Imaging for Quality Control: Comparison of Systematic Video Recording to the Operative Note in Colorectal Cancer Surgery. A Pilot Study.

BACKGROUND: Oncological and functional results after colorectal cancer surgery vary considerably between hospitals and surgeons. At present, the only source of technical information about the surgical procedure is the operative note, which is subjective and omits critical information. This study aimed to evaluate the feasibility of operative video recording in demonstrating both objective information concerning the surgical procedure and surgical quality, as using a systematic approach might improve surgical performance. METHODS: From July 2015 through November 2015, patients aged ≥18 years undergoing elective colorectal cancer surgery were prospectively included in a single-institution trial. Video recording of key moments was performed peroperatively and analyzed for adequacy. The study cases were compared with a historic cohort. Video was compared with the operative note using the amount of adequate steps and a scoring system. RESULTS: This study compared 15 cases to 32 cases from the historic control group. Compared to the written operative note alone, significant differences in availability of information were seen in favor of video as well as using a combination of video plus the operative note (N adequate steps p = .024; p = <.001. Adequacy score: p = .039; p = <.001, both respectively). CONCLUSIONS: Systematic video registration is feasible and seems to improve the availability of essential information after colorectal cancer surgery. In this respect, combining video with a traditional operative note would be the best option. A multicenter international study is being organized to further evaluate the effect of operative video capture on surgical outcomes.

A prospective trial evaluating the clinical performance of a novel surgical energy device in laparoscopic colon surgery.

INTRODUCTION: The aim of this prospective human trial was to evaluate the clinical performance of a novel THUNDERBEAT (TB) energy device in laparoscopic colon surgery. This study reports the first human trial in USA with this combined energy device in colon surgery. METHODS AND PROCEDURES: This is a prospective pilot study with 30 subjects undergoing left or right laparoscopic colon resection for neoplasm in a single institution. All soft tissue dissections and all vessel ligations were performed using TB. No other energy device was used within the abdomen. Recorded end-points were dissection time (from the start of colon mobilization to specimen removal), surgical procedure time, the number of times TB taken out of the abdominal cavity, intraoperative complications (bleeding at the time of mesenteric dissection or vessel ligation, thermal injury during surgery, injury of other organs), technical device problems, postoperative complications (bleeding, delayed thermal injuries, other complications within 30 days), length of hospital stay, and mortality. RESULTS: Thirty subjects (15 males) were enrolled in the study with median age and range 68.5 (21-86) and BMI kg/m(2) 25.5 (20-35). Twelve subjects underwent right and 18 left laparoscopic hemicolectomy. The mean surgical procedure time was 163 ± 86 min and for dissection using TB device 80.6 ± 35 min. Major vessel ligation was successful in all subjects. The median number of TB applications to seal inferior mesenteric artery was 3 (2-8). TB was taken out of the abdominal cavity during dissection for tip cleaning a medium number of two times/per case. No intraoperative or postoperative complications (bleeding, thermal injuries, etc.) related to use of TB were noted. CONCLUSIONS: The TB device demonstrated efficient and successful performance at tissue dissection and vessel ligation in left and right colectomies. TB technology can be employed in complex abdominal surgery and may save time through faster dissection but comparative studies with other energy devices are needed to confirm this.

Experience of a specialist centre in the management of anastomotic sinus following leaks after low rectal or ileal pouch-anal anastomosis with diverting stoma.

AIM: The natural history and appropriate management of anastomotic sinus has not been clearly defined. The aim of this study was to evaluate the incidence, management and outcomes of anastomotic sinus. METHOD: The medical records of all patients who underwent a low anterior resection (LAR) or an ileal pouch-anal anastomosis (IPAA) with a diverting loop ileostomy (LI) and with contrast enema performed before planned stoma closure between 2001 and 2011 were retrospectively reviewed. The radiological features of the sinus tract, treatment and outcome of anastomotic sinus were studied. RESULTS: Twenty patients (8.2%) were found to have anastomotic sinuses out of the total of 244 patients who had undergone LAR (n = 146) or IPAA (n = 98) with LI. Of these, 13 (65%) had prior symptomatic leaks, while seven did not. Twelve patients (60%) were found to have simple sinus tracts, while eight had complex sinuses (associated with either pelvic cavities or severe strictures). Five patients with simple tracts were treated with observation alone. Fifteen patients underwent surgical interventions. Overall, with a median follow-up of 28 (6-73) months, 16 patients (80%) had resolution of their sinuses. All of 12 patients (100%) with simple sinus tracts and four of eight patients (50%) with complex sinuses underwent successful stoma reversals after 8 (3.5-24) months following the initial surgery (P = 0.01). CONCLUSION: Patients with simple tracts are significantly more likely to have complete resolution of sinuses than patients with complex sinuses. Persistent sinus associated with either a pelvic cavity or severe stricture despite surgical intervention is likely to lead to a permanent stoma.

Minimally invasive surgery is safe and effective for urgent and emergent colectomy.

OBJECTIVE: There are a limited number of studies describing the role of minimally invasive colectomy for urgent or emergent conditions of the large bowel. We hypothesize that laparoscopic colectomy in urgent and emergent setting can be performed safely in select settings. METHOD: A cohort of patients treated at a single institution from 2001 to 2006 was identified from a prospective database. Patients who underwent open or minimally invasive surgery (MIS), including laparoscopic (LAP) or hand-assisted laparoscopic surgery (HALS) colectomy for urgent and emergent conditions were included. RESULTS: A total of 68 [open 32, MIS 36 [HALS 22, LAP 14)] patients underwent urgent or emergent colectomy on our colorectal service during the 5-year time period. Patients with toxic colitis were more often selected for MIS. Patients with colon perforation or large bowel obstruction were more often selected for open surgery. The MIS group had a lower body mass index (BMI), lower American Society of Anesthesiologists fitness grade and was more likely to have been immunosuppressed. There was no difference in patient morbidity between the open and MIS groups. The MIS group had a longer median operative time and fewer cases of prolonged hospitalization. CONCLUSION: We conclude that minimally invasive colectomy by experienced surgeons appears to be safe and effective for appropriately selected patients with emergent and urgent conditions of the large bowel.

Initial repair of iatrogenic colon perforation using laparoscopic methods.

BACKGROUND: Iatrogenic perforation of the colon during elective colonoscopy is a rare but serious complication. Treatment using laparoscopic methods is a novel approach, only described in the recent literature. We hypothesized that laparoscopic treatment of iatrogenic colon perforation would result in equal therapeutic efficacy, less perioperative morbidity, smaller incisions and decreased length of stay, and an overall better short-term outcome compared to open methods. METHODS: We reviewed our prospectively collected patient database from July 2001 to July 2005 and compared the intraoperative data and postoperative outcomes of patients who underwent laparoscopic primary repair versus those who had open primary repairs of iatrogenically perforated large bowel. RESULTS: The laparoscopic (mean age 70 years; range 20-91 years; 18 percent male) and open (mean age 68 years; range 36-87 years; 43 percent male) groups were similar with regard to age. Overall, patients who underwent laparoscopic (n = 11) versus open (n = 7) repair had comparable operative (OR) times (mean 104 minutes, range 60-150 minutes versus mean 98 minutes, range 40-130 minutes, p = 0.04), shorter length of stay [LOS, (5.1 +/- 1.7 days versus 9.2 +/- 3.1 days, p = 0.01)], fewer complications (two versus five, p = 0.02) and shorter incision length (16 +/- 14.7 mm versus 163 +/- 54.4 mm, p = 0.001). CONCLUSIONS: A laparoscopic approach to iatrogenic colon perforation results in decreased morbidity, decreased length of stay, and a shorter incision length compared to an open method. In those cases where it is feasible and the surgical skills exist, a laparoscopic attempt at colon repair should probably be the initial clinical approach.

Robotically assisted small intestinal strictureplasty in dogs: a survival study involving 16 Heineke-Mikulicz strictureplasties.

BACKGROUND: Robotically assisted surgery offers the advantages of improved dexterity and elimination of tremor over conventional laparoscopic surgery. There have been few studies to date, however, examining the role of robotics in intestinal surgery. This study was undertaken to determine the feasibility and safety of using a robotic surgical system in the performance of intracorporeal small bowel strictureplasties in dogs. METHODS: Using a robotic surgical system, a total of 16 strictureplasties were performed in the small bowel of eight dogs (two strictureplasties per dog). Using only intracorporeal robotic surgery, a 2.5 cm enterotomy was made longitudinally in the small bowel, and then closed in a Heineke-Mikulicz configuration with a one-layer running 3-0 braided absorbable suture (strictureplasty). All animals were allowed to survive for 7 days with prospective monitoring of bowel movements, level of activity, oral intake, and abdominal examination. After 7 days, necropsy was performed, examining all strictureplasty sites for signs of sepsis. The endpoints of the study were recovery of normal intestinal function (bowel movements), intraoperative and postoperative complications, and the appearance of the anastomoses at necropsy. RESULTS: There was no intraoperative morbidity or mortality. All eight dogs survived 7 days and recovered well. All dogs had a bowel movement on the first postoperative day, and appeared healthy throughout the study period. Necropsy revealed that all 16 strictureplasty sites were healing without signs of sepsis. The median time per strictureplasty was 65 min (range, 45-110 min). One dog developed a superficial wound infection at a trocar site. CONCLUSIONS: A robotic surgical system can successfully be employed in the performance of intestinal strictureplasties in dogs. This study supports further investigation into the role of robotics in intestinal surgery in humans.

Three cases of adenocarcinoma following restorative proctocolectomy with hand-sewn anastomosis for ulcerative colitis: a review of reported cases in the literature.

Restorative proctocolectomy (RPC) has been accepted as optimal surgical therapy for most patients with ulcerative colitis. The occurrence of adenocarcinoma adjacent to the ileoanal anastomotic site for ulcerative colitis is a serious but rare outcome. There are 16 reported cases. We report three additional cases and review previous cases in the literature.

Intraoperative carbon dioxide colonoscopy: a safe insufflation alternative for locating colonic lesions during laparoscopic surgery.

BACKGROUND: Intraoperative colonoscopy (IOC) is useful for locating colonic pathologies during laparoscopy, but bowel distention compromises the subsequent visualization and procedure. Carbon dioxide (CO2), with its rapid absorption, has been proved effective for alleviating bowel distention in ambulatory settings. Its intraoperative role, however, has never been studied. This study aimed to assess the feasibility, safety, and advantages of CO2-insufflated IOC during laparoscopy. METHODS: For this study, CO2-insufflated IOC was performed for 20 patients under CO2 pneumoperitoneum. Parameters, including end-tidal CO2 (ETCO2) and minute volume, were prospectively registered. Time until resolution of bowel distention was determined by laparoscopic evaluation. RESULTS: All lesions were located by CO2-insufflated IOC in 15 min. During IOC, ETCO2 increased, but remained within normal values, and was quickly compensated with minimal hyperventilation. Bowel distention totally disappeared in 21 min, allowing immediate initiation of laparoscopic procedures under adequate visualization. CONCLUSIONS: The findings show that CO2-insufflated IOC during laparoscopy is feasible, safe, and of practical value for minimizing bowel distention without impeding the subsequent visualization and procedure.

Use of the surgical towel in colorectal hand-assisted laparoscopic surgery (HALS).

The use of laparotomy pads or towels to displace the small intestine away from the operative site is a well-established technique in open surgery; however, its application is unfeasible or extremely challenging in standard laparoscopic surgery. We describe the use of standard surgical towels in hand-assisted laparoscopic surgery (HALS). A Pfannenstiel incision is made and a Gelport hand-access device is assembled. A sterilized surgical towel, 65 x 44 cm in size, is inserted via the Gelport, unfolded, and placed over the bowel loops laparoscopically with the assistance of the hand. The bowel loops are then housed gently in the towel and displaced away from of the operative site. HALS enables the easy insertion and handling of a large surgical towel inside the peritoneal cavity. The towel successfully retracts the small intestine, enabling the surgeon to concentrate the use of his or her hand on the targeted structures. This practical and inexpensive tip adds another advantageous component to the practice of colorectal HALS.

Laparoscopic total colectomy: hand-assisted vs standard technique.

BACKGROUND: Although hand-assisted laparoscopic surgery (HALS) has been proposed as an alternative to laparoscopically assisted surgery (LAP), little is known about its role in total colectomy. The objectives of the study were to compare the outcomes in patients undergoing total colectomy via either HALS or LAP and to determine what benefits HALS might have in extensive colorectal procedures. METHODS: We reviewed the data for 23 patients who underwent total proctocolectomy (TPC) or total abdominal colectomy (TAC) using either a HALS or LAP technique. RESULTS: There were 12 HALS (five TPC, seven TAC) and 11 LAP (seven TPC, four TAC) for ulcerative colitis (n = 17), familial polyposis (n = 5), and colonic inertia (n = 1). One LAP was converted (9.1%). The operative time was shorter for HALS than for LAP (210 vs 273 min; p = 0.03). Blood loss and incision length were similar. Postoperative recovery and morbidity rates were comparable. CONCLUSION: HALS reduces the operative time but patient morbidity rates and recovery are similar to LAP. HALS may be preferable for extensive colorectal procedures such as TPC and TAC.

Hand-assisted laparoscopic colorectal surgery using GelPort.

BACKGROUND: An easily usable hand access device will optimize success in hand-assisted laparoscopic surgery (HALS). The authors describe their initial series of HALS colorectal resections using GelPort to evaluate their current technique and results with this new device. METHODS: A retrospective study investigated 33 HALS colorectal procedures including total colectomy ( n = 16) and low anterior resection ( n = 10). All operative data, including intraoperative GelPort performance, were prospectively recorded and retrospectively analyzed. RESULTS: In this study, 3 (9.1%) of 33 HALS procedures were converted to open surgery, and 4 (13.3%) of 30 HALS procedures required minimal enlargement of incisions to facilitate extracorporeal procedures. The operative time was 263 +/- 85 min, and the blood loss was 282 +/- 148 ml. There were no device malfunctions. Three major complications (9.1%) and 7 minor wound infections (21%) were noted postoperatively. The mean hospital stay was 7.9 +/- 3.8 days. CONCLUSION: When performed with GelPort, HALS is safely and reliably applicable for various colorectal procedures.

CO2 pneumoperitoneum does not enhance tumor growth and metastasis: study of a rat cecal wall inoculation model.

INTRODUCTION: Although many studies have evaluated the effects of carbon dioxide pneumoperitoneum on port site recurrence, little is known about its outcome on tumor growth and metastasis. The effect of pneumoperitoneum with carbon dioxide on cecal tumor growth and metastasis was compared with laparotomy using a rat colon cancer cell line. METHODS: Time Course Study: Fifty WF/BN F1 hybrid rats were inoculated with 2,000,000 WB2054M5 tumor cells into the cecal wall and explored two to ten weeks after injection. Main Study: 152 rats were randomly assigned either to 6-mmHg CO2 pneumoperitoneum (30 minutes) or 4-cm laparotomy (30 minutes) two weeks after tumor inoculation and were explored four weeks after treatment. RESULTS: Time Course Study: Thirty-seven (95 percent) of the surviving rats developed a cecal wall tumor, and there was progressive tumor growth and metastasis over the ten-week period. At six weeks, metastasis occurred to the liver in 25 percent, to the lung in 38 percent, and to the lymph node in 63 percent, and peritoneal seeding occurred in 38 percent; this time period was chosen for the main study. Main Study: At the time of treatment (2 weeks), 124 rats were eligible for randomization. One hundred two rats survived the six-week period (50 pneumoperitoneum, 52 laparotomy) and were killed. There were no differences between the CO2 pneumoperitoneum and laparotomy groups regarding cecal tumor growth (1.043 vs. 0.894 g) and metastases to the liver (32 vs. 37 percent), lung (34 vs. 17 percent), lymph node (84 vs. 77 percent), and wound or port (20 vs. 23 percent). CONCLUSIONS: A cecal wall inoculation model mimics the natural cascade of colon cancer growth and metastasis. CO2 pneumoperitoneum did not affect the tumor growth and metastasis to the liver and other organs when compared with laparotomy in this model.

Laparoscopic total colectomy for acute colitis: a case-control study.

INTRODUCTION: There are no previous comparative studies of total abdominal colectomy by laparoscopic methods in ulcerative colitis and Crohn's disease patients requiring urgent colectomy. This study aimed to determine the safety and efficacy of laparoscopic colectomy in these patients compared with those undergoing conventional urgent colectomy. METHODS: Patients undergoing laparoscopic total colectomy for acute colitis were identified in a prospective registry. All patients underwent a total colectomy with creation of an end ileostomy and buried mucous fistula. No patient had fulminant disease (tachycardia, fever, marked leukocytosis, peritonitis), but all were failing to respond to medical treatment. Patients undergoing conventional total colectomy were matched for age, gender, body mass index, diagnosis, disease severity, and operative period. Median values (range) are listed. RESULTS: From 1997 to 1999, there were 19 laparoscopic and 29 matched conventional patients. There were no inadvertent colotomies or conversions in the laparoscopic group. Although there was no difference in operative blood loss in the laparoscopic group (100 (range, 50-700) ml) when compared with the conventional group (150 (range, 50-500) ml), the operative times were significantly longer in the laparoscopic group (210 (range, 150-270) vs. 120 (range, 60-180) minutes, P < 0.001). Bowel function returned more quickly in the laparoscopic group (1 (range, 1-3) vs. 2 (range, 1-4) days; P = 0.003) and the length of stay was shorter (4 (range, 3-13) vs. 6 (range, 4-24) days; P = 0.04). Complications occurred in three (16 percent) laparoscopic patients (2 wound infection and 1 ileus) and in seven (24 percent) conventional patients (3 wound infection, 3 deep venous thrombosis, 1 upper gastrointestinal bleed). CONCLUSIONS: Laparoscopic total colectomy is feasible and safe in patients with acute nonfulminant colitis and may lead to a faster recovery than conventional resection.

Laparoscopic surgery in Crohn's disease.

Laparoscopic surgeons attempting to treat Crohn's disease must have experience working with inflammatory bowel disease and advanced laparoscopic skills. Nonetheless, laparoscopy is dramatically changing all aspects of gastrointestinal surgery and inflammatory bowel disease, including Crohn's disease, is likely to benefit, as well. This article defines the role of laparoscopy in treating Crohn's disease and outlines surgical therapy.

Prospective, randomized trial comparing laparoscopic vs. conventional surgery for refractory ileocolic Crohn's disease.

INTRODUCTION: Surgeons have been reluctant to apply laparoscopic techniques to Crohn's disease surgery because of concerns with evaluating and excising inflamed tissue using laparoscopic methods. Additionally in Crohn's disease surgery, laparoscopic techniques have not been demonstrated to have clear advantages over conventional ones. METHOD: We conducted a prospective, randomized trial in one surgical department comparing laparoscopic vs. conventional techniques in 60 patients (25 males), median age 34.4 (range, 10-60.1) years, undergoing elective ileocolic resection for refractory Crohn's disease. Postoperatively, all patients underwent measurement of pulmonary function tests every 12 hours, and were treated identically on a highly controlled protocol with regard to analgesic administration, feeding, and postoperative care. RESULTS: Of the 31 patients assigned to laparoscopic and 29 to the conventional group, all had isolated Crohn's disease of the terminal ileum plus or minus the cecum. Median length of the incision was 5 cm in the laparoscopic group and 12 cm in the conventional group. Overall recovery of 80 percent of forced expiratory volume (one second) and forced vital capacity was a median of 2.5 days for laparoscopic and 3.5 days for conventional (P = 0.03). There was no difference in the amount of morphine equivalents used between groups postoperatively. Flatus and first bowel movement returned a median of 3 and 4 days, respectively, after laparoscopic vs. 3.3 and 4 days, respectively, after conventional surgery (P = 0.21). Median length of stay was five (range, 4-30) days for laparoscopic, and six (range, 4-18) days for conventional surgery. Major complications occurred in one patient in each group. Minor complications occurred in four laparoscopic and eight conventional patients (P < 0.05). There were no deaths. Two laparoscopic patients were converted to conventional as a result of adhesions or inflammation. All patients recovered well and there were no clinical recurrences in the follow-up period (median, 20; range, 12-45 months). CONCLUSIONS: Within a single institution, single surgical team, prospective, randomized trial, laparoscopic techniques offered a faster recovery of pulmonary function, fewer complications, and shorter length of stay compared with conventional surgery for selected patients undergoing ileocolic resection for Crohn's disease.