Laparoscopic Anterior Resection
Abstract
The first radical rectal surgery was first performed by Sir William Ernest Miles with a permanent stoma in 1907 while restorative rectal resection was introduced in 1948 by Claude F Dixon. The evolution of using surgical staplers in 1972 by Mark Mitchell Ravitch, doubling stapling technique by Knight and Griffen in 1980 as well as the development of coloanal anastomosis, intersphincteric dissection, and colonic-pouch anal anastomosis by Parks, Larzothes, and Parc respectively between 1980 and 1986 allows more opportunities for restorative resections for low rectal tumors. The concept of Total Mesorectal Excision (TME) with sharp dissection under direct vision and gentle continuous traction by RJ Heald [1] heralded the major milestone in modern rectal cancer surgery in significantly reducing local recurrence and improving patient outcomes. Although laparoscopic surgery began in the 1980s, the first laparoscopic colonic surgery was only performed in 1991. Laparoscopic rectal resection according to the principles of TME has been performed increasingly since with a few randomized controlled clinical trials (CLASICC, COLOR II, ACOSOG Z6051, ALaCaRT) [2–7] demonstrating significantly better postoperative pain, shorter hospital stay, and improved quality of life with controversial but mostly comparable short- and intermediate-term oncological outcomes.
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Purpose:
The aim of this paper is to propose our four-step technique, an open extraperitoneal approach for complex flank, lumbar, and iliac hernias.
Methods:
A big polypropylene mesh is placed, covering and reinforcing all the lateral abdominal wall in an extraperitoneal space. Its borders are retroxiphoid fatty triangle and the costal arch cranially and the retropubic space caudally, psoas muscle, and paravertebral region posteriorly and contralateral rectus muscle medially. Mesh dimensions do not depend from the defect size, but prosthesis has to cover all the lateral abdominal wall.
Results:
No major complications have been reported. The mean length of stay is 4.8 days (range 3-11). Mean follow-up is 44.8 months (range 5-92). One recurrence (4.5%) has been reported at the 1-year clinical evaluation.
Conclusion:
In conclusion, we believe that regardless size and location of the defect, every complex lateral hernia requires the same extensive repair because of the critical anatomy of the region with a big medium-heavyweight polypropylene mesh placed in an extraperitoneal plane, the only one that allows adequate covering of the visceral sac. Our technique is a safe, feasible, and reproducible treatment for this challenging surgical problem.
Diaphragmatic hernia (DH) usually occurs in childhood; however, in adult it is uncommon. Most common aetiology of DH in adult is trauma while spontaneous DH is a rare entity accounting for <1%. The management is primarily surgical repair in the form of open or laparoscopic approach; the later has been associated with low morbidity, mortality and excellent long term outcomes with low rate of recurrence. In this case series, confirmation of the diagnosis was done by CT scan and by laparoscopy in all the patients; laparoscopic repair was performed in all the patients along with thoracoscopic aid in two cases. We found that minimal access techniques can be safely done in DH; in conditions when the herniated content are difficult to get reduced laparoscopically alone, a simultaneous thoracoscopy has helped in great deal in reducing the content and completing the procedure entirely by minimal access techniques. This gives all the advantages of minimally invasive approach like less postoperative pain, shorter hospital stay, quicker recovery and low recurrence rate; provided tissue repair is done in tension free manner by an experienced laparoscopic surgeon.
Background
Although laparoscopic inguinal hernia repair was described about 30 years ago and advantages of the technique have been demonstrated, the utilization of this approach has not been what we would expect. Some reasons may be the need for surgeons to understand the posterior anatomy of the groin from a new vantage point, as well as to acquire advanced laparoscopic skills. Recently, however, the introduction of a robotic approach has dramatically increased the adoption of minimally invasive techniques for inguinal hernia repair.Methods
Important recent contributions to this evolution have been the establishment of a new concept known as the critical view of the Myopectineal Orifice (MPO) and the description of a new way of understanding the posterior view of the antomy of the groin (inverted Y and the five triangles). In this paper, we describe 10 rules for a safe MIS inguinal hernia repair (TAPP, TEP, ETEP, RTAPP) that combines these two new concepts in a unique way.Conclusions
As the critical view of safety has made laparoscopic cholecystectomy safer, we feel that following our ten rules based on understanding the anatomy of the posterior groin as defined by zones and essential triangles and the technical steps to achieve the critical view of the MPO will foster the goal of safe MIS hernia repair, no matter which minimally invasive technique is employed.
Purpose
Lateral abdominal wall hernias are rare defects but, due to their location, repair is difficult, and recurrence is common. Few studies exist to support a standard protocol for repair of these lateral hernias. We hypothesized that anchoring our repair to fixed bony structures would reduce recurrence rates.
Methods
A retrospective review of all patients who underwent lateral hernia repair at our institution was performed.
Results
Eight cases (seven flank and one thoracoabdominal) were reviewed. The median defect size was 105 cm² (range 36–625 cm²). The median operative time was 185 min (range 133–282 min). There were no major complications. One patient who was repaired without mesh attachment to bony landmarks developed a recurrence at ten months and subsequently underwent reoperation. Patients with mesh secured to bony landmarks were recurrence free at a median follow-up of 171 days.
Conclusions
Lateral hernias present a greater challenge due to their anatomic location. An open technique with mesh fixation to bony structures is a promising solution to this complex problem.
Background
Minimally invasive hepatectomy (MIH) has become an important option for the treatment of various liver tumours. A major concern is the learning curve required. The aim of this study was to perform a systematic review and summarize current literature analysing the learning curve for MIH.
Methods
A systematic review of the literature pertaining to learning curves in MIH to July 2019 was performed using PubMed and Scopus databases. All original full-text articles published in English relating to learning curves for both laparoscopic liver resection (LLR), robotic liver resection (RLR), or a combination of these, were included. To explore quantitatively the learning curve for MIH, a meta-regression analysis was performed.
Results
Forty studies relating to learning curves in MIH were included. The median overall number of procedures required in studies utilizing cumulative summative (CUSUM) methodology for LLR was 50 (range 25–58) and for RLR was 25 (16–50). After adjustment for year of adoption of MIH, the CUSUM-derived caseload to surmount the learning curve for RLR was 47.1 (95 per cent c.i. 1.2 to 71.6) per cent; P = 0.046) less than that required for LLR. A year-on-year reduction in the number of procedures needed for MIH was observed, commencing at 48.3 cases in 1995 and decreasing to 23.8 cases in 2015.
Conclusion
The overall learning curve for MIH decreased steadily over time, and appeared less steep for RLR compared with LLR.
This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colon Cancer focuses on systemic therapy options for the treatment of metastatic colorectal cancer (mCRC), because important updates have recently been made to this section. These updates include recommendations for first-line use of checkpoint inhibitors for mCRC, that is deficient mismatch repair/microsatellite instability-high, recommendations related to the use of biosimilars, and expanded recommendations for biomarker testing. The systemic therapy recommendations now include targeted therapy options for patients with mCRC that is HER2-amplified, or BRAF V600E mutation–positive. Treatment and management of nonmetastatic or resectable/ablatable metastatic disease are discussed in the complete version of the NCCN Guidelines for Colon Cancer available at NCCN.org . Additional topics covered in the complete version include risk assessment, staging, pathology, posttreatment surveillance, and survivorship.
This chapter focusses on the underlying mechanisms of functioning of the Roux-en-Y gastric bypass (RYGB) – from its benefits (weight loss and comorbidity improvement) through to its complications. RYGB is no longer considered a purely mechanically restrictive and malabsorptive procedure but a metabolic procedure most likely to involve complex gut-brain signalling and physiological changes. It is likely that the gut has endocrine and metabolic functions that regulate appetite, satiety, weight and glucose metabolism. The full extent of these mechanisms is still not fully understood. Here we explore the current body of evidence.
Aim:
After extended left colectomy, traditional colorectal anastomosis is often not feasible because of insufficient length of the remaining colon to perform a tension-free anastomosis. Total colectomy with ileorectal anastomosis could be an alternative but this can lead to unsatisfactory quality of life. Trans-mesenteric colorectal anastomosis or inverted right colonic transposition (so-called Deloyers procedure) are two possible solutions for creating a tension-free colorectal anastomosis after extended left colectomy. Few studies have reported their results of these two techniques and mostly via laparotomy. The aim of this study was to describe the trans-mesenteric colorectal anastomosis and the inverted right colonic transposition procedures via a laparoscopic approach and report the outcome in a series of thirteen consecutive patients.
Method:
Retrospective chart review of laparoscopic colorectal surgery with trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure from January 2015 up to 2019. An accompanying video demonstrates these two techniques.
Result:
Thirteen consecutive patients underwent either a laparoscopic trans-mesenteric colorectal anastomosis (n=9) or an inverted right colonic transposition procedure (n=4). One patient had intraoperative presacral bleeding that was stopped successfully without conversion. Two patients had a post-operative intra-abdominal abscess, but no anastomotic complications were recorded. The median number of bowel movements per day after six months was 2 (range 2-5).
Conclusions:
Trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure is feasible laparoscopically. The now well-established classical advantages of the laparoscopic approach are associated with good functional outcome after this procedure.