Intracorporeal versus extracorporeal anastomosis in minimally invasive right colectomy: an updated systematic review and meta-analysis

The initial experience of natural orifice specimen extraction surgery in laparoscopic colorectal surgery

Natural orifice specimen extraction surgery (NOSE) is an extension of minimally invasive colorectal surgery. NOSE was introduced into the unit in January 2024 in selected group of patients. The aim of this study was to evaluate the initial experience of NOSE surgery in minimally invasive surgery colorectal surgery in terms of feasibility and safety outcomes. Prospective data was collated for all cases of NOSE in colorectal surgery from Jan 2024 to Dec 2024. Data collected included patient demographics, comorbidities, underlying pathology, pre-, intra- and post-operative outcomes. There were 17 cases considered for NOSE surgery. Eight cases had successful transvaginal NOSE and six cases had successful transanal NOSE. The median age was 68.5 years (range 36-87 years). The median ASA was 3 (range 1-4). All the transvaginal NOSE were performed with laparoscopic right hemicolectomy for neoplasia. Of the six transanal NOSE, four were performed for benign and two for malignant indications. There were no intraoperative complications with no conversion to open surgery. There were no post-operative complications especially anastomotic leak, ileus, wound infection, and extraction-site related complications in transvaginal NOSE cases. There was one anastomotic leak in transanal NOSE that required laparoscopic washout and defunctioning ileostomy. All the neoplasia cases achieved satisfactory oncological outcomes (R0 resection & adequate lymph node yield). The median follow-up was 6 months (range 2-11). The early experience of NOSE in colorectal surgery is safe and feasible in well selected group of patients. It avoids abdominal wall trauma from extraction with reduction of wound infection, pain and long-term risk of incisional hernia.

Short-term outcomes for intracorporeal vs. extracorporeal anastomosis in laparoscopic right hemicolectomy for colonic cancer-a prospective cohort study (ICEA-study)

PURPOSE

The purpose of this study is to compare short-term outcomes and 1-year incisional hernia rates between intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) in laparoscopic right hemicolectomy for management of right-sided colonic cancer. The primary outcome was the complication rate assessed by the comprehensive complication index (CCI). Secondary outcomes included time to bowel movement, length of hospital stay, 30-day readmission rate, early warning scores, and 1-year incisional hernia rate.

METHOD

This was a single-center, prospective cohort study. Patients with right-sided colonic cancer eligible for laparoscopic surgery with primary anastomosis were consecutively included. Patients included in the first period underwent EA, while those in the second underwent IA. Clinical data were collected during the hospital admission up to 30 days postoperatively. Complications were evaluated by the CCI. A routine 1-year CT-scan was used to assess hernias.

RESULTS

One hundred three patients (51 in the EA and 52 in the IA groups) were included. Demographics were similar between the two groups. No significant difference in the CCI-score was found (EA: 17.9 (23.9) vs. IA: 15.0 (17.4), p = 0.85). The mean length of hospital stay was significantly shorter in the IA group (EA 6.6 days, IA 3.9 days, p = 0.02). The groups had no significant differences regarding other outcomes, including hernia rates (p = 0.12).

CONCLUSION

Laparoscopic right hemicolectomy with IA significantly reduced the length of hospital stay without increasing complication rates compared to EA.

TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov (NCT05039762).

Short-term outcomes of extracorporeal versus intracorporeal side-to-side anastomosis after laparoscopic right hemicolectomy for colon cancer: an affiliated study of a multicenter snapshot study

BACKGROUND

Laparoscopic right hemicolectomy (RHC) is the primary surgical approach for right-sided colon cancer. Different ileo-colonic anastomosis techniques may lead to varied postoperative outcomes. This study aims to compare intracorporeal versus extracorporeal side-to-side anastomosis post laparoscopic RHC for short-term outcomes in right-sided colon cancer patients.

METHODS

This prospective, multicenter, cohort study utilized 1:1 propensity score matching (PSM) and inverse propensity of treatment weighting (IPTW) to address baseline imbalances. The primary endpoint was the incidence of anastomotic leakage (AL) within 30 days postoperatively, with its definition, diagnosis, and grading criteria standardized according to a published study.

RESULTS

A total of 1028 eligible patients were analyzed, with 316 in the intracorporeal anastomosis (IA) group and 712 in the extracorporeal anastomosis (EA) group. After both PSM and IPTW, all 17 covariates were balanced between groups. No statistically significant difference in AL incidence was found between the two groups (before matching, 1.8% in EA and 1.6% in IA, P = 0.78; PSM, 1.3% in EA and 1.6% in IA, P = 0.74; IPTW, 1.9% in EA and 1.6% in IA, P = 0.76). However, peak C-reactive protein levels within 3 days postoperatively were higher in the EA group (before matching, P < 0.001; PSM, P < 0.001; IPTW, P = 0.003). Patients in the IA group had earlier postoperative defecation (before matching, P = 0.01; PSM, P < 0.001) and a shorter total hospital stay (before matching, P = 0.01; IPTW, P = 0.046). Post-PSM analysis showed earlier flatus in the IA group (P = 0.03), while post-IPTW analysis indicated later postoperative eating resumption in the IA group (P = 0.046).

CONCLUSIONS

Intracorporeal anastomosis during laparoscopic RHC for right-sided colon cancer does not increase the incidence of AL or other short-term complications. Furthermore, it facilitates postoperative bowel function recovery.

A Narrative Review on the Role of Artificial Intelligence (AI) in Colorectal Cancer Management

The role of artificial intelligence (AI) tools and deep learning in medical practice in the management of colorectal cancer has gathered significant attention in recent years. Colorectal cancer, being the third most common type of malignancy, requires an innovative approach to augment early detection and advanced surgical techniques to reduce morbidity and mortality. With its emerging potential, AI improves colorectal cancer management by assisting with accuracy in screening, pathology evaluation, precision, and postoperative care. Evidence suggests that AI minimizes missed cases during colorectal cancer screening, plays a promising role in pathology and imaging diagnoses, and facilitates accurate staging. In surgical management, AI demonstrates comparable or superior outcomes to laparoscopic approaches, with reduced hospital stays and conversion rates. However, these outcomes are influenced by clinical expertise and other dependable factors, including expertise in implementing AI-based software and detecting possible errors. Despite these advancements, limited multicenter studies and randomized trials restrict the comprehensive evaluation of AI's true potential and integration into standard practice. We used Pubmed, Google Scholar, Cochrane Library, and Scopus databases for this review. The final number of articles selected, depending on inclusion and exclusion criteria, is 122. We included papers published in the English language, literature published in the last 10 years, and adult patient populations above 35 years with colorectal cancer. We thoroughly included randomized controlled trials, cohort studies, meta-analyses, systematic reviews, narrative reviews, and case-control studies. The use of AI paves the way for the adoption of more personalized medicine. This review highlights the advantages of AI at various disease stages for colorectal cancer patients and evaluates its potential for cost-effective implementation in clinical practice.

COLOR IV: a multicenter randomized clinical trial comparing intracorporeal and extracorporeal ileocolic anastomosis after laparoscopic right colectomy for colon cancer

INTRODUCTION

Right-sided colon cancer is a prevalent malignancy. The standard surgical treatment for this condition is laparoscopic right hemicolectomy, with ileocolic anastomosis being a crucial step in the procedure. Recently, intracorporeal ileocolic anastomosis has garnered attention for its minimally invasive benefits. However, there remains a paucity of rigorously designed, large-scale, international multicenter randomized controlled trials to definitively assess the safety and efficacy of intracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy for right-sided colon cancer.

METHODS

This study is an international, multicenter, randomized, controlled, open-label, non-inferiority trial designed to compare the safety and efficacy of intracorporeal versus extracorporeal ileocolic anastomosis in patients with right-sided colon cancer undergoing right hemicolectomy. The primary endpoint is the anastomotic leakage rate within 30 days post-surgery. The main secondary endpoint is the 3-year disease-free survival rate post-surgery. A comprehensive quality assurance protocol will be established before the trial begins, including CT review, pathological evaluation, and the standardization and assessment of surgical techniques.

DISCUSSION

This study aims to evaluate the safety and efficacy of intracorporeal ileocolic anastomosis following right hemicolectomy in patients with right-sided colon cancer. The anticipated outcome is that intracorporeal ileocolic anastomosis will show an anastomotic leakage rate and a 3-year disease-free survival rate comparable to those of extracorporeal anastomosis, while offering the added benefit of faster postoperative recovery.

Short-term Outcomes of Intracorporeal Versus Extracorporeal Totally Stapled Anastomosis after Laparoscopic Colectomy: A Propensity Score-matched Cohort Study

Objectives

To describe detailed surgical techniques for totally stapled intracorporeal anastomosis (TSIA) and determine their feasibility and safety by comparing short-term outcomes with those of conventional totally stapled extracorporeal anastomosis (TSEA).

Methods

In total, 59 consecutive patients who underwent laparoscopic colectomy between June 2018 and August 2021 were retrospectively assessed. Linear staplers were used for all anastomoses. The TSIA and TSEA groups included 23 and 36 patients, respectively. Following a comprehensive description of each surgical technique, propensity score matching analysis was conducted to compare matched groups on the basis of clinicopathological characteristics, surgical and perioperative outcomes, complications, and postoperative inflammatory reactions. After matching, 17 cases each were analyzed in the TSIA and TSEA groups.

Results

Both groups were well matched. The TSIA group had significantly lesser blood loss than did the TSEA group (10 versus 20 mL, p=0.002), although this result was not clinically significant. The skin excision length (4 versus 6 cm, p<0.001) and postoperative hospital stay length (6 versus 7 days, p<0.001) were significantly shorter in the TSIA group than in the TSEA group. Increasing C-reactive protein (CRP) values at 1, 3, and 6 postoperative days were significantly lower in the TSIA group than in the TSEA group (p=0.016, p=0.011, and p=0.012, respectively).

Conclusions

TSIA is a simple, feasible, and efficient surgical technique; compared with TSEA, it is less invasive and associated with lesser blood loss, shorter skin incision lengths, shorter postoperative hospital stays, and lower CRP level increases.

Laparoscopic robotic-assisted ileo-caecal resection with intracorporeal anastomosis in children with Crohn disease: initial experience of a paediatric center and surgical feasibility

PURPOSE

Pediatric-onset Crohn's disease (CD) presents with a more aggressive course than adults. Surgical treatment is still necessary in many patients. The laparoscopic technique for treating terminal ileal CD is deemed safe and feasible, with the advantage to perform an intra-corporeal anastomosis (ICA). The robotic platform facilitates ICA creation thanks to 3D-visualization, tenfold magnification and better dexterity. The aim of this study was to report our initial experience of robotic ileocecal resection (RICR) with ICA in children with CD.

METHODS

Six patients underwent RICR for CD. Patient characteristics, intraoperative details, and postoperative outcomes were collected. The surgical technique consisted in an intra-corporeal ICR with a stapled side-to-side ileo-colic anastomosis.

RESULTS

The mean age at surgery was 14.8 years. The mean operative time was 210.8 min. No intraoperative complications or conversions were recorded. Bowel function returned on postoperative day 3 and the mean hospital stay was 8 days. Two minor complications were treated conservatively and 1 major (anastomotic dehiscence) required reoperation.

CONCLUSION

RICR is a safe and feasible technique in pediatric CD of terminal ileum. The robot offers advantages over other techniques for the precision of the suture, avoiding extracorporeal anastomosis. However, larger studies are needed to confirm these preliminary results.

Intracorporeal versus Extracorporeal Anastomosis in Laparoscopic Right Hemicolectomy: An Updated Systematic Review and Meta-Analysis of Randomized Control Trials

INTRODUCTION

Laparoscopic right hemicolectomy has become the standard surgical procedure for the treatment of right colon disease; however, the choice of anastomosis remains controversial. This study aimed to compare the safety and efficacy of intracorporeal anastomosis and extracorporeal anastomosis in laparoscopic right hemicolectomy.

METHODS

A systematic literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library. Randomized controlled trials that compared intracorporeal anastomosis with extracorporeal anastomosis in patients with laparoscopic right hemicolectomy until June 4, 2023, are selected. The primary outcomes measured were incidence of anastomotic leakage within 30 days post-operation. Statistical analyses were performed using Review Manager (version 5.4.1).

RESULTS

Seven RCTs, including 720 patients, were eligible for the meta-analysis. The incidence of anastomotic leakage showed no significant difference between the intracorporeal anastomosis group and the extracorporeal anastomosis group (RR 0.93, 95% CI: 0.49, 1.76, p = 0.83, and I2 = 0%). However, the intracorporeal anastomosis group had significantly lower rates of postoperative ileus (RR 0.67, 95% CI: 0.45-0.99, p = 0.04, I2 = 46%) and surgical site infections (RR 0.34, 95% CI: 0.16-0.74, p = 0.007, I2 = 0%) compared to the extracorporeal anastomosis group. Additionally, patients in the intracorporeal anastomosis group experienced earlier postoperative passage of gas and stool (WMD -0.39, 95% CI: -0.60, -0.19, p = 0.0002, and I2 = 67%; WMD -0.53, 95% CI: -0.85, -0.21, p = 0.001, and I2 = 75%), as well as shorter hospital stays (WMD -0.46, 95% CI: -0.74, -0.18, p = 0.001, and I2 = 34%).

CONCLUSION

In laparoscopic right hemicolectomy, intracorporeal anastomosis does not increase the incidence of anastomotic leakage within 30 days post-operation compared to extracorporeal anastomosis. In addition, intracorporeal anastomosis resulted in faster recovery of bowel function. This suggests that intracorporeal anastomosis is safe and effective.

Assessing Surgeons' Attitude to Teaching Intra-Corporeal Anastomosis

Introduction: There is a controversy in minimally invasive colorectal procedures regarding choosing optimal technique between intra-corporeal (ICA) and extra-corporeal anastomosis (ECA). Previous studies recognize the short-term benefits in right hemicolectomy with intra-corporeal approach; however, ICA can result in increased operative difficulty. The aim of this study is to understand attitudes towards teaching ICA in colorectal procedures and how this varies between subspeciality training. Methods: Active members of General Surgeons Australia were contacted through email to participate in a voluntary, unincentivized survey. Demographic details were collected and participants were asked to rate agreement for simulation-based training for increasing adoption of ICA through a Likert scale and when preferences for teaching ICA. Descriptive statistics were completed to describe frequencies and ordinal regression was completed to determine factors for Likert scale question. Results: There were 43 respondents and most participants recognized that ECA was easier to teach trainees and should be taught first. 53.5% of respondents recognized that simulation-based training would assist the adoption of ICA. Surgeons who routinely close bowel or enteric defects intra-corporeally are 354% more likely to show an interest in simulation-based training for adopting ICA, however, surgeons who are not involved in teaching trainees did not show an interest in simulation-based training. Conclusion: There is significant agreement that ECA forms the basis to learn ICA and simulation-based training would assist with the uptake of ICA. However, a multimodal approach, including expanding training avenues and providing financial incentives, would be necessary to enhance the adoption of ICA in colorectal surgery.

Intracorporeal anastomosis in minimally invasive right hemicolectomy: a nationwide survey of the Korean Society of Coloproctology

Purpose

We investigated the current practices and perceptions of colorectal surgeons in South Korea regarding intracorporeal ileocolic anastomosis (IIA) in minimally invasive right hemicolectomy (RHC).

Methods

Members of the Korean Society of Coloproctology (KSCP) participated in an online survey encompassing demographic information, surgical experiences, methods for IIA, and advantages, barriers, and perceptions of IIA. We performed a statistical analysis of survey results.

Results

Among the 1,074 KSCP members contacted, 178 responded to the survey. Most respondents were males aged 40-49 years with >10 years of experience who were affiliated with a tertiary healthcare facility. One hundred fifty-six respondents had performed <100 colorectal cancer surgeries annually. Fifty-nine respondents reported experiences of the IIA technique in minimally invasive RHC. Most respondents favored the isoperistaltic side-to-side (S-S) anastomosis and stapled S-S anastomosis, hand-sewn closure for the common channel, and the periumbilical area for primary specimen extraction. Respondents with IIA experience emphasized the reduction in postoperative complications as the primary reason for performing IIA, whereas respondents without IIA experience cited the lack of benefits as the main deterrent. Respondents commonly cited concerns regarding anastomotic leakage and intraabdominal contamination as the primary reasons for not performing IIA. Respondents with IIA experience demonstrated a more positive response towards attempting or transitioning to IIA than those without. Respondents with IIA experience prioritized self-sufficiency, whereas respondents without IIA experience prioritized proctorship and discussions of the initial cases.

Conclusion

Measures to standardize the IIA technique and appropriate training programs must be implemented to enhance its use in minimally invasive RHC.

Gastrointestinal functions after laparoscopic right colectomy with intracorporeal anastomosis: a pilot randomized clinical trial on effects of abdominal drain, prolonged antibiotic prophylaxis, and D3 lymphadenectomy with complete mesocolic excision

PURPOSE

Routine use of abdominal drain or prolonged antibiotic prophylaxis is no longer part of current clinical practice in colorectal surgery. Nevertheless, in patients undergoing laparoscopic right hemicolectomy with intracorporeal anastomosis (ICA), it may reduce perioperative abdominal contamination. Furthermore, in cancer patients, prolonged surgery with extensive dissection such as central vascular ligation and complete mesocolon excision with D3 lymphadenectomy (altogether radical right colectomy RRC) is called responsible for affecting postoperative ileus. The aim was to evaluate postoperative resumption of gastrointestinal functions in patients undergoing right hemicolectomy for cancer with ICA and standard D2 dissection or RRC, with or without abdominal drain and prolonged antibiotic prophylaxis.

METHODS

Monocentric factorial parallel arm randomized pilot trial including all consecutive patients undergoing laparoscopic right hemicolectomy and ICA for cancer, in 20 months. Patients were randomized on a 1:1:1 ratio to receive abdominal drain, prolonged antibiotic prophylaxis or neither (I level), and 1:1 to receive RRC or D2 colectomy (II level). Patients were not blinded. The primary aim was the resumption of gastrointestinal functions (time to first gas and stool, time to tolerated fluids and food). Secondary aims were length of stay and complications' rate.

CLINICALTRIALS

gov no. NCT04977882.

RESULTS

Fifty-seven patients were screened; according to sample size, 36 were randomized, 12 for each arm for postoperative management, and 18 for each arm according to surgical techniques. A difference in time to solid diet favored the group without drain or antibiotic independently from standard or RRC. Furthermore, when patients were divided with respect to surgical technique and into matched cohorts, no differences were seen for primary and secondary outcomes.

CONCLUSION

Abdominal drainage and prolonged antibiotic prophylaxis in patients undergoing right hemicolectomy for cancer with ICA seem to negatively affect the resumption of a solid diet after laparoscopic right hemicolectomy with ICA for cancer. RRC does not seem to influence gastrointestinal function recovery.

Comparing extracorporeal, semi-extracorporeal, and intracorporeal anastomosis in laparoscopic right hemicolectomy: introducing a bridging technique for colorectal surgeons

PURPOSE

Intracorporeal anastomosis (IA) in laparoscopic right hemicolectomy has been associated with faster recovery in bowel function compared to extracorporeal anastomosis (EA). However, the technical difficulty of laparoscopic suturing technique and intraabdominal fecal contamination hinder many surgeons from implementing such a procedure. We introduce and compare a bridging technique designated as "semi-extracorporeal" anastomosis (SEA), which embraces the advantages and amends the drawbacks of IA and EA.

METHODS

Between May 2016 and October 2022, 100 patients who underwent laparoscopic right hemicolectomy were analyzed. All patients who received laparoscopic right hemicolectomy underwent one of the 3 anastomosis methods (EA, SEA, and IA) by a single colorectal surgeon at a single tertiary care hospital. Data including perioperative parameters and postoperative outcomes were analyzed by each group.

RESULTS

A total of 100 patients were reviewed. Thirty patients underwent EA; 50 and 20 patients underwent SEA and IA, respectively. Operation time (minute) was 170 (range, 100-285), 170 (range, 110-280), and 147.5 (range, 80-235) in EA, SEA, and IA, respectively (P = 0.010). Wound size was smaller in SEA and IA compared to EA (P < 0.001). IA was associated with a shorter time (day) to first flatus compared to SEA and EA (4 [range, 2-13] vs. 4 [range, 2-7] vs. 2.5 [range, 1-4], P < 0.001). Postoperative complication showed no statistical significance between the 3 groups.

CONCLUSION

Semi-extracorporeal was an attractive bridging option for colorectal surgeons worrisome of the technical difficulty of IA while maintaining faster bowel recovery and smaller wound incisions compared to EA.

Single-Center Experiences: A Comparison of Intracorporeal and Extracorporeal Anastomosis Outcomes in Right Hemicolectomy

Background Anastomosis formed in minimally invasive laparoscopic right hemicolectomy (LRH) may be achieved intra-corporeally (ICA) or extra-corporeally (ECA). This study compared the return of bowel function and other associated early patient outcomes and morbidity rates after an ICA or ECA in LRH. Methodology The study conducted a single-center retrospective cohort study of elective LRH from January 2021 to September 2023. Patient demographics, surgical techniques, and outcomes were analyzed using IBM SPSS Statistics for Windows, Version 29.0 (IBM Corp., Armonk, NY). Results Ninety participants underwent LRH, and the anastomotic type was evenly distributed - with male patients comprising 53 (58.9%) of the total. The mean age was 64 (standard deviation [SD] ±16.8) years, and the median body mass index (BMI) was 27.0 (interquartile range [IQR] = 7.8). The mean follow-up period was 5.1 (SD ± 6.0) months. Univariate analysis showed that ICA had a shorter time for return of bowel function (P < 0.01). Additionally, ICA was associated with lower pain scores (P < 0.01), low morbidity (P = 0.02), and shorter hospital stays (P = 0.01). When comparing ICA to ECA, no significant difference was observed for procedure duration (P = 0.13), anastomotic leak (AL, P = 1.00), surgical-site infections (P = 0.36), lymph node yield (P = 0.26), and any-cause mortality. Multivariate logistic regression, controlling for statistically insignificant confounding factors, revealed that ECA was significantly and independently associated with increased time to first flatus (odds ratio [OR] 2.3, P = 0.01) and higher average postoperative pain (OR 1.5, P = 0.02) compared to ICA. Conclusions This single-center experience showed that ICA is associated with a quicker return to normal bowel function and low morbidity outcomes. ICA participants were positively associated with clinically relevant and health economics outcomes of shorter hospital stays without significantly adding to the procedure's duration times or compromising principles of oncological resection yield.

Incisional Hernia After Laparoscopic Right Colectomy for Colorectal Cancer: A Prospective Study with Retrospective Control on Intracorporeal Versus Extracorporeal Anastomosis

Background: Incisional hernias often occur after laparoscopic colorectal surgery, but the precise risk factors are not fully understood. This study's primary aim was to compare the incidence of incisional hernias following laparoscopic right colectomy with intracorporeal anastomotic reconstruction (ICA) versus extracorporeal anastomotic reconstruction (ECA). Materials and Methods: A cohort study compared two groups of patients who underwent elective laparoscopic right colectomy for colon cancer following a standardized perioperative enhanced recovery program (ERP): a prospective group underwent ICA from January 2018 to February 2020 and a retrospective group underwent ECA from January 2013 to December 2016. The presence of incisional hernias was assessed by reviewing patients' follow-up computed tomography scans or evaluating the patients by telephone interview or outpatient office visit and diagnostic imaging. Secondary objectives included the hospital length of stay, postoperative complications, 30-day readmission rate, reoperation, and mortality. Results: The study included 89 patients who had laparoscopic right colectomy for malignant colon neoplasms. Among these, 48 underwent ECA (ECA group), and 41 had ICA (ICA group). At a median follow-up of 36 months, incisional hernia was observed in 1 patient (2.4%) in the ICA group, in contrast to 11 (22.9%) confirmed cases in the ECA group (P = .010). The length of hospital stay was similar between the two groups (5 days versus 4 days; P = .064). The two groups showed similarities in terms of postoperative complications (P = .093), hospital readmission (P = .999), and the rate of reoperation within 30 days (P = .461). Conclusions: The ICA technique was associated with a reduced risk of incisional hernias compared with the ECA technique, with similar outcomes in short-term postoperative complications and overall patient recovery.

Intracorporeal versus extracorporeal anastomosis in minimally invasive right hemicolectomy: systematic review and meta-analysis of randomized controlled trials

Purpose

Compared with extracorporeal anastomosis (ECA), intracorporeal anastomosis (ICA) is expected to provide some benefits, including a shorter operation time and less intraoperative bleeding. Nevertheless, the benefits of ICA have mainly been evaluated in nonrandomized studies. Owing to the recent update of randomized controlled trials (RCTs) for minimally invasive surgery (MIS) of right hemicolectomy (RHC), the need to measure the actual effect by synthesizing the outcomes of these studies has emerged.

Methods

We performed a comprehensive search of the PubMed, Embase, and Cochrane databases (from inception to January 30, 2023) for studies that applied ICA and ECA for RHC with MIS. We included 7 RCTs. The operation time, intraoperative blood loss, conversion rate, length of incision, and postoperative outcomes such as ileus, anastomosis leakage, length of hospitalization, and postoperative pain were compared between ICA and ECA.

Results

A total of 740 patients were included in the study. Among them, 377 and 373 underwent ICA and ECA, respectively. There were significant differences in age (P = 0.003) and incision type (P < 0.001) between ICA and ECA. ICA was associated with a significantly longer operation time (P = 0.033). Although the postoperative pain associated with ICA was significantly lower than that associated with ECA on postoperative day 2 (POD 2) (P = 0.003), it was not different on POD 3 between the groups. Other perioperative outcomes were similar between the 2 groups.

Conclusion

In this meta-analysis, ICA did not significantly improve short-term outcomes compared to ECA; other advantages to overcome ICA's longer operation time are not clear.

The robotic NICE procedure outperforms conventional laparoscopic extracorporeal-assisted colorectal resection: results of a matched cohort analysis

INTRODUCTION

We introduced the robotic NICE procedure for left-sided colorectal resection in 2018 in which the entire procedure is performed without loss of pneumoperitoneum and without an abdominal wall incision by performing natural orifice-assisted transrectal extraction of the specimen and intracorporeal anastomosis. We compare the results of the NICE procedure versus conventional laparoscopic resection, which was our standard approach prior to 2018.

METHODS

A matched pair case-control study compared patients following the NICE procedure versus those who underwent laparoscopic left-sided colorectal resection with conventional extracorporeal-assisted technique. Cases were performed at an Academic Medical Center and recorded in a prospective database to analyze perioperative outcomes.

RESULTS

From a total cohort of 352 patients, 83 were matched in each group. When comparing the NICE procedure vs. the Extracorporeal-Assisted laparoscopic group, there were no significant differences in age (58.5 vs. 59.3 years old), sex (47 vs. 42 Female), body mass index (27.4 vs. 27.5 kg/m2), ASA, diagnosis, or type of surgery. Operative time (198.8 vs. 197.7 min), blood loss (56.0 vs. 53.3 ml), intraoperative complications (0.0% vs. 0.0%), and conversion rates (0.0% vs. 0.0%) were similar in both groups. The NICE procedure was associated with significantly earlier return of bowel function (40.7 vs. 23.6 h), shorter length of stay (3.1 vs. 2.2 days), and lower total opioid use (94.6 vs. 70.5 morphine milligram equivalents). Overall, there were no differences in postoperative abscess formation, complications, readmission, or reoperation rates.

CONCLUSION

When compared to conventional laparoscopic resection, the NICE procedure is associated with short-term benefits including earlier recovery and less opioid use without increased operative time or increased risk of complications. Multicenter studies are recommended to validate benefits and limitations of this technique.

Best Evidence for Each Surgical Step in Minimally Invasive Right Hemicolectomy: A Systematic Review

Objective

The aim of this study was to systematically review the literature for each surgical step of the minimally invasive right hemicolectomy (MIRH) for non-locally advanced colon cancer, to define the most optimal procedure with the highest level of evidence.

Background

High variability exists in the way MIRH is performed between surgeons and hospitals, which could affect patients' postoperative and oncological outcomes.

Methods

A systematic search using PubMed was performed to first identify systematic reviews and meta-analyses, and if there were none then landmark papers and consensus statements were systematically searched for each key step of MIRH. Systematic reviews were assessed using the AMSTAR-2 tool, and selection was based on highest quality followed by year of publication.

Results

Low (less than 12 mmHg) intra-abdominal pressure (IAP) gives higher mean quality of recovery compared to standard IAP. Complete mesocolic excision (CME) is associated with lowest recurrence and highest 5-year overall survival rates, without worsening short-term outcomes. Routine D3 versus D2 lymphadenectomy showed higher LN yield, but more vascular injuries, and no difference in overall and disease-free survival. Intracorporeal anastomosis is associated with better intra- and postoperative outcomes. The Pfannenstiel incision gives the lowest chance of incisional hernias compared to all other extraction sites.

Conclusion

According to the best available evidence, the most optimal MIRH for colon cancer without clinically involved D3 nodes entails at least low IAP, CME with D2 lymphadenectomy, an intracorporeal anastomosis and specimen extraction through a Pfannenstiel incision.

Intracorporeal Versus Extracorporeal Colo-colic Anastomosis in Minimally-invasive Left Colectomy: a Systematic Review and Meta-analysis

PURPOSE

The primary aim was to investigate the operative outcomes of intracorporeal (IA) and extracorporeal (EA) anastomosis in left-sided minimally-invasive colectomy.

METHODS

A comprehensive literature search was conducted for studies comparing operative outcomes and follow-up data of IA versus EA in minimally-invasive left colectomy. Studies that investigated recto-sigmoid resections using transanal circular staplers were excluded. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios (ORs) and mean differences with 95 per cent confidence intervals were calculated.

RESULTS

Eight studies with a total of 750 patients were included (IA n = 335 versus EA n = 415). IA was associated with significantly lower overall morbidity (OR 0.40, 95% CI 0.26-0.61, p < 0.0001) and less frequent surgical site infection (SSI) (OR 0.27, 95% CI 0.12-0.61, p = 0.002) as primary outcomes compared to EA. Of the secondary outcomes, length of incision (SMD -2.51, 95% CI -4.21 to -0.81, p = 0.004), time to first oral diet intake (SMD -0.49, 95% CI -0.76 to -0.22, p = 0. 0004) and time to first bowel movement (SMD -0.40, 95% CI -0.71 to -0.09, p = 0.01) were significantly in favor of IA, while operative time was significantly shorter in the EA group (SMD 0.36, 95% CI 0.14-0.59, p = 0.001).

CONCLUSIONS

IA proves to be a safe and feasible option as it demonstrates benefits in terms of lower overall morbidity, fewer rates of SSI, smaller incision length, and faster postoperative gastrointestinal recovery despite a longer operative time compared to EA.

National implementation of an optimal standardised technique for right-sided colon cancer: protocol of an interventional sequential cohort study (Right study)

PURPOSE

Minimally invasive right hemicolectomy (MIRH) is the cornerstone of treatment for patients with right-sided colon cancer. This operation has evolved during recent decades, with many innovations and improvements but this has also resulted in high variability of uptake with subsequent substantial variableness. The aim of this ongoing study is to identify current surgical variations, determine the most optimal and standardised MIRH and nationally train and implement that technique to improve short-term clinical and long-term oncological outcomes.

METHODS

The Right study is a national multicentre prospective interventional sequential cohort study. Firstly, current local practice was evaluated. Subsequently, a standardised surgical technique for right-sided colon cancer was determined using the Delphi consensus method, and this procedure was trained during hands-on courses. The standardised MIRH will be implemented with proctoring (implementation cohort), after which the performance will be monitored (consolidation cohort). Patients who will receive a minimally invasive (extended) right hemicolectomy for cT1-3N0-2M0 colon cancer will be included. The primary outcome is patient safety reflected in the 90-day overall complication rate according to the Clavien-Dindo classification. Secondary outcomes will include intraoperative complications, 90-day mortality rate, number of resected tumour-positive lymph nodes, completeness of mesocolic excision, surgical quality score, locoregional and distant recurrence and 5-year overall survival. A total number of 1095 patients (365 per cohort) will be included.

DISCUSSION

The Right study is designed to safely implement the best surgical practice concerning patients with right-sided colon cancer aiming to standardise and improve the surgical quality of MIRH at a national level.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04889456, May 2021.

Comparison of intracorporeal and extracorporeal anastomosis in left hemicolectomy: updated meta-analysis of retrospective control trials

BACKGROUND

The feasibility and effectiveness of selecting an intracorporeal or extracorporeal technique in left hemicolectomy remain poorly understood. This meta-analysis aimed to evaluate the difference between the two approaches regarding intraoperative and postoperative outcomes.

METHODS

A thorough exploration of online databases (PubMed, Embase, Cochrane, and Web of Science) was executed to identify randomized controlled trials, cohort studies, and case control studies. The outcomes contained four aspects: intraoperative outcomes, postoperative complications, postoperative patient conditions, and postoperative outcomes. All of these data were analyzed using RevMan 5.4. Seven retrospective control trials (intracorporeal, 396 patients; extracorporeal, 426 patients) were evaluated.

RESULTS

Compared to the extracorporeal group, the intracorporeal group demonstrated superiority in incision length (P = 0.005), overall complications (P = 0.01), time to first flatus (P < 0.001), time to first stool (P = 0.005), time to first diet (P < 0.001) and hospital stay duration (P = 0.001).

CONCLUSIONS

The intracorporeal technique is associated with superiority over the extracorporeal technique in reducing postoperative complications, promoting postoperative recovery of gastrointestinal function, and reducing hospital stay duration.

Ileocolic resection for Crohn's disease: robotic intracorporeal compared to laparoscopic extracorporeal anastomosis

Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79 min vs. LECA: 143 ± 52 min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2 days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5 days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time.

Short-term outcomes following intracorporeal vs. extracorporeal anastomosis after laparoscopic right and left-sided colectomy: a propensity score-matched study

BACKGROUND

To compare the short-term outcomes of patients undergoing intracorporeal anastomosis (IA) during laparoscopic colectomy to those undergoing extracorporeal anastomosis (EA).

METHODS AND MATERIALS

The study was a single-centre retrospective propensity score-matched analysis conducted. Consecutive patients who underwent elective laparoscopic colectomy without the double stapling technique between January 2018 and June 2021 were investigated. The main outcome was overall postoperative complications within 30 days after the procedure. The authors also performed a sub-analysis of the postoperative results of ileocolic anastomosis and colocolic anastomosis, respectively.

RESULTS

A total of 283 patients were initially extracted; after propensity score matching, there were 113 patients in each of the IA and EA groups. There were no differences in patient characteristics between the two groups. The IA group had a significantly longer operative time than the EA group (208 vs. 183 min, P =0.001). The rate of overall postoperative complications was significantly lower in the IA group ( n =18, 15.9%) than in the EA group ( n =34, 30.1%; P =0.02), especially in colocolic anastomosis after left-sided colectomy (IA: 23.8% vs. EA: 59.1%; P =0.03). Postoperative inflammatory marker levels were significantly higher in the IA group on postoperative day 1 but not on postoperative day 7. There was no difference in the postoperative lengths of hospital stay between the two groups, and no deaths occurred.

CONCLUSION

The data suggest that performing IA during laparoscopic colectomy can potentially reduce the risk of postoperative complications, especially in colocolic anastomosis after left-sided colectomy.

Meta‑analysis of randomized controlled trials comparing intracorporeal versus extracorporeal anastomosis in minimally invasive right hemicolectomy: upgrading the level of evidence

BACKGROUND

Minimally invasive right hemicolectomy has been increasingly used for the treatment of right hemicolectomy disease, and both intracorporeal anastomosis (ICA) and extracorporeal anastomosis (ECA) are available to restore intestinal continuity. However, the advantages and disadvantages of these two anastomoses are highly controversial. The present meta-analysis evaluated the effectiveness of ICA versus ECA in minimally invasive right colectomy to improve the grade of evidence.

METHODS

We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for randomized controlled trials (RCTs) comparing intracorporeal versus extracorporeal anastomosis in laparoscopic or robotic right hemicolectomy published from database inception to February 2023. Two researchers performed the literature review, data extraction, bias assessment, and meta-analysis of the data using Review Manager 5.4 software.

RESULTS

Seven RCTs with a total of 750 patients were included in the meta-analysis. The results showed a lower incidence of postoperative paralytic ileus (RR 0.62, 95% CI 0.39 ~ 0.99, p = 0.04) and shorter incision length (MD - 1.38; 95% CI: - 1.98 ~  - 0.78, p < 0.00001), but longer operative time (MD 10.69; 95% CI: 2.76 ~ 18.63, p = 0.008). The remaining events including bleeding (RR 0.49, 95% CI: 0.12 ~ 2.04, p = 0.33), anastomotic leak (RR 0.62, 95% CI: 0.39 ~ 0.99, p = 0.85), surgical site infection (RR 0.15, 95% CI: 0.22 ~ 1.25, p = 0.15), overall perioperative morbidity (RR 0.86, 95% CI: 0.58 ~ 1.26, p = 0.44), number of harvested lymph nodes (MD 0.75; 95% CI: - 0.15 ~ 1.65, p = 0.10), and length of hospital stay (MD - 0.27; 95% CI: - 0.91 ~ 0.38, p = 0.42) were not statistically significant.

CONCLUSIONS

Compared to ECA, ICA in minimally invasive right hemicolectomy reduced the risk of postoperative paralytic ileus and shortened the length of the incision but prolonged the operative time.

Success rates and outcomes of the robotic NICE procedure across complicated and uncomplicated diverticulitis cases

INTRODUCTION

We implemented the NICE procedure as a robotic natural orifice colorectal resection utilizing the rectum to extract the specimen and complete an intracorporal anastomosis for diverticulitis in 2018. Although complicated diverticulitis is associated with higher rates of conversion and post-operative morbidity, we hypothesized that the stepwise approach of the NICE procedure can be equally successful in this cohort. We aimed to compare feasibility and outcomes of the NICE procedure for uncomplicated and complicated diverticulitis.

METHODS

Consecutive patients presenting with diverticulitis who underwent robotic NICE procedure from May 2018 through June 2021 were included. Cases were stratified into uncomplicated and complicated diverticulitis (fistula, abscess, or stricture). Demographic, clinical, disease, intervention, and outcomes data were analyzed. The main outcome measures were return of bowel function, length of stay, opioid consumption, and postoperative complications.

RESULTS

Of a total of 190 patients, those presenting with uncomplicated diverticulitis (53.2%) were compared to those with complicated diverticulitis (47.8%). Uncomplicated diverticulitis had fewer low anterior resections (15.8% vs 49.4%; p < 0.001) and shorter median operative time (186 vs 220 min; p < 0.001). Both cohorts had equal rates of successful intracorporeal anastomosis (100%) and successful transrectal extraction (100% vs 98.9%; p = 0.285). Both cohorts had similar return of bowel function (median 21 h and 18.5; p = 0.149), median length of hospital stay (2 days, p = 0.015) and mean total opioid use (68.4 MME vs 67.3; p = 0.91). There were also no significant differences in overall postoperative complication rate over a 30-day time period (8.9% vs 12.5%; p = 0.44), readmission (6.9% vs 5.6%; p = 0.578) and reoperation (3% vs 4.5%; p = 0.578).

CONCLUSION

Despite being inherently more complex and technically challenging, complicated diverticulitis patients have similar success rates and post-operative outcomes compared to uncomplicated diverticulitis patients when undergoing the NICE procedure. These results implicate the benefits of robotic natural orifice techniques may be even more pronounced in complicated diverticulitis patients.

Surgical efficacy and learning curves of laparoscopic complete mesocolic excision with intracorporeal anastomosis for right-sided colon cancer: A retrospective two-center cohort study

BACKGROUND

There is a potential benefit on long-term outcomes following complete mesocolic excision (CME) for right-sided colon cancer when compared to conventional colectomy. This study aims to analyze the learning curve and short-term outcomes of laparoscopic CME with intracorporeal anastomosis (ICA) for right-sided colon cancer in the hands of experienced colorectal surgeons.

METHODS

A two-center cohort study of consecutive patients undergoing right-sided colectomy from September 2021 to May 2022 at two tertiary colorectal centers in Denmark. Learning curves of surgical time were estimated using a cumulative sum analysis (CUSUM).

RESULTS

A total of 61 patients were included. According to the CUSUM analysis, 32 cases were needed to obtain a peak in operative time, resulting in a decrease in time consumption (group 1/learning phase: 217.2 min [SD 53.6] and group 2/plateau phase 191.6 min [SD 45.1], p = 0.05). There was a nonsignificant reduction in the rates of severe surgical complications (Clavien-Dindo > 3) (13% vs. 7%, p = 0.67) between the two groups, while the length of hospital stay remained constant (median 3.0 days, interquartile range, IQR [2.0; 4.0]).

CONCLUSION

The learning curve of laparoscopic CME with ICA for right-sided colon cancer demonstrated that 32 cases were needed to obtain a plateau phase expressed by operative time.

Intracorporeal Anastomosis Versus Extracorporeal Anastomosis in Laparoscopic Right Colectomy: An Observational Cohort Study

BACKGROUND

Current studies did not draw definitive conclusions on comparison of intracorporeal anastomosis (ICA) with extracorporeal anastomosis (ECA) in laparoscopic right colectomy. Whether the intraperitoneal contamination induced by ICA can result in higher risk of postoperative abdominal infection remains unclear. This study was aimed to compare the short-term outcomes, especially the risk of abdominal infection after ICA versus ECA.

METHODS

This was an observational cohort study as a secondary analysis of a randomized controlled trial (RCT)-RELARC trial (NCT02619942). The patients enrolled in the RELARC trial were diagnosed with primary colon adenocarcinoma without distant metastasis and underwent radical laparoscopic right colectomy between Jan 2016 and Dec 2019. In our study the patients who converted to open surgery in RELARC trial were excluded. The short-term outcomes were compared between ICA and ECA. The primary endpoint was abdominal infection. The inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) was used for adjusting the potential confounders.

RESULTS

This study enrolled 975 patients with 119 patients undergoing ICA and 856 patients undergoing ECA. The incidence of abdominal infection was higher in ICA group (9.2% versus 1.5%, RR from IPTW = 5.7 (95%CI: 2.6-12.6), P < 0.001) as well as the incidence of wound infection (14.3% vs 3.3%, RR from IPTW = 5.0 (95%CI: 2.9-8.6), P < 0.001). ICA was associated with higher incidence of Clavien-Dindo (CD) grade I and II complications (CD-I: 15.1% versus 6.8%, RR from IPTW = 2.4 (95%CI: 1.5-3.9), P < 0.001; CD-II: 26.9% versus 8.2%, RR from IPTW = 3.6 (95%CI: 2.5-5.1), P < 0.001) but similar incidence of CD-III ~ IV complications compared to ECA (3.4% vs 2.1%, RR from IPTW = 1.2 (95%CI: 0.4-4.0), P = 0.73). In ICA group, choosing another incision rather than lengthening main port site decreased the incidence of wound infection although without statistical significance (17.3% (14/81) versus 7.9% (3/38), crude RR = 2.2 (95%CI: 0.7-7.2), P = 0.17).

CONCLUSION

ICA is likely to be associated with higher risk of abdominal infection and CD-I ~ II complications.

The usefulness of indocyanine green fluorescence imaging for intestinal perfusion assessment of intracorporeal anastomosis in laparoscopic colon cancer surgery

PURPOSE

The purpose of this study was to clarify the usefulness of indocyanine green fluorescence imaging (ICG-FI) in the assessment of intestinal vascular perfusion in patients who receive intracorporeal anastomosis (IA) in colon cancer surgery.

METHODS

This was a single-center, retrospective study using propensity score matching. We compared the surgical outcomes of colon cancer patients who underwent laparoscopic colonic resection with IA or external anastomosis (EA) with the intraoperative evaluation of anastomotic perfusion using ICG-FI from January 2019 to July 2021. The detection rate of poor anastomotic perfusion by ICG-FI was examined.

RESULTS

A total of 223 patients were enrolled. After matching, 69 patients each were classified into the IA and EA groups. There were no significant differences in age, sex, body mass index, tumor localization, or progression between the two groups. The operation time was similar (172 min vs. 171 min, p = 0.62) and the amount of bleeding was significantly lower (0 ml vs. 2 ml, p = 0.0023) in the IA group. The complication rates (grade ≥ 2) of the two groups were similar (14.5% vs. 11.6%, p = 0.59). ICG-FI identified four patients (5.8%) with poor anastomotic perfusion in the IA group, but none in the EA group (p = 0.046). All four patients with poor perfusion in the IA group underwent additional resection; none of these patients developed postoperative complications.

CONCLUSION

Poor anastomotic perfusion was detected in 5.8% of cases who underwent laparoscopic colon cancer surgery with IA. ICG-FI is useful for evaluating anastomotic perfusion in IA in order to prevent AL.

Intraoperative and postoperative short-term outcomes of intracorporeal anastomosis versus extracorporeal anastomosis in laparoscopic right hemicolectomy

Background

Intracorporeal anastomosis (IA) is a difficult but popular anastomotic approach for reconstruction of digestive tract after laparoscopic right hemicolectomy, which may reduce some limitations faced during extracorporeal anastomosis (EA).

Methods

A retrospective review of 78 patients who underwent laparoscopic right hemicolectomy by a veteran surgeon in a high-volume public tertiary hospital, including 50 patients with IA and 28 patients with EA. The intraoperative-related factors and short-term results of the two anastomotic approaches were compared.

Results

There was no significant difference in demographics and clinical characteristics between the two groups (P>0.05). The intraoperative blood loss was less (P=0.010) and the incision length was shorter (P<0.001) in the intracorporeal group. Postoperative farting time was faster (P=0.005) and postoperative pain score (VAS) was lower (P<0.001) in IA group. Although the anastomotic time of IA was shorter (P<0.001), the operative time of the two groups were similar. And number of lymph nodes harvested, NLR from POD₁ to POD₃, postoperative hospital stay and overall hospital stay between the two groups were comparable. Except for significant difference in abdominal infection rate, the Clavien-Dindo classification and the incidence of other postoperative complications were not statistically different. Moreover, the morbidity of abdominal infection decreased with time in the IA group (P=0.040).

Conclusion

IA is a reliable and feasible procedure, which has faster anastomotic time, earlier return of bowel function and superior postoperative comfort of patient, compared to EA. The postoperative complication rate of IA is similar to that of EA, and may be improved with the IA technical maturity of surgeons, which potentially contributes to the development of ERAS.

Safe implementation of robotic right colectomy with intracorporeal anastomosis

The robotic platform can overcome technical difficulties associated with laparoscopic colon surgery. Transitioning from laparoscopic right colectomy with extracorporeal anastomosis (ECA) to robotic right colectomy with intracorporeal anastomosis (ICA) is associated with a learning phase. This study aimed at determining the length of this learning phase and its associated morbidity. We retrospectively analyzed all laparoscopic right colectomies with ECA (n = 38) and robotic right colectomies with ICA (n = 67) for (pre)malignant lesions performed by a single surgeon between January 2014 and December 2020. CUSUM-plot analysis of total procedure time was used for learning curve determination of robotic colectomies. Non-parametric tests were used for statistical analysis. Compared to laparoscopy, the learning phase robotic right colectomies (n = 35) had longer procedure times (p < 0.001) but no differences in anastomotic leakage rate, length of stay or 30-day morbidity. Conversion rate was reduced from 16 to 3 percent in the robotic group. This study provides evidence that robotic right colectomy with ICA can be safely implemented without increasing morbidity.

Laparoscopic Intracorporeal Anastomosis

Given the progression of laparoscopic surgery, questions continue to arise as to the ideal technique for a laparoscopic colectomy. The most debated of these questions is whether it is best to complete an intracorporeal (ICA) or extracorporeal (ECA) intestinal anastomosis. Here, we review the literature to date and report the equivalent safety and efficacy of ICA and ECA for laparoscopic right colectomy. However, these studies also indicate that when completed, ICA may prove beneficial with respect to earlier return of bowel function, less postoperative pain, shorter incision length, and reduced risk of wound infections. For this, we present the tips and tricks for completing all forms of laparoscopic ICAs during laparoscopic colectomy.

A novel knotless hand-sewn end-to-end anastomosis using V-loc barbed suture vs. stapled anastomosis in laparoscopic left colonic surgery: A propensity scoring match analysis

Background

Laparoscopic colectomy is widely practiced for colon cancer, but many variations exist for anastomosis after laparoscopic colon cancer radical resection.

Method

We retrospectively analyzed 226 patients who underwent laparoscopic-assisted radical resection for left colon cancer with knotless hand-sewn end-to-end anastomosis (KHEA) technique with barbed V-loc™ suture material and compared perioperative outcomes, safety, and efficacy to those undergoing stapled anastomosis from 2010 to 2021.

Results

After the 1:2 propensity score matching, 123 participants with similar preoperative characteristics (age, body mass index, TNM stage, and tumor location) were enrolled in the study: 41 in the KHEA and 82 in the stapler group. Statistically significant differences were found in time to accomplish the anastomosis (mean 7.9 vs. 11.9 min, p < 0.001) and hospital costs (mean 46,569.71 vs. 50,915.35 CNY, p < 0.05) that differed between the KHEA and stapler group, respectively. No statistically significant difference was found in the mean delay to bowel function recovery (2.6 vs. 2.7 days, p = 0.466), duration of hospital stay (8.6 vs. 7.9 days, p = 0.407), or rate of postoperative complications (14.6% vs. 11.0%, p = 0.563). Anastomotic leakage occurred in 11 patients: 5 (12.2%) vs. 6 (7.3%) (p > 0.05) in the KHEA and stapler group, respectively.

Conclusion

KHEA is feasible and safe for anastomosis after laparoscopic left hemicolectomy. The KHEA technique could reduce operation time and hospital costs with complication rates comparable to stapling.

Laparoscopic right colectomies with intracorporeal compared to extracorporeal anastomotic techniques are associated with reduced post-operative incisional hernias

Background

Owing to important differences in surgical technique, laparoscopic right colectomy with intracorporeal (ICA) compared to extracorporeal (ECA) anastomotic technique may result in improved patient outcomes. We aimed to compare both techniques according to incisional hernias and other pertinent perioperative characteristics, post-operative complications, and oncologic quality markers.

Methods

All adult patients undergoing laparoscopic right colectomies between 2015 and 2020 at a single institution were included. ICA and ECA techniques were compared based on selected outcomes using univariable and multivariable statistical analyses, as appropriate. Subgroup analyses were restricted to patients with neoplastic indications for surgery and non-urgent operations.

Results

A total of 517 patients met inclusion criteria, of which 139 (26.9%) underwent ICA and 378 (73.1%) underwent ECA. ICA and ECA patients had similar baseline characteristics. At two years of follow-up, a lower proportion of ICA patients developed a hernia at the extraction incision (1.5% vs. 7.1%, p = 0.02) and ICA was associated with an 80% reduction in extraction incision hernias (aHR 0.20, p = 0.03). These results were stable through subgroup and sensitivity analyses. Median operative time was longer in the ICA group (186 min vs. 135 min, p < 0.001), but the gap in operative time narrowed during the study period. Median length of stay was one calendar day shorter in the ICA group (3 days vs. 4 days, p = 0.007) and ICA was associated with a 13% decrease in the length of stay (aRR 0.87, p = 0.02). The incidence of superficial wound infections, anastomotic leaks and re-interventions was lower in ICA patients, but this difference was not statistically significant. 90-day unscheduled visits, readmissions, and mortalities were similar across both groups, as were oncologic outcomes.

Conclusion

Laparoscopic right colectomies with intracorporeal anastomoses are associated with a reduction in incisional hernias and shorter hospital lengths of stay without compromising on patient safety or oncologic principles.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09585-0.

A standardized stepwise approach to minimally invasive ileocolic anastomosis: Tips and tricks for laparoscopic and robotic surgery

AIM

Intracorporeal anastomosis has been associated with earlier recovery of postoperative bowel function, shorter length of stay and lower surgical site infection rates. The aim of this work is to describe a step-by-step standardized technique for intracorporeal ileocolic and ileosigmoid anastomosis suitable for laparoscopic and robotic colectomy.

METHOD

Each step of the technique is illustrated using a composite collection of three operative patient videos. Two procedures were performed robotically and one was laparoscopic. Tips are provided to construct a two-layer anastomosis (both posteriorly and anteriorly). The procedures are presented in stepwise fashion, discussing the advantages and feasibility of the technique.

RESULTS

The standardized technique described herein was used in three patients for this report, of whom two underwent right colectomy and one subtotal colectomy for cancer. The median operating time was 255 (206-333) min. There were no intraoperative complications. No major postoperative complications or 30-day readmissions occurred. The median length of stay was 4 (3-5) days.

CONCLUSION

The described technique of a two-layer anastomosis can be used with any available minimally invasive approach. It is safe and feasible. Using a standardized approach, the technique can be easily taught and mastered, optimizing operating times and reducing adverse events.

Extracorporeal versus intracorporeal anastomosis for right colon cancer surgery

Laparoscopic right colectomy is currently considered the standard treatment for right colon cancer. After excision of the right colon, minimally invasive options for ileocolonic anastomosis include extracorporeal anastomosis (EA) and intracorporeal anastomosis (IA). However, the choice of anastomotic technique remains debated. As the entire IA is performed in the abdominal cavity, it is known for its advantages of a faster intestinal recovery and small incision. However, IA is time-consuming and technically difficult, limiting its widespread use. Recently, the robotic approach has increased the adoption of intracorporeal anastomotic techniques owing to the benefits of endowrist-articulated instruments and staplers. Except for a small incision and faster bowel recovery, the outcomes of the two anastomoses methods are inconsistent. To date, there has been no clear conclusion regarding whether IA or EA should be used to treat right colon cancer. This review aimed to investigate the current evidence relating to intraoperative outcomes and short-term postoperative results between both anastomotic approaches.

Robotic left hemicolectomy with intracorporeal anastomosis: Description of the technique and initial results

AIM

The aim was to describe the robot-assisted intracorporeal anastomosis technique in left colon surgery (rLCS) and report the initial results.

METHOD

The rLCS was performed in 25 consecutive patients, starting with a Pfannenstiel incision and introducing a prepared anvil. The robot was docked and the affected segment resected. Colotomy was performed and the anvil was introduced in the proximal segment. End-to-end anastomosis was performed and reinforced. An air-leak test was performed.

RESULTS

The results varied in terms of patient's age, American Society of Anesthesiologists grade, weight and the technique performed. Most patients had cancer. There was no suture failure or mortality, and the mean hospital stay was 3 days.

CONCLUSIONS

The rLCS is a safe, reproducible technique with good initial results. Prospective studies should be performed to demonstrate its advantages.

International survey among surgeons on laparoscopic right hemicolectomy: the gap between guidelines and reality

INTRODUCTION

To assess the current approaches and perioperative treatments of laparoscopic right hemicolectomy (LRHC) and to highlight similarities and differences with international guidelines and scientific evidence, we conducted a survey for surgeons across the globe.

METHODS

All digestive and colorectal surgeons registered with the database of the Research Institute against Digestive Cancer (IRCAD) were invited to take part in the survey via email and through the social media networks of IRCAD.

RESULTS

There were a total of 440 respondents from 78 countries. Most surgeons worked in the European region (38.6%) followed by the Americas (34.1%), the Eastern Mediterranean region (13.0%), the South-East Asian region (5.9%), the Western Pacific region (4.8%), and Africa (3.2%) respectively. Over half of the respondents performed less than 25% of right hemicolectomies laparoscopically where 4 ports are usually used by 68% of the surgeons. The medial-to-lateral, vessel-first approach is the approach most commonly used (74.1%). The most common extraction site was through a midline incision (53%) and an abdominal drain tube is routinely used by 52% of the surgeons after surgery. A total of 68.6% of the responding surgeons perform the majority of the anastomoses extracorporeally. Finally, we found that the majority of responders (60.7%) routinely used mechanical bowel preparations prior to LRHC.

CONCLUSION

Regarding several topics related to LRHC care, a discrepancy was observed between the current medical practice and the recommendations from RCTs and international guidelines and significant regional differences were observed.

A multicentre, prospective cohort study of handsewn versus stapled intracorporeal anastomosis for robotic hemicolectomy

AIM

Robotic right hemicolectomy is gaining in popularity due to the recognized technical benefits associated with the robotic platform. However, there is a lack of standardization regarding the optimal anastomotic technique in this cohort of patients, namely stapled or handsewn intra- or extra-corporeal anastomosis. The ergonomic benefit associated with the robotic platform lends itself to intracorporeal anastomosis (ICA). The aim of this study was to compare the short-term clinical outcomes of stapled versus handsewn ICA.

METHOD

A multicentre prospective cohort study was undertaken across four high-volume robotic centres in France between September 2018 and December 2020. All adult patients undergoing an elective robotic right hemicolectomy with an ICA performed and a minimum postoperative follow-up of 30 days were included. The primary endpoint of our study was anastomotic leak within 30 days postoperatively.

RESULTS

A total of 144 patients underwent robotic right hemicolectomy: 92 (63.8%) had a stapled ICA and 52 (36.1%) a handsewn ICA. The operative indication was adenocarcinoma in 90% with a stapled ICA compared with 62% in the handsewn ICA group (p < 0.001). The overall operating time was longer in the handsewn ICA group compared with the stapled ICA group (219 min vs. 193 min; p = 0.001). The anastomotic leak rate was 3.3% in stapled ICA and 3.8% in handsewn ICA (p = 1.00). There was no difference in the rate or severity of postoperative morbidity.

CONCLUSION

ICA robotic hemicolectomy is technically safe and is associated with low rates of anastomotic leak overall and equivalent clinical outcomes between the two techniques.

Bowel recovery after intra- vs extra-corporeal anastomosis for oncologic laparoscopic right hemicolectomy within an ERAS protocol: a retrospective study

OBJECTIVE

Restoring bowel continuity after laparoscopic right hemicolectomy with an intra-corporeal (IC) rather than an extra-corporeal (EC) ileocolic anastomosis may offer advantages in post-operative recovery. The aim of this study was to compare bowel function recovery between these two techniques, in a context of complete mesocolic excision within an enhanced recovery after surgery (ERAS) protocol.

METHODS

All consecutive patients who underwent oncologic laparoscopic right hemicolectomy from January 2012 to February 2021 in our institution were included in the study. Data were gathered from the prospectively maintained official ERAS (EIAS) database and completed through our institution's electronic health records. The primary endpoint was prolonged post-operative ileus (PPOI), defined as the need to insert a nasogastric tube, or refractory nausea VAS > 4, on or after the third post-operative day. Secondary endpoints were post-operative pain, morbidity and length of hospital stay (LoS). Groups were compared before and after propensity score matching based on age, gender, ASA score, use of epidural analgesia and post-operative complications.

RESULTS

A total of 108 patients met the inclusion criteria, 36 (30%) had IC and 72 (70%) EC anastomosis. In the unmatched population, baseline characteristics were similar except for more frequent use of epidural analgesia in the EC group (62 (72.9%) vs. 17 (47.2), p = 0.007). PSM analysis was carried out. Operative time was longer in the IC group (197 min (176-223) vs. 160 (140-189), p < 0.001). The rate of PPOI was similar (2 (5.6%) patients in the IC group vs. 10 (11.6%) in the EC group (p = 0.306)), but time to frist passage of flatus and stool was shorter in the IC group. There was no difference in morbidity but patients after IC anastomosis had lower pain VAS scores at 24 h (p = 0.004) and a trend for a shorter LoS (6 (5-8) days vs 7 (5-10) in the EC group, p = 0.054). After PSM, there were 36 patients in each group. PPOI, time to first flatus and stool, morbidity and LoS were not significantly different although there was a trend for better recovery outcomes in the IC group. Patients in the IC group had significantly longer operative times but less pain at 24 h.

CONCLUSIONS

Although IC anastomosis was not significantly associated to lower rates of PPOI, it showed trends of faster recovery and significantly less post-operative pain at the expense of longer operating times.

Anastomosis technique and leakage rates in minimally invasive surgery for right-sided colon cancer. A retrospective national cohort study

PURPOSE

The aim of this study was to describe the different techniques currently used in Denmark to construct right-sided ileocolic anastomoses in minimally invasive surgery, and investigate, compare and analyse the anastomotic configurations and their anastomotic leakage (AL) rates.

METHODS

This was a retrospective register-based, study design using prospectively collected data from the Danish Colorectal Cancer Group (DCCG) database. All patients aged 18 years or older with a malignant colorectal tumour in Denmark in the period of 1 February 2015 until 31 December 2019, and who had an elective, curative, minimally invasive right hemicolectomy (MIRH) with ileocolic anastomosis, were included.

RESULTS

Three thousand three hundred ninety-eight patients were included. The most commonly used anastomotic approach was the extracorporeal (EC) hand-sewn anastomosis (HA) with end-to-end configuration (59%) and the second most used was the EC stapled anastomosis (SA) side-to-side configuration (20%). The latter had a higher AL rate compared with the hand-sewn technique (3.8% vs. 1.3%), and had significantly higher odds ratio (OR) (OR: 2.85, 95% CI: 1.56-4.92, p < 0.0001) for AL in the adjusted regression model. The least used technique was the end-to-side HA which also had a significantly higher OR (OR: 3.05, 95% CI: 1.30-7.15, p = 0.010) compared with the end-to-end HA. Smoking was an independent factor associated with higher OR for AL.

CONCLUSION

The ileocolic end-to-end HA was the most commonly used technique and had the lowest AL rate in MIRH for colon cancer. The EC SA technique and tobacco smoking were independent risk factors for leakage of the ileocolic anastomosis.

Outcomes of intracorporeal versus extracorporeal anastomosis in laparoscopic colectomy surgery

Purpose

The aim of this study is to evaluate the feasibility and safety of intracorporeal anastomosis in laparoscopic colectomy for benign and malignant tumor diseases in actual clinical settings.

Methods

From January 2016 to June 2021, a total of 114 cases were selected for laparoscopic colectomy for benign or malignant tumor diseases. Seventeen cases that underwent simultaneous combined laparoscopic procedures were excluded from the study. The remaining patients were separated into 48 cases in the intracorporeal group and 49 cases in the extracorporeal group. Medical records were reviewed retrospectively.

Results

Patients in the intracorporeal group were older than those in the extracorporeal group (62.6 years vs. 54.9 years, p = 0.001). Body mass index, American Society of Anestheologists physical status classification, comorbidity, smoking, and laparotomy history did not differ significantly between groups. Surgeries for malignancy were performed in 35 (72.9%) and 32 cases (65.3%) in the respective intracorporeal and extracorporeal groups. Right hemicolectomy was performed in 39 (81.3%) and 45 cases (91.8%) in the intracorporeal and extracorporeal groups, respectively, and postoperative hospital stays were 9.8 and 8.9 days (p = 0.081). Operation time (216.9 minutes vs. 203.5 minutes, p = 0.212) and intraoperative blood loss (72.7 mL vs. 75.7 mL, p = 0.700) were not significantly different. Anastomotic leakage was observed in one case in each group.

Conclusion

In laparoscopic colectomy, intracorporeal anastomosis could be considered as a safe and feasible technique for benign and malignant tumor diseases.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: updated meta-analysis of randomized controlled trials

BACKGROUND

Selection of intracorporeal anastomosis (IA) or extracorporeal anastomosis (EA) in laparoscopic right colectomy (LRC) remains controversial. This meta-analysis aimed to evaluate the effectiveness and safety of IA compared with EA in LRC patients.

METHODS

Literature was searched systematically for randomized controlled trials (RCTs) that compared IA with EA in LRC patients until May 2021. The eligible studies for risk of bias were assessed using the Cochrane Risk of Bias Tool. Data were extracted and analysed for the following outcomes of interest: operative time, length of incision, nodal harvest, bowel function recovery, postoperative pain, postoperative complications (wound infection, anastomotic leak, ileus, obstruction, reoperation), death at 30 days, duration of hospital stay and 30-day readmission.

RESULTS

Five RCTs, including a total of 559 patients, were eligible for meta-analysis. All of the trials reported adequate random sequence generation and allocation concealment. There were significantly better outcomes in the IA group than in the EA group in time to first flatus (mean difference (MD) -0.71 (95 per cent c.i. -1.12 to -0.31), P = 0.0005), time to first passage of stool (MD -0.53 (95 per cent c.i. -0.69 to -0.37), P < 0.00001), visual analogue scale of pain on postoperative day (POD) 3 (MD -0.76 (95 per cent c.i. -1.23 to -0.28), P = 0.002), POD 4 (MD -0.83 (95 per cent c.i. -1.46 to -0.20), P = 0.01), POD 5 (MD -0.60 (95 per cent c.i. -0.95 to -0.25), P = 0.0007), length of incision (MD -1.52 (95 per cent c.i. -2.30 to -0.74), P = 0.0001) and wound infection (relative risk 0.46 (95 per cent c.i. 0.23 to 0.91), P = 0.02). However, there were no statistically significant differences between the two groups in duration of hospital stay (P = 0.47), operative time (P = 0.07), number of lymph nodes harvested (P = 0.70), anastomotic leak (P = 0.88), postoperative ileus (P = 0.48), bleeding (P = 0.15), bowel obstruction (P = 0.24), reoperation (P = 0.34), readmission within 30 days (P = 0.26), and death (P = 0.70).

CONCLUSION

Compared with EA, IA shows a faster recovery of bowel function with fewer wound infections.

Short-term outcomes in robot-assisted compared to laparoscopic colon cancer resections: a systematic review and meta-analysis

Background

Robot-assisted surgery is increasingly adopted in colorectal surgery. However, evidence for the implementation of robot-assisted surgery for colon cancer is sparse. This study aims to evaluate the short-term outcomes of robot-assisted colon surgery (RCS) for cancer compared to laparoscopic colon surgery (LCS).

Methods

Embase, MEDLINE, and Cochrane Library were searched between January 1, 2005 and October 2, 2020. Randomized clinical trials and observational studies were included. Non-original literature was excluded. Primary endpoints were anastomotic leakage rate, conversion to open surgery, operative time, and length of hospital stay. Secondary endpoints were surgical efficacy and postoperative morbidity. We evaluated risk of bias using RoB2 and ROBINS-I quality assessment tools. We performed a pooled analysis of primary and secondary endpoints. Heterogeneity was assessed by I², and possible causes were explored by sensitivity- and meta-regression analyses. Publication bias was evaluated by Funnel plots and Eggers linear regression test. The level of evidence was assessed by GRADE.

Results

Twenty studies enrolling 13,799 patients (RCS 1740 (12.6%) and LCS 12,059 (87.4%) were included in the meta-analysis that demonstrated RCS was superior regarding: anastomotic leakage (odds ratio (OR) = 0.54, 95% CI [0.32, 0.94]), conversion (OR = 0.31, 95% CI [0.23, 0.41]), overall complication rate (OR = 0.85, 95% CI [0.73, 1.00]) and time to regular diet (MD =  − 0.29, 95% CI [− 0.56, 0.02]). LCS proved to have a shortened operative time compared to RCS (MD = 42.99, 95% CI [28.37, 57.60]). Level of evidence was very low according to GRADE.

Conclusion

RCS showed advantages in colonic cancer surgery regarding surgical efficacy and morbidity compared to LCS despite a predominant inclusion of non-RCT with serious risk of bias assessment and a very low level of evidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08782-7.

Minimally invasive right versus left colectomy for cancer: does robotic surgery mitigate differences in short-term outcomes?

Studies comparing right (RC) and left colectomies (LC) show higher rates of ileus in RC and higher wound infection and anastomotic leak rates in LC. However, prior studies did not include robotic procedures. We compared short-term outcomes of laparoscopic and robotic RC and LC for cancer, with sub-analysis of robotic procedures. In a retrospective review of a prospective database, preoperative factors, intraoperative events, and 30-day postoperative outcomes were compared. Student's t tests and Chi-square tests were used for continuous and categorical variables, respectively. A logistic binomial regression was performed to assess whether type of surgery was associated with postoperative complications. Between January 2014 and August 2020, 115 patients underwent minimally invasive RC or LC for cancer. Sixty-eight RC [30 (44.1%) laparoscopic, 38 (55.9%) robotic] and 47 LC [13 (27.6%) laparoscopic, 34 (72.4%) robotic] cases were included. On univariate analysis, RC patients had significantly higher overall postoperative complications but no differences in rates of ileus/small bowel obstruction, wound infection, time to first flatus/bowel movement, length of hospital stay, and 30-day readmissions. On multivariate analysis, there was no significant difference in overall complications and laparoscopic surgery had a 2.5 times higher likelihood of complications than robotic surgery. In sub-analysis of robotic cases, there was no significant difference among all outcome variables. Previously reported outcome differences between laparoscopic RC and LC for cancer may be mitigated by robotic surgery.

Right colectomy with intracorporeal anastomosis for cancer: a prospective comparison between robotics and laparoscopy

Robotics in right colectomy are still under debate. Available studies compare different techniques of ileocolic anastomosis but results are non-conclusive. Our study aimed to compare intraoperative outcomes, and short-term postoperative results between robotic and standard laparoscopic right colectomies for cancer with intracorporeal anastomosis (ICA) fashioned with the same technique. All consecutive patients scheduled for laparoscopic or robotic right hemicolectomies with ICA for cancer in two hospitals, one of which is a tertiary care centre, were prospectively enrolled in our prospective observational study, from April 2018 to December 2019. ICA was fashioned with the same stapled hand-sewn technique. Continuous and categorical variables were analysed using t test and chi-squared test as required. Statistical significance was set at p < 0.05. Forty patients underwent laparoscopic surgery, and 48 underwent robotic right colectomy and were included in the intention-to-treat analysis. Operative time was not statistically different between the two groups (robotic group 265.9 min vs laparoscopic group 254.2 min, p = 0.29). The robotic group had a significantly shorter time for stump oversewing (ileum reinforcement: robotic group 9.3 min vs laparoscopic group 14.2 min, p < 0.001; colon reinforcement: robotic 7.7. min, laparoscopy 13.9 min, p < 0.001) and for ICA (robotic 31.6 min vs laparoscopy 43.0, p < 0.001). One patient underwent extracorporeal anastomosis in the robotic group. The short-term outcomes were comparable between standard laparoscopic and robotic right colectomies with ICA. The limitation of the study is its small sample size and the fact that it was done in two institutions under the supervision of one person. Our data demonstrate that intracorporeal ileocolic anastomosis is safe, and faster and easier with robotic systems. Robotics can facilitate more challenging ICA in minimally invasive surgery.

Intracorporeal versus extracorporeal anastomosis for robotic ileocolic resection in Crohn's disease

To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn's Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p < 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD.

Laparoscopic Right Colectomy. Intracorporeal Anastomosis Is Associated with Better Outcome

Colon cancer is the third most common cancer in man and woman in the developed world. Laparoscopic right colectomy is the standard of care for right colon cancer. Since the first report on laparoscopic approach in 1991, the surgical technique has been improved and currently all procedure is performed intracorporeally. The ileo-colic anastomosis can be performed either intracorporeal and extracorporeal: the differences in clinical outcome, complications rate, hospital stay and quality of life between that two techniques are not still clear and a large number of studies has been published about that. According to most recent meta-analysis, intracorporeal anastomosis have showed better outcome in anastomotic leakage rate, surgical site infection rate, development of incisional hernia, postoperative pain and recovery of gastrointestinal function.