Laparoscopic sigmoidectomy in a case of sigmoid colon cancer with situs inversus totalis

Situs inversus totalis (SIT) is a rare anatomic anomaly in which organs in the chest and abdomen exist in a mirror image reversal of their normal positions. SIT can complicate surgical procedures, and few reports have described laparoscopic surgery for colorectal cancer in patients with SIT. Here, we report a case of successful laparoscopic surgery in a patient with SIT and sigmoid colon cancer. Laparoscopic sigmoidectomy involved colonic mobilization with high ligation of the inferior mesenteric vessels and complete mesocolic excision. The operating surgeon stood on the patient's left side, opposite the normal location for sigmoidectomy. By placing a 12‐mm trocar in the left iliac fossa and using an automatic endoscopic linear stapler, the operating surgeon was able to perform left‐handed colon resection without having to change position or move the laparoscopic monitor mid‐procedure. An automatic endoscopic linear stapler is useful for laparoscopic left‐side colon surgery in a patient with SIT.     

Laparoscopic sigmoidectomy with splenic flexure mobilization for colon cancer in situs inversus totalis: Preoperative assessment and preparation

Situs inversus totalis (SIT) is a rare condition in which the internal organ's position is a mirror image of normal anatomy. Although several investigators reported laparoscopic surgery for colorectal cancer in patients with SIT, it is considered difficult even for an experienced surgeon because of the mirror position. We show a case report of laparoscopic sigmoidectomy with the splenic flexure mobilization (SFM) procedure in SIT. A 79-year-old woman with SIT was referred to our hospital for a locally advanced sigmoid cancer (cT3N1M0, cStageIIIB). We safely performed the laparoscopic sigmoidectomy with SFM, as shown in detail below. No postoperative complication occurred, and the patient is in good health with no recurrences 30 months after surgery, as of the writing this report. We propose three critical points; checking the CT angiography to understand the anatomy; using flip-horizontal video of “normal” laparoscopic sigmoidectomy to confirm an unfamiliar situation; adding the epigastric trocar to make SFM procedures safe and comfortable.     

Laparoscopic total gastrectomy for advanced gastric cancer in a patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare congenital anomaly. Generally, laparoscopic surgery is difficult to perform in patients with SIT because of both the potential challenges associated with unexpected vascular anomalies and the lack of standardized strategy for handling such cases. This is the first report of laparoscopic total gastrectomy with lymph node dissection for advanced gastric cancer in a patient with SIT. A 79‐year‐old man with SIT was diagnosed with advanced gastric cancer. We performed laparoscopic total gastrectomy with modified D2 lymph node dissection (D2 without splenectomy) and esophagojejunal anastomosis using an overlap method involving retrocolic Roux‐en‐Y reconstruction. The total operating time was 232 min, and blood loss was 110 mL. There were no postoperative complications. In summary, laparoscopic total gastrectomy for gastric cancer can be performed safely, even in a patient with SIT.     

Laparoscopic low anterior resection for rectal cancer after Whitehead's hemorrhoidectomy: A case report

A 65‐year‐old man presented with bloody stool. Colonoscopy revealed a raised tumor in the rectum, above the peritoneal reflection. He underwent endoscopic mucosal resection, but the pathological findings suggested the possibility of residual cancer. We performed laparoscopic low anterior resection using a circular stapling instrument for additional curative surgery. However, we could not insert the shaft of the endoscopic circular stapler from the anus because of anal stenosis due to Whitehead's hemorrhoidectomy the patient had undergone 20 years earlier. Therefore, we planned to use a linear stapler to insert an anvil into the rectum. The cartridge‐carrying instrument was inserted from the sigmoidal side, and we performed a side‐to‐end anastomosis. The patient was discharged without anastomotic leakage or defecation disorder. We present this case because laparoscopic low anterior resection for rectal cancer with anal stenosis has not been previously reported.     

Robot-assisted low anterior resection for a rectal cancer patient with ileal conduit: A case report

Surgery for rectal cancer patients with an ileal conduit after total cystectomy is difficult because adhesions in the pelvis and around the ileal conduit are expected. In the present case, we performed robot-assisted low anterior resection of the rectum in a 69-year-old male patient with rectal cancer who underwent ileal conduit diversion after total cystectomy. In this procedure, the port was inserted into the left upper abdomen as a first step, and two additional ports were added on the left side. Low anterior resection was performed using two left hands to create more space in the abdominal cavity for the ileal conduit. We present this minimally invasive robotic procedure that is extremely useful for dissection of adhesions in a narrow pelvic cavity.     

Synchronous rectal and esophageal cancer treated with chemotherapy followed by two-stage resection

We report a case of 61-year-old male who had synchronous advanced rectal cancer involving the urinary bladder massively associated with multiple liver metastases, and esophageal cancer successfully treated by neoadjuvant chemotherapy followed by two-stage resection. Although complete resection of each of the lesions was considered possible by performing anterior pelvic exenteration, liver resection, and esophagectomy, it might be impossible for the patient to endure the stress of all of these operative procedures at once. Therefore, we planned to perform staged treatment with prioritizing consideration. First, we instituted chemotherapy with the FOLFOX (oxaliplatin + fluorouracil + leucovorin) plus cetuximab regimen, which could adequately control both rectal and esophageal cancer. After 6 cycles of chemotherapy, high anterior resection combined with cystoprostatectomy and lateral segmentectomy plus partial hepatectomy was performed followed by staged esophagectomy with three-field lymph node dissection. It was possible to use oxaliplatin and cetuximab safely as neoadjuvant therapy not only for advanced rectal cancer but for esophageal cancer, and it was effective.     

Laparoscopic anterior resection for rectal cancer in a patient with a ventriculoperitoneal shunt

Laparoscopic surgery has been relatively contraindicated in patients with ventriculoperitoneal shunts (VPS) because of concerns about the effect of the pneumoperitoneum on shunt function. However, there have been recent reports of laparoscopic surgery on the gallbladder and cecum. This is the first report of laparoscopic high anterior resection for rectal cancer without manipulation of the VPS catheter in a patient with VPS. We made a diagnosis of advanced rectal cancer in a 77‐year‐old man who had a VPS to treat hydrocephalus after a subarachnoid hemorrhage. We performed the procedure with the patient in a 15° head‐down tilt and with 10‐mmHg pneumoperitoneum pressure. There were no postoperative complications. We concluded that laparoscopic surgery for rectal cancer can be safely performed in patients with VPS.     

Intra‐abdominal desmoid tumor after laparoscopic low anterior resection for rectal cancer: A case report

Desmoid tumors are monoclonal fibroblastic proliferations arising from soft tissue classified as intra‐abdominal, extra‐abdominal and abdominal wall types. We present a patient with an intra‐abdominal desmoid tumor diagnosed 20 months after laparoscopic resection of rectal cancer. A 70‐year‐old woman with hematochezia was diagnosed with advanced rectal cancer. Preoperative chemoradiotherapy followed by laparoscopic low anterior resection was performed. During follow‐up, a nodular soft‐tissue density measuring 28 mm was detected in the presacral region. Metastasis from rectal cancer was diagnosed and four courses of chemotherapy were given, including capecitabine, oxaliplatin and bevacizumab. Computed tomography scan showed that the mass slightly decreased in size and surgical resection was performed. Histopathological examination revealed a proliferation of spindle‐shaped cells and collagenous stroma diagnosed as a desmoid tumor. This report highlights the possibility of a desmoid tumor in the differential diagnosis of an intra‐abdominal mass found during follow‐up after resection of colorectal cancer including following laparoscopic resection.     

Robotic-assisted total gastrectomy in a patient with gastric cancer associated with situs inversus totalis: With video

Situs inversus totalis (SIT) refers to an inverted position of the major visceral organ as a “mirror image” of the regular location. We present a video of a robotic-assisted total gastrectomy in a 84-year-old man with SIT. The patient was diagnosed with advanced gastric cancer in the U region. The port placement was done as mirror images of our usual settings. Lymph node dissection was performed with a completely reverse approach to the usual procedure. After total gastrectomy, an intracorporal esophagojejunostomy was performed by circular method. All procedures were performed safely with no intraoperative complications and the patient was discharged uneventfully. Pathological diagnosis confirmed moderately differentiated adenocarcinoma and the depth of invasion was to the subserosa; there were five metastatic lymph nodes. In patients who have gastric cancer with SIT, a robotic-assisted total gastrectomy can be performed safely without surgical complication. Robots are useful for performing a total gastrectomy in SIT.     

Robot-assisted low anterior resection in a patient with rectal cancer who had a urinary reservoir: A case report

Undergoing another surgery after a previous abdominal procedure can sometimes result in significant abdominal adhesions. We present a case of robot-assisted low anterior resection in a patient with rectal cancer who had a urinary reservoir. A 65-year-old male patient underwent robot-assisted total bladder resection and creation of a urinary reservoir for bladder cancer in 2013. He presented with melena. Thus, the findings revealed advanced low rectal cancer. The robot-assisted low anterior resection was performed in 2022. Extensive adhesions were observed in the pelvic space. The indocyanine green function was appropriately used, and the robotic surgery was completed without injury to the urinary reservoir or major complications. The surgical time was 510 min, and the blood loss volume was 15 mL. The patient had been recurrence free for 12 months following the surgery. Robot-assisted surgery can be beneficial for patients with rectal cancer with significant pelvic adhesions.     

Combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy for synchronous double cancer of the rectum and the prostate

Here we report a combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy. A 74‐year‐old man was diagnosed with T4b low rectal and prostate cancer. The operation was performed after neoadjuvant chemotherapy for the rectal cancer. The procedure used eight ports in total, five for laparoscopic abdominoperineal resection and six for robotic‐assisted prostatectomy. First, laparoscopic total mesorectal excision including division of the inferior mesenteric artery was performed, and then, robotic dissection of the prostate was performed. The en bloc specimen was removed through the perineal wound. Then, robotic urethrovesical anastomosis was performed. An extraperitoneal end colostomy was created to finish the operation. The operating time was 545 min, and blood loss was 170 mL. The postoperative course was uneventful, and the patient discharged on postoperative day 17. The combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy were performed safely without any additional technical difficulty, as both procedures shared port settings and patient positions.     

Three‐dimensional laparoscopy‐assisted bowel resection for cavernous hemangioma of the rectum: Report of two cases

The safety and feasibility of 3‐D laparoscopy‐assisted bowel resection were demonstrated in the management of rectal cancer. However, this procedure’s role in the management of patients with diffuse cavernous hemangioma of the rectum has not been evaluated. Here, two patients were diagnosed with diffuse cavernous hemangioma of the rectum by colonoscopy and abdominal imaging. One case underwent pull‐through transection and coloanal anastomosis in 3‐D laparoscopy‐assisted surgery. In another patient, 3‐D laparoscopy‐assisted abdominoperineal resection was performed. The operations were safely performed in both cases. The two patients recovered uneventfully, and satisfactory postoperative outcomes were demonstrated. This report shows that 3‐D laparoscopy‐assisted bowel resection may be safe and feasible for patients with diffuse cavernous hemangioma of the rectum.     

Lateral lymph node recurrence of rectal cancer with a pathological complete response to chemotherapy confirmed by laparoscopic lateral lymph node dissection: A case report

Lateral lymph node (LLN) metastasis is one of the forms of local recurrence after surgery for lower rectal cancer. We here present a case of LLN recurrence of rectal cancer that was shown by laparoscopic lateral lymph node dissection (LLND) to have a complete pathological response to chemotherapy. A 58-year-old man underwent open low anterior resection for lower rectal cancer. After detection of right LLN recurrence 43 months after the operation, 11 cycles of capecitabine, oxaliplatin, and bevacizumab chemotherapy were administered. Laparoscopic right LLND was performed 55 months after the first operation. Pathological examination revealed no viable tumor cells in the dissected lymph nodes. The patient remains alive without recurrence 61 months after the first surgery and 6 months after laparoscopic LLND. Laparoscopic LLND for LLN recurrence of rectal cancer is feasible and should be considered a valid treatment option.     

Photodynamic therapy as salvage therapy for residual microscopic cancer after ultra-low anterior resection: A case report

BACKGROUND The rate of positive resection margins(R1) in patients with low rectal cancer is substantial. Recommended remedies such as extended resection or chemoradiotherapy have their own serious drawbacks. It has been reported that photodynamic therapy(PDT) as a remedial treatment for esophageal cancer.Colorectal cancer and esophageal cancer has many similarities,however,PDT as a salvage therapy for rectal cancer is rare.CASE SUMMARY Here,we describe a 56-year-old man who was admitted to the hospital due to a 6-mo history of hemafecia,which had been aggravated for 1 mo. Colonoscopy revealed a 3 × 4 cm ulcerated mass in the rectum 4 cm from the anus.Preoperative pathological examination showed villous adenoma,moderate-tohigh-grade dysplasia,good differentiation,and invasion of the mucosal muscle.The patient had R1 after ultra-low anterior resection,but he refused extended resection and experienced severe liver function impairment after 3 cycles of chemotherapy. Ultimately,the patient underwent PDT to remove R1. After five years of follow-up,there was no liver function impairment,recurrence,metastasis,sexual dysfunction,or abnormal defecation function.CONCLUSION This is the first case worldwide in which R1 of rectal cancer were successfully treated by PDT.     

Endoscopic fenestration in the diagnosis and treatment of delayed anastomotic submucosal abscess: A case report and review of literature

BACKGROUNDAbscess formation is one of the complications after radical resection of rectal cancer; cases with delayed postoperative anastomotic abscess are rare. Here, we report a rare case of postoperative anastomotic abscess with a submucosal neoplasm appearing after rectal surgery. Ultimately, the patient was diagnosed and treated by endoscopic fenestration. In addition, we review the literature on the appearance of an abscess as a complication after rectal cancer surgery.CASE SUMMARYA 57-year-old man with a history of rectal malignancy resection complained of a smooth protuberance near the anastomotic stoma. Endoscopic ultrasonography revealed a hypoechoic structure originating from the muscularis propria, and a submucosal tumor was suspected. The patient was subsequently referred to our hospital and underwent pelvic contrast-enhanced computed tomography, which revealed no thickening or strengthening of the anastomotic wall. In order to clarify the origin of the lesion and obtain the pathology, endoscopic fenestration was performed. After endoscopic procedure, a definitive diagnosis of delayed anastomotic submucosal abscess was established. The patient achieved good recovery and prognosis after the complete clearance of abscess.CONCLUSIONEndoscopic fenestration may be safe and effective for the diagnosis/treatment of delayed intestinal smooth protuberance after rectal cancer surgery.     

A rare case of pelvic bronchogenic cyst treated by laparoscopic surgery

A 31‐year‐old man with pain in his thigh was diagnosed with a benign presacral cystic mass. We performed laparoscopic subtotal resection of the cyst utilizing mobilization of a total mesorectal excision procedure used in low anterior resection for rectal cancer. Histopathological findings showed that the cystic lumen of the specimen was lined with pseudostratified columnar ciliated epithelium and had glandular structures and smooth muscle in its wall, leading to a diagnosis of bronchogenic cyst. The postoperative course was uneventful, and as of 6 months after surgery, the patient was doing well with no evidence of recurrence.     

Reduced‐port laparoscopic surgery for rectal cancer: Feasibility based on our early experience

We report our experience of a reduced‐port laparoscopic surgery as an advanced laparoscopic surgery for rectal cancer. Twelve selected patients with clinical T1–2 and N0 rectal cancer (clinical stage I) underwent low anterior resection of the rectum. The procedures were performed with one port plus a multiple‐instrument access port with three channels. The multiple‐instrument access port was placed at the umbilicus or the site of diverting stoma, and another port was placed in the right abdomen or in the opposite abdomen of ostomy. The median operative time and intraoperative bleeding were 280 min and 15 mL, respectively. The median number of harvested lymph nodes was 20. No major perioperative morbidities occurred in this series. The median postoperative hospital stay was 10 days. Low anterior resection performed by reduced‐port laparoscopic surgery is feasible as multiport laparoscopic surgery, and it is a reliable surgical option in selected patients with rectal cancer.     

完全内脏转位合并肠道肿瘤的诊断与治疗并文献复习

目的探讨完全内脏转位(SIT)合并肠道肿瘤患者的诊断与治疗。 方法回顾性分析1例胸腹腔内脏完全转位合并结肠癌患者的临床表现和诊治过程,并检索2007至2017年的文献进行复习。 结果患者临床表现为腹胀、贫血,胸腹部CT示：除心尖指向右以外,胸腹部组织器官完全反转;CT示肿瘤位于左侧,诊断为盲肠-升结肠癌;胃镜示胃转位。患者在全麻下行结肠癌根治术,术后病理示结肠腺癌。 结论SIT患者由于腹腔器官转位,常出现位置相反的症状表现,常易导致误诊,应尽可能完善所有相关检查明确诊断及指导手术的顺利开展;诊断及治疗均应遵循"反向思维"的原则。此外,合并消化道肿瘤的SIT患者并非腹腔镜技术及机器人技术的手术禁忌,手术效果同样安全有效。     

Diagnosis of recurrent rectal cancer deep into the vaginal wall by transvaginal endoscopic ultrasound-guided fine needle aspiration

Local recurrent rectal cancer may present with extraluminal lesions. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is good for diagnosis of such an extraluminal lesion. A 51-year-old Asian female was diagnosed with uT3N0M0 rectal adenocarcinoma 31 months ago. She had undergone chemotherapy, radiotherapy and abdominoperineal resection (APR). Eight months ago, colonoscopy and computed tomography (CT) were unremarkable. Carcinoembryonic antigen was 1.1 ng/ml. Pelvic examination revealed a 3 x 2 cm firm soft-tissue mass palpable through the left vaginal wall. EUS revealed a mass in the left lateral vaginal wall measuring up to 21 x 27 mm in cross section without invasion of adjacent pelvic structures. Transvaginal EUS-FNA was performed with a 22-gauge needle. Final cytology confirmed recurrent rectal adenocarcinoma. Subsequent surgery also confirmed a 2.3 cm grade II adenocarcinoma. The tumor focally extended to the inked margin. The uterus and ovary specimen were negative for disease. We herein report a successful role of transvaginal EUS-FNA for early detection of recurrent rectal cancer at the vaginal wall after abdominoperineal resection (APR).     

Laparoscopic abdominoperineal resection with lateral lymph node dissection for anorectal melanoma: A case report

Because anorectal melanoma, a rare cancer with a poor outcome, does not respond well to local radiation therapy or systemic chemotherapy, surgery is the primary treatment. Herein, we present a case of anorectal melanoma with lateral and inguinal lymph node metastases. A 61‐year‐old woman presented with rectal bleeding. Colonoscopy revealed a black tumor with ulceration in the anorectum. A CT scan revealed an anorectal tumor with left lateral lymph node swelling and right inguinal lymph node swelling. We performed a laparoscopic abdominoperineal resection with lateral lymph node dissection and right inguinal lymph node dissection. One year after the initial operation, pulmonary metastases were observed, and pulmonary resection was performed. After the pulmonary resection, brain metastases developed, and surgical resection was performed. Despite the recurrence of disease, the patient has survived for 52 months since the initial surgery and continues to receive systemic chemotherapy.