Sang W. Lee

Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients.

Objective:The purpose of this study was to identify patient, clinical, and surgical factors that may predispose patients to anastomotic leak (AL) after large bowel surgery. Background:Anastomotic leak is still one of the most devastating complications following colorectal surgery. Knowledge about factors predisposing patients to AL is vital to its early detection, decision making for surgical time, managing preoperative risk factors, and postoperative complications. Methods:This was a prospective observational, quality improvement study in a cohort of 616 patients undergoing colorectal resection in a single institution with the main outcome being AL within 30 days postoperatively. Some of the predictor variables were age, sex, Charlson Comorbidity Index (CCI), radiation and chemotherapy, immunomodulator medications, albumin, preoperative diagnoses, surgical procedure(s), surgical technique (laparoscopic vs open), anastomotic technique (staple vs handsewn), number of major arteries ligated at surgery, surgeons experience, presence of infectious condition at surgery, intraoperative adverse events, and functional status using 36-Item Short Form General Health Survey. Results:Of the 616 patients, 53.4% were female. The median age of the patients was 63 years and the mean body mass index was 25.9 kg/m2. Of them, 80.3% patients had laparoscopic surgery and 19.5% had open surgery. AL occurred in 5.7% (35) patients. In multivariate analysis, significant independent predictors for leak were anastomoses less than 10 cm from the anal verge, CCI of 3 or more, high inferior mesenteric artery ligation (above left colic artery), intraoperative complications, and being of the male sex. Conclusions:Multiple risk factors exist that predispose patients to ALs. These risk factors should be considered before and during the surgical care of colorectal patients.

Hand-Assisted Laparoscopic vs. Laparoscopic Colorectal Surgery: A Multicenter, Prospective, Randomized Trial

PurposeThis study was designed to compare short-term outcomes after hand-assisted laparoscopic vs. straight laparoscopic colorectal surgery.MethodsEleven surgeons at five centers participated in a prospective, randomized trial of patients undergoing elective laparoscopic sigmoid/left colectomy and total colectomy. The study was powered to detect a 30-minute reduction in operative time between hand-assisted laparoscopic and straight laparoscopic groups.ResultsThere were 47 hand-assisted patients (33 sigmoid/left colectomy, 14 total colectomy) and 48 straight laparoscopic patients (33 sigmoid/left colectomy, 15 total colectomy). There were no differences in the patient age, sex, body mass index, previous surgery, diagnosis, and procedures performed between the hand-assisted and straight laparoscopic groups. Resident participation in the procedures was similar for all groups. The mean operative time (in minutes) was significantly less in the hand-assisted laparoscopic group for both the sigmoid colectomy (175u2009±u200958 vs. 208u2009±u200955; Pu2009=u20090.021) and total colectomy groups (time to colectomy completion, 127u2009±u200931 vs. 184u2009±u200972; Pu2009=u20090.015). There were no apparent differences in the time to return of bowel function, tolerance of diet, length of stay, postoperative pain scores, or narcotic usage between the hand-assisted laparoscopic and straight laparoscopic groups. There was one (2 percent) conversion in the hand-assisted laparoscopic group and six (12.5 percent) in the straight laparoscopic group (Pu2009=u20090.11). Complications were similar in both groups (hand-assisted, 21 percent vs. straight laparoscopic, 19 percent; Pu2009=u20090.68).ConclusionsIn this prospective, randomized study, hand-assisted laparoscopic colorectal surgery resulted in significantly shorter operative times while maintaining similar clinical outcomes as straight laparoscopic techniques for patients undergoing left-sided colectomy and total abdominal colectomy.

Feasibility and safety of single-incision laparoscopic colectomy: a systematic review.

Objective:The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic colectomy (SILC). Methods:We conducted a comprehensive review for the years 1983 to March 2011 to retrieve all relevant articles. Results:A total of 23 studies with 378 patients undergoing SILC were reviewed. All studies except 2 used a commercially available single-port device. Range of body mass index was 20.9 to 30.0 kg/m2. Ranges of operative times and estimated blood losses were 83 to 225 minutes and 0 to 115 mL, respectively. Of 378 cases, a total of 6 cases (1.6%) were converted to open, 6 (1.6%) to hand-assisted laparoscopic (HALC), and 14 (4.0%) to conventional (multiport) laparoscopic colectomy (MLC) (overall conversion rate, 6.9%). An additional laparoscopic port was used in 4.9% (12/247) cases. Range of harvested lymph nodes number for malignant cases was 13.5 to 27 and surgical margins were negative in all cases. Overall mortality and morbidity rates were 0.5% (2/378) and 12.9% (45/349), respectively. The length of hospital stay (LOS) varied across reports (1.9–9.8 days). Among 4 case-matched studies, 2 showed shorter LOS after SILC than after HALC (2.7 vs 3.3 days) or after MLC/HALC (3.4 vs 4.6/4.9 days). Furthermore, one of these studies reported that maximum pain score on postoperative days 1 and 2 was significantly lower in SILS than in MLC and HALC. Conclusions:In early series of highly selected patients, SILC appears to be feasible and safe when performed by surgeons who are highly skilled in laparoscopy. Despite technical difficulties, there may be potential benefits associated with SILC over MLC/HALC but it is yet to be proven objectively.

Early multi-institution experience with single-incision laparoscopic colectomy.

PURPOSE: Single-incision laparoscopic colectomy represents a potential advance in minimally invasive surgical approaches to colorectal disease. Although widely promoted, outcome data are virtually absent. A group of highly experienced laparoscopic attending colorectal surgeons convened to standardize technique and prospectively record operative details and outcomes. METHODS: Single-incision laparoscopic colectomy was performed by 10 experienced attending colorectal surgeons with minimal or no prior single-incision laparoscopic colectomy experience. Surgeon rating of ergonomics and 15 components of operation conduct was compared with conventional multiple-port laparoscopic colectomy. Patient demographics, operative details, and outcome data were prospectively collected. RESULTS: Thirty-nine single-incision laparoscopic colectomies were performed (25 right colectomies, 5 ileocolic resections, 8 sigmoidectomies, and 1 low anterior resection). Underlying pathology included polyps (12), cancer (15), Crohns disease (5), and diverticulitis (7). Patients were highly selected with a mean body mass index of 25.6 (range, 16–40). Two conversions to open resection occurred, 1 because of fistula and 1 because of adhesions, in patients with a mean body mass index of 34. An additional port was required in 3 patients. Mean incision length was 4.2 cm (range, 2.5–8) and operative time was 120 minutes (range, 68–210). Complications included 1 wound infection and 2 anastomotic bleeds requiring transfusion. Average length of stay was 4.4 days (range, 2–8). Mean lymph node harvest was 19 (range, 12–39). Exposure, instrument conflict, ergonomics, ease of instrumentation, and camera operation were rated significantly more difficult with single-incision laparoscopic colectomy than with multiple-port laparoscopic colectomy. CONCLUSIONS: Preliminary data demonstrate that single-incision laparoscopic colectomy can be performed safely in selected patients by experienced surgeons. The benefits of single-incision compared with multiple-port laparoscopic colectomy are not immediately evident. Despite the advanced skills of the faculty, a learning curve of undetermined length still exists in which specific components of single-incision laparoscopic colectomy are more difficult than multiple-port laparoscopic colectomy, and areas of focus remain that require advances to make single-incision laparoscopic colectomy equivalent to multiple-port laparoscopic colectomy. The multi-institutional registry will enable further analysis of single-incision laparoscopic colectomy.

Laparoscopic total colectomy: hand-assisted vs standard technique

Background: Although hand-assisted laparoscopic surgery (HALS) has been proposed as an alternative to laparoscopically assisted surgery (LAP), little is known about its role in total colectomy. The objectives of the study were to compare the outcomes in patients undergoing total colectomy via either HALS or LAP and to determine what benefits HALS might have in extensive colorectal procedures. Methods: We reviewed the data for 23 patients who underwent total proctocolectomy (TPC) or total abdominal colectomy (TAC) using either a HALS or LAP technique. Results: There were 12 HALS (five TPC, seven TAC) and 11 LAP (seven TPC, four TAC) for ulcerative colitis (n = 17), familial polyposis (n = 5), and colonic inertia (n = 1). One LAP was converted (9.1%). The operative time was shorter for HALS than for LAP (210 vs 273 min; p = 0.03). Blood loss and incision length were similar. Postoperative recovery and morbidity rates were comparable. Conclusion: HALS reduces the operative time but patient morbidity rates and recovery are similar to LAP. HALS may be preferable for extensive colorectal procedures such as TPC and TAC.

Laparoscopic vs. hand-assisted laparoscopic sigmoidectomy for diverticulitis.

IntroductionSigmoid colectomy for diverticulitis can be technically challenging because of severe inflammation in the left-lower quadrant and pelvis. We hypothesized that hand-assisted laparoscopic technique may facilitate laparoscopic completion of this surgery while retaining the short-term benefits associated with “pure” laparoscopic surgery, in which an incision is made only for extracting the specimen. This study was designed to compare the outcomes of patients who underwent totally laparoscopic or hand-assisted laparoscopic sigmoidectomy for diverticulitis.MethodsWe reviewed our prospectively collected patient database from July 2001 to June 2004 and compared the intraoperative data and postoperative outcomes of patients who underwent elective laparoscopic or hand-assisted laparoscopic sigmoidectomies for diverticulitis. Complicated patients (with abscess or fistulas) also were separately analyzed.ResultsThe hand-assisted laparoscopic (mode age, 57 years; 48 percent male) and laparoscopic sigmoidectomy (mode age, 56 years; 90 percent male) groups were similar with regard to age and gender. Overall, patients who underwent laparoscopic (n = 21) vs. hand-assisted laparoscopic (n = 21) sigmoidectomies had a significantly longer operative time (197 ± 42 vs. 171 ± 34 minutes, P = 0.04) and shorter incision length (5 ± 2.1 vs. 9.3 ± 4.1xa0cm, P = 0.0001). Patients with complicated diverticulitis (n = 14; abscess, colovesical fistula, enterocolic fistula) who underwent laparoscopic sigmoidectomies (n=4) had a significantly longer operative time compared with hand-assisted laparoscopic sigmoidectomy (n = 10) group (255 ± 18 vs. 177 ± 34 minutes, P = 0.001). Conversion rate for the laparoscopic group was significantly higher (3/4 vs. 1/10, P = 0.04, Fisher exact) when complicated diverticulitis was present. There were no differences in postoperative outcomes or incision lengths in thecomplicated group.ConclusionsOutcomes after hand-assisted laparoscopic sigmoidectomy for diverticulitis are similar to those seen in the pure laparoscopic method, with lower conversion rates and shorter operative times. Hand-assisted laparoscopic sigmoid resection for diverticulitis is an attractive alternative to a “pure” laparoscopic method in complicated cases.

Hand-assisted laparoscopic colorectal surgery using GelPort

Background: An easily usable hand access device will optimize success in hand-assisted laparoscopic surgery (HALS). The authors describe their initial series of HALS colorectal resections using GelPort to evaluate their current technique and results with this new device. Methods: A retrospective study investigated 33 HALS colorectal procedures including total colectomy (n = 16) and low anterior resection (n = 10). All operative data, including intraoperative GelPort performance, were prospectively recorded and retrospectively analyzed. Results: In this study, 3 (9.1%) of 33 HALS procedures were converted to open surgery, and 4 (13.3%) of 30 HALS procedures required minimal enlargement of incisions to facilitate extracorporeal procedures. The operative time was 263 ± 85 min, and the blood loss was 282 ± 148 ml. There were no device malfunctions. Three major complications (9.1%) and 7 minor wound infections (21%) were noted postoperatively. The mean hospital stay was 7.9 ± 3.8 days. Conclusion: When performed with GelPort, HALS is safely and reliably applicable for various colorectal procedures.

Long-term outcomes of patients undergoing curative laparoscopic surgery for mid and low rectal cancer.

PURPOSE: The use of laparoscopy surgery in the management of rectal cancer is controversial, especially in the mid and low rectum. The aim of this study was to determine oncologic and long-term outcomes after laparoscopic and hand-assisted laparoscopic surgery for mid and low rectal cancer. METHODS: Between January 1999 and December 2006, 185 patients had surgery for rectal cancer; 103 these patients had mid and low rectal cancer. The source of data was inpatient/outpatient medical records. Telephone interviews were conducted for all patients. Actuarial survival was calculated with use of the Kaplan-Meier method. RESULTS: Hand-assisted laparoscopic surgery was performed in 58 (56.3%) patients, and pure laparoscopic surgery in 45 (43.7%) patients. Mean follow-up time was 42.1 months. The conversion rate was 2.9%. All specimen margins were negative. The anastomotic leak rate was 7.8% (n = 8). There was no 30-day mortality. Local recurrence rate was 5% at five years. Overall survival was 91% and disease-free survival was 73.1% at five years. CONCLUSION: Laparoscopic surgical techniques for mid and low rectal cancer seem safe and feasible with acceptable oncologic and long-term outcomes. Further studies, comparing laparoscopic and open methods, are warranted.

Intraoperative carbon dioxide colonoscopy: a safe insufflation alternative for locating colonic lesions during laparoscopic surgery

BackgroundIntraoperative colonoscopy (IOC) is useful for locating colonic pathologies during laparoscopy, but bowel distention compromises the subsequent visualization and procedure. Carbon dioxide (CO2), with its rapid absorption, has been proved effective for alleviating bowel distention in ambulatory settings. Its intraoperative role, however, has never been studied. This study aimed to assess the feasibility, safety, and advantages of CO2-insufflated IOC during laparoscopy.MethodsFor this study, CO2-insufflated IOC was performed for 20 patients under CO2 pneumoperitoneum. Parameters, including end-tidal CO2 (ETCO2) and minute volume, were prospectively registered. Time until resolution of bowel distention was determined by laparoscopic evaluation.ResultsAll lesions were located by CO2-insufflated IOC in 15 min. During IOC, ETCO2 increased, but remained within normal values, and was quickly compensated with minimal hyperventilation. Bowel distention totally disappeared in 21 min, allowing immediate initiation of laparoscopic procedures under adequate visualization.ConclusionsThe findings show that CO2-insufflated IOC during laparoscopy is feasible, safe, and of practical value for minimizing bowel distention without impeding the subsequent visualization and procedure.

Peritoneal irrigation with povidone-iodine solution after laparoscopic-assisted splenectomy significantly decreases port-tumor recurrence in a murine model

PURPOSE: The development of port-wound tumor recurrences has raised questions regarding the safety of laparoscopic methods for the resection of malignancies. The cause and the incidence of abdominal-wall tumor recurrences remain unknown. It is also not clear how to avoid or lower the incidence of port-tumor recurrences. The purpose of the current study was to determine the impact of abdominal irrigation with povidone-iodine on the port-wound tumor incidence in a murine model. METHODS: A splenic tumor model was used for this study. To establish splenic tumors, female BALB/c mice (N=48) were given subcapsular splenic injections of a 0.1 ml suspension containing 105 C-26 colon adenocarcinoma cellsvia a left-flank incision at the initial procedure. Seven days later, the animals with isolated splenic tumors (100 percent) were randomly assigned to one of three groups: 1) control, 2) saline irrigation (saline), or 3) povidone-iodine irrigation. All animals underwent laparoscopic mobilization of the spleen using a three-port technique, intra-abdominal crushing of the tumor, followed by an extracorporeal splenectomyvia a subcostal incision. No irrigation was performed for control group animals. In the saline irrigation group, the subcostal incision was closed and pneumoperitoneum was reestablished. The abdominal cavity was irrigated with 5 ml of normal saline for 60 seconds before instrument removal. In the povidone-iodine irrigation group, similar abdominal irrigation was performed, using 0.25 percent povidone-iodine. Attempts were made to recover completely the irrigation for both irrigation groups. Seven days after the splenectomy, animals were killed and inspected for abdominal-wall tumor implants. RESULTS: There were significantly more animals with at least one port-tumor recurrence in the control group than in the povidone-iodine group (P=0.007). Although not statistically significant, the number of animals with port-wound tumors was higher in the saline group than in the povidone-iodine group (P<0.08). There was no significant difference between the saline group and the control group. When each port site was considered independently, the incidence of port-wound tumors (number of ports with tumors per total number of ports) was significantly lower in the povidone-iodine group than in both the control (P=0.00001) and saline groups (P=0.03). The incidence of port-wound tumors was also significantly lower in the saline group compared with the control group incidence (P=0.03). CONCLUSIONS: Abdominal irrigation with dilute povidone-iodine solution significantly reduced the number of animals with port-tumor recurrences. Abdominal irrigation with saline was also effective in reducing the incidence of port-wound tumor formation when each port was considered separately. However, povidone-iodine irrigation was much more effective than saline irrigation in preventing port-wound tumor formation.