A laparoscopic pull-through operation for Hirschsprung’s disease: Report of two infant cases

We describe herein a primary laparoscopic pullthrough procedure that was successfully employed to treat two infants with Hirschsprung's disease. Mobilization of the rectum and sigmoid colon was performed laparoscopically, and the rectal mucosa was removed via a transanal submucosal resection. After inducing the rectal prolapse intussusceptically, the rectum was circumferentially transected, and the mobilized colon was pulled down through the rectal muscle cuff. Resection of the aganglionic bowel and the coloanal anastomosis, using the Soave-Denda method, was performed outside the anus. Both infants had an uneventful postoperative course with early recovery of bowel movement. Our experience demonstrates that this minimally invasive surgical procedure is feasible for young infants, and we believe that Hirschsprung's disease may be a definite indication for laparoscopic surgery.     

完全腹腔镜下低位直肠前切除术+预防性回肠造口术

（1）暴露乙状结肠系膜根部与后腹膜粘连形成的黄白线,由此进入Toldt's间隙,拓展间隙至肠系膜下动脉根部,完成D3淋巴结清扫;（2）在直肠固有筋膜和腹下神经前筋膜之间分离,可以完好地保留盆腔自主神经系统从而完成全直肠系膜切除术;（3）完全腹腔镜下乙状结肠-直肠端端吻合;（4）预防性回肠袢式造口,皮内浆肌层连续缝合术在完全腹腔镜下直肠癌根治术中的应用。     

Feasibility of transanal minimally invasive surgery for mid-rectal lesions

Background

Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery. We assessed the feasibility of TAMIS for lesions located in the mid rectum.

Methods

From July 2010 to October 2011, 16 consecutive patients with rectal pathology underwent TAMIS. After a single-incision laparoscopic surgery port was introduced into the anal canal, pneumorectum was established with a laparoscopic device, followed by transanal excision with conventional laparoscopic instruments, including graspers, monopolar electrocautery, and needle drivers. Clinicopathological findings, surgical procedure results, and perioperative outcomes were determined prospectively.

Results

Of the 16 patients, 11 had rectal cancers (3 T1 lesions and 8 after preoperative chemoradiotherapy), 4 had neuroendocrine tumors, and 1 had a mucocele. The median length of the lesions from anal verge was 7.5?cm (range 4–10?cm). All procedures were completed laparoscopically without conversion to conventional transanal approach. The median operating time was 86?min (range 33–160?min), and the median estimated blood loss was 15?ml (range 0–150?ml) with no patient requiring intraoperative transfusions. There was no surgical morbidity or mortality, but one patient died during follow-up due to synchronous advanced gastric cancer. The median postoperative hospital stay was 3?days (range 2–6?days).

Conclusions

TAMIS seems to be a feasible and safe treatment option for lesions located in the mid rectum.     

Implantation of Rectal Cancer in an Anal Fistula: Report of a Case

A 53-year-old man who had had an anal fistula for 20 years was admitted to our hospital with a large intestinal obstruction. Barium enema and colonoscopy confirmed advanced rectal cancer and we palpated a soft tumor, 3 cm in diameter, with inflammatory induration on the right side of the rectum. After draining a perianal abscess caused by the anal fistula, we performed low anterior resection. Histological examination of the perianal necrotic tissue obtained during resection of the perianal tumor encompassing the anal fistula revealed adenocarcinoma. Since the histology of the perianal lesion was identical to that of the rectal cancer, a diagnosis of cancer implantation rather than carcinoma originating in the anal fistula was entertained. Although the recurrence of rectal cancer by mucosal implantation is not uncommon, the coincidental implantation of rectal cancer in an anal fistula is extremely rare.     

Transanal approach after preoperative imatinib treatment of a rectal gastrointestinal stromal tumors with external anal sphincter invasion: A case report

Introduction and importanceRectal gastrointestinal stromal tumors (GISTs) are rare, and preserving anorectal function can be challenging. We report the case of a patient with rectal GIST with external anal sphincter invasion, treated via the laparoscopic and transanal approaches.Case presentationA 61-year-old man with locally advanced GIST in the right anterolateral wall of the lower rectum was examined. Lower endoscopy revealed a 50-mm submucosal tumor located 4 cm from the anal verge. On immunohistochemistry, the biopsy specimen tested positive for CD34 and C-KIT, and the patient was diagnosed with GIST. Abdominal magnetic resonance imaging (MRI) revealed external anal sphincter infiltration. Because of the large tumor size and proximity to the anal verge, preserving the anus was challenging, and colorectal resection was avoided. Instead, neoadjuvant therapy with imatinib was administered to facilitate local resection of the tumor. Post-treatment MRI showed a reduction in tumor size (30 × 20 × 30 mm), and surgery was performed. We identified an appropriate resection line for diplomatic sphincter resection of the infiltrated area by laparoscopy alone. Thus, we performed a hybrid surgery using the laparoscopic and transanal approaches. The patient had an unremarkable postoperative course and was discharged on postoperative day 23.Clinical discussionNo study has reported cases of rectal GIST with external anal sphincter invasion wherein anal function was preserved. Here, imatinib was administered preoperatively, and hybrid surgery was performed using the transanal and laparoscopic approaches.ConclusionPreoperative treatment and surgery preserved anorectal function in a patient with a massive rectal GIST.     

Transanal rectal dissection: A procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis

Background

Laparoscopic approaches for colorectal surgery have been improved recently; however, it is often difficult to achieve total mesorectal excision (TME) for lower rectal cancer laparoscopically because of a narrow pelvis and a thickened mesentery.

Methods

TME was successfully performed in 6 patients (4 men, 2 women) with dissection of the rectum transanally from the anal side of the tumor. The preoperative stage was T3N1M0 in 1 patient and T3N0M0 in 5 patients. The mean body mass index was 29.8 kg/m² (range, 28.7-31.2 kg/m²), and the mean tumor size was 46.5 mm (range, 30-60 mm).

Results

The mean duration of the anal portion of the operation was 64 minutes (56 minutes in women, 79 minutes in men). No complications occurred during surgery or postoperatively.

Conclusion

This technique is a simple and effective procedure for successfully performing laparoscopic TME of lower rectal cancer in patients with bulky tumors, narrow pelvises, and thickened mesenteries.     

Laparoscopic surgery for rectal cancer

Although laparoscopic colon cancer surgery is widely accepted as a feasible alternative to open surgery, there is still limited evidence on the use of the laparoscopic approach for rectal cancer. Although laparoscopic rectal surgery is a technically demanding procedure with a steep learning curve because of adherence to the oncologic principle of total mesorectal excision, the laparoscopic approach has some advantages over open surgery, including not only less invasiveness but also a good surgical view of the deep pelvis through its magnification effect. At this time, information is still lacking on the long-term outcomes and efficicacy of laparoscopic rectal cancer surgery based on large-scale, randomized, controlled trials, and many clinical guidelines recommend that laparoscopic rectal cancer surgery should only be performed with expertise under a clinical trial setting. Nationwide surveys show the numbers of laparoscopic rectal cancer surgery cases are increasing in Japan, and about 20% of rectal cancer operations are performed laparoscopically, but concerns about the concurrently increasing anastomotic leakage rate should be noted. The development of laparoscopic instruments specifically to facilitate dissection and transection of the rectum in the deep pelvis is expected to increase the future widespread adoption of this procedure.     

Laparoscopic resection of a gastrointestinal stromal tumor of the rectum after treatment with imatinib mesylate: report of a case

This report describes the laparoscopic resection of a rectal GIST after treatment with imatinib mesylate. A 56-year-old male presented with a submucosal tumor (longest diameter, 8?cm) arising in the lower rectum. A core needle biopsy revealed that the tumor contained bundles of spindle-like cells. Immunostaining revealed that the tumor was positive for c-kit and CD34. Analysis of the c-kit gene revealed a substitution of ACA (threonine) by GCA (alanine) at codon 574 of exon 11. Imatinib mesylate (400?mg/day) was given as preoperative adjuvant therapy for 3?months, and the tumor shrank to 5?cm in diameter. Proctectomy with transanal anastomosis could be performed laparoscopically, while preserving the anus. There was no evidence of recurrence 2?years 6?months after surgery. Preoperative adjuvant chemotherapy with imatinib mesylate may permit the use of less invasive treatment procedures, allowing anal preservation.     

肛外手工吻合在腹腔镜低位直肠癌保肛术中的应用

目的 探讨肛外手工吻合技术在腹腔镜低位直肠癌保肛术中的应用价值.方法 应用超声刀在腹腔镜下对15例低位直肠癌患者实施全直肠系膜切除原则的根治性手术,用肛外手工吻合的方式完成超低位结肠-直肠/肛管吻合术.结果 15例患者手术经过均顺利,无中转开腹.术后发生吻合口瘘1例,无腹腔出血、感染、吻合口狭窄等并发症.手术时间125～270 min,平均156 min.术中出血30～180 ml,平均70 ml.住院时间9～14 d,平均11 d.15例术后随访2～37个月,平均14个月.术后局部无复发,远处肝转移1例.结论 低位直肠癌行腹腔镜下超低位切除、肛外手工吻合保肛术是一种安全、经济、创伤小、疗效可靠的术式.     

经肛门内镜联合腹腔镜治疗结直肠肿瘤

目的探讨经肛门内镜联合腹腔镜治疗直肠和乙状结肠肿瘤的可行性及近期疗效。方法回顾性分析2010年5月至2011年5月间在上海交通大学医学院附属瑞金医院接受经肛门内镜联合腹腔镜手术治疗的26例直肠和乙状结肠肿瘤患者的临床资料。结果26例患者均在腹腔镜下成功完成手术,无中转开腹,均未行保护性末端回肠造口。手术时间为（151．6±25．9）min,术中失血量为（200．2±114．7）ml,术后排气时间为（2．0±0．5）d。肿瘤大小为（3．0±0．7）cm,所有手术切缘均阴性,淋巴结检出数为（12．9±2．2）枚。术后有6例患者出现吻合口瘘,均为低位直肠肿瘤患者,其中5例出现于前15例患者中,后11例患者仅1例出现吻合口瘘。全组无输尿管损伤、术后肠梗阻及肺部感染病例。结论经肛门内镜联合腹腔镜技术治疗结直肠肿瘤是一种安全、有效的微创手术方式．是将腹腔镜技术与经自然腔道手术概念相结合的一种进步。     

Interpretation of the Randomized EVAR Trials

Purpose : Laparoscopic surgery for colon cancer has been proven safe, but controversy continues over implementation of laparoscopic technique for rectal cancer. The aim of this study was to compare the long-term outcomes of laparoscopically assisted and open surgery for nonmetastatic colorectal cancer.

Material and methods : From January 2001 to December 2006 all patients with nonmetastatic adenocarcinoma of the colon and rectum were considered for inclusion in this prospective non-randomised trial. The primary endpoint was overall survival, disease free survival and recurrence rate. Analysis was by intention to treat.

Results : A total of 365 resections were performed for nonmetastatic adenocarcinoma of the colon and rectum during the study period. Of those resections, 220 were colonic and 145 were rectal. In the patients with colon cancer 119 (54.1%) were operated laparoscopically and 101 (45.9%) by open surgery, in the patients with rectal cancer 75 (51.7%) were treated by laparoscopy and 70 (48.3%) by open technique. No statistically significant difference was found between the laparoscopic and open group regarding 5-year overall survival (p = 0.17 for colon cancer, p = 0.60 for rectal cancer), 5-year disease free survival (p = 0.25 for colon cancer, p = 0.81 for rectal cancer) and overall recurrence (p = 0.78 for colon cancer, p = 0.79 for rectal cancer). With respect to the tumor stage, in rectal cancer the probability of 5-year disease free survival was significantly higher in the laparoscopic group in stage III (p = 0.03).

Conclusion : Laparoscopic surgery for colorectal cancer is an oncologically safe procedure that is associated with a survival and recurrence rate equal to open surgery.     

腹腔镜全系膜切除术联合经肛门内括约肌切除术治疗超低位直肠癌42例

目的探讨腹腔镜全系膜切除术（TME）联合经肛门内括约肌切除保肛术（ISR）治疗超低位直肠癌的临床疗效。方法选择2009年1月至2012年6月42例超低位直肠癌患者采用腹腔镜TME联合ISR术治疗。按TME原则完全游离切除直肠后,经肛门内括约肌切除,完成超低位直肠癌保肛手术。对患者的临床资料、术后并发症及随访结果进行分析。结果42例患者均顺利完成手术,无中转开腹或者改行Mile’s术式,13例行回肠预防性造口,2例发生吻合口瘘,经保守治疗治愈。所有患者术后肛门括约肌功能比较满意,无围手术期死亡。随访9-40个月,1例于术后15个月发生肝脏多发转移再次入院进一步治疗。结论对于术前评估早中期超低位直肠癌,特别是肿瘤没有侵犯肛门内括约肌,采用腹腔镜TME联合IRS术是安全可行的,提高了保肛成功率,提高患者术后生活质量且局部复发率低。     

Gastrointestinal Stromal Tumor of the Rectum Resected by Laparoscopic Surgery: Report of a Case

A 53-year-old man visited our hospital with the chief complaint of pain on urination. On digital rectal examination, a rigid immobile tumor mass with a smooth surface was palpated on the anterior wall on the right side of the rectum near the anal canal. Computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis revealed a heterogeneous tumor mass measuring 6.5 cm in diameter, which occupied the cavity of the lesser pelvis. This rectal tumor was diagnosed to be a gastrointestinal stromal tumor (GIST) based on the results of a transrectal needle biopsy. A laparoscopic abdominoperineal resection of the rectum was performed to remove the mass. The intraoperative findings showed an ambiguous boundary between the tumor and the rectum but clear boundaries between the tumor and the peripheral organs, and the use of a laparoscope allowed for a good separation by providing a good visual field. The bleeding volume was approximately 80 ml and the operative time was 320 min. The macroscopic findings of excised specimens of the mass showed the tumor, measuring 6.5 × 5.5 × 5.0 cm, to be growing extrinsically from the anterior wall on the right side of the rectum. A histological examination of the excised specimens revealed at most 5 mitoses per 50 high-power fields (×400). The tumor mass was diagnosed to be a GIST of low-grade malignancy based on these findings. The postoperative course was favorable, and there were no postoperative complications. The patient was discharged on the 8th hospital day. Laparoscopic surgery is a minimally invasive surgical procedure for rectal GIST, which is excellent in terms of esthetics. Laparoscopic surgery is therefore considered to be useful for a resection of the rectum, because the magnifying effect allows surgical maneuvers with a favorable visual field within the pelvis.     

Could laparoscopic colon and rectal surgery become the standard of care? A review and experience with 750 procedures

INTRODUCTION: The benefits of the laparoscopic approach to colon and rectal surgery do not seem as great as for other laparoscopic procedures. To study this further we decided to review the current literature and the 10-year experience of a surgical group from university teaching hospitals in Montréal, Québec and Toronto in performing laparoscopic colon and rectal surgery. METHODS: The prospectively designed case series comprised all patients having laparoscopic colon and rectal surgery. The procedures were carried out by a group of 4 surgeons between April 1991 and November 2001. We noted intraoperative complications, any conversions to open surgery, operating time, postoperative complications and postoperative length of hospital stay. RESULTS: The group attempted 750 laparoscopic colon and rectal procedures of which 669 were completed laparoscopically. Malignant disease was the indication for surgery in 49.6% of cases. Right hemicolectomy and sigmoid colectomy accounted for 54.5% of procedures performed. Intraoperative complications occurred in 8.3%, with 29.0% of these resulting in conversion to open surgery. The overall rate of conversion to open surgery was 10.8%, most commonly for oncologic concerns. Median operating time was 175 minutes for all procedures. Postoperative complications occurred in 27.5% of procedures completed laparoscopically but were mostly minor wound complications. Pulmonary complications occurred in only 1.0%. The anastomotic leak rate was 2.5%. The early reoperation rate was 2.4%. Postoperative mortality was 2.2%. No port site metastases have yet been detected. The median postoperative length of stay was 5 days. CONCLUSIONS: The clinical outcomes of laparoscopic colon and rectal surgery in this 10-year experience are consistent with numerous cohort studies and randomized clinical trials. Laparoscopic colon and rectal surgery in the hands of well-trained surgeons can be performed safely with short hospital stay, low analgesic requirements and acceptable complication rates compared with historical controls and other reports in the literature. Evidence from published randomized clinical trials is emerging that under these conditions laparoscopic resection represents the better treatment option for most benign conditions, but concerns regarding its appropriateness for malignant disease are still to be resolved.     

Transanal single-port microsurgery for rectal tumors: minimal invasive surgery under spinal anesthesia

Background

Transanal minimally invasive surgery (TAMIS) for rectal tumors has been introduced as an alternative approach to transanal endoscopic microsurgery (TEM). TEM has some limitations, such as the need for special equipment, expensive cost, and steep learning curve. In this study, we address the technical feasibility of TAMIS under spinal anesthesia and its short-term postoperative outcomes.

Methods

From July 2011 to September 2012, 25 consecutive patients with middle or upper third rectal masses underwent TAMIS. Tumors were located 6–17 cm from the anal verge. After spinal anesthesia, a single-incision laparoscopic surgery port was inserted into the anal canal. With this access, conventional laparoscopic instruments, including a grasper and monopolar electrocautery and suction device, were used to perform the transanal excision. A hook-type monopolar electrocautery or harmonic scalpel was used for dissection. The defect of the rectum was closed by interrupted sutures. Data concerning demographics, details of operative procedure, postoperative pain, and pathologic results were collected prospectively. To evaluate anal sphincter injury, an endoanal ultrasonography and fecal incontinence severity index survey were performed at 3–6 months after the operation.

Results

Of the 25 patients, nine had adenocarcinomas, nine had neuroendocrine tumors, three had tubular adenomas with high-grade dysplasia, three had tubular adenomas, one had a tubulovillous adenoma, and one had a gastrointestinal stromal tumor. The median distance from the tumor mass to the anal verge was 9.0 (range 6–17) cm. The median operative time was 45.0 (range 20–120) min. All patients received TAMIS without conversion to laparoscopic resection. There were no intraoperative complications or postoperative morbidity. The median postoperative hospital stay was 3.0 (range 2–7) days. No sphincter injury was detected by endoanal ultrasonography.

Conclusions

TAMIS under spinal anesthesia is a safe and feasible technique for resection of middle and upper rectal masses. Spinal anesthesia is adequate for this procedure.     

Laparoscopic radical nephrectomy incorporating intraoperative ultrasonography for renal cell carcinoma with renal vein tumor thrombus

The purpose of this study was to describe the technique of laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography in the management of renal cell carcinoma with level 1 renal vein tumor thrombus. With the patient in a modified flank position, a transperitoneal four-port approach was used to laparoscopically resect an 8.5-cm right renal mass with tumor thrombus extending to, but not into, the inferior vena cava. Early arterial control with gentle traction on the right renal vein provided a short proximal renal venous segment devoid of tumor on laparoscopic inspection. Intraoperative laparoscopic ultrasonography allowed confident identification of the proximal extent of the tumor thrombus. After hilar control, complete resection and intact removal of the renal specimen was performed using standard non-hand-assisted laparoscopic techniques. The actual surgical time was 180 minutes. Surgical resection was successfully performed laparoscopically. No postoperative complications or hospital readmission occurred. Pathologic examination confirmed T3b renal cell carcinoma with negative surgical margins. Laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography is feasible in the management of renal cell carcinoma with a large-sized level 1 renal vein thrombus. Additional studies are necessary to evaluate its role in urologic oncologic surgery.     

Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection

Background Rectal transection and anastomosis at the lower rectum is the most challenging part of laparoscopic low anterior resection. Therefore, some have demonstrated that rectal transection should be performed using instruments for open surgery with small laparotomy. In our institute, however, rectal transection using a currently available endostapler followed by anastomosis with a double stapling technique is usually performed. Methods The important points of our technique are as follows: trocar placement, optimal device choice, harmonious movement between the operator and assistant for rectal transection, optimal point of piercing with the center rod of the circular stapler, and ideal positioning of the proximal colon. Results Seventy-eight patients underwent low anterior resection using this technique. There were no conversions to open surgery. All rectal transections were completed laparoscopically with an available endostapler. A diverting ileostomy was created in six cases. Anastomotic leakage occurred in only two patients (2.6%) and rectovaginal fistula in only one patient (1.3%). Conclusions Our standardized technique is considered to be safe and feasible for rectal transection and anastomosis using the double stapling technique (DST).     

Anastomotic suture line recurrence of early rectal carcinomas that had been resected by laparoscopic surgery

We report herein a case of a 64-year-old woman found to have anastomotic suture line recurrence of an early rectal carcinoma. The patient had undergone laparoscopy-assisted low anterior rectal resection for an early rectal carcinoma 2 years before the anastomotic site recurrence. A follow-up colonoscopy revealed an elevated lesion on the anastomotic suture line. The diagnosis of adenocarcinoma was confirmed by biopsy. The patient underwent a resection of the remnant rectum. Histological examination of the resected specimen showed that the anastomotic site recurrence might have been caused by intraluminal implantation from the primary rectal cancer. We speculate that intraluminal implantation might be caused by insufficient intraoperative rectal irrigation because of limited access often encountered in laparoscopic surgery. We propose that it is necessary to devise a method with which to perform sufficient intraoperative rectal irrigation in laparoscopic surgery for rectal carcinoma.     

Laparoscopically assisted resection of the lower rectum

We report a new laparoscopic approach to the resection of the lower rectum which has been successfully used in the treatment of a patient with a small rectal carcinoid tumor. Under general anesthesia a pneumo-peritoneum was established with CO₂ gas insufflation and the rectum was mobilized from the sacrum including division of the lateral ligaments under the direct view of the laparoscope. The bowel was divided between the sigmoid colon and the rectum using an endoscopic linear stapler, and the rectum was everted through the anal canal. The lower rectum was transected extracorporeally using a linear stapler and the rectal stump was then returned to the anatomical position. An anvil of a circular stapling device into the oral colon stump through a small skin incision on the left lower abdomen was introduced and the shaft of the device through the rectal stump via anus was inserted. The device was then re-approximated under laparoscopic view and fired. Our procedure described here is applicable to the lower rectal lesion as a minimally invasive, safe, and useful therapeutic tool.     

Laparoscopy-Assisted Low Anterior Resection with a Prolapsing Technique for Low Rectal Cancer

Laparoscopy-assisted low anterior resection (LAR) for low rectal cancer is a difficult procedure, presenting problems with rectal washout, selecting the appropriate distal transection line, and achieving safe anastomosis. To resolve these problems, we used a prolapsing technique to perform laparoscopy-assisted LAR. Total mesorectal excision (TME) is performed laparoscopically. The proximal colon is transected laparoscopically with the aid of an endoscopic stapler, and the distal rectum, including the lesion, are everted and pulled transanally to outside the body. Only washout of and wiping off the distal rectum and intestinal resection are performed extracorporeally. The distal rectum is pushed back through the anus into the pelvis, and intracorporeal anastomosis is completed laparoscopically with a double-stapling technique. Our limited experience suggests that the prolapsing technique helps to prevent problems with laparoscopy-assisted LAR in selected patients with low rectal cancer.