W. J. H. J. Meijerink

Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines

BackgroundWith minimally invasive surgery (MIS), a man–machine environment was brought into the operating room, which created mental and physical challenges for the operating team. The science of ergonomics analyzes these challenges and formulates guidelines for creating a work environment that is safe and comfortable for its operators while effectiveness and efficiency of the process are maintained. This review aimed to formulate the ergonomic challenges related to monitor positioning in MIS. Background and guidelines are formulated for optimal ergonomic monitor positioning within the possibilities of the modern MIS suite, using multiple monitors suspended from the ceiling.MethodsAll evidence-based experimental ergonomic studies conducted in the fields of laparoscopic surgery and applied ergonomics for other professions working with a display were identified by PubMed searches and selected for quality and applicability. Data from ergonomic studies were evaluated in terms of effectiveness and efficiency as well as comfort and safety aspects. Recommendations for individual monitor positioning are formulated to create a personal balance between these two ergonomic aspects.ResultsMisalignment in the eye–hand–target axis because of limited freedom in monitor positioning is recognized as an important ergonomic drawback during MIS. Realignment of the eye–hand–target axis improves personal values of comfort and safety as well as procedural values of effectiveness and efficiency.ConclusionsMonitor position is an important ergonomic factor during MIS. In the horizontal plain, the monitor should be straight in front of each person and aligned with the forearm–instrument motor axis to avoid axial rotation of the spine. In the sagittal plain, the monitor should be positioned lower than eye level to avoid neck extension.

Sentinel-lymph-node procedure in colon and rectal cancer: a systematic review and meta-analysis

BACKGROUND No consensus exists on the validity of the sentinel-lymph-node procedure for assessment of nodal status in patients with colorectal cancer. We aimed to assess the diagnostic performance of this procedure. METHODS We searched Embase and PubMed databases for studies published before March 20, 2010. Eligible studies had a prospective design, a sample size of at least 20 patients, and reported the rate of sentinel-lymph-node positivity. Individual patient data were requested for localisation and T-stage stratification. A subset of reports with high methodological quality was selected and analysed. FINDINGS We identified 52 eligible studies, which included 3767 sentinel-lymph-node procedures (2961 [78·6%] colon and 806 [21·4%] rectal carcinomas). Most tumours 2339 (62·1%) were stage T3 or T4. 1887 (50·1%) of patients were male, 1880 (49·9%) female. Mean overall weighted-detection rate was 0·94 (95% CI 0·92-0·95), at a pooled sensitivity of 0·76 (0·72-0·80) with limited heterogeneity (χ(2)=286·08, degrees of freedom=51; p=0·003). A mean weighted upstaging of 0·15 (95% CI 0·12-0·19) was noted. Individual patient data were available from 19 studies that included 1168 patients. Analysis of these data showed no significant difference in sensitivity between colon (0·86 [95% CI 0·83-0·90]) and rectal cancer (0·82 [0·77-0·88]; p=0·23). Also, there was no dependency of sensitivity on T stage for both colon (pT1: 0·79 [95% CI 0·73-0·84], pT2: 0·76 [0·62-0·90], pT3: 0·73 [0·59-0·87], pT4: 0·73 [0·53-0·93]) and rectal cancer (T1 or T2: 0·81 [0·52-0·94] vs T3 or T4: 0·80 [0·51-0·93]). The subgroup of eight studies with high methodological quality showed a mean detection rate of 0·96 (95% CI 0·90-0·99) for colonic tumours and 0·95 (0·75-0·99) for rectal tumours, and a mean sensitivity of 0·90 (95% CI 0·86-0·93) for colonic tumours and 0·82 (0·60-0·93) for rectal tumours. INTERPRETATION The sentinel-lymph-node procedure shows a low sensitivity, regardless of T stage, localisation, or pathological technique. For every patient diagnosed with colon or rectal cancer without clinical evidence of lymph-node involvement or metastatic disease, this procedure in addition to conventional resection should be considered, since the prognostic information provided by this technique could be clinically significant. FUNDING Cancer Center Amsterdam Foundation, Amsterdam, Netherlands.

Intestinal Vaginoplasty Revisited: A Review of Surgical Techniques, Complications, and Sexual Function

INTRODUCTION Vaginal (re)construction is essential for the psychological well-being of biological women with a dysfunctional vagina and male-to-female transgender women. However, the preferred method for vagina (re)construction with respect to functional as well as aesthetic outcomes is debated. Regarding intestinal vaginoplasty, despite the asserted advantages, the need for intestinal surgery and subsequent risk of diversion colitis are often-mentioned concerns. The outcomes of vaginal reconstructive surgery need to be appraised in order to improve understanding of pros and cons. AIMS To review literature on surgical techniques and clinical outcomes of intestinal vaginoplasty. METHODS Electronic databases and reference lists of published articles were searched for primary studies on intestinal vaginoplasty. Studies were included if these included at least five patients and had a minimal follow-up period of 1 year. No constraints were imposed with regard to patient age, indication for vaginoplasty, or applied surgical technique. Outcome measures were extracted and analyzed. MAIN OUTCOME MEASURES Main outcome measures were surgical procedure, clinical outcomes, and outcomes concerning sexual health and quality of life. RESULTS Twenty-one studies on intestinal vaginoplasty were included (including 894 patients in total). All studies had a retrospective design and were of low quality. Prevalence and severity of procedure-related complications were low. The main postoperative complication was introital stenosis, necessitating surgical correction in 4.1% of sigmoid-derived and 1.2% of ileum-derived vaginoplasties. Neither diversion colitis nor cancer was reported. Sexual satisfaction rate was high, but standardized questionnaires were rarely used. Quality of life was not reported. CONCLUSION Based on evidence presently available, it seems that intestinal vaginoplasty is associated with low complication rates. To substantiate these findings and to obtain information about functional outcomes and quality of life, prospective studies using standardized measures and questionnaires are warranted.

Morbidity and complications of protective loop ileostomy

Objective  The creation of a loop ileostomy is considered suitable to protect a distal anastomosis in colorectal surgery. This technique is, however, associated with failure, complications and even mortality. The aim of this study was to quantify retrospectively the morbidity associated with an ileostomy and its subsequent closure.

Laparoscopic versus open total mesorectal excision for rectal cancer: An evaluation of the mesorectum’s macroscopic quality

BackgroundNext to surgical margins, yield of lymph nodes, and length of bowel resected, macroscopic completeness of mesorectal excision may serve as another quality control of total mesorectal excision (TME). In this study, the macroscopic completeness of laparoscopic TME was evaluated.MethodsA series of 25 patients with rectal cancer were managed laparoscopically (LTME) and included in this study. The pathologic specimens of the LTME group were prospectively examined and matched with a historical group of resection specimens from patients who had undergone open TME (OTME). The two groups were matched for gender and type of resection (low anterior or abdominoperineal resection). Special care was given to the macroscopic judgment concerning the completeness of the mesorectum.ResultsA three-grade scoring system showed no differences between the LTME and OTME groups.ConclusionThe current study supports the hypothesis that oncologic resection using laparoscopic TME is feasible and adequate.

Laparoscopic versus Open Total Mesorectal Excision: A Comparative Study on Short-Term Outcomes

Background: Laparoscopic total mesorectal excision (TME) is being used in rectal cancer more frequently. The aim of this study was to analyze the differences in short-term outcomes between open and laparoscopic TME. Methods: In this nonrandomized consecutive study, the short-term outcomes of 100 patients undergoing TME for proven rectal cancer were analyzed. Results: Two groups of 50 patients underwent an open or laparoscopic TME for rectal cancer. Both groups were comparable. Laparoscopic surgery took longer to perform (250 vs. 197.5 min, p < 0.01), but was accompanied by less blood loss (350 vs. 800 ml, p < 0.01). Enteric function recovered sooner after laparoscopy. The numbers of major and minor complications were comparable between both groups, although fewer patients had major complications in the laparoscopic group (6 vs. 15 patients, p = 0.03). Hospital stay was shorter for patients who underwent a laparoscopic abdominoperineal resection (10 vs. 12 days, p = 0.04). Median follow-up was 17 months for the laparoscopic group and 22 months for the open group. Survival analyses between the groups showed no statistical difference in disease-free and overall survival. Conclusion: This study shows that laparoscopic TME for rectal cancer is a safe and feasible technique with some short-term benefits over open TME.

Near infrared fluorescence lymphatic laparoscopy of the colon and mesocolon

During surgery, a surgeon relies on the vision of his eyes and the touch of his hands. While laparoscopic surgery for colon cancer has proven to be safe and effective, it still remains a technically difficult procedure. Although it is associated with reduced haptic feedback, by enforcing the power of visual guidance, the loss of this feedback can be (partly) compensated for. Here we describe how the use of near‐infrared dyes and fluorescence laparoscopy could help improve tumour staging and therefore lead to better selection of patients for postoperative adjuvant chemotherapy. More controversially, and analogous to melanoma and breast cancer surgery with sentinel node biopsy, we speculate that local resection with SLN harvesting in early colon cancer might change the therapeutic and surgical strategy in colon cancer.

Laparoscopic vs transverse incision right colectomy for colon carcinoma

Aim  We investigated whether laparoscopic right colectomy has short‐term and/or oncological advantages compared with transverse incision right colectomy.

New horizons in colorectal cancer surgery

Colorectal cancer is a major health problem. Worldwide,approximately 500,000 patients per year will die as a resultof colorectal malignancy. The standard therapy is an ade-quate segmental resection en bloc with the adjacent lymphnodes. This can be performed by conventional open sur-gery or laparoscopic resection. Sufficient evidence hasshown equal results in terms of lymph node harvesting,resection margins, and survival for both techniques. Localresection for rectal cancer in the early stages has beenshown to be safe, despite the fact that the lymph nodestatus cannot be established. Transanal endoluminalmicrosurgery (TEM) is an effective treatment for earlyrectal cancer. However, there has always been concernabout the nodal status and the need for secondary surgeryin case of lymphatic dissemination. Nodal involvement inT1 tumors has been reported in up to 10%. With (neo-)adjuvant radiochemotherapy, local resection and tumorcontrol has been proven to be efficient. Some authors evenconsider local resection in early rectal cancer to be asuperior therapy because of the huge impact on quality oflife in case of rectal resection.Imaging modalities, such as the USPIO MRI techniqueand PET scan technology, have improved the resolution toestablish nodal involvement and preoperative staging, butpathological examination remains the ‘‘gold standard.’’Colon cancer is diagnosed by endoscopic biopsies orpolyp removal. In case of invading tumors additionaladequate segmental colon resection with en bloc resectionof lymph nodes is common, facilitated by tattooing. Todaylocal resection for colon cancer is less attractive because ofthe restricted possibilities in neoadjuvant treatmentmodalities, such as local radiotherapy, and the minorimplications in loss of functionality. Although submucosalresection of colonic neoplasia is being proposed as a suf-ficient therapy in selected cases, the uncertainty about thepossible undetected concomitant lymph node metastasesremains a serious drawback of the submucosal resectiontechnique.The sentinel node concept has been proven to be valid inmany solid tumors. Since Morton et al. [1] showed thevalidity of the concept in melanoma’s and the subsequentidentification of the SLN by lymphatic mapping in breastcancer by Krag et al. [2] and Giuliano et al. [3], the use ofthe SLN in the therapeutic strategy has altered profoundlythe treatment of these cancers.Similar to melanoma and breast cancer surgery withsentinel node biopsy, we speculate that local resection withSLN harvesting in early colon cancer might change thetherapeutic and surgical strategy in colon cancer.It has been shown that patients who are operated on withcurative intent but who have lymph node metastases benefitfrom adjuvant chemotherapy in contrast to those withoutmetastases.Stage I and II colorectal cancer implies no lymph nodeinvolvement; however, up to 30% of patients with stage Ior II disease will develop locoregional recurrence or distantmetastases and will eventually die from CRC. Therefore,standard surgery might not be sufficient in 30% of thesepatients. Some of these patients may recur because ofhematogenous metastases, but a significant portion of theserecurrences may occur due to the lack of detecting lymphnode metastases, or aberrant lymphatic drainage beyondsurgical margins.

Near-Infrared Fluorescence Laparoscopy of the Cystic Duct and Artery in Pigs: Performance of a Preclinical Dye

BACKGROUND Near-infrared fluorescence laparoscopy after intravenous indocyanine green (ICG) administration has been proposed as a promising surgical imaging technique for real-time visualization of the extrahepatic bile ducts and arteries in clinical laparoscopic cholecystectomies. However, optimization of this new technique with respect to the imaging system combined with the fluorophore is desirable. The performance of a preclinical near-infrared dye, CW800-CA, was compared with that of ICG for near-infrared fluorescence laparoscopy of the cystic duct and artery in pigs. MATERIALS AND METHODS Laparoscopic cholecystectomy was performed in six pigs (average weight, 35 kg) using a commercially available laparoscopic fluorescence imaging system. The fluorophores CW800-CA and ICG (both 800 nm fluorescent dyes) were administered by intravenous injection in four and two pigs, respectively. CW800-CA was administered in three different doses (consecutively 0.25, 1, and 3 mg); ICG was intravenously injected (2.5 mg) for comparison. Intraoperative recognition of the biliary structures was recorded at set time points. The target-to-background ratio was determined to quantify the fluorescence signal of the designated tissues. RESULTS A clinically proven dose of 2.5 mg of ICG resulted in a successful fluorescence delineation of both the cystic duct and artery. In the CW800-CA-injected pigs a clear visualization of the cystic duct and artery was obtained after administration of 3 mg of CW800-CA. Time from injection until fluorescence identification of the cystic duct was reduced when CW800-CA was used compared with ICG (11.5 minutes versus 21.5 minutes, respectively). CW800-CA provided clearer illumination of the cystic artery, in terms of target-to-background ratio. CONCLUSIONS As well as ICG, CW800-CA can be applied for fluorescence identification of the cystic artery and duct using a commercially available laparoscopic fluorescence imaging system. Fluorescence cholangiography of the cystic duct can be obtained earlier after intravenous injection of CW800-CA, compared with ICG. These findings increase the possibilities of use and of optimization of this imaging technique.