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Cai L, Qiu G, Jiang Z, Zhao P, Zheng Z, Zhu M, Han S, Chen N, Liao X, Che X, Li X, Fan L. Linea alba support method of prophylactic loop ileostomy via lower abdominal midline incision for rectal cancer: a retrospective cohort study. Surg Endosc 2025; 39:1351-1361. [PMID: 39762610 DOI: 10.1007/s00464-024-11493-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Accepted: 12/08/2024] [Indexed: 02/06/2025]
Abstract
BACKGROUND The traditional method of prophylactic loop ileostomy is time-consuming and prone to complications like stoma stenosis, peristomal adhesions, or dermatitis. The aim of this study is to evaluate the clinical application value and potential benefits of a novel approach named linea alba support method (LASM) of prophylactic loop ileostomy via lower abdominal midline incision. METHODS The clinical data of rectal cancer patients admitted to the General Surgery Department of the First Affiliated Hospital of Xi'an Jiaotong University between January 2021 and December 2023 were retrospectively analyzed. The patients were divided into two groups based on different methods for prophylactic loop ileostomy they received, and clinical outcomes were further compared between the two groups. RESULTS A total of 102 patients, including 48 patients underwent LASM (LASM group) and 54 patients underwent traditional method (TM group) were included in this study. The LASM group exhibited significantly shorter operative time (201.8 vs. 223.0 min, p = 0.011), ileostomy time (10 vs. 22 min, p < 0.001), the length of postoperative visual incision (5 vs. 8 cm, p < 0.001), and operative time of stoma closure (75 vs. 90 min, p < 0.001) compared to the TM group. There were no significant differences between the two groups in postoperative complications and stoma-related complications. In addition, LASM was an independent influencing factor for shorter operative time of ileostomy. CONCLUSION LASM of prophylactic loop ileostomy via lower abdominal midline incision, seamlessly integrating simplicity, safety, and exceptional cosmetic outcomes, merits extensive promotion and adoption.
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Affiliation(s)
- Lindi Cai
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Guanglin Qiu
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Zhengdong Jiang
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Pengwei Zhao
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Zhongqiang Zheng
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Mengke Zhu
- Department of Pathology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Shangning Han
- Department of General Surgery, Honghui Hospital, Xi'an, 710054, Shaanxi, China
| | - Ni Chen
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Xinhua Liao
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Xiangming Che
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Xuqi Li
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China.
| | - Lin Fan
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China.
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Yin TC, Chen YC, Su WC, Chang TK, Chen PJ, Li CC, Tsai HL, Huang CW, Wang JY. Innovative needle-assisted technique for intracorporeal anastomosis: Simplifying closure of common enterotomy in laparoscopic gastrointestinal surgery. Surg Endosc 2024; 38:7621-7626. [PMID: 39433589 PMCID: PMC11615047 DOI: 10.1007/s00464-024-11292-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 09/13/2024] [Indexed: 10/23/2024]
Abstract
BACKGROUND Intracorporeal anastomosis offers notable advantages over extracorporeal techniques, including reduced tissue manipulation leading to faster recovery and potentially lower risks of surgical site infections and complications. However, it also involves several challenges, such as increased operative time and the need for experienced assistants and multiple trocars. Our novel technique addresses these problems. METHODS We present a novel approach for closing common enterotomies during intracorporeal anastomosis by using a linear stapler. This technique involves the use of a 6-cm straight needle, which facilitates closure of the common enterotomy. The technique can be performed independently by a single surgeon without the need for additional trocars or assistants. RESULTS This technique was applied for 20 patients undergoing laparoscopic gastrointestinal surgery between June 2023 and February 2024. The median age of the enrolled patients was 65 years, with laparoscopic right hemicolectomy with intracorporeal ileocolostomy being the most common procedure (60% of cases). The median anastomosis time was 22.5 min. No occurrence of anastomotic leakage was reported, and only one patient (5%) developed temporary postoperative bowel obstruction, which was managed conservatively. CONCLUSIONS Our technique enables efficient and safe closure of common enterotomies during intracorporeal anastomosis, minimizing reliance on additional trocars and experienced assistants. It simplifies the procedure and ensures fullthickness stapling, potentially reducing the likelihood of complications. Because of its broad applicability across various laparoscopic surgeries, this technique offers substantial benefits and is worth recommending for intracorporeal anastomosis.
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Affiliation(s)
- Tzu-Chieh Yin
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Cheng Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chih Su
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Kun Chang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Jung Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Chun Li
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan
| | - Hsiang-Lin Tsai
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
- Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Devlin J, Reed RN, Brody F, Duncan JE. Robotic Sigmoidectomy for Diverticular Disease. J Laparoendosc Adv Surg Tech A 2024; 34:967-971. [PMID: 39429143 DOI: 10.1089/lap.2024.0329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2024] Open
Abstract
Introduction: Historically, colon resection was recommended after one episode of complicated diverticulitis. However, current trends favor a more individualized approach. This review examines elective sigmoidectomy for complicated diverticulitis as well as robotic approaches for diverticular disease. Methods: The literature was reviewed for timely (post 2000) and relevant articles regarding robotics and diverticulitis. The articles included large prospective series, retrospective analysis, meta-analyses and randomized controlled trials. Results: Primary anastomosis with or without protective ileostomy has emerged as an alternative to the Hartman's procedure in emergent or urgent surgery in patients without significant comorbidities. Elective sigmoidectomy after an episode of complicated diverticulitis should be decided on a case-by-case basis considering patient characteristics, continued subacute symptoms, complications from the disease, and chance of recurrence episodes. Conclusions: There are several variations techniques for robotic sigmoidectomy outlined in this article, and familiarity with all can help depending on the logistics of the case. Minimally invasive colectomy provides superior patient satisfaction and outcomes.
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Affiliation(s)
- Joseph Devlin
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Ruth Natalie Reed
- Surgery Service, Veterans Affairs Medical Center, Washington, District of Columbia, USA
| | - Fred Brody
- Surgery Service, Veterans Affairs Medical Center, Washington, District of Columbia, USA
| | - James E Duncan
- Surgery Service, Veterans Affairs Medical Center, Washington, District of Columbia, USA
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Johnson JA, Mesiti A, Herre M, Farzaneh C, Li Y, Zambare W, Carmichael J, Pigazzi A, Jafari MD. Effect of Specimen Extraction Site on Postoperative Incisional Hernia after Minimally Invasive Right Colectomy. J Am Coll Surg 2024; 239:107-112. [PMID: 38415817 DOI: 10.1097/xcs.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Incisional hernia (IH) is a known complication after colorectal surgery. Despite advances in minimally invasive surgery, colorectal surgery still requires extraction sites for specimen retrieval, increasing the likelihood of postoperative IH development. The objective of this study is to determine the effect of specimen extraction site on the rate of IH after minimally invasive right-sided colectomy for patients with available imaging. STUDY DESIGN This is a retrospective multi-institutional cohort study at 2 large academic medical centers in the US. Adults who underwent right-sided minimally invasive colectomy from 2012 to 2020 with abdominal imaging available at least 1 year postoperatively were included in the analysis. The primary exposure was specimen extraction via a midline specimen extraction vs Pfannenstiel specimen extraction. The main outcome was the development of IH at least 1 year postoperatively as visualized on a CT scan. RESULTS Of the 341 patients sampled, 194 (57%) had midline specimen extraction and 147 (43%) had a Pfannenstiel specimen extraction. Midline extraction patients were older (66 ± 15 vs 58 ± 16; p < 0.001) and had a higher rate of previous abdominal operation (99, 51% vs 55, 37%, p = 0.01). The rate of IH was higher in midline extraction at 25% (48) compared with Pfannenstiel extraction (0, 0%; p < 0.001). The average length of stay was higher in the midline extraction group at 5.1 ± 2.5 compared with 3.4 ± 3.1 days in the Pfannenstiel extraction group (p < 0.001). Midline extraction was associated with IH development (odds ratio 24.6; 95% CI 1.89 to 319.44; p = 0.004). Extracorporeal anastomosis was associated with a higher IH rate (odds ratio 25.8; 95% CI 2.10 to 325.71; p = 0.002). CONCLUSIONS Patients who undergo Pfannenstiel specimen extraction have a lower risk of IH development compared with those who undergo midline specimen extraction.
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Affiliation(s)
- Josh A Johnson
- From the Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY (Johnson, Mesiti, Herre, Zambare, Pigazzi, Jafari)
| | - Andrea Mesiti
- From the Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY (Johnson, Mesiti, Herre, Zambare, Pigazzi, Jafari)
| | - Margo Herre
- From the Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY (Johnson, Mesiti, Herre, Zambare, Pigazzi, Jafari)
| | - Cyrus Farzaneh
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA (Farzaneh, Carmichael)
| | - Ying Li
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY (Li)
| | - Wini Zambare
- From the Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY (Johnson, Mesiti, Herre, Zambare, Pigazzi, Jafari)
| | - Joseph Carmichael
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA (Farzaneh, Carmichael)
| | - Alessio Pigazzi
- From the Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY (Johnson, Mesiti, Herre, Zambare, Pigazzi, Jafari)
| | - Mehraneh D Jafari
- From the Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY (Johnson, Mesiti, Herre, Zambare, Pigazzi, Jafari)
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Chang YY, Cheng B, Sheu GT. Clinical Outcomes after Intracorporeal versus Extracorporeal Anastomosis in Patients Undergoing Laparoscopic Right Hemicolectomy for Colon Cancer. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1073. [PMID: 39064502 PMCID: PMC11278839 DOI: 10.3390/medicina60071073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Laparoscopic right hemicolectomy (LRHC) is commonly performed for patients with colon cancer, selecting between intracorporeal anastomosis (ICA) or extracorporeal anastomosis (ECA). However, the impact of ICA versus ECA on patient outcomes remains debatable. The varying levels of experience among surgeons may influence the outcomes. Therefore, this study sought to compare the short- and long-term outcomes of LRHC using ICA versus ECA. Materials and Methods: This retrospective study extracted patient data from the medical records database of Changhua Christian Hospital, Taiwan, from 2017 to 2020. Patients with colon cancer who underwent LRHC with either ICA or ECA were included. Primary outcomes were post-surgical outcomes and secondary outcomes were recurrence rate, overall survival (OS), and cancer-specific survival (CSS). Between-group differences were compared using chi-square, t-tests, and Fisher's exact tests and Mann-Whitney U tests. Associations between study variables, OS, and CSS were determined using Cox analyses. Results: Data of 240 patients (61 of ICA and 179 of ECA) with a mean age of 65.0 years and median follow-up of 49.3 months were collected. No recognized difference was found in patient characteristics between these two groups. The ICA group had a significantly shorter operation duration (median (IQR): 120 (110-155) vs. 150 (130-180) min) and less blood loss (median (IQR): 30 (10-30) vs. 30 (30-50) mL) than the ECA group (p < 0.001). No significant differences were found in 30-day readmission (ICA vs. ECA: 1.6% vs. 2.2%, p > 0.999) or recurrence (18.0% vs. 13.4%, p = 0.377) between the two groups. Multivariable analyses revealed no significant differences in OS (adjusted hazard ratio (aHR): 0.65; 95% confidence interval (CI): 0.25-1.44) or CSS (adjusted sub-hazard ratio (aSHR): 0.41, 95% CI: 0.10-1.66) between groups. Conclusions: Both ICA and ECA in LRHC for colon cancer had similar outcomes without statistically significant differences in post-surgical complications, 30-day readmission rates, recurrence rate, and long-term survival outcomes. However, ICA may offer two advantages in terms of a shorter operative duration and reduced blood loss.
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Affiliation(s)
- Yu-Yao Chang
- Institute of Medicine, Chung Shan Medical University, No. 110, Sec. 1, Jianguo N. Road, Taichung City 402, Taiwan;
- Division of Colon and Rectal Surgery, Department of Surgery, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City 500, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, 145 Xingda Rd., Taichung City 402, Taiwan
| | - Bill Cheng
- Graduate Institute of Biomedical Engineering, National Chung-Hsing University, Taichung City 402, Taiwan;
| | - Gwo-Tarng Sheu
- Institute of Medicine, Chung Shan Medical University, No. 110, Sec. 1, Jianguo N. Road, Taichung City 402, Taiwan;
- Department of Medical Oncology and Chest Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1, Jianguo N. Road, Taichung City 402, Taiwan
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6
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Fan BH, Zhong KL, Zhu LJ, Chen Z, Li F, Wu WF. Clinical observation of extraction-site incisional hernia after laparoscopic colorectal surgery. World J Gastrointest Surg 2024; 16:710-716. [PMID: 38577097 PMCID: PMC10989329 DOI: 10.4240/wjgs.v16.i3.710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/17/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Laparoscopic colorectal cancer surgery increases the risk of incisional hernia (IH) at the tumor extraction site. AIM To investigate the incidence of IH at extraction sites following laparoscopic colorectal cancer surgery and identify the risk factors for IH incidence. METHODS This study retrospectively analyzed the data of 1614 patients who underwent laparoscopic radical colorectal cancer surgery with tumor extraction through the abdominal wall at our center between January 2017 and December 2022. Differences in the incidence of postoperative IH at different extraction sites and the risk factors for IH incidence were investigated. RESULTS Among the 1614 patients who underwent laparoscopic radical colorectal cancer surgery, 303 (18.8%), 923 (57.2%), 171 (10.6%), and 217 (13.4%) tumors were extracted through supraumbilical midline, infraumbilical midline, umbilical, and off-midline incisions. Of these, 52 patients developed IH in the abdominal wall, with an incidence of 3.2%. The incidence of postoperative IH was significantly higher in the off-midline incision group (8.8%) than in the middle incision groups [the supraumbilical midline (2.6%), infraumbilical midline (2.2%), and umbilical incision (2.9%) groups] (χ2 = 24.985; P < 0.05). Univariate analysis showed that IH occurrence was associated with age, obesity, sex, chronic cough, incision infection, and combined diabetes, anemia, and hypoproteinemia (P < 0.05). Similarly, multivariate analysis showed that off-midline incision, age, sex (female), obesity, incision infection, combined chronic cough, and hypoproteinemia were independent risk factors for IH at the site of laparoscopic colorectal cancer surgery (P < 0.05). CONCLUSION The incidence of postoperative IH differs between extraction sites for laparoscopic colorectal cancer surgery. The infraumbilical midline incision is associated with a lower hernia rate and is thus a suitable tumor extraction site.
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Affiliation(s)
- Bao-Hang Fan
- Second Clinical Medical College of Jinan University, Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Ke-Li Zhong
- Department of Gastrointestinal Surgery, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen 518020, Guangdong Province, China
| | - Li-Jin Zhu
- Department of Radiation Oncology, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen 518020, Guangdong Province, China
| | - Zhao Chen
- Second Clinical Medical College of Jinan University, Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Fang Li
- Department of Gastrointestinal Surgery, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen 518020, Guangdong Province, China
| | - Wen-Fei Wu
- Second Clinical Medical College of Jinan University, Jinan University, Shenzhen 518020, Guangdong Province, China
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Sanders DL, Pawlak MM, Simons MP, Aufenacker T, Balla A, Berger C, Berrevoet F, de Beaux AC, East B, Henriksen NA, Klugar M, Langaufová A, Miserez M, Morales-Conde S, Montgomery A, Pettersson PK, Reinpold W, Renard Y, Slezáková S, Whitehead-Clarke T, Stabilini C. Midline incisional hernia guidelines: the European Hernia Society. Br J Surg 2023; 110:1732-1768. [PMID: 37727928 PMCID: PMC10638550 DOI: 10.1093/bjs/znad284] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/08/2023] [Accepted: 08/02/2023] [Indexed: 09/21/2023]
Affiliation(s)
- David L Sanders
- Academic Department of Abdominal Wall Surgery, Royal Devon University
Foundation Healthcare Trust, North Devon District Hospital,
Barnstaple, UK
- University of Exeter Medical School,
Exeter, UK
| | - Maciej M Pawlak
- Academic Department of Abdominal Wall Surgery, Royal Devon University
Foundation Healthcare Trust, North Devon District Hospital,
Barnstaple, UK
- University of Exeter Medical School,
Exeter, UK
| | - Maarten P Simons
- Department of Surgery, OLVG Hospital Amsterdam,
Amsterdam, The
Netherlands
| | - Theo Aufenacker
- Department of Surgery, Rijnstate Hospital Arnhem,
Arnhem, The Netherlands
| | - Andrea Balla
- IRCCS San Raffaele Scientific Institute,
Milan, Italy
| | - Cigdem Berger
- Hamburg Hernia Centre, Department of Hernia and Abdominal Wall Surgery,
Helios Mariahilf Hospital Hamburg, Teaching Hospital of the University of Hamburg,
Hamburg, Germany
| | - Frederik Berrevoet
- Department for General and HPB Surgery and Liver Transplantation, Ghent
University Hospital, Ghent, Belgium
| | | | - Barbora East
- 3rd Department of Surgery at 1st Medical Faculty of Charles University,
Motol University Hospital, Prague, Czech Republic
| | - Nadia A Henriksen
- Department of Gastrointestinal and Hepatic Diseases, University of
Copenhagen, Herlev Hospital, Copenhagen, Denmark
| | - Miloslav Klugar
- The Czech National Centre for Evidence-Based Healthcare and Knowledge
Translation (Cochrane Czech Republic, Czech CEBHC: JBI Centre of Excellence, Masaryk
University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of
Medicine, Masaryk University, Brno, Czech Republic
| | - Alena Langaufová
- Department of Health Sciences, Faculty of Medicine, Masaryk
University, Brno, Czech
Republic
| | - Marc Miserez
- Department of Abdominal Surgery, University Hospital Gasthuisberg, KU
Leuven, Leuven, Belgium
| | - Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and
Digestive Surgery, University Hospital Virgen del Rocio, University of
Sevilla, Sevilla, Spain
| | - Agneta Montgomery
- Department of Surgery, Skåne University Hospital,
Malmö, Sweden
- Department of Clinical Sciences, Malmö Faculty of Medicine, Lund
University, Lund, Sweden
| | - Patrik K Pettersson
- Department of Surgery, Skåne University Hospital,
Malmö, Sweden
- Department of Clinical Sciences, Malmö Faculty of Medicine, Lund
University, Lund, Sweden
| | - Wolfgang Reinpold
- Hamburg Hernia Centre, Department of Hernia and Abdominal Wall Surgery,
Helios Mariahilf Hospital Hamburg, Teaching Hospital of the University of Hamburg,
Hamburg, Germany
| | - Yohann Renard
- Reims Champagne-Ardennes, Department of General, Digestive and Endocrine
Surgery, Robert Debré University Hospital, Reims,
France
| | - Simona Slezáková
- The Czech National Centre for Evidence-Based Healthcare and Knowledge
Translation (Cochrane Czech Republic, Czech CEBHC: JBI Centre of Excellence, Masaryk
University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of
Medicine, Masaryk University, Brno, Czech Republic
| | - Thomas Whitehead-Clarke
- Centre for 3D Models of Health and Disease, Division of Surgery and
Interventional Science, University College London,
London, UK
| | - Cesare Stabilini
- Department of Surgery, University of Genoa,
Genoa, Italy
- Policlinico San Martino, IRCCS, Genoa,
Italy
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8
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Yao Q, Sun QN, Zhou JJ, Ma Y, Ren J, Wang LH, Wang DR. Robotic-assisted intracorporeal versus extracorporeal techniques in sigmoidectomy: a propensity score-matched analysis. J Robot Surg 2023; 17:2479-2485. [PMID: 37515681 DOI: 10.1007/s11701-023-01678-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/16/2023] [Indexed: 07/31/2023]
Abstract
Scarce research has been performed to assess the safety and efficacy of anastomosis technique on robotic-assisted sigmoidectomy. This study was designed to evaluate the difference between intracorporeal and extracorporeal techniques during robotic-assisted sigmoidectomy. Clinical data of 193 cases who received robotic-assisted sigmoidectomy were retrospectively collected and analyzed. Only 116 cases were available for analysis (intracorporeal group = 58 and extracorporeal group = 58) after propensity score matching. Independent sample t test was conducted to evaluate the continuous variables. Moreover, the statistical significance of categorical variables was tested using Chi-square or Fisher's exact tests. Statistical analysis showed that the intracorporeal group demonstrated greater superiorities in pain scale on the first and second postoperative day (P < 0.05), time of catheter indwelling (P = 0.009), and length of hospital stay (P = 0.019). Additionally, the intracorporeal technique contributed to fewer complications including urinary retention (P = 0.027) and hernia (P = 0.037) than the extracorporeal group. Our analysis revealed that intracorporeal technique was safe and feasible due to the shorter time of catheter indwelling and length of hospital stay and fewer post-operation complications.
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Affiliation(s)
- Qing Yao
- Northern Jiangsu People's Hospital Affiliated to Dalian Medical University, Yangzhou, 225001, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Qian-Nan Sun
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
- Medical Research Center of Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Jia-Jie Zhou
- Northern Jiangsu People's Hospital Affiliated to Medical School of Nanjing University, Yangzhou, 225001, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Yue Ma
- Northern Jiangsu People's Hospital Affiliated to Medical School of Nanjing University, Yangzhou, 225001, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Jun Ren
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu Province, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Liu-Hua Wang
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu Province, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China
| | - Dao-Rong Wang
- Northern Jiangsu People's Hospital Affiliated to Dalian Medical University, Yangzhou, 225001, China.
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu Province, China.
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China.
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China.
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic, Yangzhou, 225001, China.
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9
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Iwamoto H, Matsuda K, Takifuji K, Tamura K, Mitani Y, Mizumoto Y, Nakamura Y, Sakanaka T, Yokoyama S, Hotta T, Yamaue H. Randomized controlled trial comparing cosmetic results of midline incision versus off-midline incision for specimen extraction in laparoscopic colectomy. Langenbecks Arch Surg 2023; 408:281. [PMID: 37460849 DOI: 10.1007/s00423-023-03018-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE A notable advantage of laparoscopic colorectal surgery is that only a small incision at the extraction site is necessary, which is considered to be cosmetically beneficial. Meanwhile, the optimal extraction site for the resected specimen in laparoscopic colectomy is controversial in terms of cosmetic benefit. This randomized controlled trial compares midline and off-midline extraction sites in laparoscopic colectomy in patients with colon cancer, with consideration of cosmetic benefits as the primary endpoint. METHODS Included were patients that underwent elective laparoscopic colectomy at WMUH between October 2014 and February 2017. Patients were randomly assigned to either midline incision group or off-midline incision group. Prospectively collected data included cosmetic results (patients and observer assessment scale) and complications including incidence of incisional hernia, SSI, and pain. This trial was registered with UMIN Clinical Trials (UMIN000028943). RESULTS Finally, 98 patients with colorectal cancer were analyzed. No significant differences were found between the two groups in patient and observer assessment scales of cosmetic results (midline 8 ± 1.1 vs off-midline 11 ± 5.9 p = 0.16, midline 13.5 ± 6.6 vs off-midline 15 ± 11 p = 0.58, respectively) or in postoperative pain. However, incisional hernia occurred in four cases in the midline group (8%), which was significantly higher than that in the off-midline group (no cases, 0%). CONCLUSION There was no significant difference in terms of cosmetic benefit, the primary endpoint, between the two groups. In this study, only the extraction site location was compared; future studies will examine differences depending on the incisional direction, including the incidence of incisional hernia.
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Affiliation(s)
- Hiromitsu Iwamoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Kenji Matsuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Katsunari Takifuji
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Koichi Tamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Yasuyuki Mitani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Yuki Mizumoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Yuki Nakamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Toshihiro Sakanaka
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Shozo Yokoyama
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Tsukasa Hotta
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan.
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10
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Calini G, Abdalla S, Aziz MAAE, Behm KT, Shawki SF, Mathis KL, Larson DW. Incisional hernia rates between intracorporeal and extracorporeal anastomosis in minimally invasive ileocolic resection for Crohn's disease. Langenbecks Arch Surg 2023; 408:251. [PMID: 37382678 DOI: 10.1007/s00423-023-02976-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/10/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE One-third of patients with Crohn's disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). METHODS This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center. RESULTS Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p = 0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p = 0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3 ± 2.5 vs. ECA-M: 4.1 ± 2.4 days; p = 0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p = 0.064] and readmission rates [7(11.9) vs. 18(9.5); p = 0.59]. CONCLUSION Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Sherief F Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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11
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Zhang T, Sun Y, Mao W. Meta‑analysis of randomized controlled trials comparing intracorporeal versus extracorporeal anastomosis in minimally invasive right hemicolectomy: upgrading the level of evidence. Int J Colorectal Dis 2023; 38:147. [PMID: 37248431 DOI: 10.1007/s00384-023-04445-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Minimally invasive right hemicolectomy has been increasingly used for the treatment of right hemicolectomy disease, and both intracorporeal anastomosis (ICA) and extracorporeal anastomosis (ECA) are available to restore intestinal continuity. However, the advantages and disadvantages of these two anastomoses are highly controversial. The present meta-analysis evaluated the effectiveness of ICA versus ECA in minimally invasive right colectomy to improve the grade of evidence. METHODS We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for randomized controlled trials (RCTs) comparing intracorporeal versus extracorporeal anastomosis in laparoscopic or robotic right hemicolectomy published from database inception to February 2023. Two researchers performed the literature review, data extraction, bias assessment, and meta-analysis of the data using Review Manager 5.4 software. RESULTS Seven RCTs with a total of 750 patients were included in the meta-analysis. The results showed a lower incidence of postoperative paralytic ileus (RR 0.62, 95% CI 0.39 ~ 0.99, p = 0.04) and shorter incision length (MD - 1.38; 95% CI: - 1.98 ~ - 0.78, p < 0.00001), but longer operative time (MD 10.69; 95% CI: 2.76 ~ 18.63, p = 0.008). The remaining events including bleeding (RR 0.49, 95% CI: 0.12 ~ 2.04, p = 0.33), anastomotic leak (RR 0.62, 95% CI: 0.39 ~ 0.99, p = 0.85), surgical site infection (RR 0.15, 95% CI: 0.22 ~ 1.25, p = 0.15), overall perioperative morbidity (RR 0.86, 95% CI: 0.58 ~ 1.26, p = 0.44), number of harvested lymph nodes (MD 0.75; 95% CI: - 0.15 ~ 1.65, p = 0.10), and length of hospital stay (MD - 0.27; 95% CI: - 0.91 ~ 0.38, p = 0.42) were not statistically significant. CONCLUSIONS Compared to ECA, ICA in minimally invasive right hemicolectomy reduced the risk of postoperative paralytic ileus and shortened the length of the incision but prolonged the operative time.
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Affiliation(s)
- Tuo Zhang
- Department of General Surgery, Qingdao Municipal Hospital, Qingdao Clinical Medical College, Nanjing Medical University, Qingdao, 266071, Shandong, China
| | - Yigong Sun
- Department of General Surgery, Qingdao Municipal Hospital of Qingdao University, Qingdao, 266071, Shandong, China
| | - Weizheng Mao
- Department of General Surgery, Qingdao Municipal Hospital, Qingdao Clinical Medical College, Nanjing Medical University, Qingdao, 266071, Shandong, China.
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12
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Calini G, Abdalla S, Aziz MAAE, Behm KT, Shawki SF, Mathis KL, Larson DW. Incisional Hernia rates between Intracorporeal and Extracorporeal Anastomosis in Minimally Invasive Ileocolic Resection for Crohn's disease.. [DOI: 10.21203/rs.3.rs-2591968/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Abstract
Purpose: One-third of patients with Crohn’s disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M).
Methods: This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center.
Results: Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p=0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p =0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3±2.5 vs. ECA-M: 4.1±2.4 days; p=0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p=0.064] and readmission rates [7(11.9) vs. 18(9.5); p=0.59].
Conclusion: Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.
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13
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Paruch JL. Extraction Site in Minimally Invasive Colorectal Surgery. Clin Colon Rectal Surg 2023; 36:47-51. [PMID: 36643827 PMCID: PMC9839428 DOI: 10.1055/s-0042-1758352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The widespread adoption of minimally invasive colorectal surgery has led to improved patient recovery and outcomes. Specimen extraction sites remain a major source of pain and potential postoperative morbidity. Careful selection of the extraction site incision may allow surgeons to decrease postoperative pain, infectious complications, or rates of hernia formation. Options include midline, paramedian, transverse, Pfannenstiel, and natural orifice sites. Patient, disease, and surgeon-related factors should all be considered when choosing a site. This article will review different options for specimen extraction sites.
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Affiliation(s)
- Jennifer L Paruch
- Department of Colon and Rectal Surgery, Ochsner Medical Center, New Orleans, Louisiana
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14
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den Hartog FPJ, van Egmond S, Poelman MM, Menon AG, Kleinrensink GJ, Lange JF, Tanis PJ, Deerenberg EB. The incidence of extraction site incisional hernia after minimally invasive colorectal surgery: a systematic review and meta-analysis. Colorectal Dis 2022; 25:586-599. [PMID: 36545836 DOI: 10.1111/codi.16455] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/09/2022] [Accepted: 11/22/2022] [Indexed: 01/06/2023]
Abstract
AIM Minimally invasive colorectal surgery reduces surgical trauma with better preservation of abdominal wall integrity, but the extraction site is still at risk of incisional hernia (IH). The aim of this study was to determine pooled incidence of IH for each type of extraction site and to compare rates of IH after midline, nonmidline and Pfannenstiel extraction. METHOD A systematic review and meta-analysis was conducted using the PRISMA guidelines. Single-armed and multiple-armed cohort studies and randomized controlled trials regarding minimally invasive colorectal surgery were searched from five databases. Outcomes were pooled and compared with random-effects, inverse-variance models. Risk of bias within the studies was assessed using the Cochrane ROBINS-I and RoB 2 tool. RESULTS Thirty six studies were included, with a total 11,788 patients. The pooled extraction site IH rate was 16.0% for midline (n = 4081), 9.3% for umbilical (n = 2425), 5.2% for transverse (n = 3213), 9.4% for paramedian (n = 134) and 2.1% for Pfannenstiel (n = 1449). Nonmidline extraction (transverse and paramedian) showed significantly lower odds ratios (ORs) for IH when compared with midline extraction (including umbilical). Pfannenstiel extraction resulted in a significantly lower OR for IH compared with midline [OR 0.12 (0.50-0.30)], transverse [OR 0.25 (0.13-0.50)] and umbilical (OR 0.072 [0.033-0.16]) extraction sites. The risks of surgical site infection, seroma/haematoma or wound dehiscence were not significantly different in any of the analyses. CONCLUSION Pfannenstiel extraction is the preferred method in minimally invasive colorectal surgery. In cases where Pfannenstiel extraction is not possible, surgeons should avoid specimen extraction in the midline.
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Affiliation(s)
- Floris P J den Hartog
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sarah van Egmond
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marijn M Poelman
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Anand G Menon
- Department of Surgery, IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands
| | - Gert-Jan Kleinrensink
- Department of Neuroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eva B Deerenberg
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
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15
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Al Dhaheri M, Ibrahim M, Al-Yahri O, Amer I, Khawar M, Al-Naimi N, Ahmed AA, Nada MA, Parvaiz A. Choice of specimen's extraction site affects wound morbidity in laparoscopic colorectal cancer surgery. Langenbecks Arch Surg 2022; 407:3561-3565. [PMID: 36219253 DOI: 10.1007/s00423-022-02701-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 09/28/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The choice for an ideal site of specimen extraction following laparoscopic colorectal surgery remains debatable. However, midline incision (MI) is usually employed for right and left-sided colonic resections while left iliac fossa or suprapubic transverse incision (STI) were reserved for sigmoid and rectal cancer resections. OBJECTIVE To compare the incidence of surgical site infection (SSI) and incisional hernia (IH) in elective laparoscopic colorectal surgery for cancer and specimen extraction via MI or STI. METHOD Prospectively collected data of elective laparoscopic colorectal cancer resections between January 2017 and December 2019 were retrospectively reviewed. MI was employed for right and left-sided colonic resections while STI was used for sigmoid and rectal resections. SSI is defined according to the US CDC criteria. IH was diagnosed clinically and confirmed by CT scan at 1 year. RESULTS A total of 168 patients underwent elective laparoscopic colorectal resections. MI was used in 90 patients while 78 patients had STI as an extraction site. Demographic and preoperative data is similar for two groups. The rate of IH was 13.3% for MI and 0% in the STI (p = 0.001). SSI was seen in 16.7% of MI vs 11.5% of STI (p = 0.34). Univariate and multivariate analysis showed that the choice of extraction site is associated with statistically significant higher incisional hernia rate. CONCLUSION MI for specimen extraction is associated with higher incidence of both SSI and IH. The choice of incision for extraction site is an independent predicative factor for significantly higher IH and increased SSI rates.
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Affiliation(s)
- Mahmood Al Dhaheri
- Colorectal Surgery Unit, Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Mohanad Ibrahim
- General Surgery, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Omer Al-Yahri
- General Surgery, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Ibrahim Amer
- Colorectal Surgery Unit, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Mahwish Khawar
- Colorectal Surgery Unit, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Noof Al-Naimi
- Colorectal Surgery Unit, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | | | - Mohamed Abu Nada
- Colorectal Surgery Unit, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Amjad Parvaiz
- Colorectal Surgery Unit, Hamad Medical Corporation, PO Box 3050, Doha, Qatar.,Champalimaud Foundation, Lisbon, Portugal
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16
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Baek SK. Extracorporeal versus intracorporeal anastomosis for right colon cancer surgery. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:91-96. [PMID: 36177372 PMCID: PMC9494010 DOI: 10.7602/jmis.2022.25.3.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/09/2022] [Accepted: 09/11/2022] [Indexed: 06/16/2023]
Abstract
Laparoscopic right colectomy is currently considered the standard treatment for right colon cancer. After excision of the right colon, minimally invasive options for ileocolonic anastomosis include extracorporeal anastomosis (EA) and intracorporeal anastomosis (IA). However, the choice of anastomotic technique remains debated. As the entire IA is performed in the abdominal cavity, it is known for its advantages of a faster intestinal recovery and small incision. However, IA is time-consuming and technically difficult, limiting its widespread use. Recently, the robotic approach has increased the adoption of intracorporeal anastomotic techniques owing to the benefits of endowrist-articulated instruments and staplers. Except for a small incision and faster bowel recovery, the outcomes of the two anastomoses methods are inconsistent. To date, there has been no clear conclusion regarding whether IA or EA should be used to treat right colon cancer. This review aimed to investigate the current evidence relating to intraoperative outcomes and short-term postoperative results between both anastomotic approaches.
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Affiliation(s)
- Seong Kyu Baek
- Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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17
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Popeskou SG, Horvath Z, Mongelli F, Roesel R, Cristaudi A, Garofalo F, Christoforidis D. Bowel recovery after intra- vs extra-corporeal anastomosis for oncologic laparoscopic right hemicolectomy within an ERAS protocol: a retrospective study. Langenbecks Arch Surg 2022; 407:2463-2469. [PMID: 35729399 DOI: 10.1007/s00423-022-02585-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Restoring bowel continuity after laparoscopic right hemicolectomy with an intra-corporeal (IC) rather than an extra-corporeal (EC) ileocolic anastomosis may offer advantages in post-operative recovery. The aim of this study was to compare bowel function recovery between these two techniques, in a context of complete mesocolic excision within an enhanced recovery after surgery (ERAS) protocol. METHODS All consecutive patients who underwent oncologic laparoscopic right hemicolectomy from January 2012 to February 2021 in our institution were included in the study. Data were gathered from the prospectively maintained official ERAS (EIAS) database and completed through our institution's electronic health records. The primary endpoint was prolonged post-operative ileus (PPOI), defined as the need to insert a nasogastric tube, or refractory nausea VAS > 4, on or after the third post-operative day. Secondary endpoints were post-operative pain, morbidity and length of hospital stay (LoS). Groups were compared before and after propensity score matching based on age, gender, ASA score, use of epidural analgesia and post-operative complications. RESULTS A total of 108 patients met the inclusion criteria, 36 (30%) had IC and 72 (70%) EC anastomosis. In the unmatched population, baseline characteristics were similar except for more frequent use of epidural analgesia in the EC group (62 (72.9%) vs. 17 (47.2), p = 0.007). PSM analysis was carried out. Operative time was longer in the IC group (197 min (176-223) vs. 160 (140-189), p < 0.001). The rate of PPOI was similar (2 (5.6%) patients in the IC group vs. 10 (11.6%) in the EC group (p = 0.306)), but time to frist passage of flatus and stool was shorter in the IC group. There was no difference in morbidity but patients after IC anastomosis had lower pain VAS scores at 24 h (p = 0.004) and a trend for a shorter LoS (6 (5-8) days vs 7 (5-10) in the EC group, p = 0.054). After PSM, there were 36 patients in each group. PPOI, time to first flatus and stool, morbidity and LoS were not significantly different although there was a trend for better recovery outcomes in the IC group. Patients in the IC group had significantly longer operative times but less pain at 24 h. CONCLUSIONS Although IC anastomosis was not significantly associated to lower rates of PPOI, it showed trends of faster recovery and significantly less post-operative pain at the expense of longer operating times.
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Affiliation(s)
- S G Popeskou
- Department of Surgery, Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Via Tesserete 46, 6900, Lugano, Switzerland. .,Department of Visceral Surgery, University Hospital of Lugano (EOC), Via Tesserete 46, 6900, Lugano, Switzerland.
| | - Zs Horvath
- Department of Surgery, Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Via Tesserete 46, 6900, Lugano, Switzerland
| | - F Mongelli
- Department of Surgery, Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Via Tesserete 46, 6900, Lugano, Switzerland
| | - R Roesel
- Department of Surgery, Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Via Tesserete 46, 6900, Lugano, Switzerland
| | - A Cristaudi
- Department of Surgery, Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Via Tesserete 46, 6900, Lugano, Switzerland
| | - F Garofalo
- Department of Surgery, Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Via Tesserete 46, 6900, Lugano, Switzerland
| | - D Christoforidis
- Department of Surgery, Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Via Tesserete 46, 6900, Lugano, Switzerland.,Department of Surgery, CHUV, University of Lausanne, Lausanne, Switzerland
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18
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Lam TJR, Udonwa SA, Yaow CYL, Nistala KRY, Chong CS. Intracorporeal Versus Extracorporeal Anastomosis in Laparoscopic Colectomy: A Meta-Analysis and Systematic Review. CURRENT COLORECTAL CANCER REPORTS 2022. [DOI: 10.1007/s11888-022-00473-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Risk factors of incisional hernia after laparoscopic colorectal surgery with periumbilical minilaparotomy incision: a propensity score matching analysis. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:24-31. [PMID: 35603344 PMCID: PMC8977500 DOI: 10.7602/jmis.2022.25.1.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 12/03/2022]
Abstract
Purpose Incisional hernia is one of the most common complications after abdominal surgery conducted through a midline incision. Considerable debate remains regarding the design, comorbidity, suture material, and method. We investigated the risk factors for incisional hernia after laparoscopic colorectal surgery in the presence of limited surgery-related factors. Methods A retrospective study was designed with 541 patients who underwent laparoscopic colorectal surgery performed by a single operator from January 2015 to December 2017. Due to open conversions, other abdominal operations, or follow-up loss, only 445 patients were included in the study. After propensity score matching, 266 patients were included. The study was based on diagnosis of incisional hernia on computed tomography at 6 and 12 months postoperatively. Results Of the 266 total patients, 133 underwent abdominal closure using PDS (Ethicon), while the remaining 133 underwent closure with Vicryl (Ethicon). Of these patients, nine were diagnosed with incisional hernia at the 12-month follow-up six (4.5%) in the Vicryl group and three (2.3%) in the PDS group (p = 0.309). The incidence of incisional hernia was significantly increased in females (odds ratio [OR], 15.233; 95% confidence interval [CI], 1.905–121.799; p = 0.010), in patients with body mass index (BMI) of >25 kg/m2 (OR, 4.740; 95% CI, 1.424–15.546; p = 0.011), and in patients with liver disease (OR, 19.899; 95% CI, 1.614–245.376; p = 0.020). Conclusion BMI of >25 kg/m2, female, and liver disease were significant risk factors for incisional hernia after elective laparoscopic colorectal surgery performed through a transumbilical minilaparotomy incision.
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Al-Taher M, Okamoto N, Mutter D, Stassen LPS, Marescaux J, Diana M, Dallemagne B. International survey among surgeons on laparoscopic right hemicolectomy: the gap between guidelines and reality. Surg Endosc 2022; 36:5840-5853. [PMID: 35064320 PMCID: PMC8782220 DOI: 10.1007/s00464-022-09044-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 01/08/2022] [Indexed: 12/14/2022]
Abstract
Introduction To assess the current approaches and perioperative treatments of laparoscopic right hemicolectomy (LRHC) and to highlight similarities and differences with international guidelines and scientific evidence, we conducted a survey for surgeons across the globe. Methods All digestive and colorectal surgeons registered with the database of the Research Institute against Digestive Cancer (IRCAD) were invited to take part in the survey via email and through the social media networks of IRCAD. Results There were a total of 440 respondents from 78 countries. Most surgeons worked in the European region (38.6%) followed by the Americas (34.1%), the Eastern Mediterranean region (13.0%), the South-East Asian region (5.9%), the Western Pacific region (4.8%), and Africa (3.2%) respectively. Over half of the respondents performed less than 25% of right hemicolectomies laparoscopically where 4 ports are usually used by 68% of the surgeons. The medial-to-lateral, vessel-first approach is the approach most commonly used (74.1%). The most common extraction site was through a midline incision (53%) and an abdominal drain tube is routinely used by 52% of the surgeons after surgery. A total of 68.6% of the responding surgeons perform the majority of the anastomoses extracorporeally. Finally, we found that the majority of responders (60.7%) routinely used mechanical bowel preparations prior to LRHC. Conclusion Regarding several topics related to LRHC care, a discrepancy was observed between the current medical practice and the recommendations from RCTs and international guidelines and significant regional differences were observed. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09044-w.
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Stabilini C, Garcia-Urena MA, Berrevoet F, Cuccurullo D, Capoccia Giovannini S, Dajko M, Rossi L, Decaestecker K, López Cano M. An evidence map and synthesis review with meta-analysis on the risk of incisional hernia in colorectal surgery with standard closure. Hernia 2022; 26:411-436. [PMID: 35018560 DOI: 10.1007/s10029-021-02555-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/27/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the incidence of incisional hernia (IH) across various type of incisions in colorectal surgery (CS) creating a map of evidence to define research trends, gaps and areas of future interest. METHODS Systematic review of PubMed and Scopus from 2010 onwards. Studies included both open (OS) and laparoscopic (LS). The primary outcome was incidence of IH 12 months after index procedure, secondary outcomes were the study features and their influence on reported proportion of IH. Random effects models were used to calculate pooled proportions. Meta-regression models were performed to explore heterogeneity. RESULTS Ninetyone studies were included reporting 6473 IH. The pooled proportions of IH for OS were 0.35 (95% CI 0.27-0.44) I2 0% in midline laparotomies and 0.02 (95% CI 0.00-0.07), I2 52% for off-midline. In case of LS the pooled proportion of IH for midline extraction sites were 0.10 (95% CI 0.07-0.16), I2 58% and 0.04 (95% CI 0.03-0.06), I2 86% in case of off-midline. In Port-site IH was 0.02 (95% CI 0.01-0.04), I2 82%, and for single incision surgery (SILS) of 0.06-95% CI 0.02-0.15, I2 81%. In case of stoma reversal sites was 0.20 (95% CI 0.16-0.24). CONCLUSION Midline laparotomies and stoma reversal sites are at high risk for IH and should be considered in research of preventive strategies of closure. After laparoscopic approach IH happens mainly by extraction sites incisions specially midline and also represent an important area of analysis.
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Affiliation(s)
- C Stabilini
- Department of Surgery (DiSC), University of Genoa, IRCCS Policlinico San Martino, Genoa, Italy
| | - M A Garcia-Urena
- Faculty of Health Sciences, Francisco de Vitoria University, Henares University Hospital, Carretera Pozuelo-Majadahonda km 1,8, 28223, Pozuelo de Alarcón, Madrid, Spain.
| | - F Berrevoet
- Department of General and Hepatobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - D Cuccurullo
- Department of Surgery, Ospedale Monaldi-Azienda Ospedaliera dei Colli, Naples, Italy
| | - S Capoccia Giovannini
- Department of Surgery (DiSC), University of Genoa, IRCCS Policlinico San Martino, Genoa, Italy
| | - M Dajko
- Gastroenterology and Clinical Oncology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - L Rossi
- Department of Surgery (DiSC), University of Genoa, IRCCS Policlinico San Martino, Genoa, Italy
| | - K Decaestecker
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - M López Cano
- Abdominal Wall Surgery Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d'Hebron Research Institute General and Gastrointestinal Surgery Research Group, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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22
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Cleary RK, Silviera M, Reidy TJ, McCormick J, Johnson CS, Sylla P, Cannon J, Lujan H, Kassir A, Landmann R, Gaertner W, Lee E, Bastawrous A, Bardakcioglu O, Pandey S, Attaluri V, Bernstein M, Obias V, Franklin ME, Pigazzi A. Intracorporeal and extracorporeal anastomosis for robotic-assisted and laparoscopic right colectomy: short-term outcomes of a multi-center prospective trial. Surg Endosc 2022; 36:4349-4358. [PMID: 34724580 PMCID: PMC9085698 DOI: 10.1007/s00464-021-08780-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 10/13/2021] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Robert K. Cleary
- Department of Surgery, Saint Joseph’s Mercy Hospital, 5325 Elliott Drive, Ste 104, Ann Arbor, MI 48106 USA
| | - Matthew Silviera
- Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Tobi J. Reidy
- Department of Surgery, Franciscan Health, Indianapolis, IN USA
| | - James McCormick
- Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA USA
| | - Craig S. Johnson
- Department of Surgery, Oklahoma Surgical Hospital, Tulsa, OK USA
| | - Patricia Sylla
- Division of Colorectal Surgery, Department of Surgery, Mount Sinai Hospital, New York, NY USA
| | - Jamie Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Henry Lujan
- Colon and Rectal Surgery, Jackson Health System, Miami, FL USA
| | - Andrew Kassir
- Colon and Rectal Clinical, Honor Health, Scottsdale, AZ USA
| | - Ron Landmann
- Department of Colon Rectal Surgery, Baptist MD Andersen Cancer Center, Jacksonville, FL USA
| | - Wolfgang Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN USA
| | - Edward Lee
- Department of Surgery, Albany Medical College, Albany, NY USA
| | - Amir Bastawrous
- Colon and Rectal Clinic, Swedish Medical Center, Seattle, WA USA
| | - Ovunc Bardakcioglu
- Department of Colorectal, Las Vegas School of Medicine, University of Nevada, Las Vegas, Las Vegas, NV USA
| | - Sushil Pandey
- West Valley Colon and Rectal Surgery Center, Sun City, AZ USA
| | - Vikram Attaluri
- Colon and Rectal Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA USA
| | - Mitchell Bernstein
- Division of Colon and Rectal Surgery, NYU Langone Medical Center, New York, NY USA
| | - Vincent Obias
- Division of Colon and Rectal Surgery, The George Washington University Hospital, Washington, DC USA
| | | | - Alessio Pigazzi
- Division of Colon and Rectal Surgery, Weill Medical College Cornell University, New York, NY USA
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23
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Gunnells D, Cannon J. Robotic Surgery in Crohn's Disease. Clin Colon Rectal Surg 2021; 34:286-291. [PMID: 34512197 DOI: 10.1055/s-0041-1729862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgery for Crohn's disease presents unique challenges secondary to the inflammatory nature of the disease. While a minimally invasive approach to colorectal surgery has consistently been associated with better patient outcomes, adoption of laparoscopy in Crohn's disease has been limited due to these challenges. Robotic assisted surgery has the potential to overcome these challenges and allow more complex patients to undergo a minimally invasive operation. Here we describe our approach to robotic assisted surgery for terminal ileal Crohn's disease.
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Affiliation(s)
- Drew Gunnells
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
| | - Jamie Cannon
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
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24
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Zappalà A, Piazza VG, Schillaci R, Vacante M, Biondi A, Piazza D. Short-term outcomes after laparoscopic right hemicolectomy for colon cancer: intracorporeal versus extracorporeal anastomosis. Minerva Surg 2021; 77:237-244. [PMID: 34338461 DOI: 10.23736/s2724-5691.21.08934-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of this study was to compare the short-term outcomes of laparoscopic right hemicolectomy between intracorporeal (IA) and extracorporeal (EA) anastomosis techniques. METHODS A retrospective chart review of 77 consecutive patients who underwent laparoscopic right hemicolectomy from January 2016 to June 2018 was performed. The intracorporeal group included 36 patients and the extracorporeal group 41 patients. RESULTS Patient demographics and disease-related characteristics were similar. Mean operative time was 152±38.3 minutes in IA vs. 148±34.8 minutes in EA (p = 0.664). IA was not associated with less overall postoperative complications and decreased rate of surgical site infections. There was no statistically significant difference in the incidence of postoperative leak, length of stay, mortality in both groups. There was no perioperative difference in median number of lymph node harvested. There was statistically significant difference in the length of larger incision [50 (50-70) mm in IA vs 80 (70-100) mm in EA; p<0.001], length of the specimen (323 ±52.7 mm in IA vs 295±64.7 mm in EA; p<0.05), free tumor margin (113.6±47.4 in IA vs 75.6±37.4 mm in EA; p<0.001). There was a statistically significant difference in IA in the less postoperative use of analgesics (p<0.032), and return of bowel function (p<0.021). CONCLUSIONS IA seems feasible and safe; it does not significantly affect the length of surgery, and it guarantees maintenance of radical oncological standards. Furthermore, IA significantly improves cosmesis and patient comfort postoperatively, reducing the rates of emesis, which leads to higher rates of early regular diet tolerance. Therefore, laparoscopic right hemicolectomy with intracorporeal anastomosis is associated with improved short-term outcomes.
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Affiliation(s)
- Angelo Zappalà
- Department of General Surgery, Santissimo Salvatore Paternò Hospital District, Paternò, Catania, Italy
| | - Vincenzo G Piazza
- Surgical Oncology Unit, Department of Oncology, Garibaldi-Nesima Hospital, Catania, Italy
| | - Riccardo Schillaci
- Department of General Surgery, Santissimo Salvatore Paternò Hospital District, Paternò, Catania, Italy
| | - Marco Vacante
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy -
| | - Antonio Biondi
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Diego Piazza
- Department of General Surgery, Santissimo Salvatore Paternò Hospital District, Paternò, Catania, Italy
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25
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Greemland I, Raveh G, Gavrielli S, Sadot E, Kashtan H, Wasserberg N. High Rates of Incisional Hernia After Laparoscopic Right Colectomy With Midline Extraction Site. Surg Laparosc Endosc Percutan Tech 2021; 31:722-728. [PMID: 34320593 DOI: 10.1097/sle.0000000000000977] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laparoscopic surgery aims at reducing wound complications and improving cosmetics, among other advantages. High rates of postoperative ventral hernia (POVH) are observed after laparoscopic-assisted colectomies. MATERIALS AND METHODS In a 2011 to 2016 retrospective study of all patients at Rabin Medical Center, we examined POVH prevalence after right hemicolectomy for neoplasia and correlation to specimen extraction site. We also compared laparoscopic-assisted colectomy to hand-assisted laparoscopic colectomy. Included were patients who had postoperative abdominal computed tomography or magnetic resonance imaging scan as part of their routine oncological follow-up to 6 months postsurgery. Patients were excluded for conversion to laparotomy, and prior abdominal surgeries after right colectomy and before follow-up computed tomography/magnetic resonance imaging scan. Demographic and surgical data were collected from patient electronic records, and scans reviewed for POVH by a designated radiologist. RESULTS Of 370 patients, 138 (mean age 70.09 y, 58 males) were included: 54 (39.1%) were diagnosed with POVH, 42/72 (58.3%) at midline extraction site, and 12/66 (18.8%) at off-midline extraction sites (P<0.0001). Surgical site infections and patients positive for tumor metastasis were associated with higher POVH rates. Most (74%) POVHs were identified within 18 months postsurgery (P<0.0001). Body mass index, age, sex, diabetes mellitus, smoking, tumor size, lymph nodes positive for metastasis, and hand-assisted laparoscopic colectomy were not associated with POVH prevalence. CONCLUSION High rates of radiologically diagnosed POVH were found after laparoscopic-assisted colectomy, with association to midline extraction site, surgical site infections, and positive tumor distant metastasis.
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Affiliation(s)
- Itzhak Greemland
- Department of Surgery
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy Raveh
- Department of Surgery
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Gavrielli
- Department of Imaging, Rabin Medical Center, Beilinson Hospital, Petach Tikva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Sadot
- Department of Surgery
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hanoch Kashtan
- Department of Surgery
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Wasserberg
- Department of Surgery
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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26
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Postoperative Pain After Enhanced Recovery Pathway Robotic Colon and Rectal Surgery: Does Specimen Extraction Site Matter? Dis Colon Rectum 2021; 64:735-743. [PMID: 33955408 DOI: 10.1097/dcr.0000000000001868] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The current opioid crisis has motivated surgeons to critically evaluate ways to balance postoperative pain while decreasing opioid use and thereby reducing opioids available for community diversion. The longest incision for robotic colorectal surgery is the specimen extraction site incision. Intracorporeal techniques allow specimen extraction to be at any location. OBJECTIVE This study was designed to determine whether the Pfannenstiel location is associated with less pain and opioid use than other abdominal wall specimen extraction sites. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted with a prospectively maintained colorectal surgery database (July 2018 through October 2019). PATIENTS Patients with enhanced recovery robotic colorectal resections with specimen extraction were included. MAIN OUTCOME MEASURES Propensity score weighting was used to derive adjusted rates for numeric pain scores, inpatient opioid use, opioids prescribed at discharge, opioid refills after discharge, and other related outcomes. For comparing outcomes between groups, p values were calculated using weighted χ2, Fisher exact, and t tests. RESULTS There were 137 cases (70.9%) with Pfannenstiel extraction site incisions and 56 (29.0%) at other locations (7 midline, 49 off-midline). There was no significant difference in transversus abdominis plane blocks and epidural analgesia use between groups. Numeric pain scores, overall benefit of analgesia scores, inpatient postoperative opioid use, opioids prescribed at discharge and taken after discharge, and opioid refills were not significantly different between groups. Nonopioid pain analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentin) prescribed at discharge were significantly less in the Pfannenstiel group (90.19% vs 98.45%; p = 0.006). Postoperative complications and readmissions were not different between groups. LIMITATIONS This study was conducted at a single institution. CONCLUSIONS The Pfannenstiel incision as the specimen extraction site choice in minimally invasive surgery is associated with similar postoperative pain and opioid use as extraction sites in other locations for patients having robotic colorectal resections. Specimen extraction sites may be chosen based on patient factors other than pain and opioid use. See Video Abstract at http://links.lww.com/DCR/B495. DOLOR POSTOPERATORIO DESPUS DE VAS DE RECUPERACIN MEJORADA EN CIRUGA ROBTICA DE COLON Y RECTO IMPORTA EL LUGAR DE EXTRACCIN DE LA MUESTRA ANTECEDENTES:La actual crisis de opioides ha motivado a los cirujanos a evaluar críticamente, formas para equilibrar el dolor postoperatorio, disminuyendo el uso de opioides y por lo tanto, disminuyendo opioides disponibles para el desvío comunitario. La incisión más amplia en cirugía colorrectal robótica, es la incisión del sitio de extracción de la muestra. Las técnicas intracorpóreas permiten que la extracción de la muestra se realice en cualquier sitio.OBJETIVO:El estudio fue diseñado para determinar si la ubicación del Pfannenstiel está asociada con menos dolor y uso de opioides, a otros sitios de extracción de la muestra en la pared abdominal.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Estudio de base de datos de cirugía colorrectal mantenida prospectivamente (7/2018 a 10/2019).PACIENTES:Se incluyeron resecciones robóticas colorrectales con recuperación mejorada y extracción de muestras.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizó la ponderación del puntaje de propensión para derivar las tasas ajustadas para los puntajes numéricos de dolor, uso de opioides en pacientes hospitalizados, opioides recetados al alta, recarga de opioides después del alta y otros resultados relacionados. Para comparar los resultados entre los grupos, los valores p se calcularon utilizando chi-cuadrado ponderado, exacto de Fisher y pruebas t.RESULTADOS:Hubo 137 (70,9%) casos con incisiones en el sitio de extracción de Pfannenstiel y 56 (29,0%) en otras localizaciones (7 en la línea media, 49 fuera de la línea media). No hubo diferencias significativas en los bloqueos del plano transverso del abdomen y el uso de analgesia epidural entre los grupos. Las puntuaciones numéricas de dolor, puntuaciones de beneficio general de la analgesia, uso postoperatorio de opioides en pacientes hospitalizados, opioides recetados al alta y tomados después del alta, y las recargas de opioides, no fueron significativamente diferentes entre los grupos. Los analgésicos no opioides (acetaminofén, antiinflamatorios no esteroideos, gabapentina) prescritos al alta, fueron significativamente menores en el grupo de Pfannenstiel (90,19% frente a 98,45%, p = 0,006). Las complicaciones postoperatorias y los reingresos, no fueron diferentes entre los grupos.LIMITACIONES:Una sola institución.CONCLUSIÓN:La incisión de Pfannenstiel como sitio de extracción de la muestra en cirugía mínimamente invasiva, se asocia con dolor postoperatorio y uso de opioides similar, a otros sitios de extracción en pacientes sometidos a resecciones robóticas colorrectales. Sitios de extracción de la muestra, pueden elegirse en función de factores del paciente distintos al dolor y uso de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B495.).
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Perez NP, Chang DC, Goldstone RN, Bordeianou L, Ricciardi R, Cavallaro PM. Relationship Between Diverticular Disease and Incisional Hernia After Elective Colectomy: a Population-Based Study. J Gastrointest Surg 2021; 25:1297-1306. [PMID: 32748338 PMCID: PMC7854815 DOI: 10.1007/s11605-020-04762-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent genetic studies identified common mutations between diverticular disease and connective tissue disorders, some of which are associated with abdominal wall hernias. Scarce data exists, however, shedding light on the potential clinical implications of this shared etiology, particularly in the era of laparoscopic surgery. METHODS The New York Statewide Planning and Research Cooperative System database was used to identify adult patients undergoing elective sigmoid and left hemicolectomy (open or laparoscopic) from January 1, 2010, to December 31, 2016, for diverticulitis or descending/sigmoid colon cancer. The incidences of incisional hernia diagnosis and repair were compared using competing risks regression models, clustered by surgeon and adjusted for a host of demographic/clinical variables. Subsequent abdominal surgery and death were considered competing risks. RESULTS Among 8279 patients included in the study cohort, 6811 (82.2%) underwent colectomy for diverticulitis and 1468 (17.8%) for colon cancer. The overall 5-year risk of incisional hernia was 3.5% among patients with colon cancer, regardless of colectomy route, which was significantly lower than that among diverticulitis patients after both open (10.7%; p < 0.001) and laparoscopic (7.2%; p = 0.007) colectomies. Multivariable analyses demonstrated that patients with diverticulitis experienced a two-fold increase in the risk for hernia diagnosis (aHR 1.8; p < 0.001) and repair (aHR 2.1; p < 0.001), and these findings persisted after stratification by colectomy route. CONCLUSIONS Patients undergoing elective colectomy for diverticulitis, including via laparoscopic approach, experience higher rates of incisional hernia compared with patients undergoing similar resections for colon cancer. When performing resections for diverticulitis, surgeons should strongly consider adherence to evidence-based guidelines for fascial closure to prevent this important complication.
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Affiliation(s)
- Numa P Perez
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA.
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA.
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Robert N Goldstone
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA
| | - Liliana Bordeianou
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA
| | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA
| | - Paul M Cavallaro
- Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA
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28
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Creavin B, Balasubramanian I, Common M, McCarrick C, El Masry S, Carton E, Faul E. Intracorporeal vs extracorporeal anastomosis following neoplastic right hemicolectomy resection: a systematic review and meta-analysis of randomized control trials. Int J Colorectal Dis 2021; 36:645-656. [PMID: 33244717 DOI: 10.1007/s00384-020-03807-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE While minimally invasive surgery is the preferred approach for right hemicolectomy, the choice of anastomotic technique is still debated. Both intracorporeal (ICA) and extracorporeal anastomosis (ECA) are described, with conflicting reports on safety and efficacy seen. This study aimed to examine impact of ICA and ECA on outcomes in right hemicolectomy. METHODS A meta-analysis of randomized control trials (RCT) was performed. The primary outcome was overall morbidity. The secondary outcomes included both perioperative and post-operative outcomes. RESULTS Four RCTs were included incorporating 399 patients (199 patients (49.9%) ICA Vs 200 (50.1%) ECA). There was no significant difference in overall morbidity (RR 0.79, 95% CI 0.43, 1.48, p = 0.47), anastomotic leak (RR 1.34, 95% CI 0.58, 3.13, p = 0.5) or surgical site infections (RR 0.53, 95% CI 0.17, 1.64, p = 0.27). ICA patients had a significantly less post-operative ileus (RR 0.53, 95% CI 0.3-0.94, p = 0.03) quicker return to first flatus (WMD - 0.71, 95% CI - 1.12, 0.31, p = 0.0005), first bowel motion (WMD - 0.53, 95% CI - 0.69, - 0.37, p < 0.00001) and first meal (WMD - 0.68, 95% CI - 1.33, - 0.03, p = 0.04). Pain scores were significantly better for ICA patients on POD 3 (WMD - 0.76, 95% CI - 1.23, - 0.28, p = 0.002), POD 4 (WMD - 0.90, 95% CI - 1.71, - 0.09, p = 0.03) and POD 5 (WMD - 0.67, 95% CI - 1.22, - 0.13, p = 0.01). Length of hospital stay was similar (WMD - 0.46, 95% CI - 1.14, 0.22, p = 0.19). CONCLUSION ICA is associated with a quicker return to normal physiological function with equivalent post-operative morbidity. Both ECA and ICA are safe and feasible for restoring normal bowel continuity.
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Affiliation(s)
- B Creavin
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland. .,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland.
| | - I Balasubramanian
- Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
| | - M Common
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland.,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
| | - C McCarrick
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland
| | - S El Masry
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland.,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
| | - E Carton
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland.,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
| | - E Faul
- Department of Surgery, Our Lady of Lourdes Hospital Drogheda, Windmill Road, Moneymore, Drogheda, Co Louth, Ireland.,Royal College of Surgeons, 123 St Stephens Green, Saint Peter's, Dublin, Ireland
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The impact of intracorporeal anastomosis in right laparoscopic colectomy in the surgical site infections and the hospital stay: a cohort study. Updates Surg 2021; 73:2125-2135. [PMID: 33590349 DOI: 10.1007/s13304-021-00998-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
Ileocolic anastomosis in laparoscopic-assisted right colectomy is frequently performed extracorporeally. Intracorporeal anastomosis could be associated with several short-term benefits. However, it is a more technically demanding procedure. The primary endpoint of the study aimed to evaluate the postoperative surgical-site infection rate and its impact on the length of hospital stay after laparoscopic right colectomy with intracorporeal anastomosis compared to extracorporeal anastomoses. Between 2010 and 2019, 108 unselected consecutive patients underwent right colectomy. An observational comparative cohort study of two anastomosis techniques, intracorporeal (IA) versus extracorporeal (EA), was conducted. Data were extracted from a prospectively maintained colorectal surgery database of a university-affiliated hospital and retrospectively analyzed. The main exclusion criteria were emergency surgery and medical or anesthetic contraindication for laparoscopy. 53 patients underwent right colectomy with IA, and 55 had extracorporeal anastomoses. The groups did not differ in demographics, anesthetic risk, intraoperative data, pathological outcomes, or overall survival. Mean operative time was longer in the IA group (156.9 vs. 146.0 min; p = 0.061). A significant reduction in the anastomotic leak rate was observed in the IA group compared with the EA group (0 vs. 7.3%; p = 0.045) with no differences in the intraabdominal abscess rate (IA: 1.9% vs. EA: 1.8%; p = 0.97). The wound infection rate was 5.7% for IA and 10.9% for EA (p = 0.324). The hospital stay was significantly shorter for those who had intracorporeal anastomoses (5.2 ± 3.3 vs. 10.8 ± 9.6 days; p = 0.000). Right colectomy with intracorporeal anastomosis was associated with less surgical-site infections and a significantly shorter hospital stay than EA technique. Surgeons should consider the IA as the first option when performing laparoscopic right colectomy. Registration number: NCT04350203 ( http://www.clinicaltrials.gov ).
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Guilbaud T, Feretti C, Holowko W, Garbarino GM, Marchese U, Sarran A, Beaussier M, Gayet B, Fuks D. Laparoscopic Major Hepatectomy: Do Not Underestimate the Impact of Specimen Extraction Site. World J Surg 2020; 44:1223-1230. [PMID: 31748884 DOI: 10.1007/s00268-019-05285-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In laparoscopic major hepatectomy, analysis of outcomes according to specimen extraction site remains poorly described. The aim was to compare postoperative outcomes according to specimen extraction site. METHODS From 2000 to 2017, all laparoscopic major hepatectomies were reviewed and postoperative outcomes were analyzed according to specimen extraction site: subcostal (Group 1), midline (Group 2), or suprapubic (Group 3) incision. RESULTS Among 163 patients, 15 (9.2%) belonged to Group 1, 49 (30.1%) in Group 2, and 99 (60.7%) in Group 3. The proportion of right-sided, left-sided, or central hepatectomies, mortality, and overall and severe complications were comparable between groups. Group 1 had larger tumors (61 vs. 38 vs. 47 mm; P = 0.014), higher operative time (338 vs. 282 vs. 260 min; P < 0.008), higher adjacent organ resection rate (46.6 vs. 16.3 vs. 7.1%; P < 0.001), and tended to increase pulmonary complications (40.0 vs. 12.2 vs. 18.2%; P = 0.064). In Group 2, a previous midline incision scar was more frequently used for specimen extraction site (65.3 vs. 26.6 and 30.3%, Group 1 and 3; P < 0.001). Postoperative incisional hernia was observed in 16.4% (n = 23) and was more frequent in Group 2 (26.6 vs. 6.6% and 10.1%, Group 1 and Group 3; P = 0.030). Finally, Group 2 (HR 2.63, 95% CI 1.41-3.53; P = 0.032) was the only independent predictive factor of postoperative incisional hernia. CONCLUSIONS While using a previous incision makes sense, the increased risk of postoperative incisional hernia after midline incision promotes the suprapubic incision.
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Affiliation(s)
- Théophile Guilbaud
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France. .,Université Paris Descartes, 15 rue de l'école de médecine, 75005, Paris, France. .,Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France.
| | - Carlotta Feretti
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.,Université Paris Descartes, 15 rue de l'école de médecine, 75005, Paris, France
| | - Waclaw Holowko
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.,Université Paris Descartes, 15 rue de l'école de médecine, 75005, Paris, France
| | - Giovanni Maria Garbarino
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.,Université Paris Descartes, 15 rue de l'école de médecine, 75005, Paris, France
| | - Ugo Marchese
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.,Université Paris Descartes, 15 rue de l'école de médecine, 75005, Paris, France
| | - Anthony Sarran
- Department of Radiology and Medical Imaging, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Marc Beaussier
- Department of Anesthesiology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Brice Gayet
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.,Université Paris Descartes, 15 rue de l'école de médecine, 75005, Paris, France
| | - David Fuks
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.,Université Paris Descartes, 15 rue de l'école de médecine, 75005, Paris, France
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Intra-versus extracorporeal anastomosis in laparoscopic right colectomy: a meta-analysis of 3699 patients. Int J Colorectal Dis 2020; 35:1673-1680. [PMID: 32691134 DOI: 10.1007/s00384-020-03675-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Laparoscopic right colectomy (LRC) has become a gold standard. However, a major current concern is still whether anastomosis should be performed extracorporeally or entirely laparoscopically. This meta-analysis assesses and compares peri- and postoperative outcomes of intracorporeal anastomosis (IA) versus extracorporeal anastomosis (EA) in LRC. METHODS The research used the PubMed, Embase and Cochrane databases for studies comparing IA with EA during LRC. Our main endpoint was parietal abscess. Secondary endpoints were 30-day morbidity, mortality, time to onset of gas and stools, length of stay, number of lymph nodes removed and postoperative incisional hernia rates. The MINORS criteria were used to evaluate the quality of the studies examined. RESULTS Twenty-four articles comprising 3699 patients, published between 2004 and 2020, were included in this meta-analysis. After sensitivity analysis, IA was associated with a decrease in parietal abscesses (OR 0.526, IC 0.333-0.832, p = 0.006). CONCLUSION This meta-analysis finds that IA allows a decrease in parietal abscesses and time to first gas and stools, surgical repair and length of stay, with similar overall complications.
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Robotic ileocolic resection with intracorporeal anastomosis for Crohn's disease. J Robot Surg 2020; 15:465-472. [PMID: 32725327 DOI: 10.1007/s11701-020-01125-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023]
Abstract
The robotic platform can overcome limitations of the laparoscopic approach, particularly in the facilitation of intracorporeal anastomosis creation. We aim to share our institutional experience with robotic ileocolic resection for Crohn's disease (CD) and compare it to a laparoscopic cohort. We identified patients who underwent ileocolic resection for CD with a purely robotic (R) or laparoscopic (L) approach between February 2015 and 2018. Chart review was performed and preoperative, intraoperative, and postoperative data was collected. A total of 47 patients with a mean age of 35.2 years old were identified and 61% were female. Seventy percent [n = 33, (23 females, 69.6%)] of the cases were performed robotically and 30% of the cases [n = 14, (6 females, 42.8%)] were performed laparoscopically. The groups were well matched for age, gender, BMI as well as disease related factors (CD duration; clinical classification and location), perioperative immunosuppression, and surgical history. Time to bowel function was shorter by about 1 day in the robotic group (R: 1.9 ± 0.88 days vs. L: 2.7 ± 0.8 days, p = 0.003). Mean operative time was longer in the robotic group by 51 min and this difference was significant (p = 0.03), however 30.3% of patients underwent ureteral stent placement, which can account for added time in robotic cases. There were less conversions in the robotic group [R: 1(4.3%) vs. L: 1(7%)], but this was not significant. There were no intraoperative complications in either group. Complication (L: 21.4% vs. R: 15.1%, p = 0.605) and reoperation rates (L: 0% vs. R: 3.03%, p = 0.429) were similar. Robotic ileocolic resection for Crohn's disease is as safe and feasible as the laparoscopic approach. This was accomplished with no leaks, major morbidity or mortality and comparable length of stay, with 1 day shorter return of bowel function, and with a lower overall complication rate. The robotic approach offers advantages in Crohn's disease which should be studied further in prospective studies.
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The risk factors for incisional hernia after laparoscopic colorectal surgery: a multicenter retrospective study at Yokohama Clinical Oncology Group. Surg Endosc 2020; 35:3471-3478. [DOI: 10.1007/s00464-020-07794-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/07/2020] [Indexed: 12/17/2022]
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Brown RF, Cleary RK. Intracorporeal anastomosis versus extracorporeal anastomosis for minimally invasive colectomy. J Gastrointest Oncol 2020; 11:500-507. [PMID: 32655928 DOI: 10.21037/jgo.2019.12.02] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Outcomes advantages for the minimally invasive approach to colon and rectal surgery have been clearly described since the original report of a laparoscopic colectomy in 1991. Advancements in minimally invasive options for colon and rectal surgery have produced the need for critical evaluation of alternative and evolving techniques. The evolution and increased adoption of the minimally invasive robotic platform has allowed the intracorporeal anastomosis, previously described with the laparoscopic approach, to be more widely available to surgeon skill sets because of robotic articulating instruments and ergonomic advantages. Studies comparing intra- and extracorporeal techniques for laparoscopic right colectomy have demonstrated some outcomes advantages for the intracorporeal approach that include fewer conversions-to-open, fewer postoperative complications, and shorter hospital length of stay. Recent robotic-assisted comparisons have also shown an intracorporeal advantage and have extended the analysis to left-sided colorectal resections. Further upgrades in minimally invasive options and techniques warrant further evidence-based considerations for surgeons choosing between these options and techniques.
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Affiliation(s)
- Rebecca F Brown
- Department of Colon and Rectal Surgery, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, MI, USA
| | - Robert K Cleary
- Department of Colon and Rectal Surgery, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, MI, USA
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35
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A propensity-matched study of full laparoscopic versus hand-assisted minimal-invasive liver surgery. Surg Endosc 2020; 35:2021-2028. [PMID: 32347389 DOI: 10.1007/s00464-020-07597-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM The implications of multi-incision (MILS) and hand-assisted (HALS) laparoscopic techniques for minimally invasive liver surgery with regard to perioperative outcomes are not well defined. The purpose of this study was to compare MILS and HALS using propensity score matching. METHODS 309 patients underwent laparoscopic liver resections (LLR) between January 2013 and June 2018. Perioperative outcomes were analyzed after a 1:1 propensity score match. Subgroup analyses of matched groups, i.e., radical lymphadenectomy (LAD) as well as resections of posterosuperior segments (VII and/or VIII), were performed. RESULTS MILS was used in 187 (65.2%) and HALS in 100 (34.8%) cases, with a significant decrease of HALS resections over time (p = 0.001). There were no significant differences with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) Score, previous abdominal surgery and cirrhosis between both groups. Patients scheduled for HALS were characterized by a significantly higher rate of malignant tumors (p < 0.001) and major resections (p < 0.001). After propensity score matching (PMS), 70 cases remained in each group and all preoperative variables as well as resection extend were well balanced. A significantly higher rate of radical LAD (p = 0.039) and posterosuperior resections was found in the HALS group (p = 0.021). No significant differences between the matched groups were observed regarding operation time, conversion rate, frequency of major complications, length of intensive care unit (ICU) stay, overall hospital stay and R1 rate. CONCLUSION Our analysis suggests MILS and HALS to be equivalent regarding postoperative outcomes. HALS might be particularly helpful to accomplish complex surgical procedures during earlier stages of the learning curve.
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LaChapelle CR, Whitney S, Aalberg J, Plietz M, Reppucci M, Salk A, Hwang S, Khaitov S, Greenstein AJ. Analysis of Outcomes by Extraction Site following Subtotal Colectomy in Ulcerative Colitis: A Retrospective Cohort Study. J Gastrointest Surg 2020; 24:933-938. [PMID: 31823318 DOI: 10.1007/s11605-019-04481-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/17/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ulcerative colitis frequently requires surgery as a definitive management strategy. The colonic specimen can be extracted from various sites including a midline incision, the stoma site, or a Pfannenstiel incision. It is unclear if one extraction site offers improved outcomes and fewer complications. METHODS A retrospective review of charts obtained of colorectal surgery patients was conducted for all patients with ulcerative colitis who underwent a subtotal colectomy between 2008 and 2016 at a single tertiary care institution. Demographic data and outcomes data including parastomal and incisional hernias, advanced wound/ostomy certified nurse referrals, surgical site infections, reoperations, and readmissions were collected. Univariate and multivariate analyses were completed to detect any significant differences in outcomes between groups based on extraction site (midline incision, stoma site, or Pfannenstiel incision). RESULTS Univariate analysis did not show any statistical differences between groups in regard to outcomes. Stoma site extraction did not statistically differ from midline extraction in regard to hernias, advanced ostomy referrals, infections, or reoperations, but midline incision extraction did have a lower risk of readmission (OR = 0.56, p = 0.0066). Pfannenstiel extraction had lower risk of incisional hernias (OR = 0.25, p = 0.0002), advanced ostomy referrals (OR = 0.45, p = 0.0164) and readmission (OR = 0.26, p < 0.0001) as compared to stoma site extraction. CONCLUSIONS While stoma site extraction can be successfully performed for most patients requiring subtotal colectomy for ulcerative colitis, Pfannenstiel extraction leads to the fewest number of complications and provides the most consistent results.
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Affiliation(s)
- Christopher R LaChapelle
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA.
| | - Stewart Whitney
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA
| | | | - Michael Plietz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA
| | - Marina Reppucci
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA
| | - Allison Salk
- Department of Obstetrics and Gynecology, Rush University Medical Center, Deerfield, IL, 60015, USA
| | - Songhon Hwang
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA
| | - Sergey Khaitov
- The Moses Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA
| | - Alexander J Greenstein
- The Moses Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 15th Floor, Box 1259, New York, NY, 10029, USA
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Abstract
The role of robotics in colon and rectal surgery has been established as an important and effective tool for the surgeon. Its inherent technologies have provided for increased visualization and ease of dissection in the minimally invasive approach to surgery. The value of the robot is apparent in the more challenging aspects of colon and rectal procedures, including the intracorporeal anastomosis for right colectomies and the low pelvic dissection for benign and malignant diseases.
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38
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Ku DH, Kim HS, Shin JY. Short-term and Medium-term Outcomes of Low Midline and Low Transverse Incisions in Laparoscopic Rectal Cancer Surgery. Ann Coloproctol 2020; 36:304-310. [PMID: 32054255 PMCID: PMC7714381 DOI: 10.3393/ac.2019.10.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022] Open
Abstract
Purpose Limited data exist on the use of low midline and transverse incisions for specimen extraction or stoma sites in laparoscopic rectal cancer surgery (LRCS). We compared the short-term and medium-term outcomes of these incisions and assessed whether wound complications in specimen extraction sites (SES) are increased by specimen extraction through the stoma site (SESS) in LRCS. Methods From March 2010 to December 2017, 189 patients who underwent LRCS and specimen extraction through low abdominal incisions were divided into 2 groups: midline (n = 102) and transverse (n = 87), and perioperative outcomes were compared. Results The midline group showed a higher frequency of temporary stoma formation (P = 0.001) and splenic flexure mobilization (P < 0.001) than the transverse group. The overall incisional hernia and wound infection rates in the SES were 21.6% and 25.5%, respectively, in the midline group and 26.4% and 17.2%, respectively, in the transverse group (P = 0.494 and P = 0.232, respectively). In patients who underwent SESS, the incisional hernia and wound infection rates of SES after stoma closure were 39.1% and 43.5%, respectively, in the midline group, and 35.5% and 22.6%, respectively, in the transverse group (P = 0.840 and P = 0.035, respectively). Conclusion In terms of incisional hernia and wound infection at the SES, a low midline incision may be used as a low transverse incision in patients without temporary stoma in LRCS. However, considering the high wound complication rates after stoma closure in patients with SESS in this study, SESS should be performed with caution in LRCS.
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Affiliation(s)
- Do Hoe Ku
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyeon Seung Kim
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jin Yong Shin
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Varathan N, Rotigliano N, Nocera F, Tampakis A, Füglistaler I, von Flüe M, Steinemann DC, Posabella A. Left lower transverse incision versus Pfannenstiel-Kerr incision for specimen extraction in laparoscopic sigmoidectomy: a match pair analysis. Int J Colorectal Dis 2020; 35:233-238. [PMID: 31823052 DOI: 10.1007/s00384-019-03444-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The ideal location of specimen extraction in laparoscopic-assisted colorectal surgery is still debatable. The aim of this study was to compare the incidence of incisional hernias and surgical site infections in patients undergoing elective laparoscopic resection for recurrent sigmoid diverticulitis by performing specimen extraction through left lower transverse incision or Pfannenstiel-Kerr incision. METHODS A total of 269 patients operated between January 2014 and December 2017 were retrospectively screened for inclusion in the study. Patients with specimen extraction through left lower transverse incision (LLT) and patients with specimen extraction through Pfannenstiel-K incision (P-K) were matched in 1:1 proportion regarding age, sex, comorbidities, and previous abdominal surgery. The incidence of incisional hernias and surgical site infections were compared by using Fisher's exact test. RESULTS After matching 77 patients in the LLT group and 77 patients in the P-K group, they were found to be homogenous regarding the above mentioned descriptive characteristics. No patients in the P-K group developed an incisional hernia compared with 10 patients (13%) in the LLT group (p = 0.001). All these patients required hernia repair with mesh augmentation. The rate of surgical site infections was 1/77 in the P-K group and 0/77 in the LLT group (p = 1.0). In the P-K group, a wound protector was used in 86% of patients whereas in the LLT group, 39% of the wounds were protected during specimen extraction (p < 0.0001). CONCLUSION The Pfannenstiel-Kerr incision may be the preferred extraction site compared with the left lower transverse incision given the significant reduction of the risk of incisional hernias.
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Affiliation(s)
- N Varathan
- University Center for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital of Basel, Spitalstrasse 21, 4002, Basel, Switzerland
| | - N Rotigliano
- University Center for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital of Basel, Spitalstrasse 21, 4002, Basel, Switzerland
| | - F Nocera
- University Center for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital of Basel, Spitalstrasse 21, 4002, Basel, Switzerland
| | - A Tampakis
- University Center for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital of Basel, Spitalstrasse 21, 4002, Basel, Switzerland
| | - I Füglistaler
- University Center for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital of Basel, Spitalstrasse 21, 4002, Basel, Switzerland
| | - M von Flüe
- University Center for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital of Basel, Spitalstrasse 21, 4002, Basel, Switzerland
| | - D C Steinemann
- University Center for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital of Basel, Spitalstrasse 21, 4002, Basel, Switzerland
| | - A Posabella
- University Center for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital of Basel, Spitalstrasse 21, 4002, Basel, Switzerland.
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Intracorporeal versus extracorporeal anastomosis in minimally invasive right colectomy: an updated systematic review and meta-analysis. Tech Coloproctol 2019; 23:1023-1035. [PMID: 31646396 DOI: 10.1007/s10151-019-02079-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/05/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Minimally invasive colectomy has become the standard for treatment of colonic disease in many centers. Restoration of bowel continuity following resection can be achieved by intracorporeal (IC) or extracorporeal (EC) anastomosis. The aim of this systematic review was to assess the outcomes of IC compared to EC anastomosis in minimally invasive right colectomy. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic literature search for studies assessing the outcome of IC and EC anastomosis in laparoscopic and robot-assisted right colectomy was conducted. The primary outcome of this review was postoperative complications. Secondary outcomes included operative time, blood loss, length of stay, conversion to open surgery, and bowel recovery. RESULTS Twenty-five studies including 4450 patients were evaluated. 47.7% of patients had IC anastomosis and 52.3% had EC anastomosis. The weighted mean length of extraction site incision in the IC group was shorter than the EC group. The EC group had significantly higher odds of conversion to open surgery (OR 1.87, 95% CI 1-3.45, p = 0.046), total complications (OR 1.54, 95% CI 1.05-2.11, p = 0.007), anastomotic leakage (AL) (OR 1.95, 95% CI 1.4-2.7, p = 0.003), surgical site infection (SSI) (OR 1.69, 95% CI 1.4-2.6, p = 0.002), and incisional hernia (OR 3.14, 95% CI 1.85-5.33, p < 0.001) compared to the IC group. Both groups had similar rates of ileus, small bowel obstruction, bleeding, and intra-abdominal infection. CONCLUSION IC anastomosis was associated with significantly shorter extraction site incisions, earlier bowel recovery, fewer complications, and lower rates of conversion, AL, SSI, and incisional hernia than has the EC anastomosis.
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Cano-Valderrama O, Sanz-López R, Domínguez-Serrano I, Dziakova J, Catalán V, Rojo M, García-Alonso M, Mugüerza JM, Torres AJ. Extraction-site incisional hernia after laparoscopic colorectal surgery: should we carry out a study about prophylactic mesh closure? Surg Endosc 2019; 34:4048-4052. [PMID: 31617098 DOI: 10.1007/s00464-019-07194-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/09/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prophylactic mesh closure has only scarcely been studied to avoid extraction-site incisional hernia after laparoscopic colorectal surgery. The aim was to analyze extraction-site incisional hernia incidence after laparoscopic colorectal surgery to assess if prophylactic mesh closure should be studied. METHODS A retrospective analytic cohort study was conducted in patients who had undergone laparoscopic colorectal surgery with an extraction-site incision. Extraction-site incisional hernia was diagnosed during clinical examination or imaging. Risk factors for extraction-site incisional hernia were analyzed. RESULTS Two hundred and twenty-five patients were included. More than 80% of the patients had a malignant disease. Ninety-two patients (40.9%) underwent right colectomy. Midline extraction-site incision was used in 86 (38.2%) patients. After a mean follow-up of 2.4 years, 39 (17.3%) patients developed an extraction-site incisional hernia. Midline extraction-site incision was associated with incisional hernia when compared to transverse and Pfannenstiel incision (39.5% vs. 3.6%, OR 17.5, p < 0.001). Surgery to repair an extraction-site incisional hernia was also more frequent in the group of patients with a midline incision (10.5% vs. 1.4%, OR 8.0, p = 0.002). In the multivariate analysis, incisional hernia was associated with body mass index, high blood pressure, and midline incision. CONCLUSIONS Extraction-site incisional hernia was mainly related to midline incisions; therefore, midline incision should be avoided whenever possible. Studying prophylactic mesh closure for Pfannesnstiel or transverse incisions is needless, as these incisions have a low incisional hernia risk.
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Affiliation(s)
- Oscar Cano-Valderrama
- Department of Surgery, Hospital Universitario Clínico San Carlos, Madrid, Spain.
- Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain.
- Department of Surgery, Hospital Universitario Clínico San Carlos, C/Profesor Martín Lagos SN, 28040, Madrid, Spain.
| | - Rodrigo Sanz-López
- Department of Surgery, Hospital Universitario Clínico San Carlos, Madrid, Spain
- Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
| | - Inmaculada Domínguez-Serrano
- Department of Surgery, Hospital Universitario Clínico San Carlos, Madrid, Spain
- Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
| | - Jana Dziakova
- Department of Surgery, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Vanesa Catalán
- Department of Surgery, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Mikel Rojo
- Department of Surgery, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Mauricio García-Alonso
- Department of Surgery, Hospital Universitario Clínico San Carlos, Madrid, Spain
- Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
| | - José M Mugüerza
- Department of Surgery, Hospital Universitario Clínico San Carlos, Madrid, Spain
- Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
| | - Antonio J Torres
- Department of Surgery, Hospital Universitario Clínico San Carlos, Madrid, Spain
- Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain
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Maxwell DW, Jajja MR, Hashmi SS, Lin E, Srinivasan JK, Sweeney JF, Sarmiento JM. The hidden costs of open hepatectomy: A 10-year, single institution series of right-sided hepatectomies. Am J Surg 2019; 219:110-116. [PMID: 31495449 DOI: 10.1016/j.amjsurg.2019.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/29/2019] [Accepted: 08/19/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Incisional ventral hernias(IVH) are a common complication following open abdominal surgery. The aim of this study was to uncover the hidden costs of IVH following right-sided hepatectomy. METHODS Outcomes and hospital billing data for patients undergoing open(ORH) and laparoscopic right-sided hepatectomies(LRH) were reviewed from 2008 to 2018. RESULTS Of 327 patients undergoing right-sided hepatectomies, 231 patients were included into two groups: ORH(n = 118) and LRH(n = 113). Median follow-up-times and time-to-hernia were 24.9-months(0.3-128.4 months) and 40.5-months(0.4-81.4 months), respectively. The incidence of hernias at 1, 3, 5, and 10 years was 6/231(2.6%), 13/231(5.6%), 15(6.5%), and 17/231(7.4%); ORH = 14, LRH = 3, p = 0.003), respectively. In terms of IVH repair(IVHR), total operative costs ($10,719.27vs.$4,441.30,p < 0.001) and overall care costs ($20,541.09vs.$7,149.21,p = 0.044) were significantly greater for patients undergoing ORH. Patients whom underwent ORHs had longer hospital stays and more complications following IVHR. Risk analysis identified ORH(RR-10.860), male gender(RR-3.558), BMI ≥30 kg/m2(RR-5.157), and previous abdominal surgery(RR-6.870) as predictors for hernia development (p < 0.030). CONCLUSION Evaluation of pre-operative hernia risk factors and utilization of a laparoscopic approach to right-sided hepatectomy reduces incisional ventral hernia incidence and cost when repair is needed.
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Affiliation(s)
- Daniel W Maxwell
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | - Mohammad Raheel Jajja
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Salila S Hashmi
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Edward Lin
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - John F Sweeney
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Rabbany J, Kim T, Koh S, Zaghiyan K, Fleshner P. Cosmesis in Patients after Multiport Laparoscopic Colorectal Surgery: Does the Extraction Incision Matter? Am Surg 2019. [DOI: 10.1177/000313481908500222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The ideal incision for specimen extraction during laparoscopic colorectal surgery is controversial. The objective of this study was to compare incision types (Pfannenstiel, periumbilical, lower midline, and right upper quadrant transverse) with regard to postoperative scar appearance, symptoms, preference, and satisfaction. This study is a retrospective survey review performed in an urban teaching hospital. The study participants were patients undergoing multiport laparoscopic colorectal surgery. Two web-based questionnaires, the Patient Scar Assessment Questionnaire and Photo-Series Questionnaire, were used to assess study parameters. The main outcome measures were incision symptoms and cosmetic satisfaction. The 112 study patients included 54 patients with a Pfannenstiel incision (Group P) and 58 patients with an alternate incision (Group A). Of the 58 patients in Group A, 19 (33%) had a periumbilical incision, 10 (17%) a lower midline incision, and 29 (50%) a right upper quadrant transverse incision. Although Groups P and Awere comparable in all five subscales of the Patient Scar Assessment Questionnaire, more Group P participants (n = 12; 22%) said their incision felt “fairly numb” than Group A participants (n = 2; 3%) (P = 0.008). There was no significant difference between study groups in all Photo-Series Questionnaire domains; however, after comparing patients’ own incisions with photographs of various alternative incisions, 36 (62%) Group A patients would choose an alternative incision compared with only 11 (19%) Group P patients (P = 0.001). Selection bias, recall bias, external validity, and variability of scar lengths were the limitations of the study. It was concluded that although a Pfannenstiel incision seems to be the optimal cosmetic choice, it is associated with a higher incidence of wound numbness than alternate extraction incisions.
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Affiliation(s)
- Jessica Rabbany
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Teresa Kim
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sharon Koh
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghiyan
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Al Natour RH, Obias V, Albright J, Wu J, Ferraro J, Akram WM, McClure AM, Shanker BA, Cleary RK. A propensity score matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted sigmoidectomy in an enhanced recovery pathway. J Robot Surg 2018; 13:649-656. [DOI: 10.1007/s11701-018-00910-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 12/04/2018] [Indexed: 12/31/2022]
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Akram WM, Al-Natour RH, Albright J, Wu J, Ferraro J, Shanker BA, McClure AM, Cleary RK. A propensity score-matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted right colectomy in an Enhanced Recovery Pathway. Am J Surg 2018; 216:1095-1100. [PMID: 29937323 DOI: 10.1016/j.amjsurg.2018.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/31/2018] [Accepted: 06/07/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION There may be short-term outcomes advantages for the intracorporeal approach to minimally invasive right colectomy. METHODS This is a retrospective propensity score-matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted right colectomy in an Enhanced Recovery colorectal surgery service. RESULTS 55 intracorporeal and 55 extracorporeal cases were compared. Operative time was significantly longer (p < 0.001) and incision length shorter in the intracorporeal group (p = 0.007). Outcomes significantly favorable for the intracorporeal group included conversion-to-open (p = 0.013), time to first flatus (p < 0.001), time to first bowel movement (p = 0.006), and dehydration (p = 0.03). There were more extraction site hernias in the midline compared to off-midline locations, though this difference did not reach statistical significance (p = 0.06). CONCLUSION There are outcomes advantages for the intracorporeal technique for robotic-assisted right colectomy when compared to the extracorporeal approach for patients in an Enhanced Recovery Pathway. Training efforts should continue to advocate the intracorporeal option.
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Affiliation(s)
- Warqaa M Akram
- Colon and Rectal Surgery Fellow, St Joseph Mercy Hospital, Ann Arbor, MI, USA.
| | - Riad H Al-Natour
- General Surgery Resident, St Joseph Mercy Hospital, Ann Arbor, MI, USA.
| | - Jeremy Albright
- Biostatistics and Epidemiology Methods Consulting, BEMC, LLC, Ann Arbor, MI, USA.
| | - Juan Wu
- Academic Research, St Joseph Mercy Hospital, Ann Arbor, MI, USA.
| | - Jane Ferraro
- Academic Research, St Joseph Mercy Hospital, Ann Arbor, MI, USA.
| | - Beth-Ann Shanker
- Division of Colon and Rectal Surgery, St Joseph Mercy Hospital, Ann Arbor, MI, USA.
| | - Amanda M McClure
- Division of Colon and Rectal Surgery, St Joseph Mercy Hospital, Ann Arbor, MI, USA.
| | - Robert K Cleary
- Division of Colon and Rectal Surgery, St Joseph Mercy Hospital, Ann Arbor, MI, USA.
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Benlice C, Stocchi L, Sapci I, Gorgun E, Kessler H, Liska D, Steele SR, Delaney CP. Impact of the extraction-site location on wound infections after laparoscopic colorectal resection. Am J Surg 2018; 217:502-506. [PMID: 30390938 DOI: 10.1016/j.amjsurg.2018.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/23/2018] [Accepted: 10/24/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND The purpose of this study was to determine the impact of the incision used for specimen extraction on wound infection during laparoscopic colorectal surgery. METHODS All patients undergoing elective laparoscopic colorectal resection in a single specialized department from 2000 to 2011 were identified from a prospectively maintained institutional database. Specific extraction-sites and other relevant factors associated with wound infection rates were evaluated with univariate and multivariate analyses. RESULTS 2801 patients underwent specimen extraction through infra-umbilical midline (N = 657), RLQ/LLQ (N = 388), stoma site (N = 58), periumbilical midline (N = 629), Pfannenstiel (N = 789) and converted midline (N = 280). The overall wound infection rate was 10% and was highest in converted midline (14.6%) and Pfannenstiel (11.4%) incisions, while the lowest rate was associated with RLQ/LLQ (N = 13, 3.3%). Independent factors associated with wound infection were increased BMI (p < 0.001), extraction site location (p = 0.006), surgical procedure (p = 0.020, particularly left-sided colectomy and total proctocolectomy), diagnosis (p < 0.001, particularly sigmoid diverticulitis and inflammatory bowel disease), intraabdominal adhesions (p = 0.033) and intrabdominal rather than pelvic procedure (p = 0.005). CONCLUSIONS A RLQ/LLQ extraction site is associated with the most reduced risk of wound infection in laparoscopic colorectal surgery.
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Affiliation(s)
- Cigdem Benlice
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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Cleary RK, Kassir A, Johnson CS, Bastawrous AL, Soliman MK, Marx DS, Giordano L, Reidy TJ, Parra-Davila E, Obias VJ, Carmichael JC, Pollock D, Pigazzi A. Intracorporeal versus extracorporeal anastomosis for minimally invasive right colectomy: A multi-center propensity score-matched comparison of outcomes. PLoS One 2018; 13:e0206277. [PMID: 30356298 PMCID: PMC6200279 DOI: 10.1371/journal.pone.0206277] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 10/10/2018] [Indexed: 02/07/2023] Open
Abstract
Background The primary objective of this study was to retrospectively compare short-term outcomes of intracorporeal versus extracorporeal anastomosis for minimally invasive laparoscopic and robotic-assisted right colectomies for benign and malignant disease. Recent studies suggest potential short-term outcomes advantages for the intracorporeal anastomosis technique. Methods This is a multicenter retrospective propensity score-matched comparison of intracorporeal and extracorporeal anastomosis techniques for laparoscopic and robotic-assisted right colectomy between January 11, 2010, and July 21, 2016. Results After propensity score-matching, there were a total of 1029 minimal invasive surgery cases for analysis—379 right colectomies (335 robotic-assisted and 44 laparoscopic) done with an intracorporeal anastomosis and 650 right colectomies (253 robotic-assisted and 397 laparoscopic) done with an extracorporeal anastomosis. There were no significant differences in any preoperative patient characteristics between groups. The minimally invasive intracorporeal anastomosis group had significantly longer operative times (p<0.0001), lower conversion to open rate (p = 0.01), shorter hospital length of stay (p = 0.02) and lower complication rate from after discharge to 30-days (p = 0.04) than the extracorporeal anastomosis group. Conclusions This comparison shows several clinical outcomes advantages for the intracorporeal anastomosis technique in minimally invasive right colectomy. These data may guide future refinements in minimally invasive training techniques and help surgeons choose among different minimally invasive options.
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Affiliation(s)
- Robert K. Cleary
- Department of Surgery, Division of Colon and Rectal Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Andrew Kassir
- Colon and Rectal Clinic of Scottsdale, Scottsdale, Arizona, United States of America
| | - Craig S. Johnson
- Department of Surgery, Oklahoma Surgical Hospital, Tulsa, Oklahoma, United States of America
| | - Amir L. Bastawrous
- Swedish Colon and Rectal Clinic, Division of Colon and Rectal Surgery, Swedish Medical Center, Seattle, Washington, United States of America
| | - Mark K. Soliman
- Colon and Rectal Clinic of Orlando, Orlando, Florida, United States of America
| | - Daryl S. Marx
- Department of Surgery, Monroe Surgical Hospital, Monroe, Louisiana, United States of America
| | - Luca Giordano
- Division of Gastrointestinal and Colorectal Surgery, Minimally Invasive and Robotic-assisted Surgery, and Bariatric Surgery, Jefferson Health Northeast Torresdale, Philadelphia, Pennsylvania, United States of America
| | - Tobi J. Reidy
- Department of Surgery, St. Francis Hospital and Health Centers, Franciscan Alliance, Indianapolis, Indiana, United States of America
| | - Eduardo Parra-Davila
- Department of Surgery, Celebration Center for Surgery, Florida Hospital Medical Group, Celebration, Florida, United States of America
| | - Vincent J. Obias
- Division of Colon and Rectal Surgery, George Washington University, Washington, District of Columbia, United States of America
| | - Joseph C. Carmichael
- Department of Surgery, Division of Colon and Rectal Surgery, University of California Irvine, Irvine, California, United States of America
| | - Darren Pollock
- Swedish Colon and Rectal Clinic, Division of Colon and Rectal Surgery, Swedish Medical Center, Seattle, Washington, United States of America
| | - Alessio Pigazzi
- Department of Surgery, Division of Colon and Rectal Surgery, University of California Irvine, Irvine, California, United States of America
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Lujan HJ, Plasencia G, Rivera BX, Molano A, Fagenson A, Jane LA, Holguin D. Advantages of Robotic Right Colectomy With Intracorporeal Anastomosis. Surg Laparosc Endosc Percutan Tech 2018; 28:36-41. [PMID: 28319493 PMCID: PMC5802257 DOI: 10.1097/sle.0000000000000384] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Through retrospective review of consecutive charts, we compare the short-term and long-term clinical outcomes after robotic-assisted right colectomy with intracorporeal anastomosis (RIA) (n=89) and laparoscopic right colectomy with extracorporeal anastomosis (LEA) (n=135). Cohorts were similar in demographic characteristics, comorbidities, pathology, and perioperative outcomes (conversion, days to flatus and bowel movement, and length of hospitalization). The RIA cohort experienced statistically significant: less blood loss, shorter incision lengths, and longer specimen lengths than the LEA cohort. Operative times were significantly longer for the RIA group. No incisional hernias occurred in the RIA group, whereas the LEA group had 5 incisional hernias; mean follow-up was 33 and 30 months, respectively. RIA is effective and safe and provides some clinical advantages. Future studies may show that, in obese and other technically challenging patients, RIA facilitates resection of a longer, consistent specimen with less mesentery trauma that can be extracted through smaller incisions.
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Affiliation(s)
| | | | | | - Andres Molano
- University of Puerto Rico Surgery Residency, San Juan, PR
| | - Alex Fagenson
- Florida International University, Herbert Wertheim College of Medicine, Miami
| | - Louis A Jane
- American University of the Caribbean School of Medicine, Coral Gables, FL
| | - Diego Holguin
- Alliance Medical Group, Waterbury Hospital, Middlebury, CT
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Felder SI, Ramanathan R, Russo AE, Jimenez-Rodriguez RM, Hogg ME, Zureikat AH, Strong VE, Zeh HJ, Weiser MR. Robotic gastrointestinal surgery. Curr Probl Surg 2018; 55:198-246. [PMID: 30470267 DOI: 10.1067/j.cpsurg.2018.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/26/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Seth I Felder
- Department of Gastrointestinal Surgery, Moffitt Cancer Center, Tampa, Florida
| | - Rajesh Ramanathan
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ashley E Russo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Melissa E Hogg
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Vivian E Strong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Herbert J Zeh
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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Reitz ACW, Lin E, Rosen SA. A single surgeon's experience transitioning to robotic-assisted right colectomy with intracorporeal anastomosis. Surg Endosc 2018; 32:3525-3532. [PMID: 29380065 DOI: 10.1007/s00464-018-6074-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 01/03/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite substantial evidence demonstrating benefits of minimally invasive surgery, a large percentage of right colectomies are still performed via an open technique. Most laparoscopic right colectomies are completed as a hybrid procedure with extracorporeal anastomosis. As part of a pure minimally invasive procedure, intracorporeal anastomosis (ICA) may confer additional benefits for patients. The robotic platform may shorten the learning curve for minimally invasive right colectomy with ICA. METHODS From January 2014 to May 2016, 49 patients underwent robotic-assisted right colectomy by a board-certified colorectal surgeon (S.R). Extracorporeal anastomosis (ECA) was used in the first 20 procedures, whereas ICA was used in all subsequent procedures. Outcomes recorded in a database for retrospective review included operating time (OT), estimated blood loss (EBL), length of stay (LOS), conversion rate, complications, readmissions, and mortality rate. RESULTS Comparison of average OT, EBL, and LOS between extracorporeal and intracorporeal groups demonstrated no significant differences. For all patients, average OT was 141.6 ± 25.8 (range 86-192) min, average EBL was 59.5 ± 83.3 (range 0-500) mL, and average LOS was 3.4 ± 1.19 (range 1.5-8) days. Four patients required conversion, all of which occurred in the extracorporeal group. There were no conversions after the 18th procedure. The 60-day mortality rate was 0%. There were no anastomotic leaks, ostomies created, or readmissions. As the surgeon gained experience, a statistically significant increase in lymph node sampling was observed in oncologic cases (p = .02). CONCLUSIONS The robotic platform may help more surgeons safely and efficiently transition to a purely minimally invasive procedure, enabling more patients to reap the benefits of less invasive surgery. Transitioning from ECA to ICA during robotic right colectomy resulted in no significant change in OT or LOS. A lower rate of conversion to open surgery was noted with increased experience.
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Affiliation(s)
| | - Ed Lin
- Department of General Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Seth A Rosen
- Division of Colorectal Surgery, Emory University School of Medicine, 6335 Hospital Parkway, Suite 110, Johns Creek, GA, 30097, USA.
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