Roger W. Motson

Restorative proctocolectomy with a three-loop ileal reservoir for ulcerative colitis and familial adenomatous polyposis. Clinical results in 66 patients followed for up to 6 years.

The results of restorative proctocolectomy with a three-loop ileal reservoir were reviewed. Of 66 patients treated between 1976 and 1982, 52 had ulcerative colitis and 14 had familial adenomatous polyposis. The temporary ileostomy was closed between 2 and 78 months previously in 63 cases. Of these, three patients had had the reservoir removed and two were lost to follow-up. One other patient was subsequently found to have Crohns disease. Function was assessed in 55 patients who had undergone closure of the ileostomy more than 8 weeks previously. Mean frequency of defecation was 3.7 per 24 hours (range 1–9.5) and 11 patients (20%) were taking antidiarrheal medication. Spontaneous defecation occurred in 22 patients (40%) while 29 (52.7%) had to use a catheter passed per anum. Four patients defecated spontaneously but sometimes used a catheter. Continence was normal in 36 (65.4%) and minor leakage once every 2 to 3 days occurred at night in 16 (29.1%). Three patients (5.4%) had some soiling during day and night. Troublesome perianal soreness (five patients, 9.1%) necessitated a defunctioning ileostomy in one. Fifty-four of the 55 patients assessed preferred their quality of life to that with an ileostomy.

Anal sphincter injury. Management and results of Parks sphincter repair.

The surgical management of a consecutive series of 97 patients with complete division of the anal sphincter musculature is reported. The sphincter damage followed operative, traumatic, or obstetric injury and resulted in frank fecal incontinence or the urgent necessity of a defunctioning colostomy. All patients were treated by delayed sphincter repair using an overlapping technique; in 93 the repair was protected by a temporary defunctioning stoma. There were no deaths. The repair, was completely successful in 65 (78%) and partially successful in 11 (13%) of the 83 patients assessed from 4 to 116 months after surgery. Complications occurred in 27 patients but did not usually affect the eventual clinical outcome. Provided there has been no major neurological damage to the sphincter complex, surgical reconstruction can be expected to restore continence in most patients.

Results of Parks operation for faecal incontinence after anal sphincter injury.

Parks operation for faecal incontinence was performed on 97 patients with total loss of anorectal control due to injury. All had sustained complete division of the anal sphincters as a result of trauma, anal surgery, or obstetric tears and either were incontinent or had been given a colostomy. In all patients the divided sphincters were repaired using an overlapping technique; in 93 the repair was protected by a temporary defunctioning stoma. There was no operative mortality. Continence was completely restored in 65 (78%) and improved in a further 11 (13%) of the 83 patients assessed from four to 116 months postoperatively. Minor complications which did not affect the eventual clinical outcome occurred in 23 patients. Factors associated with failure of the operation included breakdown of the repair in the early postoperative period, fistula, and pelvic floor neuropathy. The results show that even after severe injury to the sphincters surgical reconstruction can restore continence in most patients.

Laparoscopic resection of diverticular fistulae: a 10-year experience.

Objective  Until recently the laparoscopic approach was reserved for uncomplicated diverticular disease. We show that fistulating diverticular disease can be resected safely, with good clinical outcome via a laparoscopic approach.

Incisional hernia rates following laparoscopic colorectal resection

INTRODUCTION In published series with satisfactory follow-up incisional hernia rates following laparotomy vary between 4 and 18%, with up to 75% developing within two years of operation. This therefore represents the commonest complication following open abdominal surgery and a substantial added workload for the colorectal/general surgeon. AIM To prospectively review incisional hernia rates in patients undergoing laparoscopic colorectal resection in a single centre. METHODS All laparoscopic wounds were closed in identical fashion to open closure technique, utilising 0-monofilament, polyglyconate and a mass closure technique, followed by a subcuticular, polyglactin-910 suture for skin closure. All patients were subsequently examined in an outpatient setting by a senior surgeon independent to the original procedure. RESULTS 167 consecutive patients undergoing laparoscopic colorectal resections (94M:73F; median age 68 years) were included. Median incision length for specimen extraction was 6 cm (range 3-11 cm) and patients were followed-up for a median of 36 months (range 24-77 months). Twelve (7%) patients developed an incisional hernia (ten in specimen extraction wounds and two in port-site wounds), ten of whom underwent successful laparoscopic repairs. Of the remaining patients, one remains symptomatic and awaits repair, and one is asymptomatic and unfit for surgery. CONCLUSIONS The well-documented advantages of laparoscopic surgery include reduced hospital stay, early return to activity, decreased analgesic requirements and improved cosmesis. However, the results of this study suggest that incisional hernia rates are not decreased by laparoscopic surgery, although the hernias may be smaller and more amenable to repair by laparoscopic approaches.

Why does NICE not recommend laparoscopic herniorraphy

NICEs reluctance to recommend laparoscopic repair of hernias is based mainly on economic considerations, some of which are inaccurate, according to Roger Motson More than 100 000 inguinal herniorraphies are carried out each year in the United Kingdom, making it one of the commonest operations. Newer techniques have superseded the simple suture technique popularised by Bassini more than 100 years ago: firstly the tension-free darn with monofilament nylon and then the Lichtenstein repair with a polypropylene mesh patch. 1 2 Although there was no initial randomised trial of the Lichtenstein technique, it rapidly gained popularity during the past decade. Laparoscopic repair, which places a considerably larger polypropylene mesh patch against the inner surface of the abdominal wall than that used in the Lichtenstein technique, was first performed about 10 years ago. 3 4 This larger patch reinforces the entire groin, covering the sites of both indirect and direct inguinal hernias and also of femoral hernias. The position of the mesh is the same as that used in the open Stoppa repair,5 but the laparoscopic approach has the great advantage of avoiding the large incision required for this technique. #### Summary points Inguinal herniorraphy is one of the commonest operations in the United Kingdom Laparoscopic herniorraphy is less painful postoperatively than traditional open repair and allows the patient to return to work more quickly The true costs of laparoscopic repair are lower than those of open repair, particularly when it allows detection and simultaneous repair of an undiagnosed contralateral hernia Surgeons are under-represented on NICEs appraisal panel Laparoscopic repair has been subject to a number of randomised trials, recently summarised by the European Hernia Trials Group, who found that the incidences of recurrence in laparoscopic and Lichtenstein repairs were similar (2.3% and 2.9%, respectively).6 The only differences in clinical outcomes were a …

Training in laparoscopic colorectal surgery – experience of training in a specialist unit

INTRODUCTION Laparoscopic colorectal surgery, although technically demanding, is an increasingly desirable skill for coloproctologists. We believe that trainees with adequate supervision from an experienced trainer may perform these procedures safely with good outcome. PATIENTS AND METHODS Surgical logbooks of two senior trainees were reviewed over a 2-year period. A case note analysis was then undertaken. Patient data were recorded with regards to age, sex, operation type, American Society of Anesthesia (ASA) grade, conversion, length of hospital stay and complications. Lymph node yield, resection margins and grade of total mesorectal excision were recorded in oncological procedures. RESULTS Over the 2-year period, trainees were involved in 140 resections (age range, 23-88 years; ASA grades I-III). Seventy patients were male. Trainees were first assistant in at least 20 cases prior to undertaking the procedures themselves. Trainees performed a total of 71 operations. Median hospital stay was 7 days (range, 2-48 days). There were three conversions. Anastomotic leaks developed in two patients, one requiring a laparotomy. One patient developed small bowel obstruction secondary to a port site hernia, which was repaired laparoscopically. There was one postoperative death. All oncological resection margins were clear with adequate lymphadenectomies. All total mesorectal excisions were Quirke grade III. CONCLUSIONS Adequately trained and supervised trainees may perform major colorectal resections without compromising outcome.

Laparoscopic aortic surgery (Br J Surg 2010; 97: 1153-1154).

Sir We read with interest the well conducted randomized study by Braga and colleagues comparing laparoscopic versus open left colonic resection. There is now a consistent body of literature showing that laparoscopic colonic surgery, although associated with longer operating times, contributes towards shorter length of hospital stay, equivalent or improved morbidity, and improved early quality of life compared with open colonic resection. In a previous study by the same group, the increased hospital costs in the laparoscopic surgery group were attributed to the higher cost of laparoscopic instrumentation and longer operating times1. In the present study, the authors suggest that performing the anastomosis and splenic flexure takedown laparoscopically resulted in reducing the invasiveness of the approach. This is in contrast to their previous study on right colectomy where the bowel division and ileocolonic anastomosis was done extracorporeally and the benefits of the laparoscopic approach were not as profound. We are not convinced that bowel division and anastomosis carried out extracorporeally necessarily decreases the benefit of the laparoscopic approach. Not discussed in this article is the use of hand-assisted laparoscopic surgery (HALS) for colonic resection, where the division and anastomosis is often done extracorporeally2. HALS has been shown to produce similar shortand long-term clinical outcomes, as well as potentially decreasing the rate of conversion compared with the standard laparoscopic technique3 – 5. The most important benefit of HALS seems to be a decreased duration of operation, while maintaining the benefits of a minimally invasive approach5. Marcello and colleagues2 noted a time saving of 28 min for left colectomy and 51 min for total colectomy. There is possibly also a reduction in the need for instruments in HALS, although this has not been investigated in any of the studies. We therefore suggest that in selected patients it may be beneficial to employ HALS to decrease the operating time as well as the rate of conversion. This will be associated with a decreased hospital cost of laparoscopy overall, and allow the cost–benefit analysis to shift further in favour of the laparoscopic compared with the open technique. A. Sarin, J. W. Milsom and P. J. Shukla Surgery, Division of Colorectal Surgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA (e-mail: jwm2001@med.cornell.edu) DOI: 10.1002/bjs.7321

Laparoscopic inguinal hernia repair--how I do it.

Initial entry to the abdomen is by direct puncture at the umbilicus.1 Briefly, the umbilicus is firmly elevated with Lane’s tissue holding forceps and the very centre of the umbilicus incised with a 23 Swann Morton scalpel blade. Usually, the blade incises the fascia but often does not divide the peritoneum. Artery forceps are introduced through the incision to bluntly break through the peritoneum and a 10 mm laparoscopic cannula is introduced over a blunt tipped trocar (soon to be available from Karl Storz, Tuttlingen, Germany). Alternative entry methods are the cut down technique described by Hasson and the use of a Verres needle to create the pneumoperitoneum.

MRI for the assessment of locally advanced rectal cancer – a window of opportunity

Dear Sir, In recent years, there has been a paradigm shift in the management of rectal cancer and accurate imaging with MRI has become accepted as the modality of choice in defining preoperative disease extent [1]. However, in the management of patients with locally advanced rectal cancer [LARC: threatened ⁄ definite circumferential resection margin (CRM) involvement, T3 > 5 mm into perirectal fat, T4 tumours, and ⁄ or multiple nodes], there are concerns about the accuracy of preoperative MRI following long course chemoradiotherapy (CRT). We therefore read the paper with interest by Suppiah et al. [2], and would like to make several observations with regard to the methodology and data presented, and relate it to our own experience. We believe their conclusion that ‘MRI staging following CRT is poor’ may be flawed, because of the interval between the post-CRT MRI and definitive resectional surgery. In their paper, the median time from completion of CRT to MRI was 32 days i.e. 41⁄2 weeks, but surgery was performed at a median time of 55 days (8 weeks) i.e. just over 3 weeks later. A total of 86 patients were retrospectively analysed (as stated in their abstract), with complete data available on 64 patients; of these, 15 were subsequently excluded, including two patients who had inoperable disease despite being operable on MRI, and six patients (6 ⁄ 64, 9.4%) who were initially fit for surgery, but deteriorated either during CRT or between surgery and were deemed inoperable. Thus, only 49 of 86 patients (57%) underwent resection and are the subject of Suppiah et al.’s detailed analysis. We recently presented our 3 year experience on toxicity and response for 50 consecutive patients (36 men; median age 64 years, range 39–76 years), 47 with biopsy – proven LARC by MRI criteria and three patients with localized recurrence after previous anterior resection [3]. 48 patients (96%) completed CRT, of whom 43 (86%) underwent resection, of which 27 (63%) of which were performed laparoscopically. Thirtyseven patients (86% of those undergoing surgery) achieved an R0 resection. Importantly, only one patient developed liver metastases prior to surgery, with a median time to surgery from completion of CRT of 11 weeks (range 8–15 weeks). Of particular interest during this period, 17 patients with ‘bulky’ LARC, all of whom had CRM involvement on MRI, (extensively in six, all patients T3 or T4, ± multiple nodes), who received CRT and were felt to have an ongoing clinical response beyond MRI 2. Each had three high resolution MRI scans (before treatment, defined as MRI 1: 6–7 weeks after CRT, MRI 2; immediately preoperatively, MRI 3) [4]. All of these patients underwent definitive resection (15 anterior resection, 2 APR) 65–104 (mean 82) days post-CRT, with clear CRM in 16 patients (94%). MRI T and N staging and maximal wall thickness were correlated with the histopathological findings, with no patients having an increase in T or N stage. However, MRI 2 showed T downstaging in only 6% of patients, with a further 29.4% showing intra – T stage response from T3c to T3b. MRI 3 was performed 15–37 (mean 29) days after MRI 2, 3–21 (mean 10) days before surgery and showed further overall T stage response in 41%, and an another 17.6% had a further intra-T3 response: 50% of these responders had shown no T stage improvement on MRI 2. Applying an ordinal scale, T stage decreased from a mean of 3.57 at MRI 1– 3.3 at MRI 2– 2.51 at MRI 3 (P < 0.01; decrease in mean T stage between MRI 2 and 3, P < 0.01). In keeping with Suppiah et al.’s findings where T stage accuracy was 45%, with three times more patients overstaged on MRI rather than understaged, we found agreement between MRI 2 and final pathology was only 58.8%, with all seven inaccurately assigned patients overstaged. This is similar to other important UK studies recently, such as that by Allen et al. [5] where accuracy of prediction of T stage was 60%, N stage 70%, but median time from completion of CRT and 2nd MRI was 38 days, and median time from post-CRT MRI to surgery a further 43 days; similarly, Kulkarni et al. [6] also reported T and N stage accuracy at 43% and 78% respectively, but with MRI at 6 weeks (median), and surgery at 9 weeks. It is this gap between imaging and resection that may consistently undermine these studies, because in our series, MRI 3 T stage correlation was much higher at 82%. Fourteen of these 17 patients were also nodepositive by MRI criteria, with 50% response to CRT in seven patients by MRI 2, with no further N response on MRI 3 in the other 50%. Agreement with final pathology was 88%. Similarly, reduction in wall thickness was seen over the three scans (P < 0.01). In conclusion, we feel that preoperative MRI in the post-CRT setting is accurate if performed just before surgery, with a high correlation with final histopathology. Serial MRI can also document an ongoing response up to 12 weeks after CRT, and that waiting for this to occur appears not to be detrimental either from disease progression, or patients becoming unfit for surgery because of CRT. From both radiological and surgical