腹腔镜结直肠手术的现状与未来

腹腔镜结直肠癌手术开展至今的10余年来,除其手术创伤小、术后恢复快、术中暴露佳的优势得到广泛认可外,在手术安全可行性、肿瘤根治性、以及与肿瘤相关的远期疗效、术后生命质量、卫生经济学评价等方面也已得到一系列前瞻性随机临床对照研究（randomizedcontrolledtrial,RCT）的证实。     

腹腔镜结直肠癌手术的应用现状与进展

Laparoscopic surgery for colorectal cancer has the advantages of minimal impairment of gastrointestinal and pulmonary function, less immunosuppression and shorter hospital stay, which had been appoved by evidence-based medicine. With the development of concepts and techniques of minimally invasive surgery, the combination of laparoscope and endoscope in the treatment of colorectal cancer has attracted surgeons' attention, and some conventional surgery techniques of colorectal-anal anastomosis have been adopted during laparoscopic colorectal resection, which make ultra-low anastomosis feasible. The aspects mentioned above will promote the further development of laparoscopic surgery for colorectal cancer.     

腹腔镜结肠直肠癌手术现状及临床体会

<正>1991年,美国Jacobs医师施行了世界上首例腹腔镜右半结肠切除术[1]。1992年,K觟ckerling医师施行了世界上首例腹腔镜Miles手术[2]。近20年来,随着手术技术的不断提高和各类器械的不断完善,     

Converted laparoscopic colorectal surgery

BACKGROUND: Conversion rates following laparoscopic colorectal surgery vary widely between studies, and the outcome of converted patients remains controversial. METHODS: A comprehensive search of the English-language literature was updated until May 1999. RESULTS: Twenty-eight studies on 3232 patients were considered for analysis. The overall conversion rate was 15.38%. Seventy nine percent of the studies did not include a definition for conversion; in these studies, the conversion rate was significantly lower than in the series where a specific definition was considered (13.7% vs 18.9%, chi-square test, p < 0.001). Converted patients had a prolonged hospital stay (11.38 vs 7.41 days) and operative time (209 vs 189 min) in comparison with laparoscopically completed patients (95% confidence interval (CI), 1.70-4.00 and 35.90-37.10, respectively). The factors associated with an increased rate for conversion were left colectomy (Odds Ratio [OR] = 1.061), anterior resection of the rectum (OR = 1.088), diverticulitis (OR = 1.302), and cancer (OR = 2.944) (for each parameter, Wald chi-square value, p < 0.001). CONCLUSIONS: In nonrandomized studies, the rate of laparoscopically completed colorectal resections is close to 85%. Because converted patients have a distinct outcome, a clear definition of conversion is required to compare the results of randomized trials. Such trials should also consider a 20% rate of conversion when estimating the sample size for the desired power level. It is likely that converted patients will have a significant impact on the results of future clinical research in laparoscopic colorectal surgery.     

Robot-assisted laparoscopic colorectal surgery

Colorectal surgery can be difficult at open and laparoscopic surgery. This is particularly the case for rectal surgery deep in the pelvis. In obese males distal rectal dissection can be challenging because of instrument and visual limitations. Robot-assisted laparoscopic colorectal operations do not differ significantly from the standard laparoscopic approach but it has certainly been shown that it is feasible to perform the same operation using robotic assistance for the dissection. This allows the surgeon to benefit from vastly enhanced vision and dexterity, which may ultimately translate into benefit for the patient in terms of reduced operating time, and better preservation of pelvic nerves and other structures.     

Basic laparoscopic colorectal surgery

Laparoscopic colorectal surgery is rapidly becoming more widely available. This article covers the feasibility of laparoscopic colorectal surgery including relative contraindications, planning and patient safety. It covers the essential equipment, patient set-up and port positions for right- and left-sided resections. Basic techniques of dissection emphasizing vascular control, traction and exposure of the tissue are described in addition to advice on how to be a competent camera operator and assistant. The step-by-step modular approach to a right hemicolectomy and high anterior resection are highlighted in tabular form.     

Hand-assisted laparoscopic colorectal surgery

Hand-assisted laparoscopic surgery is a newly developed technique. It involves the intraabdominal placement of a hand or forearm through a mini-laparotomy incision while pneumoperitoneum is maintained. In this way, the hand can be used as in an open procedure to palpate organs or tumors, reflect organs atraumatically, retract structures, identify vessels, dissect bluntly along a tissue plain, and provide finger pressure to bleeding points while proximal control is achieved. Additionally, this approach is more economical than a totally laparoscopic approach, reducing both the number of laparoscopic ports and number of instruments required. Some advocates of the technique claim that it is also easier to learn and perform than totally laparoscopic approaches and that it may increase patient safety. Received: 20 December 1999/Accepted: 3 May 2000/Online publication: 7 November 2000     

Robotic-assisted laparoscopic colorectal surgery

Robotic assistance provides a number of potential benefits for laparoscopic surgery by addressing several inherent limitations. However, its utility in colorectal surgery has not been determined. This is a report of our initial experience with robot-assisted colon resections. We prospectively followed 10 patients who underwent robotic-assisted laparoscopic colorectal surgery using Zeus Microwrist System. Surgical outcomes were compared with those of 10 consecutive patients who underwent laparoscopic colorectal surgery in the same institution for similar indications prior to the start of robotic-assisted surgery. Six patients in each group had surgery for colorectal malignancy. All 10 robotic-assisted procedures were completed with no intraoperative complications, conversions, or mortality. The average blood loss was less than 150 mL in all cases. Morbidity and hospital stay were comparable to those for the patients undergoing standard laparoscopic procedures. Robotic surgery was associated with a significant increase in operative time of almost 1 hour. This time was reduced significantly after the first 4 cases. The value of robotic assistance in colorectal surgery needs to be further evaluated in a larger comparative study.     

Training period in laparoscopic colorectal surgery

BACKGROUND: Thorough training is essential to the success of colorectal laparoscopic surgery (LPS). The aim of this study was to evaluate the results of a 3-month training period in LPS. METHODS: Before beginning the study, the surgical team attended several courses of LPS and spent a long time working at a large animal facility to perfect laparoscopic techniques. Twenty-six consecutive patients underwent LPS in a 3-month training period. Controls (n = 26) who underwent open colorectal surgery (LPT) were selected to match the LPS patients for age, gender, primary disease, type of surgery, comorbidity, and nutritional status. RESULTS: Conversion to open surgery was necessary in one patient (3.8%). The operative time was 1 h longer for LPS than LPT (p < 0.001). The mean number of lymph nodes harvested was 17 in LPS and 18 in LPT (p = 0.76). The first flatus (p < 0.02) and bowel movement (p < 0.002) occurred earlier in the LPS group. The postoperative infection rate was 11.5% for LPS and 19.2% for LPT (p = 0.33). Two anastomotic leaks occurred in each group. The mean postoperative hospital stay was 9.6 days (standard deviation [SD], 2.6) for LPS and 11.0 days (SD, 5.2) for LPT (p = 0.68). Recovery of postoperative physical performance and social life occurred earlier in the LPS than the LPT group (p < 0.001). At 1-year follow-up, no difference was found in terms of cancer recurrence or long-term complications. CONCLUSION: Oncologic results and postoperative morbidity were comparable for LPS and LPT. LPS allows a faster postoperative recovery.     

Predicting conversion in laparoscopic colorectal surgery

Background: Laparoscopic colorectal surgery has clear advantages over open surgery; however, the effectiveness of the approach depends on the conversion rate. The objective of this work was to prospectively validate a model that would predict conversion in laparoscopic colorectal surgery. Methods: A simple clinical model for predicting conversion in laparoscopic colorectal surgery was previously developed based on a multivariable logistic regression analysis of 367 procedures. This model was applied prospectively to a follow-up group of 248 procedures by the same team, including 54 procedures performed by one new fellowship-trained surgeon. Results: Patients in the follow-up group were more likely to have cancer (56% vs 44%, p = 0.007) and were more obese (median, 71.0 vs 66.0 kg; p < 0.001). The rate of conversion in the follow-up group was unchanged (8.9% vs 9.0%, p > 0.05). Despite expected trends toward increasing risk of conversion with weight level (<60 kg, 6.8%; 60–<90 kg, 9.0%; >90 kg, 12.1%; p > 0.05) and malignancy (10.1% vs 7.3%, p > 0.05), the model did not distinguish well between groups at risk for conversion. Contrary to the model, however, the fellowship-trained surgeon had a conversion rate that was not higher than that of the other, more experienced surgeons (7.3% vs 9.3%, p > 0.05) even though he was less experienced, and operating on patients who were more obese (median, 75.0 vs 70 kg; p = 0.02) and more likely to have cancer (59% vs 55%, p > 0.05). Recalculated conversion scores that excluded the inexperience point for the fellowship-trained surgeon showed a good fit for the model. Considering the original and follow-up experience together (615 cases), the model clearly stratifies patients into low (0 points), medium (1–2 points), and high risk (3–4 points) for conversion, with respective rates of 2.9%, 8.1%, and 20% (p = 0.001). Conclusion: This model appears to be a valid predictor of conversion to open surgery. Fellowship training may provide sufficient experience so that learning curve issues are redundant in early practice. This model now requires validation by other centers. Presented at the combined meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the 8th World Congress of Endoscopic Surgery, New York, NY, USA, 13–16 March 2002     

Ureteral stenting in laparoscopic colorectal surgery

Background

Few studies have examined the current status of ureteral stent use or the indications for stenting, particularly in laparoscopic colorectal surgery. This study examines current national trends and predictors of ureteral stenting in patients undergoing major colorectal operations and the subsequent effects on perioperative outcomes.

Methods

The 2005–2011 National Surgical Quality Improvement participant user files were used to identify patients undergoing laparoscopic segmental colectomy, low anterior resection, or proctectomy. Trends in stent use were assessed across procedure types. To estimate the predictors of stent utilization, a forward-stepwise logistic regression model was used. A 3:1 nearest neighbor propensity match with subsequent multivariable adjustment was then used to estimate the impact of stents.

Results

A total of 42,311 cases were identified, of which 1795 (4.2%) underwent ureteral stent placement. Predictors of stent utilization included diverticular disease, need for radical resection (versus segmental colectomy), recent radiotherapy, and more recent calendar year. After adjustment, ureteral stenting appeared to be associated with a small increase in median operative time (44 min) and a trivial increase in length of stay (5.4%, P < 0.001). However, there were no significant differences in morbidity or mortality.

Conclusions

We describe the clinical predictors of ureteral stent usage in this patient population and report that while stenting adds to operative time, it is not associated with significantly increased morbidity or mortality after adjusting for diagnosis and comorbidities. Focused institutional studies are necessary in the future to address the utility of ureteral stents in the identification and possible prevention of iatrogenic injury.     

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。     

Indications for laparoscopic colorectal surgery

Background: Between November 1991 and May 1995, a series of laparoscopic colectomies were performed in our hospital. Methods: Our main aim was to define more specifically the indications for laparoscopic colectomy. Results: A total of 69 patients underwent laparoscopic surgery for benign polypoid colorectal disease (n = 10), inflammatory bowel disease (n = 24), and colorectal malignancy (n = 35). Of the latter group, four patients underwent a palliative procedure. The conversion rate of the whole group was 29%. The main reason to convert was infiltrative growth in inflammatory disease or cancer. Respectively, seven (10%) and 12 (17%) patients sustained complications in the perioperative and early postoperative phase. Two patients died perioperatively (3%). The mean hospital stay was 12 days. On follow-up, 11 patients had developed a stenotic anastomosis, which was successfully dilated in all cases. After 3 years, the survival rate according to Kaplan-Meier is 86%, 66%, 68%, and 0% for Dukes' A, B, C, and D color carcinoma, respectively. In one patient with a Dukes B carcinoma, port site metastases were found. Conclusions: Justifiable indications for laparoscopic colorectal surgery include (a) a benign polyp 20–50 cm from the anal ring; (b) mobile, inflammatory large bowel disease; (c) palliation in case of malignant disease, preferably of the left hemicolon. It remains to be proven that laparoscopic colectomy is superior and not just equivalent to open colectomy. This is especially true for resections of colorectal carcinoma with curative intent. Therefore a cost/benefit analysis should be performed in a prospective, randomized setting. Received: 1 November 1996/Accepted: 1 July 1997     

Hand-assisted laparoscopic colorectal surgery.

Hand-assisted laparoscopic surgery is a newly developed technique. It involves the intra-abdominal placement of a hand or forearm through a mini laparotomy incision while pneumoperitoneum is maintained. This way, the hand can be used as in an open procedure to palpate organs or tumours, reflect organs atraumatically, retract structures, identify vessels, dissect bluntly along a tissue plain, and provide finger pressure to bleeding points while proximal control is achieved. Additionally this approach is more economical than a totally laparoscopic approach, reducing both the number of laparoscopic ports and number of instruments required. Some advocates of the technique claim that it is also easier to learn and perform than totally laparoscopic approaches, and that there may be increased patient safety.     

Ergonomic port placement in laparoscopic colorectal surgery

Aim Port placement in laparoscopic surgery has important ergonomic implications. A manipulation angle (MA) of 60° has been shown to maximize task efficiency. We calculated the MA used during various stages of both right hemicolectomy (RH) and high anterior resection (AR). Method We compared two methods of port placement for each operation. RH‐PP1 included ports in the left iliac fossa and left upper quadrant. RH‐PP2 included ports suprapubically and in the left iliac fossa. We calculated the MA of each of these methods in mobilizing both the caecum and hepatic flexure. AR‐PP1 included ports in the right iliac fossa and right upper quadrant. AR‐PP2 included ports suprapubically and in the right iliac fossa. We calculated the MA of each of these methods in mobilizing the splenic flexure, descending–sigmoid junction and the recto–sigmoid junction. Results For RH‐PP1, the mean MA for mobilizing the caecum and hepatic flexure was 38° and 52°, respectively. For RH‐PP2, the mean MA for mobilising the caecum and hepatic flexure was 58° and 44°, respectively. For AR‐PP1, the mean MA for mobilizing the splenic flexure, the descending–sigmoid junction and the recto–sigmoid junction was 77°, 41° and 18°, respectively. For AR‐PP2, the mean MA for mobilizing the splenic flexure, the descending–sigmoid junction and the recto–sigmoid junction was 40°, 56° and 34°, respectively. Conclusion There are no two port placements that will allow for an ideal MA at every stage of mobilization for either right‐ or left‐sided resection.