Long-term consequences of not closing the mesenteric defect after laparoscopic right colectomy

Internal Hernia Through a Mesenteric Defect Following Esophagectomy and Reconstruction With a Stomach-Preserved Ileocolic Interposition

Esophagectomy is the standard treatment for esophageal cancer and often involves the stomach as a substitute organ for esophageal reconstruction. However, we actively perform stomach-preserved ileocolic interposition because of its advantages in gastrointestinal function and the prevention of reflux esophagitis. Despite its benefits, few facilities perform esophageal reconstruction with ileocolic interposition; hence, postoperative complications following this procedure have rarely been reported. We present the first case of internal hernia through a mesenteric defect following esophagectomy and reconstruction with a stomach-preserved ileocolic interposition. This type of internal hernia after esophageal cancer surgery is a rare complication following a common gastric pull-up reconstruction. A 66-year-old Japanese female underwent esophagectomy and reconstruction with stomach-preserved ileocolic interposition for stage I esophageal cancer. One month after surgery, the patient experienced abdominal pain and vomiting. CT showed a dilated small bowel and a suspected postoperative adhesive bowel obstruction. Despite conservative management, the patient experienced recurrent episodes that required hospitalization. Although an exact preoperative diagnosis was not made, we decided on a surgical exploration six months after the first symptoms appeared. Laparotomy revealed an internal herniation through a mesenteric defect between the transverse mesocolon and the ileum mesentery following ileocolic interposition. We then repositioned the fitted small intestine and closed the mesenteric defects. The patient recovered uneventfully without a hernia recurrence. Minimally invasive techniques for treating esophageal cancer are becoming more common. As survival rates improve, the number of internal hernia cases, such as those described in this report, will likely increase. Therefore, more cases are needed to determine whether closing mesenteric defects can effectively prevent herniation. However, immediate surgical treatment should be considered based on the symptoms, even when a preoperative diagnosis is difficult.

Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer

INTRODUCTION

This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC).

METHODS

Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups.

RESULTS

The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group.

CONCLUSIONS

The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.

The value of mesenteric closure after laparoscopic right hemicolectomy: a scoping review

OBJECTIVE

To evaluate the prognostic impact and describe suturing tools of mesenteric closure after laparoscopic right hemicolectomy (LRH).

METHODS

PubMed, Embase, Cochrane library, Web of Science, and Scopus databases, were searched and publications relating to mesenteric closure data and tools were extracted. Search terms: "Mesenteric Defects" and "Mesenteric Closure" were used, and manual searches of eligible articles from literature reference lists performed.

RESULT

A total of 7 publications were identified. 5 focused on prognostic impact and 4 referred to tools for mesenteric closure, two of which concerned both prognostic data and tools. All studies related to prognostic impact were single center with "low" modified GRADE quality. A high degree of heterogeneous was found.

CONCLUSION

The evidence from current research does not support routine closure of mesenteric defects. Use of a polymer ligation clip has produced favorable results in a small sample size trial and further investigation is merited. A large randomized controlled trial is still warranted.

Internal hernia after laparoscopic sigmoidectomy with splenic flexural mobilization and high ligation of the inferior mesenteric vein: A case report

Several studies have recently reported the rare occurrence of internal herniation of the small bowel after laparoscopic colorectal surgery. Most cases of internal herniation after laparoscopic colorectal surgery occur due to a mesenteric defect. However, there have been no reports on the indications for closing mesenteric defects to prevent the development of an internal hernia. This study reports a case of an internal hernia of the proximal jejunum near the ligament of Treitz in a patient who underwent laparoscopic sigmoidectomy with splenic flexural mobilization and high ligation of the inferior mesenteric vein. Assessing the risk for internal herniation before completing the initial surgery is crucial. Additionally, mesenteric defect closure should be performed to prevent the development of internal hernias among patients with a potential risk.

Ileocolic Anastomoses

Ileocolic anastomoses are commonly performed by surgeons in both open and minimally invasive settings and can be created by using many different techniques and configurations. Here the authors review both current literature and the author's preference for creation of ileocolic anastomoses in the setting of malignancy, inflammatory bowel disease, and colonic inertia. The authors also review evidence surrounding adjuncts to creation of anastomoses such as use of indocyanine green and closing mesenteric defects. While many techniques of anastomotic creation have adapted with new evidence and technologies, several key principles still provide the foundation for current practice.

Internal Hernia After Laparoscopic Left Colectomy: Case Series and Review of the Literature

Objective Laparoscopic colectomy has gained acceptance as a standard treatment for benign and malignant colorectal disease, such as diverticular disease and cancer, among others. Same as in open surgery, the laparoscopic approach carries a low risk of small bowel obstruction in the postoperative period, but in laparoscopic surgery, internal hernia after laparoscopic left colectomy may be a cause of small bowel obstruction with a significant risk of morbidity and mortality. This rare complication may be prevented with routine closure of the mesenteric defects created during the colectomy.

Methods We present four cases of internal herniation after laparoscopic colectomy. Two cases were after laparoscopic left colectomy and two after laparoscopic low anterior resection. All four cases had full splenic flexure mobilization. Routine closure of the mesenteric defect was not performed in the initial surgery.

Results The four patients were treated by laparoscopic reintervention with closure of the mesenteric defect. In two of them, conversion to open surgery was necessary. One of the patients developed recurrent internal herniation after surgical reintervention with mesenteric closure of the defect. All patients were managed without need for bowel resection, and mortality rate was 0%.

Conclusion Internal herniation after laparoscopic colorectal surgery is a highly morbid complication that requires prompt diagnosis and management and should be suspected in the early postoperative period. Additional studies with extended follow-up are required to establish recommendations regarding its prevention and management.

The SAGES MASTERS program presents: the 10 seminal articles for the Laparoscopic Right Colectomy Pathway

BACKGROUND

As one of the 12 clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, the Colorectal Pathway intends to deliver didactic content organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure (laparoscopic right colectomy, laparoscopic left/sigmoid colectomy, and intracorporeal anastomosis during minimally invasive (MIS) ileocecal or right colon resection). In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic right colectomy which surgeons should be familiar with.

METHODS

Using a systematic literature search of Web of Science, the most cited articles on laparoscopic right colectomy were identified, reviewed, and ranked by the SAGES Colorectal Task Force and invited subject experts. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, with emphasis on relevance and impact in the field, findings, strengths and limitations, and conclusions.

RESULTS

The top 10 seminal articles selected for the laparoscopic right colectomy anchoring procedure include articles on surgical techniques for benign and malignant disease, with anatomical and video illustrations, comparative outcomes of laparoscopic vs open colectomy, variations in technique with impact on clinical outcomes, and assessment of the learning curve.

CONCLUSIONS

The top 10 seminal articles selected for laparoscopic right colectomy illustrate the diversity both in content and format of the educational curriculum of the SAGES Masters Program to support practicing surgeon progression to mastery within the Colorectal Pathway.

Internal hernia following laparoscopic anterior resection for cancer: higher prevalence than expected of an under-reported complication

BACKGROUND

Internal hernia (IH) after laparoscopic colorectal surgery is a potentially severe complication. It may go undiagnosed in patients having their abdominal CT scan during oncologic follow-up. We evaluated the occurrence of IH on CT scans after laparoscopic curative resection for rectal cancer (LRRC) and routine closure of the mesenteric defect.

METHODS

Data from 189 consecutive patients undergoing elective curative LRRC in a 14-year period (June 2005-june 2019) were prospectively collected. Only patients with abdominal CT scans, performed as routine oncologic follow-up, between 3 months and 7 years post-operatively were included in the study and reviewed by a surgeon and a radiologist.

RESULTS

A total of 161 patients were eligible for the study with a median age of 69 years (IQR: 59-77) at surgery. They had abdominal follow-up CT scans at a median of 39.5 months (IQR: 12.8-62.7) after surgery. The prevalence of IH was 11.2% (18/161 patients). Of the 18 patients, 15 (83.3%) were fully asymptomatic, 2 (11.1%) reported chronic abdominal discomfort (including mostly nausea and colicky pain) during their oncologic follow-up (however, IH was not suspected neither prompted additional investigations), and 1 (5.6%) was reoperated elsewhere for IH and acute small bowel obstruction.

CONCLUSIONS

IH following LRRC is not uncommon, with a prevalence > 10% in our experience. Most of these patients remain fully asymptomatic, but in a few patients, IH might be responsible for some symptoms or require reoperation. Awareness of this complication is important, given the potential risk of acute small bowel obstruction.

Postoperative Outcomes of Closed Versus Nonclosed Mesentery Laparoscopic Colectomy: A Retrospective Single-center Study

PURPOSE

This study aimed to clarify the clinical significance of closing the mesenteric defect in laparoscopic colectomy.

MATERIALS AND METHODS

We retrospectively evaluated 369 patients who underwent left-sided or right-sided resection via laparoscopic colectomy at our institute. Patients were stratified by open versus closed handling of the mesenteric defect. The perioperative clinical factors, surgical maneuvers, and postoperative complications were statistically analyzed.

RESULTS

No significant intergroup differences were found in the perioperative clinical factors or surgical maneuvers except for number of days to the first soft diet (P=0.0214) and postoperative complications (P=0.0379). Among the postoperative complications, only ileus occurred more frequently in the closed group than in the open group (P=0.0227).

CONCLUSIONS

This study revealed that closure of the mesenteric defect following laparoscopic colectomy might be associated with an increased incidence of postoperative ileus.

Intraoperative maneuvers may affect the development of early postoperative small bowel obstruction after laparoscopic colorectal cancer surgery: Multicenter prospective cohort study

BACKGROUND

Early postoperative small bowel obstruction (EPSBO) is one of the most common complications after colorectal cancer (CRC) surgery, and clarification of its causes is desired. Several reports have demonstrated the risks of EPSBO, but few have focused on laparoscopic surgery for CRC and intraoperative maneuvers. We therefore prospectively examined the risk factors for EPSBO after laparoscopic CRC resection.

METHODS

We prospectively enrolled 706 patients with CRC that underwent laparoscopic CRC resection in our hospital and affiliated hospitals. We analyzed several factors concerning EPSBO including intraoperative procedures.

RESULTS

EPSBO developed in 43 of the 706 cases (6.1%). Univariate analysis showed that risk factors for EPSBO were male sex, increased operative time, repositioning of the small intestine before wound closure and anastomotic leakage. Risk factors for EPSBO according to multivariate analysis were increased operative time (odds ratio (OR) 2.41; P = 0.032), repositioning of the small intestine before wound closure (OR 3.58; P = 0.005) and anastomotic leakage (OR 3.91; P = 0.006).

CONCLUSION

To reduce EPSBO after laparoscopic CRC surgery, the operation should be finished as soon as possible without performing optional maneuvers. To avoid development to EPSBO, particular care is required in cases where the risk of anastomotic leakage is predicted to be high.

Case report of laparoscopic reduction of retro-ureter incarcerated small bowel obstruction

RATIONALE

Various types of internal hernias have been reported including paraduodenal, intersigmoidal, pericecal, foramen of Winslow, as well as transmesenteric and retroanastomotic hernias. However, small bowel obstruction secondary to an internal hernia caused by the ureter is rare, and only a few cases have been reported worldwide. We report a case of small bowel herniation caused by the ureter in a woman who underwent radical hysterectomy for cervical cancer.

PATIENT CONCERNS

A 53-year-old woman presented with acute abdominal pain and vomiting and reported a history of radical hysterectomy for cervical cancer 6 years prior to presentation.

DIAGNOSES

Computed tomography revealed segmental luminal dilatation of pelvic ileal loops, 2 transition zones with the beak sign in the left-sided pelvic cavity, and reduced enhancement of bowel loops. Hydronephrosis with abrupt luminal narrowing of the left distal ureter was also observed.

INTERVENTIONS

Exploratory laparoscopy revealed incarcerated bowel segments beneath an adhesive band. We did not immediately cut the adhesive band and continued to trace the course of the small bowel and attempted reduction of the hernia. Reduction of the hernia was not difficult; therefore, the entire small bowel could be disentangled from the pelvic adhesions without any small bowel injury. After reduction of the herniated small bowel, we could confirm that the adhesive band was the left ureter (ureteral peristalsis was observed). The reduced segments of the small bowel appeared viable, and resection was not required.

OUTCOMES

The patient was discharged 2 days postoperatively without any complication.

LESSONS

Cutting band during adhesiolysis enables release of bowel obstruction. However, owing to the different types of internal hernias that are known to occur, it is essential to confirm the patient's history and preoperative CT findings to avoid complications.

A cross sectional study to investigate internal hernia post left-sided colectomy preserving superior rectal artery

Background

and Purpose: Intestinal obstruction caused by an internal hernia projecting through a mesenteric defect is a rare sequela of laparoscopic colectomy, as surgeons usually leave such defects open. In this study, we investigated cases of internal hernia after laparoscopic left-sided colectomy.

Methods

Data of 308 patients who underwent laparoscopic left hemicolectomy or sigmoidectomy at our institute between 2013 and 2018 were retrospectively reviewed. Patient characteristics and surgical variables were analyzed. The distance between the superior rectal artery (SRA) and abdominal aorta at the level of aortic bifurcation was measured using postoperative computed tomography in patients who underwent SRA-preserving colectomy.

Results

In all, 3 patients (0.97%), all of whom had undergone colostomy without anastomosis and with SRA preservation, developed internal hernia passing between the SRA and the aorta. The distance between the SRA and abdominal aorta in patients who underwent ostomy was significantly more than that in patients who underwent non-ostomy (10.6 mm vs. 4.7 mm, respectively, p < 0.001).

Conclusions

SRA preservation and stoma construction are potential risk factors for internal hernia after laparoscopic left-sided colectomy. Lifting of the SRA due to stoma construction possibly enlarges the space between the SRA and aorta. When colostomy is created, it is important to evaluate the space behind the SRA.

Internal hernia after laparoscopic colorectal surgery: an under-reported potentially severe complication. A systematic review and meta-analysis

BACKGROUND

Internal hernia following laparoscopic colorectal surgery is often under-reported. The aim of this review was to evaluate the occurrence rate of internal hernia following laparoscopic colorectal surgery, and to describe clinical presentation and management strategies.

METHODS

A comprehensive literature review was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, clinicaltrials.gov, and the Cochrane Database of Systematic Reviews through April 2018. The review was conducted according to MOOSE guidelines. Quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) tool. Meta-analysis was performed using a random effects model. Studies reporting data on internal hernia after laparoscopic colorectal surgery were included.

RESULTS

Ten observational studies with a total of 8453 patients were included. All included articles were non-comparative prospective or retrospective cohort studies with an average MINORS score of 8.3 (range 6-11). Summary estimate of proportion of patients developing internal hernia after laparoscopic colorectal resection was 0.5% (95% CI 0.3-0.8%). Heterogeneity was moderate (I² 46%, p = 0.03) and study size (> 1000 vs. <1000 patients) was found to have a significant contribution to heterogeneity (p = 0.002). Thirty patients (90.9%) required surgery, with 5 non-fatal and 3 fatal postoperative complications. Quality of some studies was limited; some patients were followed up for less than 1 year; primary surgical procedures included different laparoscopic approaches.

CONCLUSIONS

Occurrence rate of internal hernia after laparoscopic colorectal resection is around 5 per 1000 patients. Small-sized studies are likely to overestimate the occurrence of internal hernia. Need for reoperation is high with a substantial risk of mortality.

Long-Term Consequences of Nonclosure of Mesenteric Defects after Traditional Right Colectomy

Background

There are still discrepancies among general/colorectal surgeons regarding closure of mesenteric defect in scientific literature. This study aimed to assess the long-term consequences of nonclosure of the mesenteric defect after open right colectomy.

Methods

A 7-year retrospectively collected and continuous database revealed 212 consecutive patients who had undergone traditional right colectomy without closing the mesenteric defects at Kaohsiung Chung-Gung Memorial Hospital; all patients were operated by a single surgeon. Among these patients, 17 were excluded (those who died within 30 days after surgery or those who received an end ileostomy). The mean age of the 195 patients (58% men and 42% women) was 61.6 ± 12.6 years, and the follow-up period was 4.1 ± 2.8 years (interquartile range 0.09 ~ 10.4).

Results

Forty-four patients (22.5%) encountered intestinal obstruction. Nine (20.4%) required surgical intervention. The cause of intestinal obstruction was adhesion (n=1), ventral hernia (n=1), and cancer recurrence (n=7). Conservative treatment was successful in 35 patients. The intestinal obstruction group (n = 44) were similar to the no-intestinal obstruction group (n = 151) in terms of the following parameters: age, sex, previous abdominal surgery, indication for colectomy, and procedure related complications. Carcinomatosis was found to increase the incidence of intestinal obstruction. No patient developed intestinal obstruction because of the nonclosure of mesenteric defects after right colectomy.

Conclusion

This study suggested that routine procedure of closing the mesenteric defect after open right colectomy might not be beneficial. Additional studies with extended long-term follow-up periods are needed to confirm the benefits of the nonclosure.

Internal hernia after laparoscopic right hemicolectomy, report of a case

Mesenteric defects are often not closed in laparoscopic colectomy. We herein report a case of an internal hernia projecting through a mesenteric defect following laparoscopy-assisted right hemicolectomy. A 74-year-old woman was hospitalized for the surgical treatment of double colon cancer. Preoperative colonoscopy demonstrated the presence of ascending colon and transverse colon cancers. A laparoscopic-assisted right hemicolectomy was performed. The mesenteric defect resulting from the colectomy was not closed. Three months after the surgery, the patient developed a bowel obstruction. Under a diagnosis of strangulated bowel obstruction, we performed a laparotomy, and found a necrotic small bowel, which had passed into the bursa omentalis through the mesenteric defect. We removed the necrotic small bowel and closed the mesenteric defect by suturing. The patient's postoperative course was uneventful. An internal hernia projecting through a mesenteric defect following laparoscopy-assisted right hemicolectomy developed a severe strangulated bowel obstruction.

Prevention of internal hernias and pelvic adhesions following laparoscopic left-sided colorectal resection: the role of fibrin sealant

BACKGROUND

Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant diseases. This growing experience has also resulted in more reports of postoperative complications from the minimally invasive approach to primary colorectal resection. Small bowel obstruction from internal hernias and pre-sacral adhesions is an uncommon but not negligible complication. However, there is little literature specific to this topic with recommendations for different methods to prevent it. We report our original technique of closing the mesenteric defect and covering the pre-sacral fascia by using fibrin sealant to prevent this complication.

METHODS

From January 2005 to December 2014, a total of 1079 patients underwent elective laparoscopic left colorectal resection (left hemicolectomy or anterior rectal resection) in our department. In the first 298 procedures, the mesenteric defect was left open, while in the following 781 procedures, it was closed using fibrin sealant with the aim of preventing postoperative small bowel obstruction.

RESULTS

Among the first 298 patients, three (1%) required reoperation for small bowel obstruction due to internal hernia (0.33%) or critical pre-sacral adhesions (0.66%). These complications did not occur in the subsequent series in which all 781 patients were treated with fibrin sealant prophylactic closure of the mesenteric defect.

CONCLUSION

In our experience, fibrin sealant closure of the mesenteric defect has demonstrated to be safe and effective in preventing postoperative small bowel obstruction that remains a complication both in open and in laparoscopic colorectal surgeries.

The risk of internal hernia or volvulus after laparoscopic colorectal surgery: a systematic review

AIM

To determine the incidence of internal hernias after laparoscopic colorectal surgery and evaluate the risk factors and strategies in the management of this serious complication.

METHOD

Two databases (MEDLINE from 1946 and Embase from 1949) were searched to mid-September 2015. The search terms included volvulus or internal hernia and laparoscopic colorectal surgery or colorectal surgery or anterior resection or laparoscopic colectomy. We found 49 and 124 articles on MEDLINE and Embase, respectively, an additional 15 articles were found on reviewing the references. After removal of duplicates, 176 abstracts were reviewed, with 33 full texts reviewed and 15 eligible for qualitative synthesis.

RESULTS

The incidence of internal hernia after laparoscopic colorectal surgery is low (0.65%). Thirty-one patients were identified. Five cases were from two prospective studies (5/648, 0.8%), 20 cases were from seven retrospective studies (20/3165, 0.6%) and six patients were from case reports. Of the 31 identified cases, 21 were associated with left-sided resection, four with right sided resection, two with transverse colectomy, one with a subtotal colectomy and in three cases the operation was not specified. The majority of cases (64.3%) were associated with a restorative left sided resection. Nearly all cases occurred within 4 months of surgery. All patients required re-operation and reduction of the internal hernia and 35.7% of cases required a bowel resection. In 52.2% of cases, the mesenteric defect was closed at the second operation and 52.6% of cases were successfully managed laparoscopically. There were three deaths (0.08%).

CONCLUSION

Mesenteric hernias are a rare but important complication of laparoscopic colorectal surgery. The evidence does not support routine closure for all cases, but selective closure of the mesenteric defect during left-sided restorative procedures in high-risk patients at the initial surgery may be considered.

Clinical Significance of Closure of Mesenteric Defects in Laparoscopic Colectomy: A Single-Institutional Cohort Study

BACKGROUND

The effect of closure of mesenteric defects to prevent complications, such as internal hernia, during laparoscopic colectomy remains controversial and is a subject of debate.

PURPOSE

This retrospective single-institution study aimed to clarify the clinical significance of mesenteric defect closure during a laparoscopic colectomy.

METHODS

We evaluated 58 patients who underwent laparoscopic right-side colectomy or transverse colectomy. The statistical relevance of complications, surgical maneuvers, and clinical factors was examined.

RESULTS

The mesenteric defects were closed in 30 patients and not closed in 28 patients. Two patients with ileus and 1 with a deep incisional surgical site infection required a second surgery. The reoperation rate was significantly higher in the nonclosure group than in the closure group (11% vs. 0%, respectively; P=0.033).

CONSIDERATION

Serious complications requiring reoperation occurred only in the nonclosure group. The procedure for closing the defect did not extend the operation time or increase the bleeding.

Result of using a biologic collagen implant (Permacol) for mesenteric defect repair after excision of a huge mesenteric lymphangioma in a child

Mesenteric lymphangiomas, which involve near total mesentery, are extremely rare. A mesenteric lymphangioma should be treated through excision because they can cause invasion of vital structures, bleeding, or infection. After excision of a huge mesenteric lymphangioma, internal herniation may occur through a large mesenteric defect leading to intestinal volvulus, obstruction, and other life-threatening circumstances. We report a case in which a biologic collagen implant (Permacol) was used for mesenteric defect repair after excision of a huge mesenteric lymphangioma. The implant did not cause any symptoms or complications during follow-up for 4 years. When encountering large defects of mesentery, closure with implant can be a feasible choice, and Permacol could be a possible implant for closing the defect.

Single-layer versus double-layer closure of the enterotomy in laparoscopic right hemicolectomy with intracorporeal anastomosis: a single-center study

BACKGROUND

The aim of our study was to evaluate the short-term outcomes of totally laparoscopic right colectomy, in particular to compare the incidence of leakage of the ileocolic anastomosis after either single-layer (SL) or double-layer (DL) enterotomy closure.

METHODS

From March 2010 to July 2014, 162 patients underwent laparoscopic right colectomy with intracorporeal ileocolic anastomosis. The enterotomy was closed with either SL (77 patients) or DL technique (85 patients). Short-term outcomes in both groups were retrospectively analyzed.

RESULTS

Median time to perform the ileocolic anastomosis was similar in the two groups (17 min in SL versus 20 min in DL, p = 0.109). DL closure was associated with a significantly lower incidence of anastomotic leakage (1.2 % in DL vs 7.8 % in SL, p = 0.044). Shorter hospital stay was also observed in the DL group.

CONCLUSIONS

Adoption of DL closure of the enterotomy resulted in significantly improved outcome. We strongly recommend a double-layer closure technique when performing an intracorporeal enterocolic anastomosis.

The incidence and risk of early postoperative small bowel obstruction after laparoscopic resection for colorectal cancer

BACKGROUND

Early postoperative small bowel obstruction is associated with considerable morbidity and mortality but has not been well documented in the era of laparoscopic surgery for colorectal cancer.

SUBJECTS AND METHODS

Consecutive patients who had undergone laparoscopic resection for colorectal cancer were studied.

RESULTS

In total, 1787 patients (105 with and 1682 without early postoperative small bowel obstruction) with colorectal cancer requiring laparoscopic colorectal surgery were evaluated in this study. Ten patients (0.56% among the total patient population, 9.5% among patients who experienced early postoperative small bowel obstruction) who did not respond to conservative treatment for more than 14 days required surgical intervention. Multivariate analysis showed that male sex (adjusted odds ratio [AOR]=2.27), combined operation (AOR=2.23), and diverting stoma (AOR=4.79) were associated with a higher early postoperative small bowel obstruction rate. For factors related to surgical difficulty, open conversion (AOR=2.85), blood transfusion (AOR=3.51), and an operation time longer than 180 minutes (AOR=1.91) were independent factors associated with an increased early postoperative small bowel obstruction rate.

CONCLUSIONS

Early postoperative small bowel obstruction following laparoscopic resection for colorectal cancer occurred in 5.9% of patients. Factors for predicting the development of early postoperative small bowel obstruction in patients with colorectal cancer are variables reflective of a more difficult surgery, rather than pathologic disease severity or anatomical location. In addition, most patients with early postoperative small bowel obstruction improved with conservative treatment, and surgical treatment was rarely needed.

Bowel obstruction caused by an internal hernia that developed after laparoscopic subtotal colectomy: a case report

Introduction

Laparoscopic surgery is a minimally invasive approach with good treatment outcomes and is currently the standard surgery for colorectal cancer in Japan. Mesenteric closure is considered unnecessary in laparoscopic colorectal surgery because it can damage the bowel and blood vessels. However, an internal hernia may develop if the mesentery is not repaired.

Case presentation

We report a case of internal hernia in a 61-year-old male of Japanese ethnicity. The patient had advanced sigmoid colon cancer, early-stage transverse colon cancer, and multiple adenomatous polyposis, and underwent laparoscopically-assisted subtotal colectomy. Bowel obstruction developed six days postoperatively and did not improve with conservative treatment. Abdominal computed tomography detected an internal hernia, prompting emergency surgery in which the ileum protruding into the mesenteric defect and an anastomotic stricture were detected. Reanastomosis, mesentery closure, and ileostomy were performed after hernia repair.

Conclusion

In this case, open surgery was necessary due to bowel obstruction after laparoscopic colectomy. This outcome indicated that mesenteric closure should have been performed. Thus, the benefits of mesenteric closure require assessment in future cases.

Internal-mesocolic hernia after laparoscopic left colectomy report of case with late manifestation

Introduction

In contrast to right colectomy, closure of the mesocolic gap after laparoscopic left colectomy is not practiced, and reports of small gut herniation through this gap are scarce.

Presentation of case

A 73 year old male was admitted as an emergency with symptoms and clinical signs, suggesting obstruction of the small bowel. Abdominal imaging, including computed tomography confirmed the diagnosis. The patient had undergone laparoscopic left colectomy for cancer, three years ago. At laparotomy small bowel loops were found to herniate through the mesocolic defect at the level of the colonic anastomosis. The small bowel loops were reduced and their viability was ascertained. Because of an iatrogenic perforation of the colon at the anastomosis during small bowel loops mobilization, the colon was temporarily exteriorized in the form of a double barrel colostomy. The postoperative course was uneventful.

Discussion

Very few cases have been reported in the liteature indicating the need of sutuing the mesenterium. Despite the limited numbe of the reported cases, there is clearly a risk of intenal hernia after laparoscopic left colectomy.

Conclusion

Although rare internal hernia after laparoscopic left colectomy may occur, and this brings forward the question of mesocolic gap closure.

A systematic review of outcome reporting in colorectal cancer surgery

AIM

Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered.

METHOD

Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies.

RESULTS

Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617).

CONCLUSION

Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.

Intracorporeal ileocolic anastomosis: a review

This study is a narrative review of the current literature regarding intracorporeal ileocolic anastomosis in laparoscopic right colon resection for benign or malignant diseases of the right colon and terminal ileum. The search strategy included Medline, Embase, CINAHL, ACP Journal Club, and Cochrane databases with laparoscopic right colectomy and intracorporeal anastomosis as keywords. All retrieved references were screened by two independent blinded reviewers. Thirteen papers including 611 patients undergoing laparoscopic right colon resection with intracorporeal ileocolic anastomosis for benign or malignant diseases of the right colon and terminal ileum were identified. There were eight case series and five case control studies. Anastomoses were fashioned as antiperistaltic or isoperistaltic, totally stapled or stapled/handsewn. The mesenteric defect was mostly left open. Overall operating time ranged from 53 to 360 min. The most common specimen extraction site locations were periumbilical, suprapubic, or transvaginal with a median incision length ranging from 3 to 6 cm. The overall rate of surgical site infection was 2.7 %. The anastomotic leak rates varied from 0 to 8.5 %. Postoperative mortality was 0.12 %. Intracorporeal ileocolic anastomosis following laparoscopic resection of the right colon is not commonly performed, but offers potential benefits if carried out by experienced surgeons in selected patients.

Laparoscopic right hemicolectomy

Over the past 20 years, laparoscopic colectomy has become a well-established technique in the surgical armamentarium of colorectal operations, with proven reductions in postoperative pain, time to return of bowel function, and length of hospital stay. After early concerns over its oncologic effects, large prospective, multicenter trials have proven its safety in colorectal adenocarcinoma, with equivalence in nodal harvest, recurrence rates, disease-free survival, and overall survival. Laparoscopic right hemicolectomy in particular is a relatively accessible technique which may be performed by a single surgeon and an assistant/camera operator; this operation serves as an excellent method to develop laparoscopic skills for more complicated colorectal procedures. In this article, we describe the technical aspects of our approach to laparoscopic right hemicolectomy, which utilizes a medial-to-lateral, no-touch technique and either an intracorporeal or extracorporeal anastomosis.

Management of intestinal obstruction following laparoscopic donor nephrectomy

Internal hernias are a rare cause of small bowel obstruction. Following laparoscopic bariatric surgery, specifically gastric bypass and laparoscopic colonic resections, there has been an increase in the incidence of internal hernias. This has been due to either a mesenteric or mesocolic defect being not closed or completely missed. Small bowel loops usually herniate through these defects and present as intestinal obstruction. Internal hernia following laparoscopic donor nephrectomy is a rare complication. The need for presenting this case is the rarity of its occurrence, to stress the fact that following major abdominal laparoscopic surgery the mesenteric or mesocolic defects should be closed, and that this complication was managed laparoscopically, through the same port sites as used earlier for the donor nephrectomy.

Laparoscopic right colon resection with intracorporeal anastomosis

BACKGROUND

This study was performed to evaluate short-term clinical outcomes of laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon.

METHODS

This was a retrospective study of selected patients who underwent laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon for tumors or Crohn's disease by a single surgeon from July 2002 through June 2012. Data were retrieved from an Institutional Review Board-approved database. Study end point was postoperative adverse events, including mortality, complications, reoperations, and readmissions at 30 days. Antiperistaltic side-to-side anastomoses were fashioned laparoscopically with a 60-mm-long stapler cartridge and enterocolotomy was hand-sewn intracorporeally in two layers. Values were expressed as medians (ranges) for continuous variables.

RESULTS

There were 243 patients (143 females) aged 61 (range = 19-96) years, with body mass index of 29 (18-43) kg/m(2) and ASA 1:2:3:4 of 52:110:77:4; 30 % had previous abdominal surgery and 38 % had a preexisting comorbidity. There were 84 ileocolic resections with ileo ascending anastomosis and 159 right colectomies with ileotransverse anastomosis. Operating time was 135 (60-220) min. Estimated blood loss was 50 (10-600) ml. Specimen extraction site incision length was 4.1 (3-4.4) cm. Conversion rate was 3 % and there was no mortality at 30 days, 15 complications (6.2 %), and 8 reoperations (3.3 %). Readmission rate was 8.7 %. Length of stay was 4 (2-32) days. Pathology confirmed Crohn's disease in 84 patients, adenocarcinoma in 152, and other tumors in 7 patients.

CONCLUSION

Laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon resulted in a favorable outcome in selected patients with Crohn's disease or tumors of the right colon.

A simple technique for safe mesenteric defect closure following bowel resection

The closure of the mesenteric defect following bowel resection remains controversial. Proponents of the intervention cite the risk of bowel herniation through an open mesenteric defect and subsequent bowel obstruction whereas supporters of the opposing view advocate that such practice may lead to inadvertent compromise of the bowel blood supply. We describe a novel technique that enables efficient mesenteric defect closure while minimizing the risk of blood vessel injury.

Internal hernia projecting through a mesenteric defect to the lesser omental cleft following laparoscopic-assisted partial resection of the transverse colon: report of a case

We herein report a case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy to the lesser omental cleft in a 61-year-old female. We performed laparoscopic-assisted partial resection of the transverse colon to treat transverse colon cancer. Three years and 6 months after the operation, the patient developed a bowel obstruction requiring surgical intervention. When we observed the intraperitoneal space under laparoscopy, we determined that the small intestine had passed into the bursa omentalis through the mesenteric defect. Additionally, an abnormal opening of the lesser omentum was present with a portion of the small intestine escaping into the space inferior to the liver. We performed reintegration of the escaped bowel and closed the mesenteric defect laparoscopically. This is the first case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy that we have experienced out of more than 2400 cases. Further research is needed to identify the patients who would benefit from the closure of mesenteric defects during laparoscopic-assisted colectomy.

Extracorporeal versus intracorporeal anastomosis after laparoscopic right colectomy for cancer: a case-control study

BACKGROUND

The purpose of this study was to compare the short-term outcome (3 months) of laparoscopic right colectomy, between intra- and extracorporeal anastomosis techniques.

METHODS

This study was designed as a case-controlled study from a prospective colorectal cancer database. Forty consecutive patients who underwent laparoscopic right hemicolectomy with intracorporeal anastomosis (totally laparoscopic colectomy, TLC) for adenocarcinoma, with the exception of T4 lesions and metastasis, were compared with 40 patients who underwent laparoscopic right hemicolectomy with extracorporeal anastomosis (laparoscopic-assisted colectomy, LAC). Controls were matched for stage, age, and gender via a statistically generated selection of all laparoscopic right hemicolectomies performed between October 2006 and August 2009.

RESULTS

In terms of operating time (median 150 min), histopathological results, surgical site complications (5% for LAC and 2.5% for TLC), nonsurgical site complications (2.5% for LAC and 5% for TLC), hospitalization (median 5 days), there were no differences between the groups (p > 0.05). Incision length was significantly shorter for TLC (p < 0.05), but no differences were observed for postoperative use of analgesics. There were six postoperative cases of vomiting with reinsertion of nasogastric tube in the LAC group and only one case in the TLC group (p < 0.05).

CONCLUSIONS

TLC seems feasible and safe, it does not significantly affect the length of surgery, and it guarantees maintenance of radical oncological standards. Furthermore, it significantly improves cosmesis and patient comfort postoperatively, reducing the rates of emesis, which leads to higher rates of early regular diet tolerance.