Need for simulation in laparoscopic colorectal surgery training

The dissemination of laparoscopic colorectal surgery (LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Performing advanced laparoscopic procedures requires dedicated surgical skills and new simulation methods designed precisely for LCS have been established: These include virtual reality simulators, box trainers, animal and human tissue and synthetic materials. Studies have even demonstrated an improvement in trainees’ laparoscopic skills in the actual operating room and a staged approach to surgical simulation with a combination of various training methods should be mandatory in every colorectal training program. The learning curve for LCS could be reduced through practice and skills development in a riskfree setting.     

Impact of sarcopenia on surgical and oncologic outcomes of laparoscopic surgery for colorectal cancer

BackgroundThe study aimed to evaluate the impact of sarcopenia on short- and long-term outcomes for laparoscopic colorectal cancer surgery.MethodsStudy participants were 209 patients who underwent laparoscopic surgery for any stage of colorectal cancer between 2016 and 2017. Skeletal muscle indices were calculated with preoperative computed tomography. Patients were divided into sarcopenic and non-sarcopenic groups based on index cut-off values and variables were compared.ResultsThe prevalence of sarcopenia was 41.1%. Sarcopenic patients experienced shorter operative times and a lower incidence of surgical site infections; however, the incidence of severe postoperative complications and readmission were increased for this group. Although the 3-year disease-free survival rate was not statistically different between groups, sarcopenic patients had a significantly worse 3-year overall survival rate compared with than the non-sarcopenic group.ConclusionSarcopenia has both favorable and unfavorable effects on patients who underwent laparoscopic colorectal cancer surgery.     

Outcome of laparoscopic colorectal resection

Background: The aim of this study was to assess the feasibility and safety of laparoscopic surgery for colorectal diseases. Methods: A retrospective review was undertaken of all patients undergoing a laparoscopic colorectal procedure (LCP) for large bowel disease. All opertions were performed by a single experienced team. Patients were divided chronologically into three consecutive groups (G1, G2, and G3). Data collection included the incidence and cause of both proper and mandatory conversions to laparotomy, the incidence and type of early and late postoperative complications, incidence of operative mortality, and the length of hospital stay. The incidences of conversion to laparotomy and of early and late postoperative complications were also determined as related to diagnosis, type of LCP attempted, and chronological group. Results: Between January 1996 and December 2001, a total of 108 patients (49 men and 59 women) with a mean age of 65.1 years underwent an LCP for colorectal disease. Proper conversion to open surgery was necessary in five patients (4.6%), whereas a mandatory conversion was needed in 10 with patients advanced cancer (9.2%). The overall morbidity rate was 11.9%. There were no anastomotic leaks. In two patients (1.85%) developed a complication requiring reoperation. Postoperative mortality was nil. Mean postoperative hospital stay was 7.2 days. The rates of conversion and of early and late complications decreased through the three chronological periods. No trocar site recurrences were observed in the cancer patients. Conclusion: Laparoscopic colorectal surgery performed in experienced centers is safe; the observed morbidity and mortality rates are low and acceptable and compare favorably to those observed after standard open surgery.     

腹腔镜直肠癌根治术的临床体会(附42例报告)

目的:探讨腹腔镜直肠癌根治术的临床疗效及应用价值。方法:回顾分析2009年4月至2011年4月为42例直肠癌患者行腹腔镜根治术的临床资料。结果:41例(97.6%)成功完成腹腔镜手术,1例中转开腹。手术时间平均95 min,术中出血量平均30 ml,术后胃肠道功能恢复时间平均36 h,平均住院9 d,无围手术期死亡及并发症发生,术后38例按Folfox及Eelox方案化疗。随访3～24个月,平均18个月,切口均无肿瘤种植转移及复发。中转开腹患者于术后3个月死于肿瘤广泛转移导致的全身多器官功能衰竭。结论:腹腔镜直肠癌根治术具有患者创伤小、术后康复快、术中出血少、解剖清晰、切除病灶彻底等优点,值得推广应用。     

Wound infection after a laparoscopic resection for colorectal cancer

PURPOSE: The aim of this study was to investigate whether the wound infection (WI) rate in laparoscopic surgery (LS) for colorectal cancer is lower than that in open surgery (OS), and to evaluate the influence of perioperative intravenous antibiotic prophylaxis on the development of WI in LS. METHODS: We performed a meta-analysis study comparing the WI rate in patients who underwent either OS or LS in randomized controlled trials (RCTs), with a relatively large number of registered patients. Moreover, a subgroup analysis of recently reported RCTs from Japan was performed, and 290 consecutive patients who underwent LS for colorectal cancer at our institution were evaluated for the influence of perioperative intravenous antibiotic prophylaxis on the development of WI. RESULTS: The WI rate of the LS group was significantly lower than that of the OS group in a meta-analysis; however, no positive effect of the intra-and postoperative antibiotic prophylaxis on the development of WI was demonstrated. CONCLUSIONS: Laparoscopic surgery for colorectal cancer is considered a surgical technique that has a lower incidence of WI in comparison to OS. Well-designed prospective, randomized controlled trials should therefore be conducted to evaluate whether intraoperative repeated dosing or postoperative repeated dosing is effective in reducing WI in LS.     

经肛肠梗阻导管联合腹腔镜手术治疗结直肠恶性梗阻

目的 评价经肛肠梗阻减压导管联合腹腔镜手术在结直肠恶性梗阻治疗中的应用价值.方法 2007年3月至2010年10月37例急性完全性结直肠恶性梗阻患者经肛置入肠梗阻导管至梗阻近端肠管,冲洗引流4～10 d后行腹腔镜探查并一期切除吻合.结果 37例患者中34例成功置入导管,导管引流时间为4～10 d,平均(5.8±1.6)d.置入肠梗阻导管后(3.8±1.3)d(1～7 d)患者腹痛、腹胀症状消失.与入院时腹围(92 4±7)cm相比,手术时腹围(84±6)cm,明显缩小(P=0.013).其中31例患者减压后完成腹腔镜一期根治切除吻合,术后患者恢复顺利,无严重并发症.结论 经肛型肠梗阻减压导管联合腹腔镜手术治疗急性结直肠梗阻安全、有效,可将急诊手术转为限期手术,在适当的肠道准备后腹腔镜下根治手术并一期吻合是可行的.

Abstract：

Objective To evaluate the safety and efficacy of transanal drainage tube followed by laparoscopic surgery in management of malignant colorectal obstruction. Methods From March 2007 to October 2010, 37 patients with colorectal cancer manifesting acute complete mechanical obstruction were treated by ileus tube drainage. After irrigation and drainage ranging from 4 to 10 days, the radical operations and anastomosis were performed by laparoscopy. Results The drainage tubes were successfully implanted in 34 patients. The decompression time of patients was (5. 8 ±1.6) d, ranging from 4 to 10 d. The abdominal pain and bloating symptoms were faded away after (3. 8 ±1.3) d (1 to 7 d) drainage. And comparing to that of patients when admission, abdominal circumference significantly reduced from ( 92 ± 7 ) cm to (84 ±6)cm(P =0. 013) before surgery. Thirty-one cases were performed radical resection and anastomosis by laparoscopy after decompression. Postoperative recovery was smooth, and there was no serious complication. Conclusions Laparoscopic surgery followed decompression by transanal ileus tube is effective and safe for acute lower colorectal obstruction. Emergency surgery may be converted to limit surgery by this method. After appropriate bowel preparation, laparoscopic radical surgery and anastomosis is feasible.     

腹腔镜结肠直肠肿瘤切除术的临床作用

目的：探讨腹腔镜手术在结肠直肠肿瘤切除术中的应用和临床效果。方法：利用腹腔镜技术对109例结肠直肠肿瘤病人进行手术，并对手术操作、术后情况以及并发症等进行分析。结果：109例病人中转开腹手术11例，占10．1％。98例采用腹腔镜方法完成手术切除，其中结肠直肠腺瘤3例，结肠直肠癌95例。95例结肠直肠癌行姑息性切除5例，根治性切除90例；术式为Miles手术31例，右半结肠切除27例，乙状结肠切除18例，前切除16例，降结肠切除2例，横结肠切除1例。本组病人术中无其他脏器损伤、大出血、气体栓塞等发生，术后无因出现并发症而行再手术治疗者，无一例死亡。在进行根治性切除并达到术后半年以上的病人中，目前有局部复发1例，肝和肺转移各1例，术后复发转移率为5．7％。目前尚未发现有腹壁切口和穿刺孔转移。结论：腹腔镜结肠直肠肿瘤切除手术创伤小，安全、可行，具有广阔的推广应用前景。     

Multidimensional analysis of the learning curve for laparoscopic colorectal surgery: lessons from 1,000 cases of laparoscopic colorectal surgery

Purpose  We consider quality of surgery throughout the learning curve and attempt to determine the learning curve for competency in performing laparoscopic colorectal surgery. Methods  The study included 1,014 patients who underwent laparoscopic colorectal resection between June 1996 and December 2007. We categorized patients into nine periods according to number of cases performed. Results  Operative time continuously decreased for right hemicolectomy (216 versus 150 min) and anterior resection (214.8 versus 147.7 min), whereas for low anterior resection it did not change over many periods and then significantly decreased after the ninth period (221.3 versus 176.4 min). The proportion of patients who had undergone previous abdominal surgery increased after the second period. Anastomotic leakage rate was 6–9% for the first 200 cases, and then decreased to less than 2%. More than 10% of operations were converted to open surgery during the first period, after which this rate significantly decreased to 2%. Number of harvested lymph nodes stabilized to 35–40 for right hemicolectomy after 200 cases, whereas for anterior and low anterior resection it was consistently 15–20 after the initial 20 cases. Overall, disease recurrence rate was 16–25%. For rectal cancer, local recurrence rate was highest (12%) in the fourth period and decreased thereafter to about 3%. Conclusion  Postoperative complications and local recurrence rate increased even after accumulation of experience because of expansion of indications for laparoscopic procedures.     

单孔腹腔镜结直肠手术经验总结

自2008年Buther成功施行了首例单孔腹腔镜右半结肠切除术以后,国内外关于结直肠手术实践的报道相继涌现。本研究回顾性分析2009年12月至2013年7月我科72例行单孔腹腔镜结直肠手术患者的临床资料,探讨单孔腹腔镜技术在结直肠疾病治疗中的临床价值。     

腹腔镜与开腹结直肠癌根治术后并发症发生率的比较

目的探讨腹腔镜与开腹结直肠癌根治术后并发症发生率的差异。方法对2000年1月至2011年9月同一组医师连续实施的910例腹腔镜结直肠癌根治术（腹腔镜组）和434例开腹结直肠癌根治术（开腹手术组）患者术后并发症发生情况的差异进行对比分析。结果腹腔镜组中转开腹48例（5．3％,48／910）,其中36例（75．0％,36／48）系因肥胖或骨盆狭窄致手术操作及显露困难。腹腔镜组和开腹手术组术后并发症总发生率分别为20．3％（185／910）和25．3％（110／434）（X^2=4．316,P〈0．05）;造口亚组中吻合口瘘的发生率分别为2．1％（3／145）和2．2％（2／93）（X^2=0．002,P〉0．05）,吻合1：3出血的发生率分别为3．4％（5／145）和4．3％（4／93）（X^2=0．113,P〉0．05）,未造口亚组中吻合口瘘的发生率分别为3．1％（22／699）和1．0％（3／301）（X^2=3．993,P〈0．05）,吻合口出血的发生率分别为1．6％（11／699）和2．3％（7／301）（X^2=0．673,P〉0．05）;肠梗阻的发生率分别为3．4％（31／910）和5．8％（25／434）（X^2=4．077,P〈0．05）;乳糜漏的发生率分别为5．8％（53／910）和3．7％（16／434）（X^2=2．757,P〉0．05,）;尿潴留的发生率分别为1．5％（14／910）和1．6％（7／434）（X^2=0．011,P〉0．05）;切口感染的发生率分别为2．2％（20／910）和4．6％（20／434）（X^2=5．913,P〈0．05）;肺部感染的发生率分别为6．4％（58／910）和10．6％（46／434）（X^2=7．349,P〈0．05）。结论腹腔镜结直肠癌根治术后总并发症的发生率显著低于开腹结直肠癌根治术,特别是前者术后肠梗阻、切VI感染与肺部感染发生率显著低于后者。     

腹腔镜结直肠癌根治术手术技术的探讨

目的:探讨腹腔镜结直肠癌根治术的手术技术,包括手术的整体配合、手术路径等.方法:回顾分析为60例结直肠癌患者施行腹腔镜结直肠癌根治术的全过程.结果:60例均顺利完成腹腔镜手术,无一例中转开腹.其中直肠癌根治术35例,包括Miles术式5例,直肠癌晚期姑息性乙状结肠造瘘2例,直肠腺瘤局部肠管切除1例,结肠癌根治术20例,...     

Wound infection after elective laparoscopic surgery for colorectal carcinoma

Background The aim of this study was to evaluate various clinical parameters that would influence the occurrence of wound infection (WI) in elective laparoscopic surgery (LS) for colorectal carcinoma. Methods The study included 290 patients who underwent LS between June 2001 and December 2005. WI was diagnosed within 30 days of the operation, and both superficial and deep incision surgical site infection were evaluated together. Results Eighteen (6.2%) were diagnosed with WI. Of the infected patients, nine (50%) had WI at the extraction site, six (33%) at the port site of the drainage tube, and three (17%) at the supraumbilical incision. Following bivariate analysis, the variables of stoma creation, intraoperative hypotension, and length of operation were selected for multivariate analysis as their P values were <0.2, the predominant cutoff, and stoma creation and intraoperative hypotension were independently predictive of developing WI. Regarding the duration of postoperative hospital stay, there was no significant difference between patients with or without WI. Conclusions Stoma creation and intraoperative hypotension were independent risk factors for WI. The results obtained in this study should be considered in an effort to prevent WI in LS for colorectal carcinoma, although these risk factors need further evaluation.     

腹腔镜手术治疗结直肠肿瘤的临床应用价值

目的:探讨腹腔镜手术治疗结直肠肿瘤的应用价值。方法:回顾分析腹腔镜手术治疗99例结直肠肿瘤患者的临床资料。结果:97例成功完成腹腔镜手术,2例中转开腹。平均手术时间167min,术中平均出血100ml,术后平均2.6d恢复肠蠕动。随访5~29个月,无切口及穿刺孔种植转移。结论:腹腔镜结直肠肿瘤手术安全可行,符合肿瘤根治原则,近期疗效满意。     

Outcomes of laparoscopic surgery for colorectal cancer in elderly patients

Objective:

To evaluate the short-term outcomes of laparoscopic colorectal surgery for cancer in the elderly compared with younger patients.

Methods:

We retrospectively considered a consecutive unselected series of 159 patients who underwent elective laparoscopic procedures for colorectal cancer at our institution between January 2007 and December 2009. Of these patients, 101 (63.5%) were ≤70 years of age (Group A), and 58 (36.5%) were >70 (Group B). Operative steps and instrumentation were standardized. Demographics, disease-related, operative, and short-term data were analyzed for each group, and an appropriate statistical comparison was made. Comorbidity was quantified by using the Charlson Comorbidity Index.

Results:

We reviewed right colectomies (29.5%), left colectomies (44.7%), rectal resections (19.5%), and other procedures (6.3%). There was no significant difference in sex ratio, body mass index, American Society of Anesthesiology score, type of surgical procedures, and tumor stage between Group A and Group B. A statistically higher comorbidity according to the Charlson index characterized Group B (2.2 vs 3.8; P=.034). Median operative time (228±78.1min vs 224.3±97.6min; NS), estimated blood loss (50.0±94.8mL vs 31.2±72.7mL; NS), conversion rate (2.0% vs 1.7%; NS), and timing to canalization (4.5±1.7dd vs 4.4±1.3dd; NS) were statistically comparable in both Groups. Group B was associated with a significantly longer length of hospital stay compared with Group A (8.1±2.8dd vs 10.8±6.6dd; P<.01) There was no statistically significant difference in major postoperative complications (3.8% vs 3.4%; NS), reoperations (0.9% vs 1.7%; NS), and 30-day mortality (0% vs 1.7%; NS).

Conclusions:

Laparoscopic colorectal surgery appears feasible and safe in elderly patients with increased comorbidity.     

降钙素原在早期诊断腹腔镜结直肠癌吻合口漏的价值

目的探讨腹腔镜结直肠癌手术患者术前及术后不同时间点血清降钙素原(PCT)水平对于评估术后吻合口漏的临床价值。方法以2014年6月至2015年10月118例行腹腔镜结直肠癌切除术患者作为研究对象,分为吻合口漏组(14例)和未出现吻合口漏对照组(104例),分别在术前、术后第1~5天检测血清PCT水平,使用SPSS 18.0进行统计学分析,组间比较采用t检验,数据以均数±标准差来表示;运用敏感性和特异性评价PCT在早期诊断腹腔镜结直肠癌术后吻合口漏方面的价值,P0.05差异有统计学意义。结果吻合口漏组患者PCT水平在术后第1天开始上升,在术后第2天PCT显著高于对照组,差异有统计学意义(P0.05),并且持续维持在较高水平直到明确诊断出术后吻合口漏。术后第5天PCT水平在预测术后吻合口漏的敏感性及特异性最具有优势;此时处于临界水平的PCT对于吻合口漏的阴性预测值为99%,提示当患者在术后第5天PCT水平低于1.22 ng/ml时,几乎不会发生吻合口漏,能够作为早期出院的客观依据。结论结果提示,通过检测患者术后血PCT水平,能为加速康复外科理念下患者的早期出院提供客观依据。当患者术后第3天PCT值小于1.94ng/ml和/或者术后第5天小于1.22 ng/ml时,可以相对安全的认为患者不会出现吻合口漏,能够早期出院。     

完全腹腔镜结直肠切除术20例报告

目的:探讨完全腹腔镜结直肠切除术的手术方法、适应证及其安全性和应用价值。方法:回顾分析2007年4月至2008年11月我院为20例患者行完全腹腔镜结直肠切除术的临床资料。结果:行完全腹腔镜全结肠部分直肠切除术2例,次全结肠切除术1例,乙状结肠癌根治性切除术6例,乙状结肠癌姑息性切除术1例,直肠癌根治性切除术10例。术中平均出血116.5ml,平均手术时间183.5min,术后平均住院8d,无严重并发症发生。随访1～19个月无复发。结论:完全腹腔镜结直肠切除术切口小,应用于全结肠部分直肠切除、乙状结肠癌、直肠癌根治术,近期疗效良好,远期疗效有待研究。     

腹腔镜治疗结直肠癌35例体会

目的探讨腹腔镜结直肠癌根治术的适应症、禁忌症和手术技巧的临床应用。方法回顾性分析我科从2005年2月到2009年12月35例在腹腔镜下行结直肠癌根治术的临床资料。所有手术均与开腹手术相同的标准进行的。结果 33例病人顺利完成腹腔镜手术。中转开腹2例。平均手术时间185分钟,术中平均出血量80ml,平均住院时间为11天。全组病人住院期间无死亡。术后随访时间10-60个月(平均36个月),最长者5年。1例直肠癌患者发生盆腔局部复发,但均无远处转移和Trocar处、切口处肿瘤种植发生。结论腹腔镜结直肠癌根治术相比传统开放手术有创伤小,恢复快的特点,肿瘤根治的彻底性、肿瘤局部复发率和远处转移率与传统开放手术相同。     

腹腔镜结直肠癌根治术学习曲线

目的探讨外科医师如何尽快掌握腹腔镜结直肠癌根治术。方法分析2000年9月至2003年5月由同一组医师完成的50例腹腔镜结直肠癌根治术,按手术先后次序分5组,每组10例,比较各组手术时间、术中出血量、术后肛门排气时间、术后住院天数和各组病灶的位置和术后并发症发生率、腹腔镜手术占同期同类手术比例和3站淋巴结清扫数目及其总数的差异。结果A组手术时间由(314.5±34.4)min至E组降为(186.0±27.6)min(P=0.000),术中出血量由(94.0±25.5)ml降至(15.5±18.3)ml(P=0.000)。肛门排气时间、住院天数、病灶的位置、术后并发症发生率、3站淋巴结清扫数及总数各组比较,差异均无显著性意义(P>0.05)。但E组无术中并发症及中转开腹。腹腔镜手术占同期同类手术总数由A组的15.2%(10/66)至E组上升为47.6%(10/21)(P=0.004);全组吻合口瘘发生率为2.0%(1/50),局部复发率为4.0%(2/50)。结论腹腔镜结直肠癌根治术学习曲线大约为40例,即可达到较熟练程度。     

腹腔镜结直肠肿瘤切除术的难点及对策(附83例报告)

目的:探讨腹腔镜结直肠肿瘤切除的常见难点及对策。方法:回顾分析2005年2月至2007年6月83例腹腔镜结直肠肿瘤切除术患者的临床资料。结果:74例手术成功,9例中转开腹。手术并发症是皮下气肿5例(6.0%)、不完全性肠梗阻5例(6.0%)、术后大出血1例(1.2%)、肠管损伤3例(3.6%)、吻合口漏1例(1.2%)等。结论:腹腔镜结直肠肿瘤切除术的常见难点为血管的识别及处理、脏器损伤特别是输尿管及肠管损伤的预防及手术操作面的显露等。正确的解剖入路、开腹手术经验丰富及良好的腹腔镜培训可减少手术并发症的发生。     

两孔腹腔镜结直肠癌根治性切除术近期疗效分析

目的单孔腹腔镜手术虽然取得了不错的临床效果,但其存在手术操作难度大、器械冲突、缺乏对抗牵引及直线视角等问题让很多外科医师望而却步。因此,有术者提出了单切口加一孔(SILS+1)的手术方法。本研究探讨运用SILS+1进行结直肠癌根治性切除术的安全性与可行性。方法采用描述性病例系列研究的方法,回顾性收集从2018年3月至2019年1月在南方医科大学南方医院普通外科进行SILS+1治疗的178例结直肠癌患者的临床资料,分析患者手术情况、术后病理以及术后恢复情况(术后并发症分级采用Clavien-Dindo标准,疼痛指标为视觉模拟评分法);通过门诊或电话进行随访,随访时间截至2019年5月。结果共有178例患者接受了SILS+1结直肠癌根治性切除术,其中男性患者111例(62.4%);平均年龄59岁。其中有11例(6.2%)患者中转加1~3个操作孔,1例(0.6%)患者因回结肠动脉出血中转开腹。全组患者手术时间为(135.2±42.3)min,术中失血量为(34.6±35.5)ml,淋巴结检出数目为(33.1±17.6)枚,远切缘(10.2±5.3)cm,近切缘(14.7±17.8)cm。术后30 d内16例(9.0%)出现手术相关并发症,其中6例为Clavien-DindoⅢ级并发症(3.4%);术后疼痛评分均低于3分。术后住院时间为(5.6±2.6)d。3例患者(1.7%)术后30 d内因肠梗阻和造口周围感染返院治疗。全组患者美容评分均为满意和基本满意。结论SILS+1治疗结直肠癌具有较好的手术安全性和可行性,可减轻患者术后疼痛。