Surgical approach to right colon cancer:From open technique to robot.State of art

This work is a topic highlight on the surgical treatment of the right colon pathologies,focusing on the literature state of art and comparing the open surgery to the different laparoscopic and robotic procedures.Different laparoscopic procedures have been described for the treatment of right colon tumors: Totally laparoscopic right colectomy,laparoscopic assisted right colectomy,laparoscopic facilitated right colectomy,hand-assisted right colectomy,single incision laparoscopic surgery colectomy,robotic right colectomy.Two main characteristics of these techniques are the different type of anastomosis: Intracorporeal(for totally laparoscopic right colectomy,single incision laparoscopic surgery colectomy,laparoscopic assisted right colectomy and robotic technique) or extracorporeal(for laparoscopic assisted right colectomy,laparoscopic facilitated right colectomy,hand-assisted right colectomy and open right colectomy) and the different incision(suprapubic,median or transverse on the right side of abdomen).The different laparoscopic techniques meet the same oncological criteria of radicalism as the open surgery for the right colon.The totally laparoscopic right colectomy with intracorporeal anastomosis and even more the single incision laparoscopic surgery colectomy,remain a technical challenge due to the complexity of procedures(especially for the single incision laparoscopic surgery colectomy) and the particular right colon vascular anatomy but they seem to have some theoretical advantages compared to the other laparoscopic and open procedures.Data reported in literature while confirming the advantages of laparoscopic approach,do not allow to solve controversies about which is the best laparoscopic technique(Intracorporeal vs Extracorporeal Anastomosis) to treat the right colon cancer.However,the laparoscopic techniques with intracorporeal anastomosis for the right colon seem to show some theoretical advantages(functional,technical,oncological and cosmetic advantages) even if all studies conclude that further prospective randomized trials are necessary.Robotic technique may be useful to overcome the problems related to inexperience in laparoscopy in some surgical centers.     

Single-Incision Versus Hand-Assisted Laparoscopic Colectomy: A Case-Matched Series

Background  

Single-incision laparoscopic colorectal surgery is an emerging modality. We incorporated this technique as an alternative to hand-assisted laparoscopic surgery. We investigated intraoperative and short-term outcomes following single-incision laparoscopic colectomy compared with hand-assisted laparoscopic colectomy.     

Laparoscopic colectomy is feasible in the mega-obese patient using a standardized technique

The use of laparoscopic colectomy in morbidly obese individuals is controversial. There are significant safety issues including increased risk of bleeding, increased anastomotic leak and high operative conversion rates. We report the first successful laparoscopic colectomy in a patient with the most extreme category of morbid obesity, mega-obesity (body mass index [BMI]>70). We describe a standardized technique using a completely intracorporeal technique with all resection lines reinforced with a bioabsorbable staple line reinforcement material. This technique has the potential of making laparoscopic colectomy more feasible for patients with morbid obesity in general.     

Single Incision (“Scarless”) Laparoscopic Total Abdominal Colectomy with End Ileostomy for Ulcerative Colitis

Introduction  

Total abdominal colectomy with ileal pouch–anal anastomosis is the intervention of choice for patients with medically uncontrolled ulcerative colitis. A three-stage approach is preferred in particularly debilitated patients. In this setting, laparoscopic surgery has shown to be safe, offering several advantages over the open approach. Single incision laparoscopic surgery is a new minimally invasive approach which represents a true scarless procedure for the first step of the restorative proctocolectomy. In this article, we describe our technique in performing the single-incision total abdominal colectomy.     

Hybrid Hand-Assisted Colectomy for Transverse Colon Cancer: A Useful Technique for Non-Expert Laparoscopic Surgeons

Background  

Laparoscopic assisted colectomy (LAC) is commonly performed, but LAC for transverse colon cancer is a complex procedure, even in the hands of experts. In particular, laparoscopic take-down of the splenic and/or the hepatic flexure and dissection of the lymph nodes around the middle colic vessels are extremely complicated maneuvers compared to the complexity of these procedures during open surgery. We herein describe a simple and less-invasive technique for performing hybrid hand-assisted laparoscopic colectomy (hybrid-HALC). This procedure combines the established convenient and safe techniques of open surgery with the less invasive hand-assisted laparoscopic approach.     

腹腔镜全结肠切除术在家族性腺瘤性结肠息肉病及溃疡性结肠炎中的临床应用

目的:探讨腹腔镜全结肠切除术在家族性腺瘤性结肠息肉病(familial adenomatous polyposis,FAP)及溃疡性结肠炎(ulcerative colitis,UC)治疗中的应用价值。方法:回顾分析2009～2012年为12例患者行腹腔镜全结肠切除术(FAP患者7例,UC患者5例)及18例传统开腹全结(直)肠切除术(FAP患者7例,UC患者11例)的临床资料。结果:腹腔镜组在切口长度、术中出血量、术后止痛药使用量、术后排气时间、拔除导尿管时间、术后住院时间等方面优于开腹组,住院总花费明显高于传统开腹手术。结论:腹腔镜全结肠切除术用于FAP及UC安全、可行,与传统开腹手术相比,具有患者创伤小、康复快等优点,手术效果不亚于传统开腹手术,具有较高的临床应用价值。     

Outcomes of laparoscopic and open colectomy at academic centers

BACKGROUND: Laparoscopic techniques have emerged as a suitable approach for colon resection. This study determined and compared the outcomes of patients undergoing laparoscopic or open colectomy at United States academic centers. METHODS: Using ICD-9-CM codes, we obtained data from the University HealthSystem Consortium database for 50,443 patients who underwent open (n = 47,090; 94%) or laparoscopic (n = 3,353; 6%) colectomy during a 5-year period (2002 to 2006). Outcomes studied included length of stay (LOS), costs, in-hospital morbidity and risk-adjusted mortality rates. RESULTS: Mean LOS (open = 11 days and laparoscopic = 7 days) was significantly shorter and mean costs (open = $23,000 and laparoscopic = $17,000) significantly fewer with the laparoscopic approach. The overall in-hospital morbidity rate was significantly lower with laparoscopic colectomy (open = 33% and laparoscopic = 24%). The risk-adjusted mortality ratio was comparable between groups (open = .9 and laparoscopic = .7). Comments: Despite the major biases inherent in this retrospective review of the University Health System Consortium, which favors the use of laparoscopic colectomy by United States academic surgeons, laparoscopic colectomy offers the potential of significantly shorter LOS, fewer costs, lower in-hospital morbidity rates, and comparable risk-adjusted mortality rates compared with open colectomy. Laparoscopic colectomy is as safe as the open approach.     

Elective laparoscopic sigmoid colectomy for diverticulitis

BACKGROUND: We undertook a prospective evaluation of elective laparoscopic sigmoid colectomy for diverticulitis in order to assess the risks and benefits of this approach. METHODS: Between November 1992 and November 1996, 54 consecutive patients were included in this study. Their mean age was 59 +/- 13 years (range, 36-81). The number of attacks of diverticulitis before colectomy ranged from one to four (mean, 2.2 +/- 0.7). The operative technique consisted of elective division of the inferior mesenteric vessels, left colonic flexure mobilization, and colorectal anastomosis using the cross-stapling technique. RESULTS: Five procedures (9.2%) were converted. The primary cause for conversion was obesity. These patients had a simple postoperative course. There were no postoperative deaths. Three patients (6.1%) developed abdominal complications, and four patients (8.2%) had abdominal wall complications. Postoperative paralytic ileus lasted only 2.3 +/- 0.7 days (range, 1-6), allowing for a rapid reintroduction of regular diet. The mean postoperative hospital stay was 6.4 +/- 2.7 days (range, 4-15). CONCLUSIONS: Elective laparoscopic colectomy for diverticulitis is feasible in most cases. In most cases, the operative risk is low and the postoperative course is uneventful. Elective sigmoid laparoscopic colectomy should be considered a good therapeutic option for symptomatic diverticulitis.     

Intracorporeal laparoscopic cecorectal anastomosis

We recently described a laparoscopically assisted subtotal colectomy with extracorporeal antiperistaltic cecorectal anastomosis (CRA). We modified this technique by performing an intracorporeal CRA: the anvil head assembly removed from the circular stapler with an ancillary trocar placed into the anvil shaft is pushed through the bottom of the cecum, the cecum with the anvil head assembly is brought into the pelvis, the circular stapler is inserted into the rectum and the cecoproctostomy is performed. Two patients underwent this new laparoscopic subtotal colectomy with CRA. The operating times were 230 and 260 minutes, respectively. There was no postoperative morbidity. Our results allow us to state that intracorporeally performed antiperistaltic cecoproctostomy after laparoscopic subtotal colectomy is feasible.     

Overnight Hospital Stay After Colon Surgery for Adenocarcinoma

A short hospital stay is one of the main advantages of the laparoscopic surgical technique. The process of developing and studying the “fast-track” process has contributed to a better understanding of the elements of perioperative care and has resulted in the reduction in length of stay (LOS) after colectomies. As we follow and refine this well-recognized multimodal approach, further decreases in the LOS can be expected. We present 2 octogenarian patients who, after receiving laparoscopic hemicolectomies for malignant disease, were discharged home <24 hours after their operations. Postoperative follow-ups did not show any adverse reaction to the early discharge. Modifying the multimodal perioperative technique with further refinement to the surgical technique appears to allow patients to be discharged home in the first 24 hours following laparoscopic colectomy.     

Laparoscopically assisted subtotal colectomy with antiperistaltic cecorectal anastomosis

Several trials have demonstrated the efficacy, low morbidity, and clinical benefit of laparoscopy, as compared with laparotomy, for the treatment of benign colorectal disease. Slow-transit constipation, also defined as colonic inertia (CI), improves after colectomy, and we recently proposed a technique for subtotal colectomy with a novel antiperistaltic cecorectal anastomosis (CRA). In this article, we propose a technique for subtotal colectomy with CRA via a laparoscopic approach. This technique was used to treat two young women affected by CI. The operating time was 320 and 360 min, respectively. There was no postoperative morbidity. The length of postoperative hospital stay was 10 days. One month after CRA, bowel frequency was regular in both cases. Our results allow us to state that laparoscopically assisted subtotal colectomy with CRA is safe and effective for patients with CI.     

Single-incision laparoscopic right colectomy for cancer: a single-centre preliminary experience

The rationale for single-incision laparoscopic surgery (SILS) is minimizing morbidity, as well as improving cosmetic results of laparoscopic approach. This technique has been used for a variety of procedures and has recently been proposed for colonic resections as well. We report our preliminary experience of right colectomy, performed through a SILS approach. Five patients (3 males, 2 females, mean age 81.6 years) were selected to undergo SILS right colectomy for cancer. The procedure was carried out through a SILS multi-port device (SILS? Port, Covidien Ltd, Norwalk, CT, USA), with either conventional or specially designed instruments. A medial-to-lateral approach and an extra-corporeal anastomosis were performed. In three cases, the procedure was completed through the SILS technique; in two of these cases a combined procedure was carried out (right colectomy plus cholecystectomy, right colectomy plus cholecystectomy plus i.o. colonoscopy and polypectomy). In one case, a switch to standard laparoscopy was necessary because of the large dimension of the tumour, while in the other case an intolerance of pneumoperitoneum was registered, thus requiring a conversion to open surgery. SILS procedures proved to be oncologically correct. No major complications occurred. In selected patients, SILS right colectomy for cancer appears to be feasible and oncologically safe. Beyond the cosmetic advantage, the procedure may reduce postoperative morbidity. Further studies are needed, with larger series and a longer follow-up, to determine the incidence of possible long-term complications and to evaluate possible cost-effectiveness of the procedure.     

Single incision laparoscopic left colectomy for carcinoma of distal transverse colon

Objective We report a single‐incision laparoscopic left colectomy for a patient with a distal transverse colon cancer. Method A 78‐year‐old man with carcinoma of the transverse colon close to the splenic flexure underwent a single‐incision laparoscopic left colectomy with full mobilization of splenic flexure using the TriPort™ Access System and ordinary laparoscopic instruments. Results The operation was successfully performed. The patient recovered uneventfully and was discharged after 3 days. Histopathological examination showed a T3N1 tumour with clear resection margins. Conclusion This case demonstrates that single‐incision laparoscopic colectomy can be applied safely to large bowel cancer close to the splenic flexure. The technique warrants further investigation.     

Laparascopic sigmoid colectomy for diverticular disease in a patient with situs inversus

We present the case of a 50-year-old man with situs inversus who underwent laprascopic colonic resection for diverticulitis. The patient, who had right-sided pain due to inversion of the viscera mimicking appendicitis, initially presented a diagnostic challenge. A barium meal confirmed situs inversus and the diagnosis of diverticulitis. We present an overview of the operative technique of what is the first documented laparoscopic colectemy in a patient with situs inversus. We then discuss the benefits of the laproscopic approach to colectomy, with reference to this interesting case with unusual anatomy.     

Laparoscopic colorectal surgery is safe in the high-risk patient: a NSQIP risk-adjusted analysis

BACKGROUND: Laparoscopic colectomy was considered initially to be contraindicated in patients at high risk for operative morbidity and mortality. We hypothesized that this procedure is safe to perform in high-risk patients, stratifying this risk using National VA Surgical Quality Improvement Program (NSQIP) algorithms. METHODS: A case-matched, comparative study was performed for high-risk veteran patients who underwent colectomy during the period October 2002-September 2004. Consecutive patients undergoing laparoscopic colectomy were matched to patients who underwent open colectomy during the same period for age, body mass index (BMI), procedure, and NSQIP-predicted risk. The groups were compared for risk-stratified, 30-day morbidity/mortality, length of stay (LOS), and operating time. RESULTS: Forty-five patients (23 laparoscopic and 22 open cases) were defined as at high risk for complications (predicted complication >0.15). The rate of major complications was significantly less in the laparoscopic group. There were 4 (18%) cases of postoperative respiratory failure in the open group and none in the laparoscopic group. There was no surgically related mortality in the laparoscopic group, compared with 2 deaths in the open group (P = .5). Median LOS was less in the laparoscopic group (5 days) compared with open (8 days) (P = .001). There were no significant differences in operating time or the number of minor complications. CONCLUSIONS: Our results suggest that the laparoscopic approach to colorectal diseases is safe in the population of patients at high risk for operative morbidity and mortality. Rather, this approach may represent a safer alternative to open access.     

Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer

The authors examined the impact of the laparoscopic approach on the early outcome of resected colon carcinomas. The role of laparoscopic techniques in the treatment of colon carcinomas is questionable. Previous studies have suggested technical feasibility of surgical resections of these cancers by laparoscopic means and have implied a benefit to laparoscopic technique for patients undergoing colorectal resections. A prospective, randomized study was conducted comparing laparoscopic assisted colectomy (LAC) open colectomy (OC) for colon cancer. We present the preliminary results in relation to the short-term outcome and judge the feasibility of the laparoscopic procedure to as a way of performing accurate oncologic resection and staging. Benefit has been demonstrated with LAC in this setting. Passing flatus, oral intake, and discharge from hospital occurred earlier in LAC- than OC-treated patients The mean operative time was significantly longer in the LAC group than in the OC group. The overall morbidity was significantly lower in the LAC group. No significant differences were observed between both groups in the number of lymph nodes removed or the pathological stage following the Astler-Coller modification of the Dukes classification. The laparoscopic approach improves the short-term outcome of segmental colectomies for colon cancer. However, the further follow-up of these patients will allow us to answer in the near future whether or not the LAC may influence the long-term outcome.Presented at the annual meeting of the Society of American Gastrointestinal Surgeons (SAGES), Orlando, FL, USA, 11–14 March 1995     

Laparoscopic procedures for colorectal cancer: analysis of 134 cases

Laparoscopic procedures to treat colorectal cancer have been increasingly adopted in the last 15 years and seem to be well accepted by the patients. We studied 134 patients treated by laparoscopic colon resection, analysing the reasons for conversion to open laparotomy and outcomes. Over the period from July 2002 to January 2005, 134 patients with different colorectal cancers were treated with a laparoscopic approach in our department. We analysed the conversion rates and reasons for conversion, perioperative complications, hospital stay and recourse to blood transfusions. The laparoscopic procedures led to shorter hospitalisation and a reduction of the blood transfusion requirement, and were well accepted by the patients. The laparoscopic approach for malignant disease of the colon and rectum can improve many aspects of this treatment: Shorter hospitalisation, reduction of blood transfusions and a better quality of life. It also seems to lead to a lower non-specific depression of the immunological response. All these aspects may contribute to better treatment of patients with colorectal cancer. All kinds of laparoscopic colectomy can be performed with oncological criteria but the rate of conversion for rectal cancer is significantly higher (28.6%). In this study the complication rates in the laparoscopic colectomy and converted group were similar.     

Comparison of efficiencies of three techniques for colon surgery

PURPOSE: To determine the most efficient technique for performing a colectomy, we used the methodology of time-motion analysis. METHODS: The efficiency of five hand-assisted and six regular laparoscopic colectomies and one open colectomy, performed by four surgeons in three different hospitals, was measured. The open colectomy was analyzed as a reference procedure. RESULTS AND CONCLUSIONS: The hand-assisted laparoscopic technique was the most efficient. Hand-assisted laparoscopy was therefore less time consuming than laparoscopic surgery. Open surgery was the fastest technique, because the time for every surgical motion is a factor of three shorter than for the two laparoscopic techniques.     

Laparoscopic surgery of colon cancer. State of art and literature review

Over the past decade advances in laparoscopic surgery have revolutionized the surgical approach to many diseases. Although the first case series on laparoscopic segmental colectomy in patient with sigmoid cancer was described in 1991, this technique has not been readily accepted. Despite reduced morbidity and improved convalescence after laparoscopic surgery for benign disorders, surgeons have been sceptical about similar advantages of laparoscopic colectomy for cancer. The safety of the procedure has been questioned because of early reports of port-site metastases and there has been uncertainty about whether minimally invasive surgery for colonic malignancies would achieve adequate oncologic resection. Open surgical resection of the primary tumor, until just recently, has been widely considered the most effective treatment of colon cancer. The adherence to the principles of complete abdominal exploration, high ligation of mesenteric vessels, lymphnodal clearance and adequate bowel resection margins is essential. Several randomized trials were initiated in the early 1990s to compare the short- and long-term outcomes of patients undergoing minimally invasive and conventional open surgery for colon cancer. Today the results of this large multiinstitutional randomized trials have been reported. This review examines recent data from randomized, controlled trials and meta-analysis, that report the short- and long-term outcomes after laparoscopic colectomy for cancer.     

Laparoscopic-assisted operation for familial adenomatous polyposis patients-two case reports.

OBJECTIVE: We describe herein the results of 2 laparoscopic operations to treat patients with familial adenomatous polyposis (FAP). METHODS: Two female FAP patients, aged 32 and 29 years old, were treated with restorative proctocolectomy and total colectomy with ileorectal anastomosis (hand-assisted laparoscopic surgery), respectively. RESULTS: The operative time was 360 minutes for the restorative proctocolectomy and 150 minutes for the total colectomy with ileorectal anastomosis. The blood loss was 500 cc for the restorative proctocolectomy and minimal for the total colectomy patient. The return of bowel movements took 3 days for each patient, and no complication occurred. Patients were discharged on the 15th and 7th postoperative days. CONCLUSION: A laparoscopic approach for restorative proctocolectomy or total colectomy with ileorectal anastomosis is safe and technically feasible, and provides good cosmesis.