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Bhattacharya P, Hussain MI, Zaman S, Mohamedahmed AY, Faiz N, Mashar R, Sarma DR, Peravali R. Comparison of Midline and Off-midline specimen extraction following laparoscopic left-sided colorectal resections: A systematic review and meta-analysis. J Minim Access Surg 2023; 19:183-192. [PMID: 37056082 PMCID: PMC10246630 DOI: 10.4103/jmas.jmas_309_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/29/2022] [Accepted: 12/15/2022] [Indexed: 02/16/2023] Open
Abstract
Aims This study aims to evaluate comparative outcomes following midline versus off-midline specimen extractions following laparoscopic left-sided colorectal resections. Methods A systematic search of electronic information sources was conducted. Studies comparing 'midline' versus 'off midline' specimen extraction following laparoscopic left-sided colorectal resections performed for malignancies were included. The rate of incisional hernia formation, surgical site infection (SSI), total operative time and blood loss, anastomotic leak (AL) and length of hospital stay (LOS) was the evaluated outcome parameters. Results Five comparative observational studies reporting a total of 1187 patients comparing midline (n = 701) and off-midline (n = 486) approaches for specimen extraction were identified. Specimen extraction performed through an off-midline incision was not associated with a significantly reduced rate of SSI (odds ratio [OR]: 0.71; P = 0.68), the occurrence of AL (OR: 0.76; P = 0.66) and future development of incisional hernias (OR: 0.65; P = 0.64) compared to the conventional midline approach. No statistically significant difference was observed in total operative time (mean difference [MD]: 0.13; P = 0.99), intraoperative blood loss (MD: 2.31; P = 0.91) and LOS (MD: 0.78; P = 0.18) between the two groups. Conclusions Off-midline specimen extraction following minimally invasive left-sided colorectal cancer surgery is associated with similar rates of SSI and incisional hernia formation compared to the vertical midline incision. Furthermore, there were no statistically significant differences observed between the two groups for evaluated outcomes such as total operative time, intra-operative blood loss, AL rate and LOS. As such, we did not find any advantage of one approach over the other. Future high-quality well-designed trials are required to make robust conclusions.
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Affiliation(s)
- Pratik Bhattacharya
- Department of General Surgery, Sandwell and West Birmingham Hospitals, Birmingham, West Midlands, UK
| | | | - Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals, Birmingham, West Midlands, UK
| | - Ali Yasen Mohamedahmed
- Department of Colorectal Surgery, The Royal Wolverhampton NHS Trust, Wolverhampton, West Midlands, UK
| | - Nameer Faiz
- Department of General Surgery, Sandwell and West Birmingham Hospitals, Birmingham, West Midlands, UK
| | - Ruchir Mashar
- Department of General Surgery, Sandwell and West Birmingham Hospitals, Birmingham, West Midlands, UK
| | - Diwakar Ryali Sarma
- Department of General Surgery, Sandwell and West Birmingham Hospitals, Birmingham, West Midlands, UK
| | - Rajeev Peravali
- Department of General Surgery, Sandwell and West Birmingham Hospitals, Birmingham, West Midlands, UK
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Paruch JL. Extraction Site in Minimally Invasive Colorectal Surgery. Clin Colon Rectal Surg 2023; 36:47-51. [PMID: 36643827 PMCID: PMC9839428 DOI: 10.1055/s-0042-1758352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The widespread adoption of minimally invasive colorectal surgery has led to improved patient recovery and outcomes. Specimen extraction sites remain a major source of pain and potential postoperative morbidity. Careful selection of the extraction site incision may allow surgeons to decrease postoperative pain, infectious complications, or rates of hernia formation. Options include midline, paramedian, transverse, Pfannenstiel, and natural orifice sites. Patient, disease, and surgeon-related factors should all be considered when choosing a site. This article will review different options for specimen extraction sites.
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Affiliation(s)
- Jennifer L Paruch
- Department of Colon and Rectal Surgery, Ochsner Medical Center, New Orleans, Louisiana
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den Hartog FPJ, van Egmond S, Poelman MM, Menon AG, Kleinrensink GJ, Lange JF, Tanis PJ, Deerenberg EB. The incidence of extraction site incisional hernia after minimally invasive colorectal surgery: a systematic review and meta-analysis. Colorectal Dis 2022; 25:586-599. [PMID: 36545836 DOI: 10.1111/codi.16455] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/09/2022] [Accepted: 11/22/2022] [Indexed: 01/06/2023]
Abstract
AIM Minimally invasive colorectal surgery reduces surgical trauma with better preservation of abdominal wall integrity, but the extraction site is still at risk of incisional hernia (IH). The aim of this study was to determine pooled incidence of IH for each type of extraction site and to compare rates of IH after midline, nonmidline and Pfannenstiel extraction. METHOD A systematic review and meta-analysis was conducted using the PRISMA guidelines. Single-armed and multiple-armed cohort studies and randomized controlled trials regarding minimally invasive colorectal surgery were searched from five databases. Outcomes were pooled and compared with random-effects, inverse-variance models. Risk of bias within the studies was assessed using the Cochrane ROBINS-I and RoB 2 tool. RESULTS Thirty six studies were included, with a total 11,788 patients. The pooled extraction site IH rate was 16.0% for midline (n = 4081), 9.3% for umbilical (n = 2425), 5.2% for transverse (n = 3213), 9.4% for paramedian (n = 134) and 2.1% for Pfannenstiel (n = 1449). Nonmidline extraction (transverse and paramedian) showed significantly lower odds ratios (ORs) for IH when compared with midline extraction (including umbilical). Pfannenstiel extraction resulted in a significantly lower OR for IH compared with midline [OR 0.12 (0.50-0.30)], transverse [OR 0.25 (0.13-0.50)] and umbilical (OR 0.072 [0.033-0.16]) extraction sites. The risks of surgical site infection, seroma/haematoma or wound dehiscence were not significantly different in any of the analyses. CONCLUSION Pfannenstiel extraction is the preferred method in minimally invasive colorectal surgery. In cases where Pfannenstiel extraction is not possible, surgeons should avoid specimen extraction in the midline.
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Affiliation(s)
- Floris P J den Hartog
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sarah van Egmond
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marijn M Poelman
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Anand G Menon
- Department of Surgery, IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands
| | - Gert-Jan Kleinrensink
- Department of Neuroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eva B Deerenberg
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
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Steiner C, Karl M, Laschke MW, Schupbach P, Venturato A, Gasser A. Comparison of extraction sites versus artificial defects with xenogenic bone substitute in minipigs. Clin Exp Dent Res 2021; 7:490-501. [PMID: 33398935 PMCID: PMC8404495 DOI: 10.1002/cre2.390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/17/2022] Open
Abstract
Objectives The preclinical evaluation of bone substitutes is frequently performed in artificially created defects. However, such defects do not reflect the predominant clinical application of bone substitutes for socket preservation. Hence, the goal of this animal study was to compare the performance of a xenogenic bone substitute in extraction sites versus artificial defects. Material and Methods Four study sites each were created in the mandibles of four minipigs in the region of the third premolars and first molars, respectively. On one side, fresh extraction sockets were established while contralaterally trephine defects were created in healed alveolar bone. All sites were augmented using a particulate xenogenic bone substitute, covered by resorbable membranes and allowed to heal for 12 weeks. The amounts of new bone, non‐bone tissue and remaining bone substitute granules were quantified through histological and micro‐CT analysis. Comparative statistics were based on t‐tests for two samples and ANOVA with the level of significance set at α = 0.05. Results Histomorphometric data from only two animals could be quantitatively analyzed due to difficulty with identifying the surgical sites. The percentage of newly formed bone ranged between 53.2% ± 5.6% for artificial defects and 54.9% ± 12.4% for extraction sites. With the exception of ANOVA indicating a greater amount of non‐bone tissue in extraction sites as compared to artificial sites (p = 0.047), no statistically significant differences were observed. Micro‐CT scans showed patterns similar to the ones observed in histomorphometry. As extraction sites could be identified only in two micro‐CT reconstructions, quantitative assessment was not undertaken. Conclusions Despite the comparable performance of bone substitute material in artificial defects and extraction sites found here, the data gathered with this experiment was insufficient for showing equivalence of both approaches.
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Affiliation(s)
| | - Matthias Karl
- Department of Prosthodontics, Saarland University, Homburg, Germany
| | - Matthias W Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Germany
| | - Peter Schupbach
- Laboratory for Histology, Electron Microscopy and Imaging, Schupbach Ltd., Thalwil, Switzerland
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Abstract
OBJECTIVES To evaluate the intra- and postoperative outcomes of patients undergoing laparoscopic radical nephrectomy with intact specimen extraction through a Pfannenstiel transverse suprapubic incision. METHODS Prospective follow-up of 26 laparoscopic transperitoneal radical nephrectomies for suspected renal tumors in which the kidneys were extracted via a Pfannenstiel lower abdominal transverse incision. RESULTS The mean operating time was 152.3 (80-255) minutes, and the mean blood loss was 90 (20-300) ml. The mean extraction time was 20.4 (12-35) minutes. The mean weight of the removed specimen was 631.5 (190-1505) grams, and the mean longest diameter of the extracted specimen was 17.4 (9-25) cm. The mean extraction incision size was 10.7 (7-16) cm. No open surgical conversions were necessary. Pain control was excellent, with minimal intravenous morphine equivalent narcotic use by patients: 15.7 (0-31) mg in the recovery room, 33.8 (0-127) mg on the first postoperative day and 8.7 (0-60) mg in the first week after discharge. The patients experienced a short duration to full ambulation and normal dietary intake. Postoperative follow-up visits were recorded for at least six months. The patients reported a high cosmetic satisfaction rate of 97.7% (60-100). No late postoperative complications were observed related to the extraction site. CONCLUSIONS The operative specimen can be extracted via a low transverse Pfannenstiel incision during radical laparoscopic nephrectomy. This incision ensures the extraction of large specimens while preserving the aesthetic and functional advantages of laparoscopy without increasing the cancer risk. The absence of muscle cutting maintains the integrity of the abdominal wall and elicits minimal pain. No postoperative incisional hernias or keloid formations were observed.
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Affiliation(s)
- Saleh Binsaleh
- Faculty of Medicine, Department of Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad Alomar
- Faculty of Medicine, Department of Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Khaled Madbouly
- Department of Urology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
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Navaratnam AV, Ariyaratnam R, Smart NJ, Parker M, Motson RW, Arulampalam TH. Incisional hernia rate after laparoscopic colorectal resection is reduced with standardisation of specimen extraction. Ann R Coll Surg Engl 2015; 97:17-21. [PMID: 25519260 PMCID: PMC4473891 DOI: 10.1308/003588414x14055925058274] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Incisional hernia is a common complication of laparoscopic colorectal surgery. Extraction site may influence the rate of incisional hernias. Major risk factors for the development of incisional hernias include age, diabetes, obesity and smoking status. In this study, we investigated the effect of specimen extraction site on incisional hernia rate. METHODS Two cohorts of patients who underwent laparoscopic colorectal resections in a single centre in 2005 (n=85) and 2009 (n=139) were studied retrospectively. In 2005 all specimens were extracted through transverse muscle cutting incisions. In 2009 all specimens were extracted through midline incisions. Demographic variables, rate of incisional hernias and risk factors for hernia development were compared between the year groups. All patients had been followed up clinically for two years. RESULTS A total of 224 patients (mean age: 67.5 years, standard deviation: 16.35 years) were included in this study. Of these, 85 patients were in the 2005 transverse group and 139 were in the 2009 midline group. The total incisional hernia rate for the series was 8.0% at the two-year follow-up visit. For the 2005 group, the incisional hernia rate was 15.3% (n=13) and for the 2009 group, it was 3.6% (n=5) (p<0.01). The body mass index was higher in patients who developed incisional hernias than in those who did not (p=0.02). CONCLUSIONS The 2005 group had a significantly higher incisional hernia rate than the 2009 group. This is due to the differences in the incision technique and extraction site between the two groups.
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Affiliation(s)
- AV Navaratnam
- Surgical Division, Colchester Hospital University NHS Foundation Trust, UK
| | | | - NJ Smart
- Surgical Division, Colchester Hospital University NHS Foundation Trust, UK
| | - M Parker
- Iceni Centre, Anglia Ruskin University, UK
| | - RW Motson
- Surgical Division, Colchester Hospital University NHS Foundation Trust, UK
| | - TH Arulampalam
- Surgical Division, Colchester Hospital University NHS Foundation Trust, UK
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Binsaleh S. Specimen processing during laparoscopic renal surgery: a review of techniques and technologies. Clinics (Sao Paulo) 2014; 69:862-6. [PMID: 25628000 PMCID: PMC4286670 DOI: 10.6061/clinics/2014(12)12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 10/01/2014] [Indexed: 12/03/2022] Open
Abstract
Laparoscopic surgery has well-defined benefits for patients and has become accepted over time as a standard access strategy for the management of benign and malignant urologic diseases. Unlike in open surgery, the surgeon is often faced with the additional challenges of specimen retrieval and extraction at the end of laparoscopic extirpative procedures. This final step often requires significant laparoscopic skill to entrap and safely extract the laparoscopic specimens. Failure to apply safe exit steps at the end of a laparoscopic procedure may lead to significant morbidity. The aim of this review is to explore the different techniques and technologies available for laparoscopic kidney retrieval, entrapment and safe extraction.
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Affiliation(s)
- Saleh Binsaleh
- Division of Urology, Department of Surgery, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
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