[Indications of laparoscopic general and digestive surgery. Evidence based guidelines of the French society of digestive surgery]

Beyond total mesorectal excision: The emerging role of minimally invasive surgery for locally advanced rectal cancer

Multivisceral resection and/or pelvic exenteration represents the only potential curative treatment for locally advanced rectal cancer (LARC); however, it poses significant technical challenges, which account for the high risk of morbidity and mortality associated with the procedure. As complete histopathologic resection is the most important determinant of patient outcomes, LARC often requires an extended resection beyond the total mesorectal excision plane to obtain clear resection margins. In an era when laparoscopic surgery and robot-assisted surgery are becoming commonplace, the optimal approach to extensive pelvic interventions remains controversial. However, acceptance of the suitability of minimally invasive surgery is slowly gaining traction. Nonetheless, there is still a lack of evidence in the literature about minimally invasive approaches in multiple and extensive surgical resections, highlighting the need for research studies to explore, validate, and develop this issue. This editorial aims to provide a critical overview of the currently available applications and challenges of minimally invasive abdominopelvic surgery for LARC. Furthermore, we discuss recent developments in the field of robotic surgery for LARC, with a specific focus on new innovations and emerging frontiers.

Comparison of short- and long-term outcomes between laparoscopic and open multivisceral resection for clinical T4b colorectal cancer: A multicentre retrospective cohort study in China

BACKGROUND

Laparoscopic surgery is controversial for patients with clinical T4b colorectal cancer (CRC) who require multivisceral resection (MVR). This study aims to explore and compare the safety and long-term oncological outcomes of laparoscopic surgery and open surgery for patients with clinical T4b CRC.

MATERIALS AND METHODS

This study was a retrospective cohort study based on a multicentre database. According to the operation method, the patients were divided into a laparoscopic MVR group and an open MVR group. The short-term and long-term outcomes were compared.

RESULTS

From January 2010 to December 2021, a total of 289 patients in the laparoscopic MVR group and 349 patients in the open MVR group were included. After propensity score matching, patients were stratified into a laparoscopic MVR group (n = 163) and an open MVR group (n = 163). Compared with the open MVR group, the laparoscopic MVR group had less blood loss (100 vs. 200, p < 0.001), a shorter time to first flatus (3 vs. 4, P < 0.001), a shorter postoperative hospital stay (10 vs. 12, P < 0.001), and a lower incidence of surgical site infection (2.5 % vs. 8.0 %, P = 0.043). The Kaplan-Meier curves showed that the two groups had similar overall survival (P = 0.283) and disease-free survival (P = 0.152).

CONCLUSION

Compared with open MVR, laparoscopic MVR had less blood loss, fewer surgical site infection complications, faster recovery and a shorter hospital stay. The long-term survival outcome of laparoscopic MVR was not inferior to that of open MVR.

Combined transabdominal and transperineal endoscopic pelvic exenteration for colorectal cancer: feasibility and safety of a two-team approach

Purpose

Pelvic exenteration (PE) is a highly invasive procedure with high morbidity and mortality rates. Promising options to reduce this invasiveness have included laparoscopic and transperineal approaches. The aim of this study was to identify the safety of combined transabdominal and transperineal endoscopic PE for colorectal malignancies.

Methods

Fourteen patients who underwent combined transabdominal and transperineal PE (T group: 2-team approach, n = 7; O group: 1-team approach, n = 7) for colorectal malignancies between April 2016 and March 2020 in our institutions were included in this study. Clinicopathological features and perioperative outcomes were compared between groups.

Results

All patients successfully underwent R0 resection. Operation time tended to be shorter in the T group (463 minutes) than in the O group (636 minutes, P = 0.080). Time to specimen removal was significantly shorter (258 minutes vs. 423 minutes, P = 0.006), blood loss was lower (343 mL vs. 867 mL, P = 0.042), and volume of blood transfusion was less (0 mL vs. 560 mL, P = 0.063) in the T group, respectively. Postoperative complications were similar between groups.

Conclusion

Combined transabdominal and transperineal PE under a synchronous 2-team approach was feasible and safe, with the potential to reduce operation time, blood loss, and surgeon stress.

Short-term and long-term outcomes of laparoscopic colectomy with multivisceral resection for surgical T4b colon cancer: Comparison with open colectomy

AIM

In response to the rising use of laparoscopic surgery, recent studies have shown that laparoscopic multivisceral resections for locally advanced colon cancer are safe, feasible, and provide acceptable oncological outcomes. However, the usefulness of laparoscopic multivisceral resection remains controversial. Here, we aimed to compare short-term and long-term outcomes between laparoscopic and open multivisceral resection approaches for treating locally advanced colon cancer.

METHODS

We retrospectively collected data on 1315 consecutive patients admitted to the National Hospital Organization, Osaka National Hospital, for surgical treatment of colorectal cancer between 2010 and 2017. We assessed invasiveness in terms of operating times, blood loss, and complications. Oncological outcomes included 5-year survival rates and recurrences.

RESULTS

We included 85 patients that underwent a colectomy with a multivisceral resection for locally advanced colon cancer; of these, 38 were treated with a laparoscopic approach and 47 were treated with an open approach. Compared to the open surgery group, the laparoscopic group had significantly less blood loss (median volume: 25 vs 140 mL, P <0.001), a lower complication rate (10.5% vs 29.8%, P = 0.036), and shorter hospital stays (12 vs 15 days, P = 0.028). After excluding patients with stage Ⅳ colon cancer, the groups showed similar pathologic outcomes and no significant differences in 5-year disease-free survival (73.9% vs 67.4%; P = 0.664) or 5-year overall survival (75.8% vs 67.7%; P = 0.695).

CONCLUSION

A laparoscopic approach for locally advanced colon cancer could be less invasive than an open approach without affecting oncological outcomes in selected patients.

Safety and Feasibility of Laparoscopic Pelvic Exenteration for Locally Advanced or Recurrent Colorectal Cancer

PURPOSE

Pelvic exenteration (PE) for locally advanced or recurrent colorectal cancer is often used to secure negative resection margins. The aim of this study was to evaluate the feasibility of laparoscopic PE.

MATERIALS AND METHODS

The clinical records of 24 patients (9, open; 15, laparoscopic) who underwent total or posterior PE for locally advanced or recurrent colorectal cancer between July 2012 and April 2016 at Osaka National Hospital were retrospectively reviewed. Operative factors were compared between the 2 groups.

RESULTS

The R0 resection rate was 100% in the laparoscopic group and 89% in the open group. The operative time and the incidence of postoperative complications were not significantly different between the 2 groups. The laparoscopic group showed less intraoperative blood loss (P=0.019), a lower C-reactive protein elevation on postoperative day 7 (P=0.025), and a shorter postoperative hospital stay (P=0.0009).

CONCLUSIONS

Laparoscopic PE is a safe and feasible procedure to reduce postoperative stress.

Safety and feasibility of laparoscopic multivisceral resection for surgical T4b colon cancers: Retrospective analyses

INTRODUCTION

Laparoscopic (Lap) surgery has not been established as a standard procedure for locally advanced colon cancers. Here, we evaluated the safety and feasibility of Lap multivisceral resection (MVR) for tumors that had invaded adjacent organs (T4b).

METHODS

We performed retrospective analyses using a single institutional database. Eighty-four patients who underwent Lap or open MVR for surgical T4b primary colon cancers satisfied the inclusion criteria.

RESULTS

Among the 84 patients, 48 underwent Lap MVR and 36 underwent open MVR. More patients in the open group were clinical T4b and were receiving neoadjuvant chemotherapy. Patients in the open group had worse performance status (P = 0.037) and tumors of greater diameter. Lap completion was achieved in 42 cases (87.5%); the conversion rate was highest in cases involving the urinary tract (40.0%). Lap reconstruction of the bladder or ureter was extremely challenging, and therefore, adjacent organ reconstruction influenced Lap completion. Regarding perioperative outcomes, Lap was superior to open surgery in terms of intraoperative blood loss, morbidity, and postoperative hospital stay. Conversion was required in six cases; five were strategic conversions, and conversion was not associated with severe morbidity. The microscopic positive surgical margin rate was not higher in the Lap group than in the open group. Kaplan-Meier analyses of overall and disease-free survival were comparable between the groups. Cox regression analyses revealed that the operative approach did not have a significant adverse effect on long-term outcomes.

CONCLUSION

The Lap approach could be considered for surgical T4b cancers, except for urinary tract invasion cases that require complicated reconstruction.

Laparoscopic treatment of advanced colonic cancer: a case-matched control with open surgery

AIM

The safety, feasibility and oncological results of laparoscopic resection for advanced colon cancer were evaluated.

METHOD

Seventy consecutive patients with a histologically proven T4 colon cancer who underwent laparoscopic (LPS) right or left colectomy were matched for comorbidity on admission (American Society of Anesthesiologists score), tumour stage and grading with 70 patients who underwent open colectomy over a 10-year period. Short- and long-term outcome measures were evaluated.

RESULTS

The overall conversion rate was 7.1%. Less intra-operative blood loss (P = 0.01), a trend toward a longer operation time (P = 0.09) and a lower peri-operative blood transfusion rate (P = 0.06) were observed in the LPS group. A similar number of lymph nodes were retrieved (P = 0.37) and the R1 resection rate (P = 0.51) was no different in the two groups. The overall mortality rate was 1.4%. The overall morbidity rate was 21.4% (15/70 patients) in the LPS group and 27.5% (19/70 patients) in the open group (P = 0.42), with anastomotic leakage rates of 7.1% and 4.2% (P = 0.32). Length of stay was shorter after LPS (P = 0.009). Five-year overall survival rate (P = 0.18) and disease-free survival rate (P = 0.20) did not differ significantly between the two groups.

CONCLUSION

Laparoscopic treatment of T4 colon cancer is safe and feasible and provides a similar surgical and oncological outcome compared with the open technique.

[Video-assisted surgery in children: current progress and future perspectives]

This review presents the evidence of video-assisted surgery in the pediatric population and discusses future progress in this field. Videosurgery minimizes the cosmetic impact and the pain induced by open procedures and has been in constant development in adults and children. Earlier training of surgeons and residents combined with advances in anesthetics and technology have expanded the use of videosurgery for more complex interventions. Although most feasible surgical procedures have been performed by laparoscopy, the literature has not yet defined it as the gold standard for most interventions, especially because of the lack of evidence for many of them. However, laparoscopy for cholecystectomy is now the preferred approach with excellent postoperative outcomes and few complications. Although no evidence has been demonstrated in children, laparoscopy has been shown to be superior in adults for gastroesophageal reflux disease and splenectomy. Laparoscopic appendectomy remains controversial. Nevertheless, meta-analyses have concluded in moderate but significant advantages in terms of pain, cosmetic considerations, and recovery for the laparoscopic approach. Laparoscopy is now adopted for undescended testes and allows both localization and surgical treatment if necessary. For benign conditions, videosurgery can be an excellent tool for nephrectomy and adrenalectomy. However, laparoscopy remains controversial in pediatric surgical oncology.

Strategies for diagnosis and treatment of small bowel obstruction

Small bowel obstruction, which is caused by a variety of etiological factors and mainly manifests as abdominal pain, vomiting and distension, is one of the most common acute abdomens. A rapid and accurate diagnosis of small bowel obstruction is needed to give reasonable and effective treatment to avoid its rapid deterioration. In this paper we discuss the strategies for diagnosis and treatment of small bowel obstruction through comparing different imaging methods for diagnosis of small bowel obstruction and reviewing the current situation of diagnosis and treatment of the disease in terms of pharmacotherapy, gastrointestinal decompression, and surgical intervention.

T4 colorectal cancer: is laparoscopic resection contraindicated?

AIM

T4 colorectal cancer remains a contraindication for laparoscopy. It is argued that the risk of incomplete resection could be higher than in open surgery. Furthermore, difficulty in dissection could lead to a very high rate of conversion. There is little information on this. The study aimed at assessing feasibility and operative and oncologic results of laparoscopic resection for T4 colorectal cancer.

METHOD

Between 2006 and 2009, 39 patients with colorectal cancer with suspected involvement of another organ (T4) on computed tomography scanning and/or magnetic resonance imaging were included. The cancers were in the right colon (n = 18), left colon (n =9) and rectum (n = 12). The distribution of possible organ involvement was abdominal or pelvic side-wall (n = 21), urinary bladder (n = 4), small bowel or colon (n = 6), vagina and ovary (n = 3), prostate or seminal vesicles (n = 3) and duodenum (n = 2).

RESULTS

The overall conversion rate was 18%. Postoperative mortality and morbidity were 2.5 and 33%, respectively. Clinical anastomotic leakage rate was 15% (n = 6). Abdominal reoperation was required in three (7%) patients. Pathological invasion to other organs (pT4) was confirmed in 30 (77%) patients. The R1 resection rate was 13% (4 of 30). After a median follow up of 19 months (range 1.5-45 months), the overall survival and disease-free survival rates were 97 and 89%, respectively.

CONCLUSION

This study suggests that laparoscopic surgery is feasible for colorectal T4 cancer resection. Laparoscopy cannot therefore be considered an absolute contraindication for T4 colorectal cancer.

Laparoscopic appendectomy in a district hospital: does the technique influence the outcome?

BACKGROUND

Laparoscopic appendicectomy (LA) has proved to be a safe, effective procedure for appendicitis. However, its application in the current surgical practice is still far less than the laparoscopic cholecystectomy. Therefore, its role as a gold standard operation for acute appendicitis (AA) is less well established.

METHODS

Between September 1999 and January 2007, a series of 200 patients (112 female, 88 male) with AA underwent LA in our surgical unit. A single consultant surgeon performed all the cases. Outcomes, including the length of stay, operative time, and complications, were evaluated. Follow-up assessment of patients was performed by outpatient appointment.

RESULTS

The indications for LA were clinical diagnosis of AA for 177 patients (85%) and interval appendicectomy for 23 patients (15%). The mean age of these patients was 18.8 years (range, 8-83). Operative diagnosis of inflamed appendix, including perforated appendicitis in 9 patients (7.5%), was made in 139 patients (69.5%), and the appendix was macroscopically normal in 40 patients (20%). Different pathologies were found in 21 patients (11.5%). Of the 40 (20%) macroscopically normal appendices, 10 (5%) appendices were reported as inflamed by histopathology examination. The operative time ranged from 13 to 62 minutes, with a mean of 18 minutes. Minor morbidity was reported in 11 patients (5.5%)

CONCLUSION

In experienced hands using a meticulous technique, LA provides diagnostic and therapeutic options, decreased operative time, rapid recovery, short hospital stay, fewer postoperative complications, and no intra-abdominal abscesses. Appendicectomy has cured right iliac fossa pain in almost all the patients.

Laparoscopic central pancreatectomy: single institution experience of 6 patients

BACKGROUND

Medial pancreatectomy is an alternative technique for benign or low-grade malignant tumors of the neck of the pancreas. We describe our experience of laparoscopic central pancreatectomy.

METHODS

We conducted a prospective evaluation of laparoscopic pancreatic resection in the Department of Abdominal Surgery at Haut-Lévêque Hospital, CHU Bordeaux. From January 1999 until February 2006, 397 patients underwent pancreatic resection for pancreatic lesions, of whom 60 (15%) were enrolled for laparoscopic pancreatic resection. Of the 60 patients, 6 underwent laparoscopic central pancreatectomy. Surgical procedure, postoperative course, and follow-up data were collected.

RESULTS

Laparoscopic central pancreatectomy was successful in all patients. In 1 case, we had to perform a laparotomy to find the specimen, which had been lost in the cavity during the anastomosis. The median operative time was 225 minutes (range, 180 to 365 minutes). None of the patients required blood transfusion in the perioperative period, and there was no mortality. Symptomatic pancreatic fistula occurred in 2 patients (33%). None of the patients required reoperation or radiologic drainage. Oral feeding was resumed in a median of 11 days (range, 9 to 21 days). The median postoperative hospital stay was 18 days (range, 15 to 25 days). At a median follow-up of 15 months (range, 4 to 34 months), all patients were alive without exocrine or endocrine insufficiency.

CONCLUSIONS

Laparoscopic central pancreatectomy is feasible and safe. Laparoscopic central pancreatectomy may become the standard approach for resection of benign or low-grade malignant tumors of the neck of the pancreas if performed by highly skilled surgeons.

[Subperitoneal inguinal hernioplasty by anterior approach, using a memory-ring patch. Preliminary results]

OBJECTIVE

Incidence of chronic pain is lower following laparoscopic hernioplasty than open surgery, probably due to the location of the patch in the preperitoneal space. But since laparoscopy is more demanding, the rates of complications and recurrences are higher. The aim of this study was to evaluate the results of a procedure consisting of placement of a patch, endowed with some memory of shape, provided by a thin peripheral memory ring, in the preperitoneal space, by inguinal incision, through the hernia orifice, under spinal or local anesthesia.

METHODS

The study was carried out in two stages. The first study consisted of evaluating the results of a prosthesis made of a polypropylene mesh endowed with a memory-ring made of a PDS cord (Ethicon SAS, 92787 Issy-les-Moulineaux). The second study evaluated the results of the Polysoft patch manufactured by Bard C degrees (Bard France, 78960 Voisins-le-Bretonneux), according to this concept.

RESULTS

The first study involved 129 hernias operated on 126 patients of mean age 60 years (27-84). There were 3 (2.3%) benign complications. With a median follow-up of 24.5 months (12-42), 124 hernias (96%) were evaluated. There were 2 recurrences (1.6%) and 7 cases (5.6%) of chronic pain. The second series involved 150 hernias operated on 139 patients of mean age 60 years (21-94). Four (2.7%) benign complications occurred. The median length of surgery was 36 min (20-60), the median postoperative hospital stay was 1 day (0-5), the median time to return to normal activity was 3 days (0-8) and the median time off work was 18 days (1(30). The patients took paracetamol for 3 days (0-10) and the total units number was 8 (0-28).

CONCLUSION

These results suggest that the method, easily reproducible, provides a low rate of complications and recurrences, as well as a low level of postoperative and chronic pain. They are worth being confirmed by a randomised comparison to the laparoscopic and Lichtenstein techniques.