Integration of transanal specimen extraction into laparoscopic anterior resection with total mesorectal excision for rectal cancer: a consecutive series of 179 patients.

BACKGROUND AND OBJECTIVES: This prospective study focused on patients with rectal cancer who underwent transanal specimen extraction after laparoscopic anterior resection with total mesorectal excision and specifically aims to investigate whether the transanal approach can be accepted as a safe and effective method for extracting the malignant specimen from the peritoneal cavity. PATIENTS AND METHODS: A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal malignancy with various tumor-node-metastasis (TNM) classifications from April 1991 to May 2011 at the Texas Endosurgery Institute was analyzed. Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of size of the pathology and distance of rectal lesions from the anal verge. RESULTS: 179 anterior resections were completed laparoscopically with intracorporeal anastomosis and transanal specimen extraction. The operating time for the entire procedures including resection, anastomosis, and specimen extraction was 170.9 ± 51.2 min, blood loss during the procedures was 86.4 ± 37.7 ml, and distance of the lower edge of the lesion from the anal verge was measured to be 11.3 ± 7.3 cm. Postoperatively, three patients developed anastomotic leakage with a leak rate of 1.7%, and the overall major complication rate after the procedures was 5.0%. Length of hospital stay was 6.9 ± 2.8 days. Two-year follow-up showed development of anal stenosis in three patients (2.0%) and erectile dysfunction in one patient (0.36%) after surgery. Finally, 9 out of 179 patients who underwent laparoscopic anterior resection with transanal specimen extraction were confirmed to have cancer recurrence, with 2-year local recurrence rate of 5.0%. CONCLUSIONS: Transanal specimen extraction in laparoscopic rectal cancer resection is a safe and effective approach with comparable local cancer recurrence rate and postoperative complication rates, suggesting it can be integrated into laparoscopic anterior resection for rectal cancer.

Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann's procedure.

BACKGROUND: This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann's procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis. METHODS: A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P < 5 % was considered statistically significant in this study. RESULTS: A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1 %) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182 ± 54.7 min, and EBL was 210 ± 170.5 ml. Six LHP (14.6 %) were converted to open Hartmann's for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1 %, respectively. For LLD, the operating time was 99.7 ± 39.8 min, and blood loss was 34.4 ± 21.2 ml. Three patients (6.4 %) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3 ± 10.1 vs. 6.7 ± 2.2 days, P < 0.01). In the long-term follow-up, the rate of colostomy closure for LHP is 72.2 %, and 21 of 47 patients who underwent LLD had elective sigmoidectomy for the source control with the rate of 44.7 %. CONCLUSIONS: Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications.

Negative pressure therapy: a viable option for general surgical management of the open abdomen.

BACKGROUND: Management of the open abdomen (OA) is challenging for surgeons and requires experienced medical teamwork. The need for improvements in temporary abdominal closure methods has led to the development of a negative-pressure therapy (NPT; ABThera OA NPT, KCI USA, Inc, San Antonio, TX). METHOD: The authors present a 19-patient case series documenting their use of NPT for OA management in nontraumatic surgery. All received NPT until the fascia was considered ready for closure. RESULTS: Of 19 patients, 17 (89.5%) achieved fascial closure with a Kaplan-Meier (KM) median time to closure of 6 days. Mean hospital and intensive care unit stays were 32.1 and 26.6 days, respectively. During their hospitalization, 5 patients (26.3%) died, with a KM median time to mortality of 53 days. CONCLUSION: These findings demonstrate effective use of NPT for managing the OA in critically ill patients, and this has led the authors to use it in their general surgery practice.

Laparoscopic appendectomy: vascular control of the appendicular artery using monopolar cauterization versus clips.

INTRODUCTION: Laparoscopic appendectomy is now the standard of treatment for acute appendicitis in medical centers where advanced minimally invasive surgery is performed, and it has become the standard of care in our institution. The techniques for laparoscopic appendectomy are widely described in surgical textbooks, but the vascular control of the appendicular artery is diverse. In this article, we compare the benefits and possible complications of different techniques to obtain vascular control. SUBJECTS AND METHODS: This is a retrospective study of prospectively collected data including all cases of laparoscopic appendectomy from September 1990 to August 2009. Here we describe the different methods used, and we present a large series of 729 cases of laparoscopic appendectomy. In the majority of the cases the diagnosis was acute appendicitis followed by laparoscopic appendectomy. In only 124 cases was an incidental appendectomy performed associated with another laparoscopic procedure. RESULTS: In 350 cases (48%) monopolar cauterization was used to obtain vascular control of the appendicular artery. In the other 379 cases the artery was either clipped or stapled (52%). There were no postoperative complications reported. There was no difference in patient outcome with either approach to obtain adequate vascular control. CONCLUSIONS: The vascular control of the appendicular artery obtained with monopolar cautery is a safe, fast, and economic approach easily done during a laparoscopic or needlescopic appendectomy with no increased risks or complications.

Laparoscopic loop ileostomy reversal: reducing morbidity while improving functional outcomes.

INTRODUCTION: Loop ileostomy reduces the morbidity associated with pelvic sepsis. However, its reversal carries a 10% to 30% complication rate. We present our technique for laparoscopic ileostomy closure. METHODS: We conducted a retrospective chart review of subjects undergoing laparoscopic-assisted loop ileostomy closure between 2006 and 2009. Operating time, length of hospital stay, return of bowel function, and complication rates were assessed. RESULTS: There were 24 (13 males) patients. Average age was 63 with a BMI of 25.9. Eighteen (75%) had a planned loop ileostomy, and 6 (25%) were emergent. Average time to reversal was 135 days. Average length of surgery was 79 minutes (range, 48 to 186), average stay was 4 days and return to bowel function was 3.6 days. We had no wound infections. Our complication rate was 29% (n=7), and reoperation rate was 12.5% (n=3). Only 1 major complication occurred, an anastomotic dehiscence. CONCLUSION: A thorough, well-visualized lysis of adhesions and mobilization of the stoma and surrounding small bowel is the main advantage of our approach. We had no wound infections and no reoperation for bowel obstruction, which we feel is a direct advantage of our technique. Our complication rate and surgical time are comparable to those of the open technique.

Needlescopic cholecystectomy.

Minimally invasive techniques have revolutionized the art of surgical practice. The laparoscopic approach to cholecystectomy has become the gold standard and is the most common laparoscopic general surgery procedure worldwide. In an effort to further enhance the advantages of laparoscopic surgery even less-invasive methods have been attempted, including smaller and fewer incisions. The objective of this study was to describe our results with over 15 years of needlescopic cholecystectomies. At the Texas Endosurgery Institute, 434 operations were done by a single surgeon from 1995 to 2010. Eighty-six percent of subjects were female, and the average age of all subjects was 41.9 years (range 14-82). The average operating time was 59.3 minutes (range 30-200). The 200-minute operation required laparoscopic CBD exploration, accounting for the extended time. Average estimated intraoperative blood loss (EBL) was <15 cc (range 0-50 cc). Two percent of cases required conversion to standard 5-mm cholecystectomy and were completed without incident. All patients are followed up at two weeks and then at six months. Since 1995, only one patient presented with a hernia at the umbilical site. Otherwise, no wound, bile duct, bile leak, bleeding, or thermal injury complications have been identified.

The use of bioabsorbable staple line reinforcement for circular stapler (BSG "Seamguard") in colorectal surgery: initial experience.

Of all the complications associated with colorectal surgery, the most devastating and constant, despite all techniques being performed properly is anastomotic leakage, especially in left colon and rectal resections with rates as high as 50% when the rectum is involved. In 2005, our center published the preliminary experience with the use of linear staple line reinforcement for colon surgery. The purpose of this paper is to present a series of cases using a new conformation of bioabsorbable reinforcement for circular staplers in 5 patients, 2 patients with rectal cancer, 2 patients with diverticular disease, and 1 patient with sigmoid cancer. These initial data are very promising and has encouraged us to continue using this device on further patients.