Totally intracorporeal laparoscopic colorectal anastomosis using circular stapler

Laparoscopic natural orifice specimen extraction, a minimally invasive surgical technique for mid-rectal cancers: Retrospective single-center analysis and single-surgeon experience of selected patients

OBJECTIVE

To evaluate the feasibility, safety, and short-term outcomes of middle rectal resection followed by transanal specimen extraction.

METHODS

Forty-four patients with small mid-rectal tumors underwent laparoscopic rectal resection followed by transanal specimen extraction.

RESULTS

The procedure was successful in all patients without intraoperative conversion or additional access. The mean operation time was 182.7 minutes (range, 130-255 minutes), the mean blood loss was 26.5 mL (range, 5-120 mL), the mean postoperative exhaust time was 31.3 hours (range, 16-60 hours), and the mean length of hospital stay was 9.5 days (range, 8-19 days). One patient developed anastomotic leakage, which was treated by intravenous antibiotics and daily pelvic cavity flushes through the abdominal drainage tube. No infection-related complications or anal incontinence were observed. The mean tumor size was 2.1 cm (range, 1.6-3.2 cm), the mean number of harvested lymph nodes was 16.5 (range, 6-31), and the mean follow-up time was 8.5 months (range, 2-16 months). By the last follow-up, no signs of recurrence had been found in any patient.

CONCLUSION

The combination of standard laparoscopic proctectomy and transanal specimen extraction could become a well-established strategy for selected patients.

A prospective study of specimen eversion to lateral rectum and valgus resection for low rectal cancer

Purpose

To investigate the safety and efficacy of a reverse puncture device (RPD) and specimen eversion of the rectum for resection in total laparoscopic proctectomy.

Methods

In a prospective study from August 2019 to March 2021, 40 patients underwent a procedure with an RPD and specimen eversion of the rectum for total laparoscopic low rectal cancer resection, that is natural orifice specimen extraction surgery (NOSES), were included in the NOSES group. Forty patients in the control group underwent conventional laparoscopic radical resection for low rectal cancer and were included in the LAP group. Intraoperative- and postoperative-related indicators, recovery and inflammatory factors, quality of life (QOL) and mental health were compared.

Results

All operations were successfully completed. Compared with the LAP group, the NOSES group showed better short-term outcomes, such as time to eating, postoperative pain, and especially postoperative incision-related complications. At the same time, postoperative inflammatory factor levels, psychological trauma, life-related anxiety and depression scores, and QOL were better in the NOSES group than in the LAP group.

Conclusions

The application of an RPD and specimen eversion of the rectum for total laparoscopic low rectal cancer resection is a technically feasible and safe approach with a short-term curative effect.

Completely intracorporeal anastomosis in robotic left colonic and rectal surgery: technique and 30-day outcomes

As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7 mL vs. 110.2 mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p =  < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30 day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA).

High Versus Low Ligation of the Inferior Mesenteric Artery During Rectal Resection for Cancer: Oncological Outcomes After Three Years of Follow-Up From the HIGHLOW Trial

Objectives

To determine the disease-free survival (DFS), disease-specific survival (DSS), and recurrence in patients who underwent laparoscopic low anterior rectal resection with total mesorectal excision (TME) with either high or low ligation of the inferior mesenteric artery (IMA).

Background

The level of IMA ligation during anterior rectal resection with TME is still a matter of debate, especially in terms of oncological adequacy.

Methods

Between June 2014 and December 2016, patients scheduled to undergo elective laparoscopic low anterior resection (LAR) and TME in 6 Italian nonacademic hospitals were randomized into 2 groups in the HIGHLOW Trial (ClinicalTrials.gov Identifier: NCT02153801) according to the level of IMA ligation: high ligation (HL) versus low ligation (LL). DFS, DSS, and recurrence were inquired. Recurrence was determined at 3, 6, 9, and 12 months and every 6 months thereafter. Patients and tumor characteristics as well as surgical outcomes were analyzed to identify risk factors for recurrence.

Results

One hundred ninety-six patients from the HIGHLOW trial were analyzed. Median follow-up for DFS was 40.6 (interquartile range [IQR], 6-64.7) and 40 (IQR, 7.6-67.8), while median follow-up for DSS was 41.2 (IQR, 10.7-64.7) and 42.7 (IQR, 6-67.6) in the HL and LL groups, respectively. The 3-year DFS rate of HL and LL patients was 82.2% and 82.1% (P = 0.874), respectively. The 3-year DSS for HL and LL patients was 92.1% and 93.4% (P = 0.897), respectively. There was no statistically significant difference in the local recurrence rate (2% HL vs 2.1% LL), in the regional recurrence rate (3% HL vs 2.1% LL), and in the distant recurrence rate (12.9% HL vs 13.7% LL). Multivariate analysis found conversion to open surgery (hazard ratio [HR], 3.68; P = 0.001) and higher stage of disease (HR, 7.73; P < 0.001) to be significant determinant for DFS.

Conclusions

The level of inferior mesenteric artery ligation during LAR and TME for rectal cancer does not affect DFS, DSS, and recurrence.

Comparison of NOSES and Conventional Laparoscopic Surgery in Colorectal Cancer: Bacteriological and Oncological Concerns

Background: Colorectal natural orifice specimen extraction surgery (NOSES) is considered to be a scarless operation that avoids the laparotomy of extraction specimen, but bacteriological and oncological concerns are raised with this technique. Objective: The purpose of this study was to compare the oncological and bacteriological outcomes of NOSES and conventional laparoscopic (CL) procedures. Methods: This is a retrospective study of prospectively collected outcomes data. Patients operated with colorectal cancer from January 2016 to December 2019 in Xiangya Hospital were assigned to the group NOSES and the group CL according to the size of the tumor. Prior to dissection, peritoneal lavage fluid was collected for cytological assessment. At the end of the procedure, peritoneal lavage fluid was collected for aerobic culture and cytological assessment. Baseline characteristics and short-term and long-term outcomes for NOSES and CL were compared. Results: Between January 2016 and December 2019, 212 patients were enrolled from our center and 185 patients were analyzed (96 and 89 in NOSES and CL groups, respectively). The bacterial positive rate of peritoneal lavage fluid was 34.4 vs. 32.6% in NOSES and CL groups, respectively (P = 0.80). The positive rate of tumor cells in peritoneal lavage fluid was 7.3 vs. 9.0% in NOSES and CL groups, respectively (P = 0.67). Univariate analysis showed that the positive rate of tumor cells in peritoneal lavage fluid was significantly associated with tumor invasion depth and lymph node metastasis (P < 0.05). T4 (OR = 20.47, 95%CI = 1.241-337.661; P = 0.04), N1 (OR = 5.445, 95%CI = 1.412-20.991; P = 0.01), and N2 (OR = 6.315, 95%CI = 1.458-27.348; P = 0.01) served as independent predictors of peritoneal lavage fluid positive oncology patients. Local recurrence-free survival was not significantly different between two groups (HR = 0.909, 95%CI = 0.291-2.840; P = 0.87). Conclusions: Compared with conventional laparoscopic procedure, NOSES is in conformity with the principle of asepsis and tumor-free technique and can be worthy of clinical application and promotion.

Safety and Oncological Outcomes of Laparoscopic NOSE Surgery Compared With Conventional Laparoscopic Surgery for Colorectal Diseases: A Meta-Analysis

Objective: To evaluate the safety and oncological outcomes of laparoscopic colorectal surgery using natural orifice specimen extraction (NOSE) compared with conventional laparoscopic (CL) colorectal surgery in patients with colorectal diseases.

Methods: We conducted a systematic search of PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs), prospective non-randomized trials and retrospective trials up to September 1, 2018, and used 5-year disease-free survival (DFS), lymph node harvest, surgical site infection (SSI), anastomotic leakage, and intra-abdominal abscess as the main endpoints. Subgroup analyses were conducted according to the different study types [RCT and NRCT (non-randomized controlled trial)]. A sensitivity analysis was carried out to evaluate the reliability of the outcomes. RevMan5.3 software was used for statistical analysis.

Results: Fourteen studies were included (two RCTs, seven retrospective trials and five prospective non-randomized trials) involving a total of 1,435 patients. Compared with CL surgery, the NOSE technique resulted in a shorter hospital stay, shorter time to first flatus, less post-operative pain, and fewer SSIs and total perioperative complications. Anastomotic leakage, blood loss, and intra-abdominal abscess did not differ between the two groups, while operation time was longer in the NOSE group. Oncological outcomes such as proximal margin [weighted mean difference [WMD] = 0.47; 95% confidence interval [CI] −0.49 to 1.42; P = 0.34], distal margin (WMD= −0.11; 95% CI −0.66 to 0.45; P = 0.70), lymph node harvest (WMD = −0.97; 95% CI −1.97 to 0.03; P = 0.06) and 5-year DFS (hazard ratio = 0.84; 95% CI 0.54–1.31; P = 0.45) were not different between the NOSE and CL surgery groups.

Conclusions: Compared with CL surgery, NOSE may be a safe procedure, and can achieve similar oncological outcomes. Large multicenter RCTs are needed to provide high-level, evidence-based results in NOSE-treated patients and to determine the risk of local recurrence.

Laparoscopic anterior resection: new anastomosis technique in a pig model

BACKGROUND AND OBJECTIVES

Bowel anastomosis after anterior resection is one of the most difficult tasks to perform during laparoscopic colorectal surgery. This study aims to evaluate a new feasible and safe intracorporeal anastomosis technique after laparoscopic left-sided colon or rectum resection in a pig model.

METHODS

The technique was evaluated in 5 pigs. The OrVil device (Covidien, Mansfield, Massachusetts) was inserted into the anus and advanced proximally to the rectum. A 0.5-cm incision was made in the sigmoid colon, and the 2 sutures attached to its delivery tube were cut. After the delivery tube was evacuated through the anus, the tip of the anvil was removed through the perforation. The sigmoid colon was transected just distal to the perforation with an endoscopic linear stapler. The rectosigmoid segment to be resected was removed through the anus with a grasper, and distal transection was performed. A 25-mm circular stapler was inserted and combined with the anvil, and end-to-side intracorporeal anastomosis was then performed.

RESULTS

We performed the technique in 5 pigs. Anastomosis required an average of 12 minutes. We observed that the proximal and distal donuts were completely removed in all pigs. No anastomotic air leakage was observed in any of the animals.

CONCLUSION

This study shows the efficacy and safety of intracorporeal anastomosis with the OrVil device after laparoscopic anterior resection.

Totally Laparoscopic Colectomy with Intracorporeal Side-to-End Colorectal Anastomosis and Transrectal Specimen Extraction for Sigmoid and Rectal Cancers

BACKGROUND

The techniques of intracorporeal anastomosis and specimen extraction after laparoscopic colectomy via a natural orifice have gained interest increasingly. We evaluated the feasibility of our unique techniques for colorectal reconstruction and report immediate postoperative outcomes in patients with rectosigmoid cancer.

METHODS

Patients with sigmoid or rectal cancer were selected depending on the size of the tumor and its distance from the anal verge. Demographic data, operative parameters, and postoperative outcomes were assessed. After complete resection of the tumor, all patients underwent an intracorporeal side-to-end colorectal anastomosis following transrectal specimen extraction.

RESULTS

Laparoscopic resection with our technique of intracorporeal anastomosis was successful in 32 patients. The average operative time was 192 ± 29 min, and mean blood loss was 51 ± 18 ml. All patients experienced mild postoperative pain, and bowel function returned before postoperative day 3 in most patients. They had an uneventful postoperative course with a median hospital stay of 6 days. Major perioperative complications or anastomotic leak were not encountered in this study. The mean size of the lesion was 3.3 ± 1.8 cm, and the mean number of harvested nodes was 14 ± 6. During the follow-up period, there were no functional disorders associated with the intracorporeal anastomosis or transrectal specimen extraction.

CONCLUSIONS

Intracorporeal side-to-end colorectal anastomosis with transrectal specimen extraction in laparoscopic colorectal surgery is a safe and effective procedure for patients with rectosigmoid malignancy.

Complete laparoscopic resection of the rectum using natural orifice specimen extraction

AIM

To investigate how complete laparoscopic anterior resection with natural orifice specimen extraction (NOSE), as a novel minimally invasive surgery, compares to conventional laparoscopic surgery.

METHODS

Twenty patients who underwent complete laparoscopic anterior resection with NOSE and 50 patients who underwent laparoscopic assisted anterior resection by the conventional method between 2011 and 2012 were studied. Selection for complete laparoscopic anterior resection with NOSE was decided on the basis of tumor size, localization of the tumor, and body mass index. Outcomes related to surgery, including operation time, postoperative wound pain, hospital stay after surgery, the number of totally dissected lymph nodes, postoperative complications (suture failure and wound infection), and anal function, were reviewed retrospectively. Anal function was assessed at 3 and 6 mo after surgery using the Wexner fecal incontinence scoring system.

RESULTS

Complete laparoscopic resection with NOSE was performed to completion in all 20 patients. There was no patient emergency that required conversion to conventional laparoscopic surgery or open surgery. The comparison between complete laparoscopic resection with NOSE and conventional laparoscopic surgery showed no significant differences in the maximal diameter of the tumor, number of totally dissected lymph nodes, bleeding volume, mean operation time, time to start of oral ingestion, postoperative hospital stay, and postoperative complications. On the other hand, with regard to pain after epidural anesthesia, the total usage of analgesia in this novel surgical technique was 1.85 ± 1.8 times, whereas it was 5.89 ± 2.86 in conventional laparoscopic surgery (P < 0.001). The postoperative pain period was 1.9 ± 1.9 d in this novel surgical technique, whereas it was 3.43 ± 1.41 d in conventional laparoscopic surgery (P < 0.004). In complete laparoscopic surgery with NOSE, the mean postoperative follow-up period was 20 mo (range: 12-30 mo). Neither local recurrence nor remote metastasis was observed during the follow-up period.

CONCLUSION

Complete laparoscopic anterior resection using NOSE does not require any incision and has excellent cosmetic properties, with mitigated postoperative pain.

Laparoscopic colon and rectal resections with intracorporeal anastomosis and trans-vaginal specimen extraction for colorectal cancer. A case series and systematic literature review

PURPOSE

Intracorporeal anastomosis associated to trans-vaginal specimen extraction decreases the extent of colon mobilisation and the number and size of abdominal incisions, improving the benefits of minimally invasive surgery in female patients. The aim of this study was to evaluate the safety and effectiveness of this procedure for colorectal cancer.

METHODS

Between 2009 and 2013, 13 female patients underwent laparoscopic colon and rectal resection for colorectal cancer with intracorporeal anastomosis and trans-vaginal specimen extraction: 2 right colectomies, 1 transverse colon resection, 4 left colectomies and 6 anterior resections were performed. A MEDLINE search of publications on the presented procedure for colon neoplasms was carried out.

RESULTS

There were no intraoperative complications and no conversions. Postoperative visual analogue scale (VAS) score in the pelvis, abdomen and shoulder was moderate. In the postoperative period, we observed two colorectal anastomotic strictures, successfully treated with pneumatic endoscopic dilation. Median length of the specimen was 18.5 cm, with a median tumour size of 5.5 cm in diameter. Median number of retrieved lymph nodes was 12. All circumferential resection margins were negative. During a mean follow-up of 31 months (range, 6-62), there was neither evidence of recurrent disease nor disorders related to the genitourinary system. The aesthetic outcome was considered satisfactory in all patients. Nine studies were identified in the systematic review.

CONCLUSIONS

Our case series, according to the results of the literature, showed that intracorporeal anastomosis associated to trans-vaginal specimen extraction is feasible and safe in selected female patients.

Complete laparoscopic resection of the rectum using natural orifice specimen extraction

AIM: To investigate how complete laparoscopic anterior resection with natural orifice specimen extraction (NOSE), as a novel minimally invasive surgery, compares to conventional laparoscopic surgery.

METHODS: Twenty patients who underwent complete laparoscopic anterior resection with NOSE and 50 patients who underwent laparoscopic assisted anterior resection by the conventional method between 2011 and 2012 were studied. Selection for complete laparoscopic anterior resection with NOSE was decided on the basis of tumor size, localization of the tumor, and body mass index. Outcomes related to surgery, including operation time, postoperative wound pain, hospital stay after surgery, the number of totally dissected lymph nodes, postoperative complications (suture failure and wound infection), and anal function, were reviewed retrospectively. Anal function was assessed at 3 and 6 mo after surgery using the Wexner fecal incontinence scoring system.

RESULTS: Complete laparoscopic resection with NOSE was performed to completion in all 20 patients. There was no patient emergency that required conversion to conventional laparoscopic surgery or open surgery. The comparison between complete laparoscopic resection with NOSE and conventional laparoscopic surgery showed no significant differences in the maximal diameter of the tumor, number of totally dissected lymph nodes, bleeding volume, mean operation time, time to start of oral ingestion, postoperative hospital stay, and postoperative complications. On the other hand, with regard to pain after epidural anesthesia, the total usage of analgesia in this novel surgical technique was 1.85 ± 1.8 times, whereas it was 5.89 ± 2.86 in conventional laparoscopic surgery (P < 0.001). The postoperative pain period was 1.9 ± 1.9 d in this novel surgical technique, whereas it was 3.43 ± 1.41 d in conventional laparoscopic surgery (P < 0.004). In complete laparoscopic surgery with NOSE, the mean postoperative follow-up period was 20 mo (range: 12-30 mo). Neither local recurrence nor remote metastasis was observed during the follow-up period.

CONCLUSION: Complete laparoscopic anterior resection using NOSE does not require any incision and has excellent cosmetic properties, with mitigated postoperative pain.

Totally laparoscopic resection with natural orifice specimen extraction (NOSE) has more advantages comparing with laparoscopic-assisted resection for selected patients with sigmoid colon or rectal cancer

PURPOSE

The purposes of this study were to compare the short-term outcomes of natural orifice specimen extraction (NOSE) and laparoscopic-assisted resection for sigmoid colon cancer or rectal cancer and to appraise whether totally laparoscopic resection with NOSE had more advantages compared with conventional laparoscopic-assisted resection.

METHODS

Sixty-five patients who underwent totally laparoscopic resection with NOSE were assigned to NOSE group, and 132 patients who underwent laparoscopic-assisted resection were assigned to laparoscopic-assisted (LA) group. Data of all 197 cases were reviewed. Short-term outcomes (including operative outcomes, gastrointestinal recovery, hospital stay, and complication) of the two groups were compared.

RESULTS

Mean numbers of lymph nodes harvested were 17.0 ± 8.3 and 18.9 ± 11.6 in NOSE group and LA group, respectively, (P = 0.248); mean operative times were 111.6 ± 25.4 min and 115.3 ± 23.0 min in the two groups (P = 0.384); and the mean blood losses in these two groups were 70.2 ± 66.1 ml and 126.3 ± 58.6 ml, respectively, (P < 0.001). Times to first flatus were 2.7 ± 0.8 and 3.4 ± 0.9 days (P < 0.001), and times to first defecation were 3.3 ± 0.6 and 3.9 ± 1.1 days (P = 0.002) in NOSE group and LA group, respectively. Hospital stay in NOSE group were 9.0 ± 1.9 and 9.9 ± 2.0 days in LA group. Incidences of peri-operative complications were 6.2 and 17.2% in the two groups, respectively (P = 0.031).

CONCLUSIONS

Without compromising oncologic outcome, totally laparoscopic resection with NOSE had more advantages including less blood loss, less pain, faster recovery of intestinal function and shorter hospital stay compared with laparoscopic-assisted resection for selected patients with sigmoid colon cancer or rectal cancer.

Totally laparoscopic resection with natural orifice specimen extraction for carcinoma of sigmoid colon and rectum: a feasible and innovative technique

GOALS

To testify the feasibility and safety of an innovative technique we performed.

BACKGROUND

An abdominal incision is required to extract a specimen for laparoscopic-assisted colorectal operation, and the incision brings some disadvantages for surgeons and patients. Natural orifice specimen extraction (NOSE) is developed to avoid these disadvantages.

STUDY

Between May 2012 and March 2013, we attempted to perform totally laparoscopic resection with NOSE in 27 patients with sigmoid colon cancer or rectal cancer. Procedure of this technique was described and clinic data of all 27 patients were collected and analyzed.

RESULTS

We successfully completed the technique of NOSE in 24 of these patients. Mean operation time was 110.0 minutes and mean intraoperative blood loss was 69.1 mL in 23 patients (not including one patient who received additional bilateral oophorectomy) who underwent NOSE. Of these 24 patients, the mean time to passing of first flatus was 3.1 days, the mean postoperative hospital stay was 9.2 days, and 2 patients used analgesics after operation; 22 patients were able to walk in first 2 days, 2 patients had postoperative complications.

CONCLUSIONS

Totally laparoscopic resection with NOSE is suited for selected patients with sigmoid colon cancer or rectal cancer, and this technique is worth to recommend and spread.

Totally laparoscopic colectomy with intracorporeal anastomosis achieved using a laparoscopic linear stapler: experience of a single institute

PURPOSE

Laparoscopic colonic surgery is now widely accepted. We assessed the safety and effectiveness of using a total intracorporeal surgical strategy to perform intracorporeal functional end-to-end anastomosis with an endoscopic linear stapler to treat colon cancer.

METHODS

Forty-three selected patients underwent elective laparoscopic colon resection for carcinoma. A total intracorporeal colon resection was performed in all patients, using a functional end-to-end anastomosis with an endoscopic linear stapler.

RESULTS

Good results were achieved in all 43 patients, none of whom required conversion to open surgery with extracorporeal anastomosis. There have been no intraoperative complications related to this technique and no instances of postoperative anastomotic leakage, intra-abdominal abscess, or wound infection.

CONCLUSION

Intracorporeal functional end-to-end anastomosis using a linear stapler can be performed safely and easily for the resection of any part of the colon. We consider it an effective modality for totally laparoscopic colon resection. Favorable results have been achieved by this method, particularly for small tumors, since natural-orifice transluminal endoscopic surgery remains a challenging method to perform.

Totally laparoscopic sigmoid colectomy with transanal specimen extraction

BACKGROUND

Conventional techniques for laparoscopic-assisted colectomy (LAC) require abdominal minilaparotomy for extraction of the specimen. Abdominal wound complications often increase the invasiveness of LAC. To decrease the incidence of wound complications, natural orifice specimen extraction (NOSE) has been reported. However, only a few devices that allow smooth extraction and reduced intracorporeal contamination have been reported previously. We performed totally laparoscopic sigmoid colectomy using transanal specimen extraction (TASE) and the Alexis(®) wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA). We document this simple and safe technique and its short-term results.

METHODS

We prospectively collected data on 18 patients who underwent totally laparoscopic sigmoid colectomy with TASE from April 2009 to July 2010. Lymph node dissection and transection of proximal and distal colon were performed in conventional manner. The transected rectal stump was opened transversely, and a long Babcock grasper was inserted transanally through the opened rectal stump. One of a pair of Alexis rings was held and pulled out of the anus. The other ring was placed in the opened rectal stump. The specimen was then extracted transanally through the Alexis. After the Alexis had been removed, the rectal opening was reclosed with a linear stapler. End-to-end colorectal anastomosis was then performed using the double-stapling technique.

RESULTS

Transanal extraction was achieved in 17 cases. We switched to conventional LAC in a case involving a bulky specimen. In 16 cases not including the combined cholecystectomy case, mean operation time was 241 min. One case was complicated by anastomotic leakage and wound infection, while another had enterocolitis. Median hospital stay was 6 days. All patients remained disease free. Mean Wexner score at 12 months after operation was 2.3.

CONCLUSION

Totally laparoscopic sigmoid colectomy using TASE and the Alexis appears to be feasible, safe, and oncologically acceptable for selected cases.

Trilumenal hybrid-NOS proctocolectomy

BACKGROUND

The authors hypothesized that by combining transumbilical, transvaginal, and transrectal accesses, complex bowel operations, including proctocolectomy with restorative J pouch [corrected] reconstruction, might be possible.

METHODS AND RESULTS

Out of a series of 30 natural orifice surgery (NOS) operations performed at the authors' institution in the past 12 months, proctocolectomy with ileoanal pouch reconstruction was planned for 3 female patients (31 years, BMI = 30; 50 years, BMI = 31; 30 years, BMI = 21) with extensive disease of ulcerative colitis, and they were operated via a 3-lumenal NOS approach. The first 2 patients received a proctocolectomy with a J-pouch formation. A 3-stage procedure was planned for the third patient, and she received a total colectomy. The colonic specimen was retrieved through the anus obviating dilation of the vagina. The J-pouch was prepared through a horizontal 2-cm incision, which later served as the protective loop ileostomy site.

CONCLUSION

Trilumenal NOS proctocolectomy is feasible and safe providing a solution to overcome the lack of triangulation using a single-lumen approach.

Population perception of surgical safety and body image trauma: a plea for scarless surgery?

BACKGROUND

Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) are prospected as the future of minimally invasive surgery. While scarless surgery (NOTES and LESS) is gaining increasing popularity, perception of these approaches should be investigated.

METHODS

An anonymous questionnaire describing laparoscopy, LESS, and NOTES was given to medical staff (n=120), paramedical staff (n=100), surgical patients (n=100), and the general population (n=100). The survey participants (median age, 37 years; range, 18-81 years) were queried about their expectations for surgical treatment and their approach preference.

RESULTS

The first concern of the survey responders was the risk of surgical complications (92%). When asked about the respective importance of surgical safety, cure, and cosmetics, cure was placed first by 74%, safety by 33%, and cosmetics by 3%. These results were not influenced by sex, age, prior surgery or endoscopy, or education. When operative risk was similar, 90% of the participants preferred a scarless approach (75% preferred LESS and 15% preferred NOTES) to laparoscopy. The scarless approach preference was significantly higher among the younger participants (age<40 years; p=0.026), whereas sex showed no influence. The LESS preference was significantly higher among patients and the general population (86%) than among medical (67%) and paramedical (70%) staffs (p<0.001). A decreasing trend of preference for LESS and NOTES was observed with increased procedural risks.

CONCLUSION

Although cure and safety remain the main concern, the population has a favorable perception of scarless surgery, even in the case of increased procedural risk, with LESS favored over NOTES. Such a popular adoption of scarless surgery should warrant the promotion of further research, technological innovations, and the establishment of surgeon training to improve its safety.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSION

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

[CS circular staplers for rectal surgery--a multicenter prospective study]

While circular staplers are used worldwide - especially for rectal anastomoses - there are relatively few publications on the effectiveness of these instruments. Between May 2008 and March 2009 in a prospective multicenter surveillance study 136 patients were enrolled from nine surgical units in Hungary. Rectal anastomoses were performed mainly in the upper and middle third of the rectum. In 115 cases adenocarcinoma, in 16 patients other type of malignant tumors and in 5 cases with anastomosis in the distal third were estimated too. 20 laparoscopic and 116 "conventional" surgery was performed. 32 mm diameter type CS circular staplers were used in 50, 28 mm in 85, and 25 mm in one case. Intraoperative technical failure of the device occurred in four cases, immediate correction were performed successfully in all of these patients and they recovered without postoperative complications. Late anastomotic leaks were detected in five patients, of which three healed spontaneously and two required reoperation. In the whole series two patients died representing a 1.4 percent mortality rate. The CS circular staplers proved to be appropriate for infraperitoneal rectal anastomoses.

Transumbilical single incision laparoscopic sigmoidectomy for benign disease

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.

Single-port access laparoscopic radical left colectomy in humans

BACKGROUND

Transumbilical single-port access (SPA) surgery is a rapidly evolving field that combines in part the cosmetic advantage of natural orifice transluminal endoscopic surgery (NOTES) with the ability to perform the operation with standard laparoscopic instruments. We report our experience with the first transumbilical single-port access radical left colectomy conforming to surgical oncologic principle and minimally invasive colectomy technique.

METHODS

Umbilical single-port access (embryonic natural orifice transluminal endoscopic surgery) left colectomy was performed in a patient with sigmoid colon adenocarcinoma in situ. During the same procedure, a single-port access cholecystectomy was performed for chronic cholecystitis.

RESULTS

Transumbilical single-port access radical left colectomy was feasible with conventional laparoscopic instruments. A 39-cm pathologic specimen with sufficient surgical margins and lymph nodes (34) was resected. Final diagnosis revealed an adenocarcinoma in situ. Operative time for left colectomy and cholecystectomy was 213 minutes. No intraoperative or postoperative complications were recorded.

CONCLUSION

Single-port access radical left colectomy is feasible when performed by experienced laparoscopic surgeons. Carcinologic surgical principles can be respected using this colectomy technique. Single-port access left colectomy may have a clinical advantage over natural orifice transluminal endoscopic surgery in offering the safety of laparoscopic colectomy. It has yet to be determined whether or not this approach would offer patient benefits, except in cosmesis, compared with standard laparoscopic left colectomy.

Single port access laparoscopic right hemicolectomy

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.