A novel laparoscopic technique for stapled colon and rectal anastomosis

Short-term outcomes of extracorporeal colo-colonic triangular anastomosis versus functional end-to-end anastomosis in laparoscopic-assisted surgery for left-sided colon cancer: a propensity score matching analysis

PURPOSE

To the best of our knowledge, no studies have compared the short-term outcomes between colo-colonic extracorporeal triangular anastomosis (TA) and functional end-to-end anastomosis (FEEA), with a focus on laparoscopic-assisted surgery for left-sided colon cancer. Therefore, this study compared the short-term outcomes of these anastomoses using propensity score matching analysis.

METHODS

This retrospective study included 129 patients with stage I-IV left-sided colon cancer who underwent laparoscopic-assisted surgery with colo-colonic extracorporeal TA (n = 75) or FEEA (n = 54) between May 2009 and March 2021. After propensity score matching, 84 patients (TA, n = 42; FEEA, n = 42) were included in the analysis. The primary endpoint was the complication rate for all grades, and the secondary endpoints were the rates of Clavien - Dindo grade ≥ 3 complications and anastomotic leakage.

RESULTS

In the matched cohort, there were no significant differences in the complication rates for all grades (35.7% vs. 26.2%, p = 0.479), Clavien - Dindo grade ≥ 3 complications (11.9% vs. 11.9%, p = 1), and anastomotic leakage (0% vs. 4.8%, p = 0.494) between the TA and FEEA groups. In the univariate logistic regression analysis, TA did not increase the frequency of complications for any grades compared with FEEA (odds ratio: 1.570, 95% confidence interval: 0.616-3.980, p = 0.347).

CONCLUSION

Extracorporeal TA demonstrated equivalent short-term outcomes compared with FEEA in cases of laparoscopic-assisted surgery for left-sided colon cancer. TA can be an alternative anastomosis technique in cases wherein FEEA is difficult to perform.

Short- and long-term outcomes of laparoscopic surgery with extracorporeal anastomosis for transverse colon cancer: comparison of triangulating anastomosis with functional end-to-end anastomosis

BACKGROUND

We compared triangulating anastomosis (TRI) with functional end-to-end anastomosis (FEEA) in terms of patient demographics, clinicopathological features, and short- and long-term outcomes in this study.

METHODS

From November 2005 to May 2016, 315 patients with transverse colon cancer underwent laparoscopic resection. TRI was performed in 62 patients and FEEA in 253 patients. Patients with another concomitant cancer, who received neoadjuvant chemotherapy, and/or who underwent another operation at the same time were excluded.

RESULTS

The patients' backgrounds were comparable in each group. Transverse colectomy was selected more frequently in TRI and right hemicolectomy in FEEA. The operation time was shorter in TRI. The rate of anastomotic leakage was comparable (1.6% in TRI vs. 0.8% in FEEA). Stricture was more common in TRI (8.1% vs. 0%) and bleeding was more common in FEEA (1.6% vs. 10.6%). The rate of long-term complications was comparable in each group. Overall survival of stage 0-III patients was comparable in each group (94.7% in TRI vs. 93.7% in FEEA). 5-year disease-free survival of stage 0-III, stage II, and stage III patients was also comparable in each group (94.8% vs. 93.0%, 100% vs. 92.1%, and 80.3% vs. 79.2% in TRI and FEEA, respectively).

CONCLUSION

The short- and long-term outcome rates were acceptable in both groups. Specific attempts to prevent complications are required for each anastomotic procedure.

Superiority of laparoscopic rectal surgery: Towards a new era

While laparoscopic colon surgery has been established to some degree over this decade, laparoscopic rectal surgery is not standard yet because of the difficulty of making a clear surgical field, the lack of precise anatomy of the pelvis, immature procedures of rectal transaction and so on. On the other hand, maintaining a clear surgical field via the magnified laparoscopy may allow easier mobilization of the rectum as far as the levetor muscle level and may result less blood loss and less invasiveness. However, some unique techniques to keep a clear surgical field and knowledge about anatomy of the pelvis are required to achieve the above superior operative outcomes. This review article discusses how to keep a clear operative field, removing normally existing abdominal structures, and how to transact the rectum and restore the discontinuity based on anatomical investigations. According to this review, laparoscopic rectal surgery will become a powerful modality to accomplish a more precise procedure which has been technically impossible so far, actually entering a new era.

Rectal transection by the Nelaton catheter pulling method during a laparoscopic low anterior resection

BACKGROUND

A laparoscopic low anterior resection with double-stapling technique for lower rectal cancer is considered to be technically challenging because it is difficult to perform rectal transection and anastomosis in the narrow pelvic cavity.

METHODS

We developed a new method for transecting the rectum with stapling a small number of cartridges. In laparoscopic low anterior resection, a 70-mm endovascular clip clamps the rectal wall at the anal side of the tumor. An endolinear stapler is applied at the rectal wall parallel and caudal to the 70-mm endovascular clip. A Nelaton catheter of 3.5 to 4.5 mm in outer diameter is inserted, and the loop of the Nelaton catheter is made behind the rectum. The Nelaton catheter loop is applied at the rectal wall parallel and caudal to the endolinear stapler and is pulled parallel the endolinear stapler toward the anterior side of the rectum. The endolinear stapler with opened jaws can be pushed deeper into the space, then the jaws can be closed in a position that can transect the rectum with one firing using only one cartridge.

RESULTS

Curative low anterior resection with rectal transection using the Nelaton catheter pulling method was performed in 13 patients with rectal cancer. The median value and range of tumor distance from the anal verge were 6.0 and 4.5 to 10.0 cm. The median duration of the operation was 284 minutes, and median blood loss was 10 mL. The number of stapling cartridges used for rectal transection was 1 in all cases, and there were no major complications.

CONCLUSIONS

We have demonstrated a safe, easy, and effective new transection method for rectal cancer resection using one firing with a Nelaton catheter.

Trilumenal hybrid-NOS proctocolectomy

BACKGROUND

The authors hypothesized that by combining transumbilical, transvaginal, and transrectal accesses, complex bowel operations, including proctocolectomy with restorative J pouch [corrected] reconstruction, might be possible.

METHODS AND RESULTS

Out of a series of 30 natural orifice surgery (NOS) operations performed at the authors' institution in the past 12 months, proctocolectomy with ileoanal pouch reconstruction was planned for 3 female patients (31 years, BMI = 30; 50 years, BMI = 31; 30 years, BMI = 21) with extensive disease of ulcerative colitis, and they were operated via a 3-lumenal NOS approach. The first 2 patients received a proctocolectomy with a J-pouch formation. A 3-stage procedure was planned for the third patient, and she received a total colectomy. The colonic specimen was retrieved through the anus obviating dilation of the vagina. The J-pouch was prepared through a horizontal 2-cm incision, which later served as the protective loop ileostomy site.

CONCLUSION

Trilumenal NOS proctocolectomy is feasible and safe providing a solution to overcome the lack of triangulation using a single-lumen approach.

Triluminal hybrid NOS as a novel approach for colonic resection with colorectal anastomosis

BACKGROUND

Minimal invasive surgery has led to a significant decrease in surgical trauma, pain, recovery time and improved cosmesis compared with open surgery. However, scar development and the risk of hot spots for infections and hernias are still present. Natural orifice surgery (NOS) promises to offer even further reduction in invasiveness and thus may lead to even faster recovery. The goal of this study was to establish a NOS colonic resection by using commercially available standard surgical instruments avoiding major abdominal incisions.

METHODS AND RESULTS

This article reports a new triluminal hybrid NOS approach for sigmoid and colonic resection (Tri-Port-NOS-SIG), established using rigid laparoscopic instruments through the umbilicus, the vagina, and the rectum, without any major abdominal incision. The specimen was retrieved through the anus avoiding dilatation of the vagina. In an early series of 5 patients the first patient was a 37-year-old woman with a 10-year history of recurrent diverticulitis. She recovered quickly and was discharged on postoperative day 2. She returned to sports activity on day 12 postoperatively and to her heavy-duty job on day 16. The following 4 patients also recovered well and were discharged on postoperative days 7 (2 patients), 8, and 11, respectively. One patient experienced a temporary, mild paresthesia of the left lower dorsal leg, most likely because of intraoperative positioning. No major complications occurred.

CONCLUSION

Tri-Port-NOS-SIG offers a feasible scarless approach for abdominal resections using commercially available surgical instruments in experienced hands.

Endo-satinsky clamp for rectal transection during laparoscopic total mesorectal excision

BACKGROUND

We describe a technique of intracorporeal rectal transection using an endo-Satinsky clamp during laparoscopic total mesorectal excision.

METHODS

We use an abdominal approach through 5 trocars. The rectum and mesorectum are mobilized completely. A flexible trocar is placed at the site of a 12-mm right lower abdominal port after the trocar originally placed there is pulled out. The 12-mm trocar originally placed in the right lower abdomen is moved to the suprapubic site, in which a Pfannenstiel incision is anticipated. The endo-Satinsky clamp is inserted through the flexible trocar, and the rectum is grasped with the endo-Satinsky clamp just above the anticipated point of transection. The endostapler is introduced through the 12-mm suprapubic port and is positioned just distal to the clamp. The rectum is then transected. The transected bowel is resected extracorporeally. Anastomosis is completed intracorporeally by use of a double-stapling technique.

RESULTS

From February 2007 to March 2009, we performed low anterior resection with use of the endo-Satinsky clamp for 11 patients with rectal cancer (laparoscopic, 10 patients; robot-assisted, 1 patient). There were no operative complications or deaths. Mean operation time was 179.5 minutes (range, 120-265 min). The average number of cartridges used for rectal transection was 1.6 per patient.

CONCLUSION

The endo-Satinsky clamp is a useful device for rectal transection and irrigation. The use of this device makes it easier to place an endostapler just distal to the clamp and to transect the rectum in a more appropriate position.

New laparoscopic double-stapling technique

BACKGROUND

Laparoscopic surgery for colon cancer has been shown by several randomized, controlled trials to be an acceptable alternative to open surgery; however, laparoscopic rectal surgery has not been evaluated in a randomized trial. One of the most serious problems associated with laparoscopic rectal surgery are bowel clamping, irrigation, and transection of the rectum, and laparoscopic rectal surgery has not been as reliable as open rectal surgery.

MATERIALS AND METHODS

We present our new technique, the laparoscopic double-stapling technique, which eliminates these problems. This technique uses curved Doyen forceps introduced through the wound just above pubis symphysis for clamping the rectal wall at the anal side of the tumor. An endolinear stapler (length 60 mm) is inserted through the same wound, applied at the rectal wall parallel and caudal to the Doyen forceps, and transects the rectum under pneumoperitoneum. We used this technique for eight cases of rectal surgery.

RESULTS AND DISCUSSION

The laparoscopic double-stapling technique provided secure bowel clamping and rectal irrigation. The number of cartridges used in laparoscopic double-stapling technique cases was not more than 2, with an average of 1.6 per patient. None of the laparoscopic double-stapling technique cases experienced major complications.

CONCLUSION

We consider that many cases of rectal cancer that are suitable for laparoscopic low anterior resection can undergo laparoscopic surgery by using this technique, which will improve the quality of rectal surgery.

Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection

BACKGROUND

Rectal transection and anastomosis at the lower rectum is the most challenging part of laparoscopic low anterior resection. Therefore, some have demonstrated that rectal transection should be performed using instruments for open surgery with small laparotomy. In our institute, however, rectal transection using a currently available endostapler followed by anastomosis with a double stapling technique is usually performed.

METHODS

The important points of our technique are as follows: trocar placement, optimal device choice, harmonious movement between the operator and assistant for rectal transection, optimal point of piercing with the center rod of the circular stapler, and ideal positioning of the proximal colon.

RESULTS

Seventy-eight patients underwent low anterior resection using this technique. There were no conversions to open surgery. All rectal transections were completed laparoscopically with an available endostapler. A diverting ileostomy was created in six cases. Anastomotic leakage occurred in only two patients (2.6%) and rectovaginal fistula in only one patient (1.3%).

CONCLUSIONS

Our standardized technique is considered to be safe and feasible for rectal transection and anastomosis using the double stapling technique (DST).

Laparoscopic colorectal surgery for neoplasm. A large series by a single surgeon

BACKGROUND

The value and efficacy of laparoscopic colorectal surgery has been validated by large multicenter, randomized, controlled trials. However the results of a large series by a single surgeon in a single center have yet to be reported. We reviewed the short-term outcome of our series of laparoscopic colorectal procedures to better define the learning curve for acquiring these skills.

METHODS

Four hundred four patients with a colorectal neoplasm underwent laparoscopic surgery between August 1998 and December 2005. Surgery was performed under 8 to 10 cm H(2)O CO(2) pneumoperitoneum. Type of operation, time of operation, and estimated blood loss were compared for each level of lymph node dissection, and the rate and reason for conversion to open procedures were determined. Time to passage of flatus, hospital stay, and postoperative complications were recorded. The learning curve for right hemicolectomy, sigmoidectomy, and low anterior resection was calculated.

RESULTS

Open conversion was required in 13 patients (3.2%). Uncontrollable bleeding occurred in four cases, and inability to divide the rectum because of adhesions or local invasion occurred in three. The time of operation for D3 level lymph node dissection was longer than for D2 in ileocecal resection, right hemicolectomy, and sigmoidectomy. Estimated blood loss was similar among the different types of operation. Blood loss of last 40 right hemicolectomies was less than in the first 40 cases, and the incidence of intraoperative complications in the first 40 sigmoidectomies was higher than subsequent cases. Time of operation, estimated blood loss, and number of complications did not change over time for low anterior resection.

CONCLUSION

The large series performed by a single surgeon is consistent with large multicenter studies that have validated the superiority of laparoscopic colorectal surgery over conventional open procedures. The learning curve flattens out after about 40 cases of right hemicolectomy and sigmoidectomy.

Totally intracorporeal laparoscopic colorectal anastomosis using circular stapler

BACKGROUND

A number of surgical techniques for colorectal anastomosis have been described for laparoscopic left-sided colectomies. Due to the complexity of these procedures, open preparation of the proximal bowel for circular stapler anastomosis through a Pfannenstiel incision has become the gold standard. We report a new laparoscopic technique for totally intracorporeal colorectal circular anastomosis (TLCCA) using a circular stapler.

METHODS

Preliminary experience using TLCCA in three patients scheduled for laparoscopic left colectomies (two) and sigmoidectomy (one).

RESULTS

Side-to-end colorectal anastomosis through TLCCA was feasible in all patients scheduled for preliminary experience. Median time from anvil insertion into abdominal cavity to anastomosis was 14 (11-17) minutes. No postoperative complications were recorded.

CONCLUSION

Side-to-end anastomosis can be easily and safely performed using conventional circular stapler through TLCCA. TLCCA is performed using four laparoscopic ports without additional skin incision (except trocars incision) and allows the retrieval of surgical pieces through a specimen bag.

Laparoscopic hemicolectomy in a patient with situs inversus totalis

As among persons with normal anatomy, occasional patients with situs inversus develop malignant tumors. Recently, several laparoscopic operations have been reported in patients with situs inversus. We describe laparoscopic hemicolectomy with radical lymphadenectomy in such a patient. Careful consideration of the mirror-image anatomy permitted safe operation using techniques not otherwise differing from those in ordinary cases. Thus, curative laparoscopic surgery for colon cancer in the presence of situs inversus is feasible and safe.

Anterior resection of rectal cancer through a one hand-size incision with or without laparoscopy: proposal of one hand-size incision surgery (OHaSIS)

BACKGROUND

One hand-size incision surgery (OHaSIS) is a surgery that is carried out through one hand-size incision with or without laparoscopy. Safety, feasibility and recovery advantage of the anterior resection of rectal cancer by the OHaSIS were studied.

STUDY DESIGN

Nineteen consecutive patients with rectal cancer, consisting of seven rectosigmoid, six upper rectal, and six lower rectal cancers, were treated with anterior resection, including seven high, six low, three super-low, and three partial intersphincteric resections, through a suprapubic longitudinal one hand-size incision. The initial 11 patients were treated in combination with laparoscopy and the following eight patients were treated without laparoscopy.

RESULTS

All anterior resections with mesorectal excision were completed in a safe manner with acceptable operative time (average 245 min), blood loss (average 280 g), and postoperative complications without any elongation of the initial incision. When compared with 12 previous high and low anterior resections by conventional open surgery (OS), the 13 high and low anterior resections by the OHaSIS showed equivalent operative time, blood loss, anastomotic procedures of single stapling, lymph node numbers dissected, surgical margin of the anal side of the tumor, and complications. Moreover, analysis of perioperative parameters for surgical invasiveness, including a body temperature >37 degrees C, days of bed rest, and days of use of parenteral narcotics, revealed a recovery advantage in the OHaSIS group compared with that in the OS group.

CONCLUSIONS

These results suggest that anterior resection for patients with rectal cancer by the OHaSIS is safe, feasible, and less invasive than conventional OS, and has sufficient operative performance. Although the survival benefit and recurrence rate by this approach must be ensured in a future trial, we would like to propose the new concept of OHaSIS for treating rectal cancer.