Laparoscopic colorectal cancer surgery

Validation and Scoring of the Greek Version of the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) Questionnaire

PURPOSE

The aim of this study was to validate the Greek version of the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) questionnaire.

DESIGN

The study was designed as a prospective questionnaire survey.

METHODS

Overall, 210 elective surgical patients were included . SCQIPP consisted of 14 items that were scored on a five point scale. After the translation and linguistic adjustments, the tool was distributed to the surgical wards. Internal consistency reliability was assessed by Cronbach's alpha. The tool construct was generated by a principal axis factoring model with promax rotation.

FINDINGS

Base Cronbach's alpha was 0.814. Due to low inter-item and item-total correlations and the increase of Cronbach's alpha (0.834) when item two was deleted, 13 items were included in the current tool version. Factor analysis identified three district subscales: nursing care, pain management, and support. Subscale and convergent validity were confirmed. The mean score of the validated tool was 55.2 (Range: 44-63). A low level of care was highlighted in most items.

CONCLUSIONS

The Greek version of the SCQIPP questionnaire is a valid and efficient tool for the evaluation of the quality of care of postoperative pain management.

Laparoscopic versus open colorectal surgery for colon cancer: the effect of surgical trauma on the bacterial translocation. A prospective randomized study

BACKGROUND

Several studies suggest that surgical manipulation of the intestine and increased intra-abdominal pressure promotes bacterial translocation (BT). This prospective randomized study has investigated the effect of surgery on BT in patients undergoing elective colectomy for colon cancer by comparing the laparoscopic with the open approach.

METHODS

One hundred nineteen consecutive patients underwent colectomy for colon cancer: 59 cases underwent open resection and 60 cases underwent laparoscopic resection. For bacterial identification, tissue samples were taken from the liver, spleen, and mesenteric lymph nodes.

RESULTS

The incidence of BT increased in laparoscopic and open group after bowel mobilization (prior to ligation of the vascular pedicle), compared with the before mobilization (P < .05). There was not a statistically significant difference in BT value between the 2 groups.

CONCLUSION

BT increase was observed during the open and laparoscopic resection for colon cancer, without significant statistical difference between the 2 groups.

Staging laparoscopy for the management of early-stage ovarian cancer: a metaanalysis

OBJECTIVE

We sought to perform a quantitative analysis on operative outcomes of laparoscopic staging surgery in patients with presumed early-stage ovarian cancer using a metaanalysis.

STUDY DESIGN

Electronic searches for studies of laparoscopic staging surgery in patients with ovarian cancer were performed within 3 electronic databases (Medline, Embase, and the Cochrane Library) using the key words "ovarian cancer," "early stage," "laparoscopy," "staging surgery," "staging laparoscopy," and "recurrence." Two authors independently screened articles, and those meeting the defined inclusion/exclusion criteria were included in the metaanalysis.

RESULTS

We identified 11 observational studies. The combined results of 3 retrospective studies showed that the estimated blood loss in laparoscopy was significantly lower than that for laparotomy (P < .001). The overall upstaging rate after laparoscopic surgery was 22.6% (95% confidence interval [CI], 18.1-27.9%) without significant heterogeneity among all study results. The overall incidence of conversion from laparoscopy to laparotomy was 3.7% (95% CI, 2.0-6.9%). The overall rate of recurrence in studies with a median follow-up period of ≥19 months was 9.9% (95% CI, 6.7-14.4%).

CONCLUSION

Through our quantitative analysis, we concluded that the operative outcomes of a laparoscopic approach in patients with early-stage ovarian cancer could be compatible with those of laparotomy. In the future, further randomized controlled trials may be needed.

Laparoscopic right radical hemicolectomy

Laparoscopic right hemicolectomy is an advanced cancer surgery in today's era. With increasing experience, we have described novel technique for this procedure. To prevent falling down of the colon in the operative field and to have early control on vessels, we go from medial to lateral approach.

Anti-inflammatory role of glycine in reducing rodent postoperative inflammatory ileus

BACKGROUND

Inflammatory events within the intestinal muscularis, including macrophage activation and leukocyte recruitment, have been demonstrated to participate in causing postoperative ileus. Recently, glycine has gained attention due to its beneficial immunomodulatory effects in transplantation, shock and sepsis.

METHODS

Muscularis glycine receptors were investigated by immunohistochemistry. Gastrointestinal motility was assessed by in vivo transit distribution histograms with calculated geometric center analysis and jejunal circular smooth muscle contractility in a standard organ bath. The impact of glycine on the muscularis inflammatory responses to surgical manipulation of the intestine were measured by real-time PCR, nitric oxide Griess reaction, prostaglandin ELISA, Luminex and histochemistry.

KEY RESULTS

Glycine-gated chloride channels were immunohistochemically localized to muscularis macrophages and postoperative infiltrating leukocytes. Preoperative glycine treatment significantly improved postoperative gastrointestinal transit and jejunal circular muscle contractility. Preoperative glycine injection significantly reduced the induction of interleukin-6 (IL-6), tumor necrosis factor-α, inducible nitric oxide synthase and intercellular adhesion molecule-1 mRNAs, which was associated with the attenuation in postoperative leukocyte recruitment. Nitric oxide and prostanoid release from the postsurgical inflamed muscularis was diminished by glycine. The secretion of the inflammatory proteins IL-6, monocyte chemotactic protein-1/chemokine ligand 2 and macrophage inflammatory protein-1α/chemokine ligand 3 were also significantly decreased by glycine pretreatment.

CONCLUSIONS & INFERENCES

The data indicate that preoperative glycine reduces postoperative ileus via the early attenuation of primal inflammatory events within the surgically manipulated gut wall. Therapeutic modulation of resident macrophages by glycine is a potential novel pharmacological target for the prevention of postoperative ileus.

Feasibility and efficacy of laparoscopic management of ovarian cancer

AIMS

The aim of this study was to evaluate the feasibility and efficacy of laparoscopically-assisted staging surgery for ovarian cancer.

METHODS

Twenty four patients were evaluated. Among them, nineteen underwent initial laparoscopic staging surgery and five patients who were incompletely staged by other institutions underwent complete restaging surgery. The procedure included pelvic lymphadenectomy, paraaortic lymphadenectomy, multiple biopsies, washing cytology, infracolic omentectomy, and appendectomy. Laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy were performed on all patients except one. Parameters such as tumor diameter, operating time, estimated blood loss, length of hospital stay, number of harvested lymph nodes, intraoperative and postoperative complications, and recurrence were evaluated.

RESULTS

The patients' mean age was 52.8 +/- 11.3 years and the mean parity was 2.5 +/- 1.6. The mean diameter of the tumors was 8.4 +/- 3.3 cm, the mean operating time was 253.7 +/- 65.7 minutes, and the mean blood loss was 567.0 +/- 170.9 mL. The mean postoperative hospital stay was 10.6 +/- 4.0 days. The mean number of harvested pelvic lymph nodes was 22.5 +/- 8.9 and the mean number of harvested paraaortic lymph nodes was 11.0 +/- 5.8. None of the operations were switched to laparotomy. There were no major intraoperative complications, however, port site metastasis developed postoperatively in one patient.

CONCLUSION

Comprehensive laparoscopically-assisted staging surgery, performed by a specialized laparoscopic oncologist with sufficient laparoscopic experience and a well-trained operating team, is both feasible and effective in treating ovarian cancers.

The effect of epidural analgesia on postoperative outcome after colorectal surgery

OBJECTIVE

The aim of this review was to determine the effects of epidural analgesia as it relates to outcome after colorectal surgery.

METHOD

We searched and reviewed studies that included colorectal surgery and epidural method of analgesia listed on the Pubmed, Medline, Embase and the Cochrane library database.

RESULTS

The majority of data demonstrate a superior effect of epidural analgesia on pain control after colorectal surgery. Well designed randomized controlled trials (RCT's) have also shown that epidural analgesia reduces the duration of ileus after colorectal surgery. Limited data suggest the additional benefit may be minimal after laparoscopic surgery or when epidural analgesia is used as part of a multimodal regime. Data does not convincingly show either a clear harmful or beneficial effect of epidural analgesia on rates of anastomotic leakage. Epidural analgesia may have beneficial effects on postoperative lung function, however due to low numbers, the effects on cardiovascular and thromboembolic complications are indeterminate. Length of hospital stay has not been shown to be shortened by sole use of an epidural and, although epidural analgesia may be apparently more costly, alternatives may incur higher indirect costs and decreased patient satisfaction.

CONCLUSION

Randomized controlled trials have shown a benefit for epidurals on postoperative pain relief, and ileus, and possibly respiratory complications. There is no proven benefit with regard to length of stay. There are a number of unresolved issues which further focussed RCT's may help clarify such as effects of epidural on complication rates after colorectal surgery.

Endogenous endotoxin participates in causing a panenteric inflammatory ileus after colonic surgery

OBJECTIVE

To investigate muscularis inflammation and endogenous endotoxin as causes of postoperative ileus.

BACKGROUND

Postoperative inflammatory ileus of the colon is associated with a significant delay in gastrointestinal transit. We investigated whether these changes are caused by the downstream obstructive barrier of the surgically altered colon or by small intestinal muscularis inflammation itself. Furthermore, we evaluated the mechanistic role of gut derived endotoxin in the development of postoperative intestinal dysfunction.

METHODS

Rats underwent surgical manipulation of the colon. Isolated gastrointestinal transit was analyzed in animals with ileostomy. The perioperative emigration of intracolonic particles was investigated by colonic luminal injection of fluorescently labeled LPS and microspheres. Mediator mRNA induction was quantified by real-time RT-PCR. Muscularis leukocytic infiltrates were characterized. In vitro circular muscle contractility was assessed in a standard organ bath.

RESULTS

Ileostomy rats presented with a significant delay in small intestinal transit after colonic manipulation. This was associated with leukocyte recruitment and inflammatory mediator mRNA induction within the small intestinal muscularis. Colonic manipulation caused the transference of intracolonic LPS and microspheres into the intestinal muscularis. Postoperative in vitro small intestinal circular muscle contractility was impaired by 42% compared with controls. Gut decontamination and TLR-4 deletion significantly alleviated the small intestinal muscularis inflammation and prevented intestinal muscle dysfunction.

CONCLUSIONS

Selective colonic manipulation initiates a distant inflammatory response in the small intestinal muscularis that contributes to postoperative ileus. The data provide evidence that gut-derived bacterial products are mechanistically involved in the initiation of this remote inflammatory cascade.

Robot-Assisted Radical Cystectomy and Pelvic Lymph Node Dissection: Initial Experience at Roswell Park Cancer Institute

OBJECTIVES

One series of robot-assisted radical cystectomy with pelvic lymph node dissection has been reported. We report our operative technique and initial experience.

METHODS

Twenty consecutive patients underwent robot-assisted radical cystectomy, pelvic lymph node dissection, and open urinary diversion for operable bladder cancer from October 2005 to June 2006. Data were collected prospectively on patient demographics, intraoperative parameters, pathologic staging, and postoperative outcomes.

RESULTS

The mean patient age was 70 years (range 56 to 90). The mean body mass index was 26 kg/m2 (range 17.3 to 36). Fourteen patients had undergone previous abdominal surgery. The mean operative time was 197 minutes for robot-assisted radical cystectomy, 44 minutes for pelvic lymph node dissection, and 133 minutes for urinary diversion. The mean blood loss was 555 mL. One case was converted to an open procedure because of the patient's inability to tolerate the Trendelenburg position. The mean hospital stay was 10 days. Two patients had major complications. One patient had positive vaginal margins and 9 of 26 nodes were positive. Four patients had incidental prostate cancer. The mean time to the return to nonstrenuous activity was 4 weeks and to strenuous activity was 10 weeks.

CONCLUSIONS

Robot-assisted radical cystectomy and pelvic lymph node dissection can be performed safely in patients who are considered candidates for open cystectomy. Long-term oncologic control data and functional outcomes are needed to assess the true benefits of robot-assisted radical cystectomy.

Restorative proctectomy with colon pouch-anal anastomosis by laparoscopic transanal pull-through: an available option for low rectal cancer?

BACKGROUND

There are sporadic reports, with different verdicts, of restorative proctectomy by laparoscopic transanal pull-through (LTPT) without the use of a minilaparotomy for a part of the procedure. This study aimed to explore the applicability and advantages of LTPT with colon pouch-anal anastomosis for low rectal cancer, and to evaluate the results.

METHODS

From January 2002 to July 2003, 10 of 12 patients (6 men and 4 women) undergoing a laparoscopic procedure for low rectal cancer (<6 cm from the anal verge) underwent LTPT. The mean age of these patients was 58 years. The results have been compared with those for 12 similar non-pull-through procedures performed during the same period.

RESULTS

There was no operative mortality. An anastomotic leakage and a hemorrhagic gastropathy occurred in the LTPT group. During a mean follow-up period of 18 months (range, 12-26 months), there was no local relapse. Four patients manifested moderate incontinence. No significant differences in functional outcome were observed between the LTPT and control groups.

CONCLUSION

The authors' experience supports use of the LTPT procedure with colonic pouch-anal anastomosis for selected lower rectal cancers with indications for a laparoscopic approach as an appropriate and reproducible surgical treatment.

[Radical laparoscopic cystectomy]

Radical laparoscopic cystectomy is being adopted by most groups with proven experience in laparoscopic surgery, especially by those who have already completed the learning curves in radical laparoscopic prostatectomy. It is still considered a highly complex technique, which has not yet been mastered in many Urology Units. In this article, we review the surgical technique and available literature on this approach, with special emphasis on its indications, advantages and most frequent morbidity.

LAPAROSCOPIC AND OPEN COLORECTAL SURGERY IN EVERYDAY PRACTICE: RETROSPECTIVE STUDY

BACKGROUND

Most studies available on laparoscopic colorectal surgery focus on highly selected patient groups. The aim of the present study was to review short- and long-term outcome of everyday patients treated in a general surgery department.

METHODS

Retrospective review was carried out of a prospective database of all consecutive patients having undergone primary laparoscopic (LAP) or open colorectal surgery between March 1993 and December 1997. Follow-up data were completed via questionnaire.

RESULTS

A total of 187 patients underwent LAP resection and 215 patients underwent open surgery. Follow up was complete in 95% with a median of 59 months (range, 1-107 months) and 53 months (range, 1-104 months), respectively. There were 28 conversions (15%) in the LAP group and these remained in the LAP group in an intention-to-treat analysis. The LAP operations lasted significantly longer for all types of resections (205 vs 150 min, P < 0.001) and hospital stay was shorter (8 vs 13 days, P < 0.001). Recovery of intestinal function was faster in the LAP group, but only after left-sided procedures (3 vs 4 days, P < 0.01). However, preoperative patient selection (more emergency operations and patients with higher American Society of Anesthesiologists (ASA) score in the open group) had a major influence on these elements and favours the LAP group. Surprisingly, the overall surgical complication rate (including long-term complications such as wound hernia) was 20% in both groups with rates of individual complications also being comparable in both groups.

CONCLUSION

Despite a patient selection favourable to the laparoscopy group, only little advantage in postoperative outcome could be shown for the minimally invasive over the open approach in the everyday patient.

Laparoscopic treatment of early ovarian cancer: surgical and survival outcomes

OBJECTIVES

To investigate the feasibility and safety of laparoscopic surgery in patients with early ovarian cancer.

PATIENTS AND METHODS

Between 05-1996 and 06-2003, 24 patients with ovarian cancer FIGO stage IA-B underwent either primary treatment or completion of staging by laparoscopy. Laparoscopic staging was performed according to the FIGO guidelines, which entails one-sided oophorectomy or bilateral salpingo-ophorectomy with laparoscopic-assisted vaginal hysterectomy, pelvic lymphadenectomy, infrarenal para-aortic lymphadenectomy, complete resection of the infundibulo-pelvic ligament, appendectomy and partial omentectomy.

RESULTS

Eleven out of 24 patients (45.8%) underwent completion of staging after a mean of 12 days (range 4-21) after primary surgery, while 13 patients out of 24 (54.2%) underwent primary laparoscopic management of an adnexal mass, diagnosed as ovarian cancer by frozen section. Mean operative time was 166 min (range 118-206) for completion of staging and 182 min (range 141-246) for primary surgery. No major intraoperative complication occurred. One out of 24 patients (4.1%) developed chylos ascites postoperatively, which was managed conservatively. Five out of 24 patients (20.8%) received adjuvant chemotherapy after a median time of 7 days (mean 5-14) following surgery. No trocar metastasis occurred. Median follow-up is 46.4 months (range 2-72). Two out of 24 patients (8.3%) developed recurrence, which was treated with resurgery and chemotherapy. After a median follow-up of 46 months, disease-free survival is 91.6% and overall survival 100%.

CONCLUSIONS

Laparoscopic management of early ovarian cancer is safe and effective and survival outcome seems acceptable.

Comparative evaluation of immune response after laparoscopical and open total mesorectal excisions with anal sphincter preservation in patients with rectal cancer

AIM: The study of immune response of open versus laparoscopical total mesorectal excision with anal sphincter preservation in patients with rectal cancer has not been reported yet. The dissected retroperitoneal area that contacts directly with carbon dioxide is extensive in laparoscopic total mesorectal excision with anal sphincter preservation surgery. It is important to clarify whether the immune response of laparoscopic total mesorectal excision with anal sphincter preservation (LTME with ASP) in patients with rectal cancer is suppressed more severely than that of open surgery (OTME with ASP). This study was designed to compare the immune functions after laparoscopic and open total mesorectal excision with anal sphincter preservation for rectal cancer.

METHODS: This study involved 45 patients undergoing laparoscopic (n = 20) and open (n = 25) total mesorectal excisions with anal sphincter preservation for rectal cancer. Serum interleukin-2 (IL-2), interleukin-6 (IL-6), tumor necrosis factor α (TNF_α) were assayed preoperatively and on days 1 and 5 postoperatively. CD3⁺ and CD56⁺ T lymphocyte count, CD3^- and CD56⁺ natural killer cell (NK) count and immunoglobulin (IgG/IgM/IgA) were assayed preoperatively and on day 5 postoperatively. The numbers of CD3⁺ and CD56⁺ T lymphocytes and CD3^- and CD56⁺ NK cells were counted using flow cytometry. An enzyme-linked immunosorbent assay (ELISA) was used for IL-2, IL-6 and TNF_α determination. And IgG, IgM, and IgA were assayed using immunonephelometry.

RESULTS: The demographic data of the two groups had no difference. The preoperative levels of CD3⁺ and CD56⁺ T lymphocyte count, CD3^- and CD56⁺ NK count, serum IgG, IgM, IgA, IL-2, IL-6 and TNF_α also had no significant difference in the two groups (P > 0.05). The CD3⁺ and CD56⁺ T lymphocyte counts had no obvious changes after surgery in laparoscopic (d = -0.79% ± 3.83%) and open (d = 0.42% ± 2.09%) groups. The CD3^- and CD56⁺ NK counts were decreased postoperatively in both laparoscopic (d = -7.23% ± 11.33%) and open (d = -9.21% ± 13.93%) groups. The differences of the determined values of serum IgG, IgM and IgA on the fifth day after operation subtracted those before operation were -2.56 ± 2.14 g/L, -252.35 ± 392.94 mg/L, -506.15 ± 912.24 mg/L in laparoscopic group, and -1.81 ± 2.10 g/L, -282.72 ± 356.75 mg/L, -252.20 ± 396.28 mg/L in open group, respectively. The levels of IL-2 were decreased after operation in both groups. However, the levels of IL-6 were decreased after laparoscopic surgery (d₁ = -23.14 ± 263.97 ng/L and d₅ = -40.08 ± 272.03 ng/L), and increased after open surgery (d₁ = 27.38 ± 129.14 ng/L and d₅ = 21.67 ± 234.31 ng/L). The TNF_α levels were not elevated after surgery in both groups. There were no significant differences in the numbers of CD3⁺ and CD56⁺ T lymphocytes and CD3^- and CD56⁺ NK cells, the levels of IgG, IgM, IgA, IL-2, IL-6 and TNF_α between the two groups (P > 0.05).

CONCLUSION: There are no differences in immune responses between the patients having laparoscopic total mesorectal excision with anal sphincter preservation and those undergone open surgery for rectal cancer.

Laparoscopic radical cystoprostatectomy: a technique illustrated step by step

OBJECTIVES

Laparoscopic surgery is expanding among urologists as a minimally invasive treatment and may now be applied to treat neoplasms of the pelvic organs. Laparoscopic cystoprostatectomy has still not been well codified and illustrated. We describe a technique of laparoscopic radical cystoprostatectomy that we have developed in 10 patients after practicing in laparoscopic radical prostatectomy.

METHODS

Between June 2001 and July 2002, 10 men with bladder cancer underwent laparoscopic cystoprostatectomy with urinary diversion. This report details step by step our 5-port transperitoneal technique with primary access to the seminal vesicles and Denonvillier's fascia, ureters detection after umbilical arteries incision, endopelvic fascia incision and dorsal vein complex control before division of the vesical and prostatic fibrovascular pedicles with a harmonic scalpel.

RESULTS

We performed 6 orthotopic ileal neobladders, 2 sigmoid ureterostomies and 2 cutaneous ureterostomies. In all cases no conversion to open surgery was necessary. The mean time to perform the laparoscopic radical cystoprostatectomy, including the lymph node dissection, was 166 minutes (range 150-180). Mean estimated blood loss was 310 ml (range 220-440). Mean hospital stay was 8.1 days (range 7-9) for ileal orthotopic neobladder, 8 days (range 7-9) for sigmoid ureterostomy and 5 days for cutaneous ureterostomy. The mean follow up is 12.3 months (range 5-18). Two patients respectively with stage T2bN0 G2-3 and stage pT1N0 (plus carcinoma in situ) G3 transitional cell carcinoma and surgical margins tumor free had diffusive metastatic disease after 6 months. The other 8 patients are free from disease.

CONCLUSIONS

Laparoscopic radical cystectomy is still an operation for pioneers but this procedure may be not strictly relegated to a few academic centers. In our opinion laparoscopic cystoprostatectomy is a feasible, fast, safe and easy procedure and urinary diversion may be performed with a laparoscopic, open or combined approach without reducing the advantages of laparoscopy.

Postoperative ileus: progress towards effective management

The pathogenesis of postoperative ileus (PI) is multifactorial, and includes activation of inhibitory reflexes, inflammatory mediators and opioids (endogenous and exogenous). Accordingly, various strategies have been employed to prevent PI. As single-modality treatment, continuous postoperative epidural analgesia including local anaesthetics has been most effective in the prevention of PI. Choice of anaesthetic technique has no major impact on PI. Minimally invasive surgery reduces PI, in accordance with the sustained reduction in the inflammatory responses, while the effects of early institution of oral nutrition on PI per se are minor. Several pharmacological agents have been employed to resolve PI (propranolol, dihydroergotamine, neostigmine, erythromycin, cisapride, metoclopramide, cholecystokinin, ceruletide and vasopressin), most with either limited effect or limited applicability because of adverse effects. The development of new peripheral selective opioid antagonists is promising and has been demonstrated to shorten PI significantly. A multi-modal rehabilitation programme including continuous epidural analgesia with local anaesthetics, enforced nutrition and mobilisation may reduce PI to 1-2 days after colonic surgery.

A Combined Technique for Radical Cystoprostatectomy and Orthotopic Ileal Neobladder

After anatomical and surgical studies on cadavers we developed a combined technique for radical cystoprostatectomy with orthotopic ileal neobladder labelled M.I. La. N. (Minimally Invasive Laparoscopic Neobladder). The aim of this technique is to combine the advantages of open and laparoscopic surgery. Between June 2001 and July 2002, 6 men aged 65 to 72 underwent combined radical cystoprostatectomy with orthotopic ileal neobladder for organ-confined bladder cancer.

The M.I. La.N. consists of 3 steps: 1) laparoscopic radical cystoprostatectomy and bilateral pelvic lymph node dissection; 2) external partial fashioning of the neobladder and side-to-side bowel anastomosis; 3) laparoscopic lower urinary tract reconstruction.

The mean time of the overall procedure was 425 minutes (range 360 to 510). Mean estimated blood loss was 312 mL (range 220 to 440). Mean hospital stay was 8.1 days (range 7 to 9). Histopathology revealed 1 pT1N0 G3 plus carcinoma in situ (Cis), 1 pT2aN0 G3 plus Cis, 4 pT2bN0 G2-3. The surgical margins were tumor free. At the time of analysis (October 2003) the mean follow-up is 18.1 months (range 15 to 21). Two patients respectively stage pT1N0 + Cis and pT2bN0 G2-3 died for metastatic disease at 20 and 18 months after the operation. One patient stage pT2aN0 plus Cis died for unrelated causes free from disease after 16 months from the procedure. The remaining 3 patients are alive and free from disease. The combined technique for radical cystoprostatectomy with orthotopic ileal neobladder (“M.I. La. N.”) can reproduce open surgery. Moreover, it provides an anatomic approach, familiar to most urologist and anatomical landmarks are easy to follow. In our opinion, the combined approach does not reduce the advantages of laparoscopy. We know that this technique may require a long learning curve and it is still a pioneristic procedure. A strict follow up is necessary to evaluate the oncological outcome that is still unpredictable for the low number of treated patients and for biology of bladder cancer.

Laparoscopic gastrointestinal surgery

In the short time since LC was first performed in humans, minimal-access surgical techniques have been applied to the full spectrum of surgical therapy of gastrointestinal diseases. For many gastrointestinal diseases, [figure: see text] laparoscopy seems to offer advantages over traditional open surgery. The long-term results of laparoscopic surgery for cancer await the results of prospective clinical trials currently underway and caution is urged when laparoscopic curative resection is performed. On the horizon are significant improvements in technology that should lead to further applications and advances in laparoscopic gastrointestinal surgery.

Minimally invasive laparoscopic neobladder

PURPOSE

To our knowledge orthotopic reconstruction after laparoscopic radical cystectomy has not been described in the human. After anatomical and surgical studies on cadavers we developed an original technique and performed the first laparoscopic radical cystectomy with pelvic lymphadenectomy and ileal orthotopic neobladder reconstruction in a patient.

MATERIALS AND METHODS

Our technique has 3 steps, namely laparoscopic pelvic clearance, external reconstruction and laparoscopic reconstruction. After cystoprostatectomy and lymphadenectomy were completed via laparoscopy we removed the surgical specimens through a 5 cm. supraumbilical incision. Through the same incision an ileal loop was extracted from the abdominal cavity, isolated, detubularized and partially reconfigured. Intestinal continuity was restored extracorporeally. All intestinal loops were inserted back into the abdomen and pneumoperitoneum was started again. The ureteroileal (nipple valve) and urethroileal anastomoses were formed via laparoscopy and the neobladder was then completed with an intracorporeal running suture.

RESULTS

Operative time was 450 minutes and blood loss was 350 ml. Postoperatively pain was minimal. The patient was ambulatory, regained bowel activity on postoperative day 2 and began food intake 2 days later. He was discharged home on postoperative day 7 with an indwelling catheter, which was removed after 7 days. Histopathological examination showed organ confined bladder cancer without margin invasion.

CONCLUSIONS

To our knowledge we report the first case of laparoscopic radical cystectomy with ileal orthotopic reconstruction. This original technique combines the advantages of minimally invasive laparoscopy with the speed and safety of open surgery.

Anaesthesia for minimally invasive gastric and bowel surgery

It is of great importance that anaesthetic regimens match surgical procedures in regard to surgical time, in reducing organ dysfunction elicited by the anaesthesia and surgical trauma and by providing optimal post-operative pain treatment, leaving the possibility of early mobilization. New, rapidly eliminated anaesthetic drugs are, by virtue of their pharmacodynamic and pharmacokinetic profiles, optimal for use; combined with continuous thoracic epidurals with local anaesthetics and low-dose opioids, these drugs may permit reduction of various post-operative complications. Minimally invasive surgical techniques (e.g. laparoscopy) lead to serious anaesthesiological considerations concerning changes in haemodynamic and pulmonary parameters and intra-abdominal blood flow changes caused by increased intra-abdominal pressures. Few studies have evaluated whether these changes affect surgical outcome and whether or not different anaesthetic regimens influence relevant morbidity parameters. In future documentation it is important that controlled, well-designed clinical studies evaluate how the advantages from multimodal anaesthetic techniques improve relevant surgical outcome.

Surgery for colorectal cancer

Colorectal cancer remains the second commonest cause of cancer death in North America and Western Europe. Surgery remains the mainstay of treatment. The aim of surgery should be to achieve cure and to avoid locoregional recurrence. The fixity of the primary tumour determines resectability, and the extent of spread determines ultimate survival. Patients with rectal cancer present a particular problem. There is good evidence that lower local recurrence rates may be achieved both by improvements in surgical technique and the use of adjuvant radiotherapy. The importance of adequate treatment of the circumferential tumour margin cannot be over-emphasised; meticulous attention is required to ensure an adequate circumferential excision. The lowest incidences of locoregional recurrence are reported by surgeons who perform total mesorectal excision. Anorectal function, sexual and urinary dysfunction may occur after rectal excision. Both postoperative and pre-operative radiotherapy can reduce the incidence of local recurrence. However, in view of the low recurrence rates obtained with TME alone, the role of adjuvant radiotherapy requires further evaluation. Several aspects of the surgical management of colorectal cancer, for example, the role of transanal local excision of selected rectal cancers and laparoscopic surgery, the management of obstructed cases and the role of follow-up remain to be defined clearly.