Daniel P. Geisler

Single-port laparoscopy in colorectal surgery

Purpose  Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single‐port laparoscopic colorectal surgery using a Uni‐X™ Single‐Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi‐channel cannula and specially designed curved laparoscopic instrumentation.

Predictive factors of pathologic complete response after neoadjuvant chemoradiation for rectal cancer.

Objective:This study evaluates factors associated with a pathologic complete response (pCR) after neoadjuvant chemoradiation for rectal cancer. Summary Background Data:Approximately 20% of rectal cancer patients undergoing neoadjuvant chemoradiation achieve pCR, which has been associated with decreased local recurrence and improved recurrence-free survival. Means of predicting pCR remain incompletely defined. Methods:A total of 306 consecutive patients with stage II or stage III rectal cancer who underwent neoadjuvant chemoradiation then surgery between 1997 and 2007 were identified from a single-institution. Sixty-four patients with concurrent inflammatory bowel disease, hereditary colorectal cancer, other malignancy, urgent surgery, incomplete chemoradiation, or insufficient data were excluded. All patients received neoadjuvant 5-FU-based chemotherapy and external beam radiation. Histologic response was categorized as pCR or not-pCR, which defined the 2 study cohorts. Variables were analyzed by univariate and multivariate analysis with pCR as the dependent variable. Fisher exact test, &khgr;2, Wilcoxon rank-sum, and logistic regression were used for analysis. P < 0.05 was considered statistically significant. Results:Of the total patients, 242 were studied, including 58 (24%) that achieved pCR. The 2 groups were statistically similar in terms of age, gender, body mass index, tumor differentiation, radiation dose, and pretreatment stage. On multivariate analysis, an interval ≥8 weeks between treatment completion and surgical resection was significantly associated with a higher rate of pCR, which correlated with decreased local recurrence and improved overall survival. Conclusion:Despite traditional beliefs that certain patient and tumor factors influence pCR, an extended interval between completion of neoadjuvant therapy and surgery was the single most important determinant in achieving a pCR.

Single incision laparoscopic total proctocolectomy with ileopouch anal anastomosis

Aim  We present our initial experience of a single port laparoscopic total proctocolectomy with ileoanal J pouch anastomosis. The single incision laparoscopic surgery (SIL), (Covidien, Norwalk, Connecticut, USA) device with a multichannel cannula and specially designed curved laparoscopic instrumentation were used.

Outcomes for case‐matched laparoscopically assisted versus open restorative proctocolectomy

The aim of this study was to compare safety, early and late outcomes, quality of life and functional results of laparoscopically assisted versus open ileal pouch–anal anastomosis (IPAA).

Hand-Assisted Laparoscopic Colectomy: Benefits of Laparoscopic Colectomy at No Extra Cost

BACKGROUND Comparison studies of hand-assisted and laparoscopic-assisted colectomy have indicated that short-term outcomes are similar. Although a few of these studies have compared costs, none has reported on the costs of hand-assisted colectomy performed in the US. Our aim was to determine the short-term outcomes and direct costs associated with hand-assisted and laparoscopic-assisted colectomy performed in the US. STUDY DESIGN One hundred hand-assisted laparoscopic colectomies were matched to 100 laparoscopic-assisted colectomies performed concurrently. Matching criteria were age (+/- 10 years), gender, diagnosis, American Society of Anesthesiologists score, earlier abdominal operation, colectomy type, and conversion. Operative time, morbidity, length of stay, reoperation, and readmission were assessed. Direct costs for the operating room, nursing care, intensive care, anesthesia, laboratory, pharmacy, radiology, emergency services and consultations, and professional and ancillary services related to the initial hospitalization and readmissions were compared. RESULTS From June 2005 to August 2008, 176 hand-assisted and 845 laparoscopic-assisted segmental and total colectomies were performed. Of 100 matched hand-assisted and laparoscopic-assisted patients, there were no differences in body mass index (29 and 28, respectively), operating time (168 and 163 minutes, respectively), length of stay (4 days), readmission (6% and 11%, respectively), or reoperation rates (5% and 9%, respectively). Overall morbidity was 16% and 32% for hand-assisted and laparoscopic-assisted colectomy, respectively (p = 0.009). Major morbidity, including abscess, hemorrhage, and anastomotic leak, were similar. Operating room costs were increased for hand-assisted colectomy (3,476 versus 3,167 US dollars); total costs were similar (8,521 versus 8,373 US dollars). CONCLUSIONS Short-term outcomes and total costs of hand-assisted and laparoscopic-assisted colectomy are similar.

Minimally invasive surgical wound infections: laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care

Aim  The morbidity of surgical site infections (SSIs) were compared in patients who underwent open (OS) vs laparoscopic (LS) colorectal surgery.

Outcomes after laparoscopic intestinal resection in obese versus non-obese patients.

The degree of benefit derived from laparoscopic bowel resection in obese compared with non‐obese patients is poorly understood.

Hand-assisted laparoscopic surgery may be a useful tool for surgeons early in the learning curve performing total abdominal colectomy

Objective  We evaluated outcomes after hand‐assisted (HALC) and straight laparoscopic (LC) techniques for the initial laparoscopic total abdominal colectomy (TAC) procedures performed by surgeons starting their laparoscopic careers.

Single-Port Laparoscopy, NOTES, and Endoluminal Surgery

Minimally invasive surgery has become the standard treatment for many disease processes. In the last decade, numerous studies have demonstrated that laparoscopic approaches to various conditions have improved the quality of life with comparable surgical and oncologic outcomes to standard open procedures. Recently, an alternative to conventional laparoscopy or robotic surgery has been developed: laparoendoscopic single-site surgery (LESS), also known as single-port surgery. Single-port laparoscopy is an attempt to further enhance the cosmetic benefits of minimally invasive surgery while minimizing the potential morbidity associated with multiple incisions. In this special issue, we will focus on 2 articles relevant to the advancement and practice of LESS. This new modality presents unique challenges, such as instrument crowding and the need to move and control a flexible camera and articulating instruments together, requiring even more advanced laparoscopic skills. Information about training and education on single-port laparoscopy is scarce in the current literature: Ramalingam et al. present their initial experience and methodology in training and education regarding this new technique. Formal training in this technique is not widely available. Expensive ports and instrumentation may be factors deterring the training. The authors address a major gap in the literature, how to train surgeons in this technique? They modified the standard laparoscopic endotrainer with improvised ports, to make it suitable for single-port laparoscopic training. For the animal lab training, they improvised ports and low-cost instruments. Thus, the overall cost of the training in LESS was reduced, and better confidence levels were achieved prior to human applications. Perhaps this will stimulate others to look at adopting this relatively low-tech technique for training in LESS. Emerging data on LESS has been reported in general surgical, gynecologic, and urologic procedures. LESS, for renal surgery, was first reported in 2007, and, since then, a handful of authors have described variations of their techniques. Derweesh and coauthors present the first prospective report in the literature of LESS radical nephrectomy with renal vein thrombectomy and cytoreductive nephrectomy. As such, this report further corroborates that increasingly complex procedures can be safely performed with the LESS platform. The feasibility of LESS for complex surgical procedures is no longer an issue. Current research and development in single-port robotics is ongoing. A single-port robotic platform may overcome technical limitations of single-site surgery (instrument crowding, lack of triangulation, and loss of depth of perception/instability with current 2D flexible optics). More importantly, it may play an essential role in the reproducibility and diffusion of LESS. Prospective studies are needed to assess the relative benefits of LESS compared with more conventional minimally invasive approaches. Pedro F. Escobar Jihad H. Kaouk Daniel Geisler Matthew Kroh Amanda Nickles Fader Tommaso Falcone

Response to Letter to the Editor: Neoadjuvant Therapy for Rectal Cancer: The Impact of Longer Interval Between Chemoradiation and Surgery

To the Editors: We thank Dr. Huerta for his kind words and thoughtful comments on our recent article. He brings forth several key issues that remain among the top challenges in treating rectal cancer. We agree that it would obviously be paramount to identify which patients would achieve a pathologic complete response (pCR), but unfortunately this is not currently possible. Indeed, our group and others are currently investigating possible genetic markers to potentially identify which patients are most likely to achieve pCR, but only the future will tell. As Dr. Huerta states, the interval of 8 weeks for analysis in this study was chosen from our previous work which identified that waiting at least 8 weeks was independently associated with a higher percentage of patients achieving pCR. This was a nonrandomized, retrospective study and the exact interval that would be most effective remains undefined. A welldesigned trial is necessary to accurately address this matter and an ongoing NIH-sponsored multicenter prospective trial is enrolling approximately 250 rectal cancer patients into one of five different treatment groups based on an increasing interval between completion of neoadjuvant therapy and surgery. The intervals being examined are 6, 12, 16, 20, and 24 weeks and the study is expected to complete enrollment within this year. Patients in the longer interval treatment arms will receive chemotherapy during the waiting period. Results of this trial will answer some of the critical issues regarding intervals between neoadjuvant chemoradiation and surgery.