Hand-assisted laparoscopic vs. laparoscopic colorectal surgery: a multicenter, prospective, randomized trial

Statistical Fragility in Minimally Invasive Colorectal Surgery Studies: A Review of Randomized Trials

Purpose: The P value has been used as a statistical tool in randomized controlled trials (RCTs) to establish significance but does not provide information on the robustness of a study when used alone. The fragility index (FI) provides a supplemental approach for demonstrating robustness in RCTs that report dichotomous outcomes. This study aims to determine the statistical fragility of RCTs that compare minimally invasive techniques with open techniques in managing benign and malignant colorectal diseases. Methods: Dichotomous outcomes of minimally invasive surgery versus open surgery in RCTs from 2000 to 2023 were assessed. The overall FI and fragility quotient (FQ) of each study were calculated. Results: Of the 1377 screened studies, 50 met the inclusion criteria. In total, 820 outcomes were recorded with 747 outcomes reported as not significant (P ≥ .05) and 73 as significant (P < .05). The overall FI for all studies including all outcomes was 5 (interquartile range [IQR] 4-7) with a FQ of 0.031 (IQR 0.014-0.062). Of the 50 RCTs, 6 (12%) reported a loss to follow-up that was greater than the overall FI of 5. Conclusions: As RCTs are judged increasingly beyond just the P value, practicing colorectal surgeons will benefit from using and interpreting the FI, FQ, and the P value of studies both in analyzing future RCTs and in determining whether or not to make a change in their clinical practice if there is an efficiently true discovery.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management

Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.

Lending a hand: The utility of hand-assisted laparoscopic surgery in diverticulitis with fistula

BACKGROUND

Current guidelines recommend elective colectomy for the management of diverticulitis-associated fistulas. These cases present considerable operative challenges, and surgical approaches and fistula tract management vary widely. Hand-assisted laparoscopic surgery offers the benefits of minimally invasive surgery while maintaining the tactile advantages of open surgery. This study aims to evaluate outcomes of hand-assisted laparoscopic surgery colectomy for diverticulitis-associated fistulas, fistula tract, and urinary catheter management.

METHODS

A retrospective review of patients with diverticulitis-associated fistula who underwent elective hand-assisted laparoscopic surgery colectomy between January 2, 2008, and September 8, 2022, was performed. Patients with Crohn disease or who underwent emergency surgery were excluded.

RESULTS

Seventy patients were included; the mean patient age was 64.1 ± 14.8 years, and the mean body mass index was 30.9 ± 9.1 kg/m2. Colovesical fistulas were most common (n = 48; 68.6%), followed by colovaginal fistulas (n = 22; 31.4%). The median operative time was 186 minutes. Conversion to an open approach occurred in 4 cases (5.7%). The fistula tract remnant was left without intervention in 35 patients (50%), and omental coverage occurred in 23 cases (32.9%). The median duration of the urinary catheter was 3 days (range = 1-63). There were no postoperative urine leaks. Three patients (4.3%) were readmitted in ≤30 days. There were no 30-day mortalities.

CONCLUSION

The challenges of colectomy for diverticulitis-associated fistulas can be mitigated using the hand-assisted laparoscopic surgery technique. We found a low conversion-to-open rate, falling below rates reported for laparoscopic colectomy. There were no cases of postoperative urine leak, suggesting that no intervention or omental coverage is a safe approach to fistula tract management.

Total Neoadjuvant Therapy in Rectal Cancer: Multi-center Comparison of Induction Chemotherapy and Long-Course Chemoradiation Versus Short-Course Radiation and Consolidative Chemotherapy

BACKGROUND

Total neoadjuvant therapy for locally advanced rectal cancer may include induction chemotherapy and chemoradiation or short-course radiotherapy and consolidative chemotherapy.

METHODS

Patients with clinical stage 2 or 3 rectal cancer who received induction chemotherapy followed by long-course chemoradiation at the University of Colorado (2016-2020) or short-course radiotherapy followed by consolidative chemotherapy at Washington University (2017-2020) were assessed.

RESULTS

Eighty-four patients received induction chemotherapy and chemoradiation and 83 received short-course radiotherapy and consolidative chemotherapy. Among patients with complete re-staging evaluation, clinical complete response rates were similar, 49% (18/37) and 53% (44/83), respectively (p = 0.659). In the induction chemotherapy and chemoradiation group, 80% (n = 67) underwent surgery and 28% (n = 19) achieved a pathologic complete response. In the short-course radiotherapy and consolidative chemotherapy group, 44 (53%) patients underwent surgery and 11% (n = 5) had a pathologic complete response. Overall, a complete response was observed in 43% (n = 36) of patients who received induction chemotherapy and chemoradiation compared to 53% (n = 44) who received short-course radiotherapy and consolidative chemotherapy (p = 0.189). Perioperative outcomes were similar in patients who received induction chemotherapy and chemoradiation compared to short-course radiotherapy and consolidative chemotherapy: intraoperative complications (2% vs 7%), complete mesorectal specimen (85% vs 84%), anastomotic leak (9% vs 7%), organ/space infection (9% vs 5%), readmission (19% vs 21%), and reoperation (8% vs 9%), respectively (all p > 0.05).

CONCLUSIONS

In patients with clinical stage 2 or 3 rectal cancer, total neoadjuvant therapy with either induction chemotherapy and chemoradiation or short-course radiotherapy followed by consolidative chemotherapy were associated with similar perioperative morbidity and complete response rates.

Hand Assisted Laparoscopic Surgery for Colorectal Cancer: Surgical and Oncological Outcomes from a Single Tertiary Referral Centre

The aim of this study was to report overall experience, perioperative and long-term survival results in a single tertiary referral center in Lithuania with hand assisted laparoscopic surgery (HALS) for colorectal cancer. A prospectively maintained database included 467 patients who underwent HALS for left-sided colon and rectal cancer, from April 2006 to October 2016. All those operations were performed by three consultant surgeons and nine surgical residents, in all cases assisted by one of the same consultant surgeons. There were 230 (49.25%) females, with an average age of 64 ± 9.7 years (range, 26–91 years). The procedures performed included 170 (36.4%) anterior rectal resections with partial mesorectal excision, 160 (34.26%) sigmoid colectomies, 81 (17.35%) left hemicolectomies, 45 (9.64%) low anterior rectal resections with total mesorectal excision, and 11 (2.25%) other procedures. Stage I colorectal cancer was found in 140 (29.98%) patients, 139 (29.76%) stage II, 152 (32.55%) stage III and 36 (7.71%) stage IV. There were five conversions to open surgery (1.1%). The mean postoperative hospital stay was 6.9 ± 3.4 days (range, 1–30 days). In total, 33 (7.06%) patients developed postoperative complications. The most common complications were small bowel obstruction (n = 6), anastomotic leakage (n = 5), intraabdominal abscess (n = 4) and dysuria (n = 4). There were two postoperative deaths (0.43%). Overall, 5-year survival for all TNM stages was 85.7%, 93.2% for stage I, 88.5% for stage II and 76.3% for stage III. Hand assisted colorectal surgery for left-sided colon and rectal cancer in a single tertiary referral center was feasible and safe, having all the advantages of minimally invasive surgery, with good perioperative parameters, adequate oncological quality and excellent survival.

Hand-assisted versus straight laparoscopy for colorectal surgery - a systematic review and meta-analysis

PURPOSE

Hand-assisted laparoscopic surgery (HALS) is an alternative to straight laparoscopy (LAP) in colorectal surgery. Many studies have compared the two in terms of efficacy, complications, and outcomes. This meta-analysis aims to uncover if there are any significant differences in conversion rates, operative times, body mass index (BMI), incision lengths, intraoperative and postoperative complications, and length of stay.

METHODS

Comprehensive searches were performed on databases from their respective inceptions to 16 December 2021, with a manual search performed through Scopus. Randomized controlled trials (RCTs), cohort studies, and case series involving more than 10 patients were included.

RESULTS

A total of 47 studies were found fitting the inclusion criteria, with 5 RCTs, 41 cohort studies, and 1 case series. Hand-assisted laparoscopic surgery was associated with lower conversion rates (odds ratio [OR] 0.41, 95%CI 0.28-0.60, p < 0.00001), shorter operative times (Mean Difference [MD] - 8.32 min, 95%CI - 14.05- - 2.59, p = 0.004), and higher BMI (MD 0.79, 95%CI 0.46-1.13, p < 0.00001), but it was also associated with longer incision lengths (MD 2.19 cm, 95%CI 1.66-2.73 cm, p < 0.00001), and higher postoperative complication rates (OR 1.15, 95%CI 1.06-1.24, p = 0.0004). Length of stay was not different in HALS as compared to Lap (MD 0.16 days, 95%CI - 0.06-0.38 days, p = 0.16, and intraoperative complications were the same between both techniques.

CONCLUSIONS

Hand-assisted laparoscopy is a suitable alternative to straight laparoscopy with benefits and risks. While there are many cohort studies comparing HALS and LAP, more RCTs would be needed for a better quality of evidence.

Evaluation of Operative Notes for Splenic Flexure Mobilization: Are the Key Aspects Being Reported?

Background: Given the importance of operative documentation, we reviewed operative notes for surgeries that required splenic flexure mobilization (SFM) to determine their accuracy. Materials and Methods: We performed a retrospective review of 51 operative notes for complete SFMs performed at a single institution from January 2015 to June 2020. Results: None of the operative notes reported a rationale for performing SFM, use of preoperative imaging to guide technical approach, reasoning for the operative method and mobilization approach used, or specific steps taken to ensure that SFM was done safely. Most reports did not include technical details, with one-third of the notes merely reporting that "the splenic flexure was mobilized." Conclusions: Increased awareness about the lack of operative documentation of the critical aspects of the SFM could stimulate initiatives to standardize the SFM method and improve the quality of operative notes for SFM.

Comparison of Short-Term Outcomes Between Hand-assisted Laparoscopic Distal Gastrectomy and Laparoscopy-assisted Distal Gastrectomy in Gastric Cancer

Hand-assisted laparoscopic surgery is considered to provide the benefits of laparoscopic surgery in various diseases. However, limited information is available regarding the feasibility of hand-assisted laparoscopic distal gastrectomy (HALDG)-a subset of hand-assisted laparoscopic surgery-as a gastric cancer treatment. This study aimed to evaluate the usefulness of HALDG compared with laparoscopy-assisted distal gastrectomy (LADG). Consecutive patients who underwent HALDG (n=58) or LADG (n=90) for stage I gastric cancer between 2005 and 2016 were eligible. Operative time was significantly shorter and blood loss was significantly higher in HALDG than in LADG (P<0.001, both). Postoperative aminotransferase levels were significantly lower in HALDG than in LADG (P<0.001). There was no significant difference in perioperative complications, a number of analgesics, postoperative C-reactive protein levels, and 3-year relapse-free and overall survival rates between the groups. This study suggests that HALDG is a safe and feasible approach and could become an effective option for stage I gastric cancer treatment.

Update on the management of sigmoid diverticulitis

Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.

Diverticulitis: An Update From the Age Old Paradigm

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

Lending a hand for laparoscopic distal pancreatectomy: the optimal approach?

BACKGROUND

Both minimally invasive surgery (MIS) and open approaches for distal pancreatectomy are acceptable. MIS options include total laparoscopic/robotic (TLR) and hand-assist laparoscopy (HAL). When considering safety profile and specimen quality, the optimal approach is unknown.

METHODS

Patients who underwent distal pancreatectomy from 2010-2018 at two major academic institutions were included. Converted procedures were categorized into final approach. Ninety-day perioperative/pathologic outcomes of MIS and open were compared. Subset analyses between TLR vs HAL and HAL vs open were performed. Intent-to-treat analysis was performed.

RESULTS

Among 1006 patients, resection was performed by MIS in 35% (n = 352), open in 65% (n = 654). MIS had similar patient comorbidity profile as open but had increased operative time (183 vs 162 min; p < 0.01), lower estimated-blood-loss (EBL; 131 vs 341 mL; p < 0.01), fewer intraoperative blood transfusions (1.4 vs 5%; p < 0.01), shorter LOS (5.2 vs 7.2 days; p < 0.01). Tumor size was smaller (3.2 vs 4.4 cm; p < 0.01) with lower lymph node (LN) yield (14 vs 16; p < 0.01). When comparing HAL (n = 109) to TLR (n = 243), despite increased prior abdominal operations (60 vs 43%; p = 0.008), HAL had shorter operative time (167 vs 191 min; p < 0.01), similar length-of-stay (LOS; 5.4 vs 5.1 days; p = 0.27), and readmission rate (15 vs 13%; p = 0.47). When comparing HAL to open, the advantages of TLR approach persisted including lower EBL (171 vs 342 mL; p < 0.01), and shorter LOS (5.4 vs 7.2 days; p < 0.01). Although HAL had smaller tumors, it had a similar LN yield (16 vs 16; p = 0.80), and higher R0-rate (97 vs 83%; p < 0.01).

CONCLUSION

Hand-assist laparoscopy is safe and feasible for distal pancreatectomy as operative time, complication profile, lymph node yield, and R0-rates are similar to open procedures, while maintaining the associated the advantages of a total laparoscopic/robotic approach with reduced blood loss and shorter length-of-stay.

"Peek port": avoiding conversion during laparoscopic colectomy-an update

PURPOSE

To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Patients considered being at high risk for conversion to formal laparotomy were initially approached via a small midline incision ("peek port") with the laparoscopic equipment readily available but unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy (HALS); if intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy.

METHODS

Data from 664 patients from a single surgeon brought to the operating room with the intention of proceeding with laparoscopic colectomy (either via straight laparoscopy or HALS) were retrieved from a prospective database. Comparison of conversion rates between groups was performed using χ² analysis.

RESULTS

The study population consisted of 361 men and 303 women with a mean age of 61 years. Inflammatory conditions accounted for 40% of the diagnoses and enteric fistulas were present in 12%. Of the 79 patients who underwent initial "peek port" exploration, 38 (48%) underwent immediate extension to formal laparotomy, whereas 41 (52%) underwent HALS colectomy, with one subsequent conversion from HALS to formal laparotomy. Of the 585 patients initially approached laparoscopically, 14 (2%) required conversion to laparotomy. Of the 626 patients from both groups who underwent laparoscopy, the overall conversion to laparotomy rate was 15/626 (2%).

DISCUSSION

The "peek port" approach to the patients with a potentially hostile abdomen allows for prompt assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy during colectomy. This technique may reduce expense and morbidity for patients who ultimately require laparotomy, while allowing some patients with complex disease to be managed laparoscopically who would not normally be considered for a minimally invasive procedure.

Minimally Invasive Surgical Approaches to Colon Cancer

Colon cancer remains the most common abdominal visceral malignancy affecting both men and women in America. Open colectomy has been the standard of care for colon cancer patients the past 100 years; although highly effective, the major trauma associated with it has a significant morbidity rate and represents a large operation for patients to recover from. Minimally invasive colon surgery was developed as a new and alternative option, and surgeons aim to continue to make it simpler, more reproducible, and easier to teach and learn. We describe herein the current state of minimally invasive colorectal surgery for colon cancer and compare it with open surgery to offer insights to future directions.

Totally-laparoscopic versus laparoscopic-assisted low anterior resection for rectal cancer: are outcomes different?

BACKGROUND

Laparoscopic low anterior resection for rectal cancer has superior short-term benefits compared to open surgery. When operative conditions do not favour a totally-laparoscopic (TL) approach, a hybrid operation can be performed. In this laparoscopic-assisted (LA) approach, mobilization and vessel ligation are performed laparoscopically, with total mesorectal excision and distal transection performed either partially or totally in an extra-corporeal fashion. We compared short-term post-operative and oncological outcomes of both approaches.

METHODS

A prospectively collected database of patients who underwent laparoscopic low anterior resection for rectal cancer between January 2009 and December 2014 was retrospectively analysed. Demographics, post-operative and oncological outcomes were compared.

RESULTS

Of 174 patients, 97 were completed by TL, 62 by LA and the remaining 15 were converted to open. Baseline demographics were similar. LA group compared to TL group had bulkier rectal cancers (6.75 cm³ versus 4.50 cm³ , P = 0.04) which were lower (6 cm versus 7 cm from anal verge, P = 0.02). They were of a more advanced tumour grade and had greater incidence of lymphovascular invasion. Yet, post-operative outcomes such as time to diet, pain scores, hospitalization duration, wound-related and anastomotic complications, 30-day morbidity and mortality were similar. There was no difference in oncological adequacy, including circumferential resection margins, distal margins, lymph node harvest and 2-year local recurrence rates.

CONCLUSION

Laparoscopic-assisted low anterior resection enables minimally invasive rectal surgery to be performed despite unfavourable tumour factors and technical challenges; and compares favourably with TL approach in terms of short-term outcomes and oncological safety.

Outcomes of open, laparoscopic, and hand-assisted laparoscopic surgeries in elderly patients with right colon cancers: A case-control study

An increasing proportion of patients aged more than 70 years old are suffering from colorectal cancers. This study aimed to compare the short- and long-terms outcomes between open surgery (OS) or conventional laparoscopic surgery (LS) and hand-assisted laparoscopic surgery (HALS) in treatment of these elderly patients with right colon cancers.We retrospectively reviewed patients who underwent right colon resections for cancers in our institution between June, 2009 and December, 2014. Short- and long-terms outcomes including surgical endpoints, postsurgical recovery data, postoperative morbidity and mortality, overall survival and disease-free survival were compared among OS, LS, and HALS groups. All data were analyzed by SPSS 22.0.Finally, 69 consecutive patients (OS = 26, LS = 24, HALS = 19) with right colon cancers were included in the analysis. Compared with OS, HALS was associated with less time to first anus exhaust (P = .013), first liquid diet (P = .045), and first soft diet (P = .036). Meanwhile, there were significant less operative time (P = .0027), blood loss (P < .001), and less time to first liquid diet (P = .009) in HALS, compared with LS. In regards to long-term outcomes, there were no significant differences in overall survival and disease-free survival among the 3 groups.Compared with OS or LS, HALS may be more favorable in the treatment of elderly right colon cancers with decreased surgical time and postoperative recovery, and comparable cancer-specific survivals.

Hand-assisted Laparoscopy: Expensive but Considerable Step Between Laparoscopic and Open Colectomy

PURPOSE

Hand-assisted laparoscopic colectomy (HALC) and laparoscopic-assisted colectomy (LAC) have been shown to have comparable short-term outcomes while there are limited data regarding costs. The aim of our study was to compare the short-term outcomes and costs of HALC and LAC.

MATERIALS AND METHODS

In total, 46 patients who underwent HALC or LAC for benign or malignant disease between January 2011 and December 2014 at our institution were included in the study. Patients were randomized into HALC or LAC group. Patients' demographics and characteristics, operative details, short-term outcomes, and costs were evaluated.

RESULTS

There were 25 patients in LAC group and 21 patients in HALC group. Patient's demographics and characteristics and short-term outcomes were comparable between the LAC and HALC groups. Conversion rate was significantly lower in the HALC group (4.7% vs. 28%, P=0.03) while surgical costs ($1706.83±203.70 vs. $1304.93±305.67, P=0.038) and total costs ($2427.18±254.27 vs. $2044.03±215.22, P=0.021) were significantly higher in HALC group.

CONCLUSIONS

HALC is associated with increased surgical and total hospital costs, and decreased rate of conversion. Although it is more expensive, HALC may be helpful by providing a step between LAC and open surgery before considering conversion.

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

BACKGROUND

"Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

METHODS

A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.

RESULTS

Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.

CONCLUSIONS

NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

Hand-assisted laparoscopic surgery versus laparoscopic right colectomy: a meta-analysis

Objective

The objective of this study is to systematically assess the clinical efficacy of hand-assisted laparoscopic surgery (HALS) and laparoscopic right colectomy (LRC).

Methods

The randomized controlled trials (RCTs) and non-RCTs were collected by searching electronic databases (Pubmed, Embase, and the Cochrane Library). The outcomes included intraoperative outcomes, postoperative outcomes, postoperative morbidity, and oncologic outcomes. Meta-analysis was performed using of RevMan 5.3 software.

Results

A total of five studies involving 438 patients were finally included, with 202 cases in HALS group and 236 cases in LRC group. Results of meta-analysis showed that there was no statistical difference between HALS and LRC in terms of conversion rate, length of hospital stay, reoperation rate, postoperative morbidity, and oncologic outcomes. The operative time was 6.5 min shorter in HALS group; however, it was not a clinically significant difference. Although the incision length was longer in HALS, it did not influence the postoperative recovery.

Conclusions

HALS can be considered an alternative to LRC which combines the advantages of open as well as laparoscopic surgery.

Hand-Assisted Laparoscopic Surgery: A Versatile Tool for Colorectal Surgeons

PURPOSE

Hand-assisted laparoscopic surgery (HALS) is a minimally invasive surgical technique with the combined benefits of laparoscopic surgery while allowing the use of the surgeon's hand for better tactile control. Obesity has been associated with higher conversion rates with multiport laparoscopic surgery, but not with HALS. This study aimed to examine the versatility of HALS in various clinical contexts.

METHODS

All HALSs performed at 2 major tertiary centers in Sydney were prospectively collected for retrospective analysis. Variables including age, sex, body mass index (BMI), previous surgeries, pathologies including size and T-stage, and the number of conversions to a midline laparotomy were examined.

RESULTS

A total of 121 HALS colorectal resections were analyzed. The median age of the patients was 62 years, with 63.6% being women. Seven patients required conversion to a midline laparotomy. Of the 121 patients, 50.2% were overweight or obese, and 52.9% had undergone previous abdominal/pelvic operations. However, neither obesity nor abdominal adhesions from previous operations were an indication for conversion to an open laparotomy in any of the 7 converted patients. The presence of intra-abdominal adhesions did not impact the operative time. HALS allowed access to the entire colon and rectum and allowed resection of the bladder, uterus, and ureter, when these organs were involved.

CONCLUSION

HALS is a versatile, minimally invasive technique, which is independent of the patient's BMI, for performing a colorectal resection.

Hand-Assisted Laparoscopic Colectomy Improves Perioperative Outcomes Without Increasing Operative Time Compared to the Open Approach: a National Analysis of 8791 Patients

INTRODUCTION

Hand-assisted laparoscopic surgery (HALS) is often used in procedures too complex for completely minimally invasive approaches. However, there are concerns for whether this hybrid approach abrogates perioperative benefits of the completely minimally invasive technique.

METHODS

We queried the 2012-2013 National Surgery Quality Improvement Program for adults undergoing elective HALS or open colectomy (OC). After propensity matching, short-term outcomes were compared. Subset analysis was performed for segmental resections. Multivariate analysis was used to determine predictors of utilizing either approach.

RESULTS

This query included 8791 patients (OC 2707, HALS 6084). Predictors of HALS included male sex (OR 1.17, p = 0.006), increasing BMI (OR 1.01, p = 0.02), benign indication (OR 1.48, p < 0.001), and total abdominal colectomy (OR 10.39, p < 0.001). Younger age, black race, ASA class ≥3, inflammatory bowel disease, and low pelvic anastomosis were predictive of OC (all p < 0.05). HALS demonstrated reduced overall complications (p < 0.001), wound complications (p < 0.001), anastomotic leak (p = 0.014), transfusion (p < 0.001), postoperative ileus (p < 0.001), length of stay (p < 0.001), and readmission (p < 0.001) without increased operative time. For segmental resection, HALS demonstrated reduced overall complications, wound complications, respiratory complications, postoperative ileus, anastomotic leak, transfusion, length of stay, and readmissions (all p < 0.05).

CONCLUSIONS

Compared to OC, HALS demonstrates improved perioperative outcomes without increased operative time.

Laparoscopic colectomy in obese patients: a comparison of laparoscopic and hand-assisted laparoscopic techniques

BACKGROUND

Recent American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP)-based evidence indicates that laparoscopic (LAP) colectomy results in improved outcomes compared to hand-assisted laparoscopic (HAL) colectomy in the general population. Previous comparative studies demonstrated that the HAL technique offers distinct advantages for obese patients. The aim of this study was to perform comparative analyses of HAL and LAP colectomy and low anterior resection (LAR) in obese patients.

METHODS

The ACS-NSQIP public use file and targeted colectomy dataset, 2012-2014, were utilized for patients undergoing colectomy and LAR. Only obese patients (BMI > 30) and laparoscopic or hand-assisted operations were included. Patient, operation, and outcome variables were compared in two separate cohorts: colectomy and LAR. Bivariate analysis compared the approaches, followed by multivariable regression.

RESULTS

Of 9610 obese patients included, HAL and LAP colectomy were performed in 3126 and 3793 patients and LAR in 1431 and 1260 patients, respectively. In comparison to LAP colectomy, HAL colectomy patients had increased comorbidities including class 2 and 3 obesity. HAL colectomy was associated with higher overall morbidity (20 vs. 16%, p < 0.001), infectious complications (10.2 vs. 7.7%, p < 0.001), anastomotic leaks (3.0 vs. 2.2%, p = 0.03), and ileus (11 vs. 8%, p < 0.001). Multivariate analysis indicated that overall morbidity (OR 1.27, 95% CI 1.11-1.44), infectious complications (OR 1.35, 95% CI 1.14-1.59), and ileus (OR 1.33, 95% CI 1.12-1.57) were each increased in the HAL colectomy cohort but not different for HAL and LAP LAR.

CONCLUSIONS

In comparison to LAP colectomy, the HAL technique is used more often in obese patients with an increased operative risk profile. While inherent bias and unmeasured variables limit the analysis, the available data indicate that the HAL technique is associated with increased perioperative morbidity. Alternatively, HAL and LAP LAR are performed in obese patients with a similar risk profile and result in similar postoperative outcomes.

Hand-assisted laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis

INTRODUCTION

In this study, we aimed to evaluate the feasibility and safety of undergoing restorative proctocolectomy through ileal pouch-anal anastomosis (RPC-IPAA) with hand-assisted laparoscopic (HALS) in patients with ulcerative colitis (UC).

PATIENTS AND METHODS

We reviewed 40 consecutive patients who underwent RPC-IPAA with HALS or open technique for treatment of UC between 2010 and 2013. Moreover, the intra-/post-operative outcomes were compared.

RESULTS

We found the median operative time was significantly longer in the HALS group while the blood loss was significantly less in patients with HALS than with open surgery. In the HALS group, the median duration of bed rest and the length of hospital stay were significantly shorter. Moreover, the rate of early post-operative complications in the HALS group was significantly less than that in the open surgery group, among which one patient died in the 30th day after surgery for the extensive use of steroids before the operation.

CONCLUSION

These findings clearly show that HALS RPC is safe and less invasiveness. HALS can become a more comfortable and standardised procedure for UC with the adoption of evolving technologies.

Impact of surgeon laparoscopic training and case volume of laparoscopic surgery on conversion during elective laparoscopic colorectal surgery

AIM

The study aimed to determine whether laparoscopic volume and type of training influence conversion during elective laparoscopic colorectal surgery.

METHOD

An Institutional Review Board-approved prospective database was reviewed for patients who underwent colorectal resection, performed by six colorectal surgeons, for all diagnoses from 2009 to 2014. Surgeons were designated as laparoscopic- or open-trained based on formal laparoscopic colorectal surgery training, and were classified as low laparoscopic volume (LLV) (i.e. had performed < 100 laparoscopic procedures) or high laparoscopic volume (HLV) (i.e. had performed ≥ 100 laparoscopic procedures). Technique was laparoscopic, open or converted (pre-emptive or reactive). Conversion was compared among three groups: LLV, laparoscopic trained (group A); LLV, open trained (group B); and HLV, open trained (group C).

RESULTS

In total, 159/567 procedures were open and 408 laparoscopic procedures were attempted. Of the 408 laparoscopic procedures, 73 were converted. Among the 567 patients [mean age: 56 ± 17 years (44% male)], the overall conversion rate was 13% (73/567), including 75% pre-emptive and 25% reactive. Conversion rates for groups A, B and C were 17.9%, 42.6% and 14.3%, respectively. Significantly higher conversion was seen in group B compared with group C (P = 0.01), but not between group A and group C (P = 0.85) or between group B and group A (P = 0.11). Converted patients were older (P < 0.001), with lower rates of proctectomy (P = 0.007), higher rates of anastomosis (P < 0.001) and higher body mass index (BMI) (P < 0.001). After adjusting for patient and surgeon factors, training type was not associated with conversion (P = 0.15). Compared with successful laparoscopy, converted patients had a significantly higher incidence of ileus (P < 0.001), length of stay (P = 0.002), time to flatus (OR = 3.21, P < 0.001) and time to solids (P < 0.001). Converted patients experienced increased morbidity.

CONCLUSION

Training is not associated with conversion. Rather, HLV surgeons, regardless of training, convert less frequently than do LLV surgeons.

Adenomatous Polyposis Syndromes: Diagnosis and Management

Familial adenomatous polyposis (FAP) syndromes make up fewer than 1% of patients diagnosed with colorectal cancer each year. Patients with familial polyposis syndromes including FAP, attenuated FAP, and MYH-associated polyposis (MAP), are an important group often cared for by colorectal surgeons. Registry and screening programs have been shown to improve survival in patients with adenomatous polyposis, as it allows patients to undergo surgical intervention prior to the development of colorectal cancer. There are several surgical options for the treatment of colorectal polyps in patients with adenomatous polyposis, so it is important to choose the appropriate procedure for each patient after discussing the risk of cancer in the rectal remnant, as well as bowel and sexual function in a predominantly young patient group. Regardless of procedure choice, long-term follow-up is important with yearly endoscopic evaluation of the pouch or remnant rectum, as well as appropriate screening for extracolonic malignancy. Adenomatous polyposis patients require an intense care regimen, but can have a normal lifespan with good quality when cared for appropriately.

Current application and prospects of hand-assisted laparoscopic surgery in gastrointestinal tumors

Hand-assisted laparoscopic surgery (HALS) refers to operations in which the surgeon inserts his/her non-dominant hand through a specific auxiliary device into the peritoneal cavity to assist the laparoscopic instruments. Because there is one hand to assist in the operation, HALS can reduce the difficulty of operation and shorten operative time. Previously, HALS is considered the transitional bridge from the traditional open surgery to laparoscopic surgery, but now, HLAS, together with total laparoscopic surgery and laparoscopic assisted surgery, is considered three forms of routine laparoscopic surgery. Along with the extensive use of laparoscopic surgery in gastrointestinal tumors, HALS, as a new method of laparoscopic surgery, has been gradually used in gastrointestinal tumors in recent years.

Hand-assisted laparoscopic restorative proctocolectomy for ulcerative colitis

AIM

To evaluate the utility of hand-assisted laparoscopic restorative proctocolectomy (HALS-RP) compared with the conventional open procedure (OPEN-RP).

METHODS

Fifty-one patients who underwent restorative total proctocolectomy with rectal mucosectomy and ileal pouch anal anastomosis between January 2008 and July 2015 were retrospectively analyzed. Twenty-three patients in the HALS-RP group and twenty-four patients in the OPEN-RP group were compared. Four patients who had purely laparoscopic surgery were excluded. Restorative total proctocolectomy was performed with mucosectomy and a hand-sewn ileal-pouch-anal anastomosis. Preoperative comorbidities, intraoperative factors such as blood loss and operative time, postoperative complications, and postoperative course were compared between two groups.

RESULTS

Patients in both groups were matched with regards to patient age, gender, and American Society of Anesthesiologists score. There were no significant differences in extent of colitis, indications for surgery, preoperative comorbidities, and preoperative medications in the two groups. The median operative time for the HALS-RP group was 369 (320-420) min, slightly longer than the OPEN-RP group at 355 (318-421) min; this was not statistically significant. Blood loss was significantly less in HALS-RP [300 (230-402) mL] compared to OPEN-RP [512 (401-1162) mL, P = 0.003]. Anastomotic leakage was noted in 3 patients in the HALS-RP group and 2 patients in the OPEN-RP group (13% vs 8.3%, NS). The rates of other postoperative complications and the length of hospital stay were not different between the two groups.

CONCLUSION

HALS-RP can be performed with less blood loss and smaller skin incisions. This procedure is a feasible technique for total proctocolectomy for ulcerative colitis.

Role of Minimally Invasive Surgery in the Reoperative Abdomen or Pelvis

Laparoscopy has become widely accepted as the preferred surgical approach in the management of benign and malignant colorectal diseases. Once considered a relative contraindication in patients with prior abdominal surgery (PAS), as surgeons have continued to gain expertise in advanced laparoscopy, minimally invasive approaches have been increasingly incorporated in the reoperative abdomen and pelvis. Although earlier studies have described conversion rates, most contemporary series evaluating the impact of PAS in laparoscopic colorectal resection have reported equivalent conversion and morbidity rates between reoperative and non-reoperative cases, and series evaluating the impact of laparoscopy in reoperative cases have demonstrated improved short-term outcomes with laparoscopy. The data overall highlight the importance of case selection, careful preoperative preparation and planning, and the critical role of surgeons' expertise in advanced laparoscopic techniques. Challenges to the widespread adoption of minimally invasive techniques in reoperative colorectal cases include the longer learning curve and longer operative time. However, with the steady increase in adoption of minimally invasive techniques worldwide, minimally invasive surgery (MIS) is likely to continue to be applied in the management of increasingly complex reoperative colorectal cases in an effort to improve patient outcomes. In the hands of experienced MIS surgeons and in carefully selected cases, laparoscopy is both safe and efficacious for reoperative procedures in the abdomen and pelvis, with measurable short-term benefits.

The Utility of Hand-Assisted Laparoscopic Surgery (HALS) in Giant Pelvic Masses

The purpose of this study was to report the outcomes of a series of patients who underwent hand-assisted laparoscopy surgery for benign giant pelvic masses, including ovarian cysts and uterine myomas. We reviewed the records of all patients who underwent laparoscopic or hand-assisted laparoscopy surgery for a variety of benign gynecological conditions. Demographic, clinical, pathologic, and follow-up information was analyzed. Twelve patients have undergone hand-assisted laparoscopy for giant pelvic mass, including four hand-assisted laparoscopic myomectomy, four oophorocystectomy, and four salpingo-oophorectomy. The median age was 35.5 (19-55). The median BMI was 22.05 (19.8-26.7 kg/m(2)). The median diameter of adnexal mass was 21 (17-24 cm). The median diameter of uterine myoma was 18.5 (16-19 cm). The median length of hand-assisted (HA) incision was 5 cm (2-6 cm). The median operation time was 100 min (70 to 180 minutes), and median estimated blood loss was 60 mL (30 to 800 mL). The median length of stay was 3 days (3-5 days). There was no case of intraoperative and postoperative complications. Hand-assisted laparoscopic surgery is safe and feasible in the management of patients with benign giant pelvic masses. Additional studies are needed to further investigate potential advantages and outcomes of the technique.

Comparison of straight vs hand-assisted laparoscopic colectomy: an assessment from the NSQIP procedure-targeted cohort

BACKGROUND

The perioperative outcomes of patients who underwent straight laparoscopic (LAP) vs hand-assisted laparoscopic (HALS) surgery were compared using a recently released procedure-targeted database.

METHODS

The 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database was used and patients were classified into 2 groups according to the final surgical approach: LAP vs HALS. Demographics, comorbidities, and 30-day outcomes were compared.

RESULTS

A total of 7,843 patients met the inclusion criteria. There were 4,656 (59%) patients in LAP colectomy and 3,187 (41%) in HALS colectomy groups. Groups were comparable in terms of preoperative characteristics and demographics. Mean operative time was slightly longer in LAP group (178 ± 86 vs 171 ± 84 minutes, P < .001). After covariate-adjustment analysis, the overall morbidity, superficial surgical site infection, and ileus rates remained slightly higher in HALS group.

CONCLUSIONS

Both straight laparoscopic and hand-assisted approaches are used in colorectal surgery and may complement each other in challenging cases. Implementing the best approach to decrease postoperative complication rates and increase use of minimally invasive techniques may play a role in improving patient care and overall quality.

Hand-Assisted versus Straight-Laparoscopic versus Open Proctosigmoidectomy for Treatment of Sigmoid and Rectal Cancer: A Case-Matched Study of 100 Patients

To assess the efficacy of laparoscopic proctosigmoidectomy for cancer treatment, 25 patients who underwent hand-assisted laparoscopic resection during the study period (9/2006 - 7/2012) were matched to 25 straight-laparoscopic and 50 open-surgery cases. The patients who underwent hand-assisted resection had higher rates of preoperative cardiac disease and hypertension than did the straight-laparoscopy and open-surgery groups. Straight-laparoscopic surgery seems to provide faster convalescence compared with open surgery and hand-assisted laparoscopic surgery.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Surgical Treatment of Diverticulitis: Hand-Assisted Laparoscopic Resection Is Predominantly Used for Complex Cases and Is Associated With Increased Postoperative Complications and Prolonged Hospitalization

Introduction Laparoscopic (LAP) colectomy is now the "gold" standard for diverticulitis; the role of hand-assisted LAP (HAL) and Open methods today is unclear. This study assessed the elective use of these methods for diverticulitis. Methods A retrospective review of demographic, comorbidity (Carlson Comorbidity Index [CCI]), resection type, and short-term outcomes was carried out. Results There were 125 (44.5%) LAP, 125 (44.5%) HAL, and 31 (11%) Open cases (overall N = 281). The mean age, body mass index, and percentage of high-risk patients (CCI score >2) of the HAL group were greater (P < .05) than the LAP group (vs Open, P = ns). The Open group's mean age and percent with CCI >2 was greater when compared with the LAP group (P < .05). More Open (P < .05) and HAL patients had complex disease (Open, 63%; HAL, 40%, LAP, 22%) and were diverted (Open, 35%; HAL, 10%; LAP, 3%). Time to bowel movement was not different; however, there was a stepwise increase in median length of stay (LOS; days) from the LAP (5 days) to HAL (6 days) to Open group (7 days) (P < .05 for all). The LAP complication rate (22.4%) was lower (P < .05) than the HAL (42.4%) or Open groups' (45.2%) rates. The LAP surgical site infection rate (5.6%) was lower (P < .05) than the HAL (12.8%) or Open groups (19.6%). Conclusion The HAL and Open groups had more high risk, complex disease, diverted, and older patients than the LAP group; likewise, the overall complication rate and LOS was higher in the HAL and Open groups. Use of HAL methods likely contributed to the high minimally invasive surgery utilization rate (89%).

Is there anything we can modify among factors associated with morbidity following elective laparoscopic sigmoidectomy for diverticulitis?

BACKGROUND

Laparoscopic sigmoidectomy for diverticulitis is widely accepted, using either endolinear staplers or traditional linear staplers under direct vision through the extraction site to transect the rectum. The aim of this study was to assess modifiable factors affecting perioperative morbidity after elective laparoscopic sigmoidectomy for diverticulitis.

METHODS

Potential associations between perioperative morbidity and demographic, disease-related, and treatment-related factors were assessed on all consecutive patients included in a prospectively collected database undergoing elective laparoscopic sigmoidectomy for diverticulitis between 1992 and 2013. Rectal transection with a linear stapler under direct vision through the extraction site was considered compatible with laparoscopic technique.

RESULTS

There were two deaths out of 1059 patients (0.19 %). Conversion rate was 13.1 %, overall morbidity 28 %, and anastomotic leak 3.7 %. Independent factors associated with morbidity in an intent-to-treat analysis were ASA 3 (OR 1.53, p = 0.006), conversion (OR 1.71, p = 0.015), and rectal transection without endolinear stapling (traditional linear stapler: OR 1.75, p = 0.003; surgical knife: OR 2.09, p = 0.002). The same factors along with complicated diverticulitis (OR 1.56, p = 0.013) were independently associated with overall morbidity among laparoscopically completed cases. BMI ≥ 35 (OR 2.3, p = 0.017), complicated diverticulitis (OR 2.37, p = 0.002), and rectal transection with a traditional linear stapler (OR 2.19, p = 0.018) were independently associated with abdomino-pelvic infections, both in an intent-to-treat analysis and among laparoscopically completed cases. The number of endolinear stapler firings was not associated with morbidity.

CONCLUSIONS

Most factors associated with morbidity of laparoscopic sigmoidectomy for diverticulitis cannot be easily modified. With the limitation of a retrospective analysis, modifiable factors to minimize morbidity are laparoscopic completion and endolinear stapling.

Endowrist versus wrist: a case-controlled study comparing robotic versus hand-assisted laparoscopic surgery for rectal cancer

BACKGROUND

Laparoscopic total mesorectal excision (TME) remains a technically challenging procedure. This study aims to compare the surgical outcomes of the robotic-assisted laparoscopic (RAL) versus hand-assisted laparoscopic (HAL) techniques in performing TME for patients with rectal cancers.

METHODS

A retrospective review of all patients who underwent RAL TME for rectal cancers was performed. These cases were matched for age, sex, and stage of malignancy with patients who underwent HAL TME. Data collected included age, sex, American Society of Anesthesiologists scores, comorbid conditions, types of surgical resections and operative times, perioperative complications, length of hospital stays, and histopathologic outcomes were analyzed.

RESULTS

From August 2008 to August 2011, 19 patients, with a median age of 62 (range, 47 to 92) years underwent RAL TME. Eight (42.1%) patients received neoadjuvant chemoradiotherapy. The median docking and operative times were 10 (range, 3 to 34) and 390 (range, 289 to 771) minutes, respectively. There was 1 (5.3%) conversion to open surgery. The grade of mesorectal excision was histopathologically reported as complete in all 19 cases. Positive circumferential margin was reported in 1 (5.3%) patient.Comparing the 2 groups, more patients in the RAL group received neoadjuvant chemoradiotherapy (8 vs. 3; P=0.048). The operative times were longer in the RAL group (390 vs. 225 min; P<0.001). A higher proportion of patients in the HAL group required conversion to open surgery (5 vs. 1; P=0.180) and developed perioperative morbidities (3 vs. 7; P=0.269). The median length of hospitalization was comparable between both groups (RAL: 7 vs. HAL: 6 d; P=0.476).The procedural cost was significantly higher in the RAL group (US$12,460 vs. US$8560; P<0.001), whereas the nonprocedural cost remained comparable between the 2 groups (RAL: US$4470 vs. HAL: US$4500; P=0.729).

CONCLUSIONS

RAL TME is associated with lower conversion and morbidity rates compared with HAL TME. The longer operating times and higher procedural costs are current limitations to its widespread adoption.

Adoption of Laparoscopic Colorectal Surgery: It Was Quite a Journey

The adoption of laparoscopic colorectal surgery has been a slow but steady progress. The first adopters rapidly expanded the application of the technology to all colorectal pathology. Issues related to extraction and port site recurrence of cancer delayed widespread adoption until incontrovertible data from well-powered prospective randomized studies confirmed equipoise with open surgery. Since that time, the data has consistently demonstrated patient-care benefits related to reductions in both short- and long-term complications historically associated with open colectomy. The potential for further improvement related to single-port access, robotic assistance, and natural orifice access for both the surgery and/or extraction will await the test of time. However, it is clear now that laparoscopic colorectal surgery is the new standard of care and a key enabler of enhanced recovery programs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative Study on Therapeutic Efficacy Between Hand-Assisted Laparoscopic Surgery and Conventional Laparotomy for Acute Obstructive Right-Sided Colon Cancer

INTRODUCTION

This retrospective study aims to compare open colectomy and hand-assisted laparoscopic surgery (HALS) in the management of acute obstructive right-sided colon cancer and to analyze and evaluate the feasibility and safety of HALS.

PATIENTS AND METHODS

Ten consecutive patients who underwent hand-assisted laparoscopic right hemicolectomy due to acute obstructive right-sided colon cancer were retrospectively well matched with 25 patients scheduled for a conventional laparotomy during the same time. Demographic, intraoperative, and postoperative data were assessed.

RESULTS

The HALS group had the advantage in the length of incision (5.8±0.7 cm) over the conventional group (16±2.3 cm) (P<.05), and the mean blood loss during the operations was significantly less in the HALS group (30±15.2 mL) than in the laparotomy group (90±29.4 mL) (P<.05). Moreover, the time of postoperative ambulation was earlier (2.5±0.8 days versus 3.2±0.9 days) (P<.05). Seven cases underwent intestinal decompression for severe intestinal dilatation and had a satisfactory result. The hand-assisted device can fairly meet the demands of a minimally invasive operation and can protect the abdominal incision and avoid infection. There was no intergroup difference in complication rate, although the conventional group had a higher rate.

CONCLUSIONS

In this study, compared with conventional laparotomy for acute obstructive right-sided colon neoplasm, HALS is associated with less blood loss, shorter incision, and earlier ambulation. Emergency laparoscopic-assisted right hemicolectomy can be safely performed in patients with obstructing right-sided colonic carcinoma. If practiced more, it might be advocated as a bridge between the conventional open approach and traditional laparoscopic surgery.

Techniques in total mesorectal excision surgery

Advances in the surgical management of rectal cancer have placed the quality of total mesorectal excision (TME) as the major predictor in overall survival. A standardized TME technique along with quality increases the percentage of patients undergoing a complete TME. Quality measurements of TME will place increasing demands on surgeons maintaining competence with present and future techniques. These efforts will improve the outcome of the rectal cancer patients.

Comparison of hand-assisted laparoscopy with open total colectomy for slow transit constipation: a retrospective study

OBJECTIVE

To compare the efficacy and safety of hand-assisted laparoscopic colectomy (HALC) and open colectomy (OC) for patients with slow transit constipation (STC).

METHODS

Data of patients with STC who underwent total colectomy from January 2008 to December 2012 were retrospectively reviewed after clinical evaluation and an exclusion of secondary causes. These patients were further divided into the HALC and OC groups. Patients' outcomes, including intraoperative and postoperative data on their recovery and complications were compared between the two groups.

RESULTS

A total of 68 patients with STC were finally enrolled in the study, including 32 in the HALC group and 36 in the OC group. The baseline characteristics did not significantly differ between the two groups. Compared with the OC group, patients in the HALC group had a shorter length of incision, a longer operative time and less blood loss volume. There was no conversion to OC for patients undergoing HALC and no intraoperative complications in both groups. Furthermore, after operation, patients in HALC group experienced less pain (3.4 ± 0.7 vs 4.8 ± 1.0), earlier first passage of flatus (58.3 ± 6.3 h vs 73.4 ± 13.0 h), shorter length of postoperative hospital stay (8.8 ± 1.2 days vs 11.3 ± 1.7 days) but higher medical cost (RMB 33 979 ± 3 135 vs RMB 29 828 ± 3 216). The overall postoperative complications and the satisfaction in defecation were comparable in the two groups.

CONCLUSION

HALC is a safe, minimally invasive and effective surgical alternative for treating STC, which is comparable to OC.