How to maintain the quality of laparoscopic surgery in the era of lack of hands?

Lack of personnel in the operating rooms is not a future problem, it is today's reality in many hospitals throughout the OECD countries. As studies anticipate that this situation will not change overnight (1), the issue of the quality of surgery within this new environment needs to be addressed on short notice. The problem is even more critical for laparoscopic surgeons, who have enjoyed proportionally more assistance since the emergence of minimally invasive surgery. After analyzing the tasks performed by OR assistants and nurses, we have looked at available techniques and tools (2) that could help laparoscopic surgeons, using the following criteria to assess their benefits : capability to address the shortage of assistance, impact on quality of surgery, economic affordability within the existing Belgian healthcare system.     

The efficacy of robot-assisted versus conventional laparoscopic vascular anastomoses in an experimental model.

BACKGROUND: Robot-assisted surgery is thought to facilitate complex laparoscopic movements, enhancing advanced laparoscopic procedures. OBJECTIVE: To evaluate the benefit of robotic assistance for laparoscopic vascular surgery. DESIGN: Experimental study using prosthetic conduits in a laparoscopic training box. METHODS: Two surgeons each performed 40 laparoscopic vascular anastomoses alternating with and without robotic assistance. A Zeus-Aesop surgical Robotic system trade mark with 3-D visualisation was used. Each surgeon made 40 anastomoses in total, using different prostheses (5 mm PTFE and 16 mm Dacron) and suture material (Prolene and PTFE). A time-action analysis was performed to evaluate surgical performance. Primary efficacy parameters were quality and leakage of the anastomosis, total time and total number of actions. RESULTS: Equal quality scores and anastomotic leakage were achieved with both techniques. Robotic assistance resulted in significant longer suture and knot tying time and significant more actions were needed compared to the manual laparoscopic procedures. Significant more failures occurred during the robot-assisted procedures. CONCLUSION: In this study, robotic (Zeus-Aesop) assistance did not improve the laparoscopic performance of the surgeon whilst making vascular anastomoses.     

Full robotic assistance for laparoscopic tubal anastomosis: a case report

Optical magnification and long instrumentation significantly increase surgical tremor, which makes laparoscopic microsuturing difficult. Therefore, laparoscopic tubal anastomosis has not gained wide acceptance among gynecologic surgeons. Robotic assistance facilitates this type of procedure by filtering tremor, reducing the surgeon's fatigue, and scaling the maneuvers. The authors have successfully completed a case of laparoscopic tubal reanastomosis using a "master-slave" robot to perform the standard microsuturing technique. A 33-year-old woman, gravida 2, para 2, requested reversal of her previous tubal ligature. A right isthmic-isthmic tubal anastomosis was performed laparoscopically, with faithful adherence to the authors' standard technique applied at laparotomy. Full robotic assistance was used to anastomose the tube. A chromotubation test showed anastomotic patency without leak. The patient recovered uneventfully after surgery and was discharged within 24 h after the procedure. Laparoscopic microsurgical tubal anastomosis with full robotic assistance is feasible and safe in humans.     

Learning curves of robot-assisted laparoscopic surgery compared with conventional laparoscopic surgery: an experimental study evaluating skill acquisition of robot-assisted laparoscopic tasks compared with conventional laparoscopic tasks in inexperienced users

BACKGROUND: Laparoscopic surgery can be demanding, resulting in longer operating time and a longer time before reaching proficiency compared with open surgery. Robotic assistance allows stereoscopic vision and improves dexterity, potentially leading to faster and safer laparoscopic surgery and a shortening of the learning curve. METHODS: Duration and accuracy were measured in inexperienced participants, performing basic and advanced laparoscopic tasks using both conventional laparoscopy and the daVinci Surgical System. RESULTS: Eight participants performed 176 laparoscopic tasks. Robotic assistance resulted in faster and more accurate performance of laparoscopic tasks. However, conventional laparoscopy showed faster skill acquisition. CONCLUSIONS: Robotic assistance resulted in faster and more accurate performance of laparoscopic tasks. However, learning curves favored conventional laparoscopy. These data suggest robotic assistance might be most beneficial in inexperienced subjects. The relatively flat learning curve in robot-assisted laparoscopy suggests robotic assistance might be less (or marginally) beneficial in experienced surgeons. This could explain why robotic assistance has failed to show clear benefit in several clinical studies. Extensive conventional laparoscopic training might lead to faster, safer, and less expensive surgery, further marginalizing the role for robotic assistance in laparoscopic surgery.     

Laparoscopy for diverticulitis

Although the literature on laparoscopic surgery for diverticulitis includes data on more than 1800 patients, the quality of the studies is insufficient to draw definitive evidence-based conclusions. Nonrandomized evidence suggests that laparoscopic resection for uncomplicated diverticulitis of the sigmoid may fare better than its conventional counterpart not only in short-term outcome (preservation of the abdominal wall, shorter disability), but also in the long term (decreased rates of late symptomatic small bowel obstruction). Five-year recurrence rates show that a laparoscopic or conventional access is unlikely to have an impact, provided that the oral bowel end is anastomosed to the proximal rectum rather than to the distal sigmoid. The superiority of laparoscopy should be proven by measuring health-related and patient-centered outcome rather than surrogate endpoints. Areas of concern include replacing a conventional resection with laparoscopic suture, drainage, and colostomy in patients with free perforation and peritonitis. The role of laparoscopic surgery should be limited to resection for uncomplicated diverticulitis of the sigmoid performed by adequately trained surgeons. Benefits can be expected with this procedure, provided that indications for surgery are not influenced by the mode of access and that postoperative complication rates remain within the range of that for traditional colorectal surgery.     

Controlled trial of the introduction of a robotic camera assistant (EndoAssist) for laparoscopic cholecystectomy

BACKGROUND: The role of the human camera holder during laparoscopic surgery keeps valuable personnel from other duties. EndoAssist is a robotic camera-holding device controlled by the operator's head movements. This study assesses its introduction into clinical practice. METHOD: Ninety-three patients undergoing laparoscopic cholecystectomy were randomized to have either the robotic (40) or a human (46) assistant. Seven patients converted to open operation were excluded. Six surgeons were evaluated. Operating time and subjective assessments were recorded. Learning curves were constructed. RESULTS: The mean operating time was less using the robotic assistant (66 min) than with human assistance (74 min) (p < 0.05, two-tailed t-test). The learning curves for operating time showed that within three operations surgeons were trained in using the robot. The device was safe in use. CONCLUSION: The EndoAssist operating device is a significant asset in laparoscopic surgery and a suitable substitute for a human assistant. Surgeons became competent in the use of the robot within three operations. The robot offers stability and good control of the television image in laparoscopic surgery.     

In vivo laparoscopic robotics

Robotic laparoscopic surgery is evolving to include in vivo robotic assistants. The impetus for the development of this technology is to provide surgeons with additional viewpoints and unconstrained manipulators that improve safety and reduce patient trauma. A family of these robots have been developed to provide vision and task assistance. Fixed-base and mobile robots have been designed and tested in animal models with much success. A cholecystectomy, prostatectomy, and nephrectomy have all been performed with the assistance of these robots. These early successful tests show how in vivo laparoscopic robotics may be part of the next advancement in surgical technology.     

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons

Background This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons. Methods From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants. Results Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10–150 cases) are needed for a claim of proficiency. Conclusion Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery. Presented at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) 2003 Scientific Session, 15 March 2003, Los Angeles, California     

Advanced laparoscopic gynecologic surgery

What is the future for laparoscopy? Any procedure thought to be impossible to perform by laparoscopy or procedures that, based on conventional wisdom, should not be done laparoscopically are being performed or developed as the reader peruses this article. Technical advances in the endoscopic equipment and development of laparoscopic instruments have allowed for performance of sophisticated procedures with laparoscopic assistance. Appropriate laparoscopic skills allow surgeons to perform these procedures in a fashion nearly identical to an open procedure; however, modifications of historically proven techniques are controversial regarding the expenses generated, equipment necessary to perform the procedure, training necessary, and potential for complications. Has the obituary of laparotomy been written? The benefits of laparoscopically assisted or performed procedures are continuing to be analyzed. LAVH has been touted as a way to reduce the number of abdominal hysterectomies while increasing the number of vaginal hysterectomies. Therefore, indications for LAVH would ideally more resemble indications for abdominal hysterectomy than vaginal hysterectomy; however, LAVH does not seem to have increased the total number of vaginal hysterectomies. Conversely, the number of abdominal hysterectomies seems to be roughly the same, whereas the number of vaginal hysterectomies has decreased and the number of LAVHs has increased. Therefore, surgeons seem to be substituting LAVH for vaginal hysterectomy. Studies comparing laparoscopic Burch procedures and open Burch procedures are just now being reported. Many early reports described procedures that are not classic Burch colposuspensions. These changes make it impossible to assume that overall success and rate of complications are the same. The same can be said for techniques for correction of pelvic organ prolapse. Although laparoscopic performance and laparoscopic assistance are increasing in popularity, most cases are not handled in this way. Clearly, not every surgeon has embraced using the laparoscope to treat patients who would otherwise have undergone abdominal or vaginal surgery.     

Remote telepresence surgery: the Canadian experience

On 28 February 2003, the world’s first telerobotic surgical service was established between St. Joseph’s Healthcare Hamilton, a teaching hospital affiliated with McMaster University, and North Bay General Hospital, a community hospital 400 km away. The service was designed to provide telerobotic surgery and assistance by expert surgeons to local surgeons in North Bay, and to improve the range and quality of advanced laparoscopic surgeries offered locally. The two surgeons have collaboratively performed 22 remote telepresence surgeries including laparoscopic fundoplications, laparoscopic colon resections, and laparoscopic inguinal hernia repairs. This article describes the important lessons learned, including the telecommunication requirements, the impact from lack of haptic feedback, surgeons’ adaptation to latency, and ethical and medicolegal issues. This is currently the largest clinical experience with assisted robotic telepresence surgery (ARTS) in the world, and the lessons learned will help guide the future design and development of telesurgical robotic platforms. It also will guide the establishment of telesurgical networks connecting various centers in the world, allowing for rapid and safe dissemination of new surgical techniques.     

The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic, and robotic surgery

There is increasing interest in understanding the toll that operating takes on a surgeon’s body. The effect of robotic surgery on surgeon discomfort has not been studied. We sought to document the discomfort of robotic surgery compared with open and laparoscopic surgery and to investigate the factors that affect the risk of physical symptoms. Nineteen-thousand eight-hundred and sixty-eight surgeons from all specialties trained in the use of robots were sent a 26-question online survey and 1,407 responded. One-thousand two-hundred and fifteen surgeons who practiced all three approaches were used in the analysis. Eight-hundred and seventy-one surgeons had physical discomfort or symptoms attributable to operating. Of those with symptoms, 55.4% attributed most of the symptoms to laparoscopic surgery, 36.3% to open surgery, and 8.3% to robotic surgery. A higher case load was predictive of increased symptoms for open and laparoscopic surgery, but not for robotic surgery. Robotic surgery was less likely than open or laparoscopic surgery to lead to neck, back, hip, knee, ankle, foot, and shoulder pain and less likely than laparoscopic surgery to lead to elbow and wrist pain. Robotic surgery was more likely than either open or laparoscopic surgery to lead to eye pain, and more likely than open surgery to lead to finger pain. Nearly a third (30.3%) of surgeons admit to giving consideration to their own discomfort when choosing an operative modality. Robotic surgery has promise in reducing the risk of physical discomfort for the operator. This is important as more surgeons consider their own health when choosing a surgical modality.     

Current state of laparoscopic rectal cancer surgery in Australasia

Background: To establish the current surgical approach to rectal cancer in a group of colorectal surgeons in Australasia and the current opinion regarding laparoscopic rectal cancer surgery. Methods: An online survey was distributed to the Colorectal Surgical Society of Australia and New Zealand members. Results: 123/177 surgeons responded. During the last year, 94.3% had performed a laparoscopic colorectal case, 77.2% a laparoscopic rectal case and 65% a laparoscopic rectal cancer case. The most common approach to high anterior resection was pure laparoscopic (52.8%). Low anterior resections were most commonly performed with a laparoscopic component (25.2% pure laparoscopic, 33.3% hybrid). Most surgeons (>50%) performed ultra‐low anterior resections or abdomino‐perineal resections via an open technique. In addition, 64.2% intended to perform laparoscopic total mesorectal excision (TME) within 2 years. Most surgeons believe that the quality of laparoscopic TME and oncological outcomes are similar, and surgical access and short‐term outcomes are superior when compared to the open procedure. The major concerns were in performing a low rectal transection, controlling haemorrhage and resource utilization/cost. Conclusion: Laparoscopic rectal surgery is now widely practiced by Australasian colorectal surgeons and projected to increase in the near future. However, only 10% of surgeons are routinely performing total laparoscopic ultra‐low anterior resections which may have implications for the generalizability of clinical trials in laparoscopic TME and the ability to credential surgeons in this technically challenging field. Quality of TME and oncological outcomes were rated similar to the open operation. Areas of concern included low rectal transection, haemorrhage control and resource utilization/cost.     

An ergonomic evaluation of surgeons' axial skeletal and upper extremity movements during laparoscopic and open surgery

BACKGROUND: Many surgeons have complained of fatigue and musculoskeletal pain after laparoscopic surgery. We evaluated differences in surgeons' axial skeletal and upper extremity movements during laparoscopic and open operations. METHODS: Five surgeons were videotaped performing 16 operations (8 laparoscopic and 8 open) to record their neck, trunk, shoulder, elbow, and wrist movements during the first hour of surgery. We also compared postprocedural complaints of pain, stiffness, or numbness between the two groups. RESULTS: Compared with surgeons performing open surgery, surgeons performing laparoscopic surgery exhibited less lateral neck flexion; less trunk flexion; more internal rotation of the shoulders; more elbow flexion; more wrist supination and wrist ulnar and radial deviation. There was a trend of more shoulder stiffness after laparoscopic operations than after open operations. CONCLUSIONS: Laparoscopic surgery involves a more static posture of the neck and trunk, but more frequent awkward movements of the upper extremities than open surgery. Ergonomic changes in the operating room environment and instrument design could ease the physical stress imposed on surgeons during laparoscopic operations.     

The impact of practice environment on laparoscopic colectomy utilization following colorectal residency: a survey of the ASCRS Young Surgeons

Aim It is often thought that practice patterns are different in private (PP) vs university hospital (UH) settings. We aimed to describe the impact of practice environment on the type of laparoscopic colectomy procedures performed by graduating colorectal surgeons. Method A review was carried out of prospectively gathered self‐reported questionnaire data. Graduates of American Society of Colon and Rectal Surgeons’ (ASCRS)‐approved colorectal residencies from 2004 to 2008 underwent an on‐line survey, developed by the ASCRS Young Surgeons’ Committee. Results About 177 (52%) of 342 graduates surveyed responded. Practice setting data were available for 157 (89%) surgeons. Gender, geographical location and age were similar in both cohorts. PP surgeons utilized a laparoscopic approach more often for rectal cancer (37%vs 19%; P = 0.003). There was no significant difference in the rate of laparoscopic surgery in colon cancer, diverticular disease, inflammatory bowel disease, Clostridium difficile or emergency surgery. PP surgeons operated more often with a partner (43%vs 8%) or surgical assistant (13%vs 4%; both P < 0.001), while UH surgeons had a colorectal resident (10%vs 21%) or general surgery resident (15%vs 55%; both P < 0.001). Impediments to performing laparoscopic surgery for PP surgeons included a perceived lack of hospital equipment (33%vs 20%) and support (29%vs 17%; both P < 0.05). Perception of personal experience, access to trained assistants, financial reimbursement, length of surgery and patient availability were equivalent in both groups. Conclusion While differences such as type of assistant and impediments to laparoscopic utilization exist between PP‐ and UH‐based practices, early laparoscopic practice patterns remain similar. PP surgeons more frequently perform laparoscopic resection for rectal cancer and with hand‐assistance. Despite differences, newly trained colorectal surgeons in both settings utilize and require laparoscopic skills.     

Laparoscopic resection of colorectal cancer

Laparoscopic surgery has revolutionised procedures such as cholecystectomy since its inception in the 1980s. After initial enthusiasm with laparoscopic colorectal resections in the early 1990s, resection of colorectal malignancy was largely abandoned outside clinical trials because of reports of inferior oncological outcomes including local and port-site recurrence. More recently, however, an increasing number of reports have demonstrated that laparoscopic surgery for colorectal cancer though technically demanding is feasible, and the results of large multi-centred randomised trials showing oncological equivalence are becoming available. Technological advances in laparoscopic equipment along with the increasing skills and experience of laparoscopic surgeons have extended the indications and reduced the contraindications for laparoscopic colectomy. This, along with the use of fast- track protocols is changing the way we manage patients. The future of laparoscopic colorectal surgery is assured, driven not only by the physical benefits to the patient in the short and medium term, the reduced financial burden on in-patient stay, and post-operative return to work, but also increasing patient demand. This in turn requires that surgeons should ensure high quality training and operative competence to maintain the high standards achieved by the pioneers in this field.     

The role of telementoring and telerobotic assistance in the provision of laparoscopic colorectal surgery in rural areas

Purpose The aim of this study was to assess whether telementoring and telerobotic assistance would improve the range and quality of laparoscopic colorectal surgery being performed by community surgeons. Methods We present a series of 18 patients who underwent telementored or telerobotically assisted laparoscopic colorectal surgery in two community hospitals between December 2002 and December 2003. Four community surgeons with no formal advanced laparoscopic fellowship were remotely mentored and assisted by an expert surgeon from a tertiary care center. Telementoring was achieved with real-time two-way audio-video communications over bandwidths of 384 kbps–1.2 mbps and included one redo ileocolic resection, two right hemicolectomies, two sigmoid resections, three low anterior resections, one subtotal colectomy, one reversal of a Hartmann operation, and one abdominoperineal resection. A Zeus TS microjoint system (Computer Motion Inc, Santa Barbara CA) was used to provide telepresence for the telerobotically assisted laparoscopic procedures, which included three right hemicolectomies, three sigmoid resections, and one low anterior resection. Results There were no major intraoperative complications. There were two minor intraoperative complications involving serosal tears of the colon from the robotic graspers. In the telementored cases, there were two postoperative complications requiring reoperation (intra-abdominal bleeding and small bowel obstruction). Two telementored procedures were converted because of the mentee’s inability to find the appropriate planes of dissection. One telerobotically assisted procedure was completed laparoscopically by the local surgeon with aid of telementoring because of inadequate robotic arm position. The median length of hospital stay for this series was 4 days. The surgeons considered telementoring useful in all cases (median score 4 out of 5). The use of remote telerobotic assistance was also considered a significant enabling tool. Conclusions Telementoring and remote telerobotic assistance are excellent tools for supporting community surgeons and providing patients better access to advanced surgical care. Supported by a grant from the Canada Health Infostructure Partnership Program (CHIPP) Presented to the Society of American Gastroenterologist Endoscopic Surgeons, Fort Lauderdale, Florida, April 2005     

Surgeon experience with laparoscopic-assisted colorectal surgery in Washington State

PURPOSE: To describe the current practice and opinions held by surgeons performing colorectal surgery in Washington regarding laparoscopic colorectal surgery. METHODS: After attempting to identify all surgeons with hospital privileges in colorectal surgery in Washington, a survey was sent to 303 surgeons. The survey asked about the surgeon's practice, volume of colon surgery in the preceding year, the number of laparoscopic colon resections ever performed, the surgeon's opinion on the future practice of laparoscopic colorectal surgery, and whether faced with the personal need to undergo colon resection at the present time, would the surgeon elect to have laparoscopic or open colon resection. RESULTS: In all 170 surveys were returned; 154 returned surveys were from surgeons who had performed at least one colon resection in the preceding year; 53 (34%) respondents had experience with fewer than 20 laparoscopic resections and 83 (55%) have never performed laparoscopic-assisted colectomy (LAC). Only 4 (3%) surgeons had performed more than 50 laparoscopic colon resections. Forty-five percent of respondents indicated that they would currently seek a laparoscopic resection for themselves to treat either a benign condition or an incurable malignancy, and 84% of respondents indicated they would have an open colectomy for a curable malignancy. CONCLUSIONS: The majority of surgeons performing colorectal resections in Washington have limited experience with LAC. Surgeon opinion regarding the role of laparoscopic colorectal surgery in clinical practice is mixed. We suggest a model for proctoring of LAC for surgeons interested in implementing laparoscopic colorectal resection into their practice.     

Robotics and allied technologies in endoscopic surgery

Endoscopic surgery was developed in the 1970s and 1980s, with initial work conducted by pioneering surgeons. After the development of laparoscopic cholecystectomy, the breakthrough of endoscopic surgery had a great effect on all surgical specialties. Starting with rather simple procedures, such as cholecystectomy, a rapid progression toward more complex procedures, such as reflux or colonic surgery, took place. It was realized at this time that the existing endoscopic instruments allowed only a limited preciseness when performing the procedures, and part of the information from inside the abdominal cavity was not available to the surgeon. This prompted a discussion with engineers concerning the development of more advanced technologies to give those performing endoscopic surgery the same quality of information and manipulation that surgeons have when performing open surgery. These qualities include (1) instruments and manipulators that allow surgical action under endoscopic control with all degrees of freedom; (2) devices that provide surgeons with tactile feedback; and (3) vision systems that provide surgeons with the same quality of visual information as with open surgery, namely, high resolution, excellent color quality, precise spatial information, and a constant clear view for optimal surgical action. At the end of 1999, some of the aforementioned quality concepts found their way into the surgical routine, but most of the concepts are still being developed. Another decade will pass before endoscopic surgery procedures will be closer to the technological goals.     

Current attitudes in laparoscopic colorectal surgery

Background: In this study, we set out to examine the current attitudes among surgeons toward laparoscopic colorectal surgery (LCS). Methods: A total of 3628 questionnaires were sent to all North American members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society of Colon and Rectal Surgeons (ASCRS); 40% of the members of each society responded (B15 respondents). Results: Currently, 85% of the respondents perform laparoscopic surgery; LCS was performed by 48% of the respondents in 21% of their patients. Although 35% of the members of SAGES have increased the number of laparoscopic colorectal operations they perform in the last 3 years, only 26% of ASCRS members did so. Our findings showed that 74% of the surgeons who perform LCS do so for diverticular disease, 68% for colonic polyps, 61% for villous adenoma, and 36% for ileal Crohn's disease. However, only 15% operate for the cure of carcinoma of any stage (16% of SAGES members and 11% of ASCRS members), whereas 8.5% and 7% operate for the cure of all upper and lower rectal carcinomas, respectively. Thirty-six percent of the surgeons who perform LCS for cancer have done between one and 10 curative resections, 8% have done 11–20 procedures, and 14% have done >20 procedures. There were 80 cases of port site recurrence reported by 4.4% of surgeons. Although 56% of the respondents would themselves undergo laparoscopic colorectal surgery for a rectal villous adenoma, only 9% would do so for a distal-third rectal carcinoma (12% of SAGES and 5% of ASCRS respondents). Conclusions: The overall percentage of respondents performing LCS has decreased over the last 3 years; moreover, surgeons are more hesitant to perform laparoscopic surgery for the cure of colonic cancer. Due to the overall low response rate, the fact that 4.4% of those surgeons who did respond have seen port site recurrences does not allow any conclusions to be drawn about the prevalence of this problem.     

左半结肠癌合并肠梗阻外科治疗策略

左半结肠癌合并肠梗阻是结直肠外科常见的棘手问题之一,其临床表现有一定特点,手术方式纷繁多样,目前其外科治疗策略存在诸多争议。传统的三期手术、Hartmann术仍有一定的临床应用价值。术中结肠灌洗结合一期切除吻合可作为急诊手术的重要选择之一。随着结肠支架的推广与使用,支架置入后再行择期手术也被证实安全、可行。结肠支架置入后择期腹腔镜根治手术的实施加快了病人术后恢复,提高了病人生活质量,这与当今微创外科、加速康复等前沿理念不谋而合。但结肠支架置入后如发生穿孔、移位,容易导致肿瘤播散,增加术后复发风险,也应引起足够重视。为了减少病人手术创伤,并提高病人的生活质量与长期预后,外科医师应借助多学科综合治疗协作组（MDT）,针对病人的具体病情制定个体化的治疗方案。