Laparoscopic medial-to-lateral approach for the curative resection of right-sided colon cancer

Cranial-first approach for laparoscopic extended right hemicolectomy

Complete mesocolic excision and central vascular ligation with D3 lymphadenectomy are important surgical principles for improving oncological outcomes in colon cancer. The cranial-first approach is a colonic mobilization-first approach to radical right hemicolectomy, which has several advantages, including early feasibility assessment, safe dissection from surrounding organs, preestablished inferior margin of lymph node dissection, and revelation of the tangible anatomy of the tributaries of the gastrocolic trunk. This video demonstrates the cranial-first approach to radical right hemicolectomy in a 66-year-old man with locally advanced cecal cancer.

The safety and short-term effect of mixed approach in laparoscopic right hemicolectomy for right colon cancer compared with middle approach: a retrospective study

PURPOSE

To investigate whether the mixed approach is a safe and advantageous way to operate laparoscopic right hemicolectomy.

METHODS

A retrospective study was performed on 316 patients who underwent laparoscopic right hemicolectomy in our center. They were assigned to the middle approach group (n = 158) and the mixed approach group (n = 158) according to the surgical approaches. The baseline data like gender、age and body mass index as well as the intraoperative and postoperative conditions including operation time, blood loss, postoperative hospital stay and complications were analyzed.

RESULTS

There were no significant differences in age, sex, BMI, ASA grade and tumor characteristics between the two groups. Compared with the middle approach group, the mixed approach group was significantly lower in terms of operation time (217.61 min vs 154.31 min, p < 0.001), intraoperative blood loss (73.8 ml vs 37.97 ml, p < 0.001) and postoperative drainage volume. There was no significant difference in the postoperative complications like postoperative anastomotic leakage, postoperative infection and postoperative intestinal obstruction.

CONCLUSIONS

Compared with the middle approach, the mixed approach is a safe and advantageous way that can significantly shorten the operation time, reduce intraoperative bleeding and postoperative drainage volume, and does not prolong the length of hospital stay or increase the morbidity postoperative complications.

"Caudal to cranial" versus "medial to lateral" approach in laparoscopic right hemicolectomy with complete mesocolic excision for the treatment of stage II and III colon cancer: perioperative outcomes and 5-year prognosis

The purpose of this study was to compare the "caudal to cranial" (CC) versus "medial to lateral" (ML) approach for laparoscopic right hemicolectomy. Pertinent data from all patients with stage II and III between January 2015 and August 2017 were entered into a retrospective database. A total of 175 patients underwent the ML (N = 109) or CC approach (N = 66). Patient characteristics were equivalent between groups. The CC group showed a shorter surgical time 170.00 (145.00, 210.00) vs. (206.50 (178.75, 226.25) min) than the ML group (p < 0.001). The time to oral intake was shorter in the CC group than in the ML group ((3.00 (1.00, 4.00) vs. 3.00 (2.00, 5.00) days; p = 0.007). For the total harvested lymph nodes, there was no statistical significance between the CC group 16.50 (14.00, 21.25) and the ML group 18.00 (15.00, 22.00) (p = 0.327), and no difference was found in the positive harvested lymph nodes (0 (0, 2.00) vs. 0 (0, 1.50); p = 0.753). Meanwhile, no differences were found in other perioperative or pathological outcomes, including blood loss and complications. For 5-year prognosis, overall survival rates were 75.76% in the CC group and 82.57% in the ML group (HR 0.654, 95% CI 0.336-1.273, p = 0.207); disease-free survival rates were 80.30% in the CC group and 85.32% in the ML group (HR 0.683, 95% CI 0.328-1.422, p = 0.305). Both approaches were safe and feasible and resulted in excellent survival. The CC approach was beneficial in terms of the surgical time and time to oral intake.

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.

Risk of Local Recurrence After Complete Mesocolic Excision for Right-Sided Colon Cancer: Post-Hoc Sensitivity Analysis of a Population-Based Study

BACKGROUND

A causal treatment effect of complete mesocolic excision for right-sided colon cancer on the risk of recurrence has been shown, but it is still unclear whether this is caused solely by a risk reduction of local recurrence.

OBJECTIVE

The goal of this study was to assess to what extent complete mesocolic excision contributes to the risk of local recurrence.

DESIGN

This study was a posthoc analyses of data from a population-based cohort. Inverse probability of treatment weighting and competing risk analyses were used to estimate the possible causal effects of complete mesocolic excision.

SETTING

Data were collected from the 4 public colorectal cancer centers in the Capital Region of Denmark.

PATIENTS

Patients undergoing elective colon resections for right-sided colon cancer without distant metastases during the period 2010-2013 were included. One center performed complete mesocolic excision and the remaining 3 centers performed conventional resections.

MAIN OUTCOME MEASURES

The primary outcome was the cumulative incidence of solely local recurrence 5.2 years after surgery. Secondary outcomes were solely distant recurrence and both local and distant recurrence diagnosed within 180 days.

RESULTS

A total of 807 patients were included with 186 undergoing complete mesocolic excision and 621 conventional resections. The 5.2-year cumulative incidence of a solely local recurrence was 3.7% (95% CI, 0.5-6.1) after complete mesocolic excision compared with 7.0% (5.0-8.9) in the control group, and the absolute risk reduction of complete mesocolic excision was 3.7% (2.5-7.1; p = 0.035). The absolute risk reduction on local and distant recurrence was 3.4% (1.3-5.6; p = 0.002) and on solely distant recurrence was 3.1% (0.0-6.2; p = 0.052).

LIMITATIONS

The recurrence risk after conventional resection might be underestimated by the use of inappropriate modalities to diagnose local recurrence for some patients and the shorter duration in this group.

CONCLUSION

This study shows a causal treatment effect of complete mesocolic excision on the risk of a solely local recurrence and of distant recurrence with or without local recurrence. See Video Abstract at http://links.lww.com/DCR/B832 .RIESGO DE RECURRENCIA LOCAL DESPUÉS DE LA ESCISIÓN MESOCÓLICA COMPLETA PARA EL CÁNCER DE COLON DEL LADO DERECHO: ANÁLISIS DE SENSIBILIDAD POST-HOC DE UN ESTUDIO POBLACIONALANTECEDENTES:Se ha demostrado un efecto del tratamiento causal de la escisión mesocólica completa para el cáncer de colon del lado derecho sobre el riesgo de recurrencia, pero aún no está claro si esto se debe únicamente a una reducción del riesgo de recurrencia local.OBJETIVO:Evaluar en qué medida la escisión mesocólica completa se atribuye al riesgo de recurrencia local.DISEÑO:Análisis posthoc de datos de una cohorte poblacional. Se utilizaron análisis de probabilidad inversa de ponderación del tratamiento y de riesgo competitivo para estimar los posibles efectos causales de la escisión mesocólica completa.AJUSTE:Datos de los cuatro centros públicos de cáncer colorrectal en la Región Capital de Dinamarca.PACIENTES:Pacientes sometidos a resecciones de colon electivas por cáncer de colon derecho sin metástasis a distancia durante el período 2010-2013. Un centro realizó escisión mesocólica completa, el resto resecciones convencionales.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la incidencia acumulada de la recidiva local únicamente, 5,2 años después de la cirugía. Los resultados secundarios fueron únicamente la recidiva a distancia y ambas,la recidiva local y a distancia diagnosticada dentro de los 180 días.RESULTADOS:Se incluyeron un total de 807 pacientes, 186 sometidos a escisión mesocólica completa y 621 resecciones convencionales. La incidencia acumulada de 5,2 años de una recidiva únicamente local fue del 3,7% (IC del 95%: 0,5 a 6,1) después de la escisión mesocólica completa en comparación con el 7,0% (5,0 a 8,9) en el grupo de control, y la reducción del riesgo absoluto de la escisión mesocólica completa fue del 3,7% (2,5-7,1; p = 0,035). La reducción del riesgo absoluto de recidiva local y distante fue del 3,4% (1,3-5,6; p = 0,0019) y de recidiva únicamente a distancia 3,1% (0,0-6,2; p = 0,052).LIMITANTES:El riesgo de recurrencia después de la resección convencional podría subestimarse por el uso de modalidades inapropiadas para el diagnostico de la recurrencia local en algunos pacientes y la duración más corta en este grupo.CONCLUSIÓN:Este estudio muestra un efecto del tratamiento causal de la escisión mesocólica completa sobre el riesgo de una recidiva únicamente local y de recidiva a distancia con o sin recidiva local. Consulte Video Resumen en http://links.lww.com/DCR/B832 . (Traducción-Dr. Mauricio Santamaria ).

The SAGES MASTERS program presents: the 10 seminal articles for the Laparoscopic Right Colectomy Pathway

BACKGROUND

As one of the 12 clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, the Colorectal Pathway intends to deliver didactic content organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure (laparoscopic right colectomy, laparoscopic left/sigmoid colectomy, and intracorporeal anastomosis during minimally invasive (MIS) ileocecal or right colon resection). In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic right colectomy which surgeons should be familiar with.

METHODS

Using a systematic literature search of Web of Science, the most cited articles on laparoscopic right colectomy were identified, reviewed, and ranked by the SAGES Colorectal Task Force and invited subject experts. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, with emphasis on relevance and impact in the field, findings, strengths and limitations, and conclusions.

RESULTS

The top 10 seminal articles selected for the laparoscopic right colectomy anchoring procedure include articles on surgical techniques for benign and malignant disease, with anatomical and video illustrations, comparative outcomes of laparoscopic vs open colectomy, variations in technique with impact on clinical outcomes, and assessment of the learning curve.

CONCLUSIONS

The top 10 seminal articles selected for laparoscopic right colectomy illustrate the diversity both in content and format of the educational curriculum of the SAGES Masters Program to support practicing surgeon progression to mastery within the Colorectal Pathway.

Initial Retrocolic Endoscopic Tunnel Approach As an Ergonomic and Oncologically Apt Laparoscopic Technique for Resection of Malignant Right Colonic Lesions: An Experience from a University Hospital

Introduction: Radical minimal access cancer surgery has demonstrated similar outcomes as open surgery of late, but with less morbidity, improving the quality of life especially in patients with colorectal cancer. Initial retrocolic endoscopic tunnel approach (IRETA) has been described in the literature by Palanivelu et al. as a laparoscopic technique for radical resection of malignant right colonic lesions (MRCL) following the modified concept of medial to lateral dissection. In this work, the authors present their experience of this ergonomic surgical technique. Materials and Methods: To begin with, retrocolic dissection was carried out to free and dissect the ascending colon up to hepatic flexure with the reflection of the peritoneum over the right colon along the white line of Toldt with abdominal wall kept intact initially to sustain intracorporeal specimen steadiness. Subsequently, the specimen is lifted medially in a distinct lymphovascular sheath, leading to high ligation of ileocolic, right colic, and the right branch of the middle colic vein with a consequent definite en bloc thorough removal of the lesion. The specimen was delivered through a transumbilical incision. Results: Ten patients (age 45.4 ± 5.6 years) underwent resection by the IRETA technique with a mean operating time of 185 ± 30 minutes and blood loss of 90 ± 20 mL. Mean hospital stay was 6 days. R0 surgical resection was achieved in all patients with proper marginal clearance. Ninety percent had adequate lymph nodal resection. One patient had an intraoperative complication and n = 3 patients developed postoperative ileus. Adjuvant chemotherapy was given and there is no recurrence on 28 months of average follow-up. Conclusion: With the increasing use of laparoscopic surgery for the management of colorectal cancers, the IRETA technique appears to be an ergonomic and oncologically robust procedure for the removal of MRCL. The presented data set needs to be increased with at least 5 years of follow-up to establish long-term surgical outcomes.

Does cranial-medial mixed dominant approach have a unique advantage for laparoscopic right hemicolectomy with complete mesocolic excision?

BACKGROUND

Complete mesocolic excision (CME) with central vascular ligation (CVL) was proposed by Hohenberger in 2009. The CME principle has gradually become the technical standard for colon cancer surgery. How to achieve CME with CVL in laparoscopic right hemicolectomy (LRH) is controversial, and a unified standard approach is not yet available. In recent years, the authors’ team has integrated the theory of membrane anatomy, tried to combine the cephalic approach with the classic medial approach (MA) for technical optimization, and proposed a cranial-medial mixed dominant approach (CMA).

AIM

To explore the feasibility of operational approaches for LRH with CME.

METHODS

In this retrospective cohort study, the clinical data of 57 patients with right-sided colon cancer (TNM stage I, II, or III) who underwent LRH with CME from January 2016 to June 2020 were collected and summarized. There were 31 patients in the traditional MA group and 26 in the CMA group.

RESULTS

There were no significant differences in baseline data between the two groups. The operation was shorter and the number of lymph nodes dissected was higher in the CMA group than in the MA group, but there was no significant difference in the number of positive lymph nodes, intraoperative blood loss, postoperative exhaust time, feeding time, postoperative hospital stay or postoperative complication incidence.

CONCLUSION

Our study shows that the CMA is a safe and feasible procedure for LRH with CME and has a unique advantage.

Modified complete mesocolic excision with central vascular ligation by the squeezing approach in laparoscopic right colectomy

PURPOSE

Complete mesocolic excision (CME) and central vascular ligation (CVL) are becoming the standard procedure in laparoscopic right-sided colectomy. However, the approach to CME and CVL has not been established, although several useful approaches have been reported. The squeezing approach described herein is a novel procedure to perform modified CME and CVL in laparoscopic right colectomy.

METHODS

The squeezing approach features retroperitoneal mobilization followed by cranial mesocolic mobilization and lymph node dissection using a cranial approach followed by a caudal approach. Dissection of the regional lymph nodes along with central vascular ligation was performed along the anterior wall of the superior mesenteric vein. In total, 177 patients (mean age, 70.6 years; male-to-female ratio, 90:87) who underwent laparoscopic right-sided colectomy were retrospectively assessed. Descriptive statistics for patient characteristics were calculated.

RESULTS

The mean operative time and blood loss were 169 min and 37 mL, respectively. Seven patients (4.0%) required conversion to open surgery, and major postoperative complications occurred in five patients (2.8%) with no anastomotic leakage. Histological R0 resection was achieved in all cases of stages 0-III colon cancer. The 5-year recurrence-free survival rates were 100% (n = 19), 100% (n = 40), 87% (n = 46), and 81% (n = 43) in pathological stages 0, I, II, and III, respectively. Node recurrence occurred in one case near the root of the middle colic artery.

CONCLUSION

The novel squeezing approach in laparoscopic right colectomy could be safely performed in terms of the technical and oncological aspects.

Securing the surgical field for mobilization of right-sided colon cancer using the duodenum-first multidirectional approach in laparoscopic surgery

Background

The aim of this study was to compare the short-term outcomes of the duodenum-first multidirectional approach (DMA) in laparoscopic right colectomy with those of the conventional medial approach to assess its safety and feasibility.

Methods

This retrospective study enrolled 120 patients who had laparoscopic surgery for right-sided colon cancer in our institution between April 2013 and December 2019. Fifty-four patients underwent colectomy using the multidirectional approach; among these, 20 underwent the DMA and 34 underwent the caudal-first multidirectional approach (CMA). Sixty-six patients underwent the conventional medial approach. Complications within 30 days of surgery were compared between the groups.

Results

There were 54 patients in the multidirectional group [29 females, median age 72 years (range 36–91 years)] and 66 in the medial group [42 females, median age 72 years (range 41–91 years)]. Total operative time was significantly shorter in multidirectional approach patients than conventional medial approach patients (208 min vs. 271 min; p = 0.01) and significantly shorter in patients who underwent the DMA compared to the CMA (201 min vs. 269 min; p < 0.001). Operative time for the mobilization procedure was also significantly shorter in patients who underwent the DMA (131 min vs. 181 min; p < 0.001). Blood loss and incidence of postoperative complications did not differ. In 77 patients with advanced T3/T4 tumors, the DMA, CMA, and conventional medial approach were performed in 13, 21, and 43 patients, respectively. Total operative time and operative time of the mobilization procedure were significantly shorter in patients undergoing DMA. Blood loss and incidence of postoperative complications did not differ. R0 resection was achieved in all patients with advanced tumors.

Conclusions

The DMA in laparoscopic right colectomy is safe and feasible and can achieve R0 resection with a shorter operative time than the conventional medial approach, even in patients with advanced tumors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-021-02444-5.

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.

Recurrence and Long-Term Survival Following Segmental Colectomy for Right-Sided Colon Cancer in 813 Patients: a Single-Institution Study

BACKGROUND

Controversy exists regarding optimal surgical approach to right-sided colon cancer due to increasing complete mesocolic excision outcome data; yet, scarce long-term surgical and oncologic outcome data from high-volume centers following right segmental resections without complete mesocolic excision make comparisons difficult to interpret. We report long-term outcomes following standard mesocolic excision for right-sided colon adenocarcinoma.

METHODS

A retrospective review of a prospective database was conducted of all consecutive adult patients undergoing surgery for a right-sided colon adenocarcinoma between 2000 and 2007. Demographics, oncologic, operative, and pathologic details are reported. Primary endpoints consisted of overall survival and recurrence. Patients with stage IV and recurrent disease were excluded.

RESULTS

Eight hundred thirteen patients were identified. Majority of tumors were stage II (n = 318, 39%). Adjuvant chemotherapy was administered to 228 patients (28%). Recurrence was observed in 97 patients (12%), at median 1.3 years. Recurrence was most commonly distant (n = 73, 9%). At median follow-up 7.3 years, 5- and 10-year overall survival was 72.4%, and 48.6%, respectively. Five- and 10-year disease-free survival was 67% and 45.8%, respectively. Multivariable analysis demonstrated that TNM stage was a significant predictor of recurrence. For disease-free survival, T stage, and N stage were significant on multivariate analysis. Multivariable predictors of overall survival included age, number of lymph nodes removed, N stage, and adjuvant chemotherapy use.

CONCLUSIONS

Excellent long-term outcomes from a large cohort of patients with non-metastatic, right colon adenocarcinoma treated by segmental colectomy without complete mesocolic excision are reported. The majority of recurrences were distant.

Laparoscopic Complete Mesocolic Excision for Right-Sided Colon Cancer: Analysis of Feasibility and Safety from a Single Western Center

BACKGROUND

Colectomies performed according to complete mesocolic excision (CME) principles have demonstrated an improvement in the quality of surgical specimen and a potential improvement of long-term results. Laparoscopic CME right hemicolectomy is considered a demanding procedure and adopted in few centers from the West. The main purpose of this paper is to present a video showing our technique for laparoscopic CME right hemicolectomy and to analyze our short-term results to prove its safety.

METHODS

Data from 38 patients operated on at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between September 2014 and February 2017, were included in the study.

RESULTS

In the present series, 37% of patients were ≥75 years old, 32% of patients were ASA class 3, 46% of patients had ≥2 comorbidities, 30% of patients had BMI >28 and 17% of patients had ≥2 previous abdominal surgeries. Despite these unfavorable clinic characteristics, no mortality was observed, Clavien-Dindo ≥3 complications occurred in 13.1% and redo surgery in 5.3%. Good quality specimens were obtained with a mean (SD) length of 34.5±7.5 cm, a proximal margin of 16.8±9.2 cm and a distal margin of 14.3±6.4 cm. The mean (SD) number of harvested lymph nodes was 24.3 (8.3).

CONCLUSIONS

When implemented in a Western center, laparoscopic CME right hemicolectomy is feasible and safe and allows obtaining good quality specimens.

Impact of medial-to-lateral vs lateral-to-medial approach on short-term and cancer-related outcomes in laparoscopic colorectal surgery: A retrospective cohort study

Background

Laparoscopic surgery is the favoured method of colorectal cancer resections. It is surgeon expertise and discretion to choose whether to mobilize colon lateral-to-medial or medial-to-lateral. We aim to identify the advantage of one approach over the other in short-term and cancerrelated outcomes.

Methods

A retrospective review of a prospectively maintained database of all laparoscopic colorectal resections with curative-intent, in a single unit, from March 2013 to October 2014. Data was collected on patient demographics, method of laparoscopic mobilisation, operating time, length-of-stay, post-operative complications, clearance of circumferential resection margins lymph node harvest and follow-up.

Results

137 patients with comparable patient demographics had laparoscopic colorectal cancer resection. 76 (60.3%) male and 50 (39.7%) female patients. 58(46.0%) of resections were performed using medial-to-lateral approach, while 68(54.0%) lateral-to-medial. Lateral group had on average 14(0–38) lymph nodes with specimen compared to 17 (6–45) in medial group. There was a statistically significant difference in the major complication rate (Clavien-Dindo IV) between the groups with 1(1.7%) in the medial-to-lateral group compared to 7 (10.2%) in the lateral-to-medial group, (p .035). Patients in the medial-to-lateral group had median length-of-stay of 7 days (range 2–55) compared to 7 days (range 2–75) in the lateral-to-medial group. There was no statistically significant difference in survival between both groups up-to 1334 days p=.413.

Conclusion

Our study shows that mobilising the colon medially in laparoscopic colorectal cancer resection increases the lymph node harvest, gives comparable CRM clearance, similar length of hospital stay and complications. It makes no statistically significant difference in the overall patient survival.

•

This study reports that no one approach is superior to the other but the patient having surgery using medial-to-lateral approach have less post operative complications and higher number of lymph node harvest.

•

There is no long-term advantage to report.

•

Meta-analysis by Ding and colleagues reported that medial-to-lateral approach is better in terms of conversion rate and complications but give less number of lymph nodes in the specimen.

Laparoscopic caudal-to-cranial approach for radical lymph node dissection in right hemicolectomy

PURPOSE

The present study evaluated the safety and feasibility of this caudal-to-cranial laparoscopic dissection approach for the curative resection of right-sided colon cancer. To the best of our knowledge, no study has reported the caudal-to-cranial approach in the laparoscopic right colectomy with curative intent for colon cancer.

METHOD

The key procedure of the caudal-to-cranial approach is the commencement of the dissection at the mesentery root, thus entering into the Toldt's space before the mesenteric vessels are accessed. We retrospectively analyzed the data obtained from a prospectively established database on 80 consecutive patients who had undergone laparoscopic right hemicolectomy with caudally approached radical lymph node dissection for curable right-sided colon cancer between June 2014 and June 2015.

RESULTS

There were 38 male and 42 female patients, with a mean age of 72.5 years (range, 53-83) and a mean BMI of 22.1 kg/m(2) (16.5-35.2). All procedures were successful without any serious intraoperative complications or any conversion to open surgery. The mean operation time was 178.3 min (range, 150-215), and the mean blood loss was 81.6 ml (range, 50-200). The mean number of harvested lymph nodes was 19 (range, 12-25).

CONCLUSIONS

The findings indicate that laparoscopic caudal-to-cranial approach for radical lymph node dissection is a feasible and safe procedure for the treatment of curable right-sided colon cancer.

Initial retrocolic endoscopic tunnel approach (IRETA) for complete mesocolic excision (CME) with central vascular ligation (CVL) for right colonic cancers: technique and pathological radicality

INTRODUCTION

The concept of complete mesocolic excision (CME) with central vascular ligation (CVL) for treatment of right colon cancer evolved over last one decade. It decreases local recurrences and improves the survival rates. We describe our novel technique which involves first posterior sharp dissection between planes of parietal and visceral fascia of mesocolon followed by ligation of ileocolic, right colic and middle colic pedicles at their origin. We highlight the technical variations with various techniques and advantages over conventional medial to lateral approach in current study.

AIM

The outcomes were measured in terms of technical feasibility, short-term outcomes and pathological radicality of current laparoscopic technique (IRETA) for CME with CVL.

MATERIALS AND METHODS

Two hundred twelve patients (163 males) who underwent laparoscopic CME for right colon cancer over the period of January 2009 to December 2013 were analysed via prospectively maintained database.

RESULTS

97.16 % of patients (n = 206) underwent laparoscopic CME while six patients required open conversion. Mean operative time was 142 ± 28.4 min with median hospital stay of 5 days (range 4-11). The median count of lymph node harvested were 24 (range 10-42). The complete mesocolic excision plane was achieved in 93.8 % patients. 84.4 % (n = 179) of our patients were having (T3, N+) disease on pathological examination. The overall morbidity (<30 days) was 9.9 %.

CONCLUSION

Laparoscopic initial retrocolic endoscopic tunnel approach (IRETA) for CME with CVL in right colonic cancers is safe, simpler and feasible laparoscopic approach with minimal complications. Creation of retro colic tunnel is key highlight of IRETA approach. This approach becomes especially useful in patients with late presentations where complete mesocolic excision remains essential to enhance oncological radicality as per evidence available.

Open Right Hemicolectomy:Lateral to Medial or Medial to Lateral Approach?

OBJECTIVE

Currently, no published studies have compared the clinical outcomes of the medial-to-lateral approach (MA) and lateral-to-medial approach (LA) for open right hemicolectomy. Thus, the present study aimed to assess whether one of these approaches has any potential benefits over the other.

METHODS

A retrospective study was performed of all patients who underwent open right hemicolectomy with pathologically confirmed disease who met the eligibility criteria between June 2008 and June 2012. The population was divided into an MA group and an LA group by propensity scoring. We compared patient demographic and clinical characteristic variables between the two groups and assessed short-term and long-term outcomes.

RESULTS

A total of 450 patients (MA, n = 150; LA, n = 300) were evaluated. The operation time (MA,138.4 minutesvs.LA,166.2 minutes; P < .05) and blood loss (MA,52.0mL vs. LA,62.6mL; P < .05)were significantly lower in the MA group. No differences in the number of harvested lymph nodes and oncologic outcomes were observed between the two groups. Further subgroup analysis for stage III colon cancer revealed that the MA group had significantly more retrieved lymph nodes (MA,18.8vs. LA,16.0; P = .028). There were no differences in other variables between the two groups.

CONCLUSIONS

The MA reduced operative time and blood loss compared with the LA. We thus concluded that the MA provided short-term benefits compared with the LA in open right hemicolectomy for right-sided colon cancer.

Short-term outcomes of simultaneous laparoscopic colectomy and hepatectomy for primary colorectal cancer with synchronous liver metastases

Although simultaneous resection of primary colorectal cancer and synchronous liver metastases is reported to be safe and effective, the feasibility of a laparoscopic approach remains controversial. This study evaluated the safety, feasibility, and short-term outcomes of simultaneous laparoscopic surgery for primary colorectal cancer with synchronous liver metastases. From September 2008 to December 2013, 10 patients underwent simultaneous laparoscopic resection of primary colorectal cancer and synchronous liver metastases with curative intent at our institute. The median operative time was 452 minutes, and the median estimated blood loss was 245 mL. Median times to discharge from the hospital and adjuvant chemotherapy were 13.5 and 44 postoperative days, respectively. Negative resection margins were achieved in all cases, with no postoperative mortality or major morbidity. Simultaneous laparoscopic colectomy and hepatectomy for primary colorectal cancer with synchronous liver metastases appears feasible with low morbidity and favorable outcomes.

Laparoscopic ileo-cecal resection: the total retro-mesenteric approach

BACKGROUND

Ileo-cecal resection is the most performed procedure in Cohn's disease. In the last decades, the laparoscopic approach became the gold standard. The dissection can be lateral to median or median to lateral. In non-malignant diseases as it is the case for Crohn's disease, the most performed dissection approach is the lateral to median. Herein, we describe a technique performed in our department: the total retro-mesenteric approach.

METHOD

The procedure requires 4 trocars with a 10- to 12-mm median suprapubic trocar. The telescope is placed in this trocar. The dissection will begin with the opening of the mesentery root creating a retro-mesenteric tunnel. This dissection gives a direct visualization of the duodenum, of the ureter and the gonadic vessels which guarantees a safe procedure considering the importance of the inflammation in this disease. At the end of the retro-mesenteric step, the right colon is only attached to the Toldt's fascia. The transection of the mesentery is done next to the bowel wall leaving at the end the choice to the surgeon to perform an extra- or endocorporeal anastomosis.

RESULTS

This retro-mesenteric approach has been used in our department since 2004. Until May 2013, 89 patients underwent laparoscopic resection for Crohn's disease with a mean operative time of 130 min, a morbidity rate of 6 % and a laparoconversion rate of 13.6 %.

CONCLUSION

We describe the total retro-mesenteric approach in the ileo-cecal resection for Crohn's disease. The approach is considered to be safe allowing the surgeon to perform a dissection far from the inflammatory site and allowing a visual identification of the duodenum and the right ureter. The morbidity of the procedure is equivalent to the other dissection techniques.

Long-term outcome of laparoscopic-assisted right-hemicolectomy with D3 lymphadenectomy versus open surgery for colon carcinoma

PURPOSE

To investigate the applicability, safety, short-term and long-term outcomes of laparoscopic surgery in the treatment of right-sided colon carcinomas with D3 lymphadenectomy.

METHODS

Between June 2003 and September 2010, 324 patients with right-sided colon carcinoma underwent surgical treatment in the same hospital, 177 cases were treated by laparoscopic surgery (LRH group) and 147 cases by open surgery (ORH group). We performed a retrospective analysis of the differences between the two groups in terms of the clinical data.

RESULTS

There were no significant differences between the two groups in the demographic data; however, the recovery time was significantly shorter in the LRH group, the number of overall lymph nodes harvested and principle lymph nodes harvested in the LRH group was significantly higher than in the ORH group, the incidence of postoperative complications was 12.99 % in the LRH group and 22.45 % in the ORH group (P < 0.05), and the recurrence rate in the LRH group was lower than that in the ORH group, although the difference was not significant (15.25 vs 19.73 %). The cumulative overall survival for all stages at 1, 3 and 5 years in the LRH group (97.18, 83.73 and 70.37 %) were not significantly different compared to those in the ORH group (94.56, 77.84 and 66.97 %).

CONCLUSIONS

Laparoscopic-assisted right hemicolectomy with D3 lymphadenectomy for colon carcinomas is safe and effective, while it is also superior to open surgery regarding the short-term outcomes, and the long-term outcomes are similar to those of open surgery.

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.

D3 Lymph Node Dissection in Right Hemicolectomy with a No-touch Isolation Technique in Patients With Colon Cancer

BACKGROUND

The role of lymph node dissection in the management of right-sided colon cancer remains controversial.

OBJECTIVE

The aim of this study was to investigate the surgical treatment of curable right-sided colon cancer by using D3 lymphadenectomy with a no-touch isolation technique and to determine the extent of lymph node dissection optimal for the prognosis of right-sided colon cancer.

DESIGN

This research is a retrospective cohort study from a prospectively collected database.

SETTING

The investigation took place in a specialized colorectal surgery department.

PATIENTS

: Data on 370 consecutive patients who underwent D3 lymph node dissection for right-sided colon cancer with a no-touch isolation technique were identified.

MAIN OUTCOME MEASURES

The survival of patients with involvement of main nodes at the roots of colonic arterial trunks along superior mesenteric vessels through intermediate nodes in the right mesocolon was determined.

RESULTS

The 5-year overall survival of patients with stage I (n = 73, 19.7%), II (n = 155, 41.9%), and III (n = 142, 38.4%) cancer were 94.5%, 87.6%, and 79.2%. The 5-year disease-specific survival of patients with stages I, II, and III cancer were 100.0%, 94.5%, and 85.0%. Eleven patients (3.0%) had metastatic involvement of main lymph nodes, whereas 49 (13.2%) had metastases to intermediate lymph nodes. The 5-year overall survival and disease-specific survival of patients with metastases to main lymph nodes were 36.4% for both, and 5-year overall survival and disease-specific survival of patients with metastases to intermediate lymph nodes were 77.6% and 83.5%.

LIMITATIONS

This study was limited by its nonrandomized retrospective design.

CONCLUSIONS

D3 lymphadenectomy with a no-touch isolation technique allows curative resection and long-term survival in a cohort of patients with cancer of the right colon.

Long-term results of laparoscopy-assisted radical right hemicolectomy with D3 lymphadenectomy: clinical analysis with 177 cases

PURPOSES

To study the feasibility, safety, and short-/long-term outcomes of laparoscopy-assisted right hemicolectomy with D3 lymphadenectomy for colon cancer.

METHODS

The clinical data of 177 cases that underwent laparoscopy-assisted radical right hemicolectomy with D3 lymphadenectomy for colon cancer between Jun 2003 and Sep 2010 was collected; the safety of operation, status of recovery, complication, oncological outcomes, and results of short-/long-term follow-up were analyzed.

RESULTS

No case died in this study; five cases (2.82 %) were converted to open surgery. Four cases (2.26 %) underwent hand-assisted laparoscopic right hemicolectomy. The average operation time was 133 ± 36 min, and the blood loss was 94 ± 34 ml. The average time for passage of flatus, liquid food eating, and hospitalization were 2.1 ± 0.7, 3.2 ± 0.5, and 10.4 ± 2.7 day, respectively. The total number of lymph nodes removed was 15.2 ± 10.1. Postoperative complications were observed in 23 of 177 patients (12.99 %). The median follow-up period was 54 months; port-site recurrence was observed in one patient; local recurrence was found in five cases (2.82 %); distant metastasis was found in 21 cases (11.86 %). The cumulative overall survival of all stages at 12, 36, 60, and 72 months was 97.18 %, 83.73 %, 70.37 %, and 68.99 %, respectively. The cancer-specific survival was 98.73 % (12 months), 87.81 % (36 months), and 80.17 % (60 months).

CONCLUSIONS

Laparoscopy-assisted right hemicolectomy with D3 lymphadenectomy can be successfully performed for right colon cancer with the advantages of minimally invasive surgery. Moreover, the results implied appropriate short- and long-term outcomes.

Single-incision laparoscopic right colectomy compared with conventional laparoscopy for malignancy: assessment of perioperative and short-term oncologic outcomes

BACKGROUND

Laparoscopic colectomy for malignancy currently is the standard operative technique together with open colectomy. Single-incision laparoscopic surgery (SIL) is a recent advance in minimally invasive surgical techniques. This study aimed to compare SIL right colectomy with conventional laparoscopy (CL) used to treat patients with colon cancer.

METHODS

This study was a retrospective analysis of data from the authors' prospectively collected colorectal surgery database. Between August 2009 and November 2010, 159 patients who underwent primary laparoscopic right colectomy at the Samsung Medical Center were recruited to participate in this study. Of these, 66 patients underwent SIL colectomy.

RESULTS

The SIL and CL right colectomy groups did not differ significantly in terms of general characteristics including age, sex, body mass index (BMI), American society of anesthesiology (ASA) score, previous abdominal operation, and diagnosis. The two groups also did not differ significantly in terms of perioperative complications (9.1 vs. 15.1 %, p = 0.335). Oncologic resection was similar in the two groups. The mean number of harvested lymph nodes was 24 for SIL and 27 for CL right colectomy (p = 0.068). Tumor size, disease stage, adjuvant chemotherapy, and proximal and distal resection margins did not differ significantly between the two groups. The mean follow-up period was 24.5 for the SIL group and 26.4 months for the CL group (p = 0.098), with six recurrences in the SIL group (9.1 %) and three recurrences in the CL group (3.2 %) (p = 0.120). One death occurred in the CL group. Disease-free survival at 24 months did not differ significantly between the two groups (89.7 vs. 96.3 %, p = 0.120).

CONCLUSION

The findings show that SIL right colectomy for colon cancer is safe and can provide resection and oncologic outcomes equal to those of conventional laparoscopic right colectomy.

Laparoscopic complete mesocolic excision (CME) with medial access for right-hemi colon cancer: feasibility and technical strategies

OBJECTIVE

This study was designed to investigate the feasibility and technical strategies of laparoscopic complete mesocolic excision (CME) for right-hemi colon cancer.

METHODS

The clinical and pathological findings of 64 patients with right-hemi colon cancer who underwent laparoscopic CME between March 2010 and September 2011 were collected retrospectively. Among them, 35 cases were eligible for the final analysis through various screening factors. The quality of surgery also was assessed by reviewing the recorded video obtained through the operations in terms of specimen anatomic planes and completeness of the excised mesocolon.

RESULTS

Laparoscopic CME is focused on applying the concept of enveloped visceral and parietal planes during the operations. Laparoscopic approach proceeds with medial access where the dissection starts at ileocolic vessel before proceeds along with the superior mesenteric vessel. The access also emphasized en bloc resection of mesocolon without defections to the planes. Besides, lymph node resections at the root of ileocolic; right colic and middle colic vessels are necessary for ileocecum cancer. Cancers at the hepatic flexure requires further dissection of subpyloric lymph nodes and of greater omentum that is within 15 cm of the tumor and along the greater curvature. Thirty-five cases were evaluated as good plane. The median total number of central lymph nodes retrieved was 19 (range, 15-25) and central lymph node metastasis was found in 5 of all stage III cases. The median operation time was 2.6 h and the blood loss was 80 mL. The median time for passage of flatus and hospitalization were 2 and 12 days respectively. Complications were observed in three cases.

CONCLUSIONS

CME is a novel concept for colon cancer surgery and might be a standard for the procedure. Laparoscopic CME with medial access is technically feasible and randomized trials are needed to evaluate its long-term outcomes.

The effect of laparoscopic surgery in stage II and III right-sided colon cancer: a retrospective study

Background

This retrospective study compared the clinicopathological results among three groups divided by time sequence to evaluate the impact of introducing laparoscopic surgery on long-term oncological outcomes for right-sided colon cancer.

Methods

From April 1986 to December 2006, 200 patients who underwent elective surgery with stage II and III right-sided colon cancer were analyzed. The period for group I referred back to the time when laparoscopic approach had not yet been introduced. The period for group II was designated as the time when first laparoscopic approach for right colectomy was carried out until we overcame its learning curve. The period for group III was the period after overcoming this learning curve.

Results

When groups I and II, and groups II and III were compared, overall survival (OS) did not differ significantly whereas disease-free survival (DFS) in groups I and III were statistically higher than in group II (P = 0.042 and P = 0.050). In group III, laparoscopic surgery had a tendency to provide better long-term OS ( P = 0.2036) and DFS ( P = 0.2356) than open surgery. Also, the incidence of local recurrence in group III (2.6%) was significantly lower than that in groups II (7.4%) and I (12.1%) ( P = 0.013).

Conclusions

Institutions should standardize their techniques and then provide fellowship training for newcomers of laparoscopic colon cancer surgery. This technique once mastered will become the gold standard approach to colon surgery as it is both safe and feasible considering the oncological and technical aspects.

Retrocolic Spaces: Anatomy of the Surgical Planes in Laparoscopic Right Hemicolectomy for Cancer

To explore the regional anatomy of the fasciae and spaces around the right-side colon from laparoscopic perspective, we observed the location, extension, and boundaries of the spaces around the right-side colon in seven cadavers and in 49 patients undergoing laparoscopic right hemicolectomy for cancer, and reviewed computed tomography images from patients and healthy individuals. Between the ascending mesocolon and prerenal fascia (PRF), there was a right retrocolic space (RRCS), which extended in all directions. The anterior, posterior, medial, lateral, cranial, and caudal boundaries of the RRCS were the ascending mesocolon, PRF, superior mesenteric vein, right paracolic sulcus, inferior margin of the duodenum, and inferior margin of the mesentery radix, respectively. Between the transverse mesocolon and the pancreas and duodenum, there was a transverse retrocolic space, which was enclosed cranially by the radix of the transverse mesocolon. In CT images, healthy PRF was noted as slender line of middle density, continuing to the transverse fascia. The retrocolic spaces was unidentifiable, unless they were filled with retroperitoneal lesions. The RRCS and transverse retrocolic space are natural surgical planes for laparoscopic right hemicolectomy for cancer. The boundaries of these fusion fascial spaces are the best access, and the PRF is the best guide.

Laparoscopic right hemicolectomy with intracorporeal anastomosis

The author presents a technique for performing laparoscopic right hemicolectomy, accompanied by an online video. This method is suitable for a single surgeon working with a single assistant, who is also the cameraman. It starts with a hybrid medial-to-lateral or lateral-to-medial dissection of the right colon and mesentery, adapting to the actual anatomical findings and adhesions encountered in each individual patient. A step-by-step approach is described. Achieving the anatomical goals of each step facilitates the performance of the next step. An intracorporeal technique for anastomosis is demonstrated.

Emergency laparoscopic surgery for right colonic diseases with peritonitis

BACKGROUND

Laparoscopic bowel resection for right colonic diseases with peritonitis is technically difficult and time-consuming, particularly in the presence of hard adhesion and dense inflammation. Moreover, peritonitis frequently leads to an emergency operation. Therefore, we evaluated the feasibility and effectiveness of emergency laparoscopic bowel resection in patients with these diseases.

METHODS

During 3 years (November 2006 to October 2009), we enrolled 31 consecutive patients who underwent an emergency laparoscopic bowel resection for right colonic disease with peritonitis. In 2 patients, perforated malignancy was suspected preoperatively, but there was no patient with malignancy at pathologic finding. We analyzed the clinical outcomes, including complications.

RESULTS

The mean operating time was 140 minutes, and the mean hospital stay was 10 days. There was 1 conversion (3%), and the other intraoperative procedures were uneventful. Four complications (13%) occurred after treatment (1 intra-abdominal abscess, 2 wound abscesses, and 1 adhesive ileus). The intra-abdominal abscess was treated by subsequent percutaneous drainage; the wound abscesses were treated conservatively. One patient with an adhesive ileus 12 months after treatment was managed with a bowel resection. After a median follow-up of 16 months, the other patients had no complications.

CONCLUSIONS

Emergency laparoscopic bowel resection may be a feasible, effective method for the treatment of right colonic diseases with peritonitis.

Laparoscopic surgery for colorectal cancer

Laparoscopic surgery as an alternative to traditional open surgery, has been accepted by an increasing number of surgeons and patients. In this paper, we review the advances in laparoscopic surgery for colorectal cancer and summarize its pros and cons by comparing with open surgery, including patient inclusion and exclusion, intraoperative outcomes, and short- and long-term outcomes. Furthermore, we provide an initial overview of the Da Vinci robotic system and the single-port laparoscopic surgery.

Comparison of short- and medium-term results between laparoscopically assisted and totally laparoscopic right hemicolectomy: a case-control study

BACKGROUND

This study aimed to compare the short- and medium-term results obtained by totally laparoscopic right colectomy (TL) with those obtained by laparoscopically assisted right colectomy (LAC) for the treatment of right colon cancer.

METHODS

A retrospective study compared two nonstatistically different groups (50 TL and 50 LAC cases) managed for nonmetastatic malignant tumors. The study outcomes included operative time, length of minilaparotomy, intraoperative complications, postoperative pain, time to resumption of the gastrointestinal functions, permanence of abdominal drain, analgesic therapy duration, postoperative complications, hospitalization time, number of harvested lymph nodes, and distant metastases onset.

RESULTS

The mean operative times were 78 ± 25 min (TL group) and 92 ± 22 min (LAC group) (p < 0.05). The findings showed a lower postoperative pain level associated with a reduction in analgesic consumption (p > 0.05) and earlier restoration of digestive function in the TL group than in the LAC group. The mean hospital stays were approximately 5 days (TL) and 7 days (LAC) (p < 0.05). No complications occurred either intra- or postoperatively, and similarly, the TL group experienced no mortality. In comparison, the LAC group had a 30% complication rate (p < 0.05). The complications included one case of intraoperative small bowel lesion, three cases of postoperative respiratory infections, three cases of anastomotic leakage, two cases of intestinal occlusion, three cases of minilaparotomy infection, one case of postoperative femoral neurosis, one case of postoperative heart attack, and one case of postoperative pancreatitis. The mortality rate was 0%. Neither group had a recurrence of the neoplastic disease during a 4-year follow-up period.

CONCLUSIONS

The findings seem to demonstrate that TL right colectomy is feasible and safe, yielding results comparable with those of the open approach but offering improved postoperative patient comfort. The limits of this retrospective comparative study do not allow definitive conclusions to be drawn despite the encouraging data for the next prospective randomized studies.

Transumbilical single incision laparoscopic sigmoidectomy for benign disease

BACKGROUND

Transumbilical single incision laparoscopic surgery (SILS) has made its initial forays into clinical minimally invasive surgery. SILS combines in part the cosmetic advantage and decrease parietal trauma of natural orifice surgery, but allow operative realization with standard and validated laparoscopic instruments. We report here the first clinical transumbilical SILS sigmoidectomy for benign disease.

METHOD

Preliminary experience with transumbilical single incision laparoscopic surgery (or embryonic natural orifice transluminal endoscopic surgery) sigmoidectomy in a female patient (34 years, BMI 22 kg/m(2)) with sigmoid stenosis caused by nodular endometriosis was reported. Transumbilical SILS treatment of pelvic endometriosis was performed during the same operation through cauterization.

RESULTS

Transumbilical single incision laparoscopic sigmoidectomy was feasible with conventional laparoscopic instruments. The combined uses of straight and articulated laparoscopic instruments allow the avoidance of transparietal sling suture for exposition. Operative time for sigmoidectomy and endometriosis therapy was 125 min. No intra-operative or postoperative complications were recorded. SILS achieved excellent cosmetic results and may be associated with accelerated recovery.

CONCLUSION

Transumbilical single incision laparoscopic sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. The combined uses of strait and articulated instruments allow transumbilical SILS sigmoidectomy without the need for additional incision or transparietal sling suture. SILS sigmoidectomy may have the clinical advantage over NOTES of offering the safety of laparoscopic colectomy and the avoidance of vaginal access. It has to be determined if SILS offers benefit to the patient, except in cosmesis, compared with standard laparoscopic sigmoidectomy.

Impact of the standardized medial-to-lateral approach on outcome of laparoscopic colorectal resection

BACKGROUND

Beginning in 2004, a standardized medial-to-lateral approach was adopted in laparoscopic colorectal resection (LapCR) in our institution. The present study aimed to compare the outcomes of patients operated on by this approach with those who were operated on prior to the adoption of this technique.

METHODS

Data were retrieved from a prospectively collected database on LapCR. The control group included 196 patients operated on from January 2002 to December 2003 and the medial approach group included 224 patients who underwent operations from January 2005 to December 2007. The patient characteristics, operative details, pathology, and surgical outcomes of the two groups were compared.

RESULTS

The patient demographics, types of operation and pathology did not show any statistically significant difference. The medial approach group was associated with significantly less median blood loss [100 (interquartile range [IQR]: 50-174) ml versus 150 (IQR:100-300) ml; p < 0.001], shorter hospital stay [4 (IQR: (4-7) versus 7 (5-9) days; p < 0.001], and more lymph nodes harvested [12 (7-17.5) versus 10 (6-15); p = 0.001]. Significantly earlier bowel function recovery was observed in the medial approach group. The mortality and complications did not show any difference.

CONCLUSIONS

A standardized medial-to-lateral approach for LapCR is associated with less blood loss, earlier return of bowel function, shorter hospital stay, and increased number of lymph nodes harvested. This should be the preferred approach in LapCR.

D3 lymphadenectomy using a medial to lateral approach for curable right-sided colon cancer

BACKGROUND AND AIMS

The extended D3 lymphadenectomy using a medial to lateral (MtL) approach for the treatment of curable right-sided colon cancer is performed with a view to improving oncologic surgery outcomes. However, the feasibility and safety of this procedure has not been fully examined. The present study investigated the feasibility and safety of D3 lymphadenectomy using the MtL approach for curable right-sided colon cancers.

METHODS

Between January 2005 and May 2007, 42 patients underwent a curative-intent right (25) or extended right (17) hemicolectomy including D3 lymphadenectomy using the MtL approach performed by the same single surgeon. The extent of the D3 lymphadenectomy followed the recommendations of the Japanese Society for Cancer of the Colon and Rectum.

RESULTS

There were 27 male and 15 female patients, with a mean age of 59.2 years (range, 30-83). The mean operation time was 172.5 min (range, 55-274) and the mean blood loss was 128.3 ml (range, 50-500). All procedures were successful and no conversions to open surgery were required in laparoscopic cases (32 patients, 76.2%). The mean number of harvested lymph nodes was 45 (range, 18-92). There was no surgical mortality or morbidity, except one case of postoperative ileus which was conservatively managed. The mean postoperative hospital stay was 8.6 days (range, 6-15).

CONCLUSION

The findings indicate that a D3 lymphadenectomy using the MtL approach is a feasible and safe procedure for the treatment of curable right-sided colon cancer.

Single port access laparoscopic right hemicolectomy

BACKGROUND

Single port access (SPA) surgery is a rapidly evolving field as it combines some of the cosmetic advantage of the Natural Orifice Translumenal Endoscopic Surgery (NOTES) and allows performing surgical procedure with standard surgical instruments. We report in this paper a new technique of umbilical SPA right hemicolectomy with conventional surgical oncologic principle and technique of minimally invasive colectomy.

METHODS

Preliminary experience with umbilical SPA right hemicolectomy in a patient with degenerated ascending colon polyp.

RESULTS

Umbilical SPA right hemicolectomy was feasible with conventional laparoscopic instruments. Carcinologic surgical principle can be respected using this technique as pathological specimen had sufficient surgical margins (>10 cm) and lymph nodes (33). Operative time was 158 min. No peroperative or postoperative complications were recorded.

CONCLUSION

SPA right hemicolectomy is feasible and safe when performed by experienced laparoscopic surgeons. SPA right hemicolectomy may have the advantage over NOTES approach to offer the safety of laparoscopic colectomy especially for haemostasis and anastomosis. It has to be determined whether or not this approach would offer benefit to patients, except in cosmesis, compared to standard laparoscopic right hemicolectomy.