Which video technology brings the higher cognitive burden and motion sickness in laparoscopic colorectal surgery: 3D, 2D-4 K or 3D-4 K? a propensity score study.

BACKGROUND: Technological development has offered laparoscopic colorectal surgeons new video systems to improve depth perception and perform difficult task in limited space. The aim of this study was to assess the cognitive burden and motion sickness for surgeons during 3D, 2D-4 K or 3D-4 K laparoscopic colorectal procedures and to report post-operative data with the different video systems employed. METHODS: Patients were assigned to either 3D, 2D-4 K or 3D-4 K video and two questionnaires (Simulator Sickness Questionnaire-SSQ- and NASA Task Load Index -TLX) were used during elective laparoscopic colorectal resections (October 2020-August 2022) from two operating surgeons. Short-term results of the operations performed with the three different video systems were also analyzed. RESULTS: A total of 113 consecutive patients were included: 41 (36%) in the 3D Group (A), 46 (41%) in the 3D-4 K Group and 26 (23%) in the 2D-4 K Group (C). Weighted and adjusted regression models showed no significant difference in cognitive load amongst the surgeons in the three groups of video systems when using the NASA-TLX. An increased risk for slight/moderate general discomfort and eyestrain in the 3D-4 K group compared with 2D-4 K group (OR = 3.5; p = 0.0057 and OR = 2.8; p = 0.0096, respectively) was observed. Further, slight/moderate difficulty focusing was lower in both 3D and 3D-4 K groups compared with 2D-4 K group (OR = 0.4; p = 0.0124 and OR = 0.5; p = 0.0341, respectively), and higher in the 3D-4 K group compared with 3D group (OR = 2.6; p = 0.0124). Patient population characteristics, operative time, post-operative staging, complication rate and length of stay were similar in the three groups of patients. CONCLUSIONS: 3D and 3D-4 K systems, when compared with 2D-4 K video technology, have a higher risk for slight/moderate general discomfort and eyestrain, but show lower difficulty focusing. Short post-operative outcomes do not differ, whichever imaging system is used.

Preoperative Prognostic Nutritional Index was not predictive of short-term complications after laparoscopic resection for rectal cancer.

BACKGROUND AND AIM: Prognostic Nutritional Index (PNI) is a useful tool to predict short-term results in patients undergoing surgery for gastrointestinal cancer. Few studies have addressed this issue in colorectal cancer or specifically in rectal cancer. We evaluated the prognostic relevance of preoperative PNI on morbidity of patients undergoing laparoscopic curative resection for rectal cancer (LCRRC). METHODS: PNI data and clinico-pathological characteristics of LCRRC patients (June 2005-December 2020) were evaluated. Patients with metastatic disease were excluded. Postoperative complications were evaluated using the Clavien-Dindo classification. RESULTS: A total of 182 patients were included in the analysis. Median preoperative PNI was 36.5 (IQR 32.8-41.2). Lower PNI was associated with females (p=0.02), older patients (p=0.0002), comorbidity status (p<0.0001), and those who did not receive neoadjuvant treatment (p=0.01). Post-operative complications occurred in 53 patients (29.1%), by the Clavien-Dindo classification: 40 grades I-II and 13 grades III-V. Median preoperative PNI was 35.0 (31.8-40.0) in complicated patients and 37.0 (33.0-41.5) in uncomplicated patients (p=0.09). PNI showed poor discriminative performance regarding postoperative morbidity (AUC 0.57) and was not associated with postoperative morbidity (OR 0.97) at multivariable analysis. CONCLUSIONS: Preoperative PNI was not associated with postoperative morbidity after LCRRC. Further research should focus on different nutritional indicators or hematological/immunological biomarkers.

Skeletal Muscle Mass and Surgical Morbidity After Laparoscopic Rectal Cancer Resection.

Background: Sarcopenia is a useful tool in predicting short-term results in patients undergoing surgery for gastrointestinal cancer. However, there are few studies addressing this issue in colorectal cancer, and even less specifically focused on rectal cancer. We evaluated the prognostic relevance of preoperative skeletal mass index on postoperative morbidity in patients undergoing laparoscopic curative resection for rectal cancer. Methods: Skeletal mass index data and clinicopathological characteristics of rectal cancer patients in a 15-year period (June 2005-December 2020) were evaluated; patients with metastatic disease at surgery were excluded; postoperative complications within 30 days were evaluated using the Clavien-Dindo classification. Results: A total of 166 patients were included in the study. The overall prevalence of sarcopenia was 60%. BMI, Hb, or albumin were not associated with sarcopenia. Hospital stay was not correlated with sarcopenia. Postoperative complications occurred in 51 patients (31%); by the Clavien-Dindo classification 31 (61%) grade I, 10 (14.5%) grade II, and 10 (14.5%) grade III. Overall complications were not significantly different in sarcopenic and nonsarcopenic patients (P = .10). Considering only patients with complications, sarcopenia was found to be a predictor of more severe postoperative morbidity (odds ratio 12.7, P = .021). On multivariable analysis, sarcopenia was not associated with postoperative morbidity. Conclusions: Skeletal muscle status in rectal cancer patients undergoing curative resection was not associated with overall postoperative morbidity, although there was a correlation between sarcopenia and more severe complications. Further studies in a larger cohort of patients are needed before conclusions can be drawn on the relationship between muscular depletion and surgical outcomes in rectal cancer patients.

Laparoscopic right hemicolectomy with 2D or 3D video system technology: systematic review and meta-analysis.

BACKGROUND: Standard laparoscopic colorectal surgery relies on 2D image systems in most centers. However, 3D vision has gained popularity and is used nowadays in a constantly rising number of units. Right hemicolectomy with intracorporeal anastomosis and lymph node dissection represents a surgical procedure that may benefit the most from 3D vision. The aim of the study was to summarize the available literature on the use of 2D vs. 3D video imaging in patients undergoing laparoscopic right hemicolectomy. METHODS: A comprehensive literature review was conducted including Medline/PubMed, Embase, and Scopus (PROSPERO registration number CRD 42022344764) through October 2022. The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The risk of bias was evaluated using the ROBINS-I tool. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines and GRADEpro to develop a summary of evidence tables. Random-effects meta-analyses were conducted. RESULTS: Five observational retrospective studies (496 patients, 275 2D and 216 3D) were included. One study was rated as having a critical risk of bias; the remaining had low to moderate risk. 2D laparoscopic right hemicolectomy patients showed longer anastomotic time in 3/3 studies (MD = 3.32; 95%CI, 1.58-5.05; p = 0.002) and an upward trend in operative time in 4/5 studies (MD = 9.98; 95%CI, -1.42, 21.37; p = 0.086) compared to 3D. The two image video systems had similar short-term outcomes, including the number of lymph nodes harvested (MD = -0.67; 95%CI, -2.47, 1.13; p = 0.47), morbidity (OR post-operative complications = 1.12; 95%CI, 0.71-1.77; p = 0.62), and length of stay (MD = 0.27; 95%CI, -0.59, 1.13; p = 0.9). CONCLUSIONS: 2D and 2D laparoscopic right hemicolectomy had similar complications rate, with a shorter anastomotic time along with a downward trend in overall operative time for 3D. Larger prospective randomized trials are awaited before definitive conclusions can be drawn.

Prognostic effect of sarcopenia in patients undergoing laparoscopic rectal cancer resection.

BACKGROUND: The importance of body composition, in particular skeletal muscle mass, as risk factor affecting survival of cancer patients has recently gained increasing attention. The relationship between sarcopenia and oncological outcomes has become a topic of research in particular in patients with gastrointestinal cancer. However, there are few studies addressing this issue in colorectal cancer, and even less specifically focused on rectal cancer, in particular in Western countries. The aim of this study was to evaluate the prognostic relevance of preoperative skeletal mass index (SMI) on long-term outcomes in patients undergoing laparoscopic curative resection for rectal cancer. METHODS: SMI data and clinicopathological characteristics of rectal cancer patients in a 15-year period (June 2005-December 2020) were evaluated; patients with metastatic disease at surgery were excluded; overall and disease-free survival as well as recurrence were evaluated. RESULTS: Hundred and sixty-five patients were included in the study. Sarcopenia was identified in 30 (18%) patients. Multivariate analysis identified sarcopenia (HR = 3.28, CI = 1.33-8.11, P = 0.015), along with age (HR = 1.06, CI = 1.02-1.10, P = 0.002) and stage III (HR = 2.63, CI = 1.13-6.08, P < 0.03) as independent risk factors for overall survival. CONCLUSION: Long-term results of rectal cancer patients undergoing curative resection are affected by their preoperative skeletal muscle status. Larger studies including comprehensive data on muscle strength along with SMI are awaited to confirm these results on both Eastern and Western rectal cancer patient populations before strategies to reverse muscle depletion can be extensively applied.

Prognostic role of platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte, and lymphocyte-to-monocyte ratio in operated rectal cancer patients: systematic review and meta-analysis.

BACKGROUND: Inflammation plays an important role in tumor growth. Novel serum blood biomarkers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR), have been proposed as useful prognostic indexes in cancer patients. However, their role in rectal cancer is controversial. METHODS: A comprehensive literature review was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, and the Cochrane Database of Systematic Reviews through May 2022. The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) tool. Aim of the study was to summarize available literature on PLR, NLR, and LMR in patients with rectal cancer undergoing resection. RESULTS: Forty-seven observational studies (14,205 patients) were included; there were 42 retrospective and 5 prospective cohort studies with an average MINORS score of 14.6 (range: 12-18). Worse overall survival was associated with high NLR (HR 1.81; 95%CI 1.52-2.15; p < 0.001), high PLR (HR 1.24; 95%CI 1.06-1.46; p = 0.009), and low LMR (HR 0.67; 95%CI 0.49-0.91; p = 0.01). High NLR and low LMR were also associated with disease-free-survival (HR 1.68; 95%CI 1.35-2.08; p < 0.001 and HR 0.71; 95%CI 0.58-0.87; p < 0.001, respectively). CONCLUSIONS: NLR, PLR, and LMR are independent clinical predictors for overall survival in patients with rectal cancer treated with curative surgery. NLR and LMR are also good predictors for disease free survival. These biomarkers, which are readily available, appear optimal prognostic indexes and may help clinicians predict the prognosis of rectal cancer and develop individualized treatment strategies.

Does 3D laparoscopic video technology affect long-term survival in right hemicolectomy for cancer compared to standard 2D? A propensity score study.

BACKGROUND: There are few studies focused on the short-term results of laparoscopic right hemicolectomy performed with 2D (two-dimension) or 3D (three-dimension) video technology and none on the oncologic effects. The aim of the study was to assess the long-term results of laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis using 3D or 2D video in patients with right colon cancer with at least three years of oncologic follow-up. METHODS: Data from patients undergoing laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis for cancer in an 11-year period (June 2008-June 2019) and ≥ 3 years of follow-up were prospectively collected. Surgical procedures were performed by two expert laparoscopic surgeons. RESULTS: 111 patients were included in the study: 56 (50.5%) in the 3D group and 55 (49.5%) in the 2D group. Tumor stage and number of lymph nodes harvested were similar. Overall and disease-free survival were not different in the two groups. Local recurrence occurred in none of the patients, and distant metachronous metastases were similar in the two groups. A propensity score weighting approach was used to account for potential confounding related to patients' nonrandom allocation to the 2 groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach. CONCLUSIONS: Laparoscopic 3D technology allows similar oncological results as 2D vision in LRH with intracorporeal anastomosis. Larger prospective randomized studies might confirm these results in the long-term follow-up.

Missing the main actor: Intra-operative diagnosis of agenesis of the gallbladder - When late is not 'too' late.

Agenesis of the gallbladder (AGB) without extrahepatic biliary atresia is a rare congenital disease. Ultrasound (US) examination can be misleading and reveal a contracted shrunken gallbladder when there is not any and the patient in most cases is taken to the OR for a standard cholecystectomy. We describe the case of a 54-year-old female with colicky right upper abdominal pain with nausea. US revealed a contracted scleroatrophic gallbladder and the patient was listed for laparoscopic cholecystectomy. At laparoscopy, despite careful search, the gallbladder was never visualised, and the suspicion of AGB was raised. An intra-operative cholangiography confirmed the hypothesis. The post-operative recovery was uneventful, and abdominal computed tomography scan failed to show the presence of gallbladder, therefore confirming the diagnosis of AGB. Lack of awareness of this condition among radiologists and surgeons is the main reason for unnecessary operations and potentially damages to the biliary tract.

Laparoscopic Welti's Maneuver: A Single-Center Experience.

Purpose: Left hemicolectomy is the standard surgical operation for a variety of colonic diseases, both benign and malignant. When colonic resection is extended, relocation of the small bowel loops can be difficult. Several techniques have been described to reposition the small intestine. Welti's technique consists in the passage of the entire small bowel to the left side of the abdomen, below the descending colon that is positioned on the right side. Methods: We retrospectively evaluated 23 patients who underwent extended left hemicolectomy and reconstruction according to the Welti's technique at our hospital. We assessed the recovery of intestinal function and the length of hospital stay; in the mid-term follow-up we searched for episodes of acute or chronic intestinal obstruction. Results: Median operative time was 215 minutes; median resumption of gas and stool emission were, respectively, 3 days (interquartile range [IQR]: 2-6) and 4 days (IQR: 2-9) after surgery. Median hospital stay was 8 (IQR: 5-37) day. After a median follow-up of 15 months (IQR: 3-132) we did not observe any episode of acute or chronic bowel obstruction. Conclusions: Welti's technique is safe and does not cause a delay in resumption of bowel functions or a delayed hospital discharge; it is a useful technique that the colorectal surgeon can use when needed.

Fully Laparoscopic Pancreas-Preserving Resection of the Third and Fourth Portion of the Duodenum for Adenocarcinomas and Gastrointestinal Stromal Tumors: Technical Report on a Case Series.

Background: Infra-ampullary duodenal lesions are rare and surgical management is controversial. The commonly accepted treatment, which allows radical resection, is pancreaticoduodenectomy, but segmental duodenal resection has been considered as alternative. Aim of the study was to describe the effectiveness of minimally invasive resection of the third/fourth portion of the duodenum for both benign and malignant lesions, with pancreas preservation and reconstruction through end-to-side duodenojejunostomy. Methods: Data from patients undergoing elective laparoscopic curative duodenal resection with pancreas preservation between June 2005 and June 2019 were prospectively collected. Results: A total of 5 patients were identified (3M/2F), median age 73 years (range: 54-83). Lesions were all located in the third or fourth portion of the duodenum and were adenocarcinoma in 2 patients (pT2N0 and pT3N2, both 3 cm in diameter) and gastrointestinal stromal tumor in 3 patients (two pT1N0 and one pT2N0, low-risk according to Miettinen, of 3, 2, and 5 cm in diameter, respectively). The operations lasted a median of 225 minutes (range: 180-300). Digestive continuity was restored with fully laparoscopic side-to-side duodenojejunostomy in all cases. One patient developed pneumonia after surgery (20%) and required also postoperative blood transfusions. Reoperation and mortality rate was nil. Median postoperative stay was 11 days (range: 10-13). The median follow-up was 30 months. Conclusions: Fully laparoscopic pancreas-preserving duodenal resection with duodenojejunal reconstruction can be a safe and feasible option for both benign and malignant lesions of the third and fourth portion of the duodenum. It brings good oncological results, but it needs to be validated with larger number of patients.

Internal hernia following laparoscopic anterior resection for cancer: higher prevalence than expected of an under-reported complication.

BACKGROUND: Internal hernia (IH) after laparoscopic colorectal surgery is a potentially severe complication. It may go undiagnosed in patients having their abdominal CT scan during oncologic follow-up. We evaluated the occurrence of IH on CT scans after laparoscopic curative resection for rectal cancer (LRRC) and routine closure of the mesenteric defect. METHODS: Data from 189 consecutive patients undergoing elective curative LRRC in a 14-year period (June 2005-june 2019) were prospectively collected. Only patients with abdominal CT scans, performed as routine oncologic follow-up, between 3 months and 7 years post-operatively were included in the study and reviewed by a surgeon and a radiologist. RESULTS: A total of 161 patients were eligible for the study with a median age of 69 years (IQR: 59-77) at surgery. They had abdominal follow-up CT scans at a median of 39.5 months (IQR: 12.8-62.7) after surgery. The prevalence of IH was 11.2% (18/161 patients). Of the 18 patients, 15 (83.3%) were fully asymptomatic, 2 (11.1%) reported chronic abdominal discomfort (including mostly nausea and colicky pain) during their oncologic follow-up (however, IH was not suspected neither prompted additional investigations), and 1 (5.6%) was reoperated elsewhere for IH and acute small bowel obstruction. CONCLUSIONS: IH following LRRC is not uncommon, with a prevalence > 10% in our experience. Most of these patients remain fully asymptomatic, but in a few patients, IH might be responsible for some symptoms or require reoperation. Awareness of this complication is important, given the potential risk of acute small bowel obstruction.

Gist of the 4th Portion of the Duodenum: Laparoscopic Resection with Pancreas Preservation.

In this video, we present the laparoscopic technique of pancreas-preserving segmental resection for GISTs of the 4th portion of the duodenum. A 54-year-old male presented with a polypoid mass of about 3 cm in diameter with a large base, in the 4th portion of the duodenum, about 4 cm from the ampulla. Multiple endoscopic biopsies were taken, and all were negative for adenocarcinoma. CT scan of the abdomen confirmed that the mass, suggestive of GIST, was limited to the duodenum, a limited part intraluminal and the vast majority in the duodenal wall. A laparoscopic segmental resection with a 3D video system was accomplished. The operation lasted 160 min. Recovery was uneventful.

The "folded" glove-finger in minimally invasive surgery: easy, quick and cheap specimen retrieval.

Laparoscopic and thoracoscopic surgery often require extraction of surgical specimens. The use of standard retrieval bag can be expensive, especially in case of multiple specimens during the same operation. We describe the use of a folded glove-finger as cheap alternative and easily reproducible means of specimen extraction. The medium finger of a glove, cut at its base, was used to locate several types of specimens. The edge of the glove was folded to allow an easier insertion and retrieval of the specimens. Using this technique in the last 5 years, we have retrieved hundreds of different types of specimens (including omentum, lymph nodes, appendix, peritoneal or pleural biopsies) during laparoscopic and thoracoscopic procedures. All the retrieval fingers were safely pulled outside and were intact when extracted through the ports with no fragmentation of the specimens. In conclusion, we suggest that a folded glove-finger can be used as an easy, quick and cheap strategy for specimen extraction during laparoscopic and thoracoscopic surgery.

A novel and simple technique to close the enterotomy after intracorporeal anastomosis in laparoscopic right hemicolectomy.

We developed a new technique to reduce the length of the enteric defect to be closed during intracorporeal anastomosis in laparoscopic right hemicolectomy (LRH), also avoiding the need to suture the first part of the anastomosis in a deep space with an acute angle. From January 2017, after the ileo-colic anastomosis was completed, an additional stapler cartridge was applied starting at the colonic rim and including the small bowel part of the anastomosis. The isoperistaltic fashion of the ileo-colonic anastomosis was maintained. The remaining defect left to be closed was 2-3 cm. We compared the results of the novel technique with those of the 'standard' closure (full-length enterotomy). In the last 30 months, this technique was successfully used in 32 patients (Group A), compared with 33 patients (2012-2016) operated with 'standard' closure (Group B). Age, BMI and post-operative stage distribution were similar. The mean operative time was 175.2 min (± 36.7) in Group A and 165.9 min (± 42.5) in Group B (p = ns), with 53.1% and 27.3% of associated procedures (cholecystectomy, ovariectomy, etc.), respectively (p < 0.05). Overall morbidity rate was 28.1% and 30.3% (Group A vs Group B, p = ns), with no anastomotic bleeding/leak in either group. This technique, which simplifies the closure of the enteric defect after LRH with intracorporeal anastomosis is safe, reproducible and easy to learn. It might help more surgeons to perform a fully laparoscopic procedure in right hemicolectomy, offering the advantages of intracorporeal anastomosis to their patients.

Two-dimensional (2-D) vs. three-dimensional (3-D) laparoscopic right hemicolectomy with intracorporeal anastomosis for colon cancer: comparison of short-term results.

BACKGROUND: There are few reports comparing safety and efficacy of 2-D and 3-D video technology in laparoscopic right hemicolectomy. The aim of the study was to assess the short-term results of laparoscopic right hemicolectomy (LHR) with intracorporeal anastomosis with 2-D/3-D video in patients with right colon cancer. METHODS: Data from 239 patients undergoing LRH for cancer in a 14-year period (June 2005-January 2020) were prospectively collected. Surgical procedures were performed by two expert laparoscopic surgeons. RESULTS: One hundred and fourteen patients were included in the study: 55 (48.2%) operated with 2-D and 59 (51.8%) with 3-D video. Tumor site and postoperative stage distribution were similar. Mean operative time was comparable in the two groups (159.0 ± 48.8 min vs. 17.06 ± 36.0 min, p = ns, group 2-D and 3-D, respectively). Group 3-D patients had a similar percentage of associated procedures (44.1% vs. 29.1%, p = ns). Intraoperative complications were nil in both groups, while postoperative complications were similar (30.9% 2-D vs 25.4% 3-D, p = ns). The mean number of lymph nodes retrieved was similar in group 3-D (26.0 ± 14.6 vs. 22.9 ± 9.3, p = ns) and the length of stay was comparable in 3-D and 2-D patients (8.4 ± 2.6 vs. 9.1 ± 3.3 days, respectively, p = ns). CONCLUSIONS: Laparoscopic 3-D vision is as equally effective as 2-D vision in LRH with intracorporeal anastomosis, with a similar proportion of associated procedures and number of lymph nodes retrieved in the same operative time. Further prospective larger randomized studies are necessary to verify if LRH with 3-D video can reduce postoperative complications, compared to 2-D video.