but not older than 64 years (P = 0.4800), to significantly increase conversion risk. Participants on cadaveric courses were highly satisfied with the teaching value yet trainees on an animal course gave less positive feedback. Structured assessment for LCS has been partially implemented. CONCLUSION This review and meta-analysis supports evidence that trainees can obtain similar clinical results like expert surgeons in laparoscopic colorectal surgery if supervised by an experienced trainer. Cadaveric models currently provide the best value for training in a simulated environment. There remains a need for further research into technical skills assessment and the educational value of simulated training.
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Learning curve for laparoscopic repair of very large hiatal hernia. Surg Endosc 2010; 25:1775-82. [PMID: 21136114 DOI: 10.1007/s00464-010-1461-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 10/05/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic repair of a large hiatal hernia is technically challenging. A significant learning curve likely exists that has not been studied to date. METHODS Since 1992, the authors have prospectively collected data for all patients undergoing laparoscopic repair of a very large hiatal hernia (50% or more of the stomach within the chest). Follow-up evaluation was performed after 3 months, then yearly. Visual analog scores were used to assess heartburn and dysphagia. Patients were grouped according to institutional and individual surgeons' experience to determine the impact of any learning curve. The outcome for procedures performed by consultant surgeons was compared with that for trainees. RESULTS From 1992 to 2008, 415 patients with a 1-year minimum follow-up period were studied. Institutional and individual experience had a significant influence on operation time, conversion to open surgery, and length of hospital stay. However, except for heartburn scores during a 3-month follow-up evaluation of institutional experience (p=0.03), clinical outcomes were not influenced by either an institutional or individual learning curve. Furthermore, in general terms, whether the procedure was performed by a consultant or a supervised trainee had little effect on outcome. CONCLUSIONS Institutional and individual learning curves had no significant influence on clinical outcomes, although improved experience was reflected in improved operation time, conversion rate, and hospital stay. These outcomes improved over the first 50 institutional cases, and the outcomes for individual surgeons improved for up to 40 cases.
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Boni L, Dionigi G, Cassinotti E, Di Giuseppe M, Diurni M, Rausei S, Cantore F, Dionigi R. Single incision laparoscopic right colectomy. Surg Endosc 2010; 24:3233-6. [PMID: 20464415 DOI: 10.1007/s00464-010-1100-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 04/21/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study was designed to describe the surgical technique for single-incision laparoscopic right colectomy and present preliminary short-term results. Laparoscopic surgery has been fully validated as alternative, minimally invasive treatment for different benign and malignant conditions. In the attempt to reduce even more the surgical trauma, natural orifices transluminal endoscopic surgery (NOTES™) and single-incision laparoscopic surgery (SILS) have been proposed. Although the lack of proper instrumentations makes NOTES™ not fully suitable for advanced procedures, SILS might play a significant role, although, to date, only limited series and few case reports of single-incision right colectomy are present in the literature. METHODS After signed, informed consent was obtained, patients with malignant tumors or large polyps of the right colon underwent single-incision colonic resection through a 3-cm incision using two different single-port devices and articulated or coaxial curved instruments. Preliminary results were analyzed retrospectively. RESULTS A total of 36 patients were selected for SILS procedure. There were no intraoperative complications or conversions to the standard laparoscopic procedure. One patient had a postoperative urinary tract infection and one prolonged ileum that did not required any surgical intervention. No complications were reported in all the remaining cases. The mean postoperative stay was 5 ± 1.2 days (range, 4-14), and mean lymph node retrieval and tumor-free margins was 24 ± 7 (range, 29-15) and 8 ± 3 (range, 6-12) cm, respectively. CONCLUSIONS Our preliminary results show that single-incision laparoscopic right colectomies are feasible and safe from the oncological point of view; nevertheless larger, randomized experiences are needed to demonstrate the benefits of SILS compared with standard laparoscopic resections.
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Affiliation(s)
- Luigi Boni
- Minimally Invasive Surgery Research Center, Department of Surgical Sciences, University of Insubria-Azienda Ospedaliera Macchi, Viale Borri n.57, 21100, Varese, Italy.
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Abstract
BACKGROUND Transumbilical single incision laparoscopic surgery (SILS) has made its initial forays into clinical minimally invasive surgery. SILS combines in part the cosmetic advantage and decrease parietal trauma of natural orifice surgery, but allow operative realization with standard and validated laparoscopic instruments. We report here the first clinical transumbilical SILS sigmoidectomy for benign disease. METHOD Preliminary experience with transumbilical single incision laparoscopic surgery (or embryonic natural orifice transluminal endoscopic surgery) sigmoidectomy in a female patient (34 years, BMI 22 kg/m(2)) with sigmoid stenosis caused by nodular endometriosis was reported. Transumbilical SILS treatment of pelvic endometriosis was performed during the same operation through cauterization. RESULTS Transumbilical single incision laparoscopic sigmoidectomy was feasible with conventional laparoscopic instruments. The combined uses of straight and articulated laparoscopic instruments allow the avoidance of transparietal sling suture for exposition. Operative time for sigmoidectomy and endometriosis therapy was 125 min. No intra-operative or postoperative complications were recorded. SILS achieved excellent cosmetic results and may be associated with accelerated recovery. CONCLUSION Transumbilical single incision laparoscopic sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. The combined uses of strait and articulated instruments allow transumbilical SILS sigmoidectomy without the need for additional incision or transparietal sling suture. SILS sigmoidectomy may have the clinical advantage over NOTES of offering the safety of laparoscopic colectomy and the avoidance of vaginal access. It has to be determined if SILS offers benefit to the patient, except in cosmesis, compared with standard laparoscopic sigmoidectomy.
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Affiliation(s)
- P Bucher
- Department of Surgery, University Hospital Geneva, 1211, Geneva, Switzerland.
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Guller U, Rosella L, Karanicolas PJ, Adamina M, Hahnloser D. Population-based trend analysis of 2813 patients undergoing laparoscopic sigmoid resection. Br J Surg 2009; 97:79-85. [PMID: 20013934 DOI: 10.1002/bjs.6787] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The use of laparoscopic sigmoid resection for diverticular disease has become increasingly popular. The objective of this trend analysis was to assess whether clinical outcomes following laparoscopic sigmoid resection for diverticular disease have improved over the past 10 years. METHODS The analysis was based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. Some 2813 patients undergoing elective laparoscopic sigmoid resection for diverticular disease from 1995 to 2006 were included. Unadjusted and risk-adjusted analyses were performed. RESULTS Over time, there was a significant reduction in the conversion rate (from 27.3 to 8.6 per cent; P(trend) < 0.001), local postoperative complication rate (23.6 to 6.2 per cent; P(trend) = 0.004), general postoperative complication rate (14.6 to 4.9 per cent; P(trend) = 0.024) and reoperation rate (5.5 to 0.6 per cent; P(trend) = 0.015). Postoperative median length of hospital stay significantly decreased from 11 to 7 days (P(trend) < 0.001). CONCLUSION This first trend analysis in the literature of clinical outcomes after laparoscopic sigmoid resection, based on almost 3000 patients, has provided compelling evidence that rates of postoperative complications, conversion and reoperation, and length of hospital stay have decreased significantly over the past 10 years.
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Affiliation(s)
- U Guller
- Department of Surgery, University of Toronto, Toronto, Canada.
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Poon JTC, Law WL, Fan JKM, Lo OSH. Impact of the standardized medial-to-lateral approach on outcome of laparoscopic colorectal resection. World J Surg 2009; 33:2177-82. [PMID: 19669230 DOI: 10.1007/s00268-009-0173-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Beginning in 2004, a standardized medial-to-lateral approach was adopted in laparoscopic colorectal resection (LapCR) in our institution. The present study aimed to compare the outcomes of patients operated on by this approach with those who were operated on prior to the adoption of this technique. METHODS Data were retrieved from a prospectively collected database on LapCR. The control group included 196 patients operated on from January 2002 to December 2003 and the medial approach group included 224 patients who underwent operations from January 2005 to December 2007. The patient characteristics, operative details, pathology, and surgical outcomes of the two groups were compared. RESULTS The patient demographics, types of operation and pathology did not show any statistically significant difference. The medial approach group was associated with significantly less median blood loss [100 (interquartile range [IQR]: 50-174) ml versus 150 (IQR:100-300) ml; p < 0.001], shorter hospital stay [4 (IQR: (4-7) versus 7 (5-9) days; p < 0.001], and more lymph nodes harvested [12 (7-17.5) versus 10 (6-15); p = 0.001]. Significantly earlier bowel function recovery was observed in the medial approach group. The mortality and complications did not show any difference. CONCLUSIONS A standardized medial-to-lateral approach for LapCR is associated with less blood loss, earlier return of bowel function, shorter hospital stay, and increased number of lymph nodes harvested. This should be the preferred approach in LapCR.
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Affiliation(s)
- Jensen T C Poon
- Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
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Abstract
BACKGROUND Laparoscopic colectomy can be performed using 2 approaches: lateral or medial. However, it is unknown if one of these techniques provides better results. Thus, the object of the present study is to assess whether one of the approaches has any potential benefits over the other. METHODS A comparative, retrospective study was performed that included all patients scheduled for left and right laparoscopic colon resection for both neoplastic and benign diseases between June 2000 and June 2006. The following factors were assessed: operation time, recovery variables (bowel sounds, passage of gases, intake of liquids and solids), length of hospital stay, and morbidity and mortality rates. The population was divided into 4 groups: right colectomy using a lateral approach (RL); right colectomy using a medial approach (RM); left colectomy using a lateral approach (LL); and left colectomy using a medial approach (LM). RESULTS A total of 202 patients were evaluated: RL: 16 (8%); RM: 37 (18.3%); LL: 110 (54.4%); LM: 39(19.3%). No differences in recovery parameters were observed between the right colectomies. However, the presence of bowel sounds and solid intake was significantly earlier in the patients subjected to left colectomies using a medial approach. A tendency toward a higher conversion rate was observed in left colectomies with lateral approach (LL: 18 vs. LM: 1, P=0.052). The operation time was significantly shorter when a medial approach was used for both right and left colectomies (RL: 185.6 min vs. RM: 148.6 min, P=0.009; LL: 205.5 min vs. LM: 139.9 min, P<0.0001). No differences in the morbidity and mortality rates were found between lateral and medial approach in both types of colectomy. CONCLUSIONS The use of a medial approach in a laparoscopic colectomy provides short-term benefits compared with a lateral approach.
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Bucher P, Pugin F, Morel P. Single port access laparoscopic right hemicolectomy. Int J Colorectal Dis 2008; 23:1013-6. [PMID: 18607608 DOI: 10.1007/s00384-008-0519-8] [Citation(s) in RCA: 383] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Single port access (SPA) surgery is a rapidly evolving field as it combines some of the cosmetic advantage of the Natural Orifice Translumenal Endoscopic Surgery (NOTES) and allows performing surgical procedure with standard surgical instruments. We report in this paper a new technique of umbilical SPA right hemicolectomy with conventional surgical oncologic principle and technique of minimally invasive colectomy. METHODS Preliminary experience with umbilical SPA right hemicolectomy in a patient with degenerated ascending colon polyp. RESULTS Umbilical SPA right hemicolectomy was feasible with conventional laparoscopic instruments. Carcinologic surgical principle can be respected using this technique as pathological specimen had sufficient surgical margins (>10 cm) and lymph nodes (33). Operative time was 158 min. No peroperative or postoperative complications were recorded. CONCLUSION SPA right hemicolectomy is feasible and safe when performed by experienced laparoscopic surgeons. SPA right hemicolectomy may have the advantage over NOTES approach to offer the safety of laparoscopic colectomy especially for haemostasis and anastomosis. It has to be determined whether or not this approach would offer benefit to patients, except in cosmesis, compared to standard laparoscopic right hemicolectomy.
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Affiliation(s)
- Pascal Bucher
- Department of Surgery, University Hospital Geneva, Geneva, Switzerland.
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