Byung-Jo Choi

The Short-term Outcomes of Conventional and Single-port Laparoscopic Surgery for Colorectal Cancer

Objective:The aim of this study was to show the safety and feasibility of single-port laparoscopic surgery (SPLS) by comparing its short-term outcomes with those following conventional laparoscopic surgery. Summary Background Data:Single-port laparoscopic surgery maximizes the advantages of laparoscopic surgery, and therefore it can be an ultimate attainment of laparoscopic surgery. However, no comparative study has addressed its role in colorectal cancer. Methods:Prospectively collected data of patients who had undergone either conventional laparoscopic surgery (n = 106) or SPLS (n = 73) for colorectal cancer between March 2006 and May 2010 were analyzed retrospectively. The short-term outcomes of these 2 operative modalities were compared. Results:Of the 179 study subjects, 103 (57.5%) had colon cancer and 76 (42.5%) had rectal cancer. Various operative methods, from right hemicolectomy to abdominoperineal resection, were used according to location through either conventional laparoscopic or SPLS approach. In its comparison, mean surgical time was greater in the SPLS group (255 vs 276 minutes, P < 0.008). Acquired length of sufficient surgical margins and the number of harvested lymph nodes were comparable. Postoperative recovery was faster in the SPLS group, in terms of shorter time duration before first flatus (SPLS vs conventional laparoscopic surgery; 2.5 ± 1.2 vs 3.2 ± 1.8 days, P = 0.004), earlier initiation of free oral fluids (1.8 ± 2.2 vs 2.6 ± 1.7 days, P = 0.000) and of a solid diet (4.2 ± 2.9 vs 6.5 ± 2.7 days, P = 0.000), less frequent usage of parenteral narcotics (2.2 ± 3.2 vs 3.5 ± 4.0 times, P = 0.029), and shorter hospital stay (9.6 ± 9.6 vs 15.5 ± 9.8 days, P = 0.000). Conclusion:This study shows that SPLS is both safe and feasible in colorectal cancer, and that it has equivalent or better short-term outcomes than conventional laparoscopic surgery. Accordingly, the authors conclude that SPLS can be an alternative to conventional laparoscopic surgery for colorectal cancer.

Overview of single-port laparoscopic surgery for colorectal cancers: past, present, and the future.

Single-port laparoscopic surgery (SPLS) is implemented through a tailored minimal single incision through which a number of laparoscopic instruments access. Introduction of operation-customized port system, utilization of a camera without a separate external light, and instruments with different lengths has brought the favorable environment for SPLS. However, performing SPLS still creates several hardships compared to multiport laparoscopic surgery; a single-port system inevitably leads to clashing of surgical instruments due to crowding. To overcome such difficulties, investigators has developed novel concepts and maneuvers, including the concept of inverse triangulation and the maneuvers of pivoting, spreading out dissection, hanging suture, and transluminal traction. The final destination of SPLS is expected to be a completely seamless operation, maximizing the minimal invasiveness. Specimen extraction through the umbilicus can undermine cosmesis by inducing a larger incision. Therefore, hybrid laparoscopic technique, which combined laparoscopic surgical technique with natural orifice specimen extraction (NOSE)--i.e., transvaginal or transanal route-, has been developed. SPLS and NOSE seemed to be the best combination in pursuit of minimal invasiveness. In the near future, robotic SPLS with natural orifice transluminal endoscopic surgerys way of specimen extraction seems to be pursued. It is expected to provide a completely or nearly complete seamless operation regardless of location of the lesion in the abdomen.

Novel approach of single-port laparoscopic appendectomy as a solo surgery: A prospective cohort study

BACKGROUND Recent advances in medical equipment and surgical techniques have enabled solo surgery, wherein a surgeon operates alone without the participation of other surgical members. However, the application of solo surgery in single-port laparoscopic surgery (SPLS) has been rarely reported. METHODS Prospectively collected databases of 60 patients who underwent solo-SPLS for appendicitis between March 2013 and June 2014 were retrospectively reviewed. Making a transumbilical incision into the peritoneal cavity was facilitated by using a Lone Star self-retaining retractor. After the establishment of a single port through the umbilicus, we installed a mechanical adjustable camera holder (Endoworld®LAP53 Holding Systems). It was anchored to the operating table rail and firmly held the laparoscope with a possibility to adjust the same as required by the operator. The operative method was identical to the SPLS appendectomy, except for the use of these instruments. RESULTS The median operation time was 50 min (25-120). None of the patients required open conversion, insertion of an additional port or help of a human assistant. The median length of hospital stay for all patients was 1.0 day (range: 1-3 days). The median dosage of required intravenous analgesics (ketorolac, 0.1 mg/kg of body weight) was 0.0 ampoule (0-4). The median interval to initiation of solid diet was 1 day (1-2). The incidence of postoperative complications was 8.3% (5/60). CONCLUSIONS Our results shows that solo-SPLS appendectomy could be performed without increasing operation time or postoperative complications when performed by a surgeon competent in performing SPLS appendectomy.

The feasibility of single-port laparoscopic appendectomy using a solo approach: a comparative study.

Purpose To investigate the feasibility and safety of solo surgery with single-port laparoscopic appendectomy, which is termed herein solo-SPLA (solo-single-port laparoscopic appendectomy). Methods This study prospectively collected and retrospectively analyzed data from patients who had undergone either non-solo-SPLA (n = 150) or solo-SPLA (n = 150). Several devices were utilized for complete, skin-to-skin solo-SPSA, including a Lone Star Retractor System and an adjustable mechanical camera holder. Results Operating times were not significantly different between solo- and non-solo-SPLA (45.0 ± 21.0 minutes vs. 46.7 ± 26.1 minutes, P = 0.646). Most postoperative variables were also comparable between groups, including the necessity for intravenous analgesics (0.7 ± 1.2 ampules [solo-SPLA] vs. 0.9 ± 1.5 ampules [non-solo-SPLA], P = 0.092), time interval to gas passing (1.3 ± 1.0 days vs. 1.4 ± 1.0 days, P = 0.182), and the incidence of postoperative complications (4.0% vs. 8.7%, P = 0.153). Moreover, solo-SPLA effectively lowered the operating cost by reducing surgical personnel expenses. Conclusion Solo-SPLA economized staff numbers and thus lowered hospital costs without lengthening of operating time. Therefore, solo-SPLA could be considered a safe and feasible alternative to non-solo-SPLA.

Determination of surgical priorities in appendicitis based on the probability of undetected appendiceal perforation.

AIM To identify risk factors of actual appendiceal perforation when computed tomography (CT) scans suggest nonperforated appendicitis and accordingly determine surgical priority. METHODS We collected database of 1362 patients who underwent an appendectomy for acute appendicitis between 2006 and 2013. A single radiologist selected 1236 patients whose CT scans were suggestive of nonperforated appendicitis. Patients were divided into 2 groups: actual nonperforation group and actual perforation group according to intraoperative and pathologic features. Comparison of the 2 groups were made using binary logistic regression. RESULTS Of 1236 patients, 90 (7.3%) were found to have actual appendiceal perforation. Four risk factors related with actual appendiceal perforation were identified: body temperature≥37.6  °C (HR=1.912, 95%CI: 1.161-3.149; P=0.011), out-of-hospital symptom duration≥72 h (HR=2.454, 95%CI: 1.292-4.662; P=0.006), age≥35 years (HR=3.358, 95%CI: 1.968-5.728; P<0.001), and appendiceal diameter on CT scan≥8 mm (HR=4.294, 95%CI: 1.034-17.832; P=0.045). Actual appendiceal perforation group showed longer operation time, later initiation of diet, longer use of parenteral narcotics, longer hospital stay, and higher incidence of postoperative complications (P<0.05). CONCLUSION We proposed here new criteria to select patients with adverse clinical outcomes after appendectomy among the patients with radiologically nonperforated appendicitis. Surgical appendectomy outcomes could be improved by determining the surgical priority according to our criteria.

Role of the spleen in liver regeneration in relation to transforming growth factor-β1 and hepatocyte growth factor

BACKGROUND Optimizing the hepatic regenerative capacity is an immediate priority after partial hepatectomy (PH). Recent reports have indicated improvement in liver regeneration after splenectomy, raising interest on the role of the spleen in liver regeneration. However, little is known about the exact mechanism underlying these effects. MATERIALS AND METHODS Eight-week-old male Sprague-Dawley rats randomly underwent either 70% PH only (PH, n = 25) or 70% PH combined with splenectomy (PHS, n = 25). The specimens, including liver and/or spleen tissues and sera, were collected and evaluated using immunohistochemistry, Western blotting, enzyme-linked immunosorbent assay, and serum biochemical analyses. RESULTS PH induced higher transforming growth factor (TGF)-β1 expression in the liver up to 72 h after PH. The PHS group showed significantly higher numbers of proliferating cell nuclear antigen-positive cells, reflecting higher liver regeneration and lower amounts of liver enzymes compared with the PH group. Splenectomy after PH resulted in increased and decreased serum concentrations of hepatocyte growth factor (HGF) and TGF-β1 in the portal vein, respectively. Moreover, the PHS group demonstrated downregulation of TGF-β1 and its receptor TGF-β-RII and upregulation of HGF and its receptor c-Met in the liver. CONCLUSIONS The spleen seemed to exhibit an inhibitory effect on liver regeneration by upregulating TGF-β1 and its receptor TGF-β-RII and downregulating HGF and its receptor c-Met in the liver. Therefore, splenectomy can be considered an option for improving liver regeneration in selected patients with reduced regenerative capacity of the liver.

Stratified computed tomography findings improve diagnostic accuracy for appendicitis

AIM To improve the diagnostic accuracy in patients with symptoms and signs of appendicitis, but without confirmative computed tomography (CT) findings. METHODS We retrospectively reviewed the database of 224 patients who had been operated on for the suspicion of appendicitis, but whose CT findings were negative or equivocal for appendicitis. The patient population was divided into two groups: a pathologically proven appendicitis group (n = 177) and a non-appendicitis group (n = 47). The CT images of these patients were re-evaluated according to the characteristic CT features as described in the literature. The re-evaluations and baseline characteristics of the two groups were compared. RESULTS The two groups showed significant differences with respect to appendiceal diameter, and the presence of periappendiceal fat stranding and intraluminal air in the appendix. A larger proportion of patients in the appendicitis group showed distended appendices larger than 6.0 mm (66.3% vs 37.0%; P < 0.001), periappendiceal fat stranding (34.1% vs 8.9%; P = 0.001), and the absence of intraluminal air (67.6% vs 48.9%; P = 0.024) compared to the non-appendicitis group. Furthermore, the presence of two or more of these factors increased the odds ratio to 6.8 times higher than baseline (95%CI: 3.013-15.454; P < 0.001). CONCLUSION Appendiceal diameter and wall thickening, fat stranding, and absence of intraluminal air can be used to increased diagnostic accuracy for appendicitis with equivocal CT findings.

Comparative analysis of outcomes after multiport and single-port laparoscopic colectomy in emergency situations: Is single-port laparoscopic colectomy safe and feasible?

BACKGROUND/OBJECTIVE Although consensus has been reached on the superiority of laparoscopy for a majority of conditions underlying acute abdominal pain, the safety and feasibility of single-port laparoscopic colectomy (SPLC) in emergency situations have not been determined. METHODS A prospective electronic database of all emergency patients who underwent either multiport laparoscopic colectomy (MPLC) or SPLC between April 2006 and December 2014 was used to compare the surgical outcomes of these operative methods. RESULTS During the study period, 31 MPLCs and 76 SPLCs were performed. These two operative methods resulted in similar operating times, transfusion amounts, lengths of stay, postoperative complications, attainment of lymph nodes, and proximal and distal cut margins. However, the SPLC group had a shorter time to first flatus (2.8±1.9 days vs. 3.8±1.5 days, p=0.005), earlier reinitiation of free oral fluids (3.2±2.1 days vs. 4.4±1.8 days, p=0.002), and lesser requirement of narcotic analgesics (2.5±3.9 times vs. 4.7±4.8 times, p=0.017). CONCLUSION SPLC could be a safe and effective alternative to MPLC, even in emergency situations when performed by surgeons who have overcome the learning curve associated with single-port laparoscopic techniques. The tendency toward earlier returns to bowel function and decreased incidence of postoperative analgesic use would be potential benefits of SPLC in emergency situations.