Intracorporeal and extracorporeal anastomosis for robotic-assisted and laparoscopic right colectomy: short-term outcomes of a multi-center prospective trial.

BACKGROUND: Studies to date show contrasting conclusions when comparing intracorporeal and extracorporeal anastomoses for minimally invasive right colectomy. Large multi-center prospective studies comparing perioperative outcomes between these two techniques are needed. The purpose of this study was to compare intracorporeal and extracorporeal anastomoses outcomes for robotic assisted and laparoscopic right colectomy. METHODS: Multi-center, prospective, observational study of patients with malignant or benign disease scheduled for laparoscopic or robotic-assisted right colectomy. Outcomes included conversion rate, gastrointestinal recovery, and complication rates. RESULTS: There were 280 patients: 156 in the robotic assisted and laparoscopic intracorporeal anastomosis (IA) group and 124 in the robotic assisted and laparoscopic extracorporeal anastomosis (EA) group. The EA group was older (mean age 67 vs. 65 years, p = 0.05) and had fewer white (81% vs. 90%, p = 0.05) and Hispanic (2% vs. 12%, p = 0.003) patients. The EA group had more patients with comorbidities (82% vs. 72%, p = 0.04) while there was no significant difference in individual comorbidities between groups. IA was associated with fewer conversions to open and hand-assisted laparoscopic approaches (p = 0.007), shorter extraction site incision length (4.9 vs. 6.2 cm; p ≤ 0.0001), and longer operative time (156.9 vs. 118.2 min). Postoperatively, patients with IA had shorter time to first flatus, (1.5 vs. 1.8 days; p ≤ 0.0001), time to first bowel movement (1.6 vs. 2.0 days; p = 0.0005), time to resume soft/regular diet (29.0 vs. 37.5 h; p = 0.0014), and shorter length of hospital stay (median, 3 vs. 4 days; p ≤ 0.0001). Postoperative complication rates were comparable between groups. CONCLUSION: In this prospective, multi-center study of minimally invasive right colectomy across 20 institutions, IA was associated with significant improvements in conversion rates, return of bowel function, and shorter hospital stay, as well as significantly longer operative times compared to EA. These data validate current efforts to increase training and adoption of the IA technique for minimally invasive right colectomy.

Endoscopic gastric polypectomy assisted by laparoscopy for giant gastric and duodenal lesion treatment: Case series from two centres.

BACKGROUND: Endoscopy has developed rapidly, generating new challenges. Today, there are several procedures done endoscopically with very good results. In the past, the assisted laparoscopic colon polypectomy has been described, reducing the morbidity of a bigger procedure. Nonetheless, little has been said about the use of hybrid surgery in the management of gastric or duodenal polyps. OBJECTIVES: Evaluating the safety and efficacy of the assisted laparoscopic gastric endoscopic polypectomy. PATIENTS AND METHODS: A retrospective review of the database at our two centres was performed from 1996 to 2014. Thirteen patients were found in whom an assisted laparoscopic gastric or duodenal endoscopic tumour resection was performed. RESULTS: Thirteen patients, eight males and five females, with a median age of 61 years and average body mass index of 29.3. The procedure was done effectively and no need for further procedures was required for any patient. No complications were reported in the early post-operative period. CONCLUSIONS: The study shows that assisted laparoscopic gastric endoscopic polypectomy is a feasible and safe procedure that can be used for the management of giant polyps, which cannot be resected with the classical endoscopic polypectomy reducing the morbidity and complications associated with larger procedures.

Laparoscopic colectomy in the obese, morbidly obese, and super morbidly obese: when does weight matter?

PURPOSE: Previous studies have demonstrated that obese patients (BMI >30) undergoing laparoscopic colectomy have longer operative times and increased complications when compared to non-obese cohorts. However, there is little data that specifically evaluates the outcomes of obese patients based on the degree of their obesity. The aim of this study was to evaluate the impact of increasing severity of obesity on patients undergoing laparoscopic colectomy. METHODS: A retrospective review was performed of all patients undergoing laparoscopic colectomy between 1996 and 2013. Patients were classified according to their BMI as obese (BMI 30.0-39.9), morbidly obese (BMI 40.0-49.9), and super obese (BMI >50). Main outcome measures included conversion rate, operative time, estimated blood loss, post-operative complications, and length of stay. RESULTS: There were 923 patients who met inclusion criteria. Overall, 604 (65.4%), 257 (27.9%), and 62 (6.7%) were classified as obese (O), morbidly obese (MO), and super obese (SO), respectively. Clinicopathologic characteristics were similar among the three groups. The SO group had significantly higher conversion rates (17.7 vs. 7 vs. 4.8%; P = 0.031), longer average hospital stays (7.1 days vs. 4.9 vs. 3.4; P = 0.001), higher morbidity (40.3 vs. 16.3 vs. 12.4%; P = 0.001), and longer operative times (206 min vs. 184 vs. 163; P = 0.04) compared to the MO and O groups, respectively. The anastomotic leak rate in the SO (4.8%; P = 0.027) and MO males (4.1%; P = 0.033) was significantly higher than MO females (2.2%) and all obese patients (1.8%). CONCLUSION: Increasing severity of obesity is associated with worse perioperative outcomes following laparoscopic colectomy.

Polipectomía colonoscópica monitorizada por laparoscopia (PCML) / Colonoscopic polypectomy monitored by laparoscopy

En pacientes con adenomas del colon, la polipectomía con asa puede ser técnicamente imposible debido a factores como la angulación del colon, imposibilidad de ver la base del pólipo, pólipos ocultos detrás de un pliegue de mucosa, o debido a cirugías previas. Para estos pacientes, la resección segmentaria del colon, abierta o laparoscópica es considerado el tratamiento óptimo. Objetivo: La combinación quirúrgica de endoscopia flexible y laparoscopia, usando CO2 en ambas, ha significado una nueva forma de manejo para estos pólipos difíciles, con la finalidad de evitar la resección colónica. Método: Estudio retrospectivo realizado en base a información colectada prospectivamente en la base de datos del Texas Endosurgery Institute. (n=320, mayo de 1990a mayo 2013). Describimos los antecedentes que nos permitieron implementar el procedimiento, de igual manera detallamos como realizamos la técnica y finalmente compartimos nuestros resulta-dos. Resultados:Se analiza la información relacionada con las 320 PCML realizadas en 198 pacientes. Conclusión: La PCML permite la exéresis de pólipos evitando la resección colónica, este procedimiento menos invasivo se traduce en tiempo de recuperación similar al de la colonoscopia sola, y se evitan las complicaciones relacionadas con la resección segmentaria del intestino grueso. Todos los pólipos son estudiados con biopsia intraoperatoria y de encontrarse hallazgos de malignidad la resección segmentaria laparoscópica es realizada(AU)

In patients with adenomas of the colon, loop polypectomy may be technically impossible due to factors as the angulation of the colon, inability to see the base of the polyp, polyps hidden behind a fold of mucosa, or due to previous surgeries. For these patients,segmental resection of the colon, open or laparoscopic is considered the optimal treatment. Objective:The surgical combination of flexible endoscopy and laparoscopy, using CO2 in both, has meant a new way of handling these difficult polyps in order to prevent colonic resections. Methods: A retrospective study carried out on the basis of information collected prospectively in the Texas Endosurgery Institute database. (n = 320, May 1990 to May 2013). We describe the background that allowed us to implement the procedure, just as detailed as we carry out the technique and finally share our results. Results: We analyzed a total of 320 CPML related information in 198 patients. Conclusion:The CPML allows excision of polyps preventing colonic resection, this procedure less invasive means similar to the single colonoscopy recovery time, and avoided the complications associated with segmental resection of the intestine. All polyps are studied with intraoperative biopsy and found malignant findings segmental resection, laparoscopic is performed(AU)

General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.

OBJECTIVE: To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America. METHODS: A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains. RESULTS: There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

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.

Clinical results using bioabsorbable staple-line reinforcement for circular stapler in colorectal surgery: a multicenter study.

INTRODUCTION: Anastomotic leakage is a serious postoperative complication of open and laparoscopic colorectal surgery, very often associated with higher morbidity and mortality. Despite proper patient selection and surgical technique, anastomotic leakage cannot be avoided. The use of a synthetic, bioabsorbable staple-line reinforcement material for the circular stapler may help reduce its prevalence. METHODS: From May to December of 2006, 14 doctors, from 18 hospitals in the United States, performed 117 laparoscopic and open colorectal procedures, in which circular bioabsorbable Seamguard (CBSG; W.L. Gore and Associates, Elkton, MD) was used. RESULTS: Eighty-three patients underwent laparoscopic surgery (70.0%) and 34 open surgery (30%). The procedures included low anterior resection in 49 patients (42%), sigmoidectomy in 46 patients (39.5%), left hemicolectomy in 12 patients (10%), and total colectomy in 10 patients (8.5%). Sixty-four patients had benign disease and 36% malignant disease. Intraoperative anastomotic leakage tests identified 4 patients with leakage (3.4%). All 4 patients had a very low anastomosis (1, 3, 4, and 6 cm, respectively, from the anal verge). Two of the leaks resolved without further intervention. A fecal diversion procedure was performed in the other 2 patients, including 1 patient with rectal bleeding, requiring a transfusion. No clinical complications related to use of CBSG were reported. CONCLUSIONS: The use of Seamguard in colorectal open and laparoscopic surgery may result in a lower incidence of anastomotic leakage.

Laparoscopic-assisted endoluminal hybrid surgery: a stepping stone to NOTES.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) is the anticipated progression of minimally invasive surgery. As it approaches, surgeons will need to develop the fundamental skills and spatial orientation needed to perform safely in this new field. The Natural Orifice Surgery Consortium for Assessment and Research has established several fundamental challenges to the safe introduction of NOTES. Our institutional experience with laparoscopic-assisted endoluminal surgery is reviewed to display the techniques and efficacy of procedures that address many of these challenges and may provide a safe transition for the general surgeon to NOTES or as an alternative to pure NOTES. METHODS: A retrospective review of all laparoscopic-assisted endoluminal surgeries from 1991 to 2007 was performed. Patients had been referred to the institution and selected after either unsuccessful attempts from traditional endoscopic resection of pathology by a gastroenterologist or being deemed an unfavorable candidate for traditional endoscopic resection. All procedures involved establishment of pneumoperitoneum, placement of trochar ports under laparoscopic visualization, balloon ports in gastric cases combined with endoscopy, intraluminal insufflation, coordinated resection of intraluminal pathology using both the endoscopic and laparoscopic instruments, and closure of the intraluminal port sites with intracorporeal suturing. RESULTS: A total of 175 procedures were performed from 1991 to 2007 using these techniques. These procedures varied and included laparoscopic monitored colonoscopic polypectomy, resection of gastric polyps, intraluminal cystgastrostomy, gastric ulcer resection, and foreign body removal. The average age was 55 years (range 38 to 75 y), length of operation 95 minutes (range 60 to 137 min), hospital stay 3.5 days, and 5 complications (2.8%). Of the total procedures, 18 (10.2%) patients were found to have malignancy on frozen section and preceded with a formal resection. There are no cancer recurrences to date with a mean follow up of 74 months (6 to 196 mo). CONCLUSIONS: Our institutional experience with these procedures seems to be a natural transition to developing skills for NOTES procedures and displays a safe and effective approach to a wide range of intraluminal pathology. The general surgeon in practice can use this union of laparoscopy and endoscopy using current instruments and technology for safe transition into the emerging field of NOTES, or even as an alternative to pure NOTES. Mastery of intraoperative endoscopy and intraluminal surgery will be essential to this transition.

Laparoscopic monitored colonoscopic polypectomy: long-term follow-up.

BACKGROUND: Colonoscopy is widely used to remove benign polyps. However, a variety of "difficult polyps" are not accessible for colonoscopic removal because of their size, broad base, or difficult location (impossible to see the polyp's base, polyps behind mucosal folds or in tortuous colonic segments). The aim of the study was to evaluate the long-term follow-up and oncologic safety of laparoscopically monitored colonoscopic polypectomy (LMCP). METHODS: From May 1990 to January 2008, all the patients undergoing LMCP were analyzed and prospectively followed with colonoscopic studies at 6 months, 1 year, and every year thereafter. RESULTS: A total of 209 polyps were removed in 160 patients: 82 men (51%) and 78 women (49%). The mean age was 74.7 years (range 46-99 years). During a mean follow-up of 63.37 months (range 6-196 months) and median follow-up of 65 months, there has been no recurrence. CONCLUSIONS: Long-term follow-up demonstrated that a combined endoscopic-laparoscopic approach is safe and effective. Malignant lesions identified during LMCP can be treated laparoscopically during the same operation, avoiding the need of a second procedure, with good long-term oncologic outcome.

The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia repair in infected and potentially contaminated fields: long-term follow-up.

INTRODUCTION: The treatment of hernias remains controversial, with multiple prosthetic meshes being exalted for a variety of their characteristics. In the event of incarcerated/strangulated hernias and other potentially contaminated fields the placement of prosthetic material remains controversial because of increased risk of recurrence and infection. Porcine small intestinal submucosa mesh (Surgisis, Cook Bloomington, IN) has been demonstrated safe and feasible in laparoscopic hernia repairs in this scenario. We present our 5-year experience, with placement of Surgisis mesh in potentially or grossly contaminated fields. METHODS: From May 2000 to October 2006, 116 patients (52 male, 64 female) with 133 procedures were performed. Placement of Surgisis mesh for either incisional, umbilical, inguinal, femoral or parastomal hernia repairs in an infected or potentially contaminated setting were achieved, and studied in a prospective fashion. RESULTS: All procedures were laparoscopically with two techniques [intraperitoneal onlay mesh (IPOM) and two-layered "sandwich" repair]. Mean follow-up was 52 +/- 20.9 months. Thirty-nine cases were in an infected field and the rest in a potentially contaminated field. Ninety-one procedures were performed concurrently with a contaminated procedure. Twenty-five presented as intestinal obstruction, 16 strangulated hernias, and 17 required small bowel resection; 29 were inguinal hernias, 57 incisional, and 38 umbilical. In 13 patients more than two different hernias were repaired. Eighty-five percent 5-year follow-up was achieved, during which we identified 7 recurrences, 11 seromas (all resolved), and 10 patients reporting mild pain. Six second looks were performed and in all cases except one the mesh was found to be totally integrated into the tissue with strong scar tissue corroborated macro- and microscopically. CONCLUSIONS: In our experience the use of small intestine submucosa mesh in contaminated or potentially contaminated fields is a safe and feasible alternative to hernia repair with minimal recurrence rate and satisfactory results in long-term follow-up.

Transvaginal extraction of the specimen after total laparoscopic right hemicolectomy with intracorporeal anastomosis.

Laparoscopic surgery for colonic disease has experienced an increased utilization by surgeons owing to decreased morbidity, less pain, earlier ambulation, earlier bowel function, fewer complications, decreased narcotic use, and improved cosmesis compared with open colon surgery. Current techniques require an abdominal incision, albeit smaller than an open laparotomy incision, which increases pain and complication rates such as infection, hernia development, and a less pleasing cosmetic result. The ability to perform a totally intracorporeal anastomosis will be an initial step to allow surgeons to perform natural orifice colon surgery in the future. One benefit of the intracorporeal anastomosis technique is that the only incision needed is for trocar placement. By combining the 2 techniques of totally intracorporeal anastomosis and transvaginal extraction of the specimen, surgeons will have the option to perform a totally laparoscopic colectomy on female patients. This case study describes a patient with a transvaginal route of specimen extraction after an oncologic laparoscopic right colon resection with intracorporeal anastomosis. It is the intent to further advance the technical options in the field of natural orifice surgery with the description of this technique. After completing a totally laparoscopic right colectomy with intracorporeal anastomosis and transvaginal extraction, an excellent postoperative recovery was demonstrated and has shown future potential for natural orifice surgery.

Laparoscopic intraluminal surgery for gastrointestinal malignancies.

INTRODUCTION: Intraluminal surgery began with the advent of endoscopy. Endoscopic endoluminal surgery has limitations; and its failure results in conventional open or laparoscopic interventions with increased morbidity. Laparoscopy-assisted intraluminal surgery is a novel alternative to open or laparoscopic surgery for a failed endoscopic endoluminal technique, minimizing the associated complications. Endoscopic resection of early gastric and duodenal cancers is restricted by the limited view of the endoscope, insufficient number of instrument channels, and inability to have adequate margins of resection without risking perforation. These cancers potentially can be treated by laparoscopy-assisted intraluminal surgery without resorting to major gastric or duodenal resection. This procedure is relatively easy to perform and oncologically effective. We present the experience of the Texas Endosurgery Institute (TEI) in treating early gastric and duodenal cancers, including large malignant polyps and carcinoid tumors, with laparoscopy-assisted endoluminal surgery. MATERIALS AND METHODS: The data for all patients with early gastric and duodenal cancers who underwent laparoscopy-assisted endoluminal surgery at TEI between 1996 and 2007 were prospectively recorded. All of the patients had been referred by the endoscopist as noncandidates for endoscopic resection. We prospectively collected data on preoperative diagnosis, operating time, estimated blood loss, postoperative complications, histopathology, and recurrence rate. All patients underwent endoluminal port placement under direct visualization after a pneumoperitoneum was established. Operations were performed in conjunction with upper endoscopy for assistance with port placement under endoluminal visualization, insufflation, and specimen retrieval. After the intraluminal portion of the operation was completed, the endoluminal port sites were closed with laparoscopic intracorporeal suturing. RESULTS: From 1996 to 2007, a total of 12 patients underwent laparoscopic endoluminal surgery. All cases were completed successfully, including 5 resections of early gastric cancer (stage I), 3 wedge resections of carcinoid tumor, 2 resections of duodenal adenocarcinoma, and 2 resections of a malignant polyp at the gastroesophagic junction; all the cases were completed with disease-free margins. No recurrence of the original pathology have been reported, and the complications were minimal. CONCLUSION: Laparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open conventional therapies; and it is associated with a lower incidence of incisional hernia formation and a lower infection rate.

Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis.

BACKGROUND: The treatment of perforated diverticulitis is changing form the current standard of laparotomy with resection, Hartmann procedure, and colostomy to a minimally invasive technique. In patients with complicated acute diverticulitis and peritonitis without gross fecal contamination, laparoscopic peritoneal lavage, inspection of the colon, and intraoperative drain placement of the peritoneal cavity appears to alleviate morbidity and improve the outcome. In this article, we report our experience of a laparoscopic peritoneal lavage technique with delayed definitive resection when necessary. METHOD AND MATERIALS: Records of patients who underwent intraoperative peritoneal lavage for purulent diverticulitis at the Texas Endosurgery Institute from April 1991 to September 2006 were retrospectively reviewed. RESULTS: Forty patients were included in the study, with a male/female ratio of 26:14. The average age was 60 years. Many had associated co-morbidities. The average operating time was 62 minutes. There were no conversions to an open procedure. Apart from mild postoperative paralytic ileus in six patients and chest infections in two, there were no significant peroperative or postoperative complications. Just over 50% underwent elective interval laparoscopic sigmoid colectomy. During the mean follow-up of 96 months, none of the other patients required further surgical intervention. CONCLUSION: Laparoscopic lavage of the peritoneal cavity and drainage is a safe alternative to the current standard of treatment for the management of perforated diverticulitis with or without gross fecal contamination. It is associated with a decrease in the overall cost of treatment; the use of a colostomy is avoided; patient improvement is immediate; and there is a reduction in mortality and morbidity as definitive laparoscopic resection can be performed in a nonemergent fashion. Perhaps the most important benefit, other than avoiding a colostomy, is the association of fewer wound complications such as dehiscence, wound infection, and the high risk of hernia formation. Laparoscopic lavage and drainage should be considered in all patients in whom medical and/or percutaneous treatment is not feasible. It carries minimal morbidity and should be considered the standard of care.