Exploring extracellular matrix and prostaglandin pathway alterations across varying resection margin distances of right-sided colonic adenocarcinoma.

BACKGROUND: Surgical resection followed by indicated adjuvant therapy offers potential curative treatment in colonic adenocarcinoma. Beyond the well-established seed and soil theory of colon cancer progression, the 'normal-appearing' tissues near the tumor are not genuinely normal and remain as remnants in patients following surgery. Our objective was to elucidate the alteration of gene expression and pathways across various distances of resection margins in right-sided colonic adenocarcinoma. METHODS: Twenty-seven fresh samples of primary cancer and 56 matched non-tumor tissues adjacent to the tumor (NAT) were collected from patients with resectable right-sided colon cancer. NAT were systematically obtained at varying distances (1, 5, and 10 cm) on both proximal and distal sides. Comprehensive gene expression analysis was performed using 770-gene PanCancer Progression Panel, delineating distinctive pathways and functional predictions for each region. RESULTS: Distinctive gene signatures and pathways exhibited by normal-appearing tissues were discovered at varying distances from cancer. Notably, SFRP2, PTGDS, COL1A1, IL1B, THBS2, PTGIS, COL1A2, NPR1, and BGN were upregulated, while ENPEP, MMP1, and NRCAM were downregulated significantly in 1-cm tissue compared to farther distances. Substantial alterations in the extracellular matrix (ECM) and prostaglandin/thromboxane synthesis were significantly evident at the 1-cm distance. Functional analysis indicated enhanced cell viability and survival, alongside reduced cellular death and apoptosis. CONCLUSIONS: Different distances exerted a significant impact on gene alteration within the normal-looking mucosa surrounding primary cancer, influenced by various mechanisms. These findings may highlight potential therapeutic targets related to the ECM and prostaglandin/thromboxane pathways for treatment strategies.

Aerosol protection using modified N95 respirator during upper gastrointestinal endoscopy: a randomized controlled trial.

Background/Aims: The coronavirus disease 2019 pandemic has affected the worldwide practice of upper gastrointestinal endoscopy. Here we designed a modified N95 respirator with a channel for endoscope insertion and evaluated its efficacy in upper gastrointestinal endoscopy. Methods: Thirty patients scheduled for upper gastrointestinal endoscopy were randomized into the modified N95 (n=15) or control (n=15) group. The mask was placed on the patient after anesthesia administration and particles were counted every minute before (baseline) and during the procedure by a TSI AeroTrak particle counter (9306-04; TSI Inc.) and categorized by size (0.3, 0.5, 1, 3, 5, and 10 µm). Differences in particle counts between time points were recorded. Results: During the procedure, the modified N95 group displayed significantly smaller overall particle sizes than the control group (median [interquartile range], 231 [54-385] vs. 579 [213-1,379]×103/m3; p=0.056). However, the intervention group had a significant decrease in 0.3-µm particles (68 [-25-185] vs. 242 [72-588]×103/m3; p=0.045). No adverse events occurred in either group. The device did not cause any inconvenience to the endoscopists or patients. Conclusions: This modified N95 respirator reduced the number of particles, especially 0.3-µm particles, generated during upper gastrointestinal endoscopy.

Is fascial closure required for a 12-mm trocar? A comparative study on trocar site hernia with long-term follow up.

BACKGROUND: Despite the infrequency of trocar site hernias (TSHs), fascial closure continues to be recommended for their prevention when using a ≥ 10-mm trocar. AIM: To identify the necessity of fascial closure for a 12-mm nonbladed trocar incision in minimally invasive colorectal surgeries. METHODS: Between July 2010 and December 2018, all patients who underwent minimally invasive colorectal surgery at the Minimally Invasive Surgery Unit of Siriraj Hospital were retrospectively reviewed. All patients underwent cross-sectional imaging for TSH assessment. Clinicopathological characteristics were recorded. Incidence rates of TSH and postoperative results were analyzed. RESULTS: Of the 254 patients included, 70 (111 ports) were in the fascial closure (closed) group and 184 (279 ports) were in the nonfascial closure (open) group. The median follow up duration was 43 mo. During follow up, three patients in the open group developed TSHs, whereas none in the closed group developed the condition (1.1% vs 0%, P = 0.561). All TSHs occurred in the right lower abdomen. Patients whose drains were placed through the same incision had higher rates of TSHs compared with those without the drain. The open group had a significantly shorter operative time and lower blood loss than the closed group. CONCLUSION: Routine performance of fascial closure when using a 12-mm nonbladed trocar may not be needed. However, further prospective studies with cross-sectional imaging follow-up and larger sample size are needed to confirm this finding.

Management of aerosol generation during upper gastrointestinal endoscopy.

In the highly contagious coronavirus disease 2019 pandemic, aerosol-generating procedures (AGPs) are associated with high-risk of transmission. Upper gastrointestinal endoscopy is a procedure with the potential to cause dissemination of bodily fluids. At present, there is no consensus that endoscopy is defined as an AGP. This review discusses the current evidence on this topic with additional management. Prevailing publications on coronavirus related to upper gastrointestinal endoscopy and aerosolization from the PubMed and Scopus databases were searched and reviewed. Comparative quantitative analyses showed a significant elevation of particle numbers, implying that aerosols were generated by upper gastrointestinal endoscopy. The associated source events have also been reported. To reduce the dispersion, certain protective measures have been developed. Endoscopic unit protocols are recommended for the concerned personnel. Therefore, upper gastrointestinal endoscopy should be classified as an AGP. Proper practices should be adopted by healthcare workers and patients.

Peroral endoscopic myotomy for management of cricopharyngeal bars (CP-POEM): a retrospective evaluation.

BACKGROUND: Cricopharyngeal bars (CPBs) are a unique etiology of oropharyngeal dysphagia. Symptomatic patients are managed with endoscopic dilation or surgical myotomy. Cricopharyngeal peroral endoscopic myotomy (CP-POEM) is an emerging technique for the management of dysphagia due to CPBs. This study evaluated technical success, clinical success, adverse events, and long-term recurrence following CP-POEM. METHODS: Consecutive patients who underwent POEM for management of CPBs between May 2015 and December 2020 at four tertiary care centers were included. Primary outcome was clinical success (defined as improvement of dysphagia score to ≤ 1). Secondary outcomes were technical success, rate and severity of adverse events, procedure duration, and symptom recurrence. RESULTS: 27 patients (mean age 69 years; 10 female) underwent CP-POEM during the study period. The most common presenting symptoms at the time of index procedure were dysphagia (26; 96.3 %) and regurgitation (20; 74.1 %). Clinical and technical success were achieved in all patients. Mild/moderate adverse events occurred in two patients (7.4 %). CP-POEM significantly reduced the median dysphagia score. CONCLUSIONS: CP-POEM was a safe and effective treatment for symptomatic CPBs. Although symptom recurrence was low, long-term outcome data are needed. CP-POEM should be considered as a management option for symptomatic CPBs at centers with POEM expertise.

Laparoscopic surgery produced less surgical smoke and contamination comparing with open surgery: the pilot study in fresh cadaveric experiment in COVID-19 pandemic.

BACKGROUND: The SARS-CoV2 virus has been identified in abdominal cavity of the COVID-19 patients. Therefore, the potential viral transmission from any surgical created smoke in these patients is of concern especially in laparoscopic surgery. This study aimed to compare the amount of surgical smoke and surgical field contamination between laparoscopic and open surgery in fresh cadavers. METHODS: Cholecystectomy in 12 cadavers was performed and they were divided into 4 groups: laparoscopic approach with or without smoke evacuator, and open approach with or without smoke evacuator. The increased particle counts in surgical smoke of each group were analyzed. In the model of appendectomy, surgical field contamination under ultraviolet light and visual contamination scale between laparoscopic and open approach were compared. RESULTS: Open cholecystectomy significantly produced a greater amount of overall particle sizes, particle sizes < 5 µm and particle sizes ≥ 5 µm than laparoscopic cholecystectomy (10,307 × 103 vs 3738 × 103, 10,226 × 103 vs 3685 × 103 and 81 × 103 vs 53 × 103 count/m3, respectively at p < 0.05). The use of smoke evacuator led to decrease in the amount of overall particle sizes of 58% and 32.4% in the open and laparoscopic chelecystectomy respectively. Median (interquatile range) visual contamination scale of surgical field in open appendectomy [3.50 (2.33, 4.67)] was significantly greater than laparoscopic appendectomy [1.50 (0.67, 2.33)] at p < 0.001. CONCLUSIONS: Laparoscopic cholecystectomy yielded less smoke-related particles than open cholecystectomy. The use of smoke evacuator, abeit non-significantly, reduced the particles in both open and laparoscopic cholecystectomy. Laparoscopic appendectomy had a lower degree of surgical field contamination than the open approach.

Outcomes of Laparoscopic Common Bile Duct Exploration by Chopstick Technique in Choledocholithiasis.

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy with common bile duct exploration (LC with LCBDE) remains the preferred technique for difficult common bile duct stone (CBDS) removal. The chopstick method uses commonly available instruments and may be cost-saving compared to other techniques. We studied the outcome of LCBDE using the chopstick technique to determine if it could be considered a first-choice method. METHODS: Data from all patients that underwent LCBDE from January 1, 2012 to April 30, 2019 were retrospectively analyzed. A standard 4-port incision and CBDS permitted extraction with two laparoscopic instruments by chopstick technique via vertical choledochotomy. Demographic data, stone clearance rate, surgical outcomes, complications, and other associated factors were evaluated. RESULTS: Thirty-two patients underwent LCBDE. The mean number of preoperative endoscopic retrograde cholangiopancreatography (ERCP) sessions was 2.4. In 65.5% of cases, the CBDS was completely removed by the chopstick technique, while 96.9% of stones were removed after using additional tools. The need for additional instruments was associated with increased age, increased numbers of stones, longer period from the latest ERCP session, and previous upper abdominal surgery. The conversion rate to open surgery was 28.1% and was significantly associated with a history of upper abdominal surgery. CONCLUSION: The chopstick technique is a good alternative and could be considered as a first-line technique in LCBDE to remove the CBDS in cases with 1 to 2 large suprapancreatic CBDS due to instrument availability, cost-effectiveness, and comparable surgical outcomes.

Successful advanced third-space endoscopic surgery by per-oral endoscopic myotomy (Z-POEM) for Zenker's diverticulum: A case report and review of literature.

INTRODUCTION: Zenker's diverticulum is a rare condition caused by herniation of the mucosa at the pharyngoesophageal junction, resulting in dysphagia. Third-space endoscopic surgery now plays an important role in its management, facilitating precise surgery with good outcomes. The aim of report is to demonstrate technical steps and outcomes of per-oral endoscopic myotomy (Z-POEM). PRESENTATION OF CASE: We report two male patients presented with dysphagia. Esophagograms revealed Zenker's diverticula of 2.1 and 2.0 cm, respectively, and diagnostic gastroscopy showed the diverticula to be 17 cm from the incisors, with tight, thick septal muscle. A 2-cm mucosal incision was made with a triangle-tipped knife, and submucosal tunneling was created by spray coagulation. The gastroscope was advanced into the submucosal space of the esophageal lumen and the diverticulum site until the bottom of the diverticulum could be clearly identified. The septal muscle was completely divided, immediately allowing the gastroscope to pass through easily, and the mucosal defect was reapproximated with hemoclips. DISCUSSION: As compared Z-POEM to previous technique; endoscopic septotomy, staple-assisted diverticulotomy, or open neck surgery, Z-POEM is less recurrent of symptoms and complications. Different types of endoscopic knife and lifting materials were used, but all provided the same outcomes. Most of the cases use though-the-scope clips to close the mucosal defect. CONCLUSION: Z-POEM provided precise treatment and complete view of the entire septal muscle can helps to avoid inadequate myotomy.

Endoscopic features of early-stage signet-ring-cell carcinoma of the stomach.

AIM: To identify the features of early signet ring cell gastric carcinoma using magnification endoscopy with narrow band imaging (NBI). METHODS: A retrospective review was conducted of 12 cases of early signet ring cell gastric carcinoma who underwent treatment in a single institution between January 2009 and April 2013. All patients had magnification endoscopy with NBI and indigo carmine contrast to closely examine the mucosal architecture, including the microvasculature and arrangement of gastric pits. Histologic examination of the final endoscopic submucosal dissection or gastrectomy specimen was performed and compared with the endoscopic findings to identify patterns specific to signet ring cell carcinoma. RESULTS: Twelve patients with early signet ring cell gastric carcinoma were identified; 75% were male, and average age was 61 years. Most of the lesions were stage T1a (83%), while the remainder were T1b (17%). The mean lesion size was 1.4 cm(2). On standard endoscopy, all 12 patients had a pale, flat lesion without any evidence of mucosal abnormality such as ulceration, elevation, or depression. On magnification endoscopy with NBI, all of the patients had irregularities in the glands and microvasculature consistent with early gastric cancer. In addition, all 12 patients exhibited the "stretch sign", an elongation or expansion of the architectural structure. Histologic examination of the resected specimens demonstrated an expanded and edematous mucosal layer infiltrated with tumor cells. CONCLUSION: The "stretch sign" appears to be specific for signet ring cell carcinoma and may aid in the early diagnosis and treatment of this aggressive pathology.

Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos).

BACKGROUND: Per-oral endoscopic myotomy (POEM) for achalasia with esophagocardiomyotomy in the lesser curvature (LC myotomy) is now established and accepted widely. However, in some cases LC myotomy is precluded by previous procedures, such as Heller myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side. OBJECTIVE: To evaluate esophagocardiomyotomy in the greater curvature (GC myotomy) as an alternative POEM technique in cases where a prior LC myotomy or supervening anatomic constraints make identification of the EGJ technically challenging. DESIGN: Prospective. SETTING: Single-center study. PATIENTS: Twenty-one achalasia patients who received POEM with GC myotomy. INTERVENTIONS: POEM. MAIN OUTCOME MEASUREMENTS: Efficacy and safety of GC myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events. RESULTS: Identification of the EGJ was achieved in all cases, resulting in a mean gastric myotomy length of 2.6±1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2±7.3 vs 10.5±2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) (P<.01). Endoscopic evidence of gastroesophageal reflux was identified in 52% of patients (11/21) postmyotomy; however, only 9.5% (2/11) were symptomatic, and these patients were successfully controlled with proton pump inhibitors. No severe adverse events were encountered. LIMITATIONS: Single center. CONCLUSIONS: GC myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints.

In vivo histopathology using endocytoscopy for non-neoplastic changes in the gastric mucosa: a prospective pilot study (with video).

BACKGROUND: Endocytoscopy (EC), as a novel ultrahigh magnification technology, enables in vivo histopathological diagnoses of the GI tract. EC is particularly exceptional when comparing dysplastic and neoplastic tissue with normal tissue. There are, however, no detailed data for minute or minimal changes in the gastric mucosa. OBJECTIVE: To describe non-neoplastic EC patterns of the gastric mucosa correlated with histopathological findings and to determine any relationship with Helicobacter pylori (HP) infection. DESIGN: A pilot prospective study. SETTING: Tertiary care referral center. PATIENTS: Sixty-four participants undergoing upper endoscopy for various indications. METHODS: Antral mucosal patterns on EC were divided into 4 categories: type 1 (normal), each papilla/pit has round smooth structure; type 2 (gastritis), extended, notched, and distorted structure with some necrotic tissue; type 3(atrophy), neighboring papilla/pit take on a lobulated appearance; type 4 (intestinal metaplasia [IM]), goblet cells are identified in a completely stained crypt. Target biopsy specimens were obtained from the region identified with these patterns, and multiple HP tests were performed. RESULTS: HP positivity was 0%, 40.9%, 50.0%, and 58.3% in types 1, 2, 3, and 4, respectively. The sensitivity and specificity of types 2+3+4 for HP positivity were 100％ and 42.5%, respectively. The positive predictive values of type 1 for normal, type 2 for chronic gastritis, type 3 for atrophic gastritis, and type 4 for IM were 100%, 62.5%, 40.0%, and 100%, respectively. The sensitivity and specificity of types 3+4 for atrophic gastritis to IM were 87.0% and 95.1%, respectively. LIMITATIONS: Small, single-center, pilot study. CONCLUSIONS: EC can differentiate gastric mucosal patterns of minimal, non-neoplastic change and appears to reliably exclude HP infection.

Giant inguinal hernia: Report of a case and reviews of surgical techniques.

INTRODUCTION: Inguinal hernia is one of the most surgical common diseases. Giant inguinal hernia is more unusual and significantly challenging in terms of surgical management. It is defined as an inguinal hernia that extends below the midpoint of inner thigh when the patient is in standing position. PRESENTATION OF CASE: A 67-year-old male presented with giant right-side inguinal hernia with symptoms of partial colonic obstruction and significant weight loss. Barium enema revealed ascending colon, cecum and ileum contained in hernia sac without significant lesions of large bowel. He underwent hernia repair with omentectomy. Hernioplasty with polypropylene mesh was performed without any complications. He recovered uneventfully. DISCUSSION: There were several repair techniques suggested by published articles such as resection of the content and increased intraabdominal volume procedure. Many key factors for management of the giant inquinal hernia were discussed. A new classification of the giant inquinal hernia was described. CONCLUSION: Surgical repair for the giant inquinal hernia is challenging and correlated with significant morbidity and mortality due to increased intra-abdominal pressure.

Anti-reflux mucosectomy for gastroesophageal reflux disease in the absence of hiatus hernia: a pilot study.

BACKGROUND: In our previous case report of circumferential mucosal resection for short-segment Barrett's esophagus with high-grade dysplasia, symptoms of gastro-esophageal reflux disease (GERD) were significantly improved. This observation suggests that anti-reflux mucosectomy (ARMS) could represent an effective anti-reflux procedure, with the advantage that no artificial devices or prostheses would be left in situ. METHODS: In this pilot study, 10 patients with treatment-refractory GERD received ARMS, 2 of whom circumferential, and the remaining 8 crescentic. RESULTS: Key symptoms of GERD improved significantly after ARMS. In the DeMeester score, mean heartburn score decreased from 2.7 to 0.3 (P=0.0011), regurgitation score from 2.5 to 0.3 (P=0.0022), and total score from 5.2 to 0.67 (P=0.0011). At endoscopic examination, the flap valve grade decreased from 3.2 to 1.2 (P=0.0152). In 24-h esophageal pH monitoring the fraction of time at pH <4 improved from 29.1% to 3.1% (P=0.1). Fraction time absorbance more than >0.14 of bile reflux was controlled from 52% to 4% (P=0.05). In 2 cases of total circumferential resection, repeat balloon dilation was necessary to control stenosis. In all cases, proton pump inhibitor prescription could be discontinued with no ill effects. CONCLUSION: This initial case series demonstrated the potential anti-reflux effect of ARMS, with a crescentic mucosal resection appearing adequate. Further longitudinal study of patients without sliding hiatus hernia will be required to establish ARMS as an effective technique to control GERD in this setting.

Outcomes of endoscopic sphincteroplasty using large balloon dilatation for difficult common bile duct stone removal: a single endoscopist experience.

OBJECTIVE: Endoscopic sphincteroplasty (ESPT) using a large CRETM Wireguided balloon dilatation is an alternative technique in removing a difficult common bile duct (CBD) stone. However the outcome and complications of endoscopic difficult CBD stone removal using ESPT have not been well demonstrated. The present study revealed the outcome of the technique which done by a single endoscopist. MATERIAL AND METHOD: Between January 2003 and December 2009, the retrospective study of ninety-three patients with CBD stones that underwent endoscopic retrograde cholangiopancreaticography (ERCP) for stone removal and had difficulty were enrolled. ESPT using a large CRE Wireguided balloon dilatation was performed in 62 patients. The success rate of complete stone clearance and post ERCP complications were analyzed RESULTS: In the aspect of complete stone removal, the success rate was 88.7%. Seven patients (11.3%) required adjunctive mechanical lithotripsy (ML) for complete stone clearance. This technique was associated with low complication rate (3.2%). Post ERCP bleeding was found in one patient (1.6%) with ESPT using a large CRE balloon dilatation. Mild post-ERCP pancreatitis occurred in only one patient. CONCLUSION: ESPT using large diameter CRE Wireguided balloon dilatation after biliary sphinctertomy is an effective technique for a difficult CBD stone removal associated with a lower rate of complications. This procedure can avoid unnecessary surgical CBD exploration for stone removal.

Peroral endoscopic myotomy for esophageal achalasia.

Peroral endoscopic myotomy (POEM) is one of the alternative treatment for achalasia. Due to concept of natural orifice transluminal endoscopic surgery (NOTES), it becomes popular and widely accepted. With the endoluminal technique, submucosal tunnel was created followed by endoscopic myotomy. POEM is not only indicated in classical achalasia but also other abnormal esophageal motility disorders. Moreover, failures of endoscopic treatment or surgical attempted cases are not contraindicated for POEM. The second attempted POEM is also safe and technically feasible. Even though the legend of success of POEM is fruitful, the possible complications are very frightened. Good training and delicate practice will reduce rate of complications. This review provides a summary of current state-of-the-art of POEM, including indication equipments, technique and complications. This perfect procedure may become the treatment of choice of achalasia and some esophageal motility disorders in the near future.

In vivo histopathological assessment of the muscularis propria in achalasia by using endocytoscopy (with video).

BACKGROUND: The histopathology of the muscularis propria (MP) is unknown in patients with achalasia. Endocytoscopy (EC) was developed as an ultra-high magnification endoscopy, and the submucosal tunnel created during peroral endoscopic myotomy (POEM) not only provides access to the MP but also enables subsequent endoscopic assessment of the MP. PATIENTS AND METHODS: In seven patients with achalasia (mean ±â€ŠSD; 35 ±â€Š18.1 years; men:women, 4:3) who underwent POEM (myotomy length: 12 ±â€Š2.2 cm), subsequent EC examination was performed from the mid-esophagus to the gastric side. EC images were compared to the results of histopathologic examination (two biopsies from the mid-esophagus and lower esophageal sphincter), which was the standard. RESULTS: In all patients, favorable EC images were obtained, and spindle-shaped smooth muscle cells were detected. In our series, we observed no notable features such as atrophy or hypertrophy of smooth muscle cells. In addition, the EC assessment was consistent with the results of biopsy. No complications were encountered during any of the procedures. CONCLUSION: In a clinical setting, real-time assessment of the MP using EC is feasible. This technique may play an important role in determining the pathology of achalasia and other diseases that affect gastrointestinal function.

Single-incision laparoscopic colectomy without using special articulating instruments: an initial experience.

BACKGROUND: Single-incision laparoscopic colectomy (SILC) was introduced as a novel minimally invasive technique. The benefits of this technique include reducing number of the incision and cosmetic improvement. Unlike the conventional laparoscopic colectomy, majority of previously reported SILC need to be performed using special curved or articulated instruments. The purpose of this study is to demonstrate our initial experience of SILC, which could be performed using the standard laparoscopic instruments. MATERIAL AND METHODS: Retrospective review of 14 patients who underwent SILC at Siriraj Hospital from May to December 2010, patient's demographic data, perioperative outcomes, early postoperative complications and pathological data were collected and analyzed. RESULTS: The mean age of all patients was 60 years. The most common operation with SILC was sigmoidectomy (n = 9), followed by right hemicolectomy (n = 2), left hemicolectomy (n = 1), anterior resection (n = 1), and total colectomy (n = 1). The trocar insertion techniques were multi-fascial incision using regular port (n = 11) and GelPOINT(®) (n = 3). The mean operative time was 155 minutes (range 90-280) and the mean estimate blood loss was 32.1 mL (range 10-100). All patients were successfully operated without conversion. The mean length of hospital stay was 9 days (range 5-20). There was no mortality. The pathological results revealed colorectal cancer (n = 12), neoplastic polyp (n = 1) and Familial adenomatous polyposis (FAP) (n = 1). The mean number of lymph nodes retrieval was 16.6 (range 3-34). CONCLUSION: SILC can successfully and safely be performed with standard laparoscopic instruments. This technique might be an alternative procedure to conventional laparoscopic colectomy with better cosmetic result.