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Li C, Wang Q, Jiang KW. What is the best surgical procedure of transverse colon cancer? An evidence map and minireview. World J Gastrointest Oncol 2021; 13:391-399. [PMID: 34040700 PMCID: PMC8131907 DOI: 10.4251/wjgo.v13.i5.391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/25/2021] [Accepted: 03/31/2021] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancers comprise a large percentage of tumors worldwide, and transverse colon cancer (TCC) is defined as tumors located between hepatic and splenic flexures. Due to the anatomy and embryology complexity, and lack of large randomized controlled trials, it is a challenge to standardize TCC surgery. In this study, the current situation of transverse/extended colectomy, robotic/ laparoscopic/open surgery and complete mesocolic excision (CME) concept in TCC operations is discussed and a heatmap is conducted to show the evidence level and gap. In summary, transverse colectomy challenges the dogma of traditional extended colectomy, with similar oncological and prognostic outcomes. Compared with conventional open resection, laparoscopic and robotic surgery plays a more important role in both transverse colectomy and extended colectomy. The CME concept may contribute to the radical resection of TCC and adequate harvested lymph nodes. According to published studies, laparoscopic or robotic transverse colectomy based on the CME concept was the appropriate surgical procedure for TCC patients.
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Affiliation(s)
- Chen Li
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, China
| | - Quan Wang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, China
| | - Ke-Wei Jiang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, China
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Kromberg LS, Kildebro NV, Mortensen LQ, Amirian I, Rosenberg J. Microbreaks in Laparoscopic Appendectomy have No Effect on Surgeons' Performance and Well-being. J Surg Res 2020; 251:1-5. [PMID: 32092608 DOI: 10.1016/j.jss.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/13/2020] [Accepted: 01/19/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Musculoskeletal fatigue and pain as a consequence of performing surgery is found in 70%-87% of surgeons. The aim of this study was to examine the effect of microbreaks on surgeons' performance and well-being during laparoscopic appendectomy. MATERIALS AND METHODS The study was a blinded randomized crossover trial. Twelve surgeons were tested at three time points: Before surgery (baseline), after surgery without intervention, and after surgery where microbreaks were used every 10 min for 10 s. The musculoskeletal endurance test was used as the primary outcome. Performance was assessed by procedure length and a manual precision test. The surgeons' well-being was measured by level of exhaustion rated on the Borg CR10 scale and visual analog scale ratings for musculoskeletal discomfort in the neck, shoulders, back, wrists, and legs. RESULTS No significant differences were found in musculoskeletal endurance, procedure time, or the manual precision test. The level of exhaustion was significantly increased after both normal procedures (P = 0.01) and procedures with microbreaks (P = 0.03). However, no significant difference was found between the two (P = 0.25). There was a significant increase from baseline regarding self-reported musculoskeletal discomfort in the back, shoulders, and legs after surgery but no significant differences between procedures with and without microbreaks. CONCLUSIONS This study did not find a positive effect of microbreaks on laparoscopic appendectomy. Exhaustion and discomfort were present after surgery, demonstrating that short surgical procedures (less than 60 min) can result in fatigue in surgeons.
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Affiliation(s)
| | | | | | - Ilda Amirian
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Jacob Rosenberg
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
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Renzi A, Brillantino A, Di Sarno G, D’Aniello F, Ferulano G, Falato A. Evaluating the Surgeons’ Perception of Difficulties of Two Techniques to Perform STARR for Obstructed Defecation Syndrome. Surg Innov 2016; 23:563-571. [DOI: 10.1177/1553350616656281] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background. After initial enthusiasm in the use of a dedicated curved stapler (CCS-30 Contour Transtar) to perform stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS), difficulties have emerged in this surgical technique. Objective. First, to compare surgeons’ perception of difficulties of STARR performed with only Transtar versus STARR performed with the combined use of linear staplers and Transtar to cure ODS associated with large internal prolapse and rectocele; second, to compare the postoperative incidence of the urge to defecate between the 2 STARR procedures. Design and Setting. An Italian multicenter randomized trial involving 25 centers of colorectal surgery. Patients. Patients with obstructed defecation syndrome and rectocele or rectal intussusception, treated between January and December 2012. Interventions. Participants were randomly assigned to undergo STARR with a curved alone stapler (CAS group) or with the combined use of linear and curved staplers (LCS group). Main Outcome Measures. Primary end-points were the evaluation of surgeons’ perception of difficulties score and the incidence of the “urge to defecate” at 3-month follow up. Secondary end-points included duration of hospital stay, rates of early and late complications, incidence of “urge to defecate” at 6 and 12 months, success of the procedures at 12 months of follow-up. Results. Of 771 patients evaluated, 270 patients (35%) satisfied the criteria. Follow-up data were available for 254 patients: 128 patients (114 women) in the CAS group (mean age, 52.1; range, 39-70 years) and 126 (116 women) in LCS group (mean age, 50.7 years; range, 41-75 years). The mean surgeons’ perception score, was 15.36 (SD, 3.93) in the CAS group and 12.26 (SD, 4.22) in the LCS group ( P < .0001; 2-sample t test). At 3-month follow-up, urge to defecate was observed in 18 (14.6%) CAS group patients and in 13 (10.7%) LCS group patients ( P = .34; Fisher’s exact test). These values drastically decrease at 6 months until no urge to defecate in all patients at 12 months was observed. At 12-month follow-up, a successful outcome was achieved in 100 (78.1%) CAS group patients and in 105 (83.3%) LCS group patients ( P = .34; Fisher’s exact test). No significant differences between groups were observed in the hospital stay and rates of early or late complications occurring after STARR. Conclusions. STARR with Transtar associated with prior decomposition of prolapse, using linear staplers, seems to be less difficult than that without decomposition. Both procedures appear to be safe and effective in the treatment of obstructed defecation syndrome resulting in similar success rates and complications.
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Zmora O, Bar-Dayan A, Khaikin M, Lebeydev A, Shabtai M, Ayalon A, Rosin D. Laparoscopic colectomy for transverse colon carcinoma. Tech Coloproctol 2009; 14:25-30. [PMID: 20033245 DOI: 10.1007/s10151-009-0551-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 10/19/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Laparoscopic resection of transverse colon carcinoma is technically demanding and was excluded from most of the large trials of laparoscopic colectomy. The aim of this study was to assess the safety, feasibility, and outcome of laparoscopic resection of carcinoma of the transverse colon. METHODS A retrospective review was performed to identify patients who underwent laparoscopic resection of transverse colon carcinoma. These patients were compared to patients who had laparoscopic resection for right and sigmoid colon carcinoma. In addition, they were compared to a historical series of patients who underwent open resection for transverse colon cancer. RESULTS A total of 22 patients underwent laparoscopic resection for transverse colon carcinoma. Sixty-eight patients operated for right colon cancer and 64 operated for sigmoid colon cancer served as comparison groups. Twenty-four patients were identified for the historical open group. Intraoperative complications occurred in 4.5% of patients with transverse colon cancer compared to 5.9% (P = 1.0) and 7.8% (P = 1.0) of patients with right and sigmoid colon cancer, respectively. The early postoperative complication rate was 45, 50 (P = 1.0), and 37.5% (P = 0.22) in the three groups, respectively. Conversion was required in 1 (5%) patient in the laparoscopic transverse colon group. The conversion rate and late complications were not significantly different in the three groups. There was no significant difference in the number of lymph nodes harvested in the laparoscopic and open groups. Operative time was significantly longer in the laparoscopic transverse colectomy group when compared to all other groups (P = 0.001, 0.008, and <0.001 compared to right, sigmoid, and open transverse colectomy, respectively). CONCLUSIONS The results of laparoscopic colon resection for transverse colon carcinoma are comparable to the results of laparoscopic resection of right or sigmoid colon cancer and open resection of transverse colon carcinoma. These results suggest that laparoscopic resection of transverse colon carcinoma is safe and feasible.
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Affiliation(s)
- O Zmora
- Department of Surgery and Transplantation, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, 52621, Tel-Aviv, Israel.
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Veenhof AAFA, Engel AF, van der Peet DL, Sietses C, Meijerink WJHJ, de Lange-de Klerk ESM, Cuesta MA. Technical difficulty grade score for the laparoscopic approach of rectal cancer: a single institution pilot study. Int J Colorectal Dis 2008; 23:469-75. [PMID: 18185936 PMCID: PMC2668628 DOI: 10.1007/s00384-007-0433-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2007] [Indexed: 02/07/2023]
Abstract
INTRODUCTION We aimed to categorize laparoscopic rectal resections according to technical difficulty to standardize learning purposes and stratify results, making future studies more comparable. MATERIALS AND METHODS Fifty patients undergoing a laparoscopic total mesorectal excision were prospectively followed. Four preoperatively known facts (gender, body mass index (BMI), tumor localization, and preoperative radiation therapy) were compared to four operative outcomes (operation time, blood loss, a visual analogue score (VAS) for difficulty rewarded by the surgeon, and oncological radicality of the procedure). RESULTS Operating time for male and female patients was 257 vs. 245 min (P=0.229), blood loss was 300 vs. 300 ml (P=0.309), the VAS was 8 vs. 6 (P<0.001), and radicality was 93% vs. 91% (P=0.806). Operating time was 215, 250, and 305 min for high, mid, and low tumors (Spearman -0.44; P=0.02), respectively. Blood loss was 105, 300, and 600 ml (Spearman -0.38; P=0.01). Lower tumors were rewarded a higher VAS (Spearman -0.57; P<0.001) and were less often radically resected (Spearman 0.32; P=0.026). Operating time for irradiated and nonirradiated patients was 277 vs. 225 min (P=0.008), blood loss was 500 vs. 150 ml (P=0.006), the VAS was 7 vs. 5 (P<0.001), and radicality was 79% vs. 100% (P=0.046). Operating time was 240 min for BMI 25-30 and 253 min for BMI>30 (Spearman 0.13; P=0.391). Blood loss was 150 ml for BMI 25-30 and 500 ml for BMI>30 (Spearman 0.38; P=0.01). Higher BMIs were rewarded a higher VAS (Spearman 0.06; P=0.704). BMI had no correlation to radicality of the procedure (Spearman -0.12; P=0.402). There was an association between technical difficulty score and operation time (P=0.007), blood loss (P<0.001), VAS (P<0.001), and radicality of surgery (P=0.043). CONCLUSION Laparoscopic surgery in male, irradiated, and obese patients with lower tumors seemed more difficult. A categorization according to technical difficulty, to preoperatively predict difficulty of the procedure, was found feasible.
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Affiliation(s)
- A. A. F. A. Veenhof
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
| | - A. F. Engel
- Department of Surgery, Zaans Medical Center, Zaandam, The Netherlands
| | - D. L. van der Peet
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
| | - C. Sietses
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
| | - W. J. H. J. Meijerink
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
| | - E. S. M. de Lange-de Klerk
- Department of Clinical Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - M. A. Cuesta
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
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Kang JC, Jao SW, Chung MH, Feng CC, Chang YJ. The learning curve for hand-assisted laparoscopic colectomy: a single surgeon’s experience. Surg Endosc 2007; 21:234-7. [PMID: 17160652 DOI: 10.1007/s00464-005-0448-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Accepted: 04/03/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical experience and outcomes for hand-assisted laparoscopic colectomy were evaluated to define a learning curve. METHODS This study included 60 patients who underwent hand-assisted laparoscopic colectomies performed by a single surgeon. They were analyzed as three consecutive equal groups: A, B, and C. Pearson's chi-square test and one-way analysis of variance (ANOVA) were used to compare differences in demographics and perioperative parameters. Operative times were analyzed to document the learning curve for the procedure. RESULTS There were no significant differences between the three groups in terms of age, sex, operative procedure, or comorbidity. Groups B and C showed significantly shorter operative times, significantly earlier recoveries of gastrointestinal function, less blood loss, and shorter hospital stays than group A. The incidence of operative complications was not significantly different among the three groups (35% vs 5% vs 15%; p = 0.07). CONCLUSIONS Approximately 21 to 25 cases were needed to achieve proficiency in this series.
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Affiliation(s)
- J-C Kang
- Division of Colorectal Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan, ROC.
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Fingerhut A, Ata T, Chouillard E, Alexakis N, Veyrie N. Laparoscopic approach to colonic cancer: critical appraisal of the literature. Dig Dis 2007; 25:33-43. [PMID: 17384506 DOI: 10.1159/000099168] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND/AIMS As laparoscopic colectomy finds its place in the surgical armamentarium, the literature concerning the safety, efficacy, and oncological rational for treatment of colonic cancer is also enriched. A review and critical appraisal of the literature on this subject was the aim of this paper. METHODS A systematic research and a hand search were conducted to gain access to all controlled studies involving laparoscopic colectomy using the Medline, Embase, HealthSTAR, Cumulative Index for Nursing and Allied Health Literature, CancerLit data bases and the Cochrane Central Register of Controlled Trials for the years 1991-2006. RESULTS Over 40 controlled randomized trials and ten systematic reviews and/or meta-analyses were found. Several of the completed controlled randomized trials have published either short- or long-term results; only partial and short-term results are available in rectal cancer. The principal conclusions are that the laparoscopic approach affords better short-term outcomes including surgical site morbidity, but with increased operative times and direct costs. Among the proven long-term outcomes, cancer recurrence and survival do not seem to be worse. Whether conversion, a source of increased operative time and costs, is responsible for poorer outcomes or whether specific settings associated with poorer outcomes are among the causes of conversion remains to be shown. However, there are still concerns as regards specific laparoscopic-related complications. CONCLUSION There seems to no real safety problems in performing laparoscopic colectomy for cancer; improvement in operative times, conversion rates, and complications should make laparoscopy the best cost-effective approach to colectomy.
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Affiliation(s)
- Abe Fingerhut
- Digestive Surgery Unit, Centre Hospitalier Intercommunal, Poissy, France.
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Bemelman WA, Dunker MS, Slors JFM, Gouma DJ. Laparoscopic surgery for inflammatory bowel disease: current concepts. Scand J Gastroenterol 2003:54-9. [PMID: 12408505 DOI: 10.1080/003655202320621463] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND The aim of a laparoscopic approach is reduced pain scores, early mobilization, virtual absence of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital and return to normal activity and improved cosmetics. Potential advantages are fewer complications due to adhesion formation, viz. small-bowel obstruction, infertility and chronic abdominal pain-advantages that are of particular importance to patients with inflammatory bowel disease (IBD) since they are young and in the middle of building up their socio-economic life. This review highlights the current status of laparoscopic surgery for patients with IBD. METHODS Virtually all abdominal procedures carried out in patients with IBD can be done laparoscopically, and vary from stoma formation to restorative proctocolectomy. RESULTS Conversion rates and operating times depend on the surgical expertise and patient-related factors, viz. prior laparotomy, the presence of intestinal fistula or inflammatory masses. Morbidity rates are similar to those of open surgery provided that the procedures are done by expert laparoscopic surgeons. The observed earlier recovery contributed to laparoscopic surgery has not been proved in well-conducted trials; however, an advantage can be expected. A very obvious feature of laparoscopic surgery is the improved cosmetics, which might turn out to be the most important advantage of the laparoscopic approach in this relatively young patient group. CONCLUSION The laparoscopic approach can be considered the procedure of first choice in patients with IBD provided the surgery is done by expert laparoscopists ensuring low conversion rates, acceptable operating times and low morbidity.
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Affiliation(s)
- W A Bemelman
- Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Cosman PH, Cregan PC, Martin CJ, Cartmill JA. Virtual reality simulators: current status in acquisition and assessment of surgical skills. ANZ J Surg 2002; 72:30-4. [PMID: 11906421 DOI: 10.1046/j.1445-2197.2002.02293.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Medical technology is currently evolving so rapidly that its impact cannot be analysed. Robotics and telesurgery loom on the horizon, and the technology used to drive these advances has serendipitous side-effects for the education and training arena. The graphical and haptic interfaces used to provide remote feedback to the operator--by passing control to a computer--may be used to generate simulations of the operative environment that are useful for training candidates in surgical procedures. One additional advantage is that the metrics calculated inherently in the controlling software in order to run the simulation may be used to provide performance feedback to individual trainees and mentors. New interfaces will be required to undergo evaluation of the simulation fidelity before being deemed acceptable. The potential benefits fall into one of two general categories: those benefits related to skill acquisition, and those related to skill assessment. The educational value of the simulation will require assessment, and comparison to currently available methods of training in any given procedure. It is also necessary to determine--by repeated trials--whether a given simulation actually measures the performance parameters it purports to measure. This trains the spotlight on what constitutes good surgical skill, and how it is to be objectively measured. Early results suggest that virtual reality simulators have an important role to play in this aspect of surgical training.
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Affiliation(s)
- Peter H Cosman
- Division of Surgery, Nepean Hospital, Sydney, New South Wales, Australia.
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Fleshman JW, Wexner SD, Anvari M, LaTulippe JF, Birnbaum EH, Kodner IJ, Read TE, Nogueras JJ, Weiss EG. Laparoscopic vs. open abdominoperineal resection for cancer. Dis Colon Rectum 1999; 42:930-9. [PMID: 10411441 DOI: 10.1007/bf02237105] [Citation(s) in RCA: 122] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of this study was to compare the safety and efficacy of laparoscopic abdominoperineal resection and open abdominoperineal resection for cancer. METHODS Records of 194 patients who underwent laparoscopic abdominoperineal resection (42 patients) or open abdominoperineal resection (152 patients) at three institutions between 1991 and 1997 were reviewed. Follow-up was through office charts, American College of Surgeons cancer registry, or telephone contact. Tumors included (laparoscopic abdominoperineal resection and open abdominoperineal resection, respectively) adenocarcinoma (86 and 92 percent), squamous (12 and 7 percent), and gastrointestinal stromal (2 and 1.4 percent) types; Stages I (17 and 26 percent), II (24 and 33 percent), III (43 and 32 percent), and IV (14 and 9 percent); and those with invasion of pelvic structures (14 and 16 percent). RESULTS Laparoscopic abdominoperineal resection was converted to open abdominoperineal resection in 21 percent because of vessel injury (33 percent), poor exposure (22 percent), adhesions (22 percent), inguinal hernia (11 percent), or radiation fibrosis (11 percent). Perineal infections occurred more often in the laparoscopic abdominoperineal resection group (24 vs. 8 percent; P=0.02). Late stoma complications were similar. Mean hospital stay was shorter after laparoscopic abdominoperineal resection (7 vs. 12 days). Radial margins were positive in 12 percent of laparoscopic abdominoperineal resection and 12.5 percent of open abdominoperineal resection specimens. Tumor recurrence was similar for both local (19 and 14 percent) and distant (38 and 26 percent) recurrence. Survival rates were similar by Kaplan-Meier curves, with median follow-up of 19 and 24 months, respectively (P=0.22; log rank). CONCLUSION Laparoscopic abdominoperineal resection can be performed safely and results in a shorter hospital stay. A randomized, prospective trial is needed to determine the long-term outcome of cancer treatment.
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Affiliation(s)
- J W Fleshman
- Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Leibl BJ, Schmedt CG, Schwarz J, Kraft K, Bittner R. Laparoscopic surgery complications associated with trocar tip design: review of literature and own results. J Laparoendosc Adv Surg Tech A 1999; 9:135-40. [PMID: 10235350 DOI: 10.1089/lap.1999.9.135] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
In the last 10 years, there has not been an abdominal surgical procedure that has not been performed by laparoscopic means. The enthusiasm of surgeons active in this field often neglects problems, especially with basic instruments which are important vehicles for the laparoscopic technique. The purpose of this study was to focus on trocar-related problems with special respect to the tip design. On the basis of a prospective study of laparoscopic transperitoneal hernia repair (TAPP) and laparoscopic Nissen fundoplication, we evaluated our data concerning trocar-related complications at the abdominal wall. We compared two groups of patients treated in a nonrandomized design with either sharp cutting single-use trocars or cone-shaped non-cutting reuseable trocars. The evaluation of our own data showed an incisional hernia in 1.83% of patients treated with a sharp trocar tip, a complication which could be significantly lowered, to 0.17%, with a conic tip design. Similar results could be seen with trocar-related bleeding events at the insertion site in the abdominal wall. In most publications, trocar design and related complications are unmentioned. Our data demonstrate a reasonable benefit for a conic tip design, which enables atraumatic insertion through the abdominal wall. The reuseable steel version furthermore holds a considerable cost-saving potential.
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Affiliation(s)
- B J Leibl
- Department of General and Visceral Surgery, Marienhospital, Stuttgart, Germany
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Abstract
Laparoscopic colon surgery is gaining acceptance for benign conditions, but cannot yet be considered an established procedure for malignancy. The main reported benefit of the technique is the reduction in length of hospital stay. Other potential benefits such as cosmesis, improvement in quality of life, physiologic and immunologic advantages, as well as reduced complication rates have not been clearly demonstrated. Concerns about laparoscopic colon surgery for cancer including the possibility of inadequate resection, tumor staging, and altered tumor spread due to pneumoperitoneum have only been partially addressed by retrospective and experimental studies and require a prospective randomized trial for definitive resolution. Details of the trial currently underway sponsored by the National Institutes of Health are described. Although innovations in clinical practice and increased familiarity account for the expanding popularity of laparoscopic colon surgery, results from this and similar worldwide trials are needed before this approach can be recommended for cancer.
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Affiliation(s)
- L Stocchi
- Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Hoffman GC, Baker JW, Doxey JB, Hubbard GW, Ruffin WK, Wishner JA. Minimally invasive surgery for colorectal cancer. Initial follow-up. Ann Surg 1996; 223:790-6; discussion 796-8. [PMID: 8645052 PMCID: PMC1235233 DOI: 10.1097/00000658-199606000-00017] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE An analysis was performed to evaluate early patterns of recurrence and survival in patients undergoing laparoscopic-assisted colectomies for primary colorectal cancer. Thirty-nine patients are available with a minimum of 24 months postoperative follow-up. SUMMARY BACKGROUND DATA The techniques and expected surgical outcomes for patients undergoing laparoscopically assisted colectomies are slowly being defined as these procedures become more common and more widely available. One of the areas of greatest concern is the use of laparoscopic-assisted colectomy for the surgical treatment of patients with primary colorectal cancer. There are anecdotal reports in the literature describing both port site recurrence and wound recurrence in patients undergoing laparoscopic-assisted colectomies for colorectal cancer. This raises concerns about whether these recurrences are more common in patients undergoing laparoscopic procedures and whether overall survival is compromised. Wound recurrences and laparoscopic port site recurrences have been described with numerous other intra-abdominal tumors, but the precise incidence remains unknown. The authors reviewed data from 39 patients to determine early patterns of recurrence and overall survival. METHODS Two-hundred thirty-eight laparoscopic-assisted colectomies were performed by the Norfolk Surgical Group between June 1992 and September 1995. Thirty-nine of the patients who underwent resection for colorectal cancer between June 1992 and September 1993 currently are available for at least a 2-year follow-up. Preoperative evaluation included physical examination, liver function studies, carcinoembryonic antigen, chest x-ray, computed tomography scans, and endoscopies with biopsy. Postoperative follow-up data consisted of physical examination, liver function tests, CEA, chest X-ray, computed tomography scan of the abdomen, and endoscopy of the colon. No patients have been lost to follow-up. Survival rates and patterns of recurrence were compared between node-negative and node-positive patients and compared with conventional data after open surgery. RESULTS There were 22 men and 17 women ranging in age from 33 to 89 years. Mean follow-up was 30 months, with a range of 24 to 40 months. There were three patients with recurrence and nine deaths. Recurrence and tumor-related death rates, respectively, for each Dukes' stage were 0/1 and 0/1 for stage A, 0/7 and 0/7 for stage B-1, 1/16 and 2/16 for stage B-2, 0/1 and 0/1 for stage C-1, and 2/8 and 1/8 for Stage C-2. All six patients with Dukes' stage D disease died of metastatic colorectal cancer within 4 to 14 months of surgery. There were two patients with anastomotic recurrence. No unusual patterns of recurrent disease were noted, and there were no wound or port site recurrences. CONCLUSIONS In this group of patients undergoing laparoscopic-assisted colectomies for primary colorectal malignancy, no adverse patterns of recurrence or decreased survival has been noted at 2-year follow-up when compared with standard open colorectal cancer surgery statistics. Prospective randomized studies with long-term follow-up will be required to better define the potential benefits and adverse effects of laparoscopic surgery for colorectal malignancy.
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Affiliation(s)
- G C Hoffman
- Department of Surgery, Eastern Virginia Medical School, Norfolk, USA
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Kwok SP, Lau WY, Carey PD, Kelly SB, Leung KL, Li AK. Prospective evaluation of laparoscopic-assisted large bowel excision for cancer. Ann Surg 1996; 223:170-6. [PMID: 8597511 PMCID: PMC1235093 DOI: 10.1097/00000658-199602000-00009] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The authors described their experience with laparoscopic-assisted colorectal resection for colorectal carcinoma, both curative and palliative, with emphasis on patient selection. The techniques of the operations were described. SUMMARY BACKGROUND DATA Laparoscopic colorectal procedures for treatment of benign lesions have been shown to be less painful and to enhance early postoperative recovery. However, use of laparoscopic procedures for treatment of colorectal cancer are controversial. The authors have used laparoscopic techniques for curative and palliative resections of colorectal carcinoma with satisfactory early results. METHODS One hundred patients with colorectal carcinoma were selected over a 30-month period for laparoscopic-assisted colorectal resection. For 17 patients, laparoscopy revealed bulky tumor or locally advanced disease, and open surgery was performed. For 83 patients, laparoscopic-assisted colon and rectal resections were attempted. Procedural data and postoperative results were entered prospectively. The median follow-up period was 15.2 months (range, 2.5-32.7 months). RESULTS Fourteen of 83 patients eventually required conversion to open surgery. The median operative time was 180 minutes. The patients could return to a normal diet in a median of 4 days. The median number of doses of analgesics required was two, and the median hospital stay was 6 days. The morbidity rate was 12%, and there was no deaths attributable to the procedure. There were four distant recurrences and one pelvic recurrence. CONCLUSIONS Laparoscopic-assisted colorectal resection for selected patients is feasible, and early postoperative results are encouraging. This procedure does not appear to be associated with an excessive recurrence rate, and long-term follow-up is necessary for late survival figures.
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Affiliation(s)
- S P Kwok
- Department of Surgery, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin
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Wishner JD, Baker JW, Hoffman GC, Hubbard GW, Gould RJ, Wohlgemuth SD, Ruffin WK, Melick CF. Laparoscopic-assisted colectomy. The learning curve. Surg Endosc 1995; 9:1179-83. [PMID: 8553229 DOI: 10.1007/bf00210923] [Citation(s) in RCA: 148] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
One hundred fifty consecutive laparoscopic-assisted colectomies performed by a surgical team were analyzed in an attempt to define a learning curve. These colectomies performed by the Norfolk Surgical Group over a 24-month period, were divided chronologically into six groups of 25 patients each. The groups were then compared to determine if any improvement in length of procedure, complication rate, conversion rate, or length of stay developed as experience increased. Colon cancer and diverticular disease were the most common indications for surgery in all groups. Right hemicolectomy, left colectomy, and low anterior resection accounted for the majority of procedures in all groups. A significant decrease in mean operative time, from 250 min to 156 min over the first 35-50 cases was observed before leveling off at approximately 140 min for the remaining group. Intraoperative complications were low in all groups (range zero to two) and did not show any trend. There was no statistically significant difference in the conversion rate (23.3% overall) among the six groups. Length of stay decreased from 6 days in the first two groups to 5 days in the last four groups, although the difference was not statistically significant. The learning curve for laparoscopic-assisted colectomies is longer than appreciated by many surgeons, requiring as many as 35-50 procedures to decrease operative time to baseline. Complications can be kept at an acceptably low level while on the curve if a cautious approach is taken and the surgeon realizes that a prolonged operative time is not only acceptable, but appropriate during this long learning process. A conversion rate of 20-25% at any phase of the learning process may in fact represent a limitation of current technology. When combined with a low complication rate it may be the sign of a careful surgeon.
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Affiliation(s)
- J D Wishner
- Department of Surgery, Eastern Virginia Medical School, Norfolk 23502, USA
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Slim K, Pezet D, Riff Y, Clark E, Chipponi J. High morbidity rate after converted laparoscopic colorectal surgery. Br J Surg 1995; 82:1406-8. [PMID: 7489179 DOI: 10.1002/bjs.1800821036] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Sixteen of 65 laparoscopically assisted colorectal operations were converted to an open procedure, usually because of dissection difficulties. Conversion was decided early in the procedure in four cases without perioperative morbidity and later in 12 cases, after a mean of 56 min. The results in patients undergoing converted operation were compared with those in 252 having a planned open colorectal procedure during the same period. The groups were comparable with regard to age, health status, factors influencing intestinal healing and grade of surgeon. A higher postoperative morbidity rate (50 versus 21 per cent) and more anastomotic leakages (25 versus 8 per cent) were apparent in the converted group. Operating time, postoperative ileus and hospital stay were longer in those requiring a converted operation. These poor results suggest that careful preoperative patient selection for laparoscopic procedures and a rapid decision to convert in case of difficulty are important.
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Affiliation(s)
- K Slim
- Service de Chirurgie Generale et Digestive, Hotel-Dieu, Clermont-Ferrand, France
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19
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Simons AJ, Anthone GJ, Ortega AE, Franklin M, Fleshman J, Geis WP, Beart RW. Laparoscopic-assisted colectomy learning curve. Dis Colon Rectum 1995; 38:600-3. [PMID: 7774470 DOI: 10.1007/bf02054118] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this paper is to establish the number of cases necessary to master laparoscopic removal of the left or right colon. METHODS Data were obtained by chart review and by individually completed questionnaires. RESULTS A total of 144 laparoscopic-assisted or intracorporeal right or left hemicolectomies were completed by four surgeons at separate institutions. Questionnaires were completed by each surgeon for each sequential hemicolectomy, and data concerning the type of surgery and total operating time were recorded. Times were plotted to diagram individual learning curves for each surgeon, and data grouping methods were used to determine the curve for each surgeon as well as for the combined data base. Learning was said to have been completed when the surgeon's operative time reached a low point and subsequently did not vary by more than 30 minutes. A total of 78 right colectomies and 66 left colectomies were completed by the group. Respectively, each surgeon appeared to learn the procedure after 16, 21, 11, and 6 cases. When the entire database was analyzed as a whole, it was shown that between 11 and 15 completed colectomies were needed for learning, after which operative times remained relatively stable. CONCLUSIONS This analysis, using total operative time as an indication of learning, shows that approximately 11 to 15 completed laparoscopic colectomies are needed to comfortably learn this procedure.
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Affiliation(s)
- A J Simons
- Division of Colorectal Surgery, University of Southern California Medical Center, Los Angeles, USA
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20
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Ramos JM, Beart RW, Goes R, Ortega AE, Schlinkert RT. Role of laparoscopy in colorectal surgery. A prospective evaluation of 200 cases. Dis Colon Rectum 1995; 38:494-501. [PMID: 7736880 DOI: 10.1007/bf02148849] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The aim of this study was to prospectively evaluate the role of laparoscopic-assisted surgery in patients presenting for routine colorectal surgical procedures. METHODS Two hundred consecutive patients were assessed for the possible use of laparoscopic surgery. The decision regarding suitability of the patient for the procedure was made by the operator. For the purpose of analysis, patients were assigned to open, converted, and laparoscopic groups. RESULTS Ninety-five of 200 patients were considered appropriate for laparoscopic surgery, 62 (65.3 percent) being successfully completed. These completed operations included right colectomy (24/30), sigmoid colectomy (22/36), appendectomy (9/10), anterior resection (3/8), abdominoperineal resection (3/5), and left colectomy (1/2). Complications attributable to laparoscopy were infrequent (6.3 percent) and were not responsible for any deaths. Patients in the laparoscopic group required less analgesia, tolerated oral intake earlier, and were discharged from the hospital earlier than those who were converted or who had open procedures. CONCLUSIONS Laparoscopic-assisted surgery is safe, effective, and applicable to many of the standard colorectal procedures. Observed benefits include less postoperative pain and shorter hospital stay.
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Affiliation(s)
- J M Ramos
- Department of Surgery, University of Southern California, Los Angeles, USA
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21
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Geis WP, Kim HC. Use of laparoscopy in the diagnosis and treatment of patients with surgical abdominal sepsis. Surg Endosc 1995; 9:178-82. [PMID: 7597589 DOI: 10.1007/bf00191962] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Patients often present to the surgeon with abdominal pain, tenderness, and fever. Many exhibit progressive sepsis due to abdominal pathology. Delay in diagnosis and treatment often occurs due to the use of multiple, time-consuming, expensive diagnostic studies. We delineate the use of diagnostic laparoscopy in subsets of patients in whom confusion exists as to the cause of abdominal sepsis--i.e., females in child-bearing years, elderly patients, obese patients, immunosuppressed patients, and patients with suppression of physical findings. The methodical assessment of the entire abdominal cavity is performed utilizing manipulation of the patient's position (Trendelenburg, supine, reverse Trendelenburg, left side up, right side up) and meticulous inspection of the entire small bowel. Diagnoses included acute appendicitis, gangrenous appendicitis, perforated appendicitis with peritonitis or abscess, gangrenous cholecystitis, ischemic bowel disease, perforating carcinoma of the colon, perforating diverticulitis with abscess or peritonitis, tubo-ovarian abscess, closed-loop small-bowel obstruction, megacolon, and perforation of the colon. Laparoscopic treatment of 96% of the patients was performed successfully and a laparoscopic-assisted approach was used in the remainder. There was one mortality (cardiac) and no major morbidity. The development of a Formal Diagnostic Exploratory Laparoscopic (FDEL) approach has aided in the assessment of each of the diagnoses of sepsis in the abdominal cavity. The diagnostic and therapeutic approach laparoscopically avoids extensive preoperative studies, avoids delay in operative intervention, and appears to minimize morbidity and shorten the postoperative recovery interval.
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Affiliation(s)
- W P Geis
- Department of Surgery, Mini-Invasive Surgical Training Institute (MISTI) of Baltimore, Saint Joseph Hospital, Towson, MD 21204, USA
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Slim K, Pezet D, Stencl J, Lagha K, Le Roux S, Lechner C, Chipponi J. Prospective analysis of 40 initial laparoscopic colorectal resections: a plea for a randomized trial. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1994; 4:241-5. [PMID: 7949381 DOI: 10.1089/lps.1994.4.241] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The experience reported herein is on our initial 40 cases of laparoscopic-assisted (LA) colorectal resection that were prospectively evaluated. The operations were performed for colonic tumors of the right segment (n = 4), sigmoid (n = 11), or rectum (n = 7), diverticular disease (n = 17), and chronic constipation (n = 1). Among 22 tumors, 11 were malignant. The operative procedures were 4 right hemicolectomies, 28 segmental left colectomies, 5 anterior resections, 2 abdominoperineal resections, and 1 total colectomy. Thirty-one patients (77.5%) had a successfully completed LA resection. The reasons for conversion in the majority of the cases (66.6%) were difficulties in dissection. In the entirely LA procedures, the mean flatus postoperative day was 3, the mean postoperative hospitalization was 10.7 days, and there were 8 complications (25%) in 7 patients. Two patients were reoperated 2 and 3 months later for adhesion and ischemic stenosis of the colon above the anastomosis. There was 1 death in the LA group (3.2%). The length of operative specimen was 19.6 cm, and the mean number of resected lymph node was six. In contrast to laparoscopic biliary surgery, the benefits of LA colorectal surgery are not obvious. A randomized trial comparing LA and open colorectal resection must be carried out.
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Affiliation(s)
- K Slim
- Service de Chirurgie Générale et Digestive, Hôtel-Dieu, Clermont-Ferrand, France
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Plasencia G, Jacobs M, Verdeja JC, Viamonte M. Laparoscopic-assisted sigmoid colectomy and low anterior resection. Dis Colon Rectum 1994; 37:829-33. [PMID: 8055730 DOI: 10.1007/bf02050150] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Laparoscopic-assisted sigmoid colectomy or low anterior resection was undertaken in 30 selected patients. The median age was 51 (range, 30-85) years. Eight patients had previous abdominal surgery: four hysterectomies, two appendectomies, and two cholecystectomies. There was no mortality. Complications occurred in three patients. One patient developed a wound infection, there was one iliac artery injury, and one postoperative bleed, which did not require transfusion. Eighteen patients were operated on for primary cancer of the colon and 12 patients for benign disease. Technical aspects are described in detail. The average hospital stay was four days with most patients receiving oral analgesics by the second postoperative day. Laparoscopic colon resection can be an alternative to open surgery.
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