"Relaparoscopy" to treat early complications following colorectal surgery.

BACKGROUND: Laparoscopic surgery has shown clear benefits that could also be useful in the emergency setting such as early reoperations after colorectal surgery. The aim of this study was to evaluate the safety and feasibility of laparoscopic reintervention ("relaparoscopy") (RL) to manage postoperative complications after laparoscopic colorectal surgery. METHODS: We performed a retrospective study based on a prospectively collected database from 2000 to 2019. Patients who required a reoperation after undergoing laparoscopic colorectal surgery were included. According to the approach used at the reoperation, the cohort was divided in laparoscopy (RL) and laparotomy (LPM). Demographics, hospital stay, morbidity, and mortality were analyzed. RESULTS: A total of 159 patients underwent a reoperation after a laparoscopic colorectal surgery: 124 (78%) had RL and 35 (22%) LPM. Demographics were similar in both groups. Patients who underwent left colectomy were more frequently reoperated by laparoscopy (RL: 42.7% vs. LPM: 22.8%, p: 0.03). The most common finding at the reoperation was anastomotic leakage, which was treated more often by RL (RL: 67.7% vs. LPM: 25.7%, p: 0.0001), and the most common strategy was drainage and loop ileostomy (RL: 65.8% vs. LPM: 17.6%, p: 0.00001). Conversion was necessary in 12 patients (9.6%). Overall morbidity rate was 52.2%. Patients in the RL group had less postoperative severe complications (RL: 12.1% vs. LPM: 22.8, p: 0.01). Mortality rate was similar in both groups. CONCLUSION: Relaparoscopy is feasible and safe for treating early postoperative complications, particularly anastomotic leakage after left colectomy.

Safety and feasibility of laparoscopic sigmoid resection without diversion in perforated diverticulitis.

BACKGROUND: Laparoscopic primary anastomosis (PA) without diversion for diverticulitis has historically been confined to the elective setting. Hartmann's procedure is associated with high morbidity rates that might be reduced with less invasive and one-step approaches. The aim of this study was to analyze the results of laparoscopic PA without diversion in Hinchey III perforated diverticulitis. METHODS: We performed a retrospective analysis of a prospectively collected database of all patients who underwent laparoscopic sigmoidectomy for diverticular disease during the period 2000-2018. The sample was divided in two groups: elective laparoscopic sigmoid resection for recurrent diverticulitis (G1) and emergent laparoscopic sigmoidectomy for Hinchey III diverticulitis (G2). Demographics, operative variables, and postoperative outcomes were compared between groups. RESULTS: A total of 415 patients underwent laparoscopic sigmoid resection for diverticular disease. PA without diversion was performed in 351 patients; 278 (79.2%) belonged to G1 (recurrent diverticulitis) and 73 (20.8%) to G2 (perforated diverticulitis). Median age, gender, and BMI score were similar in both groups. Patients with ASA III score were more frequent in G2 (p: 0.02). Conversion rate (G1: 4% vs. G2: 18%, p < 0.001), operative time (G1: 157 min vs. G2: 183 min, p < 0.001), and median length of hospital stay (G1: 3 days vs. G2: 5 days, p < 0.001) were significantly higher in G2. Overall postoperative morbidity (G1: 22.3% vs. G2: 28.7%, p = 0.27) and anastomotic leak rate (G1: 5.7% vs. G2: 5.4%, p = 0.92) were similar between groups. There was no mortality in G1 and one patient (1.3%) died in G2 (p = 0.21). CONCLUSION: Laparoscopic sigmoid resection without diversion is feasible and safe in patients with perforated diverticulitis. In centers with vast experience in laparoscopic colorectal surgery, patients undergoing this procedure have similar morbidity and mortality to those undergoing elective sigmoidectomy.

Risk of Metachronous Advanced Neoplastic Lesions in Patients with Sporadic Sessile Serrated Adenomas Undergoing Colonoscopic Surveillance.

OBJECTIVES: The risk of developing metachronous advanced neoplastic lesions (ANLs) during surveillance after resection of sessile serrated adenomas (SSAs) has not been quantified. METHODS: Patients with sporadic SSAs resected between 1 April 2007 and 31 December 2009 who underwent surveillance colonoscopy in our institution were prospectively evaluated. Patients with low-risk adenomas (LRAs), high-risk adenomas (HRAs), and negative index colonoscopy (NIC) during the same period were identified using the pathology database and electronic medical records, and were also included as a comparison cohort. The primary outcome was the comparison of the study groups with regard to incidence of metachronous ANLs during surveillance colonoscopy. RESULTS: A total of 185 patients had SSAs, of whom 75 with 101 resected polyps were finally included. The comparison cohort consisted of 564 patients: 140 LRAs (160 polyps), 87 HRAs (478 polyps), and 337 NICs. The overall mean colonoscopy follow-up was for 54.5 months (±s.d. 14). SSA patients with synchronous HRA on index colonoscopy presented a higher incidence rate of metachronous ANL (12.96 per 1,000 person-months) compared with patients with HRA (5.07 per 1,000 person-months), whereas those with synchronous LRA and without synchronous adenoma on index colonoscopy presented a low incidence rate of metachronous ANL (0 and 1.41 per 1,000 person-months, respectively) similar to LRA (1.47 per 1,000 person-months). Among patients with SSA the 3- and 5-year ANL free-cumulative probability was 64.3 and 32.1% in those with synchronous HRA, 100 and 100% in those with synchronous LRA, and 95.1 and 91.7% if no synchronous adenoma was found. CONCLUSIONS: Among patients with resected sporadic SSAs the risk of developing metachronous ANL is influenced by the presence of synchronous HRA on index colonoscopy. Patients with SSAs and synchronous HRA on index colonoscopy require closer surveillance, whereas those with synchronous LRA and those without synchronous adenomas may be followed up in the same way as those with LRAs.

Laparoscopic incisional hernia repair after colorectal surgery. Is it possible to maintain a mini-invasive approach?

Several benefits have been described in laparoscopic surgery. However, there is a lack of evidence concerning laparoscopic repair of incisional hernia after laparoscopic colorectal surgery (LCRS). We aimed to evaluate the feasibility and the results of laparoscopic incisional hernia repair after LCRS. Between May 2001 and March 2014, all charts of consecutive patients who underwent LCRS and developed an incisional hernia were evaluated. Patients with parastomal hernias or those with less than 6 months of follow-up were excluded. Patients were assigned to laparoscopic repair group (LR) and open repair group (OR). Demographics, surgical factors, and 30-day postoperative complications were analyzed. The incisional ventral hernia rate was 7 % (90/1290), and 82 incisional hernia repairs were performed. In 49 patients (60 %) an open approach was performed, and there were 33 laparoscopic repairs (2 converted due to small bowel injury). Mean age was 62 years. Average body mass index was 27.4 ± 5.2 kg/m2. The mean defect size was 56 (4-527) cm2, and there were no differences between the groups (LR: 49 cm2 vs OR: 63 cm2; p = NS). Average operative time was 107 (45-240) minutes (LR: 93 min vs OR: 116 min, p = 0.02). OR showed a higher rate of postoperative complications (OR: 51 % vs LR: 18 %, p = 0.003) and increased hospital stay (OR: 2.77 ± 4 days vs LR: 0.7 ± 0.4 days; p = 0.02). The recurrence rate was 15 % (12 patients, 6 each group; p = NS) after a follow-up of 48 (r: 6-141) months. Laparoscopic approach for incisional hernia repair after LCRS seems to be safe and feasible. Patients who received laparoscopic approach showed significantly less postoperative complications and shorter hospital staying. These observations suggest that mini-invasive surgery may be the initial approach in patients who develop an incisional hernia after LCRS.

Incisional hernia after laparoscopic colorectal surgery. Is there any factor associated?

BACKGROUND: Laparoscopic approach is related to, among others, educing abdominal wall complications such as incisional hernia (IH). However, there are scarce data concerning laparoscopic colorectal surgery (LCRS). The aim of this study was to evaluate related factors and incidence of IH following this approach. METHODS: A retrospective analysis of consecutive patients who underwent colorectal surgery with laparoscopic approach in a single center was performed. Patients with a minimum follow-up of 6 months, and also converted to open surgery were included. Uni- and multi-variate analyses were performed using the following variables: age; gender; type of surgery (left, right, total, or segmental colectomy); comorbidities [diabetes and chronic pulmonary obstructive disease (COPD)]; previous surgery; colorectal disease (benign and malignant); operative time; surgical site infection (SSI); and body mass index (BMI). Midline incisions (right colectomy) and off-midline incisions (left colectomies and rectal resections) were also compared. RESULTS: During a period of 12 years, 1051 laparoscopic colorectal surgeries were performed. The incidence of IH was 6% (n = 63). Univariate analysis showed that BMI > 30 kg/m(2) [p < 0.01, OR: 2.3 (1.3-4.7)], SSI [p < 0.01, OR: 6.5 (3.4-12.5)], operative time >180 min [p < 0.01, OR: 2.1 (1.2-3.6)] and conversion to open surgery (p = 0.01, OR: 2.4 [1.1-5.0]) were related to incisional hernias. BMI and SSI have a statistically significant relation with the incidence of IH in multivariate analysis (p < 0.01). No statistical difference between right and left colectomy was observed (6.6 vs. 6.4%, respectively). CONCLUSION: The incidence of IH after LCRS seems to be acceptable. BMI over 30 kg/m(2) and SSI are strongly associated to this complication.

Sigmoid resection and primary anastomosis for perforated diverticulitis with peritonitis: To divert or not to divert-A systematic review and meta-analysis.

BACKGROUND: The role of proximal diversion in patients undergoing sigmoid resection and primary anastomosis for diverticulitis with generalized peritonitis is unclear. The aim of this study was to compare the clinical outcomes of sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with a proximal diversion in perforated diverticulitis with diffuse peritonitis. METHOD: A systematic literature search on sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with proximal diversion for diverticulitis with diffuse peritonitis was conducted in the Medline and EMBASE databases. Randomized clinical trials and observational studies reporting the primary outcome of interest (30-day mortality) were included. Secondary outcomes were major morbidity, anastomotic leak, reoperation, stoma nonreversal rates, and length of hospital stay. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes. RESULTS: A total of 17 studies involving 544 patients (sigmoid resection and primary anastomosis: 287 versus sigmoid resection and primary anastomosis with proximal diversion: 257) were included. Thirty-day mortality (odds ratio 1.12, 95% confidence interval 0.53-2.40, P = .76), major morbidity (odds ratio 1.40, 95% confidence interval 0.80-2.44, P = .24), anastomotic leak (odds ratio 0.34, 95% confidence interval 0.099-1.20, P = .10), reoperation (odds ratio 0.49, 95% confidence interval 0.17-1.46, P = .20), and length of stay (sigmoid resection and primary anastomosis: 12.1 vs resection and primary anastomosis with diverting ileostomy: 15 days, P = .44) were similar between groups. The risk of definitive stoma was significantly lower after sigmoid resection and primary anastomosis (odds ratio 0.05, 95% confidence interval 0.006-0.35, P = .003). CONCLUSION: Sigmoid resection and primary anastomosis with or without proximal diversion have similar postoperative outcomes in selected patients with diverticulitis and diffuse peritonitis. However, further randomized controlled trials are needed to confirm these results.

Re-laparoscopy to Treat Early Complications After Colorectal Surgery: Is There a Learning Curve?

BACKGROUND: Laparoscopy for treating complications after laparoscopic colorectal surgery (LCS) is still controversial. Moreover, its learning curve has not been evaluated yet. The aim of this study was to analyze whether operative outcomes were influenced by the learning curve of re-laparoscopy. METHODS: A retrospective analysis of patients undergoing LCS and reoperated by a laparoscopic approach during the period 2000-2019 was performed. A cumulative sum analysis was done to determine the number of operations that must be performed to achieve a stable operative time. Based on this analysis, the cohort was divided in 3 groups. Demographics and operative variables were compared between groups. RESULTS: From a total of 1911 patients undergoing LCS, 132 (7%) were included. Based on the cumulative sum analysis, the cohort was divided into the first 50 (G1), the following 52 (G2), and the last 30 (G3) patients. Less computed tomography scans were performed in G3 (G1: 72% vs. G2: 63% vs. G3: 43%; P=0.03). There were no differences in the type of operation performed between the groups. The conversion rate (G1: 18% vs. G2: 4% vs. G3: 3%; P=0.02) and the mean operative time (G1: 104 min vs. G2: 80 min vs. G3: 78 min; P=0.003) were higher in G1. Overall morbidity was lower in G3 (G1: 46% vs. G2: 63% vs. G3: 33%; P=0.01). Major morbidity, mortality, and mean length of stay remained similar in all groups. CONCLUSIONS: A total of 50 laparoscopic reoperations might be needed to achieve an appropriate learning curve with reduced operative time and lower conversion rates. Further research is needed to determine the learning process of re-laparoscopy for treating complications after colorectal surgery.

Consecutive Laparoscopic Colorectal Resections in a Single Workday by the Same Surgeon: Efficient or Risky?

Background: As laparoscopic colorectal surgery (LCS) continues increasing worldwide, surgeons may need to perform more than one LCS per day to accommodate this higher demand. We aimed to determine the safety of performing consecutive LCSs by the same surgeon in a single workday. Materials and Methods: Consecutive LCSs performed by the same surgeon from 2006 to 2019 were included. The sample was divided into two groups: patients who underwent the first (G1) and those who underwent the second and the third (G2) colorectal resections in a single workday. LCSs were stratified into level I (low complexity), level II (medium complexity), and level III (high complexity). Demographics, operative variables, and postoperative outcomes were compared between groups. Results: From a total of 1433 LCSs, 142 (10%) were included in G1 and 158 (11%) in G2. There was a higher rate of complexity level III LCS (G1: 23% versus G2: 6%, P < .0001) and a longer operative time (G1: 160 minutes versus G2: 139 minutes, P = .002) in G1. There were no differences in anastomotic leak, overall morbidity, or mortality rates. Mean length of hospital stay and readmission rates were similar between groups. Conclusion: Multiple consecutive laparoscopic colorectal resections can be safely performed by the same surgeon in a single workday. This efficient strategy should be encouraged at high-volume centers with experienced colorectal surgeons.

Second Laparoscopic Colorectal Resection: Safety and Feasibility.

BACKGROUND: As laparoscopic colorectal surgery continues increasing worldwide, the need of having a second laparoscopic colorectal resection (SLCR) might increase as well. Experience with this challenging procedure is scarce. The aim of this study was to evaluate the safety and feasibility of SLCR. METHODS: A retrospective analysis of a prospectively collected database of patients undergoing colorectal surgery who needed an SLCR during the period 2008-2020 was performed. Demographics, operative variables, and postoperative outcomes were analyzed. A propensity score matching with a control population undergoing a first elective colorectal resection was performed. RESULTS: A total of 1918 patients underwent colorectal surgery and 32 patients (1.7%) who required a SLCR were included for analysis; 17 (53.1%) were male, and the mean age was 71 (39 to 89) years. The median time between the first and second operations was 69 (6 to 230) months. At the second resection: The median operative time was 170 (90 to 380) minutes, there were 3 (9%) intraoperative complications and 2 (6%) conversions. Overall postoperative morbidity and major morbidity rates were 34% and 19%, respectively. Four patients (12.5%) required reoperation and 1 (3.1%) died of septic shock after an anastomotic leak. After propensity score matching, SLCR was more frequently performed by colorectal surgeons, and no differences in perioperative variables were observed compared with the control group. CONCLUSIONS: SLCR can be safely performed without jeopardizing perioperative outcomes. Further studies are needed to confirm the benefits of the minimally invasive approach in colorectal second resection and to elucidate the long-term outcomes.

Laparoscopic resection and primary anastomosis for perforated diverticulitis: with or without loop ileostomy?

BACKGROUND: Evidence is growing about the benefits of laparoscopic resection with primary anastomosis (RPA) in perforated diverticulitis. However, the role of a diverting ileostomy in this setting is unclear. The aim of this study was to analyze the outcomes of laparoscopic RPA with or without a proximal diversion in Hinchey III diverticulitis. METHODS: This is a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for perforated Hinchey III diverticulitis during the period 2000-2019. The sample was divided into two groups: RPA without diversion (G1) and RPA with protective ileostomy (G2). Primary outcomes of interest were 30-day overall morbidity, mortality, length of hospital stay (LOS), and urgent reoperation rates. Secondary outcomes of interest included operative time, readmission, and anastomotic leak rates. RESULTS: Laparoscopic RPA was performed in 94 patients: 76 without diversion (G1) and 18 with proximal loop ileostomy (G2). Mortality (G1: 1.3% vs. G2: 0%, p = 0.6), urgent reoperation (G1: 7.9% vs. G2: 5.6%, p = 0.73), and anastomotic leak rates (G1: 5.3% vs. G2: 0%, p = 0.32) were comparable between groups. Higher overall morbidity (G1: 27.6% vs. G2: 55.6%, p = 0.02) and readmission rates (G1: 1.3% vs. G2: 11.1%, p = 0.03), and longer LOS (G1: 6.3 vs. G2: 9.2 days, p = 0.02) and operative time (G1: 182.4 vs. G2: 230.2 min, p = 0.003) were found in patients with proximal diversion. CONCLUSION: Laparoscopic RPA had favorable outcomes in selected patients with Hinchey III diverticulitis. The addition of a proximal ileostomy resulted in increased morbidity, readmissions, and length of stay. Further investigation is needed to establish which patients might benefit from proximal diversion.

"Early" Reoperation to Treat Complications Following Laparoscopic Colorectal Surgery: The Sooner the Better.

BACKGROUND: Some postoperative complications after laparoscopic colorectal surgery (LCS) require reoperation to be treated. However, if the timing to perform this reoperation has some influence on outcome remains elusive. The aim of this study was to analyze if the timing to perform the reoperation has some influence in postoperative outcomes. METHODS: A retrospective analysis of patients undergoing LCS and required a reoperation during the period 2000 to 2019 were included. The cohort was divided into 2 groups: early reoperation (ER): ≤48 hours or delayed reoperation (DR): ≥48 hours based on the interval between the suspicion of a complication and reoperation. Demographics, operative variables, and postoperative outcomes were compared between groups. RESULTS: A total of 1843 LCS were performed, 68 (43%) were included in ER and 91 (57%) in DR. A computed tomography scan was less frequently performed in the ER (ER: 45% vs. DR: 70%; P=0.001). The rates of re-laparoscopy (ER: 86% vs. 73%; P=0.04) and negative findings in the reoperation (ER: 13% vs. DR: 1%, P=0.001) were higher in ER. There were no statistically significant differences in overall major morbidity (ER: 9% vs. DR: 21%; P=0.06) and mortality rate (ER: 4% vs. DR: 8.7%; P=0.28) between groups. The need of intensive care unit was significantly higher and the length of stay longer for patients in the DR group. CONCLUSIONS: Despite a greater risk of negative findings, ER within 48 hours after the suspicion of a complication after a LCS offers higher chances of using a laparoscopic approach and it could probably provide better postoperative outcomes.

Usefulness of a mobile app to improve performance of specialists in responding correctly to CRC screening and surveillance clinical scenarios.

Background and study aims The adherence to and knowledge of physicians about colorectal cancer (CRC) screening and surveillance guidelines is still suboptimal, threatening the effectiveness of CRC screening. This study assessed the usefulness of a mobile decision support system (MDSS) to improve physician ability to recommend proper timing of and intervals for CRC screening and surveillance. Patients and methods This was a binational, single-blinded, randomized clinical trial including gastroenterologists and colorectal surgeons from Argentina and Uruguay. The specialists were invited to respond to a questionnaire with 10 CRC screening and surveillance clinical scenarios, randomized into two groups, with and without access to a dedicated app (CaPtyVa). The main outcome measure was the proportion of physicians correctly solving at least 60 % of the clinical cases according to local guidelines. Results A total of 213 physicians were included. The proportion of physicians responding correctly at least 60 % of the vignettes was higher in the app group as compared to the control group (90 % versus 56 %) (relative risk [RR] 1.6 95 % confidence interval [CI] 1.34-1.91). The performance was also higher in the app group for both vignette categories: CRC screening (93 % vs 75 % RR 1.24, 95 %CI 1.01-1.40) and surveillance (85 % vs 47 % RR 1.81 95 %CI 1.46-2.22), respectively. Physicians considered the app easy to use and of great utility in daily practice. Conclusions A MDSS was shown to be a useful tool that improved specialist performance in solving CRC screening and surveillance clinical scenarios. Its implementation in daily practice may facilitate the adherence of physicians to CRC screening and surveillance guidelines.

Laparoscopic approach to colonic perforation due to colonoscopy.

BACKGROUND: Iatrogenic perforation due to colonoscopy is the most serious complication of this procedure. Usually, resolution of this event requires segmental resection. The laparoscopic approach could be an option to minimize the outcome of this complication. The aim of the present study was to assess the effectiveness of the laparoscopic approach in treating colonic perforations due to colonoscopy. METHODS: Between July 1997 and November 2008 data were collected retrospectively on all patients who underwent colonoscopy and had a perforation caused by the procedure. Patients with other complications after colonoscopy as well as other colonic perforations were excluded. According to the method employed for the approach, the series was divided in two groups: those treated by the laparoscopic approach (group I; GI) and those treated via laparotomy (group II; GII). Morbidity and recovery parameters were compared between the two groups. Statistical analysis was performed using Student's t-test and the chi square test. RESULTS: A total of 14,713 colonoscopies were performed during the study period. Of these, 10,299 (73 %) were diagnostics and 4,414 (27%) were therapeutics. There were 20 (0.13%) iatrogenic perforations (GI = 14 versus GII = 6). The mean age of the patients was 62 +/- 12.1 years. There were no differences in patient demographics, co-morbidities, and American Society of Anesthesiologists (ASA) grades between the groups. Seventeen patients had segmental colectomy with primary anastomosis (GI: 13 versus GII: 4). One patient in each group had simple suture with diverting ileostomy, and one patient from GII underwent a Hartmann's procedure. Patients from GI had a shorter hospital stay (GI: 4.2 +/- 2.06 days versus GII 11.5 +/- 8.8 days; P = 0.007) and there were no differences in complication rate compared with GII (GI: 3 versus GII: 5; P = 0.058). CONCLUSIONS: Laparoscopic colectomy is effective in resolving colonic perforation due to colonoscopy, and it might offer benefits over the open approach.

Is a laparoscopic approach useful for treating complications after primary laparoscopic colorectal surgery?

PURPOSE: Although the use of laparoscopy for the management of postoperative complications has been previously well documented for different pathologies, there is scarce information regarding its use after laparoscopic colorectal surgery. METHODS: Data were prospectively collected from all patients undergoing laparoscopic colorectal surgery between June 2000 to October 2007. Patients were divided into two groups according to the approach used for the reoperation: laparoscopy (Group I) or laparotomy (Group II). Data were statistically analyzed by using Student's t-test and chi-squared test. RESULTS: In all, 510 patients were analyzed. Twenty-seven patients (5.2 percent), 14 men and 13 women (men/women Group I: 10/7 vs. Group II: 4/6; P = not significant (NS)), required a second surgery because of postoperative complications (Group I: 17 (63 percent); Group II: 10 (37 percent)). Mean age was 60 +/- 17 years (Group I: 61.7 +/- 17.7 vs. Group II: 57.1 +/- 16 years; P = NS). Fifteen patients (55.5 percent) had anastomotic leaks (Group I 13/17 (76.5 percent) vs. Group II 2/13 (15 percent); P = 0.004). The were no differences between the groups regarding the length of stay or postoperative complications (Group I: 11.9 +/- 9.6 vs. Group II: 18.1 +/- 19.7 days: P = NS; Group I: 1 vs. Group II: 3; P = NS). CONCLUSIONS: Laparoscopic approach is a useful tool for treating complications after laparoscopic colorectal surgery, especially anastomotic leaks. Randomized, controlled trials are necessary to validate these findings.

Patients with less than three episodes of diverticulitis may benefit from elective laparoscopic sigmoidectomy.

BACKGROUND: This study was designed to asses the predictive factors of postoperative complications in patients who underwent a laparoscopic elective approach for recurrent diverticulitis and to determine the relationship between the number of acute episodes and surgical morbidity. METHODS: A retrospective analysis was performed on patients with colonic diverticular disease treated by an elective laparoscopic approach between July 2000 and November 2007. The variables studied were age, sex, BMI, ASA, number of previous acute episodes, local severity, abdominal surgery history, comorbidity, and laparoscopic training of the surgeon. Logistic regression analysis was used to establish significant results. RESULTS: A total of 137 patients were analyzed; 87 (63.5%) were men with a mean age of 56.7 (range, 27-89) years. Intraoperative and postoperative complications occurred in 2.9% (n = 4) and 12.4% (n = 17) of the patients respectively. Conversion rate was 9.4% (n = 13). Local severity (odds ratio (OR), 16.34; 95% confidence interval (CI), 4.1-64.5, p = 0.00007), history of abdominal surgery (OR, 3.02; 95% CI, 0.8-11.5; p = 0.02), and the training of the operating surgeon (OR, 4.8; 95% CI, 1.02-22.7; p = 0.001) were significant risk factors related to surgery conversion. A history of three or more acute episodes was significantly associated with a high severity of local process and was a risk factor related to conversion (OR, 2.6; 95% CI, 0.5-12.3; p = 0.22). The severity of the local process seems to be a risk factor for perioperative complications. A significant association (chi2, 4.45; p = 0.03) between conversion and postoperative complications also was observed (OR: 3.79, 95% CI, 1.02-14.07; p = 0.04). CONCLUSIONS: A history of three or more acute episodes of diverticulitis with conservative treatment is associated with a high severity of the local process during laparoscopic sigmoidectomy and increases the rate of conversion and perioperative complications.

[Controversies in the prostate surgical anatomy. A literature review]. / Controversias en la anatomía quirúrgica prostática. Revisión de la literarura.

INTRODUCTION: Radical prostatectomy technique has improved in the last years based on accumulated surgical experience and new anatomical findings. We think it is time to update anatomical concepts to standardized the criteria formentioning structures related with radical prostatectomy MATERIAL AND METHOD: With the followings key words: "cavernosal nerves, prostatectomy, anatomy, neurovascular bundle" we search in Medline/PubMed database selecting papers fulfilling the search criteria. CONCLUSIONS: The prostate does not have a true capsule but rather an incomplete fibromuscular band as an intrinsic part of the gland. Periprostatic fascia seems to be a different structure from this fibromuscular band. Histologically Denonvilliers's fascia is formed by two thin layers that cannot be separated during surgery. The longitudinal smooth muscle fibres located beneath the posterior bladder neck corresponds to the posterior longitudinal fascia of the detrusor muscle. Cavernosal nerves are located between the two layers of the endopelvic fascia, the inner layer could be named periprostatic fascia and the outer, levator ani fascia. Cavernosal nerves merged from the pelvic plexus running within a neurovascular bundle around the prostate that could be found as a singular bundle or spread all around the anterolateral surface of this gland. There are overlapping terms to designate the pelvic fascia, therefore it could be useful for Urologists to standardized them.

Laparoscopic-assisted proctocolectomy using complete intracorporeal dissection.

PURPOSE: Although many studies have demonstrated good results using laparoscopic proctocolectomy in patients with ulcerative colitis (UC), most surgical procedures require at least one additional incision larger than 5 cm to complete the surgery. The aim of this study was to evaluate the use of laparoscopic proctocolectomy with ileoanal J pouch, with a complete intracorporeal dissection using a 4-5 cm right lower quadrant (RLQ) incision. METHODS: Data were collected prospectively from all patients with UC that were subjected to a proctocolectomy with ileoanal J pouch between August 2003 and December 2006. The dissection was performed completely by laparoscopy using a medial-lateral approach for the colon and a total mesorectal excision for the rectum. Once the rectum was resected laparoscopically, a 4-5 cm incision in the RLQ was performed to resect the specimen and then an end or a loop ileostomy was implanted at the RLQ wound. The surgery was performed in two (proctocolectomy with ileoanal J pouch and loop ileostomy) or three steps (subtotal colectomy and end ileostomy with sigmoid fistula; proctectomy with ileoanal J pouch; and loop ileostomy). RESULTS: A total of 47 surgical procedures were performed in 32 patients with a mean age of 34.5 +/- 15.7 years, of which 56% were male. The mean body mass index was 21 +/- 16 kg/m(2); 50% of patients underwent surgery in two steps and the other 50% in three steps. Surgery was converted in five (10.6%) cases due to megacolon in one case, narrow pelvis in two, and difficult rectal dissection in two; the overall morbidity rate was 14.9%. Two patients required reoperation and no mortality was registered. The mean operative time was 248 +/- 62 min; proctocolectomy 292 +/- 61 min, subtotal colectomy 203 +/- 43 min, and proctectomy 248 +/- 47 min. The mean hospital stay was 4.8 +/- 1.9 days, and the mean interval time to close loop ileostomies was 64 +/- 12 days. CONCLUSIONS: A complete laparoscopic proctocolectomy dissection is feasible and safe for surgical treatment of UC.