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After more than thirty years of development, laparoscopic surgery technology has become the main platform for surgery and has been widely applied in various fields of surgery. The safety, feasibility and efficacy of laparoscopic technique have already been confirmed in colorectal surgery. In recent years, with a deeper understanding of concepts such as laparoscopic fascial anatomy, laparoscopic colorectal surgery has made new explorations and advances in surgical approach selection, NOSES, lymph node dissection range, preservation of Denonvillier's fascia, functional protection, lateral lymph node dissection, selection of anal preservation techniques for ultra-low rectal cancer, and totally laparoscopic digestive tract reconstruction. In the field of laparoscopic gastric surgery, evidence-based medical evidence in China has entered a harvest period, moreover, functional preservation surgery, esophageal gastric junction adenocarcinoma, and total laparoscopic anastomosis have also become hot topics in this field with new progress. The medical equipment related to minimally invasive surgery has also been developping in recent years and has played an important role in improving minimally invasive surgery.
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The application of minimally invasive surgery has experienced rapid develop-ment for more than 30 years. The continuous development of minimally invasive technology and instru-ments in the fields of energy platform and imaging equipment has promoted the progress of laparos-copic surgery to be more accurate and secure, and the development of laparoscopic surgery itself has also continuously fed back the innovation of technology and instruments. In recent years, the innovative development of minimally invasive technology and instruments has been more closely combined with the current scientific and technological frontier, leading to the innovative achievements in the fields of robotic surgery, screenless surgery, artificial intelligence, electronic instrument, virtualization and so on. In the new era, surgeons should always keep an eye on the forefront of science and technology, the combination of surgery and technology, application of advanced technology to solve the key problems of current surgery, so as to inject new vitality into the next development of minimally invasive surgery.
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Scientific and technological innovation is the most important role in driving the development of minimally invasive surgery. After more than 30 years of development, modern mini-mally invasive surgery represented by laparoscopic surgery has gradually matured. Various types of minimally invasive surgeries have been popularized, and the difficulty of surgery has changed from extreme to limit. Surgical equipments and instruments can meet the needs of most clinical operations. The future of minimally invasive surgery has reached a crossroad, and only scientific and technological innovation can promote the development of minimally invasive surgery change lanes and overtake, ushering in new development, new methods, and a new world. For innovation, the most important thing is not knowledge, but vision and ideas. A new technological revolution will inevitably bring about changes in the industry. What changes will be ushered in the operation and treatment of diseases in the future? What will be the breakthrough of minimally invasive surgery? It is worth to wait and see. The authors discuss the development direction of minimally invasive surgery based on the recent application of hot technologies in laparoscopic surgery.
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Objective:To investigate the clinical value of magnetic resonance imaging (MRI) based integrated deep learning model for predicting the times of linear staplers used in double stapling technique for middle-low rectal cancer resection.Methods:The retrospective cohort study was conducted. The clinicopathological data of 263 patients who underwent low anterior resection (LAR) for middle-low rectal cancer in Ruijin Hospital of Shanghai Jiaotong University School of Medicine from January 2018 to December 2022 were collected as training dataset. There were 183 males and 80 females, aged 63(55,68)years. The clinicopathological data of 128 patients with middle-low rectal cancer were collected as validation dataset, including 83 males and 45 females, with age as 65(57,70)years. The training dataset was used to construct the prediction model, and the validation dataset was used to validate the prediction model. Observation indicators: (1) clinicopathological features of patients in the training dataset; (2) influencing factors for ≥3 times using of linear staplers in the operation; (3) prediction model construction; (4) efficiency evaluation of prediction model; (5) validation of prediction model. Measurement data with skewed distribution were represented as M( Q1, Q3), and Mann-Whitney U test was used for comparison between groups. Count data were expressed as absolute numbers, and comparison between groups was conducted using the chi-square test. Wilcoxon rank sum test was used for non-parametric data analysis. Univariate analysis was conducted using the Logistic regression model, and multivariate analysis was conducted using the Logistic stepwise regression model. The receiver operating characteristic (ROC) curve was draw and the area under the curve (AUC) was calculated. The AUC of the ROC curve >0.75 indicated the prediction model as acceptable. Comparison of AUC was conducted using the Delong test. Results:(1) Clinicopathological features of patients in the training dataset. Of the 263 patients, there were 48 cases with linear staplers used in the operation ≥3 times and 215 cases with linear staplers used in the operation ≤2 times. Cases with preoperative serum carcinoembryonic antigen (CEA) >5 μg/L, cases with anastomotic leakage, cases with tumor diameter ≥5 cm were 20, 12, 13 in the 48 cases with linear staplers used ≥3 times in the operation, versus 56, 26, 21 in the 215 cases with linear staplers used ≤2 times in the operation, showing significant differences in the above indicators between them ( χ2=4.66, 5.29, 10.45, P<0.05). (2) Influencing factors for ≥3 times using of linear staplers in the operation. Results of multivariate analysis showed that preoperative serum CEA >5 μg/L and tumor diameter ≥5 cm were independent risk factors for ≥3 times using of linear staplers in the operation ( odds ratio=2.26, 3.39, 95% confidence interval as 1.15-4.43, 1.50-7.65, P<0.05). (3) Prediction model construction. According to the results of multivariate analysis, the clinical prediction model was established as Logit(P)=-2.018+0.814×preoperative serum CEA (>5 μg/L as 1, ≤5 μg/L as 0)+ 1.222×tumor diameter (≥5 cm as 1, <5 cm as 0). The image data segmented by the Mask region convolutional neural network (MASK R-CNN) was input into the three-dimensional convolutional neural network (C3D), and the image prediction model was constructed by training. The image data segmented by the MASK R-CNN and the clinical independent risk factors were input into the C3D, and the integrated prediction model was constructed by training. (4) Efficiency evaluation of prediction model. The sensitivity, specificity and accuracy of the clinical prediction model was 70.0%, 81.0% and 79.4%, respectively, with the Yoden index as 0.51. The sensitivity, specificity and accuracy of the image prediction model was 50.0%, 98.3% and 91.2%, respectively, with the Yoden index as 0.48. The sensitivity, specificity and accuracy of the integrated prediction model was 70.0%, 98.3% and 94.1%, respectively, with the Yoden index as 0.68. The AUC of clinical prediction model, image prediction model and integrated prediction model was 0.72(95% confidence interval as 0.61-0.83), 0.81(95% confidence interval as 0.71-0.91) and 0.88(95% confidence interval as 0.81-0.95), respectively. There were significant differences in the efficacy between the integrated prediction model and the image prediction model or the clinical prediction model ( Z=2.98, 2.48, P<0.05). (5) Validation of prediction model. The three prediction models were externally validated by validation dataset. The sensitivity, specificity and accuracy of the clinical prediction model was 62.5%, 66.1% and 65.6%, respectively, with the Yoden index as 0.29. The sensitivity, specificity and accuracy of the image prediction model was 58.8%, 95.5% and 92.1%, respectively, with the Yoden index as 0.64. The sensitivity, specificity and accuracy of the integrated prediction model was 68.8%, 97.3% and 93.8%, respectively, with the Yoden index as 0.66. The AUC of clinical prediction model, image prediction model and integrated prediction model was 0.65(95% confidence interval as 0.55-0.75), 0.75(95% confidence interval as 0.66-0.84) and 0.84(95% confidence interval as 0.74-0.93), respec-tively. There was significant differences in the efficacy between the clinical prediction model and the integrated prediction model ( Z=3.24, P<0.05). Conclusion:The MRI-based deep-learning model can help predicting the high-risk population with ≥3 times using of linear staplers in resection of middle-low rectal cancer with double stapling technique.
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Represented by colorectal cancer, gastrointestinal malignancies have unique clinical characteristics and biological behaviors, ranking high in the incidence and mortality rates in China. In recent years, with technological innovations and continuous optimization of disease management models, the concept of "precision surgery" has been driving the transformation of colorectal cancer surgery from traditional empirical surgical paradigms to modern precision surgical paradigms. Rapid advancements have been made in colorectal surgical treatment, including surgical techniques, instrument platforms, various novel targeted therapies, and immune combination therapies, which have demonstrated significant efficacy in colorectal cancer treatment. Meanwhile, with 30 years of development in laparoscopic colorectal surgery in China, the surgical approach for colorectal cancer has shifted from traditional open-bellied surgery to minimally invasive surgery. The diagnostic and therapeutic models for colorectal cancer patients have gradually transitioned from experience-driven to precision-based and individualized care. Guided by the concept of "precision surgery", this article combines the current status and trends in colorectal cancer surgery to discuss relevant molecular subtyping and precision treatment strategies, aiming to promote precise surgery and comprehensive treatment for colorectal cancer.
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Virtual reality (VR) is a technology that interacts computer-generated three-dimensional scenes with the user′s senses and has been gradually applied in the real medical field. Since the first time of successful attempt in 3D laparoscopic gastrointestinal surgery VR living video broadcast in 2016, the authors have experienced the exploration of the application of this technology (2016-2017) as well as the in-depth research phase (2018-2019). Nowadays, the VR application in our center has entered into the application practice phase (2020 to present). With the technology iteration and more and more application experience acquisition, our current VR application mainly focuses on two practice settings, including the clinical teaching scenarios for early exposure to acute appendicitis for medical undergraduate students and the preoperative communication to give pati-ents an early sense of the process in the operating theatre, and has achieved good application results. With continuous breakthroughs and innovations in software and hardware, we believe that more clinical VR scenarios and the course audience will be expanded to a wider group. The integration of some new hotspots such as Meta-Universe and ChatGPT will make up for the shortcomings in VR content scenarios and interactivity, and its application prospects are infinite.
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Objective:To analyze and summarize the implementation effect of basic essential surgical training (BEST) course of laparoscopic skills over the past 10 years and the practical experience in updating course content and models.Methods:The pre-class assessment questionnaires, basic laparoscopic operation assessment results, and post-class assessment questionnaires of the students who participated in the BEST course of laparoscopic skills were collected. According to the period of the course construction, the students were divided into two groups, namely students who used the course of single training system in the early stage (traditional group) and students who used the course integrating a variety of training systems after the course model was updated in the later stage (test group). The two groups were compared for the scores of track circle moving, tunnel crossing, and high and low columns, as well as their subjective evaluation of course setting and implementation effect. The t-test, Wilcoxon test, or chi-square test was conducted according to the data type using SPSS 13.0. Results:The time for 150 traditional group students to complete track circle moving, tunnel crossing, and high and low columns was 1.08 min (0.81 min, 1.60 min), 2.20 min (1.60 min, 3.27 min), and 4.86 min (3.28 min, 6.36 min), respectively, while the time for 75 test group students to complete the three operations was 1.27 min (0.87 min, 1.83 min), 2.57 min (1.58 min, 4.07 min), and 4.35 min (2.90 min, 6.42 min), respectively, with no significant difference between the two groups ( P>0.05). In terms of students' subjective evaluation of the course, a higher percentage of the test group students were satisfied with classroom environment, teaching method arrangement, training equipment, training opportunities, helping clinical work, and meeting pre-class expectations than those in the traditional group. Conclusion:The constantly updated BEST course can ensure the training quality of trainees and obtain their higher satisfaction. The benefits of this course in clinical practice can be further verified through long-term follow-up of these trainees.
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Minimally invasive technology has entered China for 30 years. With the rapid development of minimally invasive surgery, the laparoscopic vision system has gone from standard definition to high definition, then to ultra high definition, from two-dimensional vision to three-dimensional vision, then to fluorescent visualization navigation. Laparoscopic surgery has ranged from the removal or functional repair of benign diseased organs to the radical treatment of malig-nant tumors, then to more functional protection on the basis of radical treatment. The application scope of laparoscopic surgery has also been popularized in various specialized fields of digestive surgery. The author reviews the development of minimally invasive technology in the past 30 years, sums up the experiences, and looks forward to the future, in order to pay tribute to the 20 years of working together with the Chinese Journal of Digestive Surgery.
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After nearly 30 years of high-speed development of minimally invasive gastric surgery in China, the surgical techniques are well developed. The concept of gastric cancer treatment is constantly changing as the deepening understanding of gastric cancer. Minimally invasiveness and precision is an inevitable trend in gastric surgery. At the same time, science and technology are fast-evolving, which greatly improved the performance of both soft- and hardware. In the future, surgical technology, real-time data and artificial intelligence will be further integrated to facilitate the evolution of minimally invasive surgery to digital surgery era. Therefore, in this article, the authors elaborate on the technical practice and future directions of minimally invasive surgery in this digital medicine era from technology and scientific progress.
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Surgical resection is one of the main steps in the treatment of locally advanced rectal cancer. With the popularization of total mesorectal resection and laparoscopic minimally invasive techniques, related current research on surgical treatment has now entered a relatively high-level stage. In this article, we review the research frontiers of surgical treatment on rectal cancer, including reduction of trocars, specimen retrieval through natural orifices, robotic surgery, high definition/3D/indocyanine fluorescence green surgery, surgical approach and key surgery technology. Based on the current environment of evidence-based medicine, colorectal surgeons should adapt to the changes of the times, actively absorb cutting-edge scientific concepts and technologies and integrate them with surgical equipment and instruments, and carry out rigorous and innovative large-scale prospective clinical trials.
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Objective:To investigate the clinical efficacy of gastrojejunal bypass surgery combined with radical gastrectomy following conversion therapy for gastric cancer with outlet obstruction.Methods:The retrospective and descriptive study was conducted. The clinicopatho-logical data of 10 initially unresectable gastric cancer patients with outlet obstruction who were admitted to Ruijin Hospital of Shanghai Jiao Tong University School of Medicine from October 2019 to July 2020 were collected. There were 8 males and 2 females, aged from 41 to 59 years, with a median age of 53 years. Patients underwent 'sandwich therapy' of gastrojejunal bypass surgery combined with gastrectomy following conversion therapy. Observation indicators: (1) gastrojejunal bypass surgery and postoperative situations; (2) conversion therapy and complications; (3) radical gastrectomy and postoperative situations; (4) follow-up. Follow-up using outpatient examinations or telephone interview was conducted to detect postoperative complications, progress-free survival, tumor recurrence and metastasis up to March 2019. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers. Results:(1) Gastrojejunal bypass surgery and postoperative situations: 10 patients received modified gastrojejunal bypass surgery combined with No.4sb lymph node dissection, without intraoperative serious complications, conversion to laparotomy or death. The operation time, volume of intraoperative blood loss, time to postoperative first flatus, time to liquid diet intake were 73 minutes(range, 60-87 minutes), 33 mL(range,20-110 mL), 3 days(range, 2-6 days), 4 days(range, 4-9 days). One patient had post-operative Clavien-Dindo grade Ⅱ complication of anastomotic bleeding, and was improved after transfusion of blood products. (2) Conversion therapy and complications: of 10 patients, 9 cases received 4 cycles of FLOT regimen. One of the 9 cases was suspended chemotherapy due to Clavien-Dindo grade Ⅱ anastomotic edema after 2 cycles of FLOT regimen. Of 10 patients, there were 6 cases with partial response and 4 cases with stable disease. Of 6 patients with partial response, 4 cases with preoperative cT4b stage were down stage to T4a stage, showing the relationship of tumor with transverse mesentery and pancreatic capsule clearer than the first exploration, 2 cases with preoperative lymph nodes fusion had shrank obviously. Of 4 patients with stable disease, 3 cases were negative for lymph nodes shranking, and the rest 1 case with tumor peritoneal metastasis diagnosed by initial laparoscopy can not be evaluated by imaging examination after chemotherapy. Two of 10 patients had Clavien-Dindo grade I complication of elevated blood glucose during the chemotherapy, which were improved after insulin therapy. (3) Radical gastrectomy and post-operative situations: 10 patients underwent radical resection after conversion therapy. Of 4 cases with stable disease, 3 cases with preoperative lymph nodes fusion showed obvious space between lymph nodes and surrounding tissues at resurgical exploration and received radical resection, 1 case with peritoneal metastasis showed abdominal wall nodelus and omental tuberosity as fibrous scars at resurgical exploration and received radical resection. The operation time, volume of intra-operative blood loss, time to postoperative first flatus, time to initial liquid diet intake, duration of total hospital stay, duration of postoperative hospital stay of 10 patients were 148 minutes(range, 95-195 minutes), 108 mL(range, 100-180 mL), 3 days(range, 2-7 days), 4 days(range, 3-9 days), 11 days(range, 10-21 days), 8 days(range, 7-16 days). Two of 10 patients had perioperative complications. Results of pathological examination of 10 patients showed the number of dissected lymph nodes as 25±6. There were 1 case of stage T1, 5 cases of stage T3, 4 cases of stage T4a. There were 1 case of stage N0, 2 cases of stage N1, 3 cases of stage N2, 4 cases of stage N3. There were 3 cases of tumor regression grade 1a, 1 case of grade 1b, 4 cases of grade 2, 2 cases of grade 3. (4) Follow-up: 10 patients were followed up for 3.9-13.0 months, with a median follow-up time of 6.0 months. The median progression-free survival time of 10 patients was 6.0 months. During the follow-up, 1 case underwent postoperative Clavien-Dindo grade Ⅱ complication of delayed gastric emptying and was improved after symptomatic treatment.Conclusion:The gastrojejunal bypass surgery combined with gastrectomy following conversion therapy for gastric cancer with outlet obstruction is safe and effective.
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Objective:To explore the curative effect of surgical treatment for Crohn′s disease (CD), to investigate the timing of surgical intervention and the choice of surgical methods.Methods:From January 1, 2016 to August 31, 2020, at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, the clinical data of 123 patients with CD and receiving surgical treatment were retrospectively analyzed, which included the type of lesion, the location of lesion, clinical manifestation, surgical method, preoperative inflammatory and nutritional indicators, postoperative recovery of digestive tract function, and the development and treatment of postoperative complications. CD was diagnosed according to Consensus opinion on diagnosis and treatment of inflammatory bowel disease ( Beijing 2018). Patient was classitied according to the Montreal Classification. Postoperative complications were graded according to the Clavien-Dindo Criteria. Mann-Whitney U test was used for statistical analysis. Results:Among 123 patients, according to the Montreal classification, two cases (1.6%) were diagnosed at ≤16 years old (type A1), 66 cases (53.7%) were diagnosed at 17 to 40 years old (type A2), and 55 cases (44.7%) were diagnosed at >40 years old (type A3). The lesions were 52 cases (42.3%) of terminal ileum (L1) type, 20 cases (16.3%) of colon (L2) type, and 51 cases (41.5%) of ileocolon (L3) type. Four cases (3.2%) were non-stenosis and non-penetrating (B1) type, 87 cases (70.7%) were stenosis (B2) type, and 32 cases (26.0%) were penetrating (B3) type. Eighteen patients (14.6%) underwent emergency surgery due to complete intestinal obstruction (10 cases), gastrointestinal perforation (five cases), gastrointestinal bleeding (two cases), and rectovesical fistula complicated with septic shock (one case). One hundred and five patients (85.4%) received selective surgery due to poor conservative treatment effects. 51 cases (41.5%) underwent traditional open surgery and 72 cases (58.5%) underwent laparoscopic surgery. Nineteen patients (15.4%) received temporary or permanent ostomy. The preoperative C reactive protein level of patients with emergency surgery was higher than that of patients undergoing selective surgery ((39.23±24.13) mg/L vs. (11.48±2.68) mg/L), while the levels of plasma albumin (ALB) and pre-ALB were lower than those of patients receiving selective surgery ((29.90±10.60) g/L vs. (38.38±8.30) g/L, (146.00±125.49) mg/L vs. (209.06±61.19) mg/L), and the differences were statistically significant ( Z=9.603, 8.754 and 7.111, all P<0.01). During the follow-up, a total of 23 cases (18.7%) developed postoperative complications, including one case of postoperative intra-abdominal hemorrhage and underwent re-operation (Clavien-Dindo grade Ⅲ complication); four cases of anastomotic leakage after operation; six cases of postoperative paralytic ileus; 11 cases of surgical site infection, all of which were Clavien-Dindo grade Ⅱ complications, and one case of deep venous thrombosis of lower extremity. No patient with severe intraoperative complication was observed, and no patients died during the operation or hospitalization. The postoperative exhaust time of patients was (3.2±1.4) d, the time of open fluid diet was (5.8±0.8) d, the length of hospital stay was (18.0±14.1) d, and the length of postoperative hospital stay was (11.2±8.8) d. Conclusions:The concept of multidisciplinary collaboration should be emphasized in the treatment of CD. Surgical treatment can effectively control the complications and improve the quality of life of patients, but the timing of operation and the choice of surgical methods should be decided prudently after perioperative treatment, multi-disciplinary participated and regulation of the internal environment. The standardized and targeted treatments for the surgical difficulties of inflammatory bowel disease should be conducted.
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Gastric cancer is one of the most common malignant tumors in China, with a high incidence and poor prognosis. It is still the focus of current work to improve the diagnosis rate and investigate the new treatment for gastric cancer. In recent years, intelligent medicine represented by artificial intelligence has been gradually applied in gastric cancer diagnosis and treatment, especially in gastroscopy examination, imaging examination, pathological diagnosis and so on. In terms of minimally invasive surgery for gastric cancer, the emergence of new technologies such as 4K and 3D have further improved the accuracy of surgery. At the same time, laparoscopic fluorescence imaging technology represented by indocyanine green imaging is gradually becoming a new direction for the development of minimally invasive surgery. Combined with the literature at home and abroad, the authors expound the application of minimally invasive intelligent technology in the process of diagnosis and treatment of gastric cancer to fully understand the opportunities and challenges faced by gastric cancer intelligent diagnosis and treatment, break the boundaries of disciplines, and carry out a wide range of 'medical-engineering integration′ research. This will finally benefit patients with gastric cancer.
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The oncological minimally invasive surgery,represented by laparoscopic surgery,has been developed in the past three decades.Despite the techniques and procedures have been improved,the oncological outcomes of radical surgery by minimally invasive approach in several cancer types are still controversial according to the results of recent clinical researches.Whatever the truth is,the key point of tumor radical surgery is the quality control of minimally invasive surgery.Grasping the surgical indications strictly and providing the most suitable treatment modality for cancer patients will be helpful to ensure quality control and minimize risks.In addition,with standardizing minimally invasive surgical procedures by constructing a systematic training system,the quality of minimally invasive tumor surgery can be guaranteed perioperatively.For novel minimally invasive surgical techniques,rigorous and prudent attitude is particularly proposed for the quality control.In the context of highly developed minimally invasive surgery,not only " maintaining speed",but also better "guaranteeing quality" can minimally invasive surgery bring real benefits to more cancer patients.
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Objective:To investigate the application value of three-dimensional (3D) laparoscope in the transanal total mesorectal excision (TaTME).Methods:The retrospective cohort study was conducted. The clinicopathological data of 20 patients with middle and low rectal cancer who underwent TaTME in the Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from June 2018 to October 2019 were collected. There were 15 males and 5 females, aged from 28 to 81 years, with a median age of 64 years. Of the 20 patients, 10 patients using 3D laparoscopic system for transanal approach of TaTME were divided into 3D group, and 10 patients using two-dimensional (2D) laparoscopic system for transanal approach of TaTME were divided into 2D group. Observation indicators: (1) intraoperative situations and postoperative recovery; (2) postoperative pathological examination; (3) follow-up. Follow-up was conducted by outpatient examination and telephone interview to detect survival of patients and recurrence and metastasis of tumors in patients up to April 2020. Measurement data with skewed distribution were represented as M (range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was analyzed using the Fisher exact propability. Comparison of ordinal data was analyzed using the Mann-Whitney U test. Results:(1) Intraoperative situations and postoperative recovery: patients in the two groups completed surgeries successfully, without tranversion to laparostomy from laparoscopic surgery, transversion to transabdominal surgery from transanal surgery, or intraoperative death. The cases with terminal ileostomy, cases with manual anstomosis or mechanical anastomosis (anastomotic methods), operation time, volume of intra-operative blood loss, duration of postoperative hospital stay, cases with anastomotic leakage or anastomotic hemorrahge (postoperative short-term complications), cases with anastomotic stenosis of the 3D group were 7, 4, 6, 150 minutes (range, 100-220 minutes), 50 mL (range, 30-100 mL), 8.5 days (range, 7.0-16.0 days), 2, 0, 1, respectively, versus 8, 5, 5, 180 minutes (range, 120-250 minutes), 100 mL (range, 30-200 mL), 9.5 days (range, 6.0-17.0 days), 1, 1, 1 of the 2D group. There was no significant difference in the terminal ileostomy, anastomotic methods, postoperative short-term complications, or anastomotic stenosis between the two groups ( P>0.05). There was no significant difference in the operation time, volume of intraoperative blood loss, or duration of postoperative hospital stay between the two groups ( Z=1.909, 1.827, 0.687, P>0.05). Patients with short-term complications in the two groups were improved after conservative treatments. There was 1 patient with anastomotic stenosis in either group, and they were improved after endoscopic balloon dilatation. (2) Postoperative pathological examination: the maximum tumor diameter, distal margin of the tumor, the number of lymph nodes harvested, cases with cancer nodes in the mesentery, cases with complete mesentery or median complete mesentery (the integrity of mesentery), cases in stage Ⅰ, Ⅱ, Ⅲ (postoperative pathological stage) of the 3D group were 3.8 cm (range, 1.8-5.0 cm), 1.0 cm (range, 0.5-2.5 cm), 14.5 (range, 6.0-19.0), 1, 9, 1, 4, 2, 4, respectively, versus 4.8 cm (range, 1.0-8.5 cm), 0.8 cm (range, 0.3-1.5 cm), 15.5 (range, 8.0-18.0), 1, 8, 2, 2, 4, 4 of the 2D group. There was no significant difference in the maximum tumor diameter, distal margin of the tumor, the number of lymph nodes harvested, the integrity of mesentery, or postoperative pathological stage between the two groups ( Z=1.673, 1.772, 0.038, 0.610, 0.482, P>0.05). There was no significant difference in the cases with cancer nodes in the mesentery between the two groups ( P>0.05). Patients in the two groups had negative distal margin and circumferential margin. (3) Follow-up: patients in the 3D group and 2D group were followed up for 11 months (range, 6-16 months) and 13 months (range, 6-21 months), respectively. During the follow-up, there was no local recurrence, distal metastasis, or tumor-related death. Conclusions:3D laparoscope applied in the TaTME can achieve similar clinical efficacy with 2D laparoscope, which may have a positive impact on the operation time and volume of intraoperative blood loss.
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The development and innovation of laparoscopic vision platform has promoted the innovation of surgical concept and technology from laparotomy to minimally invasive surgery. From the initial use of reflector device with candlelight to observe the interior of the human body cavity, to the high-definition and ultra-high-definition laparoscopic vision system, from laparoscopic cholecystectomy, to the popularization and promotion of various laparoscopic surgery for malignant tumor, surgery has undergone great changes due to minimally invasive technology. In the new era, the application of three-dimensional and 4K laparoscope brings a new perspective to minimally invasive surgery, so as to promote the development of surgery in the direction of accurate anatomy and functional protection. In the future, stimulated by concept renovation in post-epidemic era of COVID-19, virtual reality technology and robotic surgery supported by the fifth generation wireless systems, as well as tele-surgery and distance training and teaching based on it, will become a new perspective for the development of minimally invasive surgery.
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The development and innovation of laparoscopic vision platform has promoted the innovation of surgical concept and technology from laparotomy to minimally invasive surgery. From the initial use of reflector device with candlelight to observe the interior of the human body cavity, to the high-definition and ultra-high-definition laparoscopic vision system, from laparoscopic cholecystectomy, to the popularization and promotion of various laparoscopic surgery for malignant tumor, surgery has undergone great changes due to minimally invasive technology. In the new era, the application of three-dimensional and 4K laparoscope brings a new perspective to minimally invasive surgery, so as to promote the development of surgery in the direction of accurate anatomy and functional protection. In the future, stimulated by concept renovation in post-epidemic era of COVID-19, virtual reality technology and robotic surgery supported by the fifth generation wireless systems, as well as tele-surgery and distance training and teaching based on it, will become a new perspective for the development of minimally invasive surgery.
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Objective:To primarily investigate the application value of glasses-free three-dimensional (3D) laparoscopy system in laparoscopic radical resection of gastrointestinal malignant tumors.Methods:The retrospective cohort study was conducted. The clinical data of 165 patients with gastrointestinal malignant tumors who were admitted to the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between October 2018 and May 2019 were collected. There were 99 males and 66 females, aged from 28 to 86 years, with a median age of 63 years. There were 68 of 165 patients with gastric cancer and 97 with colorectal cancer. Sixteen patients with gastric cancer who underwent laparoscopic radical gastrectomy using the glasses-free 3D laparoscopy system were divided into glasses-free 3D gastric cancer group, and 52 patients with gastric cancer who underwent laparoscopic radical gastrectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D gastric cancer group. Nineteen patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the glasses-free 3D laparoscopy system were divided into glasses-free 3D colorectal cancer group, and 78 patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D colorectal cancer group. Observation indicators: (1) operative situations of patients with gastric cancer; (2) postoperative recovery of patients with gastric cancer; (3) postoperative pathological examination results of patients with gastric cancer; (4) operative situations of patients with colorectal cancer; (5) postoperative recovery of patients with colorectal cancer; (6) postoperative pathological examination results of patients with colorectal cancer; (7) follow-up. Follow-up was conducted by outpatient examination or telephone interview to detect complications and survival of patients up to the postoperative 30th day. Measurement data with skewed distribution were represented as M ( P25, P75) or M (range), and comparison between groups was analyzed by the Mann-Whitney U test. Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Operative situations of patients with gastric cancer: all the 68 gastric cancer patients received successfully laparoscopic radical gastrectomy, without intraoperative complication or conversion to laparotomy. Cases with distal gastrectomy or total gastrectomy(surgical methods) , operation time, volume of intraoperative blood loss were 11, 5, 195 minutes(169 minutes, 214 minutes), 20 mL (10 mL, 90 mL) in patients of the glasses-free 3D gastric cancer group, and 31, 21, 196 minutes(173 minutes, 222 minutes), 40 mL(20 mL, 100 mL) in patients of the polarized glasses 3D gastric cancer group, with no significant difference between the two groups ( χ2=0.432, Z=-0.362, -1.065, P>0.05). (2) Postoperative recovery of patients with gastric cancer: the time to first flatus, time to initial semi-fluid diet intake, duration of postoperative hospital stay were 2 days(2 days, 3 days), 6 days(5 days, 7 days), 10 days(9 days, 14 days) in patients of the glasses-free 3D gastric cancer group, and 2 days(2 days, 3 days), 6 days(5 days, 6 days), 11 days(9 days, 14 days) in patients of the polarized glasses 3D gastric cancer group, with no significant difference between the two groups ( Z=-0.163, -1.870, -0.570, P>0.05). The postoperative complication incidence of the glasses-free 3D gastric cancer group was 12.5%(2/16), including 1 case with duodenal stump fistula, 1 case with anastomotic bleeding. The postoperative complication incidence of the polarized glasses 3D gastric cancer group was 17.3%(9/52), including 2 cases with duodenal stump fistula, 2 cases with delayed gastric emptying, 1 case with pulmonary infection, 1 case with abdominal bleeding, 1 case with anastomotic leakage, 1 case with chylous fistula, 1 case with intestinal obstruction. All the patients with complications were cured after symptomatic supportive treatment. There was no significant difference in the complication incidence between the two groups ( χ2=0.209, P>0.05). (3) Postoperative pathological examination results of patients with gastric cancer: the tumor diameter, cases in stage T1, T2, T3, T4 (tumor T staging), cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, cases in stage N0, N1, N2, N3 (tumor N staging), the number of positive lymph node, the number of lymph node dissected, cases with qualified lymph node dissected, cases in stage Ⅰ, Ⅱ, Ⅲ, Ⅳ (TNM clinical staging) were 3.0 cm(2.0 cm, 5.0 cm), 5, 3, 1, 7, 8, 5, 2, 3, 2, 4, 7, 6(1, 15), 28(22, 43), 15, 4, 3, 9, 0 in patients of the glasses-free 3D gastric cancer group, and 3.5 cm(2.0 cm, 6.0 cm), 13, 10, 4, 25, 19, 23, 2, 26, 6, 7, 13, 1(0, 7), 29(21, 39), 43, 21, 10, 20, 1 in patients of the polarized glasses 3D gastric cancer group. There was no significant difference in the tumor diameter, tumor T staging, cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, the number of lymph node dissected, cases with qualified lymph node dissected, TNM clinical staging between the two groups ( Z=-0.570, -0.434, χ2 =0.926, 0.851, 1.655, Z=-0.579, χ2=1.193, Z=-1.134, P>0.05). There were significant differences in the tumor N staging and the number of positive lymph node between the two groups ( Z=-2.167, -2.283, P<0.05). (4) Operative situations of patients with colorectal cancer: all the 97 colorectal cancer patients received successfully laparoscopic radical colectomy or proctectomy, without intraoperative complications or conversion to laparotomy. Cases with radical colectomy or proctectomy (surgical methods), operation time, volume of intraoperative blood loss were 7, 12, 132 minutes(97 minutes, 156 minutes), 20 mL(10 mL, 50 mL) in patients of the glasses-free 3D colorectal cancer group, and 40, 38, 124 minutes(110 minutes, 159 minutes), 25 mL(15 mL, 65 mL) in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( χ2 =1.276, Z=-0.141, -0.863, P>0.05). (5) Postoperative recovery of patients with colorectal cancer: the time to first flatus, time to initial semi-fluid diet intake, duration of postoperative hospital stay were 2 days(1 days, 3 days), 5 days(5 days, 6 days), 8 days(7 days, 10 days) in patients of the glasses-free 3D colorectal cancer group, and 2 days(1 days, 3 days), 5 days(4 days, 6 days), 8 days(6 days, 10 days) in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( Z=-0.678, -1.751, -1.674, P>0.05). The complication incidence of the glasses-free 3D colorectal cancer group was 15.8%(3/19), including 1 case with anastomotic leakage after low anterior proctectomy, 1 case with incision infection, 1 case with urinary tract infection. The complication incidence of the polarized glasses 3D colorectal cancer group was 14.1%(11/78), including 3 cases with anastomotic leakage after low anterior proctectomy, 2 cases with intestinal obstruction, 2 cases with urinary tract infection, 2 cases with incision infection, 1 case with anastomotic bleeding, 1 case with pulmonary infection. One of the 3 cases with anastomotic leakage after low anterior proctectomy in the polarized glasses 3D colorectal cancer group was cured after remedial terminal ileostomy. The other patients with complications were cured after symptomatic supportive treatment. There was no significant difference in the complication incidence between the two groups ( χ2=0.035, P>0.05). (6) Postoperative pathological examination results of patients with colorectal cancer: the tumor diameter, cases in stage T1, T2, T3, T4 (tumor T staging), cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, cases in stage N0, N1-N2 (tumor N staging), the number of positive lymph node, the number of lymph node dissected, cases with qualified lymph node dissected, cases in stage Ⅰ, Ⅱ, Ⅲ, Ⅳ (TNM clinical staging) were 5.0 cm(3.0 cm, 6.0 cm), 3, 2, 7, 7, 3, 2, 1, 8, 11, 0(0, 4), 17(14, 23), 18, 2, 3, 12, 2 in patients of the glasses-free 3D colorectal cancer group, and 4.0 cm(3.0 cm, 5.0 cm), 7, 16, 43, 12, 14, 12, 7, 46, 32, 0(0, 1), 16(13, 19), 74, 14, 17, 40, 7 in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( Z=-0.768, -1.135, χ2 =0.049, 0.292, 0.278, 1.762, Z=-0.694, -1.349, χ2=0.001, Z=-1.011, P>0.05). (7) Follow-up: 165 patients received follow-up, with out short-term reoperation or postoperative death in the postoperative 30 days. Conclusion:There is no significant difference in the efficacy between glasses-free 3D laparoscopic surgery and polarized glasses 3D laparoscopic surgery for radical resection of gastrointestinal malignant tumors, of which the clinical value requires further study.
RESUMEN
The oncological minimally invasive surgery, represented by laparoscopic surgery, has been developed in the past three decades. Despite the techniques and procedures have been improved, the oncological outcomes of radical surgery by minimally invasive approach in several cancer types are still controversial according to the results of recent clinical researches. Whatever the truth is, the key point of tumor radical surgery is the quality control of minimally invasive surgery. Grasping the surgical indications strictly and providing the most suitable treatment modality for cancer patients will be helpful to ensure quality control and minimize risks. In addition, with standardizing minimally invasive surgical procedures by constructing a systematic training system, the quality of minimally invasive tumor surgery can be guaranteed perioperatively. For novel minimally invasive surgical techniques, rigorous and prudent attitude is particularly proposed for the quality control. In the context of highly developed minimally invasive surgery, not only "maintaining speed" , but also better "guaranteeing quality" can minimally invasive surgery bring real benefits to more cancer patients.
RESUMEN
Minimally invasive surgery has got a great development in the past 30 years.Currently,a series of new technique and novel technology have been introduced,which bring us a new prospect and also new challenges.In surgery methods,Adenocarcinoma of esophagogastric junction (AEG) is also a hot topic recently,especially the gastrointestinal tract reconstruction of AEG in total laparoscopic surgery.Transanal total mesorectal excision has several advantages in difficult cases of lower rectal cancer,but is still under debate for oncological safety.3D laparoscopic surgery,glass-free 3D laparoscopic surgery,4K laparoscopic surgery and laparoscopic indocyanine green fluorescence imaging are innovative technology in minimally invasive surgery at home and abroad.The fusion and hybrid of the new technique and novel technology might be the future of the minimally invasive surgery.