Colorectal surgeons should be open to modern surgical technologies for challenging cases

Today, colorectal surgeons globally are practicing in an exciting era where surgical technologies are constantly emerging. Most of these cutting‐edge technologies are readily available in Australia and New Zealand at present. Thus the ‘modern surgeon’ should always be defined by this open‐minded attitude towards these new and emerging surgical technologies. This review article highlights current modalities that we have been using in our north‐Brisbane public and private hospitals for cases predicted to be technically challenging using minimally invasive approaches for most of them. We examined the current evidence regarding the following modalities and critiqued their use in clinical practice: lighted ureteric stents, minimally invasive surgery approaches of laparoscopy and robotic surgery, pressure barrier insufflation devices, 3D camera systems, hand‐assist device ports and indocyanine green dye fluorescence angiography. The objective of this review paper is to alert colorectal surgeons to new surgical technologies available to them, to encourage colorectal surgeons' familiarization with these many technologies, and to support evidence‐based consideration for the clinical use of such. These technologies should be supplemental aides to the safe, oncologically adequate and efficient operation that they already routinely perform.     

Hand Surgery in Different Countries: Hand Surgery in New Zealand

Hand surgery in New Zealand has steadily grown from its origins in plastic surgery and orthopaedic surgery into its own discipline. There has been much progress and innovation in hand surgery that has originated from New Zealand and this review acknowledges the historical figures and events that have led to our present position. The current and future directions of hand surgery in our country are also discussed. As a small and remote country, we are very fortunate to have close relationships with other international hand societies. Through these relationships and the efforts of committed regional hand surgeons, the art and science of hand surgery in New Zealand continues to progress.     

Updates in robotic colorectal surgery

Since the introduction of master-slave manipulators (otherwise known as telemanipulators) in 1990, minimally invasive surgery paved the way for the development of the first robotic surgical systems to overcome the limitations of laparoscopic surgery. The robotic system over the last decade has rapidly gained acceptance and popularity among surgeons, especially colorectal surgeons around the world. Advantages of robotic surgical systems includes superior instrumentation and stable field of vision which enable precise dissection in confined spaces such as the pelvis. The feasibility and safety of robotic rectal surgery is now well established and there is increasing evidence that it might offer superior perioperative and postoperative outcomes when compared to laparoscopic rectal surgery. Robotic rectal surgery is easier to learn than laparoscopic surgery and the creation of a structured training program for robotic rectal surgery in Europe and USA has facilitated the learning of this technique in an environment that promotes patient safety and improved patient outcomes through equipment fidelity and operator skills. It is foreseeable that in the near future robotic systems will become part of routine surgical practice in colorectal surgery.     

DAY CASE ANORECTAL SURGERY

All patients referred to the University Department of Surgery, Wellington Hospital, Wellington, New Zealand, with minor anorectal conditions requiring surgery were considered for day case surgery. Eighty-three per cent of the patients were found suitable for day surgery. One hundred patients underwent 103 procedures under general anaesthesia. Admission to hospital from the day care facility was required for four patients; two for bleeding, one for pain and one for drowsiness. One patient required readmission due to inability to cope at home. Twenty-six per cent reported severe pain. Eighty-nine per cent found day surgery to be convenient and preferable to inpatient surgery. Eleven per cent found day surgery inconvenient and would prefer inpatient surgery in future. It is suggested that many anorectal procedures can be performed on a day case basis in selected patients, with safety and convenience. It is well tolerated and accepted.     

Robotic colorectal surgery

Master–slave manipulators (otherwise known as telemanipulators) were introduced into minimally invasive surgery in the 1990s to overcome the limitations of laparoscopic surgery. This led to the development of the first robotic surgical systems which, over the last 10 years, have rapidly gained acceptance among colorectal surgeons. Advantages of robotic surgical systems such as superior instrumentation and field of vision enable precise dissection in confined spaces such as the pelvis which make it a particularly attractive tool for rectal surgery. The feasibility and safety of robotic rectal surgery is now well established and there is increasing evidence that it might offer superior peri- and postoperative outcomes when compared to laparoscopic rectal surgery. Robotic rectal surgery is easier to learn than laparoscopic surgery and the creation of a structured training programme for robotic rectal surgery in Europe has facilitated the learning of this technique in an environment that promotes patient safety and improved patient outcomes through equipment fidelity and operator skill. It is foreseeable that in the near future robotic systems will become part of routine surgical practice in colorectal surgery.     

Updates in robotic colorectal surgery

Since the introduction of master-slave manipulators (otherwise known as telemanipulators) in 1990, minimally invasive surgery paved way for the development of the first robotic surgical systems to overcome the limitations of laparoscopic surgery. Over the last decade, the robotic system has rapidly gained acceptance and popularity among surgeons, especially colorectal surgeons around the world. Advantages of robotic surgical systems includes superior instrumentation and stable field of vision which enable precise dissection in confined spaces such as the pelvis. The feasibility and safety of robotic rectal surgery is now well established and there is increasing evidence that it might offer superior perioperative and postoperative outcomes when compared to laparoscopic rectal surgery. Robotic rectal surgery is easier to learn than laparoscopic surgery and the creation of a structured training program for robotic rectal surgery in Europe and USA has facilitated the learning of this technique in an environment that promotes patient safety and improved patient outcomes through equipment fidelity and operator skills. It is foreseeable that in the near future robotic systems will become part of routine surgical practice in colorectal surgery.     

我国肝胆胰外科发展与国际接轨的挑战和机遇

This article traced how western medicine and surgery were introduced into China, described where Chinese surgery stands currently at the international scene, and proposed future strategies as to how Chinese surgery can go internationally. Surgery, a major component of western medicine,was first introduced into China in the late 19th and early 20th centuries through the missionaries and the merchants of the East Indian Company. Surgical centers were soon established in the big cities along the coastal region, then spread inland along the Yellow River, the Yangtze River and the Pearl River. The establishment of general surgery centers soon led to the development of the subspecialty in hepatopancreatobiliary surgery because of high prevalence of hepatitis B related hepatocellular carcinoma, intrahepatic stones, portal hypertension caused by schistosomiasis and pancreatic disease. For historical reasons,Chinese surgery was cut off from the outside world in the 1960s.This led to the development of Chinese surgery along a different path from that taken internationally. With the opening up of China in the 1980s, and the recent economic developments,Chinese surgery needs to merge with surgery in the rest of the world. Suggested proposal for future strategies for Chinese surgery to go internationally include undergraduate medical reform, introduction of structured surgical training and examination for the whole country, life long continuing medical education for all surgeons, academic exchanges with internationally renowned centers, publication in international peer-review journals, active involvement in international surgical societies and conferences.     

Image-guided spine surgery: state of the art and future directions

Navigation technology is a widely available tool in spine surgery and has become a part of clinical routine in many centers. The issue of where and when navigation technology should be used is still an issue of debate. It is the aim of this study to give an overview on the current knowledge concerning the technical capabilities of image-guided approaches and to discuss possible future directions of research and implementation of this technique. Based on a Medline search total of 1,462 publications published until October 2008 were retrieved. The abstracts were scanned manually for relevance to the topics of navigated spine surgery in the cervical spine, the thoracic spine, the lumbar spine, as well as ventral spine surgery, radiation exposure, tumor surgery and cost-effectivity in navigated spine surgery. Papers not contributing to these subjects were deleted resulting in 276 papers that were included in the analysis. Image-guided approaches have been investigated and partially implemented into clinical routine in virtually any field of spine surgery. However, the data available is mostly limited to small clinical series, case reports or retrospective studies. Only two RCTs and one metaanalysis have been retrieved. Concerning the most popular application of image-guided approaches, pedicle screw insertion, the evidence of clinical benefit in the most critical areas, e.g. the thoracic spine, is still lacking. In many other areas of spine surgery, e.g. ventral spine surgery or tumor surgery, image-guided approaches are still in an experimental stage. The technical development of image-guided techniques has reached a high level as the accuracies that can be achieved technically meet the anatomical demands. However, there is evidence that the interaction between the surgeon (‘human factor’) and the navigation system is a source of inaccuracy. It is concluded that more effort needs to be spend to understand this interaction.     

Rare causes of abdominal pain: a primer for the admitting general surgeon

The broad uptake of the acute surgical unit (ASU) model of surgical care in Australia has resulted in general surgeons becoming increasingly involved in the management of patients with acute abdominal pain (AAP), some of whom will be labelled as having non-specific abdominal pain (NSAP) (Kinnear N, Jolly S, Herath M, et al. The acute surgical unit: An updated systematic review and meta-analysis. review. Int. J. Surg. 2021;94:106109; Lehane CW, Jootun RN, Bennett M, Wong S, Truskett P. Does an acute care surgical model improve the management and outcome of acute cholecystitis? ANZ J. Surg. 2010;80:438-42). NSAP patients lack a clear diagnosis of surgical pathology based on standard clinical, laboratory and imaging work-up, although they may require ASU admission for pain control and assessment. This article provides a review of uncommon conditions, presenting as AAP, that could possibly be mis-labelled as NSAP, with a focus on aspects of the presentation that may aid diagnosis and management including specific demographic features, clinical findings, key investigations and initial treatment priorities for ASU clinicians. Ultimately, most of the conditions discussed will not require surgical intervention, however, they require a diagnosis to be made and initial treatment planning before on-referral to the appropriate specialty. For the on-call general surgeon, some knowledge of these conditions and an index of suspicion are invaluable for the prompt diagnosis and efficient management of these patients.     

微创外科时代的胆道外科——胆囊切除术尚非平安无事

自从首例在腹腔镜下施行胆囊切除术之后,胆道外科技术经历了革命性的改变。当前,已经有越来越多的传统外科手术方法被腹腔镜外科所取代。然而,腹腔镜胆囊切除术并非平安无事。当前,由于影像学技术的发展,例如对肝内、外胆道的虚拟现实、三维重建等,可以有助于对复杂胆道外科问题如肝内胆管结石和其他肝内病变的手术前评估和手术设计。约占原发性肝癌5%～10%的肝内胆管癌由于其与肝细胞癌有不同的病理-生物学特点,故在治疗措施选择上应得到特殊的关注,一般应该施行广泛的肝切除手术而不是局部切除或消融。关于肝门部胆管癌的治疗,扩大的肝切除术可以改进早期的、无淋巴结转移病变治疗结果。当前,在微创外科时代,许多传统的外科手术将在微创外科理念下重新受到检验。     

Comparison of robotic reduced-port and laparoscopic approaches for left-sided colorectal cancer surgery

Background/objectiveThe reduced-port approach can overcome the limitations of single-incision laparoscopic surgery while maintaining its advantages. Here, we compared the effects of robotic reduced-port surgery and conventional laparoscopic approaches for left-sided colorectal cancer.MethodsBetween January 2015 and December 2016, the clinicopathological characteristics and treatment outcomes of 17 patients undergoing robotic reduced-port surgery and 49 patients undergoing laparoscopic surgery for left-sided colorectal cancer were compared.ResultsThe two groups were comparable in almost all outcome measures except for the distal resection margin, which was significantly longer in the laparoscopic group (P < 0.001). The between-group differences in reoperation, incisional hernia development, and overall and progression-free survival were nonsignificant; however, the total hospital cost was significantly higher in the robotic group than in the laparoscopic group (US$13779.6 ± US$3114.8 vs. US$8556.3 ± US$2056.7, P < 0.001).ConclusionRobotic reduced-port surgery for left-sided colorectal cancer is safe and effective but more expensive with no additional benefit compared with the conventional laparoscopic approach. This observation warrants further evaluation.     

机器人在腹部外科手术中的初步应用(附16例报告)

目的总结达芬奇机器人系统在腹部外科手术中的初步应用体会。方法回顾分析2015年2月至10月间华中科技大学同济医学院附属协和医院胃肠外科行达芬奇机器人系统手术的16例病人资料。结果 16例病人中男性7例,女性9例,均顺利完成达芬奇机器人辅助手术。手术方式为:全胃切除1例,远端胃癌根治术1例,胃局部切除术3例,食管裂孔疝修补加胃底折叠术2例,袖状胃切除术1例,十二指肠肿瘤切除术1例,胆囊切除术2例,胆总管囊肿加胆囊切除并胆肠吻合1例,乙状结肠癌根治术2例,直肠癌根治术2例。本组手术时间90~330 min,系统装机时间20~60 min。术中出血量为10~120 ml,所有病人术中均未输血。胃肠道癌淋巴结检出数25.5枚/例。术后平均胃肠功能恢复时间为2.2 d,术后平均住院时间为7.5 d。本组病人术后恢复顺利,无严重并发症发生。结论达芬奇机器人手术系统在腹部外科手术中安全可行,具有解剖分离精准、创伤小、恢复快等优点。