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.

Transanal total mesorectal excision for abdominoperineal resection is associated with poor oncological outcomes in rectal cancer patients: A word of caution from a multicentric Canadian cohort study.

AIM: The main objective of this study was to compare the oncological outcomes of patients undergoing abdominoperineal resection (APR) versus low anterior resection (LAR) through a transanal total mesorectal excision (taTME) approach. METHOD: A total of 360 adult patients with a diagnosis of rectal cancer were enrolled at participating centres from the Canadian taTME Expert Collaboration. Forty-three patients received taTME-APR and received 317 taTME-LAR. Demographic, operative, pathological and follow-up data were collected and merged into a single database. Results are presented as hazard ratio (HR) and 95% confidence interval. All analyses were performed in the R environment (v.3.6). RESULTS: The proportion of patients with a positive circumferential radial margin status was higher in the taTME-APR group than the taTME-LAR group (21% vs. 9%, p = 0.001). Complete TME was achieved in 91% of those undergoing APR compared with 96% of those undergoing LAR (p = 0.25). APR was associated with a greater rate of local recurrence relative to LAR, although it was not significant [crude HR = 3.53 (95% CI 0.92-13.53)]. Circumferential margin positivity was significantly associated with a higher rate of systemic recurrence [crude HR = 3.59 (95% CI 1.38-9.3)]. CONCLUSION: Our results demonstrate inferior outcomes in those undergoing taTME-APR compared with taTME-LAR. The use of this technique for this particular indication needs to be carefully considered.

Canadian taTME expert collaboration (CaTaCO) position statement.

INTRODUCTION: Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience. METHODS: The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology. RESULTS: The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance. CONCLUSIONS: Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.

Resection of ruptured hepatic teratoma in an adult.

INTRODUCTION: Extragonadal locations of teratomas are uncommonly reported in the literature. Teratomas are neoplasms usually found in the gonadal organs: ovaries and testis. The majority of teratomas are found in the pediatric age group. Furthermore, teratomas originating in the liver are exceedingly rare with only 11 case reports in adult populations. PRESENTATION OF CASE: We present a case of a 65 year-old female who presented to hospital with sudden onset abdominal pain from a centrally located ruptured hepatic teratoma on CT scan. The patient underwent urgent surgery. The diagnosis of cystic mature teratoma was confirmed on histopathology. Patient was discharged on post-operative day 5. At 12 week follow-up, no post-operative complications were identified. DISCUSSION: Hepatic teratomas are a rarely encountered neoplasm, especially in the adult population. Our case report is unique, as it represents the only clinical presentation of mass rupture in an adult liver teratoma. CT scan identified a well circumscribed mass containing adipose tissue, fluid, and calcifications characteristic of teratoma. Complete surgical resection is mainstay treatment. A definitive diagnosis of a mature teratoma is confirmed by histopathological findings. CONCLUSION: Presented is a rare case of ruptured hepatic teratoma in an adult who underwent surgical resection.

Trans-anal minimally invasive surgery: A new technique to avoid peritoneal entry.

INTRODUCTION: Transanal minimally invasive surgery (TAMIS) is a valuable surgical option for removal of rectal polyps and early rectal cancers. A potential complication of this technique is abdominal entry if the lesion is located above the peritoneal reflection. We present the first case series describing the use of a laparoscopic stapling device to remove a sessile lesion, and seal the resulting defect simultaneously with full thickness excision of the rectal lesion, avoiding abdominal entry. PRESENTATION OF CASES: Five patients with rectal lesions between 8 and 14 cm from the anal verge are described in this case series. Each underwent a stapled-TAMIS procedure as the lesion was suspected to be above the peritoneal reflection. The goal specimen was achieved in each procedure. DISCUSSION: This article demonstrates the feasibility of a novel technique to remove sessile polyps in the upper rectum using laparoscopic staplers trans-anally through the TAMIS port. More studies and long-term follow-up are needed to evaluate the oncologic outcomes including the recurrence rate for those lesions removed with a stapler. CONCLUSION: For rectal lesions suspected to be above the peritoneal reflection, a stapled resection through a TAMIS port could prove be a valuable addition to the standard excisional approach to TAMIS.

Rectal Dissection Simulator for da Vinci Surgery: Details of Simulator Manufacturing With Evidence of Construct, Face, and Content Validity.

BACKGROUND: Apprenticeship in training new surgical skills is problematic, because it involves human subjects. To date there are limited inanimate trainers for rectal surgery. OBJECTIVE: The purpose of this article is to present manufacturing details accompanied by evidence of construct, face, and content validity for a robotic rectal dissection simulation. DESIGN: Residents versus experts were recruited and tested on performing simulated total mesorectal excision. Time for each dissection was recorded. Effectiveness of retraction to achieve adequate exposure was scored on a dichotomous yes-or-no scale. Number of critical errors was counted. Dissection quality was tested using a visual 7-point Likert scale. The times and scores were then compared to assess construct validity. Two scorer results were used to show interobserver agreement. A 5-point Likert scale questionnaire was administered to each participant inquiring about basic demographics, surgical experience, and opinion of the simulator. Survey data relevant to the determination of face validity (realism and ease of use) and content validity (appropriateness and usefulness) were then analyzed. SETTINGS: The study was conducted at a single teaching institution. SUBJECTS: Residents and trained surgeons were included. INTERVENTION: The study intervention included total mesorectal excision on an inanimate model. MAIN OUTCOME MEASURES: Metrics confirming or refuting that the model can distinguish between novices and experts were measured. RESULTS: A total of 19 residents and 9 experts were recruited. The residents versus experts comparison featured average completion times of 31.3 versus 10.3 minutes, percentage achieving adequate exposure of 5.3% versus 88.9%, number of errors of 31.9 versus 3.9, and dissection quality scores of 1.8 versus 5.2. Interobserver correlations of R = 0.977 or better confirmed interobserver agreement. Overall average scores were 4.2 of 5.0 for face validation and 4.5 of 5.0 for content validation. LIMITATIONS: The use of a da Vinci microblade instead of hook electrocautery was a study limitation. CONCLUSIONS: The pelvic model showed evidence of construct validity, because all of the measured performance indicators accurately differentiated the 2 groups studied. Furthermore, study participants provided evidence for the simulator's face and content validity. These results justify proceeding to the next stage of validation, which consists of evaluating predictive and concurrent validity. See Video Abstract at http://links.lww.com/DCR/A551.

The Impact of Obesity on the Perioperative, Clinicopathologic, and Oncologic Outcomes of Robot Assisted Total Mesorectal Excision for Rectal Cancer.

PURPOSE: To analyze the feasibility and outcomes of robotic rectal cancer surgery in obese patients. METHODS: From 2005 to 2012, 101 consecutive rectal cancers operated robotically were enrolled in a prospective database. Patients were stratified into obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) groups. Operative, perioperative parameters, and pathologic outcomes were compared. Data were analyzed using SPSS 22.0, while statistical significance was defined as a p value ≤ .05. RESULTS: There were 33 obese patients (mean BMI 33.8 kg/m2). Patients were comparable regarding gender, T stage, and type of operation. Operative time and blood loss were higher in the obese group; only operative time was statistically significant. The conversion rate, length of stay, and anastomotic leak rates were similar. Circumferential margin positivity and lymph node yield were comparable. Disease free and overall survivals at 3 years were 75.8% versus 80.9% and 84.8% versus 92.6%, respectively for obese and non-obese subgroups. CONCLUSIONS: Robotic surgery for curative treatment of rectal cancer in the obese is safe and feasible. BMI does not influence conversion rates, length of stay, postoperative complications, and quality of the specimen or survival when the robotic platform is used.

Cytomegalovirus duodenitis associated with life-threatening duodenal hemorrhage in an immunocompetent patient: A case report.

INTRODUCTION: Cytomegalovirus (CMV) is known to be opportunistic in immunocompromised patients. However, there have been emerging cases of severe CMV infections found in immunocompetent patients. Gastrointestinal (GI) CMV disease is the most common manifestation affecting immunocompetent patients, with duodenal involvement being exceedingly rare. Presented is a case of an immunocompetent patient with life-threatening bleeding caused by CMV duodenitis, requiring surgical intervention. PRESENTATION OF CASE: A 60-year-old male with history of disseminated Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and aortic valve infective endocarditis, presented with life-threatening upper GI hemorrhage. Endoscopy revealed ulcerations, with associated generalized mucosal bleeding in the duodenum. After repeated endoscopic therapies and failed interventional-radiology arterial embolization, the patient required a duodenectomy and associated total pancreatectomy, to control the duodenal hemorrhage. Pathologic review of the surgical specimen demonstrated CMV duodenitis. Systemic ganciclovir was utilized postoperatively. DISCUSSION: GI CMV infections should be on the differential diagnosis of immunocompetent patients presenting with uncontrollable GI bleeding, especially in critically ill patients due to transiently suppressed immunity. Endoscopic and histopathological examinations are often required for diagnosis. Ganciclovir is first-line treatment. Surgical intervention may be considered if there is recurrent bleeding and CMV duodenitis is suspected because of high potential for bleeding-associated mortality. CONCLUSION: Presented is a rare case of life-threatening GI hemorrhage caused by CMV duodenitis in an immunocompetent patient. The patient failed endoscopic and interventional-radiology treatment options, and ultimately stabilized after surgical intervention.

Robotic Site Adjusted Levator Transection for Carcinoma of the Rectum: A Modification of the Existing Cylindrical Abdominoperineal Resection for Eccentrically Located Tumors.

BACKGROUND: Today, extralevator abdominoperineal resection is the standard of care for low rectal cancers with sphincter involvement or location precluding anastomosis. This procedure, while effective from an oncologic point of view, is morbid, with a high incidence of wound complications and genitourinary, and sexual dysfunction. We present a modification of this procedure via a robotic approach, which maintains the radicality while reducing the soft tissue loss and potentially the morbidity. METHODS: Over a 2-year period, five patients (four men and one woman) with eccentric low rectal cancers following neoadjuvant chemoradiation underwent a robot-assisted modified abdominoperineal resection with wide levator transection on the tumor side and conservative levator division on the opposite side. These patients were prospectively followed. Perioperative outcomes, pathologic specimen measures, wound-related problems, and local and systemic recurrences were documented and analyzed. RESULTS: All procedures were successfully completed without conversion. Average body mass index was 32 kg/m2. The mean operative time and blood loss were 370 min and 130 ml, respectively. All specimens had an intact mesorectal envelope with no tumor perforations, and the mean lymph node yield was 16. There were no urinary complications or perineal wound infections. At a median follow-up of 14 months, all patients remain disease-free. CONCLUSIONS: Modified robotic cylindrical abdominoperineal resection with site adjusted levator transection for rectal cancer is an oncologically sound operation in eccentrically located tumors. It maintains the radicality of conventional extralevator abdominoperineal resection, while also reducing the soft tissue loss and thereby potentially the morbidity.

Endoscopic control of enterocutaneous fistula by dual intussuscepting stent technique.

INTRODUCTION: Large high-output enterocutaneous fistulas pose great difficulties, especially in the setting of recent surgery and compromised skin integrity. METHODS: This video demonstrates a new technique of endoscopic control of enterocutaneous fistula by using two covered overlapping stents. In brief, the two stents are each inserted endoscopically, one proximal, and the other distal to the fistula with 2 cm of each stent protruding cutaneously. Following this, the proximal stent is crimped and intussuscepted into the distal stent with an adequate overlap. A prolene suture is passed through the anterior wall of both stents to prevent migration. The two stents used were evolution esophageal stents-10 cm long, fully covered, double-flared with non-flared and flared diameters being 20 and 25 mm, respectively (product number EVO-FC-20-25-10-E, Cook Medical, Bloomington, IN, USA). RESULTS: The patient featured in this video developed a high-output enterocutaneous fistula proximal to a loop ileostomy, which was created following a small bowel leak after a curative surgery for bladder cancer. Using the technique featured in this video (schematic depicted in Fig. 1), the patient was nutritionally optimized with oral feeds from albumin of 0.9-3.4 g/dl within 2 months despite prior failure to achieve nutrition optimization and adequate skin protection with combination of oral and/or parenteral nutrition. Three months after stenting, following nutritional optimization and improvement of skin coverage, definitive procedure consisted of uncomplicated fistula resection with primary stapled side-to-side functional end-to-end anastomosis. The stents were not completely incorporated into the mucosa and were rather easily pulled through the residual fistula opening just prior to the surgery. Only minimal fibrosis was noted and less than 20 cm of involved small bowel needed to be resected. Had the fistula have closed completely, the options would have included (1) proceeding to bowel resection with removal of the stents regardless of closure, or (2) cutting the securing prolene stitch and observation. Considering the placement of the stents in mid-small bowel, their endoscopic retrieval would have been difficult unless they were to migrate into the colon. CONCLUSIONS: Although a prior attempt at managing an enterocutaneous fistula with a stent deployed through a colostomy site was previously reported [1], there is no published account of bridging an enterocutaneous fistula with overlapping endoscopic stents through the fistula itself. This video serves as a proof of concept for temporizing enterocutaneous fistulas with endoscopic stenting.

Sacral nerve stimulation in the treatment of bowel dysfunction from imperforate anus: A case report.

INTRODUCTION: Bowel dysfunction (fecal incontinence and constipation) presents in over 50% of patients after treatment of congenital anal malformations. Sacral nerve stimulation (SNS) for the treatment of fecal incontinence improves function in the majority of patients. We present a case report of the treatment of bowel dysfunction with sacral nerve stimulation in a patient with a history of an imperforate anus. PRESENTATION OF CASE: A twenty year-old female with a history of imperforate anus at birth, repaired during infancy with anorectoplasty, presented with fecal incontinence and constipation. Since childhood, she had been suffering from intermittent constipation with worsening fecal incontinence in early adulthood. Examination revealed mild anal stenosis and mucosal prolapse. Endoanal ultrasound demonstrated intact internal and external sphincter with low resting and squeeze pressures on anal manometry. Flexible sigmoidoscopy was normal. The patient underwent permanent sacral nerve stimulation with a primary goal of improvement in continence and, secondarily, for the alleviation of intermittent chronic constipation. DISCUSSION: At 15 month follow-up, the patient had improvement in fecal incontinence (CCIS of 14 pre-SNS to 1 post-SNS), constipation (CCCS of 28 pre-SNS to 20 post-SNS), and quality of life (FIQOL improved in lifestyle (3.7), coping/behavior (3.4), self perception (3.9), and social embarrassment (4.5). CONCLUSION: Sacral nerve stimulation for the treatment of bowel dysfunction in adults secondary to imperforate anus can be performed safely and with good results.

Prevention of perineal hernia after laparoscopic and robotic abdominoperineal resection: review with illustrative case series of internal hernia through pelvic mesh.

ABSTRACT: This review is intended to raise awareness of placing a pelvic mesh to prevent perineal hernias in cases of minimally invasive (MIS) abdominoperineal resections (APR) and, in doing so, causing internal hernias through the mesh. In this article, we review the published literature and present an illustrative series of 4 consecutive cases of early internal hernia through a pelvic mesh defect. These meshes were placed to prevent perineal hernias after laparoscopic or robotic APRs. The discussion centres on 3 key questions: Should one be placing a pelvic mesh following an APR? What are some of the technical details pertaining to the initial mesh placement? What are the management options related to internal hernias through such a mesh?

RESUME: L'objectif du présent examen est de sensibiliser les praticiens au risque associé à la pose d'un treillis pelvien visant à prévenir les hernies périnéales après une résection abdominopérinéale à effraction minimale, pratique qui peut entraîner une hernie interne. Nous nous penchons ici sur les articles publiés à ce sujet et présentons une série éloquente de 4 cas consécutifs de hernies internes précoces attribuables à un défaut du treillis. Les dispositifs avaient été mis en place pour prévenir une hernie périnéale après des résections laparoscopiques ou robotiques. La discussion porte sur 3 questions centrales : Devrait-on poser un treillis pelvien à la suite d'une résection abdominopérinéale? Quels sont les éléments techniques à surveiller lors de la pose initiale? Quelles sont les options de prise en charge des hernies internes causées par les treillis?

Wide local excision of perianal Paget's disease with gluteal flap reconstruction: an interdisciplinary approach.

Perianal Paget's disease (PPD) is an extremely rare condition characterized as intraepithelial adenocarcinoma of unclear etiology. It can be either primary or secondary. The disease typically presents as an eczema-like, erythematous, and painful skin lesion that is associated with pruritus. It is usually misdiagnosed as a common anorectal problem. Surgical excision is the preferred treatment of PPD, with the specific technique being dependent upon disease invasiveness. The treatment may involve reconstructive surgery. A 61-year-old female with a history of rectal pain and intermittent pruritus for the past two years presented with large painful lesions in her perianal area including the anal verge, diagnosed as primary PPD. After excluding other malignancies elsewhere, a laparoscopic ileostomy followed by a wide local excision (WLE) of the PPD was performed by a colorectal team. Reconstruction of the defect with gluteal advancement flaps was performed by the plastic surgeon. The patient recovered uneventfully. Her surgical site showed healing without flap compromise, widely open anal opening, and full sphincter control at the three-month follow-up exam. The patient returned to normal function after ileostomy closure. WLE with bilateral V-Y gluteal flap advancement is a feasible treatment for primary PPD.

Oncologic and Clinicopathologic Outcomes of Robot-Assisted Total Mesorectal Excision for Rectal Cancer.

BACKGROUND: Minimally invasive rectal cancer surgery is challenging and technically difficult. Robotic technology offers a stable surgical platform with magnified 3-dimensional vision and endowristed instruments, which may facilitate the minimally invasive procedure. Data on short-term and long-term outcomes indicate results comparable to laparoscopic and open surgery. OBJECTIVE: We assessed the perioperative, clinicopathologic, and oncologic outcomes of robotic surgery for rectal cancer. DESIGN: This study was a review of a prospective database of patients over a 7-year period. SETTINGS: Procedures took place in the colorectal division at a tertiary hospital. PATIENTS: From August 2005 to October 2012, 101 patients with rectal cancer were operated on using the robotic approach. Rectal cancers were defined as tumors within 15 cm from the anal verge. INTERVENTIONS: Patients received either a totally robotic or a hybrid laparoscopic-robotic operation with rectal dissection performed robotically. MAIN OUTCOME MEASURES: Operative and perioperative data, pathologic outcomes, and disease-free and overall survival were examined. RESULTS: There were 63 men (62.4%) and 38 women (37.6%) in the study; the mean age was 61.5 years. Mid rectal and low rectal cancers composed 74.2% of cases. Preoperative chemoradiation was given to 74.3% of patients. Four conversions to open surgery occurred. Circumferential margin positivity was 5%, and median lymph node yield was 15. At a mean follow-up of 34.9 months, the disease-free survival was 79.2% and overall survival 90.1%. The mean cost of robotic surgery was $22,640 versus $18,330 for the hand-assisted laparoscopic approach (p = 0.005). LIMITATIONS: This was a single-institution study with no head-to-head comparative group. CONCLUSIONS: Robotic surgery for rectal cancer extirpation is safe and feasible. It has a low conversion rate, satisfies all measures of pathologic adequacy, and offers acceptable oncologic outcomes. Robotic surgery is significantly more expensive than hand-assisted laparoscopic surgery. The absence of randomized data limits recommending it as the standard of care at present.

Current status of robotic surgery for rectal cancer: A bird's eye view.

Minimally invasive surgery for rectal cancer is now widely performed via the laparoscopic approach and has been validated in randomized controlled trials to be oncologically safe with better perioperative outcomes than open surgery including shorter length of stay, earlier return of bowel function, better cosmesis, and less analgesic requirement. Laparoscopic surgery, however, has inherent limitations due to two-dimensional vision, restricted instrument motion and a very long learning curve. Robotic surgery with its superb three-dimensional magnified optics, stable retraction platform and 7 degrees of freedom of instrument movement offers significant benefits during Total Mesorectal Excision (TME) including ease of operation, markedly lower conversion rates and better quality of the specimen in addition to shorter (steeper) learning curves. This review summarizes the current evidence for the adoption of robotic TME for rectal cancer with supporting data from the literature and from the authors' own experience. All relevant articles from PubMed using the search terms listed below and published between 2000 and 2014 including randomized trials, meta-analyses, prospective studies, and retrospective reviews with substantial numbers were included.

Simultaneous development of laparoscopy and robotics provides acceptable perioperative outcomes and shows robotics to have a faster learning curve and to be overall faster in rectal cancer surgery: analysis of novice MIS surgeon learning curves.

BACKGROUND: Laparoscopy offers some evidence of benefit compared to open rectal surgery. Robotic rectal surgery is evolving into an accepted approach. The objective was to analyze and compare laparoscopic and robotic rectal surgery learning curves with respect to operative times and perioperative outcomes for a novice minimally invasive colorectal surgeon. METHODS: One hundred and six laparoscopic and 92 robotic LAR rectal surgery cases were analyzed. All surgeries were performed by a surgeon who was primarily trained in open rectal surgery. Patient characteristics and perioperative outcomes were analyzed. Operative time and CUSUM plots were used for evaluating the learning curve for laparoscopic versus robotic LAR. RESULTS: Laparoscopic versus robotic LAR outcomes feature initial group operative times of 308 (291-325) min versus 397 (373-420) min and last group times of 220 (212-229) min versus 204 (196-211) min-reversed in favor of robotics; major complications of 4.7 versus 6.5 % (NS), resection margin involvement of 2.8 versus 4.4 % (NS), conversion rate of 3.8 versus 1.1 (NS), lymph node harvest of 16.3 versus 17.2 (NS), and estimated blood loss of 231 versus 201 cc (NS). Due to faster learning curves for extracorporeal phase and total mesorectal excision phase, the robotic surgery was observed to be faster than laparoscopic surgery after the initial 41 cases. CUSUM plots demonstrate acceptable perioperative surgical outcomes from the beginning of the study. CONCLUSIONS: Initial robotic operative times improved with practice rapidly and eventually became faster than those for laparoscopy. Developing both laparoscopic and robotic skills simultaneously can provide acceptable perioperative outcomes in rectal surgery. It might be suggested that in the current milieu of clashing interests between evolving technology and economic constrains, there might be advantages in embracing both approaches.

Laparoscopic right hemicolectomy with complete mesocolic excision provides acceptable perioperative outcomes but is lengthy--analysis of learning curves for a novice minimally invasive surgeon.

BACKGROUND: Associated with reduced trauma, laparoscopic colon surgery is an alternative to open surgery. Furthermore, complete mesocolic excision (CME) has been shown to provide superior nodal yield and offers the prospect of better oncological outcomes. METHODS: All oncologic laparoscopic right colon resections with CME performed by a single surgeon since the beginning of his surgical practice were retrospectively analyzed for operative duration and perioperative outcomes. RESULTS: The study included 81 patients. The average duration of surgery was 220.0 (range 206-233) minutes. The initial durations of about 250 minutes gradually decreased to less than 200 minutes in an inverse linear relationship (y = -0.58x × 248). The major complication rate was 3.6% ± 4.2% and the average nodal yield was 31.3 ± 4.1. CumulativeSum analysis showed acceptable complication rates and oncological results from the beginning of surgeon's laparoscopic career. CONCLUSION: Developing laparoscopic skills can provide acceptable outcomes in advanced right hemicolectomy for a surgeon who primarily trained in open colorectal surgery. Operative duration is nearly triple that reported for conventional laparoscopic right hemicolectomy. The slow operative duration learning curve without a plateau reflects complex anatomy and the need for careful dissection around critical structures. Should one wish to adopt this strategy either based on some available evidence of superiority or with intention to participate in research, one has to change the view of right hemicolectomy being a rather simple case to being a complex, lengthy laparoscopic surgery.

CONTEXTE: La chirurgie du côlon par laparoscopie, qui réduit les traumatismes, est une solution de rechange à la chirurgie ouverte. De plus, il a été démontré que l'excision mésocolique complète (EMC) optimise le curage ganglionnaire et offre la perspective de meilleurs résultats oncologiques. MÉTHODES: On a examiné rétrospectivement la durée de l'opération et les résultats périopératoires de toutes les résections du côlon droit réalisées par laparoscopie avec EMC pratiquées par un seul chirurgien depuis le début de sa carrière. RÉSULTATS: L'étude a été menée auprès de 81 patients. La durée moyenne de l'intervention chirurgicale était de 220 minutes (intervalle de 206 à 233 minutes). Au début, l'intervention durait environ 250 minutes; avec le temps, sa durée a progressivement diminué de sorte qu'à la fin, elle était de moins de 200 minutes, d'après une relation linéaire négative (y = ­0,58x × 248). Le taux de complications graves s'est établi à 3,6 % ± 4,2 % et le nombre moyen de noeuds lymphatiques excisés a été de 31,3 ± 4,1. En utilisant la méthode d'analyse des sommes cumulées, on a observé un taux de complications et des résultats oncologiques acceptables depuis le début de la carrière du chirurgien en laparoscopie. CONCLUSION: En perfectionnant sa technique laparoscopique, un chirurgien formé principalement en chirurgie colorectale ouverte peut produire des résultats acceptables dans les cas d'hémicolectomie droite avancée. La durée de l'intervention chirurgicale est presque le triple de celle d'une hémicolectomie droite laparoscopique classique. La courbe d'apprentissage lente sans plateau montre bien la complexité des structures anatomiques et la nécessité de faire preuve de prudence lors de la résection autour de structures vitales. Quiconque souhaite adopter cette méthode, soit en raison de données démontrant sa supériorité ou dans le but de participer à une recherche, doit adopter une nouvelle perspective, c'est-à-dire que l'hémicolectomie droite laparoscopique n'est pas une intervention simple, mais une chirurgie complexe qui prend beaucoup de temps.

Total sacrectomy for recurrent rectal cancer - A case report featuring technical details and potential pitfalls.

INTRODUCTION: Total sacrectomy for recurrent rectal cancer is controversial. However, recent publications suggest encouraging outcomes with high sacral resections. We present the first case report describing technical aspects, potential pitfalls and treatment of complications associated with total sacrectomy performed as a treatment of recurrent rectal cancer. PRESENTATION OF CASE: A fifty-three year old man was previously treated at another institution with a low anterior resection (LAR) followed by chemo-radiation and left liver tri-segmentectomy for metastatic rectal cancer. Three years following the LAR, the patient developed a recurrence at the site of colorectal anastomosis, manifesting clinically as a contained perforation, forming a recto-cutaneous fistula through the sacrum. Abdomino-perineal resection (APR) and complete sacrectomy were performed using an anterior-posterior approach with posterior spinal instrumented fusion and pelvic fixation using iliac crest bone graft. Left sided vertical rectus abdominis muscle flap and right sided gracilis muscle flap were used for hardware coverage and to fill the pelvic defect. One year after the resection, the patient remains disease free and has regained the ability to move his lower limbs against gravity. DISCUSSION: The case described in this report features some formidable challenges due to the previous surgeries for metastatic disease, and the presence of a recto-sacral cutaneous fistula. An approach with careful surgical planning including considerationof peri-operative embolization is vital for a successful outcome of the operation. A high degree of suspicion for pseudo-aneurysms formation due infection or dislodgement of metallic coils is necessary in the postoperative phase. CONCLUSION: Total sacrectomy for the treatment of recurrent rectal cancer with acceptable short-term outcomes is possible.A detailed explanation to the patient of the possible complications and expectations including the concept of a very high chancefor recurrence is paramount prior to proceeding with such a surgery.

Laparoscopic repair of parastomal and incisional hernias with a modified Sugarbaker technique.

A parastomal hernia is the most common surgical complication following stoma formation. As the field of laparoscopic surgery advances, different laparoscopic approaches to repair of parastomal hernias have been developed. Recently, the Sugarbaker technique has been reported to have lower recurrence rates compared to keyhole techniques. As far as we know, the Sugarbaker technique has not yet been performed in Korea. We herein present a case report of perhaps the first laparoscopic parastomal hernia repair with a modified Sugarbaker technique to be successfully carried out in Korea. A 79-year-old woman, who underwent an abdominoperineal resection for an adenocarcinoma of the rectum 9 years ago, presented with a large parastomal and incisional hernias, and was treated with a laparoscopic repair with a modified Sugarbaker technique. Six months after surgery, follow-up with the patient has shown no evidence of recurrence.

Robotic single-incision anterior resection for sigmoid colon cancer: access port creation and operative technique.

BACKGROUND: Potential morbidities related to multiport laparoscopic surgeries have led to the current excitement about single-incision laparoscopic techniques. However, multiport laparoscopy is technically demanding and ergonomically challenging. We present our technique of using the Alexis wound retractor and a surgical glove to fashion an access port and the da Vinci surgical robot to perform single-incision anterior resection. METHODS: Through a small transumbilical incision, an Alexis wound retractor and a surgical glove are fashioned as an access port. Appropriate trocars are then inserted through the cut fingertips of the glove and secured. A three-arm da Vinci robot with a 30° up-scope was used. RESULTS: Twenty-two patients (12 males, 10 females) with a mean age of 58.5 years (range = 35-70) underwent robotic single-incision anterior resection for sigmoid colon cancer with this technique. There was no conversion to open surgery and one case was converted to multiport surgery. The mean estimated blood loss was 24.5 ml (range = 5-230), the mean operating time was 167.5 min (range = 112-251), the median skin incision length was 4.7 cm (range = 4.2-8.0), the mean proximal and distal resection margins were 12.9 cm (range = 7.5-25.1) and 12.3 cm (range = 4.5-19.2), respectively, and the mean lymph node harvest was 16.8 (range = 0-42). The immediate postoperative pain score was 2.8 (range = 1-5) and on postoperative day 1 it was 1.4 (range = 1-3). The mean length of hospital stay was 6 days (range = 5-9). CONCLUSION: Robotic single-incision anterior resection is a safe and viable option for selected patients. Merging the principles of reduced parietal trauma and better cosmesis with the ergonomic advantages of the robotic system is a novel evolution of single-incision laparoscopic surgery.