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Single-incision laparoscopic rectopexy (Wells) with simultaneous sigmoidectomy in a case of complete rectal prolapse and a sigmoid tumor: report of a case
Abstract and Figures
Recently, the technique of single-incision laparoscopic surgery for colorectal disease has rapidly disseminated in association with improvements in instrumentation and procedures, offering a less invasive procedure and excellent cosmetic results. We herein present the case of a 74-year-old female who suffered complete rectal prolapse with a pedunculated polyp (20 mm) in the sigmoid colon; the stalk of the polyp was too thick to perform endoscopic mucosal resection, which is associated with a high risk of bleeding. The patient was successfully managed using single-incision laparoscopic rectopexy (Wells) with simultaneous sigmoidectomy, a procedure that has not been reported in the literature to date. There were no perioperative complications. The patient's constipation caused by the rectal prolapse improved, and no recurrence was observed for 2 months after the operation. This case emphasizes that complete rectal prolapse is a benign disease occurring in elderly patients that is well suited to treatment with minimally invasive single-incision laparoscopic surgery.
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... However, only a few studies on RPLWP have been published. [3][4][5] The aim of this study was to compare outcomes between RPLWP and conventional laparoscopic 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Well's procedure (CLWP) and to investigate the learning curve of RPLWP. ...
... Laparoscopic rectopexy is the primary treatment for full-thickness rectal prolapse because this approach offers the benefits of minimally invasive surgery along with comparatively low rates of recurrence. [4] In contrast, perineal procedures tend to be less invasive, but they have significantly higher recurrence rates. [2] For these reasons, perineal procedures are not usually used, and in some cases, they have been abolished. ...
... [8] However, sigmoid colectomy caries the risk of anastomotic complications and mesh infections. [4] Therefore, sigmoid colectomy is not usually performed during laparoscopic rectopexy. [9] According to the literature on reduced port laparoscopic rectopexy, there have been 13 cases of SILS-rectopexy [3,5] and one case of RPLWP [4] [ Table 3]. ...
Introduction:
Reduced port laparoscopic Well's procedure (RPLWP) is a novel technique used to overcome the limitations of single-incision laparoscopic surgery. The aim of this study was to compare outcomes between RPLWP and conventional laparoscopic Well's procedure (CLWP) and to investigate the learning curve of RPLWP.
Patients and methods:
From January 2006 to March 2017, a retrospective review of a prospectively maintained laparoscopic surgery database was performed to identify patients had undergone CLWP and RPLWP. From these patients, each of 10 cases were manually matched for age, sex, body mass index. From January 2006 to March 2015, CLWP was used for all procedures whereas, from April 2015, RPLWP was routinely performed as a standard procedure for rectal prolapse.
Results:
No significant differences were observed between the two groups in terms of operating time, blood loss, intraoperative complications, and conversion to CLWP or open rectopexy. Based on the postoperative outcomes, the hospital stay was significantly shorter in the RPLWP group. The estimated learning curve for RPLWP was fitted and defined as y = 278.47e-0.064x with R2 = 0.838; therefore, a significant decrease in operative time was observed by using the more advanced surgical procedure.
Conclusions:
RPLWP is an effective, safe, minimally invasive procedural alternative to CLWP with no disadvantage for patients when a skilled surgeon performs it.
... Zur "single incision laparoscopic surgery" (SILS) im Kontext der Rektumprolapschirurgie existieren nur einzelne Kasuistiken oder kleinste Fallserien [43,44]. ...
Background
Various abdominal and transanal/perineal techniques are available for the surgical treatment of rectal prolapse. These different operative approaches must be measured on the basis of their functional results and prolapse recurrence rates.
Objective
The current evidence regarding surgical procedures for the treatment of external rectal prolapse was processed and evaluated.
Results
The evidence for both the transabdominal and perineal procedures comes predominantly from retrospective cohort studies and the very heterogeneous patient collectives and endpoint definitions reduce comparability. Based on the results of a Cochrane systematic review, which included 15 randomized trials, there is no proof of superiority in the comparison of transabdominal versus perineal approaches as well as in the comparison of the most common perineal procedures, Delorme’s versus Altemeier’s procedure. In transabdominal rectopexy the laparoscopic approach shows lower morbidity rates in comparison to the open approach and faster recovery with equivalent results in terms of recurrence rate and function.
Conclusion
Based on the available limited evidence a surgical gold standard cannot be defined. When selecting the surgical approach, individual symptoms (morphology and function), risk profile and preferences of the patient and expertise of the surgeon need to be considered.
... In our study, the tumor derived from COLO320DM orthotopic injection initiated intussusception in young mice, which then resulted in rectal prolapse because of obstruction of the bowel and abdominal pressure. In accordance, several case studies reported rectal prolapse when adenocarcinoma of the sigmoid colon was present [44][45][46]. Patients with rectal prolapse showed a 4.2-fold relative risk for CRC in comparison with a control group [3]. ...
In patients with rectal prolapse is the prevalence of colorectal cancer increased, suggesting that a colorectal tumor may induce rectal prolapse. Establishment of tumor xenografts in immunodeficient mice after orthotopic inoculations of human colorectal cancer cells into the caecal wall is a widely used approach for the study of human colorectal cancer progression and preclinical evaluation of therapeutics. Remarkably, 70% of young mice carrying a COLO320DM caecal tumor showed symptoms of intussusception of the large bowel associated with intestinal lumen obstruction and rectal prolapse. The quantity of the COLO320DM bioluminescent signal of the first three weeks post-inoculation predicts prolapse in young mice. Rectal prolapse was not observed in adult mice carrying a COLO320DM caecal tumor or young mice carrying a HT29 caecal tumor. In contrast to HT29 tumors, which showed local invasion and metastasis, COLO320DM tumors demonstrated a non-invasive tumor with pushing borders without presence of metastasis. In conclusion, rectal prolapse can be linked to a non-invasive, space-occupying COLO320DM tumor in the gastrointestinal tract of young immunodeficient mice. These data reveal a model that can clarify the association of patients showing rectal prolapse with colorectal cancer.
It is an established fact that Non-alcoholic fatty liver
disease (NAFLD) is the commonest disorder of liver in
developed world.1 NAFLD embraces a spectrum of
disorders, from just steatosis in liver to steatohepatitis,
Steatohepatitis can also lead to cirrhosis, liver failure
and even hepatocellular carcinoma.2
Fatty liver is
characterized by macrovesicular fat accumulation in
Hepatocytes. Whereas, non alcoholic steatohepatitis
(NASH) is characterized by hepatocellular injury,
inflammatory changes and varying degree of hepatic
fibrosis.3,4
Objective: To determine the frequency of left ventricular diastolic dysfunction in patients with type II diabetes mellitus.
Study Design: Cross sectional study.
Place and Duration of Study: This study was conducted at the Department of Medicine, KTH Peshawar for six months from February to July 2018.
Materials and Methods: A total of 171 type-II diabetic patients were observed. After
informed written consent, inclusion and exclusion criteria, all patients were subjected to detailed history, clinical examination and measurement of Body Mass Index in term of kg/m2 using standard weight machine and measuring tape. Following this, they were subjected to standard M Mode echocardiography to measure Left Ventricular Diastolic Function. Results: Total 171 (100%) patient, 72(42%) male and 99(58%) females with a mean age of 52±7.25 years, mean duration of type-II DM 14±4.372 years, mean BMI 27±3.11 were enrolled in the study. Total 72(42%) patients were diagnosed with LVDD. It was more prevalent among female 41 (24%) than males 31(18.1). None of P-value showed significant result.
Conclusion: Study concludes that the frequency of left ventricular diastolic dysfunction is quite high in female type-II diabetes mellitus. Longer the duration of Diabetes and greater the BMI, more prevalent LVDD is in Type-II DM.
We report our experience and outcomes of single-incision simultaneous laparoscopic surgery (SISLS) for two different abdominal diseases. During recent 5 years we performed SISLS in 5 patients. The mean age was 63.6 years, and 2 males and 3 females. Their preoperative diagnoses were cholecystolithasis and liver cyst in 2 cases, cholecystolithasis and chronic appendicitis, cholecystolithasis and gastric submucosal tumor and gastric submucosal tumor and right inguinal hernia in one, respectively. The operative approach used 3-ports glove method of 5-mm instruments from a transumbilical longitudinal incision 2.5 cm in diameter. There were no conversions to conventional or open method. They consisted of cholecystectomy and unroofing in 2 cases, cholecystectomy and appendectomy, cholecystectomy and local resection of stomach, and local resection of stomach and inguinal herniorrhaphy in one, respectively. The mean operation time, estimated blood loss and postoperative hospital stay were 120.8 min, 13.6 ml and 4.8 days. SISLS is a feasible and safe procedure without the elongation of operation time under the strict indication and an experienced surgeon of single-incision laparoscopic surgery.
Background:
Fashioning an ileostomy in the umbilicus and combining the trauma from extraction of colorectum with that from ileostomy should be less invasive and lead to improved cosmetic outcomes. However, there are only a few reports regarding umbilical ileostomy.
Methods:
We retrospectively collected data for 121 consecutive patients with rectal tumor who underwent elective laparoscopic rectal resection with diverting loop ileostomy between 2010 and 2015 at Osaka University Hospital, Japan. The safety and feasibility of umbilical diverting loop ileostomy and its influence on stoma care were investigated.
Results:
A total of 83 patients were included in this study; of these, 30 underwent umbilical diverting loop ileostomy and 53 underwent conventional diverting loop ileostomy, which was created in the right lower quadrant of the abdomen. The umbilical and conventional groups showed similar rates of postoperative and stoma-related complications (26.7 vs. 32.1%, p = 0.804 and 3.3 vs. 3.8%, p = 1.000, respectively). Level of parastomal dermatitis was evaluated by DET score at three time points (stoma self-management establishment, first outpatient review post-discharge, and just before stoma closure). DET scores at any time points did not differ significantly between the two groups.
Conclusions:
Umbilical diverting loop ileostomy is comparable to conventional ileostomy with regard to safety and feasibility. Our methods for umbilical ileostomy using the umbilical skin flap were less invasive and did not have a negative impact on stoma care and parastomal dermatitis. Umbilical ileostomy may be a promising alternative to conventional ileostomy in selected cases.
BACKGROUND
Complete mesocolic excision has been suggested to improve oncological outcomes for patients with colon cancer. However, the long-term outcomes of single-site laparoscopic colectomy with complete mesocolic excision remain unclear.
OBJECTIVE
We evaluated the long-term outcomes of single-site laparoscopic colectomy with complete mesocolic excision compared with conventional multiport laparoscopic colectomy for colon cancer, as well as the short-term outcomes.
DESIGN
This is a single-center, retrospective study.
SETTINGS
The study was conducted at Osaka University Hospital in Japan.
PATIENTS
A total of 971 consecutive patients who underwent laparoscopic surgery for colon cancer between 2008 and 2014 were included. Of these patients, 517 were analyzed using propensity score matching (231 with single-site laparoscopic colectomy and 286 with conventional multiport laparoscopic colectomy).
MAIN OUTCOME MEASURES
Recurrence, survival, intraoperative morbidity, and postoperative complications were analyzed.
RESULTS
Before propensity score matching, the single-site laparoscopic colectomy group had greater proportions of women and of patients with right-sided and early stage tumors compared with the conventional multiport laparoscopic colectomy group. After matching, the 2 groups each included 200 patients and did not significantly differ in any patient characteristics. The median follow-up period was 41.4 months. The 2 groups showed similar rates of intraoperative morbidity ( p = 0.22) and postoperative complications ( p = 0.87). Rates of 3-year disease-free and overall survival in single-site laparoscopic colectomy and conventional, multiport, laparoscopic colectomy groups were 95.5% and 91.3% ( p = 0.44) and 100.0% and 98.7% ( p = 0.24). The 3-year disease-free and overall survival rates in each stage did not significantly differ between the 2 groups.
LIMITATIONS
This study was limited by its retrospective nature.
CONCLUSIONS
Single-site laparoscopic colectomy with complete mesocolic excision for colon cancer provided acceptable perioperative outcomes and oncological outcomes, similar to those achieved with conventional multiport laparoscopic colectomy. Evidence accumulation from randomized controlled trials will be necessary to promote the wide acceptance of single-site laparoscopic colectomy. See Video Abstract at http://links.lww.com/DCR/A326.
Rectal prolapse is a debilitating condition with a complex etiology. Symptoms are most commonly prolapse of the rectum and pain with bowel movements or straining, with worsening fecal incontinence over time due to progressive stretching of the anal sphincters. Physical findings are fairly consistent from patient to patient - most notably diastasis of the levator ani muscles, deep pouch of Douglas, redundant sigmoid colon, a mobile mesorectum, and occasionally a solitary rectal ulcer. Evaluation includes a physical exam or imaging demonstrating the prolapse, and evaluating for other causes of pelvic floor dysfunction. Multiple surgical repairs are available, but treatment must be individualized based on patient symptoms and the presence or absence of constipation or other pelvic floor disorders. Mesh repairs have shown promising results, but carry the added risks of mesh erosion, infection, and mesh migration. The optimal repair has not been clearly demonstrated at this time. © Thieme Medical Publishers333 Seventh Avenue, New York, NY 10001, USA.
Single-site laparoscopic colectomy (SLC) is an emerging concept that, compared with conventional multiport laparoscopic colectomy (MLC), yields reduced postoperative pain and improved cosmesis. Complete mesocolic excision (CME) is a novel concept for colon cancer surgery that provides improved oncologic outcomes; however, there are no reports of SLC with CME. We conducted a prospective case-control study to evaluate the feasibility and safety of SLC with CME for colon cancer.
Prospectively collected data of patients with stage I-III colon cancer who underwent SLC (n = 150) or MLC (n = 150) between June 2008 and March 2012 were analyzed. Patients who underwent SLC were, in terms of clinical characteristics and tumor location, matched as closely as possible with those undergoing MLC. Within each group, patients were classified as having right-sided (n = 69 in each group) or left-sided (n = 81 in each group) colon cancer, and short-term outcomes were compared between the two procedures overall and per side.
Overall perioperative outcomes, including operation time, blood loss, number of lymph nodes harvested, length of the resected specimen, and complications, were similar between the two procedures, whereas postoperative pain was significantly lower with SLC. Operation time for right-sided SLC was significantly shortened. SLC with CME was completed successfully in 94 % (65/69) of right-sided cases and in 88 % (71/81) of left-sided cases. Conversion rates were 1.4 % (1/69) and 1.1 % (1/81), respectively. The umbilical scars were nearly invisible 3 months after the procedure, and most patients reported being quite satisfied with the cosmetic outcomes.
SLC with CME for colon cancer is feasible when performed by experienced surgeons in selected patients. Excellent cosmesis and reduced postoperative pain as well as oncologic clearance can be expected. A large-scale, prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over MLC with CME.
Transumbilical single-incision laparoscopic surgery is an emerging concept that could offer excellent cosmetic results [1]. The authors describe an index case of curatively intended resection of early-stage sigmoid colon cancer using this technique [2, 3].
A 75-year-old woman with a body mass index of 24 underwent surgery by two colorectal surgeons who had hundreds of experiences with laparoscopic colorectal surgery. Three 5-mm ports were placed linearly in the vertical 2-cm skin incision in the umbilicus. Almost all the procedures were performed with usual laparoscopic instruments such as a 5-mm flexible laparoscope and the Harmonic ACE (Ethicon Endo-Surgery, Cincinnati, OH, USA). Also, the operative procedures were much the same as in usual laparoscopic surgery. The sigmoid colon was mobilized using a medial approach. Then the root of the superior rectal artery and inferior mesenteric vein were divided using the EnSeal tissue sealing and hemostasis system (SurgRx, Inc. Redwood City, CA, USA). Low-profile trocars were mandatory to minimize interferences among instruments. The rectum was divided 5 cm distal to the lesion with one firing of an endoscopic stapler. The specimen was extracted through a 2-cm transumbilical laparotomy. End-to-side anastomosis using a circular stapler was performed intraabdominally, and air tightness was confirmed by the anastomotic leak test.
The operative time was 192 min. There was no intra- or postoperative morbidity. Altogether, 20 cm of sigmoid was resected with negative tumor margins, and 14 lymph nodes were harvested. The patient started receiving meals and was discharged on postoperative days 2 and 7, respectively. The final pathology showed Tis, N0, M0, stage 0. The scar was invisible at 1 month.
Single-incision laparoscopic colectomy is feasible and safe for selected patients and gives a favorable cosmetic result. By well-trained surgeons, this technique could be a realistic option for colorectal cancer surgery.
Sigmoid resection is indicated in the treatment of complete rectal prolapse (CRP) in patients with prolonged colorectal transit time (CTT). Its use however has been limited due to fear of anastomotic leakage. This study challenges the current practice of dividing the mesorectum by prospectively evaluating the impact of sparing the superior rectal artery (SRA) on leak rates after laparoscopic sigmoid resection (LSR) for CRP. During 30 months data on 33 selected patients with CRP were prospectively collected. Three patients were withdrawn from the analysis, as they had neither resection nor anastomosis. Twenty-nine women and one man (median age 55 range 21-83 years) underwent LSR with preservation of SRA for a median CRP of 8 (3- 15) cm. There were 20 ASA I and 10 ASA II patients. Ten patients had undergone previous surgery. Four patients complained of dyschezia, whereas incontinence was present in 26 patients. Anal ultrasound showed isolated internal sphincter defects in two patients. Four young adults (21-32 years) had normal CTT, whereas 26 older patients had a median CTT of 5 (4-6) days. Defecography demonstrated 10 enteroceles, two sigmoidoceles, and one rectal hernia through the levator ani muscle. Mortality was nil. Median operating room time was 180 (120-330) min, suprapubic incision length 5 (3-7) cm, estimated blood loss 150 (50-500) ml, specimen length 20 (12-45) cm, solid food resumption 3 (1-6) days, and length of stay 4.5 (2-7) days. Thirty-day complications were not related to anastomosing and occurred in 20% of the patients. Although the evidence provided by the present study suggests that sparing SRA has a favorable impact on anastomotic leak rates, these nonrandomized results need further evaluation. The division of the mesorectum at the rectosigmoid junction seems not necessary, and its sparing should therefore be considered as it may contain anastomotic leak rates.
Marlex rectopexy is a popular and effective procedure for the repair of rectal prolapse. Heretofore, this operation has required a generous laparotomy. As videolaparoscopy provides superior pelvic exposure, performing a modified Ripstein procedure was a logical progression of minimally invasive surgery. Experience with the first sutured Marlex rectopexy suggested the need for a simple fixation device to secure the mesh to the sacrum. A commercially available orthopedic staple allows quick and secure fixation. Five cases of laparoscopic Marlex rectopexy provide our initial clinical experience. The LCR staple has reduced operating times by up to 1 h. Results in these cases show virtual complete repair of the prolapse, minimal postoperative analgesic requirements, and no postoperative incontinence. There was one postoperative complication requiring reoperation. There were no deaths. Laparoscopic stapled Marlex rectopexy is a promising modality for the treatment of procidentia.
Rectal prolapse is a condition that has puzzled surgeons for many centuries. Ancient documents, including the Old Testament, give accurate descriptions of the condition. Surgical treatments for rectal prolapse emerged at the end of the nineteenth century, some of which have stood the test of time, although most remain historical curiosities. There is a voluminous literature on rectal prolapse, a PubMed search will identify nearly 3,000 articles focused on rectal prolapse. However, there is little level 1 evidence, with few properly powered randomized trials to provide a scientific evidence base to guide treatment [1]. This chapter on rectal prolapse gives an overview of current thinking on this condition while accepting that many questions remain unanswered.
Background and objectives:
To examine the technical and oncological feasibility of laparoscopic surgery for rectal carcinoma, we conducted a single-arm phase II trial to evaluate laparoscopic surgery for stage 0/I rectal carcinoma, and short-term surgical outcomes were evaluated.
Methods:
Accredited surgeons from 43 institutions in Japan participated in the study. Eligibility criteria included histologically proven rectal carcinoma; clinical stage 0/I; tumor size 8 cm or smaller; patient age 20 to 75 years; no bowel obstruction; and written informed consent. Patients were registered preoperatively. The planned sample size was 490. Surgical outcomes were evaluated.
Results:
A total of 495 patients were registered between February 2008 and August 2010. Five patients were ineligible after registration. Conversion to open surgery was needed for 8 (1.6%) patients. Sphincter-preserving procedures were performed in 477 (97%) patients. Median operative time was 270 minutes, and median blood loss was 28 mL. Postoperative median intervals until liquid and solid intake were 1 and 3 days, respectively, and the median postoperative hospital stay was 12 days. The positive resection margin rate was 0.4% (2/490), and 68.6% (336/490) of the patients were graded stage 0/I. There were no perioperative mortalities. Twenty-four intraoperative and 160 postoperative complications occurred, and the morbidity rate was 23.9% (117/490). The anastomotic leakage rate in patients who underwent anterior resection was 8.3% (33/400), and that in patients who underwent intersphincteric resection was 9.1% (7/77). Nineteen (3.9%) patients underwent reoperation.
Conclusions:
Technically, laparoscopic surgery can be used for safe and radical resection of clinical stage 0/I rectal carcinoma. (ClinicalTrials.gov No. NCT00635466.).
Single-incision laparoscopic surgery has recently been investigated as a novel approach to colorectal pathology. This article describes 3 cases of single-incision laparoscopic sigmoidectomy with rectopexy for the treatment of rectal prolapse. We demonstrate our surgical approach and results from these initial patients treated with this novel technique.
