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Liang JT, Liao YT, Chen TC, Huang J, Hung JS. Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer. Int J Surg 2024; 110:1577-1585. [PMID: 38051917 PMCID: PMC10942203 DOI: 10.1097/js9.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC). METHODS Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups. RESULTS The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group. CONCLUSIONS The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.
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Affiliation(s)
- Jin-Tung Liang
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, Taipei
| | - Yu-Tso Liao
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu
| | - Tzu-Chun Chen
- Department of Surgical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan, Republic of China
| | - John Huang
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, Taipei
| | - Ji-Shiang Hung
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, Taipei
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Long-Term Consequences of Nonclosure of Mesenteric Defects after Traditional Right Colectomy. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9123912. [PMID: 30356463 PMCID: PMC6178510 DOI: 10.1155/2018/9123912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 09/12/2018] [Indexed: 12/26/2022]
Abstract
Background There are still discrepancies among general/colorectal surgeons regarding closure of mesenteric defect in scientific literature. This study aimed to assess the long-term consequences of nonclosure of the mesenteric defect after open right colectomy. Methods A 7-year retrospectively collected and continuous database revealed 212 consecutive patients who had undergone traditional right colectomy without closing the mesenteric defects at Kaohsiung Chung-Gung Memorial Hospital; all patients were operated by a single surgeon. Among these patients, 17 were excluded (those who died within 30 days after surgery or those who received an end ileostomy). The mean age of the 195 patients (58% men and 42% women) was 61.6 ± 12.6 years, and the follow-up period was 4.1 ± 2.8 years (interquartile range 0.09 ~ 10.4). Results Forty-four patients (22.5%) encountered intestinal obstruction. Nine (20.4%) required surgical intervention. The cause of intestinal obstruction was adhesion (n=1), ventral hernia (n=1), and cancer recurrence (n=7). Conservative treatment was successful in 35 patients. The intestinal obstruction group (n = 44) were similar to the no-intestinal obstruction group (n = 151) in terms of the following parameters: age, sex, previous abdominal surgery, indication for colectomy, and procedure related complications. Carcinomatosis was found to increase the incidence of intestinal obstruction. No patient developed intestinal obstruction because of the nonclosure of mesenteric defects after right colectomy. Conclusion This study suggested that routine procedure of closing the mesenteric defect after open right colectomy might not be beneficial. Additional studies with extended long-term follow-up periods are needed to confirm the benefits of the nonclosure.
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Prevention of internal hernias and pelvic adhesions following laparoscopic left-sided colorectal resection: the role of fibrin sealant. Surg Endosc 2016; 31:3048-3055. [PMID: 28039651 DOI: 10.1007/s00464-016-5328-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 10/31/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant diseases. This growing experience has also resulted in more reports of postoperative complications from the minimally invasive approach to primary colorectal resection. Small bowel obstruction from internal hernias and pre-sacral adhesions is an uncommon but not negligible complication. However, there is little literature specific to this topic with recommendations for different methods to prevent it. We report our original technique of closing the mesenteric defect and covering the pre-sacral fascia by using fibrin sealant to prevent this complication. METHODS From January 2005 to December 2014, a total of 1079 patients underwent elective laparoscopic left colorectal resection (left hemicolectomy or anterior rectal resection) in our department. In the first 298 procedures, the mesenteric defect was left open, while in the following 781 procedures, it was closed using fibrin sealant with the aim of preventing postoperative small bowel obstruction. RESULTS Among the first 298 patients, three (1%) required reoperation for small bowel obstruction due to internal hernia (0.33%) or critical pre-sacral adhesions (0.66%). These complications did not occur in the subsequent series in which all 781 patients were treated with fibrin sealant prophylactic closure of the mesenteric defect. CONCLUSION In our experience, fibrin sealant closure of the mesenteric defect has demonstrated to be safe and effective in preventing postoperative small bowel obstruction that remains a complication both in open and in laparoscopic colorectal surgeries.
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Ooi G, Narasimhan V, Ban EJ, Loh D. Strangulated internal hernia through pars flaccida defect after laparoscopic fundoplication and right hemicolectomy. ANZ J Surg 2016; 88:E631-E633. [PMID: 27080581 DOI: 10.1111/ans.13582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/02/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Geraldine Ooi
- General Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Centre for Obesity Research and Education, Monash University, Melbourne, Victoria, Australia
| | - Vignesh Narasimhan
- General Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Ee Jun Ban
- General Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Damien Loh
- General Surgical Unit, The Alfred Hospital, Melbourne, Victoria, Australia
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Clinical Significance of Closure of Mesenteric Defects in Laparoscopic Colectomy: A Single-Institutional Cohort Study. Surg Laparosc Endosc Percutan Tech 2015; 26:82-5. [PMID: 26679686 DOI: 10.1097/sle.0000000000000234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The effect of closure of mesenteric defects to prevent complications, such as internal hernia, during laparoscopic colectomy remains controversial and is a subject of debate. PURPOSE This retrospective single-institution study aimed to clarify the clinical significance of mesenteric defect closure during a laparoscopic colectomy. METHODS We evaluated 58 patients who underwent laparoscopic right-side colectomy or transverse colectomy. The statistical relevance of complications, surgical maneuvers, and clinical factors was examined. RESULTS The mesenteric defects were closed in 30 patients and not closed in 28 patients. Two patients with ileus and 1 with a deep incisional surgical site infection required a second surgery. The reoperation rate was significantly higher in the nonclosure group than in the closure group (11% vs. 0%, respectively; P=0.033). CONSIDERATION Serious complications requiring reoperation occurred only in the nonclosure group. The procedure for closing the defect did not extend the operation time or increase the bleeding.
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Reggio S, Sciuto A, Cuccurullo D, Pirozzi F, Esposito F, Cusano D, Corcione F. Single-layer versus double-layer closure of the enterotomy in laparoscopic right hemicolectomy with intracorporeal anastomosis: a single-center study. Tech Coloproctol 2015; 19:745-50. [PMID: 26470861 DOI: 10.1007/s10151-015-1378-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 09/25/2015] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- S Reggio
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli" - Monaldi Hospital, Via Leonardo Bianchi s.n.c., 80131, Naples, NA, Italy
| | - A Sciuto
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli" - Monaldi Hospital, Via Leonardo Bianchi s.n.c., 80131, Naples, NA, Italy
| | - D Cuccurullo
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli" - Monaldi Hospital, Via Leonardo Bianchi s.n.c., 80131, Naples, NA, Italy
| | - F Pirozzi
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli" - Monaldi Hospital, Via Leonardo Bianchi s.n.c., 80131, Naples, NA, Italy
| | - F Esposito
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli" - Monaldi Hospital, Via Leonardo Bianchi s.n.c., 80131, Naples, NA, Italy
| | - D Cusano
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli" - Monaldi Hospital, Via Leonardo Bianchi s.n.c., 80131, Naples, NA, Italy
| | - F Corcione
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli" - Monaldi Hospital, Via Leonardo Bianchi s.n.c., 80131, Naples, NA, Italy.
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Daskalaki A, Kaimasidis G, Xenaki S, Athanasakis E, Chalkiadakis G. Internal-mesocolic hernia after laparoscopic left colectomy report of case with late manifestation. Int J Surg Case Rep 2014; 6C:88-91. [PMID: 25528033 PMCID: PMC4334638 DOI: 10.1016/j.ijscr.2014.11.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 11/23/2014] [Accepted: 11/23/2014] [Indexed: 12/18/2022] Open
Abstract
Introduction In contrast to right colectomy, closure of the mesocolic gap after laparoscopic left colectomy is not practiced, and reports of small gut herniation through this gap are scarce. Presentation of case A 73 year old male was admitted as an emergency with symptoms and clinical signs, suggesting obstruction of the small bowel. Abdominal imaging, including computed tomography confirmed the diagnosis. The patient had undergone laparoscopic left colectomy for cancer, three years ago. At laparotomy small bowel loops were found to herniate through the mesocolic defect at the level of the colonic anastomosis. The small bowel loops were reduced and their viability was ascertained. Because of an iatrogenic perforation of the colon at the anastomosis during small bowel loops mobilization, the colon was temporarily exteriorized in the form of a double barrel colostomy. The postoperative course was uneventful. Discussion Very few cases have been reported in the liteature indicating the need of sutuing the mesenterium. Despite the limited numbe of the reported cases, there is clearly a risk of intenal hernia after laparoscopic left colectomy. Conclusion Although rare internal hernia after laparoscopic left colectomy may occur, and this brings forward the question of mesocolic gap closure.
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Affiliation(s)
- Anna Daskalaki
- Department of General Surgery, Heraklion University Hospital, 71110 Heraklion, Crete, Greece
| | - George Kaimasidis
- Department of General Surgery, Heraklion University Hospital, 71110 Heraklion, Crete, Greece
| | - Sofia Xenaki
- Department of General Surgery, Heraklion University Hospital, 71110 Heraklion, Crete, Greece.
| | - Elias Athanasakis
- Department of General Surgery, Heraklion University Hospital, 71110 Heraklion, Crete, Greece
| | - George Chalkiadakis
- Department of General Surgery, Heraklion University Hospital, 71110 Heraklion, Crete, Greece
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Mukherjee K, Wise PE. Internal Hernia through the Gastrohepatic Ligament after Laparoscopic Restorative Proctocolectomy. Am Surg 2013. [DOI: 10.1177/000313481307900609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kaushik Mukherjee
- Division of Trauma and Surgical Critical Care Vanderbilt University Medical Center Nashville, Tennessee
| | - Paul E. Wise
- Division of Colon and Rectal Surgery Washington University in St. Louis School of Medicine St. Louis, Missouri
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Al Abed YA, Lafferty K, Kosmoliaptsis V. A simple technique for safe mesenteric defect closure following bowel resection. J Surg Tech Case Rep 2012; 4:22-3. [PMID: 23066458 PMCID: PMC3461772 DOI: 10.4103/2006-8808.100348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The closure of the mesenteric defect following bowel resection remains controversial. Proponents of the intervention cite the risk of bowel herniation through an open mesenteric defect and subsequent bowel obstruction whereas supporters of the opposing view advocate that such practice may lead to inadvertent compromise of the bowel blood supply. We describe a novel technique that enables efficient mesenteric defect closure while minimizing the risk of blood vessel injury.
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Affiliation(s)
- Yahya A Al Abed
- Department of General Surgery, Basildon and Thurrock University Hospitals, Essex SS16 5NL, United Kingdom
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Masubuchi S, Okuda J, Tanaka K, Kondo K, Asai K, Kayano H, Yamamoto M, Uchiyama K. Internal hernia projecting through a mesenteric defect to the lesser omental cleft following laparoscopic-assisted partial resection of the transverse colon: report of a case. Surg Today 2012; 43:814-7. [PMID: 22820993 PMCID: PMC3682091 DOI: 10.1007/s00595-012-0264-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 03/05/2012] [Indexed: 02/08/2023]
Abstract
We herein report a case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy to the lesser omental cleft in a 61-year-old female. We performed laparoscopic-assisted partial resection of the transverse colon to treat transverse colon cancer. Three years and 6 months after the operation, the patient developed a bowel obstruction requiring surgical intervention. When we observed the intraperitoneal space under laparoscopy, we determined that the small intestine had passed into the bursa omentalis through the mesenteric defect. Additionally, an abnormal opening of the lesser omentum was present with a portion of the small intestine escaping into the space inferior to the liver. We performed reintegration of the escaped bowel and closed the mesenteric defect laparoscopically. This is the first case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy that we have experienced out of more than 2400 cases. Further research is needed to identify the patients who would benefit from the closure of mesenteric defects during laparoscopic-assisted colectomy.
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Affiliation(s)
- Shinsuke Masubuchi
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
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Abstract
PURPOSE The controversy regarding closing the mesenteric defect after laparoscopic right colectomy remains a subject of debate. This study describes the consequences of not closing the mesenteric defect. METHODS A 7-year prospective database revealed 530 consecutive patients who underwent laparoscopic right colectomy for neoplasia. No mesenteric defects were closed. Small bowel obstruction was determined by clinical assessment and diagnostic imaging. Statistical analysis included the Student t test and Mann-Whitney U test. RESULTS On average, the 530 patients (44% male) were 69.6 years old +/- 12.5 years with American Society of Anesthesiologists' category 2, body mass index 26.6 +/- 5.7, operative time 175 +/- 65 minutes, incision length 5.7 +/- 3.0 cm. Thirty-six patients (6.8%) were converted. Median length of stay was 5 days (interquartile range 4-7). Median follow-up was 20 months (interquartile range 8-45). Four patients (0.8%) had complications attributed to the mesenteric defect: 2 had small bowel obstruction due to internal herniation and 2 had torsion of the anastomosis through the defect. Twenty-six patients (4.9%) had a small bowel obstruction during the follow-up period. Nonoperative treatment was successful in 12 patients. In the 14 patients who were operated on, small bowel obstruction was due to adhesions (4), incarcerated abdominal wall hernias (4), mesenteric defect (4), and cancer recurrence (2). The small bowel obstruction group (n = 26) had a significantly higher percentage of males than the non-small bowel obstruction group (n = 504; 69% vs 43%; P = .008). CONCLUSIONS These data do not support routinely closing the mesenteric defect after laparoscopic right colectomy for neoplasia. Additional studies with extended long-term follow-up are needed.
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Wong JFS, Ho HSS, Tan YH, Cheng CWS. Rare cause of intestinal obstruction after laparoscopic radical nephrectomy: internal herniation via a mesenteric defect. Urology 2008; 72:716.e13-4. [PMID: 18597821 DOI: 10.1016/j.urology.2007.12.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 12/07/2007] [Accepted: 12/10/2007] [Indexed: 12/11/2022]
Abstract
A 43-year-old man had painless macroscopic hematuria and was diagnosed with a 9-cm renal carcinoma in the lower pole of the left kidney. He underwent laparoscopic transperitoneal left radical nephrectomy (LRN) with an uneventful recovery. Eleven days later, he developed intestinal obstruction (IO). Abdominal computed tomography scan showed dilated small bowels occupying the left renal fossa. Laparotomy revealed closed-loop small bowel obstruction resulting from internal intestinal herniation via a 5-cm mesenteric defect. It was repaired after the herniated bowels were reduced. This case illustrates a rare cause of IO after LRN, in which mesenteric defect is necessary.
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Affiliation(s)
- Joelle F S Wong
- Department of Urology, Singapore General Hospital, Singapore
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