Laparoscopic right radical hemicolectomy: Central vascular ligation and complete mesocolon excision vs D3 lymphadenectomy - How I do it?

In colon cancer surgery, ensuring the complete removal of the primary tumor and draining lymph nodes is crucial. Lymphatic drainage in the colon follows the vascular supply, typically progressing from pericolic to paraaortic lymph nodes. While NCCN guidelines recommend the removal of 10-12 lymph nodes for adequate oncological resection, achieving complete oncological resection involves more than just meeting these numerical targets. Various techniques have been developed and studied over time to attain optimal oncological outcomes. A key technique central to this goal is identifying the ileocolic vessels at their origin from the superior mesenteric vessels. Complete excision of the visceral and parietal mesocolon ensures the intact removal of the specimen, while D3 lymphadenectomy targets all draining regional lymph nodes. Although these principles emphasize different aspects, they ultimately converge to achieve the same goal of complete oncological resection. This article aims to simplify the surgical steps that align with the principle of central vascular ligation and mesocolon mobilization while ensuring adequate D3 dissection.

Comparing extracorporeal, semi-extracorporeal, and intracorporeal anastomosis in laparoscopic right hemicolectomy: introducing a bridging technique for colorectal surgeons.

Purpose: Intracorporeal anastomosis (IA) in laparoscopic right hemicolectomy has been associated with faster recovery in bowel function compared to extracorporeal anastomosis (EA). However, the technical difficulty of laparoscopic suturing technique and intraabdominal fecal contamination hinder many surgeons from implementing such a procedure. We introduce and compare a bridging technique designated as "semi-extracorporeal" anastomosis (SEA), which embraces the advantages and amends the drawbacks of IA and EA. Methods: Between May 2016 and October 2022, 100 patients who underwent laparoscopic right hemicolectomy were analyzed. All patients who received laparoscopic right hemicolectomy underwent one of the 3 anastomosis methods (EA, SEA, and IA) by a single colorectal surgeon at a single tertiary care hospital. Data including perioperative parameters and postoperative outcomes were analyzed by each group. Results: A total of 100 patients were reviewed. Thirty patients underwent EA; 50 and 20 patients underwent SEA and IA, respectively. Operation time (minute) was 170 (range, 100-285), 170 (range, 110-280), and 147.5 (range, 80-235) in EA, SEA, and IA, respectively (P = 0.010). Wound size was smaller in SEA and IA compared to EA (P < 0.001). IA was associated with a shorter time (day) to first flatus compared to SEA and EA (4 [range, 2-13] vs. 4 [range, 2-7] vs. 2.5 [range, 1-4], P < 0.001). Postoperative complication showed no statistical significance between the 3 groups. Conclusion: Semi-extracorporeal was an attractive bridging option for colorectal surgeons worrisome of the technical difficulty of IA while maintaining faster bowel recovery and smaller wound incisions compared to EA.

Incarcerated Bochdalek Hernia in Adults.

In this case report, the diagnostic challenge and emergency management of a Bochdalek hernia in adults in Mexico are outlined. This case report can help the medical community to consider the clinical presentation in adults and the importance of early diagnosis and management. We present a 57-year-old female patient with a history of arterial hypertension who, following a bout of abdominal pain, was diagnosed with a Bochdalek hernia. Following emergency surgery, there was an increase in intra-abdominal pressure, which was continuously monitored due to the possibility of compartment syndrome, potentially necessitating a second emergency surgery.

Mucocoele of the appendix.

Introduction: Mucocoele of the appendix occurs in 0.2-0.7% of people in the world without any well-defined clinical symptoms. It occurs when there is an accumulation of mucous in the lumen of the appendix. Case Presentation: We present three cases: a 48-year-old male admitted to the emergency room with a one-day history of right iliac fossa pain. Abdominal examination was suggestive of acute appendicitis. The initial abdominal computerised tomography scan was reported as being unremarkable. At surgery, a firm tumour of the appendix was found, and a limited right hemicolectomy was done. Histopathology confirmed a mucocoele of the appendix with borderline mucinous histology.The second case is a 63-year-old man who presented with a one-year history of abdominal distension and weight loss. Previous abdominal ultrasound was suggestive of liver cirrhosis with significant ascitic fluid. Abdominal magnetic resonance imaging found an appendix mucocoele with infiltration of the omentum and scalloping of the liver surface suggestive of pseudomyxoma peritonei. A percutaneous biopsy of the omental mass confirmed metastatic mucinous adenocarcinoma of the appendix.The third case is a 68-year-old man who, during an annual medical check-up, had an incidental finding of a cystic right iliac fossa mass on ultrasound, confirmed on abdominopelvic computerised tomography scan to be an appendix mucocele. He had laparoscopic appendicectomy. The histopathological diagnosis confirmed a mucinous cystadenoma of the appendix. Conclusion: Preoperative diagnosis of appendiceal mucocoele is difficult and commonly discovered intraoperatively. The prognosis is good for the histologically benign type, but it is poor when malignant or peritoneal lesions are present. Funding: None declared.

The effect of ileal resection length on postoperative complications and prognosis in right colon cancer.

BACKGROUND: There is a lack of literature on the length of the terminal ileum to be resected in right hemicolectomy for colon cancer. Therefore, we aimed to determine the mean ileal loop length and the effect of this variation on postoperative complications and long-term oncological outcomes in patients who underwent right hemicolectomy. METHODS: Right hemicolectomy surgeries performed for colon cancer in a tertiary care hospital between January 2011 and December 2018 were retrospectively analyzed from a prospective database. Two patient groups were established based on the mean length of the resected ileum above and below 7 cm. The two groups were compared for clinicopathological data, postoperative complications, mortality, long-term overall survival (OS) and disease-free survival (DFS). The factors contributing to OS and DFS were analyzed. RESULTS: The study included 217 patients. Body mass index (BMI) values were significantly higher in the ileum resection length > 7 cm group (p = 0.009). Pathological N stage, tumor diameter, and number of metastatic lymph nodes were significantly higher in the ileum resection length > 7 cm group (p = 0.001, p = 0.001, and p = 0.026, respectively). There was no significant difference for postoperative complication and mortality rates between the two groups. The mean follow-up period was 61.2 months (2-120) in all patients. The total number of deaths was 29 (11.7%) while the 60-month OS was 83.5% and 50-month DFS was 81.8%. There was no significant difference between the groups in terms of OS and DFS rates (p > 0.05). CONCLUSIONS: Excessive resection of the distal ileum in right hemicolectomy does not provide any benefit in terms of prognosis and complications.The ileum resection length and values close to it in our study appear to be sufficient.

Diffuse large B-cell lymphoma-induced intussusception: A case report and literature review.

Adult intussusception necessitates early surgical intervention. We emphasis the significance of considering diffuse large B-Cell lymphoma in differential diagnoses for adult intussusception, particularly in the colon, to ensure precise diagnosis and optimal management.

Ascending colon cancer metastasized to the right testicle: a case report.

BACKGROUND: Testicular metastasis from malignant solid tumors is extremely rare. It is usually found by chance during autopsy or pathological examination of testicular specimens. Therefore, we consider it necessary to report our patient's case of testicular metastasis from colon cancer. CASE PRESENTATION: We report a 61-year-old Han Chinese male patient who presented to our clinic with progressive painless swelling of the right testicle for 2 years. Positron emission tomography-computed tomography scans showed increased 18F-fluorodeoxyglucose metabolism in the right testicle, possibly owing to distant metastasis. His previous medical history suggested that he had undergone laparoscopic-assisted right hemicolectomy for ascending colon cancer 4 years ago. Considering the ascending colon cancer metastasis to the right testicle, we performed a right radical testicular resection through an inguinal approach. Postoperative histological examination showed intestinal metastatic adenocarcinoma. CONCLUSION: Colon cancer metastasis to the testes is uncommon. The clinical and imaging manifestations of this tumor are nonspecific, so the diagnosis relies on postoperative pathology. If testicular metastasis is found, treatment principles for advanced colon cancer should be followed.

Making the cut? Reviewing the quality of surgical care in adults with Crohn's disease.

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reviewed the quality of care provided to adult patients undergoing surgery for Crohn's disease. The study reviewed elective, and emergency surgical pathways and the report highlighted clinical and organisational changes that should be made to improve patient care and outcomes.

A retrospective cohort study of intra-corporeal versus extra-corporeal anastomosis for right hemicolectomy with cost-effectiveness analysis.

BACKGROUND: We aimed to compare outcomes and cost effectiveness of extra-corporeal anastomosis (ECA) versus intra-corporeal anastomosis (ICA) for laparoscopic right hemicolectomy using the National Surgical Quality Improvement Programme data. METHODS: Patients who underwent elective laparoscopic right hemicolectomy for colon cancer from January 2018 to December 2022 were identified. Non-cancer diagnoses, emergency procedures or synchronous resection of other organs were excluded. Surgical characteristics, peri-operative outcomes, long-term survival and hospitalisation costs were compared. Incremental cost-effectiveness ratio (ICER) was used to evaluate cost-effectiveness. RESULTS: A total of 223 patients (175 ECA, 48 ICA) were included in the analysis. Both cohorts exhibited comparable baseline patient, comorbidity, and tumour characteristics. Distribution of pathological TMN stage, tumour largest dimension, total lymph node harvest and resection margin lengths were statistically similar. ICA was associated with a longer median operative duration compared with ECA (255 min vs. 220 min, P < 0.001). There was a quicker time to gastrointestinal recovery, with a shorter median hospital stay in the ICA group (4.0 versus 5.0 days, P = 0.001). Overall complication rates were comparable. ICA was associated with a higher surgical procedure cost (£6301.57 versus £4998.52, P < 0.001), but lower costs for ward accommodation (£1679.05 versus £2420.15, P = 0.001) and treatment (£3774.55 versus £4895.14, P = 0.009), with a 4.5% reduced overall cost compared with ECA. The ICER of -£3323.58 showed ICA to be more cost effective than ECA, across a range of willingness-to-pay thresholds. CONCLUSION: ICA in laparoscopic right hemicolectomy is associated with quicker post-operative recovery and may be more cost effective compared with ECA, despite increased operative costs.

Adult Ileocolic Intussusception Secondary to Cecal Lipoma: A Case Report.

Large intestinal intussusception is rare in adults. Among potential pathologic lead points for intussusception are lipomas, benign tumors very infrequently found in the large bowel. A 30-year-old woman presented to the emergency department with a chief complaint of generalized abdominal pain for two weeks. A computed tomography scan of her abdomen and pelvis showed an ileocolic intussusception with a lead point of 6.7 cm. The lead point appeared to be predominantly fat. A colonoscopy revealed a large, obstructing lesion in the transverse colon. The patient underwent exploratory laparotomy with a right hemicolectomy, and a pathologic diagnosis of a lipoma was made. The patient recovered from surgery without complications and returned to her normal diet three weeks after discharge. This case highlights an unusual and rare presentation of an ileocolic intussusception caused by a cecal lipoma acting as a lead point.

Cecal volvulus in pregnancy: A rare case report.

INTRODUCTION AND IMPORTANCE: Cecal volvulus is a rare cause of obstruction in pregnancy. It accounts for ∼1.5 % of all intestinal obstructions. The diagnosis is challenging and causes increased morbidity and mortality to the mother and fetus. This case report will highlight the life-threatening nature of this condition and emphasize the critical importance of early diagnosis and intervention. CASE PRESENTATION: A 30-year-old gravida-3 para-2 patient presented with colicky abdominal pain of 24 h duration. She had associated abdominal distension, vomiting and fever. She had amenorrhea of 05-months. The past medical and surgical histories were negative. Her vital signs were deranged and had tenderness all over the abdomen. Ultrasound showed gaseous abdomen and viable fetus in the uterus. Laparotomy has revealed gangrenous cecal volvulus. A right hemicolectomy and end-to-side ileo-transverse colon anastomosis were performed. She expelled a dead fetus after 12 h. She was discharged in good clinical status. DISCUSSION: Cecal volvulus involves axial rotation of the ascending colon, cecum, and terminal ileum about associated mesentery. Pregnancy is among the pre-disposing factor for cecal volvulus. The diagnosis is often challenging because of non-specific presentations. Radiologic procedures are helpful in the diagnosis. The primary treatment is surgical intervention. CONCLUSION: Cecal volvulus is a rare life-threatening cause of obstruction in pregnancy. It is an emergency situation, and early diagnosis and intervention are crucial to decreasing morbidity and mortality. The most effective treatment is surgical resection.

Three twisted tales: A case series of caecal volvulus.

INTRODUCTION: Caecal volvulus is a form of intestinal obstruction with life-threatening potential. While rare, it represents a perilous aetiology of intestinal blockage, with clinical manifestations spanning from abdominal discomfort to mortality. CASE SERIES: We report the cases of three young adults (two males and one female) who presented to the emergency department with different manifestations of severe abdominal pain. All occurred within one month in a tertiary referral centre. Radiological evaluations confirmed the diagnosis of caecal volvulus in all. Subsequently, these individuals underwent right hemicolectomies with end-to-end anastomosis. All experienced an uncomplicated perioperative course. CLINICAL DISCUSSION: Caecal volvulus is uncommon, but its yearly incidence is increasing. Early detection and a heightened level of suspicion lead to a timely diagnosis, reducing morbidity and mortality rates. CONCLUSION: We report a case series of caecal volvulus, emphasizing its variable presentation and highlighting the critical importance of an early diagnosis. Typically, patients have a history of similar episodes that resolve without any medical intervention. Definitive treatment involves right hemicolectomy while conservative management is associated with very high recurrence rates. Early detection allows for prompt intervention, resulting in reduced morbidity and mortality rates.

Laparoscopic ileocecal-sparing vs traditional right hemicolectomy for cancer of the hepatic flexure or proximal transverse colon: a dual-center propensity score-matched study.

Background: Traditional right hemicolectomy (TRH) is the standard treatment for patients with nonmetastatic right colon cancer. However, the ileocecum, a vital organ with mechanical and immune functions, is removed in these patients regardless of the tumor location. This study aimed to evaluate the technical and oncological safety of laparoscopic ileocecal-sparing right hemicolectomy (LISH). Method: Patients who underwent LISH at two tertiary medical centers were matched 1:2 with patients who underwent TRH by propensity score matching based on sex, age, body mass index, tumor location, and disease stage. Data on surgical and perioperative outcomes were collected. Oncological safety was evaluated in a specimen-oriented manner. Lymph nodes (LNs) near the ileocolic artery (ICA) were examined independently in the LISH group. Disease outcomes were recorded for patients who completed one year of follow-up. Results: In all, 34 patients in the LISH group and 68 patients in the TRH group were matched. LISH added 8 minutes to the dissection of LNs around the ileocolic vessels (groups 201/201d, 202, and 203 LNs), without affecting the total operation time, blood loss, or perioperative adverse event rate. Compared with TRH, LISH had a comparable lymphadenectomy quality, specimen quality, and safety margin while preserving a more functional bowel. The LISH group had no cases of LN metastasis near the ICA. No difference was detected in the recurrence rate at the 1-year follow-up time point between the two groups. Conclusion: In this dual-center study, LISH presented comparable surgical and oncological safety for patients with hepatic flexure or proximal transverse colon cancer.

Single-Center Experiences: A Comparison of Intracorporeal and Extracorporeal Anastomosis Outcomes in Right Hemicolectomy.

Background Anastomosis formed in minimally invasive laparoscopic right hemicolectomy (LRH) may be achieved intra-corporeally (ICA) or extra-corporeally (ECA). This study compared the return of bowel function and other associated early patient outcomes and morbidity rates after an ICA or ECA in LRH. Methodology The study conducted a single-center retrospective cohort study of elective LRH from January 2021 to September 2023. Patient demographics, surgical techniques, and outcomes were analyzed using IBM SPSS Statistics for Windows, Version 29.0 (IBM Corp., Armonk, NY). Results Ninety participants underwent LRH, and the anastomotic type was evenly distributed - with male patients comprising 53 (58.9%) of the total. The mean age was 64 (standard deviation [SD] ±16.8) years, and the median body mass index (BMI) was 27.0 (interquartile range [IQR] = 7.8). The mean follow-up period was 5.1 (SD ± 6.0) months. Univariate analysis showed that ICA had a shorter time for return of bowel function (P < 0.01). Additionally, ICA was associated with lower pain scores (P < 0.01), low morbidity (P = 0.02), and shorter hospital stays (P = 0.01). When comparing ICA to ECA, no significant difference was observed for procedure duration (P = 0.13), anastomotic leak (AL, P = 1.00), surgical-site infections (P = 0.36), lymph node yield (P = 0.26), and any-cause mortality. Multivariate logistic regression, controlling for statistically insignificant confounding factors, revealed that ECA was significantly and independently associated with increased time to first flatus (odds ratio [OR] 2.3, P = 0.01) and higher average postoperative pain (OR 1.5, P = 0.02) compared to ICA. Conclusions This single-center experience showed that ICA is associated with a quicker return to normal bowel function and low morbidity outcomes. ICA participants were positively associated with clinically relevant and health economics outcomes of shorter hospital stays without significantly adding to the procedure's duration times or compromising principles of oncological resection yield.

Unique Presentation of Adult Ileocecal Intussusception Unveiling a Rare Culprit: A Carcinoid Tumor.

Intussusception is a prominent contributor to bowel obstruction, marked by the invagination of a proximal bowel section into a distal segment. Ileocecal intussusception occurs when a portion of the terminal ileum folds into the cecum. In adults, intussusception is infrequent compared to pediatric cases, and represents a minority of bowel obstructions. Structural lead points are more commonly observed in adult intussusception compared to pediatric cases where risk factors include infection, Meckel's diverticulum, and intestinal polyps. Obstructions in adults are usually a result of benign or malignant neoplasms. In this particular case, a carcinoid tumor originating in the ileum acted as the structural lead point for intussusception. The patient underwent exploratory laparotomy resulting in a right hemicolectomy. This patient did not present with the classic triad of symptoms associated with carcinoid syndrome. In response to this particular case, a laparoscopic right-sided hemicolectomy with lymph node dissection was performed.

A case of acute appendicitis caused by obstruction due to caecal cancer.

Acute appendicitis supposedly results from appendix obstruction caused by various conditions, including caecal cancer. Here, we report an adenocarcinoma found in the specimen of a 65-year-old man diagnosed with acute appendicitis. The adenocarcinoma was detected in the appendix stump after emergency laparoscopic appendectomy. The patient was diagnosed with caecal cancer based on post-operative lower endoscopy findings, and an additional laparoscopic right hemicolectomy was performed. Acute appendicitis can occur at any age and may require emergency surgery. It is a benign disease that can be cured entirely by appendectomy in most cases but may result from an underlying malignant disease in some cases, especially in patients >40 years of age. Thus, clinicians should consider the possibility of a malignancy while diagnosing and treating acute appendicitis.

[Robotic vs. laparoscopic right hemicolectomy-An analysis of costs]. / Robotische vs. laparoskopische Hemikolektomie rechts ­ eine Kostenanalyse.

The use of robotic surgical methods for performing right-sided hemicolectomy has been somewhat controversial, primarily due to concerns related to costs. The purpose of this study is to document the initial robotic right hemicolectomies conducted at our institution and to compare them with a laparoscopic reference group. A significant focus of this study is the detailed analysis of the costs associated with both techniques within the German healthcare system.Surgical and cost-related data for 34 cases each for robotic and laparoscopic right-sided hemicolectomy performed at Nürnberg Hospital were compared. This comparison was conducted through a retrospective single-center case-matched analysis. Cost analysis was carried out following the current guidelines provided by the Institute for the Hospital Remuneration System (InEK) of Germany.The average age of the patient cohort was 70 years, with a male patient proportion of 57.4%. Analysis of perioperative parameters indicated similar outcomes for both surgical techniques. Regarding the incidence of complications of Clavien-Dindo stages III-V (8.8% vs. 17.6%; p = 0.48), a positive trend towards robotic surgery was observed. The cost analysis showed nearly identical total costs for the selected cases in both groups (mean €13,423 vs. €13,424; p = 1.00), with the most significant cost difference noted in surgical (operative) costs (€5,779 vs. €3,521; p < 0.01). The lower costs for laparoscopic cases were primarily due to the reduced material costs (mean €2,657 vs. €702; p < 0.05).In conclusion, both surgical approaches are clinically equivalent, with only minor differences in the total case costs.

Extent of Resection and Long-Term Outcomes for Appendiceal Adenocarcinoma: a SEER Database Analysis of Mucinous and non-Mucinous Histologies.

BACKGROUND: Mucinous appendiceal adenocarcinomas (MAA) and non-mucinous appendiceal adenocarcinomas (NMAA) demonstrate differences in rates and patterns of recurrence, which may inform the appropriate extent of surgical resection (i.e., appendectomy versus colectomy). The impact of extent of resection on disease-specific survival (DSS) for each histologic subtype was assessed. PATIENTS AND METHODS: Patients with resected, non-metastatic MAA and NMAA were identified in the Surveillance, Epidemiology, and End Results database (2000-2020). Multivariable models were created to examine predictors of colectomy for each histologic subtype. DSS was calculated using Kaplan-Meier estimates and examined using Cox proportional hazards modeling. RESULTS: Among 4674 patients (MAA: n = 1990, 42.6%; NMAA: n = 2684, 57.4%), the majority (67.8%) underwent colectomy. Among colectomy patients, the rate of nodal positivity increased with higher T-stage (MAA: T1: 4.6%, T2: 4.0%, T3: 17.1%, T4: 21.6%, p < 0.001; NMAA: T1: 6.8%, T2: 11.4%, T3: 25.6%, T4: 43.8%, p < 0.001) and higher tumor grade (MAA: well differentiated: 7.7%, moderately differentiated: 19.2%, and poorly differentiated: 31.3%; NMAA: well differentiated: 9.0%, moderately differentiated: 20.5%, and 44.4%; p < 0.001). Nodal positivity was more frequently observed in NMAA (27.6% versus 16.4%, p < 0.001). Utilization of colectomy was associated with improved DSS for NMAA patients with T2 (log rank p = 0.095) and T3 (log rank p = 0.018) tumors as well as moderately differentiated histology (log rank p = 0.006). Utilization of colectomy was not associated with improved DSS for MAA patients, which was confirmed in a multivariable model for T-stage, grade, and use of adjuvant chemotherapy [hazard ratio (HR) 1.00, 95% confidence interval (CI) 0.81-1.22]. CONCLUSIONS: Colectomy was associated with improved DSS for patients with NMAA but not MAA. Colectomy for MAA may not be required.

The Management of a Urinary Bladder Leak in a Patient with Radiation Cystitis.

Urinary dysfunction following treatment for rectal adenocarcinoma is a common and complex complication. We present a case of a 69-year-old male who underwent laparoscopic-assisted left hemicolectomy and loop ileostomy after receiving chemotherapy and radiation therapy for rectal adenocarcinoma. Postoperatively, it was incidentally discovered the patient had urinary frequency and urgency. Cystoscopy revealed radiation changes to the bladder walls and a bladder leak was confirmed by cystogram. The patient underwent successful repair of the urinary bladder leak, with challenges posed by prior radiation therapy. Effective prevention and management strategies for urinary dysfunction require a comprehensive preoperative risk assessment, consideration of nerve-preserving surgical techniques, and prompt identification and repair of postoperative complications.

An Unusual Presentation of Adult Intussusception.

Intussusception is a condition characterized by the invagination of a proximal segment of the intestine into a distal segment. In adults, intussusception is commonly associated with a lead point. The most alarming lead point is an obstructing malignancy. Here, we present the case of a 57-year-old woman with ileocolic intussusception secondary to colonic adenocarcinoma. The patient presented to the emergency department following an incidental finding of bradycardia, with a heart rate of around 40 beats per minute. She presented with several weeks of cramping, right lower quadrant abdominal pain, lightheadedness, fatigue, and palpitations. A computed tomography scan revealed ileocolic intussusception. After the placement of a semi-permanent right subclavian pacer, the patient underwent a right hemicolectomy. Surgical findings were consistent with ileocolic intussusception suspicious of being initiated by a mass in the right cecum involving the appendiceal orifice and ileocecal valve that invaded through the muscularis propria into subserosal tissue. The mass was resected and sent to pathology, where it was classified as stage II colonic adenocarcinoma. This case highlights a nonspecific presentation of intussusception that was only identified due to incidental bradycardia.