Ronan A. Cahill

Single-Access Laparoscopic Sigmoidectomy as Definitive Surgical Management of Prior Diverticulitis in a Human Patient

HYPOTHESIS Single-access laparoscopic surgery should offer minimal scarring without compromising surgical outcome. It is enhanced by both innovative port technology and technical expertise learned by developing natural orifice transluminal endoscopic surgery (NOTES). DESIGN Sigmoidectomy in a human via a single laparoscopic port. SETTING University hospital. Patient A 40-year-old woman with previously documented diverticular abscess. INTERVENTIONS The multichannel single port (Triport; Advanced Surgical Concepts, Wicklow, Ireland) was placed at the umbilicus. The sigmoid was retracted by both intraluminal sigmoidoscopy and magnetic anchoring. Mesenteric dissection between the mid-descending colon and the colorectal junction was carried out close to the colon using a Ligasure Advance (Covidien, Valley lab, Norwalk Connecticut). The stapler anvil was passed retrogradely per ano to lie within the descending colon. A linear stapler effected proximal and distal sigmoidal transection. Magnetic attraction then delivered the in situ anvil pike into a colotomy placed adjacent to the proximal staple line. After its position was secured with an endoloop, the pike was mated with its stapler head positioned in the rectal stump. This allowed creation of a double-stapled colorectal anastomosis 10 cm from the anal verge. Specimen retrieval was performed via the umbilical port site. MAIN OUTCOME MEASURES Extent of scarring, occurrence of surgical complications, technical adequacy, and clinical outcome. RESULTS No intraoperative complications occurred during the 90-minute procedure. A total of 40 cm of sigmoid was resected. The patient convalesced without complication and went home 4 days after surgery. At the 1-month review, she was fully recovered and her single umbilical scar was well healed. CONCLUSIONS With advancing surgical technology and technique, truly minimally invasive surgical procedures are feasible. Understanding of NOTES can therefore extend beyond its experimental application into contemporary surgical practice.

Single-Port Laparoscopic Total Colectomy for Medically Uncontrolled Colitis

PURPOSE: New-generation multi-instrument ports for laparoscopic surgery now allow abdominal surgery via a single-access small incision. Here, we detail how laparoscopic total colectomy can be safely performed within the constraints of such single site operating. METHODS: Three patients (2 males and 1 female; mean age, 28.3 y; mean body mass index, 24.1 kg/m2) requiring urgent total colectomy with end ileostomy for colitis resistant to medical therapy fully consented to have their operation performed by a single-port laparoscopic approach. The single port was placed at the site marked preoperatively for the end ileostomy. The operation commenced with rectosigmoid transection and proceeded with a close pericolic dissection proximally along the colon to the cecum. The resected colon was withdrawn via the port site and the end ileostomy fashioned within this wound. RESULTS: The operation was safely completed in its entirety without additional abdominal access in each case. Mean operative time was 206 minutes. All patients are well with normal stoma appearance and function at a minimum follow-up of 4 months. CONCLUSION: Judicious patient selection and considered operative technique allow major resectional colonic surgery to be safely performed solely by a single-port technique. Proof of clinical benefit along with refined instrumentation is required if such surgery is to progress from anecdotal reports to mainstream practice.

Single port sigmoidectomy in an experimental model with survival.

Introduction. Single port laparoscopic access could reduce morbidity associated with additional trocar placement and, through the development of a hybrid intermediate, facilitate the clinical adoption of evolving techniques such as natural orifice transluminal endoscopic surgery. Advanced trocar technology, as much as adapted surgical technique, seems necessary to best facilitate this, however. Methods. A novel port (Airseal, Surgiquest) that uses vortex technology to create an air-curtain seal to maintain the pneumoperitoneum while facilitating the simultaneous passage of multiple working instruments was trialed. For this, 6 pigs (30 kg each) underwent sigmoid resection and reanastomosis using the port as the sole laparoscopic access for conventional instrumentation. All animals were thereafter survived for observation during a 2-week convalescence before undergoing repeat general anesthesia, sigmoidoscopy for anastomotic assessment, and forensic laparotomy for determination of intraperitoneal healing and complications. Results. The operation was technically feasible via a single port within a short time in every animal (mean duration 12.3 minutes). One anastomosis had to redone because of staple misfire but this too was accomplishable without additional port placement. All animals survived and convalesced normally without evincing clinical complication. At follow-up, all anastomoses were patent at sigmoidoscopy and only 1 animal had evidence of complicated anastomotic healing (the same animal that had needed anastomotic refashioning). Conclusions. Single port colonic resection and reanastomosis is readily achievable in this animal model. As an operative approach, it may both advance in its own right as much as facilitate the evolution and clinical incorporation of other developmental access routes.

Near-infrared laparoscopy for real-time intra-operative arterial and lymphatic perfusion imaging

Multimodal laparoscopic imaging systems possessing the capability for extended spectrum irradiation and visualization within a unified camera system are now available to provide enhanced intracorporeal operative anatomic and dynamic perfusion assessment and potentially augmented patient outcome. While ultraviolet‐range energies have limited penetration and hence are probably more useful for endoscopic mucosal interrogation, the near‐infrared (NIR) spectrum is of greater potential utility for the purposes of examining inducible fluorescence in abdominopelvic tissue that can be achieved by administration of specific tracer agents, either directly into the circulation (e.g. for anastomotic perfusion assessment at the time of stapling) or into the lymphatic system (e.g. for lymph basin road‐mapping and/or focussed target nodal assessment). This technology is also capable of supplementing anatomic recognition of the biliary system while implantable fibres can also be inserted intraoperatively for the purpose of safeguarding vital structures such as the oesphagus and ureters especially in difficult reoperations. It is likely that this technological capability will find a clear and common indication in colorectal specialist and general surgical departments worldwide in the near future.

Could lymphatic mapping and sentinel node biopsy provide oncological providence for local resectional techniques for colon cancer? A review of the literature

BackgroundEndoscopic resectional techniques for colon cancer are undermined by their inability to determine lymph node status. This limits their application to only those lesions at the most minimal risk of lymphatic dissemination whereas their technical capacity could allow intraluminal or even transluminal address of larger lesions. Sentinel node biopsy may theoretically address this breach although the variability of its reported results for this disease is worrisome.MethodsMedline, EMBASE and Cochrane databases were interrogated back to 1999 to identify all publications concerning lymphatic mapping for colon cancer with reference cross-checking for completeness. All reports were examined from the perspective of in vivo technique accuracy selectively in early stage disease (i.e. lesions potentially within the technical capacity of endoscopic resection).ResultsFifty-two studies detailing the experiences of 3390 patients were identified. Considerable variation in patient characteristics as well as in surgical and histological quality assurances were however evident among the studies identified. In addition, considerable contamination of the studies by inclusion of rectal cancer without subgroup separation was frequent. Indeed such is the heterogeneity of the publications to date, formal meta-analysis to pool patient cohorts in order to definitively ascertain technique accuracy in those with T1 and/or T2 cancer is not possible. Although lymphatic mapping in early stage neoplasia alone has rarely been specifically studied, those studies that included examination of false negative rates identified high T3/4 patient proportions and larger tumor size as being important confounders. Under selected circumstances however the technique seems to perform sufficiently reliably to allow it prompt consideration of its use to tailor operative extent.ConclusionThe specific question of whether sentinel node biopsy can augment the oncological propriety for endoscopic resective techniques (including Natural Orifice Transluminal Endoscopic Surgery [NOTES]) cannot be definitively answered at present. Study heterogeneity may account for the variability evident in the results from different centers. Enhanced capacity (perhaps to the level necessary to consider selective avoidance of en bloc mesenteric resection) by its confinement to only early stage disease is plausible although not proven. Specific study of the technique in early stage tumors is clearly essential before proffering this approach.

A Simple Technical Option for Single-Port Cholecystectomy

Health Link Europe, Tilburg, The Netherlands) has indeed a proven track record as a means of robust abdominal access and could be used to allow multiple trocars provide access to the peritoneum by their placement through the gel in a single incision. We recently used this system as a single umbilical access to perform a laparoscopic cholecystectomy in a 30-year-old woman with symptomatic cholelithisais. For the operation, a 2-cm incision was performed into the umbilicus. The plastic ring of the wound retractor was inserted into the abdomen allowing the wound to be retracted but the retractor was not entirely rolled. The GelSeal cap paper protection was removed and, after the port’s fixation, three 10-mm trocars were inserted at a distance of 5 cm each. A CO2 pneumoperitoneum was induced and, thanks to the wide deployment of the intraabdominal ring, an excellent seal ensured no gas leakage. A 10-mm lateral view laparoscope, including a 6-mm working channel (ref 26034 AA, Karl Storz Company, Tuttlingen, Germany) was used allowing both a good-quality view of the operative field and an added operative channel for the introduction of a grasper. Exposure and dissection were performed using single use articulated instruments (Endo Grasp, Endo Dissect, Endo Shears, Covidien, Mansfield, MA) that enabled triangulation as well as a safe dissection of the Calot’s triangle. Arteries as well as the cystic duct were controlled by clip application and the gallbladder was removed after its freeing and introduction into a bag (Endocatch, Covidien) inserted through the umbilical access. No additional stitches or retraction devices were required. The main advantage of this technique lies in the fact that all instrumentation used is immediately commercially available and is already familiar to many surgeons. The use of a wound retractor that has no rigid part in contrast to standard trocars or indeed several single-access ports allows easy mobilization The evolution of surgery today is toward less and less invasiveness. If the NOTES (natural orifice translumenal endoscopic surgery) approach is taken to constitute the peak of this trend, 1-trocar surgery may be viewed as an intermediary development that is gaining increasing support. Its main inherent difficulties, however, remain the lack of readily available, sophisticated trocars that can allow safe introduction of multiple surgical instruments simultaneously and the limited facility for high-quality exposure of the entire operative field through a single, small incision. These constraints mean that the instrumentation used does not easily realize the ideals of triangulation for dissection while providing effective traction/countertraction remains difficult. To overcome these challenges, several surgical teams are employing varying means of suspension off the inner abdominal wall, including sutures or wires. Although initial reports are promising, such techniques add risk, including potential complications such as bile leaks when they are employed for cholecystectomy. Furthermore, in this procedure, dissection and cystic duct control require multiple differing instruments. Although their concurrent insertion could be obtained by means of a flexible endoscope, multiple ports, or recently developed multiaccess single trocars (Uni-X Single Port Access Laparoscopic System, Pnavel System, Cleveland, OH), TriPort system (Advanced Surgical Concept, Wicklow, Ireland) equally, the adaptation of surgical devices that have been already validated on the market may offer significant advantages. One such product (GelPort Hand Access System, Applied Medical, Surgical Innovation Volume 15 Number 4 December 2008 332-333

Implementation and usefulness of single access laparoscopic segmental and total colectomy.

Aim  Single‐access laparoscopic surgery is a recent vogue in the field of minimally invasive colorectal surgery. While selected series have indicated feasibility, we prospectively examined its usefulness for resectional surgery in routine practice.

Transanal total mesorectal excision.

The latter half of the 20th century saw broad standardization of complex surgical resections for many cancers across all specialties. Total mesorectal excision (TME) of rectal cancer is a typical example of this maturation of intervention beyond simple feasibility1. It proved that correct and fastidious operative understanding and respect of embryological planes could improve disease-specific outcomes and also allow clear communication of critical concepts, representing an advance that could be reproduced across different healthcare systems2. TME brought qualitative assessment of the resection specimen into focus, initially as an indicator and then a driver of surgical quality improvement3. Close interaction with advanced imaging technologies with increasingly accurate delineation of the extent of disease also allowed clearer distinct identification of suboptimal technique4. Through its standardized surgical baseline quality, TME allowed the role of adjuvant and neoadjuvant chemoradiotherapy to be established5. This focus on an oncological package resection also facilitated the logical development of laparoscopic access, providing its proponents with reassurance that the same operation could be performed via reduced abdominal wall access even before the availability of long-term outcome data6. Low rectal access from the abdominal compartment, whether open or laparoscopic, however, remains difficult, most notably in men with increased body mass index, given the constraints of operating within a bony compartment placed at right angles to the peritoneal cavity. This difficulty has led to the emergence of novel technologies, skills sets and concepts (including transanal microsurgery, single-port laparoscopy and natural-orifice transluminal endoscopic surgery) to address the lower two-thirds of the rectum and mesorectum from below, starting the operation by a transanal or transperineal/intersphincteric approach. The past 5 years has seen these operations move from theory to practical reality so that transanal TME (taTME) is now sufficiently mature to be examined critically with a view to wider adoption (Video S1, supporting information). Its development, along the IDEAL (Innovation, Development, Exploration, Assessment, Long-term study) framework7, has gone from initial clinical experiences8,9 through case–control cohort series10 into multicentre trials. It can be taught using standardized nomenclature and an educational curriculum. A key component of this has been an open international registry, run via the LOREC (LOw REctal Cancer) national development programme and the Pelican Cancer Foundation in the UK11, which now has over 400 patients recorded to share experience and truncate learning curve difficulties among the colorectal community12. In concept and early practice, it seems likely that taTME has most potential value for tumours of the mid-rectum (3–4 cm above the anal sphincter), especially when there are concerns about anterior clearance. The exciting prospect, therefore, is that this approach, whether performed by two teams working in tandem or by sequential above and below surgery, will complement and advance existing approaches for patient benefit. The advent of the COLOR III randomized trial13, scheduled to commence later this year specifically to assess its potential impact on reducing circumferential margin positivity compared with that after conventional resection, represents a level of acceptance of both potential and practicality among the colorectal surgical community, reflecting evidence from secondary analysis of the COLOR II study14. If extralevator and intersphinteric approaches can be shown to be valuable, further modifications might identify patient subsets benefiting from a specific approach. Although generally seen as complementary to laparoscopic resection from above, taTME may also assist in the procedure commenced by, or converted to, laparotomy. Proponents of robotic surgery might argue that the control arm for randomization against taTME should be robot-assisted low anterior resection, in which increased freedom of movement overcomes some of the limitations of conventional laparoscopic surgery in the pelvis. Although preliminary results from the ROLARR (Robotic versus Laparoscopic Resection for Rectal

Fully Laparoscopic Colorectal Anastomosis Involving Percutaneous Endoluminal Colonic Anvil Control (PECAC)

Introduction: A novel technique for secure placement of the anvil for mechanical stapled anastomosis in the proximal colon without exteriorization of the bowel is described. Methods: After standard laparoscopic segmental colonic mobilization, a needle-cannula from a percutaneous endoscopic gastrostomy kit is passed under direct endoscopic vision transparietally into the colon at the site intended for anvil placement. A wire passed through the cannula into the colon is then withdrawn endoscopically per ano. The stapler anvil is fixed to the wire and pulled back along the intestine before being positioned by traction through the needle puncture site. After distal specimen transection, a standard stapled anastomosis is performed. Results: The technique is illustrated in 2 patients undergoing laparoscopic sigmoidectomy by either a single port or a multiport procedure with transanal specimen extraction. Conclusion: By positioning the anvil without colon exteriorization, this technique enables pure intraperitoneal colonic anastomoses that may advance natural orifice operating.

Feasibility of right and left transvaginal retroperitoneal nephrectomy: from the porcine to the cadaver model.

PURPOSE Minimally invasive nephrectomy performed through a natural orifice such as the vagina could enhance cosmesis and improve patient acceptance of the procedure and postoperative recovery. As the vagina has already been proposed as a site of specimen extraction in patients undergoing laparoscopic nephrectomy, the aim of this study was to explore the feasibility of transvaginal, retroperitoneal natural orifice transluminal endoscopic surgery (NOTES) nephrectomy for both left- and right-sided kidneys initially in a porcine model and thereafter in a human cadaver model. MATERIALS AND METHODS Ten female pigs underwent NOTES nephrectomy (five having a left nephrectomy and five having right nephrectomy). To do this, each pig was anesthetized and placed in a supine position. A retroperitoneal conduit was established by means of a posterior colpotomy and the retroperitoneal space then entered with a conventional double-channel endoscope (Storz). Thereafter, careful blunt dissection allowed a passage to be created up to the renal vessels and proximal ureter which were then dissected and divided separately after endoscopic clipping. We then attempted to reproduce the technique in two formaldehyde-preserved female cadavers. RESULTS All the porcine procedures were accomplished by a totally NOTES approach with a mean operative time of 50 minutes (range 45-60). No bleeding or injury to any of the retroperitoneal structures occurred. In the two cadavers, the retroperitoneal access was reproduced, but a complete dissection of the kidney was not possible because of the rigor of the surrounding tissues. CONCLUSIONS Transvaginal retroperitoneal NOTES right and left nephrectomy is certainly accomplishable in the porcine model, and the feasibility of the access was confirmed in two cadavers. As a retroperitoneal transvaginal dissection preserves the peritoneum and obviates bowel handling, this work should encourage further development of NOTES accesses for renal surgery.