两种腹腔镜手术方案在乙状结肠癌患者中的疗效对比

目的对比传统腹腔镜乙状结肠癌根治术与腹部无切口经直肠取出标本腹腔镜手术的近期疗效。方法以2015年1月-2016年12月于该院拟实施腹腔镜辅助乙状结肠癌根治手术的患者中选出34例实施腹部无切口经直肠取出标本腹腔镜乙状结肠癌根治术的患者作为腹部无切口组。以1∶2的配对方式选择同期内年龄、性别一致,体质指数(BMI)相近的实施腹腔镜辅助乙状结肠癌根治手术的患者68例作为对照组。对比两种腹腔镜手术方案的手术时间、手术出血量、术后排气时间、术后疼痛评分、手术并发症、术后住院时间、附加镇痛处理情况、肠管切除长度、近远端切缘、肿瘤大小、淋巴结清扫数目和p TNM分期。结果腹部无切口组乙状结肠癌患者的手术时间、手术出血量明显高于对照组,腹部无切口组乙状结肠癌患者的术后排气时间、术后清醒时疼痛评分、术后第1天的疼痛评分明显低于对照组,差异有统计学意义(P0.05);两组乙状结肠癌患者的肠管切除长度、远近端切缘、肿瘤大小、淋巴结清扫数目和p TNM分期差异无统计学意义(P0.05)。腹部无切口组随访5~8个月,平均6个月;对照组随访6~9个月,平均7个月,均未发现肿瘤局部复发及远处转移。结论相比于传统腹腔镜手术,腹部无切口经直肠取出标本腹腔镜乙状结肠癌根治术可以明显降低患者的疼痛程度,缩短术后排气时间,肿瘤根治效果相近。     

Sigmoid volvulus after laparoscopic surgery for sigmoid colon cancer

We report the first case of sigmoid volvulus after laparoscopic surgery for sigmoid colon cancer. The patient is a 75‐year‐old man who presented with the sudden onset of severe abdominal pain. He had undergone laparoscopic sigmoidectomy for cancer 2 years before presentation. CT scan showed a distended sigmoid colon with a mesenteric twist, or “whirl sign.” Colonoscopy showed a mucosal spiral and luminal stenosis with dilated sigmoid colon distally and ischemic mucosa. The diagnosis of ischemic colonic necrosis due to sigmoid volvulus was established. Resection of the necrotic sigmoid colon was performed and a descending colon stoma was created. A long remnant sigmoid colon and chronic constipation may contribute to the development of sigmoid volvulus after laparoscopic sigmoidectomy. Prompt diagnosis is essential for adequate treatment, and colonoscopy aids in the diagnosis of ischemic changes in patients without definitive findings of a gangrenous colon.     

Laparoscopic reduced port surgery for schwannoma of the sigmoid colon: A case report

A 74‐year‐old woman who developed schwannoma of the sigmoid colon was referred to our hospital for colonography to determine the cause of her stool occult blood. Colonoscopy revealed a submucosal tumor, which measured 3 cm in diameter, in the sigmoid colon. Endoscopic ultrasonography revealed a low echoic, homogeneous and demarcated submucosal tumor that continued into the fourth layer of the colonic wall. Gastrointestinal stromal, myogenic or neurogenic tumor was suspected, and thus, laparoscopic sigmoidectomy was carried out. We used two ports during the operation, a SILS Port in the umbilical region and a 12‐mm port in the right lower abdominal wall, and performed sigmoidectomy with D2 lymph node dissection. Histological findings revealed spindle‐like tumor cells with multiform nuclei. The tumor was diagnosed by immunostaining as benign schwannoma of the sigmoid colon. The conventional surgical treatment for schwannoma of the digestive tract is partial resection, but if preoperative diagnosis is unknown, radical resection with lymphadenectomy is acceptable for submucosal tumors in the digestive tract. In this case, laparoscopic reduced port surgery using only one or two ports may be more feasible and beneficial with regard to cosmesis and reduced postoperative pain than conventional laparoscopic colectomy.     

Case of laparoscopic right hemicolectomy for ascending colon cancer after aortic graft replacement and revascularization of the superior mesenteric artery

A 67‐year‐old man who presented with a bloody stool was diagnosed with ascending colon cancer. He had previously experienced thoracic and abdominal aortic dissections, which were treated with thoracic and abdominal aortic grafts and superior mesenteric artery revascularization. We performed a laparoscopic right hemicolectomy with a D3 lymph node dissection. During the laparotomy, we identified the superior mesenteric artery and an enlarged anterior superior pancreaticoduodenal artery. Injury to the latter artery could lead to severe ischemia in multiple organs; therefore, it was crucial to identify the primary feeding artery and vascular anatomy before and during surgery. We chose the laparoscopic right hemicolectomy to avoid injuring the anterior superior pancreaticoduodenal artery and the intra‐abdominal abscess. This case study was the first to describe a laparoscopic hemicolectomy after thoracic and abdominal aortic grafts and superior mesenteric artery revascularization.     

Severe cellulitis and abdominal wall emphysema following laparoscopic colonic surgery: A case report

Abdominal wall emphysema is a common complication of laparoscopic surgery. This condition is usually harmless; however, if an infection occurs, it can develop into a serious condition such as necrotizing fasciitis. We report a case of a 51‐year‐old woman suffering from severe cellulitis that spread from an area of abdominal wall emphysema after laparoscopic surgery for sigmoid colon cancer. Recognizing this complication, early diagnosis, and prompt treatment are cornerstones for successful management of this potentially fatal disease.     

Retrograde colon intussusception in an adult due to adenoma: Treatment by combined laparoscopic and endoscopic approach

This report describes the case of a young patient who underwent laparoscopic surgery to reduce for a retrograde intussusception of the sigmoid‐descending colon caused by adenoma of the sigmoid colon. A 36‐year‐old woman visited our hospital, complaining primarily of vomiting and abdominal pain. Abdominal CT scan showed the typical finding of intussusception. An emergency colonoscopy revealed that the invaginated colon with a polypoid mass was protruding into the descending colon. A gastrografin enema showed the invaginated bowel segment at the descending colon. We performed endoscopic polypectomy and then hand‐assisted laparoscopic reduction. The pathological finding showed tubular adenoma. Laparoscopy is a diagnostic or therapeutic tool for selected cases of adult intussusception. Benign tumor is one of the causes of intussusception in adults and a good indication for laparoscopic surgery.     

腹腔镜内侧径路法乙状结肠癌切除术

目的 探讨腹腔镜内侧径路法治疗乙状结肠癌的手术方法。方法 分析2001年4月～2002年11月施行的13例腹腔镜乙状结肠癌切除术患者的手术方法，采用内侧径路法，即先处理肠系膜根部及中枢侧淋巴、血管，后处理病变肠管。结果 13例患者均成功完成腹腔镜手术，平均手术时间130min，术中平均出血30mL，平均术后住院日7d，无手术并发症和死亡发生，随诊6～21个月，未发现局部或全身肿瘤复发、转移。结论 只要严格掌握手术指征，合理选择手术方式，腹腔镜内侧径路法治疗结肠肿瘤是安全、有效的。     

Laparoscopic subtotal proctocolectomy for synchronous triple colorectal cancers: a case report

A 42‐year‐old woman presented with abdominal pain. On the basis of CT results, we diagnosed her condition as bowel obstruction caused by advanced transverse colon cancer. Colonoscopy findings showed three lesions: (i) an advanced tumor in the transverse colon; (ii) a laterally spreading descending colon tumor; and (iii) a rectal polyp. The tumors and the polyp were all pathologically diagnosed as adenocarcinoma. After inserting a self‐expanding metallic stent into the main tumor of the transverse colon to decompress the bowel, we performed endoscopic submucosal dissection of the laterally spreading descending colon tumor. Pathological examination results showed submucosal invasion and a positive margin. Because we endoscopically identified that the rectal polyp was invading the submucosa, we performed laparoscopic subtotal proctocolectomy and ileorectal anastomosis with lymph node dissection along the surgical trunk; we also performed central vascular ligation of the ileocolic artery, right and left branches of the middle colic artery, and inferior mesenteric artery. The patient's postoperative course was uneventful. We present this case because there have been few reports on laparoscopic subtotal or total proctocolectomy for synchronous multiple colorectal cancers.     

One‐stage completely laparoscopic restorative proctocolectomy for ulcerative colitis complicated with sigmoid colon cancer – a case report

Recent advances in laparoscopic surgery have made it possible to perform restorative proctocolectomy (RP) for ulcerative colitis (UC) or familial adenomatous polyposis (FAC). However, most of these procedures are performed as two‐stage operations with the creation of diverting ileostomy. Furthermore, they are performed with a small abdominal incision from 4 to 8cm in length. We describe the first case of ulcerative colitis that underwent a single‐stage completely laparoscopic restorative proctocolectomy without an abdominal incision. The patient also underwent lymph node dissection since he had a sigmoid colon cancer. The postoperative course was uneventful and the functional outcome was satisfactory. Considering the improved cosmetic as well as functional results achieved by this procedure, the present technology can be applied for selected patients, especially young UC or FAP patients needing RP who seek for a superior cosmetic result.     

Case of intra‐abdominal spindle cell tumor after laparoscopic resection of sigmoid colon cancer

We herein report a rare case of a patient who developed a spindle cell tumor at the inferior mesenteric artery clipping site. A 58‐year‐old man underwent laparoscopy‐assisted sigmoid colectomy for sigmoid colon cancer. As follow‐up, CT scans were performed every 6 months after the primary surgery. At the 1‐year CT, an nodular soft tissue density mass measuring 54 mm in diameter was found in the mesentery. Although we initially suspected locoregional recurrence of the colon cancer resected 1 year earlier, PET‐CT showed that the tumor was unrelated to the previous cancer. During the subsequent laparotomy, the mass appeared to originate from the inferior mesenteric artery clipping site, and it adhered to the jejunum and the left ureter. We completely resected the tumor and part of the jejunum, which we separated from the abdominal aorta and left ureter. The tumor was histologically diagnosed of a spindle cell tumor. The patient has been free from recurrence since the surgery more than 4.5 years ago. Preoperative PET‐CT was helpful in ruling out local recurrence of colon cancer, which might have made palliative care a better option than surgical resection.     

Two‐stage laparoscopic curative resection for synchronous multiple colorectal cancers: A case report

A 75‐year‐old man tested positive for occult blood in the stool. A subsequent examination indicated concurrent locally advanced cancer (cT3) at the hepatic flexure and lower rectum cancer in the external anal sphincter. Because of the locally advanced rectal cancer (cT4), preoperative chemoradiotherapy was administered. First, laparoscopic right hemicolectomy and colostomy were performed at the sigmoid colon. Chemoradiotherapy for rectal cancer was initiated on day 18 after the surgeries. Seven weeks after chemoradiotherapy had been completed, laparoscopic abdominoperineal resection and right lateral pelvic lymph node dissection were performed. This case demonstrated that a second radical surgery for rectal cancer could be performed safely and laparoscopically after laparoscopic colectomy and colostomy.     

Sterile abdominal abscess resulting from remnant laparoscopic clips after sigmoidectomy: A case report and literature review

The occurrence of intra‐abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74‐year‐old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine‐needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory‐white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.     

Laparoscopic repair of an irreducible femoral hernia containing an epiploic appendage of the sigmoid colon

Here we present the first report of laparoscopic repair of an irreducible femoral hernia containing an epiploic appendage of the sigmoid colon. A 73‐year‐old woman presented with a 1‐week history of a left groin mass below the inguinal ligament with no abdominal symptoms. Abdominal CT demonstrated a 21 × 18‐mm oval‐shaped, fat‐dense structure in the left groin area. The hernia contents were considered potentially associated with the omentum; thus, a left irreducible femoral hernia was diagnosed. Elective laparoscopic surgery revealed an irreducible femoral hernia containing an epiploic appendage of the sigmoid colon, which was then reduced. The reduced epiploic appendage showed no ischemic changes, inflammation, torsion, or swelling, obviating the need for resection. The femoral hernia was laparoscopically repaired via a transabdominal preperitoneal approach with mesh. The patient's postoperative recovery was uneventful, and no recurrence of the femoral hernia was noted at the 6‐month follow‐up.     

Laparoscopic surgery for sigmoidocutaneous fistula due to diverticulitis: A case report

Sigmoidocutaneous fistulas due to sigmoid colon diverticulitis are very rare. Here we report a case in which laparoscopic sigmoidectomy was used to successfully treat a sigmoidocutaneous fistula due to diverticulitis. A 41‐year‐old man was admitted to our hospital because of redness and swelling of the left inguinal skin. Enhanced abdominal CT revealed a subcutaneous abscess in the left lower abdomen. Percutaneous drainage was performed, and fistulography revealed a fistula between the sigmoid colon and left inguinal skin. Therefore, a sigmoidocutaneous fistula was diagnosed, and laparoscopic sigmoidectomy and fistulectomy were performed. The sigmoid colon had several diverticula, and a pathological examination revealed that the sigmoidocutaneous fistula was due to diverticulitis. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. In cases of sigmoidocutaneous fistula, laparoscopic treatment can be safely performed.     

Laparoscopic high anterior resection for triple colorectal cancers with persistent ascending and descending mesocolons: A case report

Persistent mesocolon is an embryological anomaly of the colon resulting from failure of the primitive dorsal mesocolon to fuse with the parietal peritoneum. We herein present a case of laparoscopic high anterior resection for triple colorectal cancers with persistent ascending and descending mesocolons and a right‐bound inferior mesenteric artery. Preoperative 3‐D CT demonstrated that the sigmoid colon had shifted to the right abdomen and was located under the ascending colon. Moreover, the inferior mesenteric artery and vein traveled toward the right abdomen accompanied by the mesentery of the descending colon. Adhesiolysis between the ascending and sigmoid colon was initially performed, and the sigmoid colon was placed in its normal position. The inferior mesenteric artery was then divided with lymph node dissection using a medial approach, and high anterior resection was completed. An understanding of the anatomical characteristics of persistent mesocolon is important to ensure safe laparoscopic surgery.     

Bowel obstruction associated with endoscopic tattooing of the colon with India ink

During a laparoscopic resection of small colorectal lesions, preoperative endoscopic marking with India ink is useful for identifying the location of the lesion. India ink has been thought to be a safe agent with few adverse effects. We herein report a case who suffered from postoperative abdominal pain resulting in bowel obstruction, due to massive adhesion around the area with India ink. A 61‐year‐old man with early transverse colon cancer underwent a laparoscopy‐assisted transverse colon resection. Prior to the operation, endoscopic tattooing with India ink was performed. At the operation, spillage of India ink into the peritoneal cavity was observed. Many small black spots were thereafter seen on the peritoneum, mesentery and omentum, but neither severe inflammation nor any adhesion was noticed. The operation was performed without any difficulty. Though his immediate postoperative course was uneventful, a bowel obstruction gradually developed from a week postoperatively. Finally, he had to undergo a re‐operation, and was found to have diffuse and massive adhesion around areas with India ink. Especially, severe omental adhesion involved and squeezed the transverse colon. A resection of the omentum with stenotic colon and re‐anastomosis was performed. India ink can cause severe inflammation and adhesion when it accidentally leaks into the peritoneal cavity.     

Inguinoscrotal hernia containing the urinary bladder successfully repaired using laparoscopic transabdominal preperitoneal repair technique: A case report

We report herein a patient with an inguinoscrotal hernia containing the urinary bladder. The hernia was safely repaired using the laparoscopic transabdominal preperitoneal repair technique. A 76‐year‐old man was admitted to our hospital with abdominal pain, vomiting, and diarrhea. His scrotum was swollen to fist size. Abdominal CT showed herniation of the sigmoid colon and the bladder into the right inguinal region, and his abdominal pain was attributed to incarceration of the sigmoid colon; this was manually reduced. About 1 month later, we performed transabdominal preperitoneal repair. After the direct hernial orifice was identified, the bladder was noted to be sliding from the medial side of the hernia; this was reduced. Peeling on the medial side was carried out to the middle of the abdominal wall, and the myopectineal orifice was covered with mesh. The patient was discharged on postoperative day 1.     

Laparoscopic right hemicolectomy for metachronous ascending colon cancer with preservation of an ileal conduit constructed after previous radical cystectomy for bladder cancer

A 79‐year‐old woman who had undergone laparoscopic radical cystectomy and ileal conduit construction for bladder cancer 4 years earlier presented to our hospital with anemia. We diagnosed advanced ascending colon cancer (cT4bN2M1) and documented tumor regression after six courses of folinic acid, 5‐fluorouracil, and oxaliplatin therapy. We then performed laparoscopic right hemicolectomy. Intraoperatively, we found that the right colic artery was the feeding artery of the tumor, whereas the ileocolic artery, which was the main feeder of the conduit, was not. We performed lymph node dissection along the surgical trunk with central vascular ligation of the right colic artery and the right branch of the middle colic artery while preserving the ileal conduit and its blood supply (ileocolic artery and ileal branches). The postoperative course was uneventful, and the patient remains well and cancer‐free 2 years after colonic surgery. We believe that this is the first report of laparoscopic right colectomy in a patient with an ileal conduit.     

Using indocyanine green fluorescent imaging to successfully resect metachronous regional lymph node recurrence of rectosigmoid cancer

A 39‐year‐old female patient underwent anterior resection with locoregional lymph node dissection for rectosigmoid cancer at another hospital. The procedure involved transection of the superior rectal artery just below the origin of the left colic artery. Postoperative diagnosis was stage III B. The patient received adjuvant chemotherapy with oxaliplatin plus capecitabine for 6 months. Sixteen months after the operation, PET‐CT scans revealed regional lymph node metastases around the root of the inferior mesenteric artery. The patient was referred to our hospital with a recurrence of rectosigmoid cancer. We performed laparoscopic lymph node dissection with real‐time indocyanine green fluorescent images superimposed on color images to prevent intraoperative vascular insufficiency. We were able to successfully observe the sufficient blood flow in the descending colon. Postoperative pathological findings showed lymph node recurrence after initial surgery. She was discharged 7 days after the operation. In the 8 months since the second operation, the patient has not had any indication of further recurrence.     

One-stage completely laparoscopic restorative proctocolectomy for ulcerative colitis complicated with sigmoid colon cancer--a case report.

Recent advances in laparoscopic surgery have made it possible to perform restorative proctocolectomy (RP) for ulcerative colitis (UC) or familial adenomatous polyposis (FAC). However, most of these procedures are performed as two-stage operations with the creation of diverting ileostomy. Furthermore, they are performed with a small abdominal incision from 4 to 8 cm in length. We describe the first case of ulcerative colitis that underwent a single-stage completely laparoscopic restorative proctocolectomy without an abdominal incision. The patient also underwent lymph node dissection since he had a sigmoid colon cancer. The postoperative course was uneventful and the functional outcome was satisfactory. Considering the improved cosmetic as well as functional results achieved by this procedure, the present technology can be applied for selected patients, especially young UC or FAP patients needing RP who seek for a superior cosmetic result.