Stereotactic navigation for TAMIS-TME.

Stereotactic navigation allows for real-time, image-guided surgery, thus providing an augmented working environment for the operator. This technique can be applied to complex minimally invasive surgery for fixed anatomic targets. Transanal minimally invasive surgery represents a new approach to rectal cancer surgery that is technically demanding and introduces the potential for procedure-specific morbidity. Feasibility of stereotactic navigation for TAMIS-TME has been demonstrated, and this could theoretically translate into improved resection quality by improving the surgeon's spatial awareness. The future of minimally invasive surgery as it relates to augmented reality and image-guided surgery is discussed.

Stereotactic navigation for TAMIS-TME: opening the gateway to frameless, image-guided abdominal and pelvic surgery.

BACKGROUND: Frameless stereotaxy is an established method for real-time image-guided surgical navigation in neurological surgery. Though this is capable of providing sub-millimeter accuracy, it has not been used by other surgical specialists. METHODS AND PROCEDURE: A patient with locally advanced, distal rectal cancer and tumor abutting the prostate was selected for transanal TME using TAMIS, with intra-operative CT-guided navigation to ensure an R0 resection. RESULTS: The use of stereotactic TAMIS-TME was successfully performed with an accuracy of ±4 mm. The surgical specimen revealed an R0 resection, and this new approach aided in achieving adequate resection margins. CONCLUSION: This is the first report of the use of frameless stereotactic navigation beyond the scope of neurosurgery. Stereotactic navigation for transanal total mesorectal excision is shown to be feasible. Stereotactic navigation may potentially be applied toward other pelvic and fixed abdominal organs, thereby opening the gateway for a broader use by the general surgeon.

Vaginal Access Minimally Invasive Surgery (VAMIS): A New Approach to Hysterectomy.

Vaginal hysterectomy is the original natural orifice operation. Although one of the most common gynecologic operations performed, the surgical approach has not changed significantly during the past century. This article describes a new approach to hysterectomy using vaginal access minimally invasive surgery (VAMIS). VAMIS hysterectomy is successfully performed on a cadaveric model. The step-by-step description of the surgical technique is depicted with video supplement.

Robotic transanal surgery for local excision of rectal neoplasms.

Robotic transanal surgery (RTS) has been a natural evolution of transanal minimally invasive surgery. This video demonstrates how RTS is performed for the full-thickness excision of a malignant rectal polyp, with endoluminal robotic suturing of the rectal wall defect. The general approach to RTS, including the approach to docking of the robotic cart, are also illustrated in video format.

An extended paIn relief trial utilizing the infiltration of a long-acting Multivesicular liPosome foRmulation Of bupiVacaine, EXPAREL (IMPROVE): a Phase IV health economic trial in adult patients undergoing ileostomy reversal.

BACKGROUND: Opioid analgesics are effective for postsurgical pain but are associated with opioid-related adverse events, creating a significant clinical and economic burden. Gastrointestinal surgery patients are at high risk for opioid-related adverse events. We conducted a study to assess the impact of an opioid-sparing multimodal analgesia regimen with liposome bupivacaine, compared with the standard of care (intravenous [IV] opioid-based, patient-controlled analgesia [PCA]) on postsurgical opioid use and health economic outcomes in patients undergoing ileostomy reversal. METHODS: In this open-label, multicenter study, sequential cohorts of patients undergoing ileostomy reversal received IV opioid PCA (first cohort); or multimodal analgesia including a single intraoperative administration of liposome bupivacaine (second cohort). Rescue analgesia was available to all patients. Primary outcome measures were postsurgical opioid use, hospital length of stay, and hospitalization costs. Incidence of opioid-related adverse events was also assessed. RESULTS: Twenty-seven patients were enrolled, underwent the planned surgery, and did not meet any intraoperative exclusion criteria; 16 received liposome bupivacaine-based multimodal analgesia and eleven received the standard IV opioid PCA regimen. The multimodal regimen was associated with significant reductions in opioid use compared with the IV opioid PCA regimen (mean, 20 mg versus 112 mg; median, 6 mg versus 48 mg, respectively; P < 0.01), postsurgical length of stay (median, 3.0 days versus 5.1 days, respectively; P < 0.001), and hospitalization costs (geometric mean, $6482 versus $9282, respectively; P = 0.01). CONCLUSION: A liposome bupivacaine-based multimodal analgesic regimen resulted in statistically significant and clinically meaningful reductions in opioid consumption, shorter length of stay, and lower inpatient costs than an IV opioid-based analgesic regimen.

Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients.

BACKGROUND: Since its inception in 2009, transanal minimally invasive surgery has been used increasingly in the United States and internationally as an alternative to local excision and transanal endoscopic microsurgery for local excision of neoplasms in the distal and mid rectum. Despite its increasing acceptance, the clinical benefits of transanal minimally invasive surgery have not yet been validated. OBJECTIVE: The aim of this study is to assess the adequacy of transanal minimally invasive surgery for the local excision of benign and malignant lesions of the rectum. DESIGN: This is a retrospective analysis of consecutive patients who underwent transanal minimally invasive surgery for local excision of neoplasms at a single institution. SETTINGS: The study was conducted by a single group of colorectal surgeons at a tertiary referral center. PATIENTS: Eligible patients with early-stage rectal cancer and benign neoplasms were offered transanal minimally invasive surgery as a means for local excision. Data from these patients were collected prospectively in a registry. MAIN OUTCOME MEASURES: The primary outcome measures included the feasibility of transanal minimally invasive surgery for local excision, resection quality, and short-term clinical results. RESULTS: : Fifty patients underwent transanal minimally invasive surgery between July 2009 and December 2011. Twenty-five benign neoplasms, 23 malignant lesions, and 2 neuroendocrine tumors were excised. All lesions were excised using transanal minimally invasive surgery without conversion to an alternate transanal platform. The average length of stay was 0.6 days (range, 0-6), and 68% of patients were discharged on the day of surgery. The average distance from the anal verge was 8.1 cm (range, 3-14 cm). All lesions were excised completely with only 2 fragmented specimens (4%). All specimens were removed with grossly negative margins, although 3 (6%) were found to have microscopically positive margins on final pathology. There were 2 recurrences (4%) at 6- and 18-month follow-up. Early complications occurred in 3 patients (6%). No long-term complications were observed at a median follow-up of 20 months. LIMITATIONS: The study was limited by its retrospective nature and midterm follow-up. CONCLUSIONS: Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for resecting benign neoplasms, as well as carefully selected, early-stage malignancies of the mid and distal rectum.

Transanal minimally invasive surgery: a giant leap forward.

BACKGROUND: Our novel approach is a hybrid between transanal endoscopic microsurgery (TEM) and single-port laparoscopy that we have termed TransAnal Minimally Invasive Surgery (TAMIS). We report the clinical application of this technique and present preliminary data that show TAMIS to be an effective tool for resection of both malignant and benign lesions of the rectum. METHODS: Over a 3-month period (May-July 2009) all patients with rectal lesions who were candidates for conventional transanal excision were offered the option to undergo TAMIS resection. Patients with biopsy-proven malignant lesions were required to undergo endorectal ultrasound preoperatively to determine tumor stage. To perform TAMIS, a single-incision laparoscopic surgery port (SILS Port, Covidien) is introduced into the anal canal by applying steady manual pressure. Once seated in position, endoscopic access to the rectal vault is gained and pneumorectum is established. With this access, ordinary laparoscopic instruments, including graspers, thermal energy devices, and needle drives, are used to perform the transanal excisions. RESULTS: Six patients, aged 43-85 years old (mean = 59.8), underwent TAMIS resection of rectal lesions. The average distance from the anal verge was 9.3 cm and the mean tumor diameter confirmed by pathology measured 2.93 cm. There were no conversions from TAMIS to conventional transanal excision. While the average operating time was 86 min, four of the six TAMIS resections (67%) were completed in less than 1 h. The mean set-up time was only 1.9 min and this may be one reason that the mean operative time was considerably less than the average operative time for TEM surgery (120-140 min). In short-term follow-up, there was no morbidity or mortality observed. CONCLUSIONS: TAMIS is a feasible alternative to TEM, providing its benefits at a fraction of the cost.

Postoperative surveillance recommendations for early stage colon cancer based on results from the clinical outcomes of surgical therapy trial.

PURPOSE: Intensive postoperative surveillance is associated with improved survival and recommended for patients with late stage (stage IIB and III) colon cancer. We hypothesized that stage I and IIA colon cancer patients would experience similar benefits. PATIENTS AND METHODS: Secondary analysis of data from the Clinical Outcomes of Surgical Therapy trial was performed by analyzing results according to TNM stage; early (stage I and IIA, 537 patients) and late (stage IIB and III, 254 patients) stage disease. Five-year recurrence rates were higher in patients with late (35.7%) versus early stage disease (9.5%). Early and late stage salvage rates, recurrence patterns and methods of first detection were compared by chi(2) test. RESULTS: Salvage rates for early- and late-stage disease patients with recurrence were the same (35.9% v 37%; P = .9, respectively). Median survival after second surgery after recurrence was 51.2 and 35.8 months for early- and late-stage patients, respectively. Single sites of first recurrence did not significantly differ between early and late stage, but multiple sites of recurrence occurred less often in early-stage patients (3.6% v 28.6%, for early v late, respectively; P < .001). METHODS of first detection of recurrence were not significantly different: carcinoembryonic antigen (29.1% v 37.4%), computed tomography scan (23.6% v 26.4%), chest x-ray (7.3% v 12.1%), and colonoscopy (12.7% v 8.8%), for early versus late stage disease, respectively. CONCLUSION: Patients with early-stage colon cancer have similar sites of recurrence, and receive similar benefit from postrecurrence therapy as late-stage patients; implementation of surveillance guidelines for early-stage patients is appropriate.

Stapled transanal rectal resection vs. transvaginal rectocele repair for treatment of obstructive defecation syndrome.

PURPOSE: Stapled transanal rectal resection has been introduced as a new technology for the management of obstructive defecation syndrome. In this study we observed the clinical outcomes for stapled transanal rectal resection as compared with transvaginal rectocele repair for obstructive defecation syndrome. METHODS: This study is a retrospective review of patients who received transvaginal rectocele repair for obstructive defecation syndrome from June 1997 to February 2002 as compared with patients who received stapled transanal rectal resection from June 2005 to August 2007. The clinical outcomes observed were operative time, estimated blood loss, length of stay, complication rate, procedure failure rate, recurrence rate, time to recurrence, and dyspareunia rate. RESULTS: Thirty-seven patients had transvaginal rectocele repair for management of obstructive defecation syndrome, and 36 patients had stapled transanal rectal resection. There was no difference in the age of patients receiving either procedure (transvaginal rectocele repair, 57.92 years old; stapled transanal rectal resection, 53.19 years old; P = 0.1096). Evaluation of the clinical outcomes showed that transvaginal rectocele repair had a longer operative time (transvaginal rectocele repair, 85 minutes; stapled transanal rectal resection, 52 minutes; P = or<0.0001), greater estimated blood loss (transvaginal rectocele repair, 108 ml; stapled transanal rectal resection, 43 ml; P = 0.0015), and a lower complication rate (transvaginal rectocele repair, 18.9 percent; stapled transanal rectal resection, 61.1 percent; P = 0.0001). CONCLUSION: The stapled transanal rectal resection procedure can be done with shorter operative times and less blood loss than transvaginal rectocele repair, however, it has a higher complication rate.

Surgeon volume does not predict outcomes in the setting of technical credentialing: results from a randomized trial in colon cancer.

OBJECTIVE: To test the hypothesis that surgeon volume would not predict short- and long-term outcomes when evaluated in the setting of technical credentialing. SUMMARY BACKGROUND DATA: Surgical volume is a known predictor of outcomes; the importance of technical credentialing has not been evaluated. METHODS: Fifty-three credentialed surgeons operated on 871 patients in the Clinical Outcomes of Surgical Therapy Study (NCT00002575), investigating laparoscopic versus open surgery for colon cancer. Credentialing required that each surgeon document performance of at least 20 laparoscopic colon cases and demonstrate oncologic techniques on a video-recorded case. Surgeons were separated based on volume entered into the trial (low, < or =5 cases (n = 39); medium, 6-10 cases (n = 9); or high, >10 cases (n = 5)) and compared by outcomes. RESULTS: Patients treated by high volume compared with medium or low volume surgeons were older (70, 66, and 68 years; P < 0.001), more often had right-sided tumors (63%, 46%, and 53%; P < 0.001) and had more previous operations (48%, 38% and 45%; P < 0.004), respectively. Mean operative times were shorter (123, 147 and 145 minutes; P < 0.001), distal margins longer (13.4, 12.4 and 11.6 cm; P = 0.005), and lymph node harvest greater (14.8, 12.8, 12.6; P = 0.05) for high versus medium versus low volume surgeons. However, rates of conversion, complications, 5-year survival, and disease-free survival showed no significant differences. CONCLUSION: When tested in a randomized controlled trial with case-specific surgical technical credentialing and auditing, surgeon volume did not predict differences in rates of conversion, complications, or long-term cancer outcomes. Case-specific technical credentialing should be further studied specific to the role it could play in creating consistent, high quality outcomes.

Prevention of postoperative abdominal adhesions by a novel, glycerol/sodium hyaluronate/carboxymethylcellulose-based bioresorbable membrane: a prospective, randomized, evaluator-blinded multicenter study.

INTRODUCTION: Postoperative abdominal adhesions are associated with significant morbidity and mortality, placing a substantial burden on healthcare systems worldwide. Development of a bioresorbable membrane containing up to 23 percent glycerol and chemically modified sodium hyaluronate/carboxymethylcellulose offers ease of handling and has been shown to provide significant postoperative adhesion prevention in animals. This study was designed to assess the safety of glycerol hyaluronate/carboxymethylcellulose and to evaluate its efficacy in reducing the incidence, extent, and severity of postoperative adhesion development in surgical patients. METHODS: Twelve centers enrolled 120 patients with ulcerative colitis or familial polyposis who were scheduled for a restorative proctocolectomy and ileal pouch-anal anastomosis with diverting loop ileostomy. Before surgical closure, patients were randomized to no anti-adhesion treatment (control) or treatment with glycerol hyaluronate/carboxymethylcellulose membrane under the midline incision. At ileostomy closure, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision. RESULTS: Data were analyzed using the intent-to-treat population. Treatment with glycerol hyaluronate/carboxymethylcellulose resulted in 19 of 58 patients (33 percent) with no adhesions compared with 6 of 60 adhesion-free patients (10 percent) in the no treatment control group (P = 0.002). The mean extent of postoperative adhesions to the midline incision was significantly lower among patients treated with glycerol hyaluronate/carboxymethylcellulose compared with patients in the control group (P < 0.001). The severity of postoperative adhesions to the midline incision was significantly less with glycerol hyaluronate/carboxymethylcellulose than with control (P < 0.001). Adverse events were similar between treatment and no treatment control groups with the exception of abscess and incisional wound complications were more frequently observed with glycerol hyaluronate/carboxymethylcellulose. CONCLUSIONS: Glycerol hyaluronate/carboxymethylcellulose was shown to effectively reduce adhesions to the midline incision and adhesions between the omentum and small bowel after abdominal surgery. Safety profiles for the treatment and no treatment control groups were similar with the exception of more infection complications associated with glycerol hyaluronate/carboxymethylcellulose use. Animal models did not predict these complications.