The necessity of routine screening for deep vein thrombosis before surgery.

Background: Pulmonary embolism (PE) from deep venous thrombosis (DVT) can be a fatal postoperative complication. Preventive measures for venous thromboembolism (VTE) was evaluated in this hospital. Materials and methods: Preoperative DVT screening following surgery under general anesthesia in 2009-2016 was examined, and then, 217 patients diagnosed with DVT by preoperative leg-ultrasound (US) between 2014 and 2016 were retrospectively analyzed. Results: There were 24,826 operations under general anesthesia in the study period. Preoperative leg-US was performed in 5345 (21.5%) patients, and 648 (12.1% of patients, 2.6% of total operations) were diagnosed with DVT. In 2014-2016, 217 patients, which is 11.7% of patients undergoing leg-US, were diagnosed with DVT. DVT was found in the proximal veins (upper popliteal vein) in 86 (39.6%) patients. A total of 143 (62%) patients were considered to have organized thrombi, no patient developed pulmonary embolism, and 133 (58%) patients were discharged without follow-up examination for DVT. Ninety-six patients were evaluated for changes on leg-US, with no difference in the results with and without anticoagulant use. On multivariate logistic regression analysis, anticoagulants appeared effective for non-organized thrombi, higher D-dimer levels (≥10 µg/mL), or orthopedic surgery. Conclusion: Preoperative screening for DVT did not appear useful, and treatment of asymptomatic DVT was not always necessary.

Transperineal abdominoperineal resection in the prone jackknife position in male patients with low rectal cancer.

INTRODUCTION: In male patients with low rectal cancer undergoing abdominoperineal resection (APR), successful dissection of the anterior anorectum is key to reducing the risk of circumferential resection margin involvement, intraoperative bowel perforation, and local recurrence, but it is challenging. To overcome difficulties dissecting the anterior anorectum, we present a safe and feasible procedure using a transperineal endoscopic approach during APR (TpAPR). MATERIALS AND SURGICAL TECHNIQUE: The male patient is placed in the prone jackknife position. TpAPR precedes the procedure from an abdominal approach. We use some pelvic tissues as clear anatomical landmarks to dissect the anterior anorectum. The key steps of this procedure are shown in the video. DISCUSSION: The identification of a clear anatomical dissection plane of the anterior anorectum is difficult because of the complex surgical anatomy of the region. Clear anatomical landmarks for dissection of the anterior anorectum are necessary for safe implementation of this procedure. Therefore, TpAPR in the prone jackknife position can be performed to obtain better visualization of each anatomical landmark at a glance.

Transanal total pelvic exenteration in the prone jackknife position for rectal cancer invading the bladder, seminal vesicles, and small intestine.

A 58-year-old man had rectal cancer directly invading the urinary bladder and small intestine, without distant metastasis. We successfully performed complete resection using a hybrid approach, including laparoscopic surgery and transanal total pelvic exenteration (TaTPE) with the patient in the prone jackknife (PJK) position. In the PJK position, gravity and pelvic morphology lead to a clear and wide surgical field. This case demonstrates that total pelvic exenteration using laparoscopic surgery and TaTPE in the PJK position provides a better surgical field than either TaTPE or laparoscopic surgery in the supine position. TaTPE in the PJK position may also be useful for curative surgery in locally advanced rectal cancer.

Transanal total mesorectal excision in the prone jackknife position without being conscious of the size of prostatic enlargement for lower rectal cancer.

In 1982, it was demonstrated that a total mesorectal excision alone could achieve low rectal cancer recurrence rates in the pelvis and high disease-free survival rates. Nowadays, the total mesorectal excision is the gold-standard surgery for rectal cancer. Currently, the transanal total mesorectal excision has attracted attention as a promising alternative to the anterior approach. The transanal approach is superior to the anterior approach, because it facilitates total mesorectal excisions of the lower rectum, improves visualization, and shortens the surgical time. Some factors are particularly favorable for the transanal approach, including lesions in the lower third of the rectum, a narrow pelvis, a large tumor, male sex, and a prostatic enlargement. The transanal total mesorectal excision is commonly performed in the Lloyd-Davies position. However, in the Lloyd-Davies position, the sacral bone prevents the mobilized rectum from moving away from the pelvic base. From the perspective of pelvic morphology, we reasoned that, in the prone jackknife position, the mobilized rectum could spontaneously move toward the head, due to gravity, and this would broaden the pelvic surgical field. Consequently, this position could facilitate the transanal total mesorectal excision. Here, we described a transanal total mesorectal excision performed in the prone jackknife position for treating lower rectal cancer with a prostatic enlargement.

Hybrid approach using laparoscopy and transanal minimally invasive surgery to treat rectal cancer with invasion to the seminal vesicles.

We treated a 64-year-old man for rectal cancer with direct invasion to the seminal vesicles and no distant metastases by complete resection with laparoscopy and transanal minimally invasive surgery (TAMIS). We inserted the TAMIS device into the anal canal to above the anorectal ring and dissected to prostate level. High ligation of the inferior mesenteric artery and vein was performed by standard medial laparoscopy. The sigmoid and descending colon were mobilized, and in the postrectal space, we dissected to the space made by TAMIS. The membranous peritoneum was dissected on both sides of the rectum to the cul de sac. The peritoneum was dissected anterolaterally to reveal the seminal ducts, which were ligated and dissected on both sides. The seminal vesicles were dissected from the posterior wall of the bladder to the prostate level. The rectal specimen was now fully mobilized. Lower rectal resection with combined laparoscopy and TAMIS provided a better surgical plane than standard laparoscopy.

Laparoscopic radical lymph node dissection for advanced colon cancer close to the hepatic flexure.

INTRODUCTION: Complete mesocolic excision is currently recognized as a standard procedure for colon cancer. Gastroepiploic, infrapyloric, and superficial pancreatic head lymph node metastases in the gastrocolic ligament have been reported for colon cancer close to the hepatic flexure. We sought to investigate metastases in the gastrocolic ligament in colon cancer close to the hepatic flexure. METHODS: This was a single-center retrospective study. All patients with T2 or deeper invasive colon cancer in the relevant tumor location who underwent laparoscopic right hemicolectomy or extended right hemicolectomy at our institution between 1 April 2011 and 31 March 2015 were included. RESULTS: Lymph node dissection in the gastrocolic ligament was performed in 35 cases. Complications occurred in 11 patients (31%) and were grades I and II according to the Clavien-Dindo classification. Lymph node metastases in the gastrocolic ligament were found in only three patients (9%). Each metastasis was larger than 9 mm. CONCLUSIONS: Metastases in the gastrocolic ligament occurred in 9% of patients with T2 or deeper invasive colon cancer close to the hepatic flexure. Laparoscopy was feasible and useful during gastrocolic ligament resection. This study included a small sample and lacked an extended follow-up. Further studies are needed to determine the clinical relevance of this finding, particularly in terms of recurrence and long-term survival.

Single-access laparoscopic colectomy utilizing gravity in the lateral decubitus position.

BACKGROUND: Only a limited number of instruments can be used in single-access laparoscopic colectomy, and triangulation must be forfeited to avoid instrument collision. We investigated whether this problem could be overcome by performing laparoscopic colectomy by the use of the lateral decubitus position, making full use of gravity. OBJECTIVE: The aim of this study was to determine whether single-access laparoscopic colectomy could be achieved while maintaining patients in the lateral decubitus position. DESIGN: This was a prospective study. SETTING: This single-center study was conducted in a hospital. PATIENTS: Ten consecutive patients (4 men and 6 women) with stage II or III colon cancer were included. INTERVENTIONS: Each patient was placed in the lateral decubitus position. Single-port access to the abdomen was provided by a 3.0-cm incision at the umbilicus. The roots of the supplying or draining vessels were isolated and divided for lymphadenectomy. Next, the colon was dissected from a lateral approach, without the help of the assistant. The specimen was extracted from the single-access incision. Extracorporeal or intracorporeal anastomosis was performed. MAIN OUTCOME MEASURES: The primary outcome measured was the feasibility of single-access laparoscopic colectomy in the lateral decubitus position. RESULTS: There were no intraoperative complications and no need for conversions to conventional laparoscopic surgery, open surgery, or the supine position. The median total surgical time was 154 minutes (interquartile range, 135-220 minutes). Surgical blood loss was slight (<20 mL) in all patients. No postoperative complications occurred. The median postoperative hospital stay was 7 days (interquartile range, 5-7 days). LIMITATIONS: The sample size was small. CONCLUSIONS: Our results show that single-access laparoscopic colectomy in the lateral decubitus position is safe and feasible.

Single-scar laparoscopic colectomy with intracorporeal attachable and detachable instruments.

BACKGROUND: In single-access laparoscopic colectomy, the number of instruments that can be inserted through the single-access site is limited by instrument collision. To compensate, triangulation is necessary, but the operative field becomes inadequate. To overcome this problem, intracorporeal attachable and detachable instruments can broaden the field of visceral tissue by retracting from at least 2 points. OBJECTIVE: We tested this new procedure for colon cancer surgery. DESIGN: This is a prospective study. SETTING: This study was conducted at a single-center hospital. PATIENTS: Ten consecutive patients (3 male and 7 female) with stage II or III colon cancer underwent the procedure. INTERVENTIONS: All patients received a 3.0-cm incision at the umbilicus or right iliac fossa. At least 2 clips and a suspending bar were inserted through a 12-mm port in a multiport access device. The clips grasped the mesocolon at different points and were retracted with either an extracorporeal magnet or fine-loop retractors; this broadened the operative field in the mesocolon by at least 2 points. The mesocolon was dissected with a medial to lateral approach. The suspended bar was tied to 2 fine-loop retractors and manipulated to enlarge the operative field in the mesocolon. The roots of the vascular pedicles were isolated and divided during lymph node dissection. After extracting the specimen, an anastomosis was performed. MAIN OUTCOME MEASURES: Intra- and postoperative complications due to inadequate access were the primary outcomes measured. RESULTS: There were no intraoperative complications and no need for conversions to open surgery or second access ports. The median total surgical time was 182 minutes (range, 122-245). Surgical blood loss was slight (range, 1-20 mL) in all patients. No postoperative complications occurred. The postoperative hospital stay was 5 to 7 days. LIMITATIONS: The sample size was small. CONCLUSIONS: This study showed that intracorporeal attachable and detachable instruments were safe and feasible for this procedure.

Single-access laparoscopic low anterior resection with vertical suspension of the rectum.

PURPOSE: Single-access laparoscopic surgery was first introduced for colectomy and later adapted for anterior resection. During single-access laparoscopic pelvic procedures, such as total mesorectal excision, it is often difficult to obtain an adequate operative field. By suspending the rectum vertically, we were able to execute a total mesorectal excision with single-access laparoscopy. We describe here the use of this new procedure to treat rectal cancer. METHODS: The selected 7 patients (1 male and 6 female) with stage II or III rectal cancer underwent the procedure. Single-port access to the abdomen was provided by a 3.0-cm incision at the right iliac fossa. The descending mesocolon was dissected by use of a medial approach, and a columnar magnet was placed on the surface of the abdominal wall to restore triangulation. The inferior mesenteric artery was skeletonized and the superior rectal artery divided during lymph node dissection. The total mesorectal excision extended to the pelvic floor and the rectum was vertically retracted with a suspending bar in collaboration with an extracorporeal magnet tool. The rectum was then transected below the reflection of the peritoneum. Intracorporeal anastomosis was performed with the double-stapling technique. Two pelvic drains were inserted through the single incision and the anus, respectively, for all patients. A defunctioning ileostomy was not created in any patient. RESULTS: Median total surgical time was 205 minutes (range, 175-245 min). Intraoperative blood loss was minimal in all patients (range, 1-20 mL). None of the cases required conversion to open surgery or addition of a second port. The only preoperative or postoperative complication occurred in one patient with clinical anastomotic leakage. CONCLUSION: Low anterior single-access laparoscopic resection seems safe and feasible when the rectum is suspended like a swing to ensure an adequate operative field.

Multimedia article. Radical lymphadenectomy for advanced colon cancer via separation of the mesocolon into two layers as in filleting fish.

BACKGROUND: Radical lymphadenectomy for advanced colon cancer performed via the medial approach improves oncologic outcomes. However, D3 radical lymphadenectomy possesses some unresolved problems such as the complicated vascular anatomy and concerns over surgical morbidity [1-5]. The authors present a simple and safe procedure for laparoscopic right or left hemicolectomy using a medial approach to overcome these problems. The key characteristic of their procedure is separation of the mesocolon into two layers along the superior or inferior mesenteric artery, showing the course of these branches under the mantle of the vascular sheath. This procedure resembles filleting fish into two pieces. METHODS: Between October 2009 and March 2010, 11 consecutive patients with advanced colon cancer underwent a curative laparoscopic right (n=5) or left (n=6) hemicolectomy via a medial approach by a single surgeon. The body mass image (BMI) for the 11 patients ranged from 22 to 32 kg/m2. With this procedure, the D3 lymphadenectomy procedure is performed first [6]. The mesocolon is dissected between the superficial layer of the fat tissue and the deep layer of the vascular sheath along the superior or inferior mesenteric artery. After the course of each branch is exposed, each supplying or draining vessel is transected at its root [7, 8]. The use of a laparoscope and a spatula-type electric cautery greatly contributes to this procedure [9]. Next, the bowel is mobilized, and the specimen is retrieved through the small incision. Finally, extra- or intracorporeal anastomosis is performed. RESULTS: No intraoperative complications occurred. The median number of retrieved lymph nodes was 23 (range, 13-52). The median total operative time was 220 min (range, 145-318 min), and the intraoperative blood loss was minimal (range, 0-70 g). The postoperative course was uneventful for all the patients. CONCLUSIONS: The authors consider the described method to be simple and safe for radical lymphadenectomy during a laparoscopic right or left hemicolectomy.

Single-access laparoscopic left and right hemicolectomy combined with extracorporeal magnetic retraction.

PURPOSE: In single-access laparoscopic colectomy, the number of forceps inserted through the umbilical incision is limited. To compensate for the single-access site, triangulation must be lost or instrument collision must be sustained. Extracorporeal magnetic retraction can overcome this problem. This report describes the use of this new procedure for colon cancer resection. METHODS: All patients had advanced cancer of the descending or the ascending colon. Single access to the abdomen was achieved with a 3.0- to 4.0-cm umbilical incision. Short vascular forceps and 2 rolls of gauze were inserted into the incision and a columnar magnet was placed on the surface of the abdominal wall. A specially made port access device was attached at the incision. The vascular forceps grasping the tissue were retracted by moving the magnet, enabling triangulation in cooperation with a second forceps. The mesocolon was dissected using a medial to lateral approach. The roots of the vascular pedicles were isolated and divided from the superior or the inferior mesenteric artery during lymph node dissection. Extracorporeal anastomosis was performed. RESULTS: There were no intraoperative complications, no need to convert to open surgery, and no need to add a second port. The median total surgical time was 255 (range, 220-315) minutes. Surgical blood loss was slight (range, 1-20 mL) in all patients. No postoperative complications occurred. The postoperative hospital stay was 7 days for each patient. CONCLUSIONS: This procedure can be safely and feasibly performed using extracorporeal magnetic retraction.

Single-access laparoscopic colectomy with a novel multiport device in sigmoid colectomy for colon cancer.

PURPOSE: Laparoscopic-assisted colectomy is a common procedure for colorectal disease, and laparoscopic colectomy from a single access point is rapidly evolving. This report describes the use of single-access laparoscopic colectomy (SALC) with a novel multiport device in sigmoidectomy for colon cancer. METHODS: Data were collected retrospectively on 5 patients who underwent the procedure for colon cancers in the period from November 2008 through January 2009. The abdomen was approached through a 3- to 4-cm incision via the umbilicus in every case. To ensure maintenance of the pneumoperitoneum, the procedure was performed with a specially developed multiport device enveloped by a glove containing 3 5-mm ports. In all 5 patients, the root of the inferior mesenteric artery was isolated and divided at the distal side where the left colic artery branched off. RESULTS: The median total surgical time was 185 (range, 176-210) minutes. In all patients, surgical blood loss was slight (range, 0-20 mL). Only one patient required conversion into laparoscopic-assisted colectomy by the addition of 2 ports, because the location adjacent to the descending colon made it necessary to mobilize the splenic flexure. The median number of harvested lymph nodes was 17 (range, 12-24). No postoperative complications occurred. The postoperative hospital stay was 7 days for every patient. CONCLUSIONS: Single-access laparoscopic sigmoidectomy seems to be feasible and safe when performed by experienced laparoscopic surgeons who are familiar with the unique principles of this procedure. Additional experience and continued investigations are warranted.