Philippe Morel

A Prospective, Randomized, Single-Blind Comparison of Laparoscopic Versus Open Sigmoid Colectomy for Diverticulitis

Objective:The aim of this study was to compare open and laparoscopic sigmoid resection for diverticulitis with the patient and the nursing staff blinded to the surgical approach. Methods:A total of 113 patients scheduled for an elective sigmoidectomy were randomized to receive either a conventional open (54 patients) or a laparoscopic (59 patients) approach. Postoperatively, an opaque wound dressing was applied and left in place for 4 days, and patients from both groups were managed similarly. The primary endpoints for analysis were (1) postoperative pain; (2) duration of postoperative ileus; and (3) duration of hospital stay (ClinicalTrials.gov, number NCT 00453830). Results:The median duration of procedure was 165 minutes (range, 90–285) in the laparoscopy group and 110 minutes (range, 70–210) in the open group (P < 0.0001). The median delay between surgery and first bowel movement was 76 (range, 31–163) hours in the laparoscopy group versus 105 (range, 53–175) hours in the open group (P < 0.0001). The median score for maximal pain (assessed by a visual analog scale) was 4 (range, 1–10) in the laparoscopy group and 5 (range, 1–10) in the open group (P = 0.05). Finally, the median duration of hospital stay was 5 days (range, 4–69) in the laparoscopy group versus 7 days (range, 5–17) in the open group (P < 0.0001). Conclusion:Laparoscopic sigmoid resection is associated with a 30% reduction in duration of postoperative ileus and hospital stay; by comparison, benefits in terms of postoperative pain appear less impressive, when the patient is blinded to the surgical technique.

Visual clues act as a substitute for haptic feedback in robotic surgery

ObjectiveThe lack of haptic feedback (HF) in robotic surgery is one of the major concerns of novice surgeons to that field. The superior visual appearances acquired during robotic surgery may give clues that make HF less important.MethodsWe surveyed 52 individuals on their perception of HF during robotic surgery. The first group of 34 surgically inexperienced people used the da Vinci robot for their first time (drylab). The second group included 8 laparoscopic surgeons with experience up to a fifth robotic operation. The third group included 10 surgical experts with substantial experience (150-650 robotic cases). Visual analog assessment was made of perception of HF, how much HF was missed, how much the absence of HF impaired the operators’ level of comfort. Robotic experts were asked if complications have occurred as a result of a lack of HF.ResultsOf the first group, 50% reported the perception of HF, as did 55% of the second group and 100% of the third group (difference between group 1 and group 3: pxa0<xa00.05). The first group missed HF for 6.5; the second group for 4.3, and the third group for 4 (difference between groups 1 and 3: pxa0<xa00.05). The surgical experts claimed to have missed HF for 7.2 s when they first started robotic surgery (Difference to now: pxa0<xa00.05). The lack of HF caused discomfort for the first group of 4; for the second group of 4,4, and for the third group of 2,6. One complication was reported by the robotic experts as resulting from the lack of HF.ConclusionsThe data support the conclusion that even beginners quickly experience the perception of HF when performing robotic surgery. With more experience, perception of HF and the level of comfort with robotic surgery increases significantly. This perception of HF makes “real” HF less important and demonstrates that its importance is overestimated by novices in robotic surgery.

Laparoscopic versus open sigmoid resection for diverticulitis: long-term results of a prospective, randomized trial

BackgroundElective laparoscopic sigmoid resection for diverticulitis has proven short-term benefits, but little data are available from prospective randomized trials regarding long-term outcome, quality of life, and functional results.MethodsOf 113 patients randomized to undergo laparoscopic (LAP) versus open (OP) sigmoid resection for diverticulitis, 105 (93%, LAPxa0=xa054, OPxa0=xa051) patients were examined and answered the Gastrointestinal Quality of Life Index (GIQLI) questionnaire, with a median follow-up of 30 (range, 9–63) months after surgery.ResultsIncisional hernias were detected in five (9.8%) patients in the OP group versus seven (12.9%) in the LAP group, Pxa0=xa00.84). Overall satisfaction with the operation on a scale of 0 (very poor) to 10 (excellent) was 9 (range, 2–10) in the OP group versus 9 (range, 2–10) in the LAP group (Pxa0=xa00.78). Median GIQLI score was 115 (range, 57–144) in the OP group versus 110 (range, 61–134) in the LAP group (Pxa0=xa00.17). Overall satisfaction with the cosmetic aspect of the scar on a scale of 0 (very poor) to 10 (excellent) was 8 (range, 1–10) in the OP group versus 9 (range, 0–10) in the LAP group (Pxa0=xa00.01). Finally, median hospital cost (including reoperations for hernias) was 11,606 (5,230–147,982) CHF in the LAP group versus 12,138 (6,098–39,786) CHF in the OP group (Pxa0=xa00.47).ConclusionsBoth open and laparoscopic approaches for sigmoid resection achieve good long-term results in terms of gastrointestinal function, quality of life, and patients’ satisfaction. Significant long-term benefits of laparoscopic surgery are restricted to cosmetic (ClinicalTrials.gov protocol #NCT00453830).

Set‐up and docking of the da Vinci® surgical system: prospective analysis of initial experience

Set‐up and docking of the da Vinci® surgical system are assumed to extend overall operating times. We hypothesized that these tasks could be achieved in adequate times. Therefore, a prospective analysis of set‐up and docking times of the da Vinci® Surgical System was conducted.

Impact of IQ, computer-gaming skills, general dexterity, and laparoscopic experience on performance with the da Vinci surgical system.

Due to improved ergonomics and dexterity, robotic surgery is promoted as being easily performed by surgeons with no special skills necessary. We tested this hypothesis by measuring IQ elements, computer gaming skills, general dexterity with chopsticks, and evaluating laparoscopic experience in correlation to performance ability with the da Vinci® robot.

Risk factors for mortality–morbidity after emergency–urgent colorectal surgery

BackgroundThe aim of this study was to assess the risk factors associated with mortality and morbidity following emergency or urgent colorectal surgery.Materials and methodsAll data regarding the 462 patients who underwent emergency colonic resection in our institution between November 2002 and December 2007 were prospectively entered into a computerized database.ResultsThe median age of patients was 73 (range 17–98)xa0years. The most common indications for surgery were: 171 adenocarcinomas (37%), 129 complicated diverticulitis (28%), and 35 colonic ischemia (7.5%). Overall mortality and morbidity rates were 14% and 36%, respectively. In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss >500xa0cm3 (odds ratio (OR)u2009=u20093.33, 95% confidence interval (CI) 1.63–6.82, pu2009=u20090.001). There were three parameters which correlated with postoperative morbidity: ASA score ≥3 (ORu2009=u20092.9, 95% CI 1.9–4.5, pu2009<u20090.001), colonic ischemia (ORu2009=u20093.4, 95% CI 1.4–7.7, pu2009=u20090.006), and stoma creation (ORu2009=u20092.2, 95% CI 1.4–3.4, pu2009=u20090.0003).ConclusionsThe main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: (1) patients’ ASA score, (2) colonic ischemia, and (3) perioperative bleeding. These variables should be considered in the elaboration of future scoring systems to predict outcome of emergency colorectal surgery.

Robotic single-incision transabdominal and transvaginal surgery: initial experience with intersecting robotic arms

Single‐incision laparoscopic and natural orifice translumenal endoscopic surgery (NOTES) are technically challenging methods. Robotics might have the potential to overcome such hurdles with computer technology.

Amyand's hernia: 10 years' experience

BACKGROUNDnAmyands hernia is an atypical groin hernia which contains the vermiform appendix. The aim of this study was to review a single institutions experience in the clinical presentation, management and prognostic factors of this rare hernia.nnnMETHODSnThe authors reviewed records of all patients undergoing hernia surgery from 1996 to 2006 at their institution, a tertiary care, University-affiliated hospital.nnnRESULTSnTwelve patients (six men) with a median age of 88 years (range 60-97) were included. Six presented with right inguinal hernias and six presented with right femoral hernias. All required emergency surgery: eight for strangulated hernias, two for hernias with lower quadrant peritonism and two for incarcerated hernia. Despite small differences in outcome and length of hospitalisation between Amyand types, appendix inflammation, pre-operative blood examinations and hernia localisation, only right lower quadrant peritonism as a presenting sign (p=0.004) and age greater than 90 years old (p=0.04) were significantly associated with a poor outcome.nnnCONCLUSIONnAmyands hernia is a rare hernia which is seldom diagnosed before operation. It must be considered in the evaluation of a strangulated or incarcerated hernia. Further studies are required to define the optimal surgical strategy, prognostic factors and risks of hernia recurrence.

Laparoscopic versus open resection for appendix carcinoid

BackgroundSince an increasing number of appendectomies are performed via laparoscopy, it is crucial to determine the impact of this approach on appendix carcinoid (AC) outcome. The goal of this study was to compare results of laparoscopic (LAP) versus open (OP) appendectomy for AC according to intend to treat approach.MethodsA retrospective review (1991–2003) identified 39 patients (median age, 36 years; range, 12–83) treated by laparoscopy (LAP) or laparotomy (OP) for AC in a single institution. Follow-up was complete for all patients (median, 67 months; range, 4–132).ResultsMost cases had associated acute appendicitis (64%). Median carcinoid size was 1.1 cm (range, 0.3–5) and 0.4 cm (range, 0.2–3) in the LAP and OP groups, respectively. LAP and OP were performed in 21 (54%) and 18 (46%) patients, respectively. Surgical margins were positive in two patients in the LAP group and one patient in the OP group (p = 0.6). Right colectomies were performed for AC >2 cm in five patients after LAP and in four patients after OP (p = 0.9). Actuarial 5-year survival rates were 100 and 94% in the LAP and OP groups, respectively (p = 0.2). Two patients died in the OP group, one due to metastatic carcinoid and the other due to metachronous colorectal cancer. Synchronous or metachronous colorectal carcinomas developed in six patients (15%).ConclusionLaparoscopic appendectomy is a safe procedure for AC, with carcinologic and long-term results similar to those of conventional appendectomy. Thus, pre- or per-operative suspicion of AC is not a contraindication to LAP. Prognosis of AC appears more dependent on carcinoid malignant potential or associated tumors. Risk for developing colorectal adenocarcinoma is high in AC patients and warrants follow-up of all patients with colonoscopic screening.

Robotic laparoendoscopy single site surgery: a transdisciplinary review

Recent developments in minimal invasive surgery have led to laparoendoscopic single site surgery (LESS). This new approach has great potential but remains technically challenging. In order to relieve these difficulties many authors have adapted robotic technology to single site surgery. Numerous approaches have been developed and there is no real consensus.