Full laparoscopic total pancreatectomy with and without spleen and pylorus preservation: a feasibility report

Background/purpose

Laparoscopic pancreatic surgery is gaining acceptance and clear advantages have been demonstrated in distal resection. Total pancreaticoduodenectomy (TPD) combines the operative steps of distal pancreatectomy and pancreaticoduodenectomy, but facilitates reconstruction and lowers the risk of common complications by avoiding the need for a pancreatic anastomosis. The aim of this report is to analyse the feasibility of laparoscopic total pancreaticoduodenectomy, with and without spleen and pylorus preservation.

Methods

Two patients underwent laparoscopic TPD for pancreatic intraductal mucinous neoplasm and endocrine tumors. Total splenopancreaticoduodenectomy (TSP) and pylorus- and spleen-preserving total pancreaticoduodenectomy (PSPTP) were performed.

Results

The two procedures were successfully completed laparoscopically. PSPTP was more time-consuming (420 vs. 360 min) and had an increased risk of hemorrhage (600 vs. 200 ml) compared with TSP. After both procedures, the postoperative outcome was uneventful and the postoperative length of hospital stay was 8 days.

Conclusions

This report confirms the feasibility of full laparoscopic TPD, and presents the first full laparoscopic pylorus- and spleen-preservation technique with conservation of the splenic vessels, without robotic assistance. No conclusions can be drawn from this report, but it shows that the laparoscopic approach provides visual magnification, improved exposure, and delicate manipulation of tissues, which may reproduce the clear advantages of laparoscopic distal pancreatectomy.     

Laparoscopic extralevator abdominoperineal excision of the rectum: short-term outcomes of a prospective case series

Background

Laparoscopic approaches for the resection of low rectal cancer and the extralevator technique for abdominoperineal excision are both becoming increasingly popular. There are little published data regarding the combined application of these techniques to the resection of low rectal tumours. The aim of this study was to assess the feasibility of such an approach and to appraise short-term outcomes in a consecutive series of patients undergoing laparoscopic extralevator abdominoperineal excision (ELAPE).

Methods

Consecutive patients undergoing laparoscopic ELAPE at our institution between 2008 and 2011 were identified from a prospectively maintained database. The abdominal phase of the operation was performed laparoscopically, and following extralevator resection, the perineum was reconstructed using a biologic mesh. All patients were enrolled in an enhanced recovery programme.

Results

Of 166 patients undergoing radical resection of rectal cancer at our institution between 2008 and 2011, 28 underwent laparoscopic ELAPE. Median age was 70 years, median body mass index was 27.5 kg/m², and 71 % were male. The conversion rate to laparotomy was 18 %. Three patients (10.8 %) had circumferential resection margins <1 mm; no intraoperative tumour perforation occurred. The median length of stay was 7 days, with a 30-day readmission rate of 21 % and no 30-day mortality. Post-operative perineal wound complications occurred in 25 %. At median 38-month follow-up (range 23–66 months), overall survival was 75 %, disease-free survival was 71 %, and there were three local recurrences (11 %).

Conclusions

Laparoscopic extralevator abdominoperineal excision can be safely performed without compromising short-term outcomes.     

There is no difference in outcome between laparoscopic and open surgery for rectal cancer: a systematic review and meta-analysis on short- and long-term oncologic outcomes

Background

Until recently there has been little data available about long-term outcomes of laparoscopic rectal cancer surgery. But new randomized controlled trials regarding laparoscopic colorectal surgery have been published. The aim of this study was to compare the short- and long-term oncologic outcomes of laparoscopy and open surgery for rectal cancer through a systematic review of the literature and a meta-analysis of relevant RCTs.

Methods

A systematic review of Medline, Embase and the Cochrane library from January 1966 to October 2016 with a subsequent meta-analysis was performed. Only randomized controlled trials with data on circumferential resection margins were included. The primary outcome was the status of circumferential resection margins. Secondary outcomes included lymph node yield, distal resection margins, disease-free and overall survival rates for 3 and 5 years and local recurrence rates.

Results

Eleven studies were evaluated, involving a total of 2018 patients in the laparoscopic group and 1526 patients in the open group. The presence of involved circumferential margins was reported in all studies. There were no statistically significant differences in the number of positive circumferential margins between the laparoscopic group and open group, RR 1.16, 95% CI 0.89–1.50 and no significant differences in involvement of distal margins (RR 1.13 95% CI 0.35–3.66), completeness of mesorectal excision (RR 1.22, 95% CI 0.82–1.82) or number of harvested lymph nodes (mean difference = ?0.01, 95% CI ?0.89 to 0.87). Disease-free survival rates at 3 and 5 years were not different (p = 0.26 and p = 0.71 respectively), and neither were overall survival rates (p = 0.19 and p = 0.64 respectively), nor local recurrence rates (RR 0.88, 95% CI 0.63–1.23).

Conclusions

Laparoscopic surgery for rectal cancer is associated with similar short-term and long-term oncologic outcomes compared to open surgery. The oncologic quality of extracted specimens seems comparable regardless of the approach used.

     

Laparoscopic left lateral sectionectomy as a training procedure for surgeons learning laparoscopic hepatectomy

Background

Laparoscopic liver resection remains limited to a relatively small number of institutions because of insufficient hepatic and laparoscopic surgical experience and few training opportunities. The aim of this study was to assess the feasibility and safety of an improved laparoscopic left lateral sectionectomy technique as a training procedure for new surgeons.

Methods

Twenty-four laparoscopic left lateral sectionectomies (LLLSs) were retrospectively reviewed. Patients were divided into 3 groups with 8 patients in each: those undergoing surgery by expert surgeons prior to 2008 (Group A); those undergoing surgery by expert surgeons after 2008, when a standardized LLLS technique was adopted (Group B); and those undergoing LLLS by junior surgeons being trained (Group C).

Results

The median operative time was significantly shorter for Group B (103 min; range, 99–109 min) and C (107 min; range, 85–135 min) patients than for Group A (153 min; range, 95–210 min) patients. There were no significant differences in blood loss or hospital stay. In Groups B and C, no conversions to open laparotomy or complications occurred.

Conclusion

The standardized LLLS procedure was both safe and feasible as a technique for training surgeons in laparoscopic hepatectomy.     

Laparoscopic ventral rectopexy: a prospective long-term evaluation of functional results and quality of life

Background

Laparoscopic ventral rectopexy for rectal prolapse combines the advantages of a minimally invasive approach with the low recurrence rate observed after abdominal procedures. To date, only a few long-term functional studies and no quality of life assessment are available. The aim of this study was to assess long-term functional outcomes and quality of life after laparoscopic ventral rectopexy.

Methods

Between January 2007 and December 2008, patients who underwent laparoscopic ventral rectopexy for full-thickness external rectal prolapse and/or rectocele were prospectively included. Fecal incontinence and constipation were scored (Wexner score and Rome II criteria). Quality of life was assessed using the gastrointestinal quality of life form (GIQLI).

Results

Thirty-three patients were included and 30 (91 %) completed all the questionnaires. There was no morbidity or mortality. The mean length of hospital stay was 5 ± 1 days (range 3–7 days). After a mean follow-up of 42 ± 7 months (range 32–52 months), recurrence of rectocele was observed in two patients (6 %). At the end of follow-up, constipation was improved in 13/18 patients (72 %) and two patients (7 %) presented de novo constipation. The patients’ Wexner score improved between preoperative status and end of follow-up (12 ± 7 vs. 4 ± 3, p = 0.002). Compared to the preoperative score, quality of life significantly improved over time: 77 ± 21 preoperatively versus 107 ± 17 at 1 year versus 109 ± 18 at the end of follow-up (p < 0.001).

Conclusions

This prospective study showed that laparoscopic ventral rectopexy was associated with excellent postoperative outcomes and a low long-term recurrence rate. Long-term functional results were excellent in terms of continence, with significant improvement of quality of life and without worsening constipation.     

Treatment results of laparoscopic surgery in Japanese patients with upside-down stomach

Introduction

Upside-down stomach, an atypical form of esophageal hiatal hernia, is a rare pathology. Due to its anomalous anatomical characteristics, the level of difficulty of laparoscopic surgery is considered to be high. However, as the number of patients is very small in Japan, surgical results have not been fully investigated. We examined the results of surgical treatment for Japanese patients with upside-down stomach.

Materials and methods

The subjects were 11 patients given a diagnosis of upside-down stomach based on upper gastrointestinal tract radiographic imaging and who had undergone laparoscopic surgery at least 6 months prior to this study. Surgical results, postoperative recurrence, and postoperative oral intake of gastric acid-suppressive medications were examined.

Results

The subjects consisted of one man and ten women (91 %). The mean age was 73.0 ± 9.2 years and the mean disease period was 38.7 months. The operation time was 175.5 ± 49.1 min (range 110–280) and the intraoperative blood loss was 122.7 ± 214.9 mL (range 0–550). None of the patients had required conversion to laparotomy. The mean postoperative hospital stay was 8.9 ± 3.4 days (range 7–18) and two patients had persistent dysphagia after surgery, which improved with endoscopic dilatation. While two patients (18 %) had a postoperative recurrence of hiatal hernia, none required reoperation. Two patients (18 %) needed oral gastric acid-suppressive medications postoperatively.

Conclusions

Laparoscopic surgery could be performed in all patients with upside-down stomach. Because of the significant recurrence rate of postoperative esophageal hiatal hernia, the use of a mesh may be required.     

Transanal minimal invasive surgery with the EndorecTM trocar: a low cost but effective technique

Purpose

Transanal endoscopic microsurgery (TEM) is a well-established surgical approach for local excision of benign adenomas and early-stage rectal cancer. This technique is expensive and associated with a long learning curve. To avoid these obstacles, we have developed an alternative approach using the Endorec^TM trocar (Aspide, France), which combines the advantages of local transanal excision and single-port access. The aim of this study was to evaluate the feasibility of this technique.

Patients and methods

Fourteen consecutive patients underwent transanal resection using Endorec trocar and standard laparoscopic instruments. A retrospective evaluation of the outcome of this technique was performed.

Results

Fourteen patients were successfully operated. Rectal lesions included adenoma in ten patients, T1 adenocarcinoma in three and one T2 adenocarcinoma not amenable for abdominal surgery. The average distal margin from the anal verge was 10 cm (range 5–17 cm), and the mean diameter was 3.5 cm (range 1–5 cm). Negative margins were obtained in 13 patients (92,8 %). Median operating time was 60 min (range 20–100). The excisional area was sutured in nine patients. Median postoperative stay was 4 days (range 1–13). Postoperative complications (21 %) included postoperative fever in one patient and two patients were readmitted with rectal blood loss 6 and 15 days postoperatively and were treated with conservative measures.

Conclusions

Our current data show that transanal surgery using Endorec trocar is feasible and safe. Although long-term outcomes and definite indications should be yet evaluated, we believe that this new technique offers a promising alternative to TEM.     

Robotic right colectomy for cancer with intracorporeal anastomosis: short-term outcomes from a single institution

Purpose

Laparoscopic surgery for colon cancer has widely accepted as safe and effective. However, few studies report outcomes on robotic right colon resection with confectioning of the intracorporeal ileocolic anastomosis. This study aims to evaluate the feasibility and safety of robotic right colon resection with intracorporeal ileocolic anastomosis (RRCIA) in patients with cancer.

Methods

Data of consecutive series of 20 patients undergoing RRCIA between June 2011 and May 2012 at our institution were prospectively collected in order to evaluate surgical and oncological short-term outcomes.

Results

Seven males and 13 females were operated of RRCIA during the study period. Mean age is 66.7 years. The mean overall operative time was 327.5 min (255–485), and the robot time was 286 min (range 225–440 min). No conversion to open or laparoscopy occurred. The mean specimen length was 32.7 cm (range 26–44 cm), and the mean number of harvested lymph nodes was 17.6 (range 14–21). During the 30 postoperative days, only one complication occurred, consisting in an infection of surgical specimen extraction wound.

Conclusion

The RRCIA is a feasible and safe for patients with right colon cancer, also in terms of intraoperative oncological outcomes.     

Die laparoskopische Versorgung iatrogener Kolonperforation

Background

Iatrogenic colon perforation is a rare but life-threatening complication of colonoscopy. Although conservative therapy is possible in selected cases, if it fails it often leads to the necessity of more extensive operations with increased morbidity in contrast to immediate and definitive surgery. Laparoscopic colorectal surgery offers the possibility of minimizing the invasiveness and associated complications.

Patients and methods

The data of all patients who underwent laparoscopic surgery for iatrogenic colon perforation within a 10-year time period (1997–2009) were recorded prospectively and analyzed retrospectively with regard to age, sex, localization of the perforation, diagnoses and clinical symptoms, type of procedure, intra- and postoperative complications as well as postoperative course.

Results

In the observation period 24 patients with iatrogenic colon perforation were treated laparoscopically. In 17 cases the perforation was associated with therapeutic colonoscopy and in 7 cases with diagnostic colonoscopy. In 19 patients the affected part of the colon was resected and in 5 patients a simple closure by suture was performed. Four cases required conversion. The median operating time was 165 min (range: 90–420 min) and the median hospital stay 11 days (range: 7–25 days). There were no surgical complications in the postoperative course. One patient (91 years) developed cardiac decompensation leading to death.

Conclusion

Laparoscopic treatment of iatrogenic colon perforations offers a minimally invasive and definitive solution to this life-threatening complication. In the hands of an experienced surgeon a laparoscopic approach is a safe and efficient enrichment to the therapeutic options in iatrogenic colon perforation.     

Laparoscopic ventral rectopexy in an elderly population with external rectal prolapse: clinical and anal manometric results

Aim

We report the clinical and anal manometric results of elderly patients treated with laparoscopic ventral rectopexy (LVR) for full-thickness rectal prolapse.

Method

From March 2009 to June 2012, patients were consecutively included. A modified laparoscopic Orr-Loygue procedure with posterior mobilisation was used. The patients were evaluated preoperatively, 2 months postoperatively and after 1 year. We registered Wexner incontinence scores and laxative uses by a questionnaire and performed simple anal manometry.

Results

A total of 46 patients underwent operation, all women. The median age was 83 years (range 34–99), median prolapse size was 8 cm (range 2–15), and 30 % had previous prolapse surgery. The median operative time was 135 min (range 90–215), and the median length of stay was 2 days (range 1–14). The 30-day morbidity rate was 15 %, and there were two (4 %) deaths within 30 days. There was a significant reduction in incontinence scores after 2 months and 1 year. The anal resting pressures improved from 10 cm H₂O slightly to 16 cm H₂O after 2 months, significantly, and still significant after 1 year at 13 cm H₂O. There were no changes in the use of laxatives. The median follow-up time was 1.5 years (range 0.5–3), and there were two prolapse recurrences (4 %) in this period.

Conclusions

Laparoscopic ventral rectopexy with posterior mobilisation seems to be effective and relatively well tolerated, although not without mortality in elderly debilitated patients. It improves incontinence. With increased life-year expectance, these patients may benefit from a lower risk of recurrence compared with perineal procedures.     

Laparoscopic major liver resection in Korea: a multicenter study

Introduction

We report our experience with laparoscopic major liver resection in Korea based on a multicenter retrospective study.

Materials and methods

Data from 1,009 laparoscopic liver resections conducted from 2001 to 2011 were retrospectively collected. Twelve tertiary medical centers with specialized hepatic surgeons participated in this study.

Results

Among 1,009 laparoscopic liver resections, major liver resections were performed in 265 patients as treatment for hepatocellular carcinoma, metastatic tumor, intrahepatic duct stone, and other conditions. The most frequently performed procedure was left hemihepatectomy (165 patients), followed by right hemihepatectomy (53 patients). Pure laparoscopic procedure was performed in 190 patients including 19 robotic liver resections. Hand-assisted laparoscopic liver resection was performed in three patients and laparoscopy-assisted liver resection in 55 patients. Open conversion was performed in 17 patients (6.4 %). Mean operative time and estimated blood loss in laparoscopic major liver resection was 399.3 ± 169.8 min and 836.0 ± 1223.7 ml, respectively. Intraoperative transfusion was required in 65 patients (24.5 %). Mean postoperative length of stay was 12.3 ± 7.9 days. Postoperative complications were detected in 53 patients (20.0 %), and in-hospital mortality occurred in two patients (0.75 %). Mean number and mean maximal size of resected tumors was 1.22 ± 1.54 and 40.0 ± 27.8 mm, respectively. R0 resection was achieved in 120 patients with hepatic tumor, but R1 resection was performed in eight patients. Mean distance of safe resection margin was 14.6 ± 15.8 mm.

Conclusions

Laparoscopic major liver resection has become a reliable option for treatment of liver disease in Korea.     

Laparoscopic surgery should be considered in T4 colon cancer

Introduction

Laparoscopy in T4 colon cancers is not widely advocated due to concerns regarding safety and oncologic efficacy. We conducted this study to compare the short- and long-term oncological outcomes between laparoscopic and open approaches in T4 colon cancers.

Methods

A retrospective analysis of all patients who underwent surgery for T4 colon cancer from 2008 to 2014 was performed. Margin positive rate, lymph node yield, local or distant recurrence and overall survival were analysed.

Results

A total of 59 patients received open surgery, whilst 93 underwent laparoscopic surgery, with a conversion rate of 8.6%.There was no difference in the various measured outcomes between the laparoscopic and open groups. The relative risks of positive margins and inadequate lymph node yield for staging were 0.95 (0.74–1.23, p = 0.692) and 1.01 (0.97–1.05, p = 0.710), respectively, for the laparoscopic group when compared to the open approach.Regarding long-term outcomes, the relative risk of local recurrence in the laparoscopic group was 0.99 (0.96–1.02, p = 0.477), whilst there were also no increased risks of developing distal recurrences at the liver (RR 1.19, 0.51–2.82, p = 0.684), lungs (RR 1.20, 0.50–2.87, p = 0.678) and peritoneum (RR 1.22, 0.51–2.95, p = 0.653) in the laparoscopic group.There was also no difference in the overall survival (RR 0.70, 0.42–1.16, p = 0.168). Patients were followed up for a median of 73.3 months (range 34.8–144.7).

Conclusion

Laparoscopic surgery does not compromise oncological outcomes in T4 colon cancers compared to the open approach. Because of its proven associated benefits, laparoscopy should be considered in selected T4 colon cancers.

     

Postchemoradiation laparoscopic resection and intraoperative electron-beam radiation boost in locally advanced rectal cancer: long-term outcomes

Background

In selected patients with rectal cancer, laparoscopic surgery is as safe as open surgery, with similar resection margins and completeness of resection. In addition, recovery is faster after laparoscopic surgery. We analyzed long-term outcomes in a group of patients with locally advanced rectal cancer (LARC) treated with preoperative therapy followed by laparoscopic surgery and intraoperative electron-beam radiotherapy (IOERT).

Methods and materials

From June 2005 to December 2010, 125 LARC patients were treated with 2 induction courses of FOLFOX-4 (oxaliplatin 85 mg/m²/d1, intravenous leucovorin at 200 mg/m²/d1–2, and an intravenous bolus of 5-fluorouracil 400 mg/m²/d1–2) and preoperative chemoradiation (4,500–5,040 cGy) followed by total mesorectal excision (laparoscopic, 35 %; open surgery, 65 %) and a presacral boost with IOERT.

Results

Patients in the laparoscopic surgery group lost less blood (median 200 vs 350 mL, p < 0.01) and had a shorter hospital stay (7 vs 11 days; p = 0.02) than those in the open surgery group. Laparoscopic procedures were shorter than open surgery procedures (270 vs 302 min; p = 0.67). Postoperative morbidity (32 vs 44 %; p = 0.65), RTOG grade ≥3 acute toxicity (25 vs 25 %; p = 0.97), and RTOG grade ≥3 chronic toxicity (7 vs 9 %; p = 0.48) were similar in the laparoscopy and open surgery groups. The median follow-up time for the entire cohort of patients was 59.5 months (range 7.8–90); no significant differences were observed between the groups in locoregional control (HR 0.91, p = 0.89), disease-free survival (HR 0.80, p = 0.65), and overall survival (HR 0.67, p = 0.52).

Conclusions

Postchemoradiation laparoscopically assisted IOERT is feasible, with an acceptable risk of postoperative complications, shorter hospital stay, and similar long-term outcomes when compared to the open surgery approach.     

Impact of rectopexy on sexual function: a cohort analysis

Purpose

Laparoscopic ventral rectopexy (LVR) is an established surgical technique for the treatment of both rectal prolapse and symptomatic rectoceles. It is, however, not known whether LVR influences sexual function (SF). The aim of this study was, therefore, to determine the impact of this procedure on the SF of patients.

Methods

All female patients after LVR procedure in a single institution were identified and were sent a questionnaire concerning SF. This addressed sexual activity, satisfaction, preoperative SF, and the impact of surgery on SF. Furthermore, the PISQ-12 validated sexual functioning questionnaire was sent to all female patients.

Results

A total of 217 patients were sent a questionnaire. These patients underwent LVR for rectal prolapse, symptomatic rectocele, or enterocele between 2004 and 2011. Mean age was 62 years (range 22–89). Mean follow-up was 30 months (range 5–83). Response rate was 64 % (139 patients). The number of sexual active patients dropped from 71 to 54 % after surgery. The number of patients being satisfied with their SF remained relatively equal; 91 % of patients before and 85 % of patients after surgery. Forty-three percent of patients stated that the LVR procedure did not influence their sexual function, in 16 % of patients, the procedure positively influenced their SF, and in 13 % of respondents, SF decreased after surgery. The mean PISQ-12 score postoperatively was 34 out of 48.

Conclusions

The impact of LVR on SF of patients seems limited in this cross-sectional study in a large cohort of patients.     

Clinical outcomes of robot-assisted intersphincteric resection for low rectal cancer: comparison with conventional laparoscopy and multifactorial analysis of the learning curve for robotic surgery

Background

This study evaluated the feasibility of robot-assisted intersphincteric resection (ISR) for low rectal cancer. Further, we attempted to analyze the learning curve for robotic surgery.

Methods

A total of 64 patients were retrospectively chart-reviewed. Patients were classified into a laparoscopic procedure (n?=?28) group and a robot-assisted (n?=?36) group. Comparisons of age, gender, clinical staging, operating time, complications, and pathologic status were analyzed. Besides, we used a seventh-order moving average method for the construction of a learning curve in robotic surgery.

Results

Operating time was 374.3 min (range, 210–570 min) in the laparoscopic group and 485.8 min (range, 315–720 min) in the robotic group, with statistical difference between these two groups (P?<?0.001). Thirteen patients (46.4 %) received diverting stoma in the laparoscopic group and seven patients (19.4 %) in the robotic group, with statistical difference between these two groups (P?=?0.021). Operative experience of robotic ISR showed that the mean operating time was 519.5 min (range, 360–720 min) in the first stage and 448.2 min (range, 315–585 min) in the second stage, with statistical difference between these two stages (P?=?0.02). Multifactorial analysis showed that protective diverting stoma creation or neorectum necrosis was not associated with age, sex, pretreatment T stage, or surgeons’ experience.

Conclusions

Our data shows that robot-assisted ISR for low rectal cancer is feasible and safe with no compromising oncological outcomes. The surgeons’ experience improves operating time in robotic surgery.     

Robotic-assisted and laparoscopic ventral rectopexy in the treatment of rectal prolapse: a matched-pairs study of operative details and complications

Background

Laparoscopic ventral rectopexy has been proven to be safe and effective in the treatment of rectal prolapse or intussusception. Robotic-assisted surgery may offer potential benefits to this operation. This study describes the comparison of robotic-assisted and conventional laparoscopic ventral rectopexy in terms of clinical parameters, operative details, postoperative complications and short-term outcomes.

Methods

Twenty patients operated on for rectal prolapse or intussusception using the Da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale CA, USA) were prospectively followed for 3 months. The cases were pair-matched with laparoscopically operated controls from registry files.

Results

Mean operating time was 159 min (standard deviation; ±37 SD) and 153 min (±33 SD) and mean total time in the operating theatre 231 min (±39 SD) and 234 min (±41 SD) for robotic-assisted and laparoscopic operations, respectively. Mean blood loss was 25 ml (±49 SD) in robotic-assisted and 37 ml (±50 SD) in laparoscopic procedures. There was one (5 %) significant complication in each group. Mean length of hospital stay was 3.1 (±2 SD) and 3.3 (±1.3 SD) days for the robotic-assisted and laparoscopic groups, respectively. The subjective benefit rate was the same in both groups: 16/20 (80 %). One patient in the robotic-assisted group continued to have symptoms of obstructed defecation, and there was one recurrence of prolapse in the laparoscopic group.

Conclusions

Robotic-assisted laparoscopic ventral rectopexy is safe, feasible and not more time consuming than the laparoscopic technique even at the beginning of the learning curve. The short-term results are comparable with those of laparoscopy. We found no arguments to support the routine use of robotic assistance in rectopexy operations.     

Laparoscopic direct suture of perforation after diagnostic colonoscopy

Background

Increasing colonoscopy use increases the incidence of iatrogenic colon perforation. Operative management of iatrogenic colonoscopic perforation is diverse. This study retrospectively reviewed our experiences in treating diagnostic colonoscopy-associated bowel perforation by laparoscopic direct suturing.

Methods

A total of 89,014 patients underwent diagnostic colonoscopy at our institution during the past 6 years. We identified 17 iatrogenic perforations (0.019 %) that were all managed by laparoscopic direct suturing.

Results

Perforation patients included 11 men and 6 women (mean age 60?±?18 years). Sixteen patients (94 %) had severe comorbidities or previous abdominal surgery. Perforations were noticed by the endoscopist during the procedure in 13 cases (76 %) while the remaining 4 cases (24 %) were diagnosed within 24 h after colonoscopy. The estimated mean longitudinal perforation length was 4.4?±?2.1 cm. Mean operation time was 2.3?±?0.6 h, without significant blood loss or other severe complication. The mean time to bowel function return was 3.4?±?1.2 days, the mean time to initial oral intake was 3.9?±?2.0 days and the mean hospitalization duration was 6.8?±?4.2 days.

Conclusions

Diagnostic colonoscopic perforation occurred in less than 2/10,000 patients when colonoscopy was performed by experienced operators in our endoscopy center. Most of the perforation patients had severe comorbidities, to which the surgeon should pay close attention during colonoscopy. Laparoscopic primary suture of colon perforations caused by diagnostic colonoscopy is a safe and feasible repair method. Further efforts will definitively assess the feasibility of routinely using laparoscopic direct suture to repair colon perforations.     

Short-term follow-up after laparoscopic versus conventional total mesorectal excision for low rectal cancer in a large teaching hospital

Purpose

Laparoscopic resection for low rectal cancer remains controversial, and large randomized studies on oncologic outcome are lacking. The objective of this study was to analyze the short-term results of laparoscopic resection versus conventional total mesorectal excision (TME) for low rectal cancer (≤10 cm from the anal verge).

Methods

The institutional colorectal surgery database was reviewed, and 166 consecutive patients operated for low rectal cancer between 2006 and 2011 were included in this analysis which focuses on the first 18 months of follow-up.

Results

Eighty patients underwent conventional TME, whereas 86 patients underwent laparoscopic TME. Patient characteristics were comparable between groups. Conversion rate was 17 %. Laparoscopic rectal resection resulted in significantly less blood loss (200 versus 475 ml, p?=?<0.001) and a 3-day shorter hospital stay (median, 7 versus 10 days; p?=?0.06). Oncologic results from resected specimens were comparable, although significantly more lymph nodes were harvested in laparoscopic resections (median, 13 versus 11; p?=?0.005). Disease-free survival after curative resection was better in the laparoscopic group (p?=?0.04), but this was no longer significant after correction for potential confounders.

Conclusions

This analysis of short-term results of laparoscopic versus conventional TME for low rectal cancer demonstrates that laparoscopic surgery is feasible and safe, resulting in similar oncologic outcomes with less blood loss, a trend towards less postoperative complications and shorter duration of hospital stay. Further randomized studies are needed to attribute to the body of evidence of equivalence or even superiority of laparoscopic resections compared to conventional resections for distal rectal cancer.     

Totally laparoscopic hepatectomy exposing the major vessels

Background

Even during laparoscopic hepatectomy, a technique is often required to expose the major vessels, for example, in anatomical hepatectomy. We have standardized and performed such laparoscopic hepatectomy as successfully as open hepatectomy.

Methods

We divide the liver parenchyma without pre-coagulation, exposing the major vessels using CUSA. To control the bleeding, we keep the central venous pressure low and often perform Pringle’s maneuver. Over 49 months, we performed totally laparoscopic hepatectomies in 41 patients with the technique of exposing the major vessels. These included major hepatectomy in 7, sectorectomy in 17, segmentectomy in 14, and others in 3.

Results

The median operative time was 361 (range 176–605) minutes, with median blood loss of 216 (range 0–1600) g. The conversion rate was 4.9 %. Postoperative morbidity rate was 9.8 % (prolonged ascites in 1, port site infection in 1, peroneal palsy in 2). Mortality was zero. The median length of hospital stay after surgery was 8 (range 5–28) days. No local recurrence was found at the time of writing.

Conclusions

By using our standardized procedure exposing the major vessels, we could raise the quality of laparoscopic hepatectomy toward the level of open hepatectomy significantly.     

Safety and factors contributing to the difficulty of laparoscopic surgery for rectal cancer treated with preoperative chemoradiotherapy

Background

The safety of laparoscopic surgery for rectal cancer following chemoradiotherapy (CRT) has not been fully established. The aim of our retrospective study was to examine the outcomes and the factors contributing to the difficulty of laparoscopic surgery after CRT.

Methods

Eighty-seven consecutive rectal cancer patients treated with CRT were analyzed. Clinicopathological factors were compared between laparoscopic surgery (n = 57) and open surgery (n = 30) groups, and factors that correlated with operation time and blood loss were analyzed in low anterior resection (LAR) cases in the laparoscopic surgery group (n = 46).

Results

There was less blood loss in the laparoscopic surgery group than in the open surgery group (191 vs. 1,043 ml, p = 0.0001), and the operation time in the two groups was similar (329 vs. 322 min, p = 0.8). The rate of conversion from laparoscopic surgery to open surgery was 1.8 %. There was no significant difference in the morbidity rate (laparoscopic surgery 22.8 % vs. open surgery 33.3 %, p = 0.3). All circumferential resection margins were clear. Three-year cumulative rates of local recurrence were as follows: laparoscopic surgery: 1.9 % vs. open surgery: 8.4 % (p = 0.4), and distant recurrence was 28.5 % in laparoscopic surgery vs. 22.7 % in open surgery (p = 0.8) and these rates were not significantly different. In laparoscopic LAR cases, a shorter distance of the tumor from the anal verge was associated with a longer operation time. A high computed tomography Hounsfield units value of the mesorectum (CTV) was associated with increased blood loss in the first 23 cases, but not in the other 23 cases.

Conclusions

Laparoscopic surgery following CRT was safe and feasible. A shorter anal verge was associated with a longer operation time. Blood loss increased in cases with high CTV, but this can likely be mitigated by experience.