Junji Okuda

Perioperative tumor localization for laparoscopic colorectal surgery

AbstractBackground: Because of the inability to palpate colonic tumors during laparoscopy, their location must be precisely identified before resection is undertaken. Method: A retrospective study was performed of 58 patients in order to be able to describe our methods of tumor localization for laparoscopic colorectal operations and to review their effectiveness. Results: In all patients, the entire colon was examined preoperatively by colonoscopy. In one patient, preoperative colonoscopic localization was inaccurate. In 31 patients, tumors were easily detectable at surgery. In five patients with the tumor in the right colon, even though the lesion was not detectable at surgery, right colectomy was performed without marking because preoperative colonoscopy reliably identified the lesion adjacent to the ileocecal valve. Twenty-two patients required some type of procedure to localize the tumor. The procedures and their problems were as follows: preoperative tattoo (five)—tattoo not visualized (one); intraoperative colonoscopy alone (six), combined with intraoperative tattoo (four) or clip (three)—poor operative exposure due to bowel distension (nine), hard to see the clip (three), dislodged clip (two), inadequate resection margin (one); intraoperative proctoscopy alone (two), combined with laparoscopic stitch (two)—no problems. In no patient was tumor present at a resection line and in no patient was the wrong segment resected. Conclusions: Reliable preoperative identification of the tumor adjacent to the ileocecal valve can permit right colectomy without marking. Lesions in the upper rectum can be approached via intraoperative proctoscopy ± suture placement. If the surgeon anticipates intraoperative localization may be difficult, lesions other than rectal or cecal ones should probably be marked by preoperative tattooing. Further studies regarding the technique of tattooing are warranted.

Does laparoscopic vs. conventional surgery increase exfoliated cancer cells in the peritoneal cavity during resection of colorectal cancer

PURPOSE: Traumatic manipulation of cancer specimens during laparoscopic colectomy may increase exfoliation of malignant cells into the peritoneal cavity, causing an early occurrence of peritoneal carcinomatosis or port-sites recurrence. Because of this concern, the routine use of intraperitoneal chemotherapy after laparoscopic colectomy for cancer was suggested recently. We assessed if laparoscopicvs. conventional surgery increases exfoliated malignant cells in the peritoneal cavity during resection of colorectal cancer. METHODS: In a prospective, randomized fashion, 38 colorectal cancer patients undergoing an elective, curative operation were assigned to either a conventional or laparoscopic procedure between June 1996 and May 1997. In either group (n=19), after the abdominal cavity was entered, saline was instilled into the peritoneal cavity, and the fluid was collected (Specimen 1). During surgery, all irrigating fluids were collected (Specimen 2). Both specimens were assessed for malignancy using four techniques: filtration process (ThinPrep®), smear, cell block, and immunochemistry using Ber-EP4. The change in the amount of tumor cells in both specimens was compared between surgical groups. A pilot study was performed to validate the proposed cytologic method. RESULTS: In the pilot study of 20 consecutive patients with colorectal cancer, postresectional peritoneal cytology was positive in six patients, including two Stage II (T3,N0,M0) patients. The pilot study also validated that our semiquantitative scoring system can be reliably used to assess the amount of free peritoneal cancer cells. In the main study, 16 right colectomies, 3 extended right colectomies, 17 proctosigmoidectomies, and 1 left colectomy were performed. The T and N stages were T1 (n=13), T2 (n=5), T3 (n=8), T4 (n=11); N0 (n=22), N1 (n=8), N2 (n=7). Malignant cells were not detected in any Specimens 1 or, more importantly, in Specimens 2 in either surgical group. CONCLUSION: When performed according to strict oncologic surgical principles, laparoscopic techniques in curative colorectal cancer surgery did not have an increased risk of intraperitoneal cancer cell spillage, compared with conventional techniques. We hope that these results can decrease some of the concerns about tumors cell spillage and seeding during laparoscopy.

Effect of previous abdominal surgery on outcomes following laparoscopic colorectal surgery.

OBJECTIVE: The impact of previous abdominal surgeries on the need for conversion to open surgery and on short-term outcomes during/after laparoscopic colectomy was retrospectively investigated. DESIGN: This retrospective cohort study was conducted from December 1996 through December 2009. SETTING: This study was conducted at Osaka Medical College Hospital. PATIENTS: A total of 1701 consecutive patients who had undergone laparoscopic resection of the colon and rectum were classified as not having previous abdominal surgery (n = 1121) or as having previous abdominal surgery (n = 580). MAIN OUTCOME MEASURES: Short-term outcomes were recorded, and risk factors for conversion to open surgery were analyzed. RESULTS: There were no significant differences in operative time, blood loss, number of lymph nodes removed, or conversion rate between the groups. The rate of inadvertent enterotomy was significantly higher in the previous abdominal surgery group than in the not having previous abdominal surgery group (0.9% versus 0.1%; p = 0.03), and the postoperative recovery time was significantly longer in the previous abdominal surgery group than in the not having previous abdominal surgery group. Ileus was more frequent in the previous abdominal surgery group than in the not having previous abdominal surgery group (3.8% versus 2.1%; p = 0.04). Significant risk factors for conversion to open surgery were T stage ≥3 (OR, 2.81; 95% CI, 1.89–3.75), median incision (OR, 4.34; 95% CI, 1.23–9.41), upper median incision (OR, 2.78; 95% CI, 1.29–5.42), lower median incision (OR, 1.82; 95% CI, 1.09–3.12), and transverse colectomy (OR, 1.76; 95% CI, 1.29–2.41). CONCLUSION: The incidence of successfully completed laparoscopic colectomy after previous abdominal surgery remains high, and the short-term outcomes are acceptable.

Oncological impact of laparoscopic lymphadenectomy with preservation of the left colic artery for advanced sigmoid and rectosigmoid colon cancer.

Background: Laparoscopic lymphadenectomy around the inferior mesenteric artery (IMA) with preservation of the left colic artery (LCA) remains a controversial approach. The aim of the study was to investigate the clinical outcomes. Methods: This study analysed 211 patients who underwent laparoscopic resection of advanced (≥T3) sigmoid and rectosigmoid colon cancers with D3 lymphadenectomy including 91 high ligations of the IMA (HL) and 120 low ligations with preservation of the LCA (LL) from January 1998 to December 2009. Results: There were no significant differences in operative result between the groups. In stage II cancer, the overall survival rate (94.8% HL vs. 91.8% LL; 95% confidence interval (CI), -0.8 to 0.68, p = 0.920) and disease-free survival (93.0% HL vs. 87.6% LL; 95% CI, -0.8 to 0.40, p = 0.540) did not differ significantly between the two groups. A similar tendency in overall survival was observed in patients with stage III cancer (88.3% HL vs. 86.9% LL; 95% CI, -0.44 to 0.57, p = 0.989) and disease-free survival (71.4% HL vs. 69.8% LL; 95% CI, -0.38 to 0.40, p = 0.637). Conclusions: Laparoscopic lymphadenectomy around the IMA with preservation of the LCA resulted in acceptable clinical outcomes in patients with advanced sigmoid and rectosigmoid colon cancer.

Atraumatic and expeditious laparoscopic bowel handling using a new endoscopic device

In laparoscopic colorectal surgery, effective handling of the bowel is mandatory to avoid bowel injury and excessive manipulation and to obtain adequate traction and clear exposure. We have developed a simple laparoscopic tool that permits effective and safe retraction of the small or large intestine and that is especially helpful in taking down the hepatic and splenic flexures and in dissecting the mesorectum.