SAGES masters program: the top 10 seminal articles for the laparoscopic left and sigmoid colectomy pathway for complex disease.

BACKGROUND: The SAGES University Colorectal Masters Program is a structured educational curriculum that is designed to aid practicing surgeons develop and maintain knowledge and technical skills for laparoscopic colorectal surgery. The Colorectal Pathway is based on three anchoring procedures (laparoscopic right colectomy, laparoscopic left and sigmoid colectomy for uncomplicated and complex disease, and intracorporeal anastomosis for minimally invasive right colectomy) corresponding to three levels of performance (competency, proficiency and mastery). This manuscript presents focused summaries of the top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease. METHODS: A systematic literature search of Web of Science for the most cited articles on the topic of laparoscopic complex left/sigmoid colectomy yielded 30 citations. These articles were reviewed and ranked by the SAGES Colorectal Task Force and invited subject experts according to their citation index. The top 10 ranked articles were then reviewed and summarized, with emphasis on relevance and impact in the field, study findings, strength and limitations and conclusions. RESULTS: The top 10 seminal articles selected for the laparoscopic left/sigmoid colectomy for complex disease anchoring procedure include advanced procedures such as minimally invasive splenic flexure mobilization techniques, laparoscopic surgery for complicated and/or diverticulitis, splenic flexure tumors, complete mesocolic excision, and other techniques (e.g., Deloyers or colonic transposition in cases with limited colonic reach after extended left-sided resection). CONCLUSIONS: The SAGES Colorectal Masters Program top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease anchoring procedure are presented. These procedures were the most essential in the armamentarium of practicing surgeons that perform minimally invasive surgery for complex left and sigmoid colon pathology.

Robotic versus conventional laparoscopic rectal cancer surgery in obese patients.

AIM: Obesity adds to the technical difficulty of laparoscopic colorectal surgery. The robotic approach has the potential to overcome this limitation because of its proposed technical advantages over laparoscopy. The aim of this retrospective study was to compare the short-term outcomes of robotic surgery (RS) vs conventional laparoscopy surgery (LS) in this patient population. METHOD: Patients with a body mass index ≥ 30 kg/m2 undergoing RS or LS for rectal cancer between January 2011 and June 2014 were identified from an institutional database. Perioperative parameters, oncological findings and postoperative 30-day short-term outcomes were compared between the RS and LS groups. RESULTS: The RS and LS groups included 29 and 27 patients, respectively. Groups were comparable in terms of patient demographics, body mass index (34.9 ± 7.2 vs 35.2 ± 5.0 kg/m2 , P = 0.71), comorbidities, surgical and tumour characteristics. Comparison of the intra-operative findings revealed no significant differences between the groups including operative time (329.0 ± 102.2 vs 294.6 ± 81.1 min, P = 0.13), blood loss (434.0 ± 612.4 vs 339.4 ± 271.9 ml, P = 0.68), resection margin involvement (6.9% vs 7.4%, P = 0.99), conversions (3.4% vs 18.5%, P = 0.09) and complications (6.9% vs 0%, P = 0.49). Regarding postoperative outcomes, there were no significant differences in morbidity except that robotic surgery was associated with a quicker return of bowel function (median 3 vs 4 days, P = 0.01) and shorter hospital stay (median 6 vs 7 days, P = 0.02). CONCLUSION: Robotic surgery for rectal cancer in obese patients has short-term outcomes similar to laparoscopy, but accelerated postoperative recovery.

What are the consequences of enlarging the extraction site to exteriorize a large specimen during laparoscopic surgery for Crohn's enteritis?

AIM: The implications of extraction site enlargement for the removal of large specimens during laparoscopic surgery for Crohn's disease have not been clearly described; such a description is the aim of this study. METHOD: An institutional database was queried to identify patients undergoing laparoscopic resection for Crohn's disease through midline incision between 1995 and 2013. Perioperative outcomes were compared among cases completed through their initial extraction site (L), completed after increasing the length of the initial extraction site (IL) for specimen exteriorization, and cases converted to open surgery (C). Univariate and multivariate statistical analyses were performed. RESULTS: Out of 309 patients, 52 required IL and 36 required C. Heavier, older, male patients were more likely to require IL or C. There were no differences in disease behaviour (P = 0.260), procedures performed (P = 0.12) or postoperative morbidity (P = 0.33). IL and L groups had a comparable initial length of hospital stay (LOS), which was shorter than in the C group. While there were no significant differences in causes of readmission (P = 0.31), IL had increased readmission rates compared with L [odds ratio (OR) 2.80, P = 0.021] or C (OR 13.89, P = 0.015). When combining initial and readmission LOS, C and IL groups had comparable overall LOS [median ratio (MR) 1.09, P = 0.57], which was significantly longer than in the L group (MR 1.27, P = 0.02). CONCLUSION: Extraction site enlargement during laparoscopic surgery for enteric Crohn's disease had no impact on primary LOS. However, the shorter initial LOS was offset by increased readmission rates when compared with formal conversion. The threshold to convert in case of anticipated difficulty due to a large specimen should be low.

Laparoscopic versus open fecal diversion: does laparoscopy offer better outcomes in short term?

BACKGROUND: Laparoscopic fecal diversion is performed in patients with complicated colon and rectal diseases. We aim to compare operative and short-term outcomes between laparoscopic and open fecal diversion. METHODS: After obtaining institutional review board approval, patients undergoing laparoscopic or open fecal diversion between February 2010 and September 2012 were reviewed. A straight comparison of the open and laparoscopic groups was made initially; then, patients who underwent laparoscopic fecal diversion were case-matched with open counterparts based on stoma type and primary diagnosis. RESULTS: While body mass index (BMI) was higher in the laparoscopy group (p = 0.04), American Society of Anesthesiologists (ASA) score (p = 0.33) and gender (p = 0.74) were comparable between the study groups in the straight comparison. In the case-matched analysis, type of prior operations (p > 0.05), age (p = 0.79), gender (p > 0.99), BMI (p = 0.1), and ASA (p = 0.25) score were comparable between the groups. Open surgery was associated with increased estimated blood loss (p = 0.01), longer hospital stay (p = 0.0002), higher postoperative ileus (p = 0.03), and higher readmission rates (p = 0.002). CONCLUSIONS: Considering the short-term benefits as regards postoperative recovery and morbidity, fecal diversions should be performed laparoscopically when feasible.

Comparison of hospital costs for single-port and conventional laparoscopic colorectal resection: a case-matched study.

BACKGROUND: Whether single-port laparoscopic (SPL) colorectal resection is cost-effective in comparison to conventional laparoscopy remains unclear. The aim of this study is to compare hospital costs for single-port versus conventional laparoscopic colorectal resections. METHODS: Patients with available cost data who underwent (SPL) colorectal resection between December 2007 and December 2010 were matched with conventional (multiport) laparoscopic (CL) counterparts for age, gender, American Society of Anesthesiologists score, body mass index, operation type and year of surgery. Patients who underwent hand-assisted laparoscopic surgery were not included in the study. Direct hospital costs for the two groups were compared. RESULTS: There were 90 patients in the SPL group and 90 patients in the CL group. Age (p = 0.79), gender (p = 0.88), body mass index (p = 0.82), American Society of Anesthesiologists score (p = 1) and diagnosis (p = 0.85) were similar in both groups. Operation type (p = 1), estimated blood loss (p = 0.17) and length of hospital stay (p = 0.06) were comparable between the groups. Operation time was significantly shorter in the SPL group (p < 0.001), thus anesthesia cost was significantly lower in this group (p = 0.003). Total costs (p = 0.5), operating room (p = 0.65), nursing (p = 0.13), pharmacy (p = 0.6), radiology (p = 0.27), professional (p = 0.38) and pathology/laboratory (p = 0.46) costs were similar between the two groups. CONCLUSIONS: Single-port laparoscopic colorectal resection can be performed with comparable hospital costs to conventional multiport laparoscopy.

Single-port laparoscopic colectomy.

Single-port laparoscopy (SPL) for colorectal surgery was first described for a right hemicolectomy in 2008. Since then, technology and experience have advanced, and SPL is now reported for a variety of colorectal procedures. Multiple case series and reports have demonstrated the adequate safety of SPL, but there are few reports of a measurable benefit of the technique. SPL is a difficult procedure to learn, it may have relatively high costs, and it is more difficult to perform as well as more physically and mentally taxing on the surgeon. Despite the difficulty and potentially increased cost, SPL suits colorectal patients well as they commonly have a stoma or extraction site adequate in size for a single port. There are cosmetic advantages to this technique, but they apply to a small subset of patients requiring colorectal surgery. There are many tips to incorporate SPL into practice successfully, but the procedure requires patience and experience. As surgeons become more facile with this technique, a group that derives a clear benefit beyond cosmesis will arise, likely a subset of reoperative patients requiring fecal diversion. The accompanying video demonstrates, step by step, the authors' technique of total proctocolectomy and ileo-anal pouch using a single-port device.