Long-Term Anorectal Manometry Outcomes After Laparoscopic and Transanal Total Mesorectal Excision

Background: During transanal total mesorectal excision (TaTME), sustained dilation of the anal canal occurs, which can cause anatomical and functional damage to the sphincter complex. This study aimed to analyze the impact of laparoscopic total mesorectal excision (LaTME) and TaTME in anorectal sphincter function. Materials and Methods: An observational study was conducted comparing two cohorts of patients who underwent LaTME or TaTME for rectal cancer. The two groups were paired for comparison based on age, gender, and distance of the neoplasm to the anal margin. The anorectal function was assessed by manometry before surgery and at least 6 months after primary intervention or stoma closure. The intestinal function was assessed using the low anterior resection syndrome (LARS) score. Results: Twenty-two patients were included. There were no significant differences in baseline characteristics between groups except for the time between surgery and testing. A decrease in the mean resting and squeeze pressures between pre- and postoperative manometry was observed in both the treatment groups, the difference being only significant in the squeeze pressure values (TaTME P = .003; LaTME P = .004). After surgery, squeeze pressure reduction correlated with a worsening of the LARS point count (rho 0.587; P = .004). The time elapsed since surgery was negatively correlated with the LARS point count (rho -0.696; P = .001) and the difference between pre- and postoperative mean squeeze pressures (rho -0.499; P = .018). Conclusion: Manometric findings after TME are comparable between the laparoscopic and the transanal approach. Deterioration of both anal sphincter function and LARS improves with time after surgery.

Incidence and Risk Factors of Incisional Hernia After Single-Incision Endoscopic Surgery

Introduction: Abdominal wall complications are one of the most controversial issues regarding single-incision endoscopic surgery. The aim of this study was to analyze the incidence and risk factors of incisional hernia after single-incision endoscopic cholecystectomy. Materials and Methods: An observational retrospective study was performed, on a cohort of patients cholecystectomized laparoscopically through a transumbilical single incision due to gallbladder lithiasis or polyps. Postoperative complications were analyzed, with special interest in the incisional hernia rate, whose results were assessed in the long-term follow-up. Univariate and multivariate analyses were also performed to evaluate possible variables associated with the appearance of incisional hernia. Cumulative sum charts (CUSUM) were used to identify trends in the incisional hernia risk. Results: Some 109 patients were included in the study. With a mean follow-up of nearly 38 months, an incisional hernia incidence of 5.5% was found, with 67% being diagnosed during the first year of follow-up. In the Cox regression analysis, two variables showed an independent association with the emergence of incisional hernia, body mass index (hazard ratio [HR] 1.30; 95% confidence interval [CI 1.053-1.606]; P .015), and wound infection (HR 26.32; [3.186-217.40]; P .002]. CUSUM charts showed a decrease in the risk of incisional hernia after the first 10 cases. Conclusions: Single-incision endoscopic cholecystectomy is associated with a substantially high risk of postoperative incisional hernia (5.5%).

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

Background

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

Methods

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

Results

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

Conclusions

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Outcomes after laparoscopic ventral hernia repair: does the number of previous recurrences matter? A prospective study

BACKGROUND

It is not yet clearly known whether laparoscopic ventral hernia repair (LVHR) is superior to the open approach in recurrent hernias. The aim of this study is to determine the safety and efficacy of laparoscopic technique for ventral hernias and investigate whether these outcomes are affected by the number of previous failed repairs.

METHODS

Data from 124 consecutive patients who underwent LVHR using a standardized technique between September 2007 and June 2014 were collected prospectively. In all repairs, a composite prosthesis was tailored to overlap the defect by at least 5 cm and fixed with a double crown of spiral tacks. Clinical follow-up visits were performed at 1 week, 1, 6, and 12 months, and yearly thereafter. Patients were classified in 3 groups (0, 1, and ≥ 2) according to the number of previous hernia repairs for further statistical analysis.

RESULTS

Long-term surveillance was available in 116 (93%) patients. Of these, 96 (82.8%) were recurrent hernias. There were 2 (1.7%) conversions, both in recurrent cases, and in 3 (2.6%) patients a hybrid access was used. Mean operating time was 55 min. There was an overall postoperative complication rate of 16%, with no mortality. During a mean follow-up of 30 (range 20-90) months, 3 (2.6%) recurrences were diagnosed 6, 8, and 9 months after surgery, respectively. A univariate analysis related to demographic, clinical, and perioperative variables did not find any significant relationship between the number of previous recurrences and operating time, conversion rate, hospital length of stay, overall morbidity, or recurrence.

CONCLUSIONS

This study suggests that laparoscopic approach in recurrent incisional hernias is a safe and feasible alternative to open techniques. Furthermore, our experience supports the idea that LVHR may be the best option for recurrent cases in properly selected patients, independently of the number of previous recurrences.

Primary cutaneous mucormycosis in an immunocompetent patient

Mucormycosis is most common in immunocompromised patients, but it can also occur in healthy hosts, most frequently as primary cutaneous mucormycosis (PCM) and predominantly as a result of skin trauma. We present an uncommon case of PCM in a healthy, young man with no previous history of local trauma. Despite rapid progression of the infection, the patient was successfully treated through surgical intervention and by administering liposomal amphotericin B and posaconazole. He made a full recovery without the need for skin grafting.

Systematic review and meta-analysis of randomized controlled trials comparing single incision versus conventional laparoscopic appendectomy

BACKGROUND

Single incision laparoscopic appendectomy (SILA) has been proposed as an alternative to conventional laparoscopic appendectomy (CLA).

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of SILA when compared with CLA through a systematic review.

METHODS

We performed an electronic search of EMBASE, PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) that compared SILA with CLA were included.

RESULTS

Six RCTs met eligibility criteria, which included a total of 800 patients, 401 in the SILA group and 399 in the CLA group. There were no significant differences in terms of overall complications (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.59-1.47; p = 0.77). SILA had a higher technical failure rate (OR 3.30; 95% CI 1.26-8.65; p = 0.01) and required a longer operative time (mean difference [MD] 4.67; 95% CI 1.76-7.57; p = 0.002). SILA was associated with better cosmetic results (standardized MD -0.4; 95% CI -0.64 to -0.16; p = 0.001) and earlier return to normal activity (MD -0.64; 95% CI -1.09 to -0.20; p = 0.005), although these advantages should be taken with caution due to the small number of studies reporting these two items and the short follow-up in the evaluation of cosmetic results. There were no significant differences in terms of postoperative pain or length of hospital stay between groups.

CONCLUSIONS

SILA is comparable to CLA in selected patients, although it is associated with a higher technical failure rate and longer operative time. Further randomized trials are needed to determine if SILA really offers benefits over CLA.

Pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The aim of this systematic review was to compare postoperative outcomes between pancreaticogastrostomy and pancreaticojejunostomy after pancreaticoduodenectomy.

METHODS

Six databases were systematically reviewed to identify randomized controlled trials comparing pancreaticogastrostomy and pancreaticojejunostomy. Studies reporting postoperative complications, reoperations, and mortality were included (PROSPERO registration number CRD42013005383).

RESULTS

The search provided a total of 1,646 references. Seven studies were selected including 1,121 patients, 562 in the pancreaticogastrostomy group and 559 in the pancreaticojejunostomy group. Overall incidence of pancreatic fistula and the incidence of more severe fistulas (grade B/C) were lower in the pancreaticogastrostomy group (relative risk 0.67; 95% confidence interval (CI) 0.52 to 0.86; p = 0.002 and relative risk 0.61; 95 % CI 0.40 to 0.93; p = 0.02). Abdominal collections were more frequent in the pancreaticojejunostomy group. However, pancreaticogastrostomy was associated with an increased risk of postoperative intraluminal hemorrhage, and there were no differences in overall morbidity, reoperations, or mortality.

CONCLUSIONS

In this systematic review and meta-analysis, a reduction in the incidence of postoperative pancreatic fistula in the pancreaticogastrostomy group was observed. Although this evidence comes from randomized trials, pancreaticogastrostomy cannot be considered superior to pancreaticojejunostomy due to the presence of clinical heterogeneity among studies and the absence of differences in overall morbidity, reoperations, and mortality.

Intra-abdominal pulmonary secuestration as an exceptional cause of abdominal mass in the adult

INTRODUCTION

Pulmonary sequestration (PS) is an extremely rare malformation defined as a portion of lung tissue isolated from the pulmonary system. PSs are classified into intralobar type and intra-abdominal PS that represents only 2.5% of cases. There are 20 cases of PS reported in adults and only two were managed by laparoscopic approach. We report a case of intra-abdominal PS mimicking a gastroesophageal duplication cyst in an adult. Besides its rarity, this is the first intra-abdominal PS in an adult managed by an anterior laparoscopic approach.

PRESENTATION OF CASE

A 60-year-old female patient had had epigastric and left upper quadrant pain for several days. Physical examination was normal. Image test were consistent with a gastroesophageal duplication. The patient was taken to the operating room for laparoscopic exploration and resection. The pathological diagnosis was extralobar pulmonary sequestration.

DISCUSSION

Less than 20 cases of PS have been reported in adults and only two cases were managed by a lateral laparoscopic approach. In contrast to these reports, we used an anterior approach due to the GEJ suspected origin of the mass.

CONCLUSION

Extralobar intra-abdominal PS is an extremely rare condition during adulthood but this diagnosis should be included in the differential diagnosis of a left-sided suprarenal mass. Due to the difficulty in achieving a definitive preoperative diagnosis, surgery is recommended. Laparoscopic resection is safe and effective but careful preoperative imaging studies are recommended in order to plan the most suitable approach.

Ergonomics in laparoendoscopic single-site surgery: survey results

BACKGROUND

Ergonomic issues are frequently reported by surgeons performing laparoendoscopic single-site (LESS) surgery. However, few studies have analysed this issue.

METHODS

We used a web format survey to evaluate the opinion of surgeons with experience in this laparoscopic technique. This survey collected demographic information, surgical experience, physical and psychological symptoms, and technical problems related to this type of surgery.

RESULTS

Some 78 surgeons filled out the questionnaire. All participants had clinical experience in this type of laparoscopic approach, and 68 % had performed more than 30 procedures. Two or more musculoskeletal symptoms were reported during or after performing LESS surgery by 81 % of all surgeons. Surgeons with more experience in this approach reported fewer symptoms and technical difficulties.

CONCLUSIONS

LESS surgery is accompanied by musculoskeletal problems and technical difficulties for surgeons. Technological advancements and greater surgical experience in the technique will alleviate these issues. More in-depth ergonomic studies are needed.

[Single incision laparoscopic surgery: analysis of the national register]

INTRODUCTION

Laparoscopic surgery through a single incision is an innovative concept which is a challenge for surgeons to implement and develop. The interest aroused by these techniques in Spain led to the Endoscopy Section of the Spanish Association of Surgeons (AEC) to start a National Register for Single-Incision Surgery (RNCIU). The aim of this study was to collect the primary clinical data, techniques, and the possible complications of these techniques in Spain.

MATERIAL AND METHODS

Data were gathered using a form available on the AEC website. The forms included in this study correspond to those received between June 2010 and June 2011.

RESULTS

A total of 35 centers had taken part during the study period, with 1,198 forms being collected. The surgeries performed included 62.2% cholecystectomies, 22% appendectomies, and 7.8% colectomies. Procedures on solid organs (3.4%), bariatric surgery (2.7%), and various hernia repairs (1.9%), were also registered. The overall incidence of complications was 0.8%. The mortality rate in the series was 0.1%.

CONCLUSIONS

Single incision laparoscopic surgery is a novel concept that is not beyond our scientific community. The results of the Register demonstrate the feasibility of numerous effective and safe procedures. Finally, the RNCIU is an important data source to be able to study sub-groups of diseases in detail, with the aim of advancing the knowledge of these techniques and generating scientific evidence.

Pelvic reconstruction after abdominoperineal resection: a pilot study using an absorbable synthetic prosthesis

BACKGROUND

Abdominoperineal resection (APR) is not free of complications, in particular complications due to the occupation of the pelvis by the small bowel after surgery. A number of surgical techniques have been described to prevent the small bowel from entering and adhering to the pelvis (pelvic partition), but there is no agreement concerning their use. The aim of this study was to evaluate the feasibility, effectiveness and safety of using an absorbable synthetic prosthetic material for pelvic partitioning after APR.

METHODS

A prospective non-randomised longitudinal pilot study was carried out on a series of 10 patients who underwent APR due to lower-third rectal cancer, in order to evaluate the feasibility, safety and efficacy of pelvic partitioning with an absorbable synthetic prosthetic material.

RESULTS

In all the patients, it was possible to perform a radical resection and to install the prosthesis. After a mean follow-up of 9 months (range: 4-18 months), no abdominal or perineal complications were detected. One patient (10%) suffered chronic pelvic pain.

CONCLUSIONS

Pelvic partition after APR of the rectum with an absorbable synthetic prosthesis is feasible, effective and safe.

[Parastomal hernias: background, current status and future prospects]

Parastomal hernia (PH) is the most common delayed complication in stoma surgery. Only a third of these are operated on, something which is partly explained by the high recurrence rate observed after repair. The use of prosthetic materials has improved the results, although they continue to be below the ideal. For this reason, it has been proposed that the best solution may be in preventing the PH. Several studies show promising results, with very marked reductions in the percentage of IH, on placing a prophylactic peristomal prosthesis. In this article we present a review of the risk factors associated with PH, a classification of the existing diversity of repair techniques, and an algorithm is proposed for the management of PH, including its prevention.

Laparoscopic liver surgery: 8 years of multicenter Spanish register

BACKGROUND

To present the data of laparoscopy in liver surgery and to assess the real indications and outcomes of this kind of approach.

METHODS

From February 2000 to March 2008, a prospective study was performed on 182 patients from 15 Spanish surgical centres.

RESULTS

A total of 308 lesions was collected. The mean age was 57 years old, and 61.5% were female. Among patients with cystic lesions we found: 45 simple cysts, 19 policystic diseases, 12 hydatidic cysts and 2 cystoadenomas. Among solid lesions (n = 104), we found 34 patients with benign pathology (12 focal nodular hyperplasia, 10 adenomas, 7 haemangyomas and 5 other lesions) and 70 with malignant pathology (38 metastases, 29 hepatocellular carcinomas, 2 cholangiocarcinomas and 1 lymphoma). The global rate of conversion was 8.8%. The global morbidity rate was 14.8%, and 5 of them required re-intervention.

CONCLUSIONS

Nowadays there are strong criteria for patients being submitted to laparoscopy procedures based both on type and location features. The postoperative morbidity rate is low, also for hepatocellular carcinoma in cirrhotic liver. In case of malignant pathology, we think the use of ultrasonography is mandatory to obtain a free margin, which implies a long-term survival rate.

Prevention of Trocar Site Hernias: Description of the Safe Port Plug Technique and Preliminary Results

The aim of this study was to describe a new technique to prevent the development of incisional hernias in trocar sites. Between March and June 2006, a pilot study was conducted to determine the feasibility of the safe port plug technique using the Bioabsorbable Hernia Plug to prevent incisional hernia in trocar sites. The device was implanted in the umbilical trocar site (10-11 mm) of 17 patients undergoing laparoscopic surgery during the study period. The mean follow-up of patients was 14.6 months. Implantation of the Bioabsorbable Hernia Plug device by the safe port plug technique was possible in all cases. No patient presented complications in the follow-up. Our preliminary experience suggests that this technique is simple and feasible, and we hypothesized that this technique could be superior to conventional fascial closure: a hypothesis that must be proven in a randomized prospective trial that is currently in progress.

Division of the small bowel with the LigaSure Atlas device during the right laparoscopic colectomy

BACKGROUND

Bowel division and anastomosis were facilitated greatly with the advent of stapling techniques. Since then, there have not been any new evolving technologies to facilitate these maneuvers. For this reason, we recently applied the LigaSure Atlas device (Valleylab, Boulder, CO) to the division of the small bowel during this procedure to obtain a reliable and low-cost division of the ileum.

METHODS

After vessel ligation and ileocolic mobilization, the terminal ileum is sealed and divided with the LigaSure Atlas. This device is applied sequentially along the small bowel twice to ensure an adequate seal before the cut. A terminolateral ileotransversostomy is performed extracorporeally with a mechanical circular stapling device, installing the anvil of the circular stapler into the ileal stump.

RESULTS

We have not encountered any problems with this technique since its introduction in our institution, and no leakage or bursting of the ileal stumps.

CONCLUSIONS

This technique enables an easy, reliable, and inexpensive technical option to optimize the right laparoscopic colectomy procedure.

Laparoscopic appendectomy during pregnancy: between personal experiences and scientific evidence

BACKGROUND

Although laparoscopic appendectomy is a safe and effective procedure for management of acute appendicitis, data about the feasibility and safety during pregnancy are limited. We aimed to study our experience in this field and to review the scientific evidence available.

STUDY DESIGN

All patients undergoing laparoscopic appendectomy during pregnancy, from January 2003 to December 2005, were included. Medical files were reviewed retrospectively. In addition, 133 cases from the literature were reviewed. General features of the cases, surgical technique details, and outcomes were analyzed.

RESULTS

All laparoscopic procedures were completed without conversion to open operation. No substantial hemodynamic or gasometric changes were detected during the procedures. Tocolytic medication was not administered in any patient. All patients were discharged from hospital within the first 48 postoperative hours, and no complications were recorded during this period or in the followup. All newborns had an adequate weight for gestational age, satisfactory parameters of well-being at birth, and an uneventful development after 1-year followup.

CONCLUSIONS

Laparoscopic appendectomy during pregnancy is as effective and safe as the conventional approach and has all the benefits of minimally invasive operation, provided that specific recommendations for these types of patients are strictly followed. It must be mentioned that there is only limited scientific evidence to support this statement.

Experience with a Spanish-language laparoscopy website

INTRODUCTION

Although there are no clearly defined electronic tools for continuing medical education (CME), new information technologies offer a basic platform for presenting training content on the internet. Due to the shortage of websites about minimally invasive surgery in the Spanish language, we set up a topical website in Spanish.

MATERIALS AND METHODS

This study considers the experience with the website between April 2001 and January 2005. To study the activity of the website, the registry information was analyzed descriptively using the log files of the server. To study the characteristics of the users, we searched the database of registered users.

RESULTS

We found a total of 107,941 visits to our website and a total of 624,895 page downloads. Most visits to the site were made from Spanish-speaking countries. The most frequent professional profile of the registered users was that of general surgeon.

CONCLUSION

The development, implementation, and evaluation of Spanish-language CME initiatives over the internet is promising but presents challenges.

[Intestinal perforation secondary to impaction of a retained endoscopic capsule]

We present the first documented case of intestinal perforation due to impaction of an endoscopic capsule. The capsule was used to investigate anemia in an 80-year-old woman and was retained in the intestinal lumen for 2 months without producing symptoms. The patient presented to the emergency service with sudden, intense, diffuse abdominal pain. Hollow viscus perforation was suspected and surgery was performed. The diagnosis was distal ileum perforation secondary to an impacted endoscopic capsule in an area of severe postsurgical adhesions under a subcostal cholecystectomy incision performed 10 years previously. After reviewing the literature, we believe it important to report this exceptional complication of capsule endoscopy and suggest the possible management of capsules retained in the digestive tract.

Apendicectomía laparoscópica y embarazo. Experiencia personal y revisión de la bibliografía

INTRODUCTION

Pregnancy has been considered to be an absolute contraindication to the laparoscopic approach because of the theoretical effects of the pneumoperitoneum on the fetus and the occupation of the working space by the gravid uterus. Despite the growing literature on the subject, experience with frequent entities, such as acute appendicitis, is limited.

OBJECTIVE

The aim of this study was to report our experience with laparoscopic appendicectomy in pregnancy, to review the scientific evidence available on the safety of this procedure, and to establish the most relevant practical features for the use of this approach during pregnancy.

MATERIAL AND METHODS

We retrospectively reviewed six laparoscopic appendectomies performed in pregnant women. We also reviewed the available literature on well documented laparoscopic appendectomies during pregnancy.

RESULTS

All the procedures were laparoscopically completed. The mean operating time was 46 min. All patients were discharged within the first 48 postoperative hours. There were no surgical complications. All patients delivered healthy infants with appropriate weight for gestational age. For the literature review, 17 references were collected that included data on 94 laparoscopic appendectomies performed in pregnant women. There was only one fetal death associated with the surgical approach and the overall fetal mortality rate was less than that classically registered in the literature for the open approach.

CONCLUSIONS

Laparoscopic appendectomy in pregnant women is as safe and effective as the open approach and confers all the benefits of minimally invasive surgery.

Resultados iniciales del Registro Nacional de Cirugía Hepática por Laparoscopia

INTRODUCTION

Experience in laparoscopic liver surgery is limited, and multicenter studies with large series are required for a critical evaluation of this type of surgery.

OBJECTIVE

To analyze the results of the National Registry of Laparoscopic Liver Surgery. Indications, technical features, conversion rates, morbidity, and mortality were analyzed.

PATIENTS AND METHOD

Seventy-four patients from 10 centers who underwent surgery between February 2000 and April 2005 were included. There were 58 women and 16 men, with a mean age of 55 years. More than one lesion was present in 16 patients. Consequently, 74 patients with 156 lesions were treated.

RESULTS

Forty-six patients had cystic lesions (26 simple cysts, 13 polycystic disease, five hydatid cysts and two cystic adenomas). Surgical treatment consisted of 37 fenestrations, five cystopericystectomies, two atypical resections, one segmentectomy and one bisegmentectomy of segments II-III. In 28 patients the lesions were solid (four adenomas, six focal nodular hyperplasias, three hemangiomas, four hepatocarcinomas, five colorectal metastases, two lung metastases, one breast metastasis, one malignant melanoma metastasis, one pancreatic vipoma metastasis, and one lymphoma). Ten bisegmentectomies of segments II-III, 17 atypical resections and one segmentectomy of segment III were performed. Other surgery was associated in 23 patients. The mean operating time was 160.5 minutes and the conversion rate was 8%. The mean length of hospital stay was 5.6 days and was less than 5 days in 78% of the patients. Analgesia was administered for less than 48 hours in 55%. Morbidity was observed in eight patients (10.8%). Reoperations were performed in three patients. There was no mortality in this series.

CONCLUSIONS

Laparoscopic hepatic resection is safe and feasible in selected patients. Large, controlled series are required to determine long-term outcomes. The national registry provides a good basis for evaluating laparoscopic liver surgery in Spain.