Implementation of intracorporeal anastomosis in laparoscopic right colectomy is safe and associated with a shorter hospital stay

Design and validation of a simulation-based training module for ileo-transverse intracorporeal anastomosis

BACKGROUND

The benefits of the totally laparoscopic right hemicolectomy have been established, but its adoption has been limited by the challenges of intracorporeal suturing. While simulation is effective for training advanced surgical skills, no dedicated simulation-based course exists for intracorporeal ileo-transverse anastomosis (ICA). This study aimed to develop and validate a simulation module for training in ICA.

METHODS

This study employed a proof-of-concept design for an educational tool. Key aspects of the anastomosis were identified using the team's surgical experience, surgical videos, and existing evidence. Surgeons were recruited to test and refine successive simulation models through an iterative process until a functional prototype was achieved and assessed. Subsequently, surgeons with varying experience levels were invited to perform an ICA in the model. Performance was evaluated by two blinded surgeons through video recordings, utilizing a modified Objective Structured Assessment of Technical Skills (OSATS), a Specific Rating Score (SRS), and operative time measurements. Non-parametric descriptive and analytical methods were applied, with results presented as median [IQR].

RESULTS

An ex vivo based model was developed. Seventeen participants evaluated the model. Eighty-three percent declared acceptable or maximum fidelity regarding the colon. Resemblance to the surgical scenario in terms of ergonomic and anatomical similarity was highlighted. All participants found the model useful to train intracorporeal suturing. Thirteen subjects performed the ICA. Experts achieved significantly higher OSATS scores (22.3 [22-22.5] vs 18 [16-19.5]; p = .013), exhibited a trend toward higher SRS, and obtained shorter operative times (21.5 vs 36 min; p = .039).

CONCLUSION

An ex vivo simulation module for ICA was developed, demonstrating acceptable fidelity in replicating the surgical environment. The simulated scenario could successfully distinguish between levels of surgical experience, as evidenced by significant differences in OSATS scores and operative times, thereby confirming its construct validity.

Short-term Outcomes of Intracorporeal Versus Extracorporeal Totally Stapled Anastomosis after Laparoscopic Colectomy: A Propensity Score-matched Cohort Study

Objectives

To describe detailed surgical techniques for totally stapled intracorporeal anastomosis (TSIA) and determine their feasibility and safety by comparing short-term outcomes with those of conventional totally stapled extracorporeal anastomosis (TSEA).

Methods

In total, 59 consecutive patients who underwent laparoscopic colectomy between June 2018 and August 2021 were retrospectively assessed. Linear staplers were used for all anastomoses. The TSIA and TSEA groups included 23 and 36 patients, respectively. Following a comprehensive description of each surgical technique, propensity score matching analysis was conducted to compare matched groups on the basis of clinicopathological characteristics, surgical and perioperative outcomes, complications, and postoperative inflammatory reactions. After matching, 17 cases each were analyzed in the TSIA and TSEA groups.

Results

Both groups were well matched. The TSIA group had significantly lesser blood loss than did the TSEA group (10 versus 20 mL, p=0.002), although this result was not clinically significant. The skin excision length (4 versus 6 cm, p<0.001) and postoperative hospital stay length (6 versus 7 days, p<0.001) were significantly shorter in the TSIA group than in the TSEA group. Increasing C-reactive protein (CRP) values at 1, 3, and 6 postoperative days were significantly lower in the TSIA group than in the TSEA group (p=0.016, p=0.011, and p=0.012, respectively).

Conclusions

TSIA is a simple, feasible, and efficient surgical technique; compared with TSEA, it is less invasive and associated with lesser blood loss, shorter skin incision lengths, shorter postoperative hospital stays, and lower CRP level increases.

Multidimensional assessment of the learning curve of intracorporeal anastomosis during laparoscopic right colectomy

PURPOSE

After resection during a laparoscopic right colectomy (LRC), reconstruction can be conducted with an intracorporeal (IA) or extracorporeal anastomosis. Although IA benefits are well documented, its implementation has been slow due to a steep learning curve (LC) mainly associated with intracorporeal suturing. The aim of this study is to assess the LC of IA in LRC.

METHODS

Consecutive patients undergoing a LRC with IA between January 2016 and June 2023 were included. Clinical, perioperative, and histopathological variables were collected. Correlation and cumulative sum (CUSUM) analyses between the operating time and case number were performed. 'Surgical success' as a composite outcome was also analysed by performing a CUSUM plot. Completion LC case number was determined based on these analyses. Pre-LC and post-LC perioperative outcomes were compared.

RESULTS

Two-hundred-and-ninety patients underwent a LRC during the study period. Sixty-seven met inclusion criteria. Correlation analysis identified a significant operating time reduction with increasing case numbers (p = 0.034). Total complications during implementation period were 25,3%, with 6% of severe complications. Operative time CUSUM analysis identified a consistent downwards trend after case 36 and surgical success CUSUM analysis after case 37. Two phases were established: pre-LC (case 0-37th) and post-LC (38th-67). Pre-LC and post-LC revealed a significant decrease in operative time (187vs177.8 min;p = 0.016), and length of stay (4vs3 days;p < 0.001). No difference between overall complications, severe complication, or reoperation rates were detected.

CONCLUSION

The LC of laparoscopic IA can be achieved after 37 cases in centres with experience in advanced laparoscopic surgery. Further studies will be required to confirm these results.

Learning curve and safety of the implementation of laparoscopic complete mesocolic excision with intracorporeal anastomosis for right-sided colon cancer: results from a propensity score-matched study

BACKGROUND

Retrospective studies and randomized controlled trials support the safety of laparoscopic complete mesocolic excision (CME) for the treatment of right-sided colon cancer (RSCC). Few studies, however, examine the learning curve of this operation and its impact on safety during an implementation period. We aim to evaluate the learning curve and safety of the implementation of laparoscopic CME with intracorporeal anastomosis for RSCC.

METHODS

Consecutive patients undergoing a laparoscopic right colectomy with intracorporeal anastomosis for RSCC between January 2016 and June 2023 were included. Clinical, perioperative, and histopathological variables were collected. Correlation and cumulative sum (CUSUM) analyses between the operating time and case number were performed. Breakpoints of the learning curve were estimated using the broken-line model. CME and conventional laparoscopic right colectomy outcomes were compared after propensity score matching (PSM).

RESULTS

Two hundred and ninety patients underwent laparoscopic right colectomy during study period. One hundred and eight met inclusion criteria. After PSM, 56 non-CME and 28 CME patients were compared. CME group had a non-statistically significant tendency to a longer operating time (201 versus 195 min; p = 0.657) and a shorter hospital stay (3 versus 4 days; p = 0.279). No significant differences were found in total complication rates or their profile. Correlation analysis identified a significant trend toward operating time reduction with increasing case numbers (Pearson correlation coefficient =  - 0.624; p = 0.001). According to the CUSUM analysis, an institutional learning curve was deemed completed after 13 cases and the broken-line model identified three phases: learning (1-6 cases), consolidation (7-13 cases), and mastery (after 13 cases).

CONCLUSION

The learning curve of laparoscopic CME for RSCC can be achieved after 13 cases in centers with experience in advanced laparoscopic surgery and surgeons with familiarity with this technique. Its implementation within this setting seems to be as safe as performing a conventional right colectomy.

Clinical Outcomes after Intracorporeal versus Extracorporeal Anastomosis in Patients Undergoing Laparoscopic Right Hemicolectomy for Colon Cancer

Background and Objectives: Laparoscopic right hemicolectomy (LRHC) is commonly performed for patients with colon cancer, selecting between intracorporeal anastomosis (ICA) or extracorporeal anastomosis (ECA). However, the impact of ICA versus ECA on patient outcomes remains debatable. The varying levels of experience among surgeons may influence the outcomes. Therefore, this study sought to compare the short- and long-term outcomes of LRHC using ICA versus ECA. Materials and Methods: This retrospective study extracted patient data from the medical records database of Changhua Christian Hospital, Taiwan, from 2017 to 2020. Patients with colon cancer who underwent LRHC with either ICA or ECA were included. Primary outcomes were post-surgical outcomes and secondary outcomes were recurrence rate, overall survival (OS), and cancer-specific survival (CSS). Between-group differences were compared using chi-square, t-tests, and Fisher's exact tests and Mann-Whitney U tests. Associations between study variables, OS, and CSS were determined using Cox analyses. Results: Data of 240 patients (61 of ICA and 179 of ECA) with a mean age of 65.0 years and median follow-up of 49.3 months were collected. No recognized difference was found in patient characteristics between these two groups. The ICA group had a significantly shorter operation duration (median (IQR): 120 (110-155) vs. 150 (130-180) min) and less blood loss (median (IQR): 30 (10-30) vs. 30 (30-50) mL) than the ECA group (p < 0.001). No significant differences were found in 30-day readmission (ICA vs. ECA: 1.6% vs. 2.2%, p > 0.999) or recurrence (18.0% vs. 13.4%, p = 0.377) between the two groups. Multivariable analyses revealed no significant differences in OS (adjusted hazard ratio (aHR): 0.65; 95% confidence interval (CI): 0.25-1.44) or CSS (adjusted sub-hazard ratio (aSHR): 0.41, 95% CI: 0.10-1.66) between groups. Conclusions: Both ICA and ECA in LRHC for colon cancer had similar outcomes without statistically significant differences in post-surgical complications, 30-day readmission rates, recurrence rate, and long-term survival outcomes. However, ICA may offer two advantages in terms of a shorter operative duration and reduced blood loss.

Comparison of intracorporeal and extracorporeal anastomosis in laparoscopic right colectomy: an updated meta-analysis and trial sequential analysis

This meta-analysis was conducted to provide updated evidence regarding perioperative safety and efficacy, of IC and EC anastomosis in laparoscopic right colectomies. In this study, the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines were applied. The study protocol received a PROSPERO registration (CRD42020214596). A systematic literature search of the electronic scholar databases (Medline, Web of Science and Scopus) was performed. To reduce type I error, a trial sequential analysis (TSA) algorithm was introduced. The quality of evidence was evaluated based on the GRADE methodology. In total, 46 studies were included in this meta-analysis, Pooled comparisons and TSA confirmed that IC is superior in terms of incisional hernia (0.29; 95%CI: 0.19, 0.44), open conversion (0.45; 95%CI: 0.30, 0.67), reoperation (0.62; 95%CI: 0.46, 0.84]), LOS (- 0.76; 95%CI: - 1.03, - 0.49), blood loss (- 11.50; 95%CI: - 18.42, - 4.58), and cosmesis (- 1.71; 95%CI: - 2.01, - 1.42). Postoperative pain and return of bowel function were, also, shortened when the anastomosis was fashioned intracorporeally. The grading of most evidence ranged from 'low' to 'high'. Due to the discrepancy in the results of RCTs and non-RCTs, and the proportionally smaller sample size of the former, further randomized trials are required to increase the evidence of this comparison.

Laparoscopic Right Hemicolectomy for Inflammatory Bowel Disease: Is Intracorporeal Anastomosis Feasible? A Retrospective Cohort Comparison Study

Background: Inflammatory bowel disease (IBD) affects all ages and backgrounds, and many individuals require surgical intervention during their disease course. The adoption of laparoscopic techniques in this patient population has been slow, including intracorporeal anastomosis (ICA). The aim of our study was to determine if ICA was feasible and safe in patients with IBD undergoing laparoscopic right hemicolectomy (LRHC). Methods: This is a retrospective, single institution cohort study of elective and emergent cases of LRHC at a single academic center. Patients included underwent LRHC or ileocolic resection for IBD. Exclusion criteria: conversion to laparotomy, resection without anastomosis, or unconfirmed diagnosis of IBD. Main outcomes studied were anastomotic leak rate, surgical site infection (SSI), postoperative length of stay, 30-day readmission/reoperation, and operative time. Secondary outcomes were incisional hernia rates and rates of disease recurrence. Results: A total of 70 patients were included, 12 underwent ICA and 58 extracorporeal anastomosis. Anastomotic leak rate (intracorporeal 8.3% [n = 1], extracorporeal 8.6% [n = 5], P = .97), and SSI rates (intracorporeal 0%, extracorporeal 6.9% [n = 4], P = .36) were similar. Mean postoperative length of stay, rates of 30-day readmission/reoperation and diagnosis of hernia at 1 year were not significantly different. Rates of IBD recurrence and location of recurrence at 1 year were similar. However, operative time was significantly longer in those undergoing ICA (intracorporeal 187 minutes versus extracorporeal 139 minutes, P = < .05). Conclusions: ICA is a safe option in patients with IBD undergoing LRHC.

Extent of Lymph Node Harvest: A Retrospective Cohort Comparison of Intracorporeal Versus Extracorporeal Anastomosis in Right Hemicolectomy

Background: Minimally invasive surgery has been demonstrated to have clear advantages in colon cancer management, with a decrease in the morbidity and mortality associated with surgery. With the introduction of intracorporeal anastomosis (ICA), the entire mesenteric dissection and division is performed under vision laparoscopically and may lead to superior lymph node harvest. The aim of our study is to evaluate lymph node harvest in patients undergoing totally laparoscopic right hemicolectomy with ICA compared to laparoscopic-assisted right hemicolectomy with extracorporeal anastomosis (ECA). Methods: This is a single institution retrospective cohort study. Eligible patients underwent laparoscopic right hemicolectomy at our institution between 2012 and 2022. Patients were identified using a hospital database, and surgeon office databases. Patients included underwent laparoscopic right hemicolectomy for neoplastic lesions (colon cancer/unresectable polyps), or benign etiologies. We excluded patients who underwent laparotomy (intra-operative conversion), resection without anastomosis, resection for IBD, or lack of documented lymph node number. Data were compared using two-sided t-test evaluation with a 95% confidence interval. Results: A total of 679 patients were included, 493 ECA (72.6%) and 186 ICA (27.4%). Patient demographics (age, biologic sex, American Society of Anesthesiologists and body mass index) were not significantly different. Lymph node harvest was significantly higher in those with ICA (24 ± 14 versus 21 ± 1, P < .05). In subgroup analysis, this difference was maintained in patients with malignant processes (27 ± 14 versus 23 ± 10, P < .05). Conclusions: In our experience, ICA has higher lymph node harvest in comparison to ECA. This may improve outcomes and options for adjuvant therapies in malignant indications.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: a retrospective study

BACKGROUND

The surgical procedure for laparoscopic right colectomy (LRC) is not standardized. Some published studies show the superiority of ileocolic anastomosis (IIA), but the evidence so far is insufficient. This study aimed to investigate the potential advantages in postoperative recovery and safety of IIA in LRC.

METHODS

A total of 114 patients who underwent LRC with IIA (n = 58) or extracorporeal ileocolic anastomosis (EIA, n = 56) between January 2019 and September 2021 were enrolled. We collected certain factors as clinical features, intraoperative characteristics, oncological outcomes, postoperative recovery, and short-term outcomes. Our primary outcome was time to gastrointestinal (GI) function recovery. Secondary outcomes were postoperative complications within 30 days, postoperative pain, and length of hospital stay.

RESULTS

Faster GI recovery and less postoperative pain were observed in patients with IIA compared to EIA [time to first flatus: (2.4 ± 0.7) vs (2.8 ± 1.0) days, p < 0.01; time to liquid intake: (3.5 ± 0.7) vs (4.0 ± 1.1) days, p = 0.01; postoperative visual analogue scale score: (3.9 ± 1.0) vs (4.3 ± 0.6), p = 0.02]. No significant differences were detected in oncological outcomes or postoperative complications. IIA, rather than EIA, tended to be performed in patients with higher body mass index [(23.93 ± 3.52) vs (22.36 ± 2.87) kg/m², p = 0.01].

CONCLUSIONS

IIA is associated with faster GI function recovery and less postoperative pain and may be more favorable for obese patients.

Extracorporeal Hand-Sewn vs. Intracorporeal Mechanic Anastomosis During Laparoscopic Right Colectomy

BACKGROUND AND OBJECTIVES

To compare the outcomes of extracorporeal hand-sewn side-to-side isoperistaltic ileocolic anastomosis (EHSIA) versus intracorporeal mechanic side-to-side isoperistaltic ileocolic anastomosis (IMSIA) during laparoscopic right hemicolectomy for adenocarcinoma.

METHODS

This is a retrospective propensity score-matched analysis of prospectively collected data. Fifty-four patients who underwent surgery with EHSIA (intervention group) were paired with 54 patients who underwent surgery with IMSIA (control group) based on patients' demographics and type of surgery (standard right hemicolectomy or extended right hemicolectomy).

RESULTS

Fifty-four patients were included for each group. Statistically significant differences between groups were not observed in patients' demographics and type of surgery. Conversion occurred in three patients of the intervention group due to intra-abdominal adhesions for previous surgery (5.6%) (p = 0.079). Median operative time was statistically significant shorter in the control group in comparison to the intervention group (85 and 117.5 minutes, respectively, p ≤ 0.0001). In both groups one anastomotic leakage was observed (1.9%) (Clavien-Dindo grade III-a). In the control group one patient (1.9%) underwent reintervention for acute postoperative anemia (Clavien-Dindo grade III-b). Median number of harvested lymph-nodes was 17 and 12 (p ≤ 0.0001), in the intervention and the control group, respectively. Median hospital stay was statistically significant lower in the control group in comparison to the intervention group (5 and 6.5 days, respectively, p ≤ 0.013).

CONCLUSION

IMSIA showed lower operative time and hospital stay in comparison to EHSIA. Further randomized studies are required to draw definitive conclusions about the best anastomotic technique during laparoscopic right hemicolectomy.

The effect of operative duration on the outcome of colon cancer procedures

BACKGROUND

Prolonged operative duration has been associated with increased post-operative morbidity in numerous surgical subspecialties; however, data are limited in operations for colon cancer specifically and existing literature makes unwarranted methodological assumptions of linearity. We sought to assess the effects of extended operative duration on perioperative outcomes in those undergoing segmental colectomy for cancer using a methodologically sound approach.

METHODS

We conducted a retrospective cohort study of patients undergoing segmental colectomy for cancer between 2014 and 2018, logged in the National Surgical Quality Improvement Program datasets. Our primary outcome was a composite of any complication within 30 days; secondary outcomes included length of stay and discharge disposition. Our main factor of interest was operative duration.

RESULTS

We analyzed 26,380 segmental colectomy cases, the majority of which were approached laparoscopically (64.95%) and were right sided (62.93%). Median operative duration was 152 (95% CI 112-206) minutes. On multivariable regression, increased operative duration was linearly associated with any complication (OR = 1.003, 95% CI 1.003-1.003, p < 0.0001) in the overall cohort, as was length of stay (p < 0.0001). All subgroups except for the laparoscopic left colectomy group were linearly associated with operative duration. In the laparoscopic left colectomy group, an inflection point in the odds of any complication was found at 176 min (OR = 1.39, 95% CI 1.20-1.61, p < 0.0001).

CONCLUSIONS

This study suggests that the risk of perioperative complications increases linearly with increasing operative duration, where each additional 30 min increases the odds of complication by 10%. In those undergoing laparoscopic left colectomy, the risk of complications sharply increases after ~ 3 h, suggesting that surgeons should aim to complete these procedures within 3 h where possible.