Minimally invasive surgery for maximally invasive tumors—pelvic exenterations for rectal cancers: are we prepared?

Despite the public awareness of colorectal cancer screening with more and more early premalignant or malignant lesions detected, surgeons still face the challenges of operating for a patient suffering from locally advanced rectal carcinoma which required pelvic exenterations, and surgical outcomes mostly influenced by margin status, adjuvant chemotherapy, positive lymph nodes and liver metastasis, etc. Open pelvic exenteration has been the adopted approach in the past and laparoscopic surgery is another option in expert centers. A study in this issue of the Journal of Minimally Invasive Surgery demonstrated promising results of minimally invasive approaches for pelvic exenteration in patients with locally advanced rectal carcinoma, with overall complication rate of 28.2% with a 7.3% circumferential resection margin positivity and with no distal margin involvement, with local recurrence rate of 8.1% and overall survival of 85.2% by 2-year follow-up. We are expecting more results in the future to support the routine implementation of minimally invasive pelvic exenterations.

The Impact of Double Fixation with Titanium Tack and N-Butyl Cyanoacrylate Glue (NBCG) Mesh Fixation versus NBCG Fixation Only in Totally Extra-Peritoneal Hernioplasty with 3-Dimensional Configured Polyester Mesh: A Comparative Study

PURPOSE: Our aim is to compare 3-dimensional mesh fixation using titanium tacks combine with n-butyl cyanoacrylate glue (NBCG) (COMBINE group) versus NBCG only (NBCG group) in totally extraperitoneal inguinal hernioplasty (TEP). METHODS: This is a retrospectively study of patients diagnosed with unilateral inguinal hernia and underwent TEP with 3-dimensional configured polyester mesh fixation using titanium tacks combine NBCG or NBCG only at the University of Hong Kong-Shenzhen Hospital with data prospectively collected. Operative details and outcomes were compared including: operating time, size of defect, total hospital cost, post-operative pain scores and recurrence. RESULTS: From 08.2013 to 03.2016 a total of 219 patients were included. There was no significant difference between COMBINE group and NBCG group in mean age (52.5 years versus 48.2 years), mean size of defects (2.4 cm versus 2.6 cm), and operating time (121 mins versus 111 mins). There were significant differences between COMBINE group and NBCG group in total hospital cost (3035 USD versus 2022 USD), post-operative pain score on day 2 to day 4 (VAS: 1.4 versus 1.0, 1.0 versus 0.4, 0.5 versus 0.2). There was one recurrence in COMBINE group (p=0.276) with overall recurrence of 0.46%. CONCLUSION: Patients with inguinal hernia underwent TEP with 3-dimensional configured polyester mesh with NBCG fixation only having comparative surgical outcome to COMBINE group. A recurrence of 0.46% can be achieved with this combination. Tacks fixation may cause more post-operative pain and increase hospital cost. Use of N-butyl cyanoacrylate glue in TEP is safe and effective in our clinical series.

Colorectal Surgery Training in the Hong Kong Special Administrative Region and China

Until 1st July 1997, Hong Kong was under the governance of the British Government; therefore, the British system of education was followed. After internship, 7 years of general surgical training is required to obtain registration and fellowship qualifications of the College of Surgeon of Hong Kong and Edinburg. After having become a specialist in general surgery, the surgeon could choose to specialize in colorectal surgery with an additional 3 to 5 years of specialist training in an accredited centre and 6 months of overseas training with subsidies. On the contrary, China has more than 600 medical schools, and students can enroll in different programs to become a medical practitioner. Despite a great discrepancy exists in the quality of teaching and supervision but there are comprehensive regulations governing the accreditation of hospitals, credentialing of operations, medical records, etc. to ensure medical and patient safety. Vast amounts of resources are being invested to strengthen the quality and to advance the technology used in patient care, not only by supporting basic and clinical research but also by providing extra resources to “import” experts and help develop services with clinical excellence. To accomplish this, the aim of the “three fames project” with a 5-year funding of 3 million United States dollar is to invite overseas experts to help build medical teams in specific areas. Due to its huge population (more than 1.3 billion people), China is a country full of potential for development in clinical research, collaboration, knowledge exchange, and the provision of premier medical services.

Minimally Invasive Approach to Supra-pubic and Non-Midline Lower Abdominal Ventral Hernia: An Extended Indication of TAPE Technique

Repair of lower abdominal incisional hernia is always a surgical challenge. TAPE technique has been described for the repair of supra-pubic midline incisional hernia with satisfactory outcome. Its indication can be extended for treatment of non-midline lower abdominal hernia. Peritoneal incision is created just below the hernia defect with pre-peritoneal dissection to expose supra-pubic preperitoneal space with Cooper's ligament exposed. Non-adhesive mesh then placed over preperitoneal space and partially intra-peritoneally, and cover the whole extra-peritoneal space prepared to ensure enough overlapping. Mesh is fixed by tackers for intra-peritoneal part, most inferior fixation points were at peritoneal incision line. Extra-peritoneal part of meshes is fixed at the safety zone and covered up by the peritoneal flap to avoid mesh migration. Fixation of the meshes at the lateral aspects were facilitated by the peritoneal flap and subsequent fibrosis and adhesion to the extra-peritoneal structures in cases of lateral lower abdominal hernia. Repair of midline and lateral lower abdominal incisional hernia with this novel modified technique with prosthetic mesh is safe and effective. A larger case series and longer follow-up is required for validation of this technique.