Standardized laparoscopic intracorporeal right colectomy for cancer: short-term outcome in 111 unselected patients

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.

Inferior versus medial approach in laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer: A propensity-score-matched analysis

AIM

In laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer, either an inferior approach (IA) or a medial approach (MA) is selected in our institution based on the surgeon's preference. The present study compared the treatment outcomes between IA and MA.

METHOD

This retrospective, single-centre study using propensity score matching analysed the short- and long-term outcomes of laparoscopic surgery in patients with right-sided colon cancer from 2010 to 2019 at Cancer Institute Hospital.

RESULTS

After patient selection, 1011 patients remained for the analysis, of which 67% underwent IA surgery and 33% underwent MA surgery. After propensity score matching (1:1), 325 patients in each group were analysed. Regarding the short-term outcomes, there were no significant differences in the operation time, rate of conversion to open surgery or postoperative complication rate (Clavien-Dindo Grade ≥ III) between the two groups, although the intra-operative median blood loss was significantly less in the IA group than in the MA group (IA, 13 ml vs. MA, 20 ml, P < 0.0001). Regarding the long-term outcomes, the relapse-free survival, liver-relapse-free survival, cancer-specific survival and overall survival were all similar between groups.

CONCLUSION

Both the IA and MA in laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer are safe and feasible approaches; the IA may have an advantage over the MA in terms of reduced intra-operative blood loss. Based on their similar oncological outcomes, either the IA or MA can be selected, based on one's preference.

Medium-term oncological outcomes of totally laparoscopic colectomy with intracorporeal anastomosis for right-sided and left-sided colon cancer: propensity score matching analysis

Background

This retrospective study aimed to compare long-term oncological outcomes between laparoscopic-assisted colectomy (LAC) with extracorporeal anastomosis (EA) and totally laparoscopic colectomy (TLC) with intracorporeal anastomosis (IA) for colon cancers, including right- and left-sided colon cancers.

Methods

Patients with stage I–III colon cancers who underwent elective laparoscopic colectomy between January 2013 and December 2017 were analyzed retrospectively. Patients converted from laparoscopic to open surgery and R1/R2 resection were excluded. Propensity score matching (PSM) analysis (1:1) was performed to overcome patient selection bias.

Results

A total of 388 patients were reviewed. After PSM, 83 patients in the EA group and 83 patients in the IA group were compared. Median follow-up was 56.5 months in the EA group and 55.5 months in the IA group. Estimated 3-year overall survival (OS) did not differ significantly between the EA group (86.6%; 95% confidence interval (CI), 77.4–92.4%) and IA group (84.8%; 95%CI, 75.0–91.1%; P = 0.68). Estimated 3-year disease-free survival (DFS) likewise did not differ significantly between the EA group (76.4%; 95%CI, 65.9–84.4%) and IA group (81.0%; 95%CI, 70.1–88.2%; P = 0.12).

Conclusion

TLC with IA was comparable to LAC with EA in terms of 3-year OS and DFS. TLC with IA thus appears to offer an oncologically feasible procedure.

Tunnel versus medial approach in laparoscopic radical right hemicolectomy for right colon cancer: a retrospective cohort study

PURPOSE

This study aimed to explore the feasibility and safety of the tunnel approach in laparoscopic radical right hemicolectomy for colon cancer.

METHODS

From July 2016 to October 2018, a total of 106 consecutive patients with colon cancer who underwent laparoscopic radical right hemicolectomy at the Affiliated Cancer Hospital of Zhengzhou University were enrolled. The patients were stratified into either a tunnel approach (TA) (n = 56) group or traditional medial approach (MA) (n = 50) group according to the surgical technique performed. The baseline demographics, perioperative outcomes and oncologic outcomes were compared between the two groups.

RESULTS

The baseline characteristics did not differ between groups. The TA group had significantly less blood loss [20.0 (10.0-40.0) vs. 100 (100.0-150.0) ml, p < 0.001] and a shorter operation time [128.4 ± 16.7 vs. 145.6 ± 20.3 min, p < 0.001] than the MA group. The time to first flatus and postoperative hospital stay were similar [3.0 (2.0-4.0) vs. 3.0 (3-4.0) days, p = 0.329; 10.4 ± 2.6 vs. 10.7 ± 3.0 days, p = 0.506] between the two groups. The conversion to laparotomy and complication rates were similar between groups (0 vs. 6.0%, p = 0.203; 14.3% vs. 18.0%, p = 0.603, respectively). No treatment-related deaths occurred in either group. The TA group did not have significantly better survival outcomes than the MA group (p = 0.372).

CONCLUSIONS

The TA seems to allow for more favourable results in terms of blood loss and operative time than the MA, with similar results regarding time to first flatus, hospital stay, postoperative complication rate, conversion rate and oncologic outcomes; moreover, the TA is easier for beginners to master.

Short-term outcomes after laparoscopic right hemicolectomy for colon cancer: intracorporeal versus extracorporeal anastomosis

BACKGROUND

The purpose of this study was to compare the short-term outcomes of laparoscopic right hemicolectomy between intracorporeal (IA) and extracorporeal (EA) anastomosis techniques.

METHODS

A retrospective chart review of 77 consecutive patients who underwent laparoscopic right hemicolectomy from January 2016 to June 2018 was performed. The intracorporeal group included 36 patients and the extracorporeal group 41 patients.

RESULTS

Patient demographics and disease-related characteristics were similar. Mean operative time was 152±38.3 minutes in IA vs. 148±34.8 minutes in EA (p = 0.664). IA was not associated with less overall postoperative complications and decreased rate of surgical site infections. There was no statistically significant difference in the incidence of postoperative leak, length of stay, mortality in both groups. There was no perioperative difference in median number of lymph node harvested. There was statistically significant difference in the length of larger incision [50 (50-70) mm in IA vs 80 (70-100) mm in EA; p<0.001], length of the specimen (323 ±52.7 mm in IA vs 295±64.7 mm in EA; p<0.05), free tumor margin (113.6±47.4 in IA vs 75.6±37.4 mm in EA; p<0.001). There was a statistically significant difference in IA in the less postoperative use of analgesics (p<0.032), and return of bowel function (p<0.021).

CONCLUSIONS

IA seems feasible and safe; it does not significantly affect the length of surgery, and it guarantees maintenance of radical oncological standards. Furthermore, IA significantly improves cosmesis and patient comfort postoperatively, reducing the rates of emesis, which leads to higher rates of early regular diet tolerance. Therefore, laparoscopic right hemicolectomy with intracorporeal anastomosis is associated with improved short-term outcomes.

Management of intraoperative complications during laparoscopic right colectomy

BACKGROUND

Minimally invasive right colectomy is increasingly performed as standard treatment for diseases of right colon. Complete mesocolic excision has been introduced for cancer treatment to improve oncological results. Both standard and complete mesocolic excision techniques are associated with intraoperative complications. The purpose of this study was to analyse incidence and management of intraoperative complications in patients who underwent laparoscopic right colectomy with complete mesocolic excision in a single institution.

METHODS

This is a retrospective study conducted in a single Italian centre from April 2017 to October 2020. Data of non-metastatic cancer patients who underwent laparoscopic right colectomy were collected to analyse onset of intraoperative complications, their management and rate of conversion to open surgery.

RESULTS

A total of 92 patients were included in this study. The 1.09% of patients were converted to open surgery due to adhesions and bowel occlusion. The 5.43% of patients had intraoperative complications: bleeding from Henle's trunk, pre-pancreatic plane and ileocolic artery stump account for 3.26%, gonadal vessel injury for 1.09% and bowel lesion for 1.09%.

CONCLUSIONS

Despite the limits of this study, it shows that bleeding is one of the most frequent complications in laparoscopic right colectomy. Bleeding, occlusion and adhesions are most common reasons for conversion to open surgery.

A novel and simple technique to close the enterotomy after intracorporeal anastomosis in laparoscopic right hemicolectomy

We developed a new technique to reduce the length of the enteric defect to be closed during intracorporeal anastomosis in laparoscopic right hemicolectomy (LRH), also avoiding the need to suture the first part of the anastomosis in a deep space with an acute angle. From January 2017, after the ileo-colic anastomosis was completed, an additional stapler cartridge was applied starting at the colonic rim and including the small bowel part of the anastomosis. The isoperistaltic fashion of the ileo-colonic anastomosis was maintained. The remaining defect left to be closed was 2-3 cm. We compared the results of the novel technique with those of the 'standard' closure (full-length enterotomy). In the last 30 months, this technique was successfully used in 32 patients (Group A), compared with 33 patients (2012-2016) operated with 'standard' closure (Group B). Age, BMI and post-operative stage distribution were similar. The mean operative time was 175.2 min (± 36.7) in Group A and 165.9 min (± 42.5) in Group B (p = ns), with 53.1% and 27.3% of associated procedures (cholecystectomy, ovariectomy, etc.), respectively (p < 0.05). Overall morbidity rate was 28.1% and 30.3% (Group A vs Group B, p = ns), with no anastomotic bleeding/leak in either group. This technique, which simplifies the closure of the enteric defect after LRH with intracorporeal anastomosis is safe, reproducible and easy to learn. It might help more surgeons to perform a fully laparoscopic procedure in right hemicolectomy, offering the advantages of intracorporeal anastomosis to their patients.

Short- and medium-term outcomes of intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: a propensity score-matched study

BACKGROUNDS

Though better short-term outcomes were frequently reported, differences in specimen parameters and the rate of subsequent peritoneal recurrence between intracorporeal anastomosis (IA) and extracorporeal anastomoses (EA) for laparoscopic right hemicolectomy have not been analyzed. We aimed to compare the pathologic differences and oncological outcomes between these two approaches.

METHODS

We retrospectively analyzed 217 consecutive patients who underwent laparoscopic right hemicolectomies from September 2016 to April 2018 and classified them into IA and EA groups, based on the approach used. Propensity score matching analysis was performed, after which 101 patients were included in each group with the patients matched for demographics, tumor stage, and localization.

RESULTS

The IA group had a longer operative time, shorter length of stay, shorter time to first flatus and tolerating a soft diet, and better pain scale scores at postoperative day 3. No inter-group differences in conversion, postoperative complication, mortality, or readmission rates were found. The IA group had a longer resected colon length (23.67 vs. 19.75 cm, p = 0.010) and nearest resected margin (7.51 vs. 5.40 cm, p = 0.010) for cancer near the hepatic flexure. There are comparable 3-year overall survival (87.7% vs. 89.6%, p = 0.604) and disease-free survival (75.0% vs. 75.7%, p = 0.842) between the IA and EA groups. The rate of peritoneal recurrence was similar between the two groups (5.9% vs. 7.9%, p = 0.580).

CONCLUSIONS

The overall survival, disease-free survival, and the rate of peritoneal recurrence were comparable between the IA and EA procedures. IA ensures better recovery and comparable complications to EA and achieved a more precise tumor excision; thus, IA can be considered a safe procedure for patients with right-sided colon lesions.

Laparoscopic right hemicolectomy with intracorporeal anastomosis and natural orifice surgery extraction/minimal extraction site surgery in the obese

BACKGROUND

Despite advantages associated with laparoscopic colorectal surgery, there is significant morbidity associated with incisions required for specimen extraction and restoration of bowel continuity. In laparoscopic colorectal surgery, the length of the longest incision depends upon that required to facilitate extra-corporeal steps. The purpose of this study was to analyse obese patients (body mass index >30 kg/m² ) who have undergone laparoscopic small bowel or right-sided colonic resection with intracorporeal anastomosis (ICA) and natural orifice surgery extraction (NOSE)/minimal extraction site (MES) surgery.

METHODS

A retrospective review of 11 obese patients who have undergone laparoscopic small bowel and right-sided colonic resection with ICA and NOSE/MES was conducted.

RESULTS

Mean body mass index was 40.4 kg/m² (range 32.7-56 kg/m² ) in 11 patients. Procedures performed were laparoscopic right hemicolectomy (7) - one with high anterior resection, pelvic peritonectomy, bilateral salpingo-oophorectomy and greater omentectomy, small bowel resection (2), transverse colotomy (1) and segmental transverse colectomy (1). All colonic specimens were extracted via NOSE (vaginal colpotomy or transcolonic), except two requiring a miniaturized extraction wound. Small bowel specimens were extracted via a 12-mm port hole, without extension. Mean operating time was 240 min (range 100-510 min). Mean time to discharge was 4 days (range 4-6 days). Complications included a superficial wound infection in a patient presenting with an obstructed tumour and a second patient developed a seroma following small bowel resection for an incarcerated hernia.

CONCLUSION

Obese patients can undergo laparoscopic small bowel and right-sided colonic resection with ICA and NOSE/MES surgery and benefit from short length of stay and low morbidity.

Current status and trend of laparoscopic right hemicolectomy for colon cancer

Laparoscopic right hemicolectomy (LRH) is utilized worldwide as one of the standard surgical treatments for right-sided colon cancer. However, there have been issues concerning its applicability, techniques, and trend. The present study aimed to elucidate the current status and trend of LRH by reviewing literature focusing on important issues associated with this surgery. Based on previous studies, LRH most likely provides better short-term outcomes and similar oncological outcomes compared to open surgery. Despite the increasing use of robotic approach in this surgery, it seems to have always been associated with longer operative times and greater hospital cost with limited advantage. Intracorporeal anastomosis seems to improve short-term outcomes, such as quicker recovery of bowel function, compared to extracorporeal anastomosis. However, it does not contribute to shorter hospital stay. With regard to dissection technique, various approaches, and landmarks have been advocated to overcome the technical difficulty in LRH. This difficulty is likely to be caused by anatomical variation, especially in venous structures. The superiority of one approach or landmark over another is still argued about due to the lack of large-scale prospective studies. However, deep understanding both of anatomical variation and characteristics of each approach would be of extreme importance to minimize adverse effects and maximize patient benefit after LRH.

Right Colectomy with Extended D3 Mesenterectomy: Anterior and Posterior to the Mesenteric Vessels

BACKGROUND

In right colectomy for cancer, complete mesocolic excision and D3 lymphadenectomy each leave behind lymphatic tissue anterior and posterior to the superior mesenteric vein (SMV) and artery (SMA). In this article, we present D3 extended mesenterectomy: a surgical technique that excises the lymphatic tissue en bloc with the right colectomy specimen.

MATERIAL AND METHODS

A 3D map of the mesentery of the right colon was reconstructed from staging CT-angiogram scans. The surgical technique of right colectomy with D3 extended mesenterectomy consisted of eight steps: 1) reveal the SMV and SMA; 2) isolate the ileocolic artery; 3) isolate the middle colic artery; 4) resolve the anterior mesenteric flap; 5) specimen de-vascularization; 6) colectomy; 7) resolve the posterior mesenteric flap; and 8) anastomosis.

RESULTS

One-hundred-seventy-six patients (77 men) 66 years of age were operated upon from February 2011 to January 2017. There were 169 adenocarcinomas: 16.0% Stage I, 49.1% Stage II, 33.7% Stage III, 1.2% Stage IV. Tumor locations were 50.6% cecum, 41.5% ascending colon, 4.5% hepatic flexure, and 2.3% transverse colon. Mean operating time was 200 minutes, blood loss 273 ml, and length of stay 7.9 days. There were 9 anastomotic leakages and 15 reoperations. One patient underwent small bowel resection due to SMA tear. There was no postoperative mortality. The mean number of lymph nodes per specimen (40.9) was comprised of 27.1 in the D2 volume and 13.8 in the D3 volume. The mean number of metastatic lymph nodes was 1.2 in the D2 volume and 0.13 in D3. There were 7 patients with lymph node metastasis in D3, 2 of whom had node metastasis solely within D3.

CONCLUSION

This study shows that 1.2% of patients would have been incorrectly diagnosed as Stage II if extended D3 mesenterectomy had not been performed. Similarly, lymph node metastases would have been left behind in 4.1% of patients if extended D3 mesenterectomy had not been performed.

Total laparoscopic surgery for treatment of leiomyoma of the transverse colon in a patient with an abdominal mesh: A case report

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Leiomyomas of the colon are rare and account for 3% of gastrointestinal leiomyomas.

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The patient had an abdominal mesh from a prior surgery.

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Laparoscopic colectomy was used for treatment of leiomyoma of the transverse colon.

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Laparoscopic colectomy prevented damage to the abdominal mesh.

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Total laparoscopic surgery is a viable option in patients with abdominal mesh.

Introduction

Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract; however, gastrointestinal leiomyomas are relatively rare. Surgical resection is recommended for leiomyomas and gastrointestinal stromal tumors of the colon. We present a case in which we performed laparoscopic right hemicolectomy with intraabdominal anastomosis for treating leiomyoma of the transverse colon in a patient with an abdominal mesh.

Presentation of case

A 64-year-old woman with a history of right subtotal adrenalectomy and right mastectomy was incidentally found to have an abdominal mass on a follow-up computed tomography (CT) scan, which was confirmed as a gastrointestinal stromal tumor of the mesentery following abdominal contrast-enhanced CT. We planned surgical resection for preoperative diagnosis because the tumor was >5 cm in diameter. However, she had undergone transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after right mastectomy, in which the TRAM flap was replaced with an abdominal mesh; hence, total laparoscopic surgery was performed to avoid damaging the mesh owing to the risk of mesh infection. Laparotomy revealed that the tumor originated from the transverse colon; thus, transverse colectomy with intraabdominal anastomosis was performed. The total operative time and blood loss were 3 h 32 min and 5 mL, respectively. No postoperative leakage or mesh infection was observed. The resected specimen revealed a leiomyoma without malignancy.

Discussion

We successfully performed colectomy that minimized the resection range and intraabdominal anastomosis.

Conclusion

Total laparoscopic surgery was effective for colonic leiomyoma with an abdominal mesh to avoid mesh-related complications.

A single surgeon's experience transitioning to robotic-assisted right colectomy with intracorporeal anastomosis

BACKGROUND

Despite substantial evidence demonstrating benefits of minimally invasive surgery, a large percentage of right colectomies are still performed via an open technique. Most laparoscopic right colectomies are completed as a hybrid procedure with extracorporeal anastomosis. As part of a pure minimally invasive procedure, intracorporeal anastomosis (ICA) may confer additional benefits for patients. The robotic platform may shorten the learning curve for minimally invasive right colectomy with ICA.

METHODS

From January 2014 to May 2016, 49 patients underwent robotic-assisted right colectomy by a board-certified colorectal surgeon (S.R). Extracorporeal anastomosis (ECA) was used in the first 20 procedures, whereas ICA was used in all subsequent procedures. Outcomes recorded in a database for retrospective review included operating time (OT), estimated blood loss (EBL), length of stay (LOS), conversion rate, complications, readmissions, and mortality rate.

RESULTS

Comparison of average OT, EBL, and LOS between extracorporeal and intracorporeal groups demonstrated no significant differences. For all patients, average OT was 141.6 ± 25.8 (range 86-192) min, average EBL was 59.5 ± 83.3 (range 0-500) mL, and average LOS was 3.4 ± 1.19 (range 1.5-8) days. Four patients required conversion, all of which occurred in the extracorporeal group. There were no conversions after the 18th procedure. The 60-day mortality rate was 0%. There were no anastomotic leaks, ostomies created, or readmissions. As the surgeon gained experience, a statistically significant increase in lymph node sampling was observed in oncologic cases (p = .02).

CONCLUSIONS

The robotic platform may help more surgeons safely and efficiently transition to a purely minimally invasive procedure, enabling more patients to reap the benefits of less invasive surgery. Transitioning from ECA to ICA during robotic right colectomy resulted in no significant change in OT or LOS. A lower rate of conversion to open surgery was noted with increased experience.

Right colectomy: a New York state of mind

Although mortality rates attributable to colon cancer have significantly improved over the past decades, it is still one of the leading causes of death in the USA. As newer technology and surgical techniques and concepts are being introduced, substantial confusion and dissenting opinions have come into fray as well. Naturally, different practice patterns emerged in Asia, Western Europe as well as in the USA. In this special article, we focus on the right colon and examine the unique challenges and oddities of practicing academic colorectal surgery in the New York metropolitan area.

Hybrid Transvaginal NOTES and Mini-Laparoscopic Colectomy: Benefit Through Synergy

Background and Objectives:

Hybrid-natural orifice surgery combines the advantages of traditional transabdominal laparoscopic surgery, while limiting surgical trauma to the abdominal wall. Among various routes of intra-abdominal access, the transvaginal method is most appealing because of its utility and proven safety. We describe a series of 4 colonic resections performed with this approach, combined with minilaparoscopy and needlescopic approaches, and discuss the technical aspects, efficacy, and applicability of this technique.

Methods:

Three patients were selected to undergo hybrid transvaginal natural-orifice right hemicolectomy. A fourth patient, who underwent a segmental resection of a splenic flexure carcinoma, was included. Transvaginal port access was obtained via posterior colpotomy, and was used for dissection, vascular ligation, bowel division, and anastomosis. We used a combination of standard laparoscopic, minilaparoscopic, and needlescopic instruments transabdominally, focusing on reduced size and number of access points.

Results:

Duration of laparoscopy, oncologic outcomes and rate of operative morbidity were comparable to the published literature. Early return of gastrointestinal function and low analgesic requirements was observed in all patients. No morbidity related to transvaginal access was observed and the procedure was performed without difficulty in all cases.

Conclusion:

Colonic resection performed by hybrid natural-orifice technique offers several advantages over purely transabdominal laparoscopic procedures. Transvaginal access is easy to perform and offers excellent safety, efficacy, and versatility, especially for right hemicolectomy. Techniques to reduce abdominal wall surgical trauma, such as minilaparoscopy and needlescopic graspers, can be combined effectively in colonic resections, and may act synergistically to reduce postoperative pain and improve outcomes.

Laparoscopic right colectomy vs laparoscopic-assisted colonoscopic polypectomy for endoscopically unresectable polyps: a randomized controlled trial

AIM

A randomized controlled trial (RCT) was conducted to test the null hypothesis that there is no difference in complication rates and length of stay (LOS) between laparoscopic right colectomy (LRC) and laparoscopic-assisted colonoscopic polypectomy (LACP) for endoscopically unresectable polyps of the right colon.

METHOD

A single-centre RCT (NCT01986699) was conducted on patients with polyps of the right colon deemed by the gastroenterologist to be unresectable. Patients underwent a repeat colonoscopy with biopsy by an interventional endoscopist and were allocated to LRC or LACP. Patients with a nonlift sign, dysplasia, adenocarcinoma, inflammatory bowel disease or familial adenomatous polyposis were excluded from the trial. The study was powered to detect a 73% difference in the LOS which required 17 patients in each arm with an α error of 0.05 and a power of 95%.

RESULTS

Thirty-four patients were comparable for age (P = 0.919), gender (P = 0.364), body mass index (P = 0.634), American Society of Anesthesiologists class (P = 0.388) and previous abdominal surgery (P = 0.366). There was no significant difference in the preoperative morphology (P = 0.485), location (P = 0.297), size (P = 0.690) or histology of the polyps (P = 0.779). LRC patients experienced a longer operating time (180 vs 90 min; P = 0.001), required more intravenous infusion (3.1 vs 2.0 l; P = 0.025), took significantly longer to pass flatus (2.88 vs 1.44 days; P < 0.001), resumed solid food later (3.94 vs 1.69 days; P < 0.001) and had a longer postoperative LOS (4.94 vs 2.63 days; P < 0.001). Postoperative complications (P = 0.656), readmissions (P = 0.5) and reoperations (P = 0.5) did not differ. Final size (P = 0.339) and histology (P = 0.104) of the polyps did not differ. There were four cancers in the LRC arm. At follow-up colonoscopy with biopsy of the scar in 10 patients at 15.3 months, one patient had recurrence of the polyp at the site of the previous LACP.

CONCLUSION

LACP and LRC had similar complication rates, but LOS was shorter after LACP.

Total laparoscopic right hemicolectomy with 3-step stapled intracorporeal isoperistaltic ileocolic anastomosis for colon cancer: An evaluation of short-term outcomes

Laparoscopic right hemicolectomy with extracorporeal anastomosis is a widely used procedure; several authors have published their approach to intracorporeal anastomosis. In this paper, we present an approach developed by us and compare short-term outcomes with those of extracorporeal anastomosis in colon cancer patients.Retrospective review of colon cancer patients treated with laparoscopic right hemicolectomy either with intracorporeal anastomosis (TLG group) or extracorporeal anastomosis (LG group) at the Zhangjiagang Hospital Affiliated to Soochow University between January 2011 and October 2015. Operative and postoperative data are compared.Around 85 patients underwent laparoscopic hemicolectomy (56 TLG and 29 LG) during the reference period for this study. Age, gender, body mass index (BMI), stage of cancer, operation time, number of lymph nodes harvested, and length of hospital stay were comparable between the 2 groups. In the TLG group, the ileocolic anastomosis time was significantly shorter (9.9-15.5 minutes vs 13.5-18.2 minutes in LG; P < 0.001), the mean intraoperative blood loss was lower (83.2 mL [range, 56.5-100.5 mL] vs 93.3 mL [range, 75.8 - 110.3 mL]; P < 0.001), the recovery of bowel function was faster (P < 0.001), and the postoperative pain score was lower (P < 0.001) as compared to that in the LG group. Complications in the LG group included wound infection (4 patients), obstruction (1), and postoperative bleeding complications (1); however, only 1 patient developed complication (wound infection) in the TLG group.Total laparoscopic right hemicolectomy with 3-step stapled intracorporeal anastomosis for colon cancer is a safe and reliable procedure. Its advantages include short anastomosis time, less intraoperative blood loss, less postoperative pain, and early bowel function recovery.

Single-port plus an additional port robotic complete mesocolic excision and intracorporeal anastomosis using a robotic stapler for right-sided colon cancer

The concept of complete mesocolic excision and central vascular ligation for colonic cancer has been recently introduced. The paper describes a technique of right-sided complete mesocolic excision and intracorporeal anastomosis by using a single-port robotic approach with an additional conventional robotic port. We performed a single-port plus an additional port robotic surgery using the Da Vinci Single-Site platform via the Pfannenstiel incision and the wristed robotic instruments via an additional robotic port in the left lower quadrant. The total operative and docking times were 280 and 25 minutes, respectively. The total number of lymph nodes harvested was 36 and the proximal and distal resection margins were 31 and 50 cm, respectively. Single-port plus an additional port robotic surgery for right-sided complete mesocolic excision and intracorporeal anastomosis appears to be feasible and safe. This system can overcome certain limitations of the previous robotic systems and conventional single-port laparoscopic surgery.

Intracorporeal versus extracorporeal anastomosis in right hemicolectomy: a systematic review and meta-analysis

Background

Laparoscopic right hemicolectomy for colon cancer is associated with substantial morbidity despite the introduction of enhanced recovery protocols and laparoscopic surgery. Laparoscopic right hemicolectomy with an intracorporeal anastomosis (IA) is less invasive than laparoscopic assisted hemicolectomy, possibly leading to further decrease in post-operative morbidity and faster recovery. The current standard technique includes an extracorporeal anastomosis with mobilization of the colon, mesenteric traction and a extraction wound located in the mid/upper abdomen with relative more post-operative morbidity compared to extraction wounds located in the lower abdomen.

Methods

A systematic review of PubMed and Embase databases was performed on studies comparing the intracorporeal versus the extracorporeal performed anastomosis in laparoscopic right hemicolectomy. Primary outcomes were mortality, short-term morbidity and length of stay. For quality assessment, the MINORS checklist was used. Meta-analysis was performed using a random-effects model, and a subgroup analysis was performed for data regarding short-term morbidity and length of stay in studies published in 2012≥.

Results

A total of 2692 papers were identified, 12 non-randomized comparative studies were included in the analysis with a total number of 1492 patients. No significant change in mortality was found (OR 0.36, 95 % CI 0.09–1.46; I² = 0 %). Short-term morbidity decreased significantly in favour of IA (OR 0.68, 95 % CI 0.49–0.93; I² = 20 %). Length of stay was decreased, but with serious risk of heterogeneity (MD −0.77 days, 95 % CI −1.46 to −0.07; I² = 81 %). Subgroup analysis for papers published in 2012≥ resulted in an even larger decrease in short-term morbidity (OR 0.65, 95 % CI 0.50–0.85; I² = 0 %) and a significant decrease in length of stay with low risk of heterogeneity (MD −0.77 days, 95 % CI −1.17 to −0.37; I² = 4 %).

Conclusion

Intracorporeal anastomosis in laparoscopic right hemicolectomy is associated with reduced short-term morbidity and decreased length of hospital stay suggesting faster recovery as shown in this meta-analysis.

CT assessment of right colonic arterial anatomy pre and post cancer resection - a potential marker for quality and extent of surgery?

BACKGROUND

There is conflicting opinion as to the optimum extent of resection for right-sided colonic cancer, which is currently graded by pathological analysis of the resected specimen. It is not known if computed tomography (CT) analysis of residual post-resection arterial stump length could be used as an alternative in vivo marker for extent of mesenteric resection. Ileocolic artery stumps have been demonstrated previously on CT after right hemicolectomy, but only in the early postoperative period.

PURPOSE

To analyze preoperative right colonic arterial anatomy using portal venous colorectal cancer staging CT and subsequently determine if post-resection arterial stumps (a potential in vivo marker of surgical resection) could be consistently identified using routine follow-up CT scans many months after cancer resection.

MATERIAL AND METHODS

A retrospective analysis of routine staging and follow-up CT scans for 151 patients with right-sided colorectal cancer was performed. Preoperative right colonic arterial anatomy and postoperative arterial stumps were analyzed and measured.

RESULTS

Preoperative ileocolic (98.8%), middle (94.7%), and right colic artery (23.8%) identification was comparable to catheter angiogram studies. Postoperative ileocolic stumps were consistently demonstrated (88.3%) many months (average, 2 years and 42 days) after resection and were significantly longer than expected for a standard D2 resection (paired t-test, t(127) = -11.45, P ≤ 0.001).

CONCLUSION

This is the first study to successfully demonstrate ileocolic arterial stumps many months (and years) after cancer resection using routine portal venous CT. Further prospective research should assess whether arterial stumps can be used as an in vivo marker of surgical quality and extent.

Laparoscopic right hemicolectomy: short- and long-term outcomes of intracorporeal versus extracorporeal anastomosis

BACKGROUND

The use of laparoscopy for right hemicolectomy has gained popularity allowing the option of a totally laparoscopic intracorporeal anastomosis (IA) for intestinal reconstruction. This technique may alleviate some of the technical limitations that a surgeon faces with a laparoscopic-assisted extracorporeal anastomosis (EA).

METHODS

A retrospective chart review of 195 consecutive patients who underwent laparoscopic right hemicolectomy by four colorectal surgeons at three institutions from March 2005 to June 2014 was performed. Multivariate regression analysis was used to compare postoperative and oncologic outcomes.

RESULTS

A total of 195 patients underwent laparoscopic right hemicolectomy over the study period, with 86 (44 %) patients receiving IA and 109 (56 %) patients receiving an EA. The most common indication for surgery in both groups was cancer: 56 (65 %) of IA cases and 57 (52 %) of EA cases. IA had a significantly higher rate of minor complications but no difference in serious complications compared to EA. Conversion to open resection was higher in EA. Using multivariate analysis to compare IA versus EA, there was no significant difference in length of stay, return of bowel function, risk of anastomotic leak, risk of intraabdominal abscess or risk of wound complications. Amongst cancer resections, there was no significant difference in the median number of lymph nodes harvested (18 LNs in IA group vs. 19 LNs in EA group, P > 0.05). There was also no significant difference in overall survival and disease-free survival at 5.7 years between the two groups.

CONCLUSIONS

IA in laparoscopic right hemicolectomy is associated with similar postoperative and oncologic outcomes compared to EA. IA may possess advantages in terms of conversion and flexibility of specimen extraction, but this is counterbalanced by a higher incidence of minor complications. These findings suggest that IA represents a valid technique in the arsenal of the experienced colorectal surgeon without compromising outcomes.

Single-Incision Laparoscopic Right Hemi-Colectomy: a Systematic Review

As surgeons became more adept with laparoscopic colon surgery, other less invasive procedures, such as single-incision laparoscopic right hemi-colectomy (SIL-RH), have been applied. The objective of this study was to evaluate the safety of SIL-RH as well as its intraoperative and postoperative outcomes for right-sided colon diseases. A detailed search in PubMed for citations that included SIL-RH from 2000 to 2014 revealed 21 studies fulfilling the criteria of the present review. A total of 684 patients were analyzed. Of the patients, 50.2 % were men. Mean patient age was 64.8 years. Of the patients, 36.1 % had already undergone an abdominal operation before the performance of SIL-RH, while 69 % of the patients underwent SIL-RH for colon cancer. Relatively low rates of overall morbidity (15 %) and mortality (0.75 %) were reported in the included studies. Mean length of postoperative hospital stay (LOS) was 5.5 days. Bowel motility return had a mean value of 2.8 days. Mean number of harvested lymph nodes (LN) was 19.2 LN. All resection margins were tumor-free. SIL-RH was a safe alternative to multiport laparoscopic right hemi-colectomy (ML-RH) in terms of morbidity and mortality, postoperative gastrointestinal function recovery, LOS, as well as oncological radicalness.

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.

Robotic right colectomy with intracorporeal anastomosis: experience with 52 consecutive cases

BACKGROUND

In laparoscopic right hemicolectomy (LRC), extracorporeal or intracorporeal (ICA) anastomosis can be performed. Several authors have suggested advantages to ICA. This study reports our transition to and our experience with robotic right colectomy (RRC) with ICA.

MATERIALS AND METHODS

From June 2009 to September 2012 we performed 58 consecutive RRCs, of which 52 were with ICA. Data were prospectively stored and retrospectively reviewed.

RESULTS

Twenty-eight female and 30 male patients with a mean age of 71.6 ± 8.3 years (range, 52-89 years) were studied. Indications for surgery included adenocarcinoma (n=30), adenoma (n=20), diverticulitis (n=1), and Crohn's disease (n=1). For RRC with ICA (n=52), mean operative time (OT) was 193.2 ± 42.2 minutes (range, 123-239 minutes). Mean estimated blood loss (EBL) was 47.8 ± 59.5 mL (range, 5-300 mL). Mean length of hospital stay (LOS) was 3.7 ± 3.2 days (range, 1-21 days). Mean extraction-site incision size was 4.61 ± 0.78 cm (range, 2.5-6.5 cm). Mean lymph node harvest was 20.7 ± 8.2 (range, 6-40). Mean specimen length was 18.9 ± 7.2 cm (range 10-37). No intraoperative complications, conversions, or 30-day mortality occurred. Nine postoperative complications (19.1%) occurred, with one anastomotic leak (1.7%). For LRC with ICA as reported in the literature, OT ranges from 136 to 190 minutes, EBL ranges from 0 to 500 mL, median LOS ranges from 3 to 5 days, complication rates range from 6% to 15%, with ileus <22%, and conversion rates are <5%.

CONCLUSIONS

RRC with ICA is safe and feasible. OTs and outcomes compare favorably with those published in the literature for LRC with ICA. The robot may facilitate transition to ICA, and if future studies confirm advantages of ICA, the role of RRC may gain importance.

Intracorporeal versus extracorporeal anastomosis. Results from a multicentre comparative study on 512 right-sided colorectal cancers

BACKGROUND

Although nowadays considered as feasible and effective surgery in terms of short- and long-term results and oncological radicality, laparoscopic right colectomy is performed by a small number of surgeons, and in the vast majority of cases, this technique was performed with an extracorporeal anastomosis. Current literature failed to solve the controversies between intracorporeal and extracorporeal anastomosis after laparoscopic right colectomy.

METHODS

A multicenter case-controlled study has been designed, including 286 patients who underwent laparoscopic right hemicolectomy with intracorporeal anastomosis (IA) compared with 226 matched patients who underwent laparoscopic right hemicolectomy with extracorporeal anastomosis (EA).

RESULTS

There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Surgical post history, tumor localization, and stage of disease according to AJCC/UICC TNM were similar too. Although similar oncologic radicality in term of number of lymph nodes harvested (25.7 ± 10.7 of IA group vs. 24.8 ± 8.7 of EA group; p = 0.3), as well as similar operative time (166 ± 43.7 min. in IA group vs. 157.5 ± 67.2 min in EA group) have been registered, time to flatus was statistically lower after intracorporeal anastomosis (40.8 ± 24.3 h in TLRC group vs. 55.2 ± 19.2 h in LARC group; p < 0.001) Laparoscopic colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 0.65, 95 % CI 0.44, 0.95, p = 0.027). However, when stratifying according to clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 0.63, 95 % CI 0.42, 0.94, p = 0.025), but not for class III, IV, and V complications (OR 1.015, 95 % CI 0.64, 1.6, p = 0.95).

CONCLUSION

Our results are encouraging to consider the intracorporeally approach the better way to fashion the anastomosis after laparoscopic right colectomy. This study clearly provides the rationale for a randomized clinical trial, which would be useful to give definitive conclusion.

Totally intracorporeal laparoscopic colectomy (TILC) is associated with similar surgical outcomes in high and low operative risk patients

PURPOSE

Patients undergoing laparoscopic-assisted colectomy with obesity, high American Society of Anesthesiologists (ASA) grade, and left-sided colon tumors are at high risk for operative conversion and complications. We hypothesized that a completely intracorporeal laparoscopic colectomy would be beneficial for high-risk patients compared with healthy, low-risk patients.

METHODS

We conducted a retrospective study of 136 consecutive patients undergoing a standardized totally intracorporeal laparoscopic colectomy for neoplasms from February 2004 to September 2011. Patients were stratified into a high-risk group with 1 or more factors: body mass index >30, ASA grade ≥ 3, and left-sided tumors or a low-risk group with no factors. Variables compared were case frequency during the learning curve, body mass index, estimated blood loss, operative time, conversion, 30-day complications, and length of stay. Comparisons between groups were made by χ2 analysis or t test where appropriate. Data are expressed as median ± SD, odds ratio, and significance defined as P<0.05.

RESULTS

Laparoscopic colectomy was performed in 136 patients with a conversion rate of 4%. There were 86 high-risk patients and 50 low-risk patients. High-risk patients had a significantly (P<0.005) longer operative time (225 ± 66 vs. 186 ± 55 min) but no significant difference in estimated blood loss, conversion rates, learning curve, complications, or length of stay compared with low-risk patients.

CONCLUSIONS

When laparoscopic colectomy is performed totally intracorporeally, surgical outcomes in high-risk patients with obesity, high ASA grade, and left-sided tumors are equally successful to results achieved for low-risk patients that are thin, healthy, with right-sided lesions.

Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review was to compare intracorporeal (IA) versus extracorporeal anastomosis (EA) after laparoscopic right hemicolectomy for cancer.

METHODS

The meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Studies published from 2009 to 2012 that compare IA and EA after laparoscopic right hemicolectomy were identified. The included non-randomized studies were assessed for their methodological quality using the revised and modified grading system of the Scottish Intercollegiate Guidelines Network. Intraoperative, early postoperative, and postoperative recovery outcomes were compared using weighted mean differences and odds ratios.

RESULTS

Five non-randomized controlled trials published between 2009 and 2011, comprising 425 patients, were included in this analysis. IA was associated with significant faster bowel movement, faster first flatus, shorter time to solid diet, decreased use of analgesics, and shorter duration of the hospital stay. No differences were observed for nasogastric tube reintroduction rate, operative time, incision length, number of nodes harvested, intraoperative complications, mortality, non-surgical site complications, surgical site complications (anastomotic leakage, anastomotic bleeding, wound infection, ileus), reintervention, and readmission rate.

CONCLUSIONS

Even when the limitations are taken into account due to the observational nature of the included studies, the results suggest that the IA after laparoscopic right hemicolectomy for cancer results in better postoperative recovery outcomes, such as shorter hospital stay, faster bowel movement recovery, faster first flatus, faster time to solid diet, and lesser analgesic usage.

Medial versus lateral approach in laparoscopic colorectal resection: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to investigate the safety and efficacy of the medial approach (MA) and the lateral approach (LA) in the treatment of colorectal disease.

METHODS

Studies published since 1994 that compared MA versus LA in laparoscopic colorectal resection were collected. Data on conversion rate, operative time, blood loss, number of harvested lymph nodes, hospital stay, complications, mortality, rate of recurrence, and hospitalization costs for MA and LA were meta-analyzed using fixed-effect and random-effect models.

RESULTS

Five cohort studies (2 randomized controlled trials and 3 retrospective studies) that included 881 patients were studied. Of these patients, 475 and 582 had undergone laparoscopic colorectal resection via MA and LA, respectively. There were significant reductions in conversion rate and operative time and possible reductions in blood loss and hospitalization costs for MA compared to LA; however, there were fewer harvested lymph nodes for MA compared with LA, which remains to be further studied. Other outcome variables such as postoperative complications, postoperative immune function, mortality, and rate of recurrence were not found to be statistically significant for either group. Sensitivity analysis on the pooled data from randomized controlled trials showed that the conversion rates were not significantly different between MA and LA.

CONCLUSIONS

Compared with the lateral approach, the medial approach has the advantages of shorter operative time and possibly lower conversion rate; it also can be as safe as the lateral approach. Whether the MA has less blood loss and lower hospitalization costs remains to be confirmed, and its oncological safety and long-term prognosis are not clear. Due to insufficient data from a limited number of studies, inadequate assessment of the results may arise.

Right colectomy: value of the totally laparoscopic approach

The role of laparoscopy for right colectomy remains controversial - largely because of a lack of standardization of the operative procedure, including a diversity of techniques including laparoscopy-assisted cases with extra-corporeal anastomosis and totally laparoscopic procedures with intra-corporeal anastomosis.

METHODS

The charts of all patients who underwent right colectomy by a totally laparoscopic approach in our service since 2004 were reviewed and pre-, intra-, and postoperative data were collected.

RESULTS

Eighty-two patients underwent totally laparoscopic right colectomy; of these, 32 had a BMI greater than 20 kg/m2 (39%). The mean operative duration was 113 minutes. In most cases, the operative specimen was extracted through a supra-pubic Pfannenstiel incision measuring 4-6 cm in length. Three cases were converted to a laparoscopy-assisted technique (in order to control the ileo-cecal vascular pedicle because of extensive nodal invasion in two cases, and to evaluate a hepatic flexure polyp in the third case). Overall morbidity was 29.3% and parietal morbidity was only 9.8%; there was no difference in morbidity between obese patients (BMI>30 kg/m2) and non-obese patients (BMI<30 kg/m2). The mean duration of hospitalization was 9 days and two patients developed ventral hernia in the extraction incision in long-term follow-up.

CONCLUSION

These satisfactory results show that the totally laparoscopic approach to right colectomy is technically feasible and safe, even in obese patients. In addition, the very low rate of parietal complications is an argument in favor of this approach.

Laparoscopic right colectomy: a systematic review and meta-analysis of observational studies comparing two types of anastomosis

Because of its technical difficulty, totally laparoscopic right colectomy with intracorporeal anastomosis is performed only by a small number of surgeons and most of them use a laparoscopic-assisted technique with extracorporeal anastomosis. This systematic review aims to evaluate differences in outcomes of patients undergoing right laparoscopic colectomy, either with intracorporeal or extracorporeal anastomosis. Electronic databases were searched for studies published between 1991 and 2012. Randomized controlled trials and case-control studies comparing intracorporeal to extracorporeal anastomosis in laparoscopic right colectomy were included in the systematic review. Meta-analytical models were used to evaluate anastomotic leak rate and short-term overall morbidity. Defined primary outcomes of interest were operating time, conversion rate, return of bowel function, anastomotic leak rate, and length of hospital stay. Randomized controlled trials were not found, confirming the paucity of the literature on this topic. Six case-control studies were identified involving 484 patients undergoing right laparoscopic colectomy, 272 with intracorporeal and 212 with extracorporeal anastomosis. Best outcomes seem to be associated with totally laparoscopic right colectomy with intracorporeal anastomosis, especially in terms of return of bowel function, length of hospital stay, and cosmetic results. However, our meta-analysis did not show a significant difference between the two techniques in terms of anastomotic leak rate (OR 0.98; 95 % CI 0.30-3.15) or for short-term overall morbidity (OR 0.68; 95 % CI 0.41-1.12). Comparative analysis of outcomes is in favor of intracorporeal anastomosis. However, the meta-analysis results do not allow us to draw definitive conclusions. Further prospective randomized trials are necessary to confirm our findings.

Intracorporeal ileocolic anastomosis: a review

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

Short- and long-term outcomes of intracorporeal versus extracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy for colon cancer

BACKGROUND

We assessed the short- and long-term outcomes of intracorporeal ileocolic anastomosis (IA) in laparoscopic right hemicolectomy for colon cancer compared with extracorporeal anastomosis (EA).

METHODS

A retrospective chart review of 86 consecutive patients who underwent laparoscopic right hemicolectomy for colon cancer from March 2005 to June 2010 was performed.

RESULTS

There were 51 and 35 patients who underwent intracorporeal and extracorporeal anastomosis, respectively. The two groups were demographically comparable. The conversion rate to open surgery was 8.6 % in the EA group, but none in the IA group (p = 0.064). There was no significant difference in operative time, estimated blood loss, complications (intra-abdominal abscess, anastomotic leak, ileus, and wound infection), and length of hospital stay between the groups. There was no perioperative mortality in both groups. There was no significant difference in median number of retrieved lymph node. The overall survival and the disease-free survival at 3 years were not different between the groups.

CONCLUSIONS

Compared with the extracorporeal anastomosis technique, intracorporeal ileocolic anastomosis produces comparable short- and long-term outcomes in laparoscopic right hemicolectomy for colon cancer.

Natural orifice specimen extraction in laparoscopic colorectal surgery: transanal and transvaginal approaches

BACKGROUND

This study was designed to evaluate the outcomes of patients who underwent various laparoscopic colorectal procedures with natural orifice specimen extraction (NOSE) at our institute over a 20-year period. Specifically, the study aimed to investigate whether transanal and transvaginal approaches are safe and effective alternatives for extracting the specimen during laparoscopic colorectal surgeries.

METHODS

We analyzed a prospectively designed database of a consecutive series of patients who underwent various laparoscopic colorectal surgeries for different rectal pathologies between April 1991 and May 2011 at the Texas Endosurgery Institute. The selection criteria for the NOSE approach were based on disease entities, site and size of tumors, and distance of colorectal lesions from the anal verge.

RESULTS

A total of 303 patients underwent laparoscopic colorectal procedures with the NOSE approach for specimen extraction, including 277 transanal and 26 transvaginal extractions. The operative time for procedures with transanal specimen extraction was 164.7 ± 47.5 min, the estimated blood loss was 87.5 ± 46.7 ml, and the rate of postoperative complications was 3.6 %. For laparoscopic right hemicolectomy with transvaginal specimen extraction, the operative time was 159 ± 27.1 min and the estimated blood loss was 83.5 ± 14.4 ml. Intraoperatively, transvaginal extraction was associated with 2 complications (7.7 %); however, this procedure was not associated with any postoperative complications. The length of hospital stay was 6.9 ± 2.8 and 5.5 ± 2.5 days for patients who underwent transanal extraction and transvaginal extraction, respectively.

CONCLUSIONS

Both transanal and transvaginal specimen extractions in laparoscopic colorectal surgeries are safe and effective approaches with comparable postoperative complication rates. In comparison with transanal specimen extraction, transvaginal extraction is more complicated due to the anatomy of the pouch of Douglas. The transvaginal approach thus needs more effective extraction devices for preventing injury to adjacent organs, especially the sigmoid colon and rectum.

Intracorporeal versus extracorporeal anastomosis during laparoscopic right hemicolectomy - systematic review and meta-analysis

BACKGROUND

Since 2005, after an initial scanty spreading, the vast majority of surgeons advice against the intracorporeal ileocolic anastomosis following right hemicolectomies. In the subsequent years, greater interest was re-discovered for the intracorporeal ileocolic anastomosis formed after video-assisted right hemicolectomies

OBJECTIVE

The aim of this systematic review is to compare the intra-abdominal versus extra-abdominal anastomosis after right laparoscopic colectomy.

DATA SOURCES

A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central and the Science Citation Index.

STUDY SELECTION

A total of 191 publications were identified; seven non-randomized studies published between 2004 and 2012 with a total of 945 patients, who underwent laparoscopic right colectomy for malignant and benign disease, were included in this systematic review.

INTERVENTION

Intra-abdominal versus extra-abdominal confectioning of ileo-coloc anastomosis after right laparoscopic colectomy.

MAIN OUTCOME MEASURES

Anastomotic leak, overall post-operative morbidity and overall 30-days post-operative mortality.

RESULTS

Anastomotic leak rate resulted similar in IA (1.13%) and EA (1.84%) group (P=0.81, OR of 0.90, 95% CI 0.24-3.10) (Chi(2)=3.90, P=0.42, I(2)=0%). The mortality rate was lower in the IA group (0.34% versus 1.32%), although no statistically difference was demonstrated between the two groups (P = 0.48, OR of 0.52 95% CI 0.09-3.10). It was not possible to conduct a meta-analysis of post-operative morbidity as the data reported in the included studies were too heterogeneous.

LIMITATIONS

The weakness in our results was due to the lack of evidence in current published literature.

CONCLUSIONS

The present systematic review of literature and meta-analysis failed to solve the controversies between intracorporeal and extracorporeal anastomosis after laparoscopic right hemicolectomy. Future randomized, controlled trials are needed to further evaluate different surgical anastomosis after laparoscopic right hemicolectomy.

Total laparoscopic approach for the treatment of right colon cancer: a technical critique

BACKGROUND AND AIMS

Total laparoscopic surgery is not a new concept, but it is not preferred generally for right colectomy. The aim of the study is to evaluate the outcomes, which are related with surgical technique after total laparoscopic right colectomy (TLRC) and laparoscopic-assisted right colectomy (LARC) for right colon cancer in 30 consecutive patients.

MATERIALS AND METHODS

Thirty patients with right colon cancer, half of which were treated with TLRC and half of which were treated with LARC, were compared with regard to patient demographics, operative and postoperative data, histopathologic findings, follow-up data, and the complications related to the surgical technique.

RESULTS

There were 16 men and 14 women, median age was 63 years (range 41-86) with a body mass index (BMI) of 27 kg/m2 (range 20-33). There were no differences between the groups for BMI, harvested lymph node number, or distal and radial margins. The length of the incision and the length of the postoperative stay was shorter in the TLRC group (p=0.000). Overall complications were higher in the LARC group than in the TLRC group (p=0.014). The median follow-up was 28 months (range 5-99). In the late period, two patients in the LARC group were reoperated on. The cause of reoperation was internal herniation in one patient due to ileal twisting and incisional hernia in the other one.

CONCLUSION

Our preliminary data indicate that TLRC could result in better outcomes for right colon cancer patients than LARC.

A totally mini-invasive approach for colorectal laparoscopic surgery

AIM

To study the short-term outcome of patients treated with laparoscopic right colectomy and how intracorporeal anastomosis has improved the outcome.

METHODS

We retrospectively examined all patients affected by colorectal cancer who underwent a laparoscopic right colectomy between January 2006 and December 2010 in our department. Our evaluation criteria were: diagnosis of colorectal carcinoma at presurgical biopsy, elective surgery, and the same surgeon. We excluded: emergency surgery, conversions from laparotomic colectomy, and other surgeons. The endpoints we examined were: surgical time, number of lymph nodes removed, length of stay (removal of nasogastric tube, bowel movements, gas evacuation, solid and liquid feeding, hospitalization), and major complications. Seventy-two patients were divided into two groups: intracorporeal anastomosis (39 patients) and extracorporeal anastomosis (33 patients).

RESULTS

Significant differences were observed between intracorporeal vs extracorporeal anastomosis, respectively, for surgical times (186.8 min vs 184.1 min, P < 0.001), time to resumption of gas evacuation (3 d vs 3.5 d, P < 0.001), days until resumption of bowel movements (3.8 d vs 4.9 d, P < 0.001), days until resumption of liquid diet (3.5 d vs 4.5 d, P < 0.001), days until resuming a solid diet (4.6 d vs 5.7 d, P < 0.001), and total hospitalization duration (7.4 d vs 8.5 d, P < 0.001). In the intracorporeal group, on average, 19 positive lymph nodes were removed; in the extracorporeal group, on average, 14 were removed P < 0.001). Thus, intracorporeal anastomosis for right laparoscopic colectomy improved patient outcome by providing faster recovery of nutrition, faster recovery of intestinal function, and shorter hospitalization than extracorporeal anastomosis.

CONCLUSION

Short-term outcomes favor intracorporeal anastomosis, confirming that a less traumatic surgical approach improves patient outcome.

Totally laparoscopic versus laparoscopic assisted right colectomy for cancer

INTRODUCTION

Colorectal cancer (CRC) is one of the leading causes of cancer death all over the world and right-sided colon cancer represents approximately 15% of all cases of CRC. Laparoscopic colectomies produce advantages in short-term outcome compared to open procedures and have recently benefited by a long term oncologic validation. This study was designed to compare the short- and medium-term surgical outcomes of totally laparoscopic (TLRC) and laparoscopic-assisted right colectomy (LARC) for neoplasia, hypothesizing they may be at least similar.

METHODS

A consecutive unselected series of 72 patients undergone elective surgery for right-sided colon cancer from April 2006 to April 2011 was retrospectively evaluated. All patients were treated by laparoscopic medial-to-lateral right colectomy. In 42 patients a TLRC was performed, in 30 a LARC. Perioperative care plan, operative steps and surgical instrumentations were standardized. All the operations were performed or supervised by the same Surgeon (I.S.). Data on the patients' demographics, disease features, operative details and follow up were recorded and analyzed. Complications were classified using the Clavien-Dindo classification system. Continuous variables were expressed as mean ± standard deviation and analyzed with the Student t test. Categorical ones were expressed as percent value and analyzed with Fischer test or Chi-square test, where appropriate. P < 0.05 were considered statistically significant.

RESULTS

There was no significant difference in term of age, sex, body mass index and American Society of Anesthesiology score between the two groups. Comorbidities, site of tumor and stage of disease were similar too. No conversion to laparotomy was registered. Median operative time (186.3 ± 40.1 min vs 176.5 ± 40.0 min; not significant (NS)) and estimated blood loss (43.3 ± 89.8 ml vs 31.2 ± 51.3 ml; NS) were statistically comparable in both groups. Timing of first defecation (3.4 ± 0.9 dd vs 2.9 ± 0.9; P = 0.023) and length of hospital stay (7.2 ± 1.3 dd vs 6.2 ± 1.1 dd; P < 0.001) were statistically lower in TLRC cohort. A significantly longer length of skin incision characterized LARC group compared with TLRC group (71.0 ± 13.5 mm vs 48.2 ± 10.2 mm; P < 0.001). Both groups achieved an adequate number of lymph nodes harvested (22.0 ± 8.2 vs 25.9 ± 9.0; P = 0.036) and oncological resection of the tumor (proximal margin 7.6 ± 7.7 vs 6.1 ± 3.8; NS - distal margin 13.3 ± 7.7 vs 13.6 ± 5.8; NS). Post-operative complications according to Clavien-Dindo classification were statistically comparable in both cohorts. No readmission within 60 days of discharge was observed. The mean follow-up recorded was 27.7 ± 16.6 months. Late complications consisted in 1 case of incisional hernia (3.8%) in LARC group.

CONCLUSIONS

Although more appropriate indications must be set by future studies, we encourage the choice of a TLRC for the treatment of cancer of the right colon. TLRC is actually a feasible and safe technique, which has resulted in an encouraging short-term outcome, low incidence of major complications and preservation of oncologic principles, without affecting operative times.

Improving the advantages of single port in right hemicolectomy: analysis of the results of pure transumbilical approach with intracorporeal anastomosis

Background. Single-port laparoscopic surgery has recently emerged as a method to improve patient recovery and cosmetic benefits of laparoscopic surgery. The evolution of our technique has led us to move from a periumbilical incision to a transumbilical one, avoiding the use of drain and maintaining a pure single-port approach with intracorporeal anastomosis in order to maintain the incision as smaller as possible. Method. We report a prospective clinical analysis of our first 38 patients. Oncological surgical steps were followed as during the standard laparoscopic approach, performing the anastomosis intracorporeally in all cases. Results. Mean age of 68,39 years old and an average BMI of 27,88%. (range 19,81–41,5). Most lesions were adenocarcinoma (65,8%), while the remaining were polyps (31,5%) and one a mucocele of the appendix. We moved from a periumbilical incision, initial 14 cases, into a transumbilical one, (medium size of the incision 3,25 cm). Average surgical time was 117,42 minutes. Drains was only used in our first 3 cases. Mean hospital stay was 5,2 days, (86,5% stayed less than 5 days). Total morbidity was 13%. Histological exams of the specimens showed that the oncological criteria were preserved. Conclusions. Single-port right hemicolectomy with intracorporeal anastomosis is feasible and safe. The advantages of a total intracorporeal anastomosis include that there is no need to enlarge the umbilical incision and avoid traction of the pedicle of the mesenterium of the transverse colon during the extracorporeal anastomosis. A transumbilical incision offers better cosmetic results, and the use of drains can be avoided, which increase, patient's satisfaction.

The anatomical and surgical consequences of right colectomy for cancer

BACKGROUND

Current practice when performing right colectomy for cancer is to divide the feeding vessels for the right colon on the right side of the superior mesenteric vein.

OBJECTIVE

This study aims to show that arterial stumps can be visualized through an early postoperative CT and analyze their anatomical and surgical characteristics.

DESIGN

This study presents a retrospective review of prospective data.

SETTINGS

:The study was conducted at the Department of Surgery, Vestfold Hospital, Tonsberg, Norway.

PATIENTS

Patients with leakage after a right colectomy for cancer (2003-2011) were identified through a local prospective complication registry (FileMaker Pro 9.0v3 software).

INTERVENTIONS

Both preoperative and postoperative CTs were retrieved, reanalyzed, and 3-dimensionally reconstructed (Osirix v.3.0.2./Mimics v.13.1.). Patients without postoperative CTs were excluded.

MAIN OUTCOME MEASURES

The main outcomes measured were length, caliber of presumed and actual arterial stumps, and their position relative to the superior mesenteric vein.

RESULTS

Eighteen patients, median age 69 (10 men) were included. All patients had postoperative CTs, and 15 patients had preoperative CTs. Median time from operation to postoperative CT was 5 days. The ileocolic artery was found in 14 (11 CT pairs) patients, and the right colic artery was found in 5 (4 pairs) patients. Actual stump lengths were 28.0 mm (SD 9.3) and 37.3 mm (SD 14.9). A significant statistical difference between presumed and actual ileocolic artery stump lengths was found (P = .002). Posterior crossing to the superior mesenteric vein was noticed in 8 of 14 ileocolic arteries and in 3 of 5 right colic arteries. There was no statistical difference in mean caliber for the preoperative and postoperative right colic artery (P = .505) and ileocolic artery (P = .474).

LIMITATIONS

Difficulties when interpreting the postoperative images, due to intra-abdominal effusion, staples, edema, and altered syntopy of blood vessels, were overcome through comparison with preoperative CTs.

CONCLUSION

An early postoperative CT can show arterial stumps after right colectomy for cancer. These stumps appear to be significantly longer than presumed; implying a significant improvement potential when specimen size is concerned.