Introduction of a new surgical robot platform "hinotori™" in an institution with established da Vinci surgery™ for digestive organ operations.

BACKGROUND: New platforms for robotic surgery have recently become available for clinical use; however, information on the introduction of new surgical robotic platforms compared with the da Vinci™ surgical system is lacking. In this study, we retrospectively determined the safe introduction of the new "hinotori™" surgical robot in an institution with established da Vinci surgery using four representative digestive organ operations. METHODS: Sixty-one patients underwent robotic esophageal, gastric, rectal, and pancreatic operations using the hinotori system in our department in 2023. Among these, 22 patients with McKeown esophagectomy, 12 with distal gastrectomy, 11 with high- and low-anterior resection of the rectum, and eight with distal pancreatectomy procedures performed by hinotori were compared with historical controls treated using da Vinci surgery. RESULTS: The console (cockpit) operation time for distal gastrectomy and rectal surgery was shorter in the hinotori group compared with the da Vinci procedure, and there were no significant differences in the console times for the other two operations. Other surgical results were almost similar between the two robot surgical groups. Notably, the console times for hinotori surgeries showed no significant learning curves, determined by the cumulative sum method, for any of the operations, with similar values to the late phase of da Vinci surgery. CONCLUSIONS: This study suggests that no additional learning curve might be required to achieve proficient surgical outcomes using the new hinotori surgical robotic platform, compared with the established da Vinci surgery.

Feasibility Study of a Newly Developed Hybrid Energy Device Used During Laparoscopic Liver Resection in a Porcine Model.

BACKGROUND: Although various devices have been clinically used for laparoscopic liver resection (LLR), the best device for liver parenchymal transection remains unknown. Olympus Corp (Tokyo, Japan) developed a laparoscopic hybrid pencil (LHP) device, which is the first electric knife to combine ultrasound and electric energy with a monopolar output. We aimed to evaluate the feasibility of using the LHP device and to compare it with the laparoscopic monopolar pencil (LMP) and laparoscopic ultrasonic shears (LUS) devices for LLR in a porcine model. METHODS: Nine male piglets underwent laparoscopic liver lobe transections using each device. The operative parameters were evaluated in the 3 groups (n = 24 lobes) during the acute study period. The imaging findings from contrast-enhanced computed tomography and histopathological findings of autopsy on postoperative day 7 were compared among groups (n = 6 piglets) during the long-term study. RESULTS: The transection time was shorter ( P = .001); there was less blood loss ( P = .018); and tip cleaning ( P < .001) and instrument changes were less often required ( P < .001) in the LHP group than in the LMP group. The LHP group had fewer instances of bleeding ( P < .001) and coagulator usage ( P < .001) than did the LUS group. In the long-term study, no postoperative adverse events occurred in the 3 groups. The thermal spread and depth of the LHP device were equivalent to those of the LMP and LUS devices (vs LMP: P = .226 and .159; vs LUS: P = 1.000 and .574). CONCLUSIONS: The LHP device may be an efficient device for LLR if it can be applied to human surgery.

Assessment of the Safety of the New Hybrid Pencil Type Energy (NP) Device Used Close to the Recurrent Laryngeal Nerve in a Porcine Model: Comparison With a Conventional Electrosurgical Knife.

BACKGROUND: Recurrent laryngeal nerve (RLN) paralysis is mainly associated with esophagectomy, and it may result in not only other morbidities, such as aspiration pneumonia, but also in long-term issues. Therefore, an approach to prevent RLN paralysis is necessary. The present study was designed to determine the technical usability of the new hybrid pencil type energy (NP) device developed by Olympus Corporation (Tokyo, Japan) and compare it with a conventional electrosurgical knife (EK) for resection around the RLN lymph nodes. METHODS: This nonsurvival (acute) study included 10 pigs (20 RLNs) and investigated the threshold for thermal RLN damage with the NP device and a conventional EK. To obtain basic information for our study, a preliminary experiment for heat spread was performed. RESULTS: When using the EK device, the amplitude value disappeared at a distance of 1 mm from the RLN, but when using the NP device, the amplitude value was maintained up to a distance of 0.5 mm. There were significant differences at distances of 0 mm, 0.5 mm, and 1 mm between the NP and EK devices. Furthermore, heat spread was lower with the NP device than with the EK device. CONCLUSIONS: The new energy device developed by Olympus Corporation was found to be technically safe for resection of the RLN lymph nodes in a porcine model. To the best of our knowledge, this is the first study to demonstrate the potential advantages of using this new energy device in a clinical aspect.

Differences in surgical site infection between laparoscopic colon and rectal surgeries: sub-analysis of a multicenter randomized controlled trial (Japan-Multinational Trial Organization PREV 07-01).

BACKGROUND: The incidence of surgical site infection (SSI) is reportedly lower in laparoscopic colorectal surgery than in open surgery, but data on the difference in SSI incidence between colon and rectal laparoscopic surgeries are limited. METHODS: The incidence and risk factors for SSI, and the effect of oral antibiotics in colon and rectal laparoscopic surgeries, were investigated as a sub-analysis of the JMTO-PREV-07-01 (a multicenter, randomized, controlled trial of oral/parenteral vs. parenteral antibiotic prophylaxis in elective laparoscopic colorectal surgery). RESULTS: A total of 582 elective laparoscopic colorectal resections, comprising 376 colon surgeries and 206 rectal surgeries, were registered. The incidence of SSI in rectal surgery was significantly higher than in colon surgery (14 vs. 8.2 %, P = 0.041). Although the incidence of incisional SSI was almost identical (7 %) between the surgeries, the incidence of organ/space SSI in rectal surgery was significantly higher than in colon surgery (6.3 vs. 1.1 %, P = 0.0006). The lack of oral antibiotics was significantly associated with the development of SSI in colon surgery. Male sex, stage IV cancer, and abdominoperineal resection were significantly associated with SSI in rectal surgery. The combination of oral and parenteral antibiotics significantly reduced the overall incidence of SSI in colon surgery (relative risk 0.41, 95 % confidence interval 0.19-0.86). CONCLUSION: The incidence of SSI in laparoscopic rectal surgery was higher than in colon surgery because of the higher incidence of organ/space SSI in rectal surgery. The risk factors for SSIs and the effect of oral antibiotics differed between these two procedures.

Oral and Parenteral Versus Parenteral Antibiotic Prophylaxis in Elective Laparoscopic Colorectal Surgery (JMTO PREV 07-01): A Phase 3, Multicenter, Open-label, Randomized Trial.

OBJECTIVE: To confirm the efficacy of oral and parenteral antibiotic prophylaxis (ABX) in the elective laparoscopic colorectal surgery. BACKGROUND: There is no evidence for the establishment of an optimal ABX regimen for laparoscopic colorectal surgery, which has become an important choice for the colorectal cancer patients. METHODS: The colorectal cancer patients scheduled to undergo laparoscopic surgery were eligible for this multicenter, open-label, randomized trial. They were randomized to receive either oral and parenteral prophylaxis (1 g cefmetazole before and every 3 h during the surgery plus 1 g oral kanamycin and 750 mg metronidazole twice on the day before the surgery; Oral-IV group) or parenteral prophylaxis alone (the same IV regimen; IV group). The primary endpoint was the incidence of surgical site infections (SSIs). Secondary endpoints were the incidence rates of Clostridium difficile colitis, other infections, and postoperative noninfectious complications, as well as the frequency of isolating specific organisms. RESULTS: Between November 2007 and December 2012, 579 patients (289 in the Oral-IV group and 290 in IV group) were evaluated for this study. The incidence of SSIs was 7.26% (21/289) in the Oral-IV group and 12.8% (37/290) in the IV group with an odds ratio of 0.536 (95% CI, 0.305-0.940; P = 0.028). The 2 groups had similar incidence rates of C difficile colitis (1/289 vs 3/290), other infections (6/289 vs 5/290), and postoperative noninfectious complications (11/289 vs 12/290). CONCLUSIONS: Our oral-parenteral ABX regimen significantly reduced the risk of SSIs following elective laparoscopic colorectal surgery.

Pure Robotic Surgery for Intraluminally Growing Gastrointestinal Stromal Tumors around the Esophagogastric junction or Pyloric Ring.

BACKGROUND/AIMS: Laparoscopic resection of gastrointestinal stromal tumors has become wide-spread as a minimally invasive surgical method. However, the limitations of laparoscopic surgery for GISTs are well recognized. METHODOLOGY: We developed a local resection by pure robotic surgical procedure to treat intraluminally growing GISTs located in sites that are unsuitable for laparoscopic surgery. Using articulated robotic arms, the GIST is completely excised with a safe margin while employing a unique technique to provide a good operative view and to prevent the intra-abdominal dissemination of the tumor from the cut edge created by robotic excision. The defect created after excision of the tumor is closed using robotic sewing. RESULTS: Four patients were successfully treated with pure robotic surgery without conversion to laparoscopic or open surgery or changing in the method of gastrectomy. CONCLUSIONS: Using robotic surgery, intraluminally growing GISTs located in sites unsuitable for conventional laparoscopic surgery can be treated with minimally invasive procedures.

[A case of locally advanced sigmoid colon cancer treated with neoadjuvant chemoradiotherapy].

The patient was a 38-year-old woman who visited our hospital complaining of nausea and abdominal pain. A colonoscopy revealed an advanced cancer in the sigmoid colon. A computed tomography (CT) scan showed left hydronephrosis and lymph node metastasis to the left iliopsoas muscle and left ureter. No distant metastasis was found. Since the surgical margins were likely to be positive with a one-stage resection, 3 cycles of FOLFOX4 (folinic acid, fluorouracil, and oxaliplatin)were administered after creating a transverse loop colostomy. Although the tumor decreased in size, the surgical margins were still suspected to be positive. For further regional tumor control, radiotherapy (1.8 Gy/day for 25 days) to the medial region of the left iliac bone and oral UFT/LV (uracil and tegafur/Leucovorin)were administered. A partial response(PR)was determined in accordance with the Response Evaluation Criteria in Solid Tumors(RECIST). Sigmoidectomy with partial resection of the left ureter was performed by laparotomy. The histologic response was assessed as Grade 2 and all surgical margins were negative. Preoperative chemoradiotherapy may be an effective therapeutic option for locally advanced colon cancer resistant to conventional preoperative chemotherapy.

Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis.

BACKGROUND: Laparoscopic rectal surgery involving rectal transection and anastomosis with stapling devices is technically difficult. The aim of this study was to evaluate the risk factors for anastomotic leakage (AL) after laparoscopic low anterior resection (LAR) with double-stapling technique (DST) anastomosis. METHODS: This was a retrospective single-institution study of 154 rectal cancer patients who underwent laparoscopic LAR with DST anastomosis between June 2005 and August 2013. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses. The outcome of interest was clinical AL. RESULTS: The overall AL rate was 12.3% (19/154). In univariate analysis, tumor size (P = 0.001), operative time (P = 0.049), intraoperative bleeding (P = 0.037), lateral lymph node dissection (P = 0.009), multiple firings of the linear stapler (P = 0.041), and precompression before stapler firings (P = 0.008) were significantly associated with AL. Multivariate analysis identified tumor size (odds ratio [OR] 4.01; 95% confidence interval [CI] 1.25-12.89; P = 0.02) and precompression before stapler firings (OR 4.58; CI 1.22-17.20; P = 0.024) as independent risk factors for AL. In particular, precompression before stapler firing tended to reduce the AL occurring in early postoperative period. CONCLUSIONS: Using appropriate techniques, laparoscopic LAR with DST anastomosis can be performed safely without increasing the risk of AL. Important risk factors for AL were tumor size and precompression before stapler firings.

Feasibility and safety of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for severe ulcerative colitis.

INTRODUCTION: The laparoscopic approach is accepted as a treatment option for patients with ulcerative colitis (UC) who are otherwise in good health. However, its application for patients with severe UC remains controversial. The purpose of this study was to evaluate the feasibility of the laparoscopic approach for severe UC cases. Short- and long-term clinical outcomes after laparoscopic total proctocolectomy with ileal pouch-anal anastomosis were compared between severe and mild-to-intermediate UC patients. METHODS: Cases treated between March 2002 and September 2010 were retrieved retrospectively from the database of Kyoto Medical Center and Kyoto University Hospital. Intraoperative complications and short- and long-term clinical outcomes were compared. RESULTS: A total of 31 patients underwent laparoscopic total proctocolectomy with ileal pouch-anal anastomosis. A comparison of short- and long-term clinical outcomes after one- or two-stage laparoscopic ileal pouch-anal anastomosis between severe (n = 7) and mild-to-intermediate (n = 21) UC patients revealed no significant differences. The proportion of patients with restoration of intestinal continuity did not differ between the groups (severe: 86%, mild to intermediate: 95%; P = 0.69). CONCLUSION: The present findings suggest that laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for severe UC patients could be a good alternative approach when performed by an experienced hand.

Efficacy of transanal drainage for anastomotic leakage after laparoscopic low anterior resection of the rectum.

INTRODUCTION: Anastomotic leakage remains a devastating complication following low anterior resection of the rectum. Our aim was to retrospectively assess the efficacy of transanal drainage. METHODS: Twenty-five patients with anastomotic leakage after laparoscopic low anterior resection (using the double-stapling technique) were reviewed. Transanal drainage was performed when an abscess was localized within the pelvic cavity, and any leakage was detected through radiological study and digital examination. In each patient, the fistula was dilated with a forefinger, and the abscess was drained into the rectum. A suction drain tube was indwelled transanally when the abscess cavity was large or unstable. Clinical outcomes of patients after transanal drainage were then analyzed. RESULTS: Nine of the 25 patients required an emergency operation. The remaining 16 cases with localized disease were treated conservatively as an initial treatment. This included 12 patients treated by transanal drainage, 10 of whom were successfully cured. Two eventually required a defunctioning ileostomy because of fistula formation with other organs (treatment success rate: 83.3%). The median duration of drain placement, fasting and postoperative hospitalization were 10, 10 and 45 days, respectively. CONCLUSIONS: Transanal drainage may be a viable option for the treatment of anastomotic leakage after low anterior resection of the rectum.

[A case of lung metastases of carcinoma of the ampulla of vater effectively treated with S-1].

A 70-year-old female patient underwent pylorus-preserving pancreaticoduodenectomy for carcinoma of the ampulla of Vater in March 2007. In April 2009, multiple lung metastases were detected by CT scanning. The patient was treated with S-1 (80mg/day, day 1-28, followed by 2-weeks withdrawal)from April 2009. The shrinkage of lung metastases was diagnosed as a complete response based on the Response Evaluation Criteria in Solid Tumors(RECIST). No severe toxicities were observed. S-1 is an effective and safe anti-cancer agent available for lung metastases of carcinoma of the ampulla of Vater.

Intracorporeal esophagojejunal anastomosis after laparoscopic total gastrectomy for patients with gastric cancer.

BACKGROUND: To facilitate acceptance of laparoscopic total gastrectomy (LTG) for patients with upper gastric cancer, a simple, secure technique of reconstruction is necessary. The authors developed a new technique for intracorporeal esophagojejunal anastomosis that does not require hand sewing. METHODS: From September 2006 to January 2008, 16 patients (11 men and 5 women) with gastric cancer underwent LTG at the authors' institution. Laparoscopic esophagojejunal anastomosis using the following method was attempted for all patients. The esophagus was transected while being rotated by about 45 degrees counterclockwise to make the subsequent anastomosis easier. After the Y-anastomosis was created, an endoscopic linear stapler was applied to create a side-to-side anastomosis between the left dorsal side of the esophagus and the jejunal limb. The entry hole was first closed roughly with hernia staplers. Subsequently, an endoscopic linear stapler was applied so that all hernia staplers could be removed and the closure completed. RESULTS: Laparoscopic esophagojejunal anastomosis was successfully performed for 15 patients. Intracorporeal anastomosis failed for one patient because a nasogastric tube was caught between the jaws of an endostapler, which resulted in a conversion to open procedure. No postoperative anastomotic complications occurred. CONCLUSIONS: Using the new technique, intracorporeal linear-stapled esophagojejunal anastomosis can be performed easily and securely. This technique could become one of the standard methods for reconstruction after LTG, facilitating the acceptance of LTG as a surgical option for patients with upper gastric cancer.

Video. A novel laparoscopic approach for safe and simplified suprapancreatic lymph node dissection of gastric cancer.

BACKGROUND: Lymph node dissection is a crucial procedure for curative resection of gastric cancer [1]. To avoid portal vein injury during laparoscopic extended lymph node dissection for gastric cancer, taping of the common hepatic artery and subsequent confirmation of the portal vein have been recommended [2, 3]. This taping method, however, makes laparoscopic nodal dissection technically complicated. This study introduces a novel procedure for safe and simple laparoscopic suprapancreatic nodal dissection without taping of the common hepatic artery. METHODS: The authors' novel, simplified method consists of four steps: (1) dissection along the cranial edge of the pancreas from right to left, (2) dissection along the splenic artery with exposure of the left renal fascia, (3) dissection along the left gastric and the common hepatic arteries, and (4) retraction of the lymph nodes surrounding the common and proper hepatic arteries and their complete dissection from the portal vein. This procedure is reversely directed compared with conventional open gastrectomy (i.e., the nodal dissection is from left to right). For this study, the lymph node stations and groups were defined according to the 13th edition of the Japanese Classification for Gastric Carcinoma. The described procedures were performed for 58 consecutive patients with gastric cancer. The indication for this operation is primary T1/T2 gastric cancer without clinical nodal metastasis. RESULTS: In all cases, safely extended suprapancreatic lymph node dissection was successfully accomplished using the described technique. A total of 43.5 +/- 18 lymph nodes were retrieved, including 14.4 +/- 6.3 second-tier lymph nodes. The overall number of retrieved lymph nodes in this study was similar to that reported previously [4]. Postoperative morbidity occurred at a rate of 22.3%, and the mortality rate was 0%. There was no conversion to open surgery. The mean blood loss was 127 ml (range, 0-490 ml), and the mean operative time was 289 min (range, 104-416 min) in the last 20 consecutive cases. To date, no tumor recurrence has been observed. The median postoperative observation period was 1.4 years (range, 0.4-2.4 years). CONCLUSION: The described novel procedure would be sufficient and convenient for dissection of the suprapancreatic lymph nodes.

Safety and efficacy of modified FOLFOX6 for treatment of metastatic or locally advanced colorectal cancer. A single-institution outcome study.

BACKGROUND: Although a variety of FOLFOX regimens (5-fluorouracil and L-leucovorin combined with oxaliplatin) are widely used for the treatment of advanced colorectal cancer, the neurotoxicity caused by oxaliplatin is often problematic. The aim of this observational study was to assess the safety and efficacy of a modified version of the FOLFOX6 regimen (mFOLFOX6) when administered using the 'stop-and-go' strategy. PATIENTS AND METHODS: A total of 112 eligible patients treated between June 2005 and July 2007 were identified using the prospective cohort database system of Kyoto University Hospital. RESULTS: The median follow-up was 16.3 months (range 1.6-33.9), and the response rate was 33.3% (95% CI 14.5-52.2), 40.0% (95% CI 22.5-57.5) and 14.0% (95% CI 3.6-24.3) for patients who received mFOLFOX6 as first-line therapy, second-line therapy and third- or later-line therapy, respectively. The estimated median progression-free survival was 8.7 months (95% CI 2.3-15.1) and 8.2 months (95% CI 7.3-9.1) for patients on first-line and second-line therapy, respectively. The median overall survival was not reached as of April 2008 for the patients on first-line therapy, while it was 27.1 months (95% CI 22.0-32.2) for those on second-line therapy. Severe neurotoxicity occurred in only 4 patients (3.6%). CONCLUSION: mFOLFOX6 administered using the stop-and-go strategy significantly reduced oxaliplatin-induced neurotoxicity relative to conventional FOLFOX treatment, without compromising efficacy.

Long-term outcomes of peripheral arm ports implanted in patients with colorectal cancer.

BACKGROUND: Venous ports are mandatory for chemotherapy in cancer patients because prolonged infusions are required. The aim of this study was to assess the safety of peripheral arm ports for chemotherapy in patients with colorectal cancer. METHODS: A peripheral venous access port was placed in the upper arm in 113 consecutive patients with metastatic colorectal cancer (MCRC). All patients received modified FOLFOX (5-fluorouracil [5-FU]/l-leucovorin [LV]/oxaliplatin [L-OHP]) 6 or FOLFIRI (5-FU/LV/irinotecan hydrochloride [CPT-11]) regimens at least once via the venous access port. All patients were followed up at least once every 2 weeks. RESULTS: Puncture of the basilic veins was successfully completed under real-time sonographic guidance or radiographic guidance in all patients. The median operative time was 30 min. The cumulative follow-up period was 29 886 catheter days (range, 9-560 days; mean, 264 days). No procedural complications, such as pneumothorax, hemothorax, arterial puncture, or cardiovascular problems, occurred in our series. A total of nine patients (8.0%) had complications. Port-site infection occurred in six patients (5.3%; 0.20 infections per 1000 catheter-days). One patient (0.9%) had an episode of ultrasound-documented deep vein thrombosis in the ipsilateral upper extremity (0.03/1000 catheter-days). Dislocation or migration of the catheter tip occurred in two patients (0.07/1000 catheter-days). A second port was placed in six patients (5.3%) after removal of the fi rst port. CONCLUSION: Peripheral arm ports can be maintained with excellent short-and long-term outcomes. Peripheral arm ports are considered to be a good alternative to central venous ports implanted in the chest in patients with MCRC.

Molecular insights into Peutz-Jeghers syndrome: two probands with a germline mutation of LKB1.

LKB1 encodes a serine/threonine protein kinase that is defective in patients with Peutz-Jeghers syndrome (PJS), a hereditary disorder characterized by gastrointestinal hamartomatous polyposis and an increased risk of cancer development. Although a tentative molecular classification of PJS patients was recently made according to their LKB1 mutation status, it is difficult to clarify the genotype-phenotype relationship because of the rarity and genetic heterogeneity of this disease. Here we report on two probands with PJS whose intestinal hamartomatous polyposis was treated by laparoscopyassisted polypectomy. Direct sequencing analyses revealed a nonsense mutation at codon 240 in exon 5 in one patient, and a mutation at a splicing donor site in intron 5 in the other patient. No additional somatic mutations were detected in the resected hamartomas in either case. Immunohistochemical analysis revealed an elevated expression of cyclooxygenase-2, and almost complete loss of LKB1 expression in the polyps, suggesting that a biallelic inactivation of the LKB1 gene was responsible for the hamartoma formation. Methylation-specific polymerase chain reaction analysis revealed no hypermethylation of the LKB1 promoter. Mutation analysis is useful in making a precise diagnosis of PJS in candidate probands, and may in the near future provide valuable information for predicting cancer risk based on genotype-phenotype correlations.

Multimedia article. Autonomic nerve-preserving total mesorectal excision in the laparoscopic era.

PURPOSE: Although technically demanding, laparoscopy may be advantageous in magnifying the anatomy of the pelvic autonomic nervous system when performing total mesorectal excision for rectal cancer. We present our method for laparoscopic total mesorectal excision for men. METHODS: We performed laparoscopic total mesorectal excision for 36 men with middle or low rectal cancer. The rectum was mobilized through a medial approach down to the pelvic floor without minilaparotomy or hand assist. Anteriorly, the dissection plane was in front of Denonvilliers fascia. Anterolaterally, to preserve the pelvic plexus and neurovascular bundle, Denonvilliers fascia must be cut at its lateral continuity. We found that the most important factor in obtaining a good surgical view is keeping adequate tension in the dissection plane by coordination between the surgeon and assistant. Dissection was performed by using only electrocautery without an ultrasonic dissector or vessel sealing device. RESULTS: No case was converted to open surgery. The short-term feasibility was acceptable. CONCLUSIONS: Our method of laparoscopic total mesorectal excision is a feasible approach and may be beneficial for the standardization and popularization of laparoscopic total mesorectal excision. Long-term results, including survival data and urogenital function, are needed to evaluate the true efficacy of this procedure.

Esophagojejunostomy through minilaparotomy after laparoscopic total gastrectomy.

Although laparoscopic distal gastrectomy (LDG) has been accepted as a surgical option for the treatment of early gastric cancer, laparoscopic total gastrectomy (LTG) has been adopted less often, because a more difficult surgical technique is required for reconstruction. To reduce the technical difficulties, we made some modifications to the functional end-to-end anastomosis technique and performed esophagojejunal anastomosis through a minilaparotomy. First, for easier handling of the esophagus, the first application of the linear stapler to create the esophagojejunal anastomosis was performed before transection of the esophagus. Second, the jejunal limb was anastomosed to the left side of the esophagus, which, compared with the right side, made available more free space, sufficient to operate the stapling device. Third, to close the entry hole and complete the gastrectomy concurrently, a linear stapler was applied through the left lower trocar. With this technique, the closure of the access opening was performed easily and was monitored directly through the minilaparotomy. We successfully performed LTG with Roux-en-Y reconstruction using our modified procedure in seven patients without any anastomotic complications. We believe our procedure is a secure and reliable method for reconstruction after LTG and will facilitate adoption of LTG as a surgical option for patients with early upper gastric cancers.

Laparoscopic restorative total proctocolectomy with mucosal resection.

PURPOSE: Laparoscope-assisted restorative proctocolectomy is an alternative to conventional surgery for the treatment of ulcerative colitis. We present our approach of laparoscopic dissection and transection of rectum combined with transanal rectal mucosectomy. METHODS: A total of 21 patients underwent laparoscopic total proctocolectomy with transanal rectal mucosectomy for ulcerative colitis. The rectum was mobilized and transected by using a combination of laparoscopic dissection and trans-anal mucosectomy without hand-assist or mini-laparotomy. The extent of laparoscopic dissection and the transection method varied according to the difficulty of pelvic dissection or the surgeon's experience (early-phase method: laparoscopic transection of the muscular-cuff after transanal mucosectomy; intermediate-phase method: transection of the posterior side transanally and anteriolateral side laparoscopically; and recent-phase method: laparoscopic dissection down to the pelvic outlet and transanal circumferential transection of the rectum after mucosectomy). RESULTS: Using this approach, the median operative time was 404 minutes and the median operative blood loss was 120 g. There was no operative mortality, and no patients reported sexual or urinary complications during short-term follow-up. CONCLUSIONS: Laparoscopic total proctocolectomy for the treatment of ulcerative colitis is a feasible approach that demonstrates excellent views of the pelvis, which could be advantageous compared with conventional surgery. A step-by-step approach according to the surgeon's experience and the difficulty of pelvic dissection may help minimize the risk of pelvic autonomic nerve injury.