Single-port laparoscopic sphincter-saving mesorectal excision for rectal cancer: report of the first 4 human cases.

HYPOTHESIS: Single-port laparoscopic rectal surgery can be performed using the principles of oncologic surgery in institutes experienced in laparoscopy with the advantages of minimally invasive surgery. DESIGN: Sphincter-saving mesorectal excision in 4 human cases via a single laparoscopic port. SETTINGS: A university hospital and a private hospital. PATIENTS: A series of 4 patients who underwent single-port laparoscopic sphincter-saving rectal resection for rectal cancer. Two of them were total and 2 were partial mesorectal excisions. INTERVENTIONS: An umbilical incision was made to place the multichannel single port. The sigmoid colon was hung to the left lateral abdominal wall using an intracorporeal stitch passing through its appendices epiploicae to achieve medial dissection and vascular ligation. The mesorectum was sharply dissected down to the pelvic floor. Endoscopic linear roticulating staplers were used to divide the rectum and proximal colon. A specimen was retrieved using an extraction bag through the umbilicus. Anastomosis was performed using a circular stapler, or pull-through hand-sewn anastomosis was performed. MAIN OUTCOME MEASURES: Duration of the operation, length of hospital stay, surgical complications, wound size, and histopathologic data. RESULTS: There were no perioperative or postoperative complications. Mean operative time was 347 minutes (range, 240-480 minutes). Mean hospital stay was 4.25 days (range, 4-5 days). Mean wound size was 3.5 cm (range, 3-4 cm). Mean number of harvested lymph nodes was 15 (range, 8-28). CONCLUSIONS: With the help of sophisticated surgical technology and techniques, single-port laparoscopic surgery for rectal cancer will be feasible while also maintaining oncologic principles and patient safety.

Minimally invasive parathyroid surgery in 103 patients with local/regional anesthesia, without exclusion criteria.

BACKGROUND: Parathyroid surgery for sporadic primary hyperparathyroidism (pHPT) can be accomplished with local/regional anesthesia and intraoperative monitoring of intact parathyroid hormone without exclusion criteria through a 1.0- to 1.25-inch (2.5- to 3.2-cm) incision (MIPL) in a high proportion of patients. METHODS: One hundred thirty-one consecutive patients with pHPT were offered MIPL. One hundred three patients elected to have this procedure. Patients were not excluded because of inadequate localization, previous parathyroid surgery, or need for concomitant thyroid surgery. Preoperative localization with ultrasound and/or sestamibi-single photon emission computed tomography scan was done in all patients. Almost all patients had intraoperative monitoring of intact parathyroid hormone (IMPTH). RESULTS: MIPL was accomplished in 89 of these 103 patients (86.4%), but 14 required conversion to general anesthesia. The main reasons for conversion were concomitant thyroid surgery, no positive preoperative localization, and previous parathyroid surgery. This procedure was accomplished in 13 patients requiring a bilateral procedure, 5 patients requiring thyroid surgery, 4 patients with no positive preoperative localization, and in 3 patients with previous parathyroid surgery. The complications of MIPL were comparable to the traditional bilateral exploration with general anesthesia. No patient experienced permanent hypoparathyroidism or postoperative bleeding. Two patients had transient recurrent laryngeal nerve paresis, and surgery failed to correct hypercalcemia in 5 (4.9%) of the patients. There appears to be less need for antiemetic medication in the MIPL patients compared with patients who had general anesthesia. CONCLUSIONS: Parathyroid surgery for sporadic pHPT can be accomplished through a 1.0- to 1.25-inch (2.5- to 3.2-cm) incision with local/regional anesthesia, without exclusion criteria. Accurate preoperative localization, particularly localization to the same site by both ultrasound and 99mTc-sestamibi scan, and IMPTH can limit the surgery to a unilateral approach. One should be cautious in proceeding with MIPL in patients with need for concomitant thyroid surgery, no preoperative localization, or previous parathyroid surgery.