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

Management of non-curative endoscopic resection of T1 colon cancer

Endoscopic resection techniques enable en-bloc resection of T1 colon cancers. A complete removal of T1 colon cancer can be considered curative when histologic examination of the specimens shows none of the high-risk factors for lymph nodes metastases. Criteria predicting lymph nodes metastases include deep submucosal invasion, poor differentiation, lymphovascular invasion, and high-grade tumor budding. In these cases, complete (R0), local endoscopic resection is considered sufficient as negligible risk of lymph nodes metastases does not outweigh morbidity and mortality associated with surgical resection. Challenges arise when endoscopic resection is incomplete (RX/R1) or high-risk histological features are present. The risk of lymph node metastasis in T1 CRC ranges from 1% to 36.4%, depending on histologic risk factors. Presence of any risk factor labels the patient "high risk," warranting oncologic surgery with mesocolic lymphadenectomy. However, even if 70%-80% of T1-CRC patients are classified as high-risk, more than 90% are without lymph node involvement after oncological surgery. Surgical overtreatment in T1 CRC is a challenge, requiring a balance between oncologic safety and minimizing morbidity/mortality. This narrative review explores the landscape of managing non-curative T1 colon cancer, focusing on the choice between advanced endoscopic resection techniques and surgical interventions. We discuss surveillance strategies and shared decision-making, emphasizing the importance of a multidisciplinary approach.

Do Laparoscopic Approaches Ensure Oncological Safety and Prognosis for Serosa-Exposed Colon Cancer? A Comparative Study against the Open Approach

The adoption of laparoscopic surgery in the management of serosa-exposed colorectal cancer has raised concerns. This study aimed to investigate whether laparoscopic surgery is associated with an increased risk of postoperative recurrence in patients undergoing resection for serosa-exposed colon cancer. A retrospective analysis was conducted on a cohort of 315 patients who underwent curative resection for pathologically confirmed T4a colon cancer without distant metastases at the Asan Medical Center between 2006 and 2015. Patients were categorized according to the surgical approach method: laparoscopic surgery (MIS group) versus open surgery (Open group). Multivariate analysis was employed to identify risk factors associated with overall survival (OS) and disease-free survival (DFS). The MIS group included 148 patients and the Open group had 167 patients. Of the total cohort, 106 patients (33.7%) experienced recurrence during the follow-up period. Rates, patterns, and time to recurrence were not different between groups. The MIS group (55.8%) showed more peritoneal metastasis compared to the Open group (44.4%) among recurrence sites, but it was not significant (p = 0.85). There was no significant difference in the five-year OS (73.5% vs. 78.4% p = 0.374) or DFS (62.0% vs. 64.6%; p = 0.61) between the Open and MIS groups. Age and the pathologic N stage were independently associated with OS, and the pathologic N stage was the only associated risk factor for DFS. The laparoscopic approach for serosa-exposed colon cancer did not compromise the DFS and OS. This study provides evidence that laparoscopic surgery does not compromise oncologic outcomes of patients with T4a colon cancer although peritoneal seeding is the most common type of disease failure of serosa-exposed colon cancer.

Impact of laparoscopic surgery on short-term and long-term outcomes in elderly obese patients with colon cancer

Background

Laparoscopic surgery is reported to be useful in obese or elderly patients with colon cancer, who are at increased risk of postoperative complications because of comorbidities and physical decline. However, its usefulness is less clear in patients who are both elderly and obese and may be at high risk of complications.

Methods

Data for obese patients (body mass index ≥25) who underwent laparoscopic or open surgery for stage II or III colon cancer between January 2009 and December 2013 were collected by the Japan Society of Laparoscopic Colorectal Surgery. Surgical outcomes, postoperative complications, and relapse-free survival (RFS) were compared between patients who underwent open surgery and those who underwent laparoscopic surgery according to whether they were elderly (≥70 y) or nonelderly (<70 y).

Results

Data of 1549 patients (elderly, n = 598; nonelderly, n = 951) satisfied the selection criteria for analysis. Length of stay was shorter and surgical wound infection was less common in elderly obese patients who underwent laparoscopic surgery than in those underwent open surgery. There were no significant between-group differences in overall complications, anastomotic leakage, ileus/small bowel obstruction, or RFS. There were also no significant differences in RFS after laparoscopic surgery according to patient age.

Conclusion

Laparoscopic surgery is safe in elderly obese patients with colon cancer and does not worsen their prognosis. There was no significant difference in the effectiveness of laparoscopic surgery between obese patients who were elderly and those who were nonelderly.

Laparoscopic vs. open loop ileostomy reversal: a meta-analysis of randomized and non-randomized studies

PURPOSE

The present meta-analysis compares laparoscopic loop ileostomy reversal (LLIR) with open loop ileostomy reversal (OLIR) to evaluate the advantages of the laparoscopic technique compared to the traditional open technique in ileostomy reversal.

METHODS

Primary endpoints were hospital stay and overall complications. Secondary endpoints were operative time, EBL, readmission, medical complications, surgical complications, reoperation, wound infection, anastomotic leak, intestinal obstruction, and cost of the procedures. The included studies were also divided based on the type of anastomotic approach: extracorporeal laparoscopic loop ileostomy reversal (ELLIR) and intracorporeal laparoscopic loop ileostomy reversal (ILLIR).

RESULTS

In the analysis, 4 studies were included. Three hundred fifty-four patients were enrolled. As primary outcomes, a significant difference was found in hospital stay between the LLIR and OLIR groups (MD = -0.67, 95% CI -1.16 to -0.19, P = 0.007). The overall complications outcome resulted in favor of the LLIR group (RR = 0.64, 95% CI 0.43-0.95, P = 0.03). As secondary outcomes, the operative time was in favor of the OLIR group (MD = 19.18, 95% CI 10.20-28.16, P < 0.001). Surgical complications were lower in the LLIR group than in the OLIR group. No other differences between the secondary endpoints were found. Subgroup analysis showed a significant difference in hospital stay between the ILLIR and OLIR groups (MD = -0.92, 95% CI -1.55 to -0.30, P = 0.004). The overall complications outcome significantly favored the ILLIR group (RR = 0.38, 95% CI 0.15-0.96, P = 0.04).

CONCLUSION

Our meta-analysis shows an advantage in terms of shorter post-operative hospitalization and reduction of complications of LLIR compared to OLIR. The sub-group analysis shows that performing an extracorporeal anastomosis exposes the same risks of the open technique.

Benefits of a laparoscopic approach for second colorectal resection after colectomy or proctectomy -a retrospective study

BACKGROUND

A laparoscopic approach generally provides several benefits in patients who undergo colon or rectal surgery without jeopardizing oncological outcomes. However, there is a paucity of studies on comparative outcomes of laparoscopic versus open approaches for second primary colorectal lesions after colectomy or proctectomy.

METHODS

From patients with colorectal disease who underwent surgery between 2008 and 2022 at our hospital, we collected 69 consecutive patients who had previous colorectal surgery for this retrospective study. Based on the second surgery approach (laparoscopic or open), patients were classified into the Lap (n = 37) or Op group (n = 32). Patients' baseline data and perioperative and postoperative outcomes were compared between the two groups.

RESULTS

Four patients (11%) of the Lap group needed conversion to laparotomy. The intraoperative blood loss was lower in the Lap group than the Op group (median: 45 ml vs. 205 ml, p = 0.001). The time to first bowel movement was shorter in the Lap group than the Op group (median: 2.8 days vs. 3.6 days, p = 0.007). The operative time, frequencies of postoperative morbidities, and overall survival did not differ between the two groups.

CONCLUSION

Laparoscopic surgery appeared feasible and beneficial for selected patients undergoing second colorectal resection after colectomy or proctectomy regarding blood loss and bowel function recovery without affecting other outcomes.

Results of Laparoscopic Surgery and D3 Lymph Node Dissection Combined With Chemotherapy for the Radical Treatment of Advanced-Stage Right Colon Cancer: A Single-Center Observational Study in Vietnam

AIM

To describe the results of laparoscopic surgery and D3 lymph node dissection combined with adjuvant chemotherapy (ACT) for the treatment of advanced-stage right colon cancer (stages II and III).

METHODS

A total of 172 right colon cancer patients (with tumour, node, and metastasis (TNM) stage II and III; mean age of 59.30±14.27 years; 58.1% male, 41.9% female) who had undergone complete mesocolic excision (CME) with D3 lymph node dissection at Nguyen Tri Phuong Hospital, Ho Chi Minh City, Vietnam, were included in this study. They were divided into two groups: group 1 (n=34) without ACT and group 2 (n=138) with ACT. We collected clinical and laboratory data twice (before and after one year of performing laparoscopic surgery). Rates of recurrence and mortality were obtained during a five-year follow-up.

RESULTS

After one year of surgery, the rate of anemia and the increase in serum carcinoembryonic antigen (CEA) levels in group 1 were significantly higher than those in group 2 (p<0.001). After five years of follow-up, the recurrence rate was 11.6% (that of group 1 was 41.2%, which is higher than that of group 2, i.e., 4.3%; p<0.001), and the mortality rate was 8.7% (that of group 1 was 32.4%, which is higher than that of group 2, i.e., 2.9%; p<0.001). Preoperative serum CEA levels were predictive of recurrence and mortality, with an area under the curve (AUC) of 0.729 and 0.805, respectively (p<0.001).

CONCLUSIONS

Laparoscopic CME surgery and D3 lymph node dissection combined with ACT reduced the five-year recurrence and mortality rates for advanced-stage right colon cancer patients.

Laparoscopic surgery for rectal cancer, specimen extraction: transanal or transabdominal?

BACKGROUND

Comparison of natural orifice specimen extraction (NOSE) and transabdominal specimen extraction (TASE) in colorectal surgery remains controversial. Herein, we aimed to perform a retrospective analysis on surgical outcomes of NOSE and TASE at three hospitals in east of Iran.

METHOD

Consecutive locally advanced rectal adenocarcinoma patients who underwent laparoscopic surgery using either NOSE or TASE from 2011 to 2017 were recruited. These patients were followed-up till 2020. Data, including postoperative complications, long-term overall and recurrence-free survival were analyzed retrospectively.

RESULTS

239 eligible patients were included in this study. 169 (70.71%) patients underwent NOSE, and 70 (29.29%) patients underwent TASE. Although this study has achieved similar outcomes in terms of overall and recurrence-free survival, metastasis, circumferential margin involvement as well as complications of intra-operative bleeding, obstruction, anastomosis-fail, rectovaginal-fistula in women and pelvic collection/abscess in both groups, we observed higher rates of locoregional recurrence, incontinency, stenosis and the close distal margins involvement in NOSE group and also obstructed defecation syndrome in TASE cases.

CONCLUSION

According to our findings, NOSE laparoscopic surgery showed significantly higher incontinency, impotency, stenosis and involvement of the close distal margins rates. Nevertheless, considering the similarity of long-term overall and recurrence-free survival, metastasis, circumferential margin involvement, NOSE procedure is still could be considered as a second choice for lower rectal adenocarcinoma patients.

Laparoscopic versus open surgery for colonoscopic perforation: A systematic review and meta-analysis

BACKGROUND

The efficacy of laparoscopic surgery (LS) for the treatment of colonoscopic perforation is still controversial. The purpose of this meta-analysis was to evaluate the effectiveness and safety of LS versus open surgery (OS) for colonoscopic perforation.

METHODS

All clinical trials that compared laparoscopic with OS for colonoscopic perforation published in English were identified in PubMed, EMBASE, Web of Science, and Cochrane Library searches. A modified scale was used to assess the quality of the literature. We analyzed the age, sex ratio, aim of colonoscopy, history of abdominopelvic surgery, type of procedure, size of perforation, operation time, postoperative fasting time, hospital stay, postoperative complication morbidity, and postoperative mortality. Meta-analyses were performed using weighted mean differences for continuous variables, and odds ratios for dichotomous variables.

RESULTS

No eligible randomized trials were identified, but eleven nonrandomized trials were analyzed. In the pooled data of 192 patients who underwent LS and 131 OS, there were no significant differences in age, sex ratio, aim of colonoscopy, history of abdominopelvic surgery, perforation size, and operative time between the groups. LS group had shorter time of hospital stay and postoperative fasting time, less postoperative complication morbidity, but there were no significant difference in postoperative mortality rate between LS group and OS group.

CONCLUSIONS

Based on the current meta-analysis, we conclude that LS is a safe and efficacious technique for colonoscopic perforation, with fewer postoperative complications, less hospital mortality, and faster recovery compared with OS.

Robotic natural orifice specimen extraction surgery versus conventional robotic resection for patients with colorectal neoplasms

Background

Laparoscopic natural orifice specimen extraction surgery (NOSES) has been widely used in colorectal neoplasms. However, only a few studies have focused on robotic NOSES. This study compared the short-term clinical outcomes and long-term survival outcomes between robotic NOSES and conventional robotic resection (CRR) groups.

Methods

From March 2016 to October 2018, a consecutive of 143 patients who underwent robotic sigmoid and rectal resection at the Department of Gastrointestinal Surgery, The Second Xiangya Hospital, Central South University, were considered for inclusion in this study. Propensity-score matching (PSM) was conducted to account for differences in the baseline characteristics. After PSM, 39 patients were included in the robotic NOSES group, and 39 patients in the CRR group. The baseline characteristics between the two groups were all balanced and comparable.

Results

Patients in the NOSES group experienced less intraoperative blood loss (p=0.001), lower requirements for additional analgesia (p=0.020), shorter time to first flatus (p=0.010), and a shorter time to first liquid diet (p=0.003) than the CRR group. The 3-year overall survival rates (NOSES: 92.3% vs. CRR: 89.7% p=1.000) and 3-year disease-free survival rates (NOSES: 82.1% vs. CRR: 84.6% p=0.761) between the two groups were comparable.

Conclusion

Robotic natural orifice specimen extraction surgery is a safe and feasible surgery for patients with colorectal neoplasms. Robotic NOSES is associated with better short-term clinical outcomes and similar long-term survival outcomes to conventional robotic resection.

Short term results in a population based study indicate advantage for laparoscopic colon cancer surgery versus open

The aim of this study was to compare LAP with OPEN regarding short-term mortality, morbidity and completeness of the cancer resection for colon cancer in a routine health care setting using population based register data. All 13,683 patients who were diagnosed 2012-2018 and underwent elective surgery for right-sided or sigmoid colon cancer were included from the Swedish Colorectal Cancer Registry and the National Patient Registry. Primary outcome was 30-day mortality. Secondary outcomes were 90-day mortality, length of hospital stay, reoperation, readmission and positive resection margin (R1). Weighted and unweighted multi regression analyses were performed. There were no difference in 30-day mortality: LAP (0.9%) and OPEN (1.3%) (OR 0.89, 95% CI 0.62-1.29, P = 0.545). The weighted analyses showed an increased 90-day mortality following OPEN, P < 0.001. Re-operations and re-admission were more frequent after OPEN and length of hospital stay was 2.9 days shorter following LAP (P < 0.001). R1 resections were significantly more common in the OPEN group in the unweighted and weighted analysis with P = 0.004 and P < 0.001 respectively. Therefore, the favourable short-term outcomes following elective LAP versus OPEN resection for colon cancer in routine health care indicate an advantage of laparoscopic surgery.

The Extraperitoneal Approach to Left-Sided Colorectal Resections: A Human Cadaveric Study

INTRODUCTION

Technical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position.

METHODS

The technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure.

RESULTS

Eight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures-psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures.

CONCLUSIONS

This novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population.

Outcomes following open versus laparoscopic multi-visceral resection for locally advanced colorectal cancer: A systematic review and meta-analysis

BACKGROUND

This meta-analysis aims to compare morbidity, mortality, oncological safety, and survival outcomes after laparoscopic multi-visceral resection (MVR) of the locally advanced primary colorectal cancer (CRC) compared with open surgery.

MATERIALS AND METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic and open surgery in patients with locally advanced CRC undergoing MVR were selected. The primary endpoints were peri-operative morbidity and mortality. Secondary endpoints were R0 and R1 resection, local and distant disease recurrence, disease-free survival (DFS), and overall survival (OS) rates. RevMan 5.3 was used for data analysis.

RESULTS

Ten comparative observational studies reporting a total of 936 patients undergoing laparoscopic MVR (n = 452) and open surgery (n = 484) were identified. Primary outcome analysis demonstrated a significantly longer operative time in laparoscopic surgery compared with open operations (P = 0.008). However, intra-operative blood loss (P<0.00001) and wound infection (P = 0.05) favoured laparoscopy. Anastomotic leak rate (P = 0.91), intra-abdominal abscess formation (P = 0.40), and mortality rates (P = 0.87) were comparable between the two groups. Moreover the total number of harvested lymph nodes, R0/R1 resections, local/distant disease recurrence, DFS, and OS rates were also comparable between the groups.

CONCLUSION

Although inherent limitations exist with observational studies, the available evidence demonstrates that laparoscopic MVR in locally advanced CRC seems to be a feasible and oncologically safe surgical option in carefully selected cohorts.

Minimally Invasive Compared to Open Colorectal Cancer Resection for Older Adults: A Population-based Analysis of Long-term Functional Outcomes

OBJECTIVE

We sought to compare long-term healthcare dependency and time-at-home between older adults undergoing minimally invasive surgery (MIS) for colorectal cancer (CRC) and those undergoing open resection.

BACKGROUND

Although the benefits of MIS for CRC resection are established, data specific to older adults are lacking. Long-term functional outcomes, central to decision-making in the care for older adults, are unknown.

METHODS

We performed a population-based analysis of patients ≥70years old undergoing CRC resection between 2007 to 2017 using administrative datasets. Outcomes were receipt of homecare and "high" time-at-home, which we defined as years with ≤14 institution-days, in the 5years after surgery. Homecare was analyzed using time-to-event analyses as a recurrent dichotomous outcome with Andersen-Gill multivariable models. High timeat-home was assessed using Cox multivariable models.

RESULTS

Of 16,479 included patients with median follow-up of 4.3 (interquartile range 2.1-7.1) years, 7822 had MIS (47.5%). The MIS group had lower homecare use than the open group with 22.3% versus 31.6% at 6 months and 14.8% versus 19.4% at 1 year [hazard ratio 0.87,95% confidence interval (CI) 0.83-0.92]. The MIS group had higher probability ofhigh time-at-home than open surgery with 54.9% (95% CI 53.6%-56.1%) versus 41.2% (95% CI 40.1%-42.3%) at 5years (hazard ratio 0.71, 95% CI 0.68-0.75).

CONCLUSIONS

Compared to open surgery, MIS for CRC resection was associated with lower homecare needs and higher probability of high time-at-home in the 5 years after surgery, indicating reduced long-term functional dependence. These are important patient-centered endpoints reflecting the overall long-term treatment burden to be taken into consideration in decision-making.

Is fascial closure required for a 12-mm trocar? A comparative study on trocar site hernia with long-term follow up

BACKGROUND

Despite the infrequency of trocar site hernias (TSHs), fascial closure continues to be recommended for their prevention when using a ≥ 10-mm trocar.

AIM

To identify the necessity of fascial closure for a 12-mm nonbladed trocar incision in minimally invasive colorectal surgeries.

METHODS

Between July 2010 and December 2018, all patients who underwent minimally invasive colorectal surgery at the Minimally Invasive Surgery Unit of Siriraj Hospital were retrospectively reviewed. All patients underwent cross-sectional imaging for TSH assessment. Clinicopathological characteristics were recorded. Incidence rates of TSH and postoperative results were analyzed.

RESULTS

Of the 254 patients included, 70 (111 ports) were in the fascial closure (closed) group and 184 (279 ports) were in the nonfascial closure (open) group. The median follow up duration was 43 mo. During follow up, three patients in the open group developed TSHs, whereas none in the closed group developed the condition (1.1% vs 0%, P = 0.561). All TSHs occurred in the right lower abdomen. Patients whose drains were placed through the same incision had higher rates of TSHs compared with those without the drain. The open group had a significantly shorter operative time and lower blood loss than the closed group.

CONCLUSION

Routine performance of fascial closure when using a 12-mm nonbladed trocar may not be needed. However, further prospective studies with cross-sectional imaging follow-up and larger sample size are needed to confirm this finding.

Oncologic safety of colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction: Current evidence and prospects

Approximately 7%-29% of patients with colorectal cancer present with colonic obstruction. The concept of self-expandable metal stent (SEMS) insertion as a bridge to surgery (BTS) is appealing. However, concerns on colonic stenting possibly impairing oncologic outcomes have been raised. This study aimed to review current evidence on the short- and long-term oncologic outcomes of SEMS insertion as BTS for left-sided malignant colonic obstruction. For short-term outcomes, colonic stenting facilitates a laparoscopic approach, increases the likelihood of primary anastomosis without a stoma, and may decrease postoperative morbidity. However, SEMS-related perforation also increases local recurrence and impairs overall survival. Moreover, colonic stenting may cause negative oncologic outcomes even without perforation. SEMS can induce shear forces on the tumor, leading to increased circulating cancer cells and aggressive pathological characteristics, including perineural and lymphovascular invasion. The conflicting evidence has led to discordant guidelines. Well-designed collaborative studies that integrate both oncologic outcomes and data on basic research (e.g., alteration of circulating tumors) are needed to clarify the actual benefit of colonic stenting as BTS.

Time trends in the incidence rates of venous thromboembolism following colorectal resection by indication and operative technique

AIM

It is important for patient safety to assess if international changes in perioperative care, such as the focus on venous thromboembolism (VTE) prevention and minimally invasive surgery, have reduced the high post colectomy VTE risks previously reported. This study assesses the impact of changes in perioperative care on VTE risk following colorectal resection.

METHOD

This was a population-based cohort study of colectomy patients in England between 2000 and 2019 using a national database of linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Within 30 days following colectomy, absolute VTE rates per 1000 person-years and adjusted incidence rate ratios (aIRRs) using Poisson regression for the per year change in VTE risk were calculated.

RESULTS

Of 183 791 patients, 1337 (0.73%) developed 30-day postoperative VTE. Overall, VTE rates reduced over the 20-year study period following elective (relative risk reduction 31.25%, 95% CI 5.69%-49.88%) but not emergency surgery. Similarly, yearly changes in VTE risk reduced following minimally invasive resections (elective benign, aIRR 0.93, 95% CI 0.90-0.97; elective malignant, aIRR 0.94, 95% CI 0.91-0.98; and emergency benign, aIRR 0.96, 95% CI 0.92-1.00) but not following open resections. There was a per year VTE risk increase following open emergency malignant resections (aIRR 1.02, 95% CI 1.00-1.04).

CONCLUSION

Yearly VTE risks reduced following minimally invasive surgeries in the elective setting yet in contrast were static following open elective colectomies, and following emergency malignant resections increased by almost 2% per year. To reduce VTE risk, further efforts are required to implement advances in surgical care for those having emergency and/or open surgery.

Factors influencing acceptance, adoption and adherence to sentinel node biopsy recommendations in the Australian Melanoma Management Guidelines: a qualitative study using an implementation science framework

BACKGROUND

Sentinel node biopsy (SN biopsy) is a surgical procedure used to accurately stage patients with primary melanoma at high risk of recurrence. Although Australian Melanoma Management Guidelines recommend SN biopsy be considered in patients with melanomas > 1 mm thick, SN biopsy rates in Australia are reportedly low. Our objective was to identify factors impacting the acceptance, adoption and adherence to the Australian SN biopsy guideline recommendations.

METHODS

Opinions of Australian key informants including clinicians, representatives from melanoma education and training providers, professional associations and colleges, and melanoma advocacy organisations were collected through semi-structured interviews (n = 29) and from publicly released statements (n = 14 news articles). Data analysis involved inductive and deductive thematic analysis using Flottorp's determinants framework.

RESULTS

A complex interplay of contemporary and historical factors was identified as influencing acceptance, adoption and adherence to the SN biopsy guideline recommendations at the individual, guideline, patient, organisational and social levels. Expert and peer opinion leaders have played an important role in facilitating or inhibiting adoption of guideline recommendations, as have financial incentives driven by healthcare-funding policies and non-financial incentives including professional identity and standing. Of critical importance have been the social and knowledge boundaries that exist between different professional groups to whom the guidelines apply (surgeons, dermatologists and primary care practitioners) with adherence to the guideline recommendations having the potential to shift work across professional boundaries, altering a clinician's workflow and revenue. More recently, the emergence of effective immunotherapies and targeted therapies for patients at high risk of recurrence, the emergence of new opinion leaders on the topic (in medical oncology), and patient demands for accurate staging are playing crucial roles in overcoming the resistance to change created by these social and knowledge boundaries.

CONCLUSIONS

Acceptance and adherence to SN biopsy guideline recommendations in Australia over the past 20 years has involved a process of renegotiation and reframing of the evidence for SN biopsy in melanoma by clinicians from different professional groups and networks. This process has helped to refine the evidence for SN biopsy and our understanding of appropriate adoption. New effective systemic therapies have changed the balance towards accepting guideline recommendations.

Minimally invasive hepatopancreatic and biliary surgery in children: a large centre experience and review of the literature

BACKGROUND

Minimally invasive surgery (MIS) for hepatopancreatic and biliary (HPB) diseases has been widely used in adults, while in children, its application is limited due to its complexity. Herein, we report the experience of MIS for paediatric HPB diseases and literature review.

METHODS

All children (≤18 years-old) undergoing major HPB operations by MIS during January 2017-June 2020 in our institution were prospectively enrolled.

RESULTS

Out of 139 children operated on for HPB diseases with MIS, 26 (18.7%) patients (age: 11 (1-17) years-old; weight: 41.9 (10.7-75.5) kg) underwent major HPB surgery, including 11 pancreatic resections and 15 liver resections, all performed by a full-laparoscopic-technique. Four (15.3%) surgeries were electively converted to an open-technique for safer operative management. None required a blood transfusion. The median hospital admission was 6 days. Post-operatively, all patients had early mobilization and good recovery. Two (7.7%) patients experienced post-operative complications requiring radiological intervention. Oncological radical resection (R0) was achieved in all tumours, and after 2 years, all children were free of tumour recurrence.

CONCLUSION

MIS for HPB surgery is safe and feasible in children, with less surgical trauma, short hospital-stay and better aesthetic results. An adequate learning curve in specialized centres is essential for good outcomes.

Preliminary results of a program for the implementation of laparoscopic colorectal surgery in an Italian comprehensive cancer center during the COVID-19 pandemic

Despite operative benefit and oncological non-inferiority, videolaparoscopic (VLS) colorectal surgery is still relatively underutilized. This study analyzes the results of a program for the implementation of VLS colorectal surgery started in an Italian comprehensive cancer center shortly before COVID-19 outbreak. A prospective database was reviewed. The study period was divided in four phases: Phase-1 (Open surgery), Phase-2 (Discretional phase), Phase-3 (VLS implementation phase), and Phase-4 (VLS consolidation phase). Formal surgical and perioperative protocols were adopted from Phase-3. Postoperative complications were scored by the Clavien–Dindo classification. 414 surgical procedures were performed during Phase-1, 348 during Phase-2, 360 during Phase-3, and 325 during Phase-4. In the four phases, VLS primary colorectal resections increased from 11/214 (5.1%), to 55/163 (33.7%), 85/151 (57.0%), and 109/147 (74.1%), respectively. The difference was statistically significant (P < 0.001). All-type VLS procedures were 16 (3.5%), 61 (16.2%), 103 (27.0%), and 126 (38.6%) (P < 0.001). Conversions to open surgery of attempted laparoscopic colorectal resections were 17/278 in the overall series (6.1%), and 12/207 during Phase-3 and Phase-4 (4.3%). Severe (grades IIIb-to-V) postoperative complications of VLS colorectal resections were 9.1% in Phase-1, 12.7% in Phase-2, 12.8% in Phase-3, and 5.3% in Phase-4 (P = 0.677), with no significant differences with open resections in each of the four phases: 9.4% (P = 0.976), 11.1% (P = 0.799), 13.8% (P = 1.000), and 8.3% (P = 0.729). Despite the difficulties deriving from the COVID-19 outbreak, our experience suggests that volume of laparoscopic colorectal surgery can be significantly and safely increased in a specialized surgical unit by means of strict operative protocols.

Goal-Directed Fluid Therapy Enhances Gastrointestinal Recovery after Laparoscopic Surgery: A Systematic Review and Meta-Analysis

(1) Background: Whether goal-directed fluid therapy (GDFT) provides any outcome benefit as compared to non-goal-directed fluid therapy (N-GDFT) in elective abdominal laparoscopic surgery has not been determined yet. (2) Methods: A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, Web of Science, and Scopus. The main outcomes were length of hospital stay (LOHS), time to first flatus and stool, intraoperative fluid and vasopressor requirements, serum lactate levels, and urinary output. Pooled risks ratios (RRs) with 95% confidence intervals (CI) were calculated for dichotomous outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. (3) Results: Eleven studies were included in the quantitative, and fifteen in the qualitative synthesis. LOHS (WMD: −1.18 days, 95% CI: −1.84 to −0.53) and time to first stool (WMD: −9.8 h; CI −12.7 to −7.0) were significantly shorter in the GDFT group. GDFT resulted in significantly less intraoperative fluid administration (WMD: −441 mL, 95% CI: −790 to −92) and lower lactate levels at the end of the operation: WMD: −0.25 mmol L−1; 95% CI: −0.36 to −0.14. (4) Conclusions: GDFT resulted in enhanced recovery of the gastrointestinal function and shorter LOHS as compared to N-GDFT.

Consecutive Laparoscopic Colorectal Resections in a Single Workday by the Same Surgeon: Efficient or Risky?

Background: As laparoscopic colorectal surgery (LCS) continues increasing worldwide, surgeons may need to perform more than one LCS per day to accommodate this higher demand. We aimed to determine the safety of performing consecutive LCSs by the same surgeon in a single workday. Materials and Methods: Consecutive LCSs performed by the same surgeon from 2006 to 2019 were included. The sample was divided into two groups: patients who underwent the first (G1) and those who underwent the second and the third (G2) colorectal resections in a single workday. LCSs were stratified into level I (low complexity), level II (medium complexity), and level III (high complexity). Demographics, operative variables, and postoperative outcomes were compared between groups. Results: From a total of 1433 LCSs, 142 (10%) were included in G1 and 158 (11%) in G2. There was a higher rate of complexity level III LCS (G1: 23% versus G2: 6%, P < .0001) and a longer operative time (G1: 160 minutes versus G2: 139 minutes, P = .002) in G1. There were no differences in anastomotic leak, overall morbidity, or mortality rates. Mean length of hospital stay and readmission rates were similar between groups. Conclusion: Multiple consecutive laparoscopic colorectal resections can be safely performed by the same surgeon in a single workday. This efficient strategy should be encouraged at high-volume centers with experienced colorectal surgeons.

OUP accepted manuscript

Background

Natural orifice specimen extraction (NOSE) is a technique that involves collecting a specimen for extraction through a natural opening avoiding a mini-laparotomy incision. The aim of this study was to compare NOSE and transabdominal specimen extraction in laparoscopic (LAP) colorectal cancer surgery for postoperative outcomes and oncological safety.

Method

A systematic search was conducted in five electronic databases from inception till October 2020. Articles were selected based on the inclusion criteria (studies comparing LAP and NOSE colorectal surgeries reporting at least one of the outcomes) and analysed. Primary outcomes included postoperative complications, pathological results (resection margins and lymph node collection), and oncological outcomes. Secondary outcomes included operating time, blood losses, use of analgesics, functional recovery, duration of hospital stay, and cosmetic results. Fixed and random-effect models were used to measure the pooled estimates.

Results

Nineteen studies involving a total of 3432 participants were analysed (3 randomized clinical trials (RCTs) and 16 retrospective non-randomized studies). Pooled results showed significantly reduced postoperative complications (OR 0.54; 95 per cent c.i. 0.44 to 0.67; P < 0.00001). Pathological outcomes of NOSE were comparable to LAP with no significant difference noted in terms of resection margins (P > 0.05) and lymph node collection (weighted mean difference (WMD) −0.47; 95 per cent c.i. −0.94 to 0; P = 0.05). Pooled analysis demonstrated comparable long-term outcomes in terms of cancer recurrence (OR 0.94; 95 per cent c.i. 0.63 to 1.39; P = 0.75), 5-year disease-free survival (HR 0.97; 95 per cent c.i. 0.73 to 1.29; P = 0.83), and overall survival (HR 0.93, 95 per cent c.i. 0.58 to −1.51; P = 0.78). Finally, the NOSE group had decreased use of additional analgesia after surgery and earlier resumption of oral intake when compared with LAP (respectively OR 0.28; 95 per cent c.i. 0.20 to 0.37; P < 0.00001 and WMD −0.35; 95 per cent c.i. −0.54 to −0.15; P = 0.0005).

Conclusion

This meta-analysis showed that in comparison with LAP, NOSE decreases severe postoperative morbidity while improving postoperative recovery without compromising oncological safety, but it is limited by the small number of RCTs performed in this field.

Potential considerations in decision making on laparoscopic colorectal resections in Hungary based on administrative data

Background

Laparoscopic colorectal surgeries offer numerous advantages over their open counterparts. To compare these measurable short-time outcomes of open and laparoscopic resections in Hungary, data of colorectal surgeries were collected and analysed. The study focused on identifying patients’ characteristics that can influence the decision on laparoscopic colorectal resections and on comparing efficiency of Hungarian colorectal operations with international data.

Methods

Using patients’ data of laparoscopic and open colorectal surgery performed in 2015 and 2016 from the National Health Insurance Fund of Hungary, a countrywide retrospective comparative analysis was done. Logistic regression was used to explore main influencing factors for laparoscopic colorectal surgery.

Results

A total of 17,876 colorectal surgical cases, including 14,876 open and 3,000 laparoscopic resections were selected and analysed. Laparoscopy was used only in 16.78% of all cases. Comparison of age groups showed that odds ratio (OR) of laparoscopic colorectal resections was significantly lower in over 40 years than in younger patients (18–39 years). In university institutes patients had higher odds (OR: 2.23 p<0.0001) for laparoscopic colorectal resections. Presence of comorbidity codes and preoperative treatment in internal medicine department decreased odds for laparoscopic colorectal operations.

Conclusions

Patients’ age, comorbidities and hospital type influenced the likelihood of decision on laparoscopic colorectal resection. Selection of patients contributed to improved laparoscopic outcomes.

2D vs 3D laparoscopic right colectomy: A propensity score-matching comparison of personal experience with systematic review and meta-analysis

BACKGROUND

The benefits of laparoscopic approach for right colectomy have been well established. However, the technical difficulty to construct the intra-corporeal anastomosis is still cumbersome.

AIM

To analyze the results of 3D and 2D laparoscopic right colectomy and to compare it to the published series through a systematic review and meta-analysis.

METHODS

A retrospective study with propensity score matching analysis of patients undergoing laparoscopic right colectomy at Umbria2 Hospitals from January 2014 to March 2020 was performed. A systematic review was accomplished comparing 2D and 3D right colectomy.

RESULTS

In the personal series 47 patients of the 2D group were matched to 47 patients of the 3D group. The 3D group showed a favorable trend in terms of mean operative time (170.7 ± 32.9 min vs 183.8 ± 35.4 min; P = 0.053) and a significant lower anastomotic time (16.9 ± 2.3 min vs 19.6 ± 2.9 min, P < 0.001). The complete mesocolic excision (CME) subgroups analysis showed a shorter anastomotic time (16.5 ± 1.8 min vs 19.9 ± 3.0 min; P < 0.001) and operative time (175.0 ± 38.5 min vs 193.7 ± 37.1 min; P = 0.063) in the 3D group. Six studies and our series were included in the meta-analysis with 551 patients (2D group: 291; 3D group: 260).The pooled analysis demonstrated a significant difference in favour of the 3D group regarding the operative time (P < 0.001) and the anastomotic time (P < 0.001) while no differences were identified between groups in terms of blood loss (P = 0.827), LNH yield (P = 0.243), time to first flatus (P = 0.333), postoperative complications (P = 0.718) and length of stay (P = 0.835).

CONCLUSION

The meta-analysis results showed that 3D laparoscopic right colectomy shortens operative and anastomotic time without affecting the standard lymphadenectomy. In our series, the advantage of the 3D system becomes evident when CME and/or more complex associated procedure are requested significantly reducing both the total operative and the anastomotic time.

Postoperative Complications Associated With Intra- Versus Extracorporeal Anastomosis for Laparoscopic Right Colectomy

OBJECTIVE

To compare the postoperative complications of intracorporeal anastomosis (ICA) and extracorporeal anastomosis (ECA) in patients undergoing laparoscopic right colectomy (LRC).

BACKGROUND

Although several studies have compared postoperative complications of ICA and ECA after LRC, most were retrospective studies.

METHODS

We performed a comprehensive electronic search of the literature to identify studies that compared postoperative complications between ICA and ECA in patients who underwent LRC. We performed meta-analysis using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI) of experiencing complications, and we analyzed heterogeneity using I² statistics.

RESULTS

Fifteen studies consist of randomized controlled trials, case-control studies, and propensity score matching studies involving a total of 3219 patients who underwent LRC were included. Among 1377 patients who received ICA, 255 (18.5%) had postoperative complications, whereas among 1652 patients who received ECA, 373 (22.6%) had such complications. The results of the meta-analysis revealed that ICA was associated with a significantly reduced risk of postoperative complications (RR, .73; 95% CI: .57-.95; P = .02; I² = 57%) compared with ECA. Although there was no significant difference between the 2 groups in risk of anastomotic leakage (RR, .67; 95% CI: .39-1.17; P = .16; I² = 8%), there was a significant difference between them in risk of surgical site infection (RR, .50; 95% CI: .34-.71; P = .0002; I² = 0%).

CONCLUSIONS

Intracorporeal anastomosis is associated with a reduced risk of postoperative complications compared with ECA in patients undergoing LRC.

Urogenital function following robotic and laparoscopic rectal cancer surgery: meta-analysis

BACKGROUND

Mixed results are reported on clinical and cancer outcomes in laparoscopic rectal cancer surgery (LRCS) compared with robotic rectal cancer surgery (RRCS). However, more favourable functional outcomes are reported following RRCS. This study compared urinary and sexual function following RRCS and LRCS in male and female patients.

METHODS

A systematic review and meta-analysis of urinary and sexual function after RRCS and LRCS was performed following PRISMA and MOOSE guidelines, and registered prospectively with PROSPERO (ID:CRD42020164285). The functional outcome reporting tools most commonly included: the International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) and Female Sexual Function Index (FSFI). Mean scores and changes in mean scores from baseline were analysed using RevMan version 5.3.

RESULTS

Ten studies were included reporting on 1286 patients. Some 672 patients underwent LRCS, of whom 380 (56.5 per cent) were men and 116 (17.3 per cent) were women (gender not specified in 176 patients, 26.2 per cent). A total of 614 patients underwent RRCS, of whom 356 (58.0 per cent) were men and 83 (13.5 per cent) were women (gender not specified in 175 patients, 28.5 per cent). Regarding urinary function in men at 6 months after surgery, IPSS scores were significantly better in the RRCS group than in the LRCS group (mean difference (MD) -1.36, 95 per cent c.i. -2.31 to -0.40; P = 0.005), a trend that persisted at 12 months (MD -1.08, -1.85 to -0.30; P = 0.007). ΔIIEF scores significantly favoured RRCS at 6 months [MD -3.11 (95%CI -5.77, -0.44) P <0.021] and 12 months [MD -2.76 (95%CI -3.63, -1.88) P <0.001] post-operatively. Mixed urinary and sexual function outcomes were reported for women.

CONCLUSION

This meta-analysis identified more favourable urinary and erectile function in men who undergo robotic compared with conventional laparoscopic surgery for rectal cancer. Outcomes in women did not identify a consistently more favourable outcome in either group. As robotic rectal cancer surgery may offer more favourable functional outcomes it should be considered and discussed with patients.

Robotic versus laparoscopic anterior resections for rectal and rectosigmoid cancer: an institutional experience

INTRODUCTION

Colorectal surgery has evolved with the advent of laparoscopic techniques and now robotic-assisted surgery. There is significant literature supporting the use of laparoscopic techniques over open surgery with evidence of enhanced post-operative recovery, reduced use of opioids, smaller incisions and equivalent oncological outcomes. Robotic minimally invasive surgery addresses some of the limitations of laparoscopic surgery, providing surgical precision and improvements in perception and dexterity with a resulting decrease in tissue damage.

METHODS

We retrospectively reviewed the medical records of patients who underwent robotic-assisted anterior resection for cancer of the rectum or rectosigmoid junction in our institution since our robotic programme began in 2017. Patient demographics were identified via electronic databases and patient charts. A matched cohort of laparoscopic cases was identified.

RESULTS

A total of 51 consecutive robotic-assisted anterior resections were identified and case matched with laparoscopic resections for comparison. Robotic-assisted surgery was associated with a shorter length of stay (p = 0.04), reduced initial post-operative analgesia requirements (p < 0.01) and no significant difference in time to bowel movement or stoma functioning (p = 0.84). All patients had an R0 resection, and there was no statistical difference in lymph node yield between the groups (p = 0.14). Robotic surgery was associated with a longer operative duration (p < 0.001).

CONCLUSION

In this early experience, robotic surgery has proven feasible and safe and is comparable to laparoscopic surgery in terms of completeness of resection and recovery. As costs and operating times decline and as technology progresses, robotic surgery may one day replace traditional laparoscopic techniques.

Safe Introduction of New Technologies and Techniques in Minimally Invasive Colorectal Surgery

In the past 20 years, colorectal surgery has experienced important advances as a result of new technologies that have increasingly transformed conventional open surgery into maximal usage of minimally invasive approaches. While many tools are being developed to change the way that operations are being performed, quality must not suffer. We describe here some of the aspects to pursue to achieve optimal and safe outcomes while utilizing minimally invasive techniques such as robotic surgery, transanal total mesorectal excision, as well as the role of immunofluorescence.

Laparoscopic vs open surgery during the COVID-19 pandemic: what are the risks?

INTRODUCTION

The initial intercollegiate surgical guidance from the UK during the COVID-19 pandemic resulted in significant changes to practice. Avoidance of laparoscopy was recommended, to reduce aerosol generation and risk of virus transmission. Evidence on the safety profile of laparoscopy during the pandemic is lacking. This study compares patient outcomes and risk to staff from laparoscopic and open gastrointestinal operations during the COVID-19 pandemic.

METHODS

Single-centre retrospective study of gastrointestinal operations performed during the peak of the COVID-19 pandemic. Demographic, comorbidity, perioperative and survival data were collected from electronic medical records and supplemented with patient symptoms reported at telephone follow up. Outcomes assessed were: patient mortality, illness among staff, patient COVID-19 rates, length of hospital stay and postdischarge symptomatology.

RESULTS

A total of 73 patients with median age of 56 years were included; 55 (75%) and 18 (25%) underwent laparoscopic and open surgery, respectively. All-cause mortality was 5% (4/73), was related to COVID-19 in all cases, with no mortality after laparoscopic surgery. A total of 14 staff members developed COVID-19 symptoms within 2 weeks, with no significant difference between laparoscopic and open surgery (10 vs 4; p=0.331). Median length of stay was shorter in the laparoscopic versus the open group (4.5 vs 9.9 days; p=0.011), and postdischarge symptomatology across 15 symptoms was similar between groups (p=0.135-0.814).

CONCLUSIONS

With appropriate protective measures, laparoscopic surgery is safe for patients and staff during the COVID-19 pandemic. The laparoscopic approach maintains an advantage of shorter length of hospital stay compared with open surgery.

Impact of anastomotic leakage on postoperative survival of patients with colorectal cancer: A meta-analysis using propensity score matching studies

OBJECTIVE

To explore the influence of anastomotic leakage (AL) on postoperative survival in patients with colorectal cancer (CRC).

BACKGROUND

Although several studies have compared the postoperative survival of patients with CRC with and without AL, the background characteristics of the two groups were not aligned in most studies.

METHODS

We performed a comprehensive electronic search of the literature up to March 2020 to identify propensity score matching (PSM) studies that compared postoperative survival between CRC patients with and without AL. A meta-analysis was performed using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI), and heterogeneity was analyzed using I (Akiyoshi et al., 2011) [2] statistics.

RESULTS

Four PSM studies involving a total of 1676 patients with CRC undergoing surgery were included in this meta-analysis. Among 234 patients who had AL, 163 (69.7%) survived at 5 years after surgery, whereas among 1422 patients who did not have AL, 1156 (81.3%) survived at 5 years after surgery. Background characteristics of the two groups were adjusted with PSM in all 4 studies. The result of the meta-analysis revealed a significant difference between the two groups (RR, 1.63; 95% CI, 1.09-2.45; P = 0.02; I² = 66%) in 5-year overall survival (OS).

CONCLUSIONS

The results of this meta-analysis demonstrate a significantly decreased 5-year OS in patients with CRC who had AL compared with patients with CRC who did not have AL.

A tailored approach to abdominoperineal resection for rectal cancer: multicentre analysis of short-term outcomes and impact on oncological survival

PURPOSE

Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach.

METHODS

This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures.

RESULTS

A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively.

CONCLUSION

Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.

Training for laparoscopic colorectal surgery creating an appropriate porcine model and curriculum for training

Background

Laparoscopic colorectal surgery (LCRS) was first described in 1991, and its safety, efficacy and patient benefit were adequately documented in literature. However, its penetration and acceptability is poor in most countries, due to its long learning curve and lack of surgeons training and confidence. A Minimal Access Surgery (MAS) Training Center in Mumbai has over the last 7 years trained more than 8000 surgeons in various MAS specialities. The centre has initiated courses for LCRS training.

Materials and Methods

The anatomy of the pig colon is very different from human anatomy. The pig colon anatomy is altered to mimic human colon anatomy in the porcine abdomen, permitting hands-on practice on most laparoscopic colorectal surgical procedures, as part of the LCRS training course, under mentorship of expert faculty, who simultaneously assess participants performance.

Results

Each participant performs and assists for at least three procedures and is evaluated at each step of the procedure by a structured format. The overall evaluation by Faculty which though subjective, is detailed and favourable. Feedback of each participant is good and acceptable as a very helpful course.

Conclusion

This porcine model is ideal for hands-on training for LCRS. Participants achieve a good degree of skill level and confidence in performing LCRS procedures on fresh bleeding porcine cadaver models. The centre is factual and pragmatic and stresses that it needs more than a course to make a safe surgeon; operation room mentorship is the finishing school.

Clinical-Pathologic Characteristics and Long-term Outcomes of Left Flexure Colonic Cancer: A Retrospective Analysis of an International Multicenter Cohort

BACKGROUND

Colorectal cancer seldom presents at the splenic flexure. Small series on left flexure tumors reported a high occurrence of negative prognostic factors called into question as causes of poor prognosis. However, because of the small number of cases, no definite conclusions can be drawn.

OBJECTIVE

The aim of this study was to compare clinical-pathologic characteristics and short- and long-term outcomes of left flexure tumors with other colonic locations.

DESIGN

This was a retrospective analysis of consecutive patients who underwent surgery for tumors at the splenic flexure. Each tumor was paired in a 1 to 1 fashion with a right-sided and sigmoid tumor.

SETTINGS

The study was conducted in 10 international centers.

PATIENTS

A total of 641 patients with left flexure tumors were included in the study.

MAIN OUTCOME MEASURES

Overall survival and cancer-specific survival were measured.

RESULTS

Left flexure tumors presented more frequently with stenosis (30.5%; p < 0.001), with lesions infiltrating beyond the serosa (21.9%; p = 0.001) and with a high rate of mucinous histology (8.8%; p = 0.001). Looking at long-term prognosis, no differences were observed among the 3 groups, both considering overall and cancer-specific survival. However, left flexure tumors recurred more frequently as peritoneal carcinomatosis (20.6%; p < 0.001).

LIMITATIONS

This study was limited because of its retrospective nature.

CONCLUSIONS

Although left flexure tumors display several negative prognostic factors, they are not characterized by a worse prognosis compared with other colon cancer locations. See Video Abstract at http://links.lww.com/DCR/B395. CARACTERÍSTICAS CLÍNICO-PATOLÓGICAS Y RESULTADOS A LARGO PLAZO DEL CÁNCER DE COLON DE ÁNGULO IZQUIERDO: UN ANÁLISIS RETROSPECTIVO DE UNA COHORTE MULTICÉNTRICA INTERNACIONAL: El cáncer colorrectal rara vez se presenta en el ángulo esplénico. Pequeñas series sobre tumores de ángulo izquierdo informaron una alta incidencia de factores pronósticos negativos cuestionados como causas de mal pronóstico. Sin embargo, debido al pequeño número de casos, no se pueden sacar conclusiones definitivas.El objetivo de este estudio fue comparar las características clínico-patológicas, los resultados a corto y largo plazo de los tumores de ángulo izquierdo con otras ubicaciones de colon.Análisis retrospectivo de pacientes consecutivos que se sometieron a cirugía por tumores en el ángulo esplénico. Cada tumor se emparejó de forma individual con un tumor del lado derecho y sigmoide.El estudio se realizó en 10 centros internacionales.Se incluyeron en el estudio un total de 641 pacientes con tumores del ángulo izquierdo.Supervivencia general y específica del cáncerLos tumores de ángulo izquierda se presentaron con mayor frecuencia con estenosis (30.5%, p <0.001), con lesiones infiltradas más allá de la serosa (21.9%, p = 0.001), y con una alta tasa de histología mucinosa (8.8%, p = 0.001). En cuanto al pronóstico a largo plazo, no se observaron diferencias entre los tres grupos, considerando la supervivencia general y específica del cáncer. Sin embargo, los tumores de ángulo izquierdo recurrieron con mayor frecuencia como carcinomatosis peritoneal (20,6%; p <0,001).Este estudio fue limitado debido a su naturaleza retrospectiva.Aunque los tumores de ángulo izquierdo muestran varios factores pronósticos negativos, no se caracterizan por un peor pronóstico en comparación con otras ubicaciones de cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B395.

Feasibility and Safety of Laparoscopic Radical Colectomy for T4b Colon Cancer at a University Hospital in Vietnam

BACKGROUND

The choice of optimal treatment strategies for T4b colon cancers has still been discussed, particularly the initiation of neoadjuvant therapy or surgery. We conducted this study to evaluate the safety and feasibility of laparoscopic multivisceral resection for T4b colon cancers.

METHODS

We used the retrospective design to include all 43 patients with T4b colon cancer at a university hospital in Vietnam from March 2017 to March 2019. All patients were followed 30 days after the surgery, and information about the day of the first flatus, length of hospital stay, iatrogenic complications, postoperative morbidity, mortality, and adjuvant chemotherapy was collected.

RESULTS

The mean operating time was 187 minutes (ranging from 80 to 310), the mean blood loss was 64.3 ml (5-200), and the conversion rate was 2.3%. The mean number of lymph nodes harvested was 15.5 (SD = 8.06), and 33 patients (76.7%) had at least 12 lymph nodes harvested. A total of 21 patients (48.8%) had lymph node metastases with a mean number of lymph node metastases of 1.89 (SD = 3.4). The radial resection margin was R0 in all 43 patients (100%). The median time until the first flatus and hospital stay were 3 days (2-5) and 7.1 (6-11) days, respectively. There was no mortality at 30 days postoperatively, and one patient had iatrogenic complication (2.3%).

CONCLUSION

Laparoscopic radical colectomy was feasible and safe for patients with T4b colon cancer except those requiring major and complicated reconstruction.

A Paradigm Shift in Physician Reimbursement: A Model to Align Reimbursement to Value in Laparoscopic Colorectal Surgery in the United States

BACKGROUND

Despite common beliefs, underuse of laparoscopic colorectal surgery remains an issue. A paradigm shift to increase laparoscopy and align payment with effort is needed, with pressures to improve value.

OBJECTIVE

The purpose of this study was to compare reimbursement across surgical approach and payer for common colorectal procedures and to propose a novel way to increase use in the United States.

DATA SOURCES

Centers for Medicare & Medicaid Services (Medicare) reimbursement and commercial claims data from 2012 to 2015 were used.

STUDY SELECTION

Reimbursement across payers was mapped for the 10 most common colorectal procedures using the open and laparoscopic approaches.

MAIN OUTCOME MEASURES

The reimbursement difference across approaches by payer and potential value proposition from a cost-shifting model increasing reimbursement with corresponding increases in laparoscopic use was measured.

RESULTS

For Medicare, reimbursement was lower laparoscopically than open for the majority. With commercial, laparoscopy was reimbursed less for 3 procedures. When laparoscopic reimbursement was higher, the amount was not substantial. Medicare payments were consistently lower than commercial, with corresponding lower reimbursement for laparoscopy. Increasing reimbursement by 10%, 20%, and 30% resulted in significant cost savings with laparoscopy. Savings were amplified with increasing use, with additional savings over baseline at all levels, except 30% reimbursement/10% increased use.

LIMITATIONS

The study was limited by the use of claims data, which could have coding errors and confounding in the case mix across approaches.

CONCLUSIONS

Reimbursement for laparoscopic colorectal surgery is comparatively lower than open. Reimbursement can be increased with significant overall cost savings, as the reimbursement/case is still less than total cost savings with laparoscopy compared with open cases. Incentivizing surgeons toward laparoscopy could drive use and improve outcomes, cost, and quality as we shift to value-based payment. See Video Abstract at http://links.lww.com/DCR/B290. CAMBIOS EN LOS PARADIGMAS DE REEMBOLSOS MÉDICOS: UN MODELO PARA ALINEAR EL REEMBOLSO AL VALOR REAL DE LA CIRUGÍA COLORRECTAL LAPAROSCÓPICA EN LOS ESTADOS UNIDOS: A pesar de las creencias comunes, la subutilización de la cirugía colorrectal laparoscópica sigue siendo un problema. Se necesita un cambio en los paradigmas para aumentar y alinear el rembolso de la laparoscopia aplicando mucho esfuerzo para obtener una mejoría en su valor real.Comparar los reembolsos del abordaje quirúrgico y los de la administración para procedimientos colorrectales comunes y proponer una nueva forma de aumentar su uso en los Estados Unidos.Reembolsos en los Centros de Servicios de Medicare y Medicaid (Medicare) y los datos de reclamos comerciales encontrados de 2012-2015.El reembolso administrativo se mapeó para los diez procedimientos colorrectales más comunes utilizando los enfoques abiertos y laparoscópicos.Diferencias de reembolso entre los enfoques por parte de la administración y la propuesta de valor real de un modelo de cambio de costos que aumentan el reembolso con los aumentos correspondientes si se utiliza la laparoscopía.Para Medicare, el reembolso fue menor para una mayoría por vía laparoscópica que abierta. Comercialmente, la laparoscopia se reembolsó menos por 3 procedimientos. Cuando el reembolso laparoscópico fue mayor, la cantidad no fue sustancial. Los pagos de Medicare fueron consistentemente más bajos que los pagos comerciales, con el correspondiente reembolso más bajo por laparoscopia. El aumento del reembolso en un 10%, 20% y 30% resultó en ahorros de costos significativos con la laparoscopía. Los ahorros se amplificaron con el aumento de la utilización, con ahorros adicionales sobre la línea de base en todos los niveles, excepto el 30% de reembolso / 10% de mayor uso.Uso de datos de reclamos, que podrían tener errores de codificación y confusión en la combinación de casos entre enfoques.El reembolso por la cirugía colorrectal laparoscópica es comparativamente más bajo que el abordaje abierto. El reembolso se puede aumentar con ahorros significativos en los costos generales, ya que el reembolso / caso es aún menor que el ahorro total en los costos de la laparoscopia en comparación con los casos abiertos. Incentivar a los cirujanos hacia la laparoscopía podría impulsar la utilización y mejorar los resultados, el costo y la calidad a medida que se pasa al pago basado en el valor real. Consulte Video Resumen en http://links.lww.com/DCR/B290. (Traducción-Dr Xavier Delgadillo).

Value of the surgeon's sightline on hologram registration and targeting in mixed reality

Purpose

Mixed reality (MR) is being evaluated as a visual tool for surgical navigation. Current literature presents unclear results on intraoperative accuracy using the Microsoft HoloLens 1^®. This study aims to assess the impact of the surgeon’s sightline in an inside-out marker-based MR navigation system for open surgery.

Methods

Surgeons at Akershus University Hospital tested this system. A custom-made phantom was used, containing 18 wire target crosses within its inner walls. A CT scan was obtained in order to segment all wire targets into a single 3D-model (hologram). An in-house software application (CTrue), developed for the Microsoft HoloLens 1, uploaded 3D-models and automatically registered the 3D-model with the phantom. Based on the surgeon’s sightline while registering and targeting (free sightline /F/or a strictly perpendicular sightline /P/), 4 scenarios were developed (FF-PF-FP-PP). Target error distance (TED) was obtained in three different working axes-(XYZ).

Results

Six surgeons (5 males, age 29–62) were enrolled. A total of 864 measurements were collected in 4 scenarios, twice. Scenario PP showed the smallest TED in XYZ-axes mean = 2.98 mm ± SD 1.33; 2.28 mm ± SD 1.45; 2.78 mm ± SD 1.91, respectively. Scenario FF showed the largest TED in XYZ-axes with mean = 10.03 mm ± SD 3.19; 6.36 mm ± SD 3.36; 16.11 mm ± SD 8.91, respectively. Multiple comparison tests, grouped in scenarios and axes, showed that the majority of scenario comparisons had significantly different TED values (p < 0.05). Y-axis always presented the smallest TED regardless of scenario tested.

Conclusion

A strictly perpendicular working sightline in relation to the 3D-model achieves the best accuracy results. Shortcomings in this technology, as an intraoperative visual cue, can be overcome by sightline correction. Incidentally, this is the preferred working angle for open surgery.

Urinary catheter in colorectal surgery: current practices and improvements in order to allow prompt removal. A cross-sectional study

BACKGROUND

Despite the publication of the guidelines for enhanced recovery after surgery (ERAS), attitudes to urinary catheter (UC) management vary widely in colorectal surgery. The aim of the present study was to define current practices in UC management in colorectal surgery.

METHODS

Cross-sectional observational study carried out in March-April 2019, based on the responses to a survey administered to public hospitals in Catalonia. Respondents were asked about their observance of ERAS programs, the percentage of laparoscopic procedures performed, and the time of UC withdrawal in surgery of the colon and rectum.

RESULTS

Forty-three of 45 hospitals contacted eventually responded (95.6%). As two hospitals reported that they did not perform colorectal surgery, the study is based on the results from 41 centers. Thirty-five (85.4%) reported following ERAS programs; 30 (73.2%) have coloproctology units, and 39 (95.1%) perform more than 70% of colorectal surgeries by laparoscopy. In colon surgery, 27 (65.9%) remove the UC at 24 h, and 12 (29.3%) on day 2 or day 3. In rectal surgery, 17 (58.6%) remove the UC on day 2-3.

CONCLUSIONS

Management of UC in colon and rectal surgery varies widely. There is clearly room for improvement in UC management, but needs to be thoroughly assessed in randomized multicenter studies.

Laparoscopic versus open liver resections of posterolateral liver segments - a systematic review and meta-analysis

INTRODUCTION

Laparoscopic resection has become an accepted approach to liver tumour surgery. However, it is considered difficult, especially in unfavourably located lesions.

AIM

To compare the outcomes of laparoscopic (LLR) and open liver resection (OLR) of posterolateral segments.

MATERIAL AND METHODS

We searched the PubMed, EMBASE, and Scopus databases from inception to 30 September 2019. Full text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines.

RESULTS

From 643 articles, 15 studies (N = 1196 patients) were included in the meta-analysis. All of them were non-randomised. Our findings showed that LLR had significantly lowered overall morbidity compared to OLR (MD = 0.66; 95% CI: 0.51-0.86; p = 0.002). Length of hospital stay (MD = 2.48; 95% CI: -3.87, -1.08; p < 0.001) was also shorter in the LLR group. Operative time (MD = 55.65; 95% CI: 24.14-87.16; p < 0.001) was significantly shorter in the OLR group. In terms of blood loss, major complications, R0 resection rates, and resection margin, there were no significant differences.

CONCLUSIONS

Our meta-analysis showed that the laparoscopic approach to resections of posterolateral liver segments is beneficial. However, the results are based on non-randomised trials, and further research is needed to fully establish their clinical application.

Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated Diaphragm Injury After Penetrating Trauma

BACKGROUND

Isolated diaphragm injury (IDI) occurs in up to 30% of penetrating left thoracoabdominal injuries. Laparoscopic abdominal procedures have demonstrated improved outcome including decreased postoperative pain and length of stay (LOS) compared to open surgery. However, there is a paucity of data on this topic for penetrating IDI. The aim of this study was to examine the prevalence and outcome of laparoscopic diaphragmatic repair versus open diaphragmatic repair (LDR vs ODR) of IDI.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients with IDI who underwent ODR versus LDR. A bivariate analysis using Pearson chi-square and Mann-Whitney test was performed to determine LOS among the two groups.

RESULTS

From 2039 diaphragm injuries, 368 patients had IDI; 281 patients (76.4%) underwent ODR and 87 (23.6%) underwent LDR. Compared to LDR, the ODR patients were older (median, 31 vs 25 years, P < .001) and had a higher injury severity score (mean, 11.2 vs 9.6, P = .03) but had similar rates of intensive care unit LOS, unplanned return to the operating room, ventilator days, and complications (P > .05). Patients undergoing ODR had a longer LOS (5 vs 4 days, P = .01), compared to LDR. There were no deaths in either group.

CONCLUSIONS

Trauma patients presenting with IDI undergoing ODR had a longer hospital LOS compared to patients undergoing LDR with no difference in complications or mortality. Therefore, we recommend when possible an LDR should be employed to decrease hospital LOS. Further research is needed to examine other benefits of laparoscopy such as postoperative pain, incisional hernia, and wound-related complications.

Surgical complications in colorectal cancer patients

BACKGROUND

Advancements in diagnostic and therapeutic sciences have allowed early diagnosis and treatment of cancer. Colorectal cancer is one of the most commonly reported cancers, particularly in elderly patients.

METHODS

Open and laparoscopic surgeries are used for the removal of the tumor, along with chemotherapy, depending on the stage of cancer. However, colorectal cancer surgery is associated with a great number of complications, that affect the efficacy of the surgery and overall health and survival of the patient.

RESULTS

Prevalence of these complications have shown discrepancies depending on the condition of the patient and disease and surgical skills of the surgeon. Preoperative evaluation, intraoperative care and postoperative measures can reduce the incidence of these complications.

CONCLUSION

This review highlights some frequently reported complications associated with colorectal cancer surgery, their risk factors and subsequent therapeutic measures to treat them.

Robotic versus Laparoscopic Sigmoid Colectomy: Analysis of Healthcare Cost and Utilization Project Database

Minimally invasive sigmoid colectomy via the laparoscopic approach (LA) has numerous benefits. We seek to compare outcomes between laparoscopic and robotic sigmoid colectomies. We analyzed the data using the National Inpatient Sample database between 2008 and 2014. Utilization and outcome measures were compared. The seven-year average number of patients who underwent elective sigmoid colectomy in the United States from 2008 to 2014 was estimated to be 197,053. Of these, 95.1 per cent were conducted using the LA. The mean age was 58.33 + 13.6 years and 58.23 + 12.8 years in laparoscopic and robotic approaches, respectively. No significant differences existed in respect to morbidities. Postoperative complications were comparable with respect to other complications. Length of hospital stay was statistically significantly shorter in the robot-assisted approach compared with the LA (mean 4.8 + 4 vs 5.7 + 5 days, respectively, P < 0.001). Patients who underwent robotic surgery had significantly higher total hospital charges than those who underwent laparoscopic surgery (median $45,057 vs $57,871 USD, P < 0.001). The advent of robot-assisted surgery has provided more options for patients and surgeons. Compared with laparoscopy, robot-assisted sigmoid colectomy has no clinical advantages in morbidity and mortality. However, the robotic approach has a significantly higher total charge to the patient.

Comparing the safety, efficacy, and oncological outcomes of laparoscopic and open colectomy in transverse colon cancer: a meta-analysis

INTRODUCTION

In order to compare the safety, efficacy, and oncological outcomes of laparoscopic (LC) and open colectomy (OC) for transverse colon cancer (TCC) patients, the present systematic review of the literature and meta-analysis was designed.

METHODS

This study was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. A systematic screening of the electronic databases was performed (Medline, Web of Science and Scopus). The validity of the pooled results was verified through the performance of trial sequential analysis (TSA). The level of evidence was estimated using the GRADE approach.

RESULTS

Overall, 21 studies and 2498 patients were included in our study. Pooled comparisons and TSA analyses reported a superiority of LC over OC in terms of postoperative complications (OR 0.64, p = 0.0003), blood loss (WMD - 86.84, p < 0.00001), time to first flatus (WMD - 0.94, p < 0.00001) and oral diet (WMD - 1.25, p < 0.00001), and LOS (WMD - 2.39, p < 0.00001). Moreover, OC displayed a lower operation duration (p < 0.00001). A higher rate of complete mesocolic excision (p = 0.001) was related to OC. Although inconclusive in TSA, the recurrence rate in LC group was lower. LC and OC were equivalent in terms of postoperative survival outcomes.

CONCLUSIONS

Considering several limitations of the eligible studies and the subsequent low level of evidence, further RCTs of a higher quality and methodological level are required to verify the findings of our meta-analysis.

Clinical outcome of open surgery versus laparoscopic surgery for cirrhotic hepatocellular carcinoma patients: a meta-analysis

BACKGROUND AND AIM

Open surgery remains the major approach to treat hepatocellular carcinoma, and laparoscopy-assisted liver resection has been recommended as a superior treatment. However, the efficacy of laparoscopic surgery versus open surgery for cirrhotic patients is under debate. Therefore, the aim of this meta-analysis was to compare the clinical outcomes of laparoscopic and open resection of hepatocellular carcinoma in patients with cirrhosis.

METHODS

Electronic databases were searched for eligible literature updated on November 2018. After rigorous review of quality, the data were extracted from eligible trials. All the data were pooled with the corresponding 95% confidence interval using RevMan software. Sensitivity analyses and heterogeneity were quantitatively evaluated.

RESULTS

Fourteen trials met the inclusion criteria. According to the pooled result of surgery duration, laparoscopic surgery was associated with significantly shorter hospital stay [STD mean difference (SMD) = -0.61, 95% confidence interval -0.89 to -0.32; P < 0.0001], lower intraoperative blood loss (SMD = -0.56, 95% confidence interval -0.99 to -0.12; P = 0.01), fewer complications (odds ratio = 0.38, 95% confidence interval 0.28 to 0.52; P < 0.00001) and lower transfusion rate (odds ratio = 0.58, 95% confidence interval 0.36-0.93; P = 0.02). Nevertheless, there was no remarkable difference in operative time (SMD = 0.17, 95% confidence interval -0.25 to -0.59; P = 0.42) between the two groups. The pooled analysis of overall survival showed that laparoscopic surgery did not achieve benefit compared with open surgery (P = 0.02). Moreover, the pooled results of three subgroups indicated that laparoscopic surgery was associated with significantly better disease-free survival (P < 0.05).

CONCLUSION

The current analysis indicates that laparoscopic liver resection for hepatocellular carcinoma improved intraoperative and disease-free survival, with similar overall survival compared to the open procedure. Laparoscopic surgery may serve as a safe and feasible alternative for selected hepatocellular carcinoma patients with cirrhosis.

The effect of preemptive use of pregabalin on postoperative morphine consumption and analgesia levels after laparoscopic colorectal surgery: a controlled randomized trial

PURPOSE

In order to reduce postoperative opioid administration and pain levels in patients submitted to laparoscopic colectomy, we assessed the efficacy of preemptive use of pregabalin (PG), as part of a multimodal analgesia scheme, in a randomized controlled trial setting.

METHODS

Overall, fifty adult patients scheduled for elective laparoscopic colectomy were included and randomized in our trial. In the experimental group, 23 patients received preoperatively 2 doses of 150 mg PG per os, whereas the control group consisted of 27 cases, where a matching to PG placebo was administered at the same scheme. The two groups had identical analgesia and anesthesia regimens otherwise. Our study endpoints included postoperative morphine consumption, postoperative pain, and complication rates.

RESULTS

Patients in the PG group displayed a significantly reduced morphine consumption at 8 h, 24 h, and 48 h postoperatively. The two groups were comparable in terms of postoperative pain (rest and movement assessment) and side effects.

CONCLUSIONS

The preoperative addition of PG resulted in a significant reduction of the postoperative opioid consumption in patients undergoing laparoscopic colectomy. However, an association with the postoperative pain scores was not identified.

Clinical and oncological outcomes of single-incision vs. conventional laparoscopic surgery for rectal cancer

BACKGROUND

To evaluate the clinical and oncological outcomes of single-incision laparoscopic surgery (SILS) vs. conventional laparoscopic surgery (CLS) for patients with rectal cancer (RC) who underwent total mesorectal excision (TME) surgery.

METHODS

This was a retrospective case-control study of patients with RC operated between 12/2013 and 12/2017 in Ruijin Hospital North, Shanghai Jiaotong University School of Medicine. In total, 177 patients who underwent CLS and 51 who underwent SILS met the inclusion and exclusion criteria and were matched 1:1 using propensity score matching method (PSM).

RESULTS

Compared with the CLS group, the SILS group showed shorter operation time [105 (40) vs. 125 (55) min, P = 0.045], shorter total incision length [4 (1) vs. 6.5 (1.5) cm, P < 0.001], lower VAS score on POD2 [1 (1) vs. 2 (1), P < 0.001], shorter time to soft diet [7 (1) vs. 8 (2) days, P = 0.048], and shorter length of hospital stay [9 (2) vs. 11 (3) days, P < 0.001]. The postoperative complications were similar between two groups [1(2%) vs. 5 (9.8%), P = 0.205]. No readmissions or mortality in either group occurred within 30 days of surgery. All 102 specimens met the requirements of TME. No significant differences were observed in the pathologic outcomes between the two groups. The median follow-up period was 32.6 months in the SILS group and 36.8 months in the CLS group (P = 0.053). The 3-year disease-free survival rates and overall survival rates of the SILS and CLS groups were 89.8% vs. 96.0% (P = 0.224) and 90.9% vs. 96.9% (P = 0.146), respectively.

CONCLUSIONS

Compared with CLS, TME surgery for rectal cancer can be performed safely and effectively using the SILS technique with better cosmetic results, less postoperative pain, faster postoperative recovery, and acceptable clinical and oncological outcomes.

Real-time automatic surgical phase recognition in laparoscopic sigmoidectomy using the convolutional neural network-based deep learning approach

BACKGROUND

Automatic surgical workflow recognition is a key component for developing the context-aware computer-assisted surgery (CA-CAS) systems. However, automatic surgical phase recognition focused on colorectal surgery has not been reported. We aimed to develop a deep learning model for automatic surgical phase recognition based on laparoscopic sigmoidectomy (Lap-S) videos, which could be used for real-time phase recognition, and to clarify the accuracies of the automatic surgical phase and action recognitions using visual information.

METHODS

The dataset used contained 71 cases of Lap-S. The video data were divided into frame units every 1/30 s as static images. Every Lap-S video was manually divided into 11 surgical phases (Phases 0-10) and manually annotated for each surgical action on every frame. The model was generated based on the training data. Validation of the model was performed on a set of unseen test data. Convolutional neural network (CNN)-based deep learning was also used.

RESULTS

The average surgical time was 175 min (± 43 min SD), with the individual surgical phases also showing high variations in the duration between cases. Each surgery started in the first phase (Phase 0) and ended in the last phase (Phase 10), and phase transitions occurred 14 (± 2 SD) times per procedure on an average. The accuracy of the automatic surgical phase recognition was 91.9% and those for the automatic surgical action recognition of extracorporeal action and irrigation were 89.4% and 82.5%, respectively. Moreover, this system could perform real-time automatic surgical phase recognition at 32 fps.

CONCLUSIONS

The CNN-based deep learning approach enabled the recognition of surgical phases and actions in 71 Lap-S cases based on manually annotated data. This system could perform automatic surgical phase recognition and automatic target surgical action recognition with high accuracy. Moreover, this study showed the feasibility of real-time automatic surgical phase recognition with high frame rate.