Restorative proctectomy with colon pouch-anal anastomosis by laparoscopic transanal pull-through: an available option for low rectal cancer?

Natural Orifice Specimen Extraction With Single Stapling Colorectal Anastomosis for Laparoscopic Anterior Resection: Feasibility, Outcomes, and Technical Considerations

BACKGROUND

Double and triple stapling techniques to close the rectal stump in laparoscopic anterior resection are fraught with technical drawbacks that could possibly be avoided with the use of the single stapling technique. However, little is known of its safety in laparoscopic surgery or outcomes when combined with natural orifice specimen extraction.

OBJECTIVE

This study aims to analyze the feasibility and the operative and immediate postoperative outcomes of single-stapled anastomosis and natural orifice specimen extraction with conventional techniques. It intends to evaluate technical variations related to colon, mesentery, and pelvic anatomy characteristics.

DESIGN AND PATIENTS

A consecutive series of 188 patients underwent elective surgery for benign or malignant lesions between 10 and 40 cm from the anal verge, 5 cm or less in diameter on radiological examination, stage T1 to T3, Nx, M0, with 2 different methods of rectal stump closure (pursestring vs linear-stapled closure) associated with single or double stapling and per anus vs conventional specimen extraction.

SETTING

This study was conducted at China Medical University Hospital, Taiwan, a tertiary referral center, between January 2012 and April 2015.

MAIN OUTCOME MEASURES

The main outcomes measured are feasibility and operative and immediate postoperative outcomes.

RESULTS

Single-stapled resection with natural orifice specimen extraction was feasible in 94% patients with an 11% perioperative morbidity rate. The patients required statistically significantly less analgesia, had earlier return of bowel movements, and shorter hospital stay, whereas there was no statistically significant difference in the overall readmission rate and overall morbidity, including anastomotic leakage.

LIMITATIONS

This was a single-center, retrospective case-matched study.

CONCLUSION

Anatomic variations (short colon and short mesentery) can be managed adequately with intracorporeal anvil head fixation. The single stapling technique is feasible and as safe as conventional double stapling techniques, although it is technically more demanding. The transanal endoscopic operation platform can be useful when the rectal stump is long.

Minimally invasive surgery for inflammatory bowel disease: Review of current developments and future perspectives

Patients with inflammatory bowel disease (IBD) comprise a population of patients that have a high likelihood of both surgical treatment at a young age and repetitive operative interventions. Therefore surgical procedures need to aim at minimizing operative trauma with best postoperative recovery. Minimally invasive techniques have been one of the major advancements in surgery in the last decades and are nowadays almost routinely performed in colorectal resections irrespective of underlying disease. However due to special disease related characteristics such as bowel stenosis, interenteric fistula, abscesses, malnutrition, repetitive surgeries, or immunosuppressive medications, patients with IBD represent a special cohort with specific needs for surgery. This review summarizes current evidence of minimally invasive surgery for patients with Crohn’s disease or ulcerative colitis and gives an outlook on the future perspective of technical advances in this highly moving field with its latest developments in single port surgery, robotics and trans-anal techniques.

Surgery for Crohn's disease: new developments

BACKGROUND/AIMS

Crohn's disease is a chronic relapsing inflammatory bowel disease requiring surgery in a large number of patients. This review describes new developments in surgical techniques for treating Crohn's disease.

RESULTS

Single-incision laparoscopic surgery decreases abdominal wall trauma by reducing the number of abdominal incisions, possibly improving postoperative results in terms of pain and cosmetics. The resected specimen can be extracted through the single-incision site or the future stoma site. Another option is to use natural orifices for extraction (i.e. transcolonic/transanal), but actual benefits of these procedures have not yet been determined. In patients with extensive perianal disease or rectal involvement, transperineal completion proctectomy is often feasible, thereby avoiding relaparotomy. By using a close rectal intersphincteric resection, damage to the pelvic autonomic nerves is avoided. In addition, the risk of presacral abscess formation is reduced by leaving the mesorectal tissue behind.

CONCLUSION

Minimally invasive surgery and associated techniques have become standard clinical practice in surgical treatment of patients with Crohn's disease. New developments aim at further reducing the hospital stay and morbidity, and improving the cosmetic outcomes.

S052: a comparison of robot-assisted, laparoscopic, and open surgery in the treatment of rectal cancer

BACKGROUND

In recent years, robot-assisted surgery using the da Vinci System® has been proposed as an alternative to traditional open or laparoscopic procedures. The aim of this study was to compare the short-term outcomes for open, laparoscopic, and robot-assisted rectal resection for cancer.

METHODS

Two hundred sixty-three patients with rectal cancer who underwent curative resection between 2007 and 2009 were included. Patients were classified into an open surgery group (OS, n = 88), a laparoscopic surgery group (LAP, n = 123), and a robot-assisted group (RAP, n = 52). Data analyzed include operating time, length of recovery, methods of specimen extraction, quality of total mesorectal excision, and morbidity.

RESULTS

The mean operating time was 233.8 ± 59.2 min for the OS group, 158.1 ± 49.2 min for the LAP group, and 232.6 ± 52.4 min for the RAP group (p < 0.001). Patients from the LAP and RAP groups recovered significantly faster than did those from the OS group (p < 0.05). The proportion of operations performed through a natural orifice (intracorporeal anastomosis with transanal or transvaginal retrieval of specimens) was significantly higher in the RAP group (p < 0.001). The specimen quality--with a distal resection margin, harvested lymph nodes, and circumferential margin--did not differ among the three groups. The overall complication rates were 20.5, 12.2, and 19.2% in the OS, LAP, and RAP groups, respectively (p = 0.229).

CONCLUSIONS

RAP and LAP reproduce the equivalent short-term results of standard OS while providing the advantages of minimal access. For the experienced laparoscopic colorectal oncologist, use of the da Vinci robot resulted in no significant short-term clinical benefit over the conventional laparoscopic approach.

Laparoscopic resection with transcolonic specimen extraction for ileocaecal Crohn's disease

BACKGROUND

Ileocolic resection for Crohn's disease can be performed entirely laparoscopically. However, an incision is needed for specimen extraction. This prospective observational study assessed the feasibility of endoscopic transcolonic specimen removal.

METHODS

Endoscopic specimen removal was attempted in a consecutive series of ten patients scheduled for laparoscopic ileocolic resection. Primary outcomes were feasibility, operating time, reoperation rate, pain scores, morphine requirement and hospital stay. To assess applicability, outcomes were compared with previous data from patients who had laparoscopically assisted operations.

RESULTS

Transcolonic removal was successful in eight of ten patients; it was considered not feasible in two patients because the inflammatory mass was too large (7-8 cm). Median operating time was 208 min and median postoperative hospital stay was 5 days. After surgery two patients developed an intra-abdominal abscess, drained laparoscopically or percutaneously, and one patient had another site-specific infection. The operation took longer than conventional laparoscopy, with no benefits perceived by patients in terms of cosmesis or body image.

CONCLUSION

Transcolonic removal of the specimen in ileocolic Crohn's disease is feasible in the absence of a large inflammatory mass but infection may be a problem. It is unclear whether the technique offers benefit compared with conventional laparoscopic surgery.

Laparoscopic high anterior resection with natural orifice specimen extraction (NOSE) for early rectal cancer

Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. We describe a technique for laparoscopic resection of an early-stage upper rectal cancer in a 51-year-old man followed by transanal specimen delivery, hence avoiding the need for making any additional abdominal incisions for retrieval of the specimen. Pneumoperitoneum was created, followed by medial-tolateral mobilization of the sigmoid colon, and take down of the splenic flexure and division of the inferior mesenteric vessels laparoscopically. The upper rectum distal to the tumour and proximal colon was transected with a laparoscopic stapler. The specimen was retrieved transanally via an opening in the rectal stump. The proximal colon was then delivered transanally and the anvil of the circular stapler inserted before returning it to the pelvic cavity. The rectal stump was transected again just below the opening to close off the stump, and the colorectal anastomosis was then completed intracorporeally. The patient, a 51-year-old male (BMI 18.6 kg/m(2)) with a 2.5-cm, early-stage posterior rectal cancer 12 cm from the anal verge, underwent the above-described procedure. Postoperative recovery was uneventful. He resumed normal daily activities 1 week after surgery. Histology confirmed a T1N0 upper rectal cancer. In the effort to minimize surgical trauma and postoperative pain, natural orifice specimen extraction techniques have been attempted. This procedure may be applicable to benign tumours and early colorectal cancer, and serves as an intermediate step between laparoscopic and natural orifice surgery.