Does the extraction-site location in laparoscopic colorectal surgery have an impact on incisional hernia rates?

BACKGROUND: Incisional hernias are a common postoperative complication with abdominal surgery. The major risk factors for their development include wound infection, obesity, and age. This study aimed to evaluate the impact of extraction-site location and technique on incisional hernia rates in laparoscopic colorectal surgery. METHODS: A prospective study of 208 consecutive patients who underwent laparoscopic colorectal surgery between March 2002 and July 2006 was performed. The study included only patients who had an extraction site on the abdominal wall. Patients were excluded if they were lost to follow-up evaluation or underwent conversion to open procedure. For the 166 patients included in the study, the mean follow-up period was 20.2 +/- 14.4 months. Extraction-site incisions were classified into two groups: midline or off-midline. Midline wounds involved sharp division of the linea alba and were closed with a single layer of no.1 Vicryl. Off-midline incisions involved sharp division of the anterior and posterior sheaths with blunt spreading of the muscular layers and were closed in two layers with no. 1 Vicryl. Risk factors including wound infection, body mass index (BMI), age, and diabetes were analyzed. RESULTS: The incisional hernia rate for the entire series was 7.8%. The incisional hernia rate was 17.6% for the midline group (n = 74) and 0% for the off-midline group (n = 92) (p = 0.0002, statistically significant). There was no statistically significant difference in age, BMI, diabetes, follow-up time, or wound infection rate between the two groups. CONCLUSION: In this series, the midline extraction site resulted in a significantly higher incisional hernia rate statistically than the off-midline extraction sites. The authors therefore have adopted an off-midline blunt muscle-splitting extraction site when performing laparoscopic colorectal surgery.

Can community surgeons perform laparoscopic colorectal surgery with outcomes similar to tertiary care centres?

INTRODUCTION: The use of the laparoscopic approach in colorectal surgery (LCS) is the subject of active debate. Studies demonstrating its safety and feasibility in tertiary care centres are now available. The aim of this study was to examine the results of LCS performed in a community hospital setting. METHODS: We prospectively studied 100 patients who underwent an LCS at the North Bay District Hospital (a 200-bed community hospital located 350 km away from the nearest tertiary care centre). All operations were performed by 2 community surgeons who transitioned themselves from an open to a laparoscopic approach. RESULTS: Between October 2000 and December 2003, 100 patients (56 women and 44 men, mean age 64 yr) underwent an LCS for benign (n = 54) and malignant (n = 46) disease. Median operating time was 165 minutes (range 70350 min), and the conversion rate was 10%. The intraoperative complication rate was 3%. There were 10 major postoperative complications and 14 minor postoperative complications. There was no intraoperative mortality and one 30-day mortality secondary to cardiogenic shock. The median length of stay was 4.5 days (range 245 d). At a mean follow-up of 18 months, no trocar site or wound recurrences were noted. The mean number of resected lymphnodes was 10.6. CONCLUSION: Our study suggests that it is possible for community surgeons to transition themselves from an open to a laparoscopic approach and to perform LCS with outcomes similar to those of tertiary care centres.

Early experience of stapled hemorrhoidectomy in a community hospital setting.

BACKGROUND: Stapled hemorrhoidectomy was introduced as a new procedure for the surgical management of hemorrhoidal disease in 1993. We present a cohort longitudinal study performed in a community hospital setting where the short-term outcomes of stapled hemorrhoidectomy were compared with those of conventional hemorrhoidectomy. METHODS: We compared 41 consecutive patients who underwent a conventional open diathermy (Ferguson) hemorrhoidectomy between September 1999 and September 2001 with 40 consecutive patients who underwent a stapled hemorrhoidectomy procedure between September 2001 and June 2004. We analyzed perioperative and postoperative complications, length of hospital stay, patient satisfaction and case costing for both groups. RESULTS: The stapled hemorrhoidectomy group comprised 13 men and 27 women. The open hemorrhoidectomy group comprised 9 men and 32 women. There were no intraoperative complications in either group. In the stapled hemorrhoidectomy group, 3 patients presented with postoperative complications and 3 required admission. In the open hemorrhoidectomy group, 14 patients presented with postoperative complications and 11 required admission. At 2-week follow-up, 35 patients (88%) presented no complaints in the stapled hemorrhoidectomy group, versus 27 (66%) in the open hemorrhoidectomy group. The total cost calculated for the stapled hemorrhoidectomy procedure was dollar 716.38, whereas the total cost of the open hemorrhoidectomy procedure was dollar 760.00. CONCLUSIONS: The stapled hemorrhoidectomy technique is a safe alternative to the traditional open hemorrhoidectomy. It can be performed as an outpatient procedure, is well tolerated by patients and is no more expensive than conventional surgical therapy.

The impact of latency on surgical precision and task completion during robotic-assisted remote telepresence surgery.

OBJECTIVE: It has been suggested that robotic-assisted remote telepresence surgery with a signal transmission latency of greater than 300 ms may not be possible. METHODS: We evaluated the impact of four different latencies of up to 500 ms on task completion and error rate in five surgeons after completion of three different surgical tasks. RESULTS: The surgeons were able to complete all tasks with a latency of 500 ms. However, higher latency was associated with higher error rates and task completion time (TCT). There were significant variations between surgeons and different tasks. CONCLUSION: Surgeons are able to complete tasks with a signal transmission latency of up to 500 ms. The clinical impact of slower TCT and increased error rates encountered at higher latency needs to be established.

Establishment of the world's first telerobotic remote surgical service: for provision of advanced laparoscopic surgery in a rural community.

OBJECTIVE: To establish a telerobotic surgical service between a teaching hospital and a rural hospital for provision of telerobotic surgery and assistance to aid rural surgeons in providing a variety of advanced laparoscopic surgery to their community patients. SUMMARY BACKGROUND DATA: The above service was established between St. Joseph's Hospital in Hamilton and North Bay General Hospital 400 km north of Hamilton on February 28, 2003. The service uses an IP-VPN (15 Mbps of bandwidth) commercially available network to connect the robotic console in Hamilton with 3 arms of the Zeus-TS surgical system in North Bay. RESULTS: To date, 21 telerobotic laparoscopic surgeries have taken place between North Bay and Hamilton, including 13 fundoplications, 3 sigmoid resections, 2 right hemicolectomies, 1 anterior resection, and 2 inguinal hernia repairs. The 2 surgeons were able to operate together using the same surgical footprint and interchange roles seamlessly when desired. There have been no serious intraoperative complications and no cases have had to be converted to open surgeries. The mean hospital stays were equivalent to mean laparoscopic LOS in the tertiary institution. CONCLUSIONS: Telerobotic remote surgery is now in routine use, providing high-quality laparoscopic surgical services to patients in a rural community and providing a superior degree of collaboration between surgeons in teaching hospitals and rural hospitals. Further refinement of the robotic and telecommunication technology should ensure its wider application in the near future.

Telementoring: an important enabling tool for the community surgeon.

This study evaluated the efficacy of telementoring as an enabling tool for community general surgeons to perform advanced laparoscopic surgical procedures. We present a series of 19 patients who underwent advanced laparoscopic surgical procedures in two community hospitals, between November 2002 and July 2003, by four community surgeons with no formal advanced laparoscopic training. Each surgeon was telementored by an expert surgeon from a tertiary care hospital. Telementoring was achieved with real-time two-way audio-video communications over Internet Protocol or Integrated Services Digital Network lines with bandwidths from 385 kbps to 1.2 mbps. The procedures included 10 bowel resections, 5 Nissen fundoplications, 2 splenectomies, 1 reversal of a Hartmann procedure, and 1 ventral hernia repair. Two of the 19 procedures (11%) were converted to open. There were no intraoperative complications and two postoperative complications (11%). The primary surgeon considered telementoring useful in all cases (median score, 4 of 5). The mentor was also comfortable with the quality of the laparoscopic surgery performed (median score, 4 of 5). Telecommunication bandwidth for audio and video transmission was found to be a critical factor in the quality of telementoring process. Telementoring is safe and feasible. It allows community surgeons with no formal advanced laparoscopic training to benefit from expert intraoperative advice during the performance of advanced laparoscopic procedures. It may also reduce health-care costs by avoiding the need to refer and transfer patients to tertiary care centers.