Early results after robot-assisted colorectal surgery.

INTRODUCTION: Implementation of robotic technology in surgery is challenging in many ways. The aim of this study was to present the implementation process and results of the first two years of consecutive robot-assisted laparoscopic (RAL) colorectal procedures. MATERIAL AND METHODS: The study was a retrospective study of a consecutive, unselected patient population. All outcome parameters were predefined and all patients completed 30-day follow-up. All parameters were reported, including complication rate, reoperation rate and mortality. RESULTS: From April 2010 to April 2012, a total of 223 elective RAL colorectal procedures were performed. The procedures were grouped as follows: left colectomy/sigmoid resection (n = 65), low anterior resection (n = 50), abdominoperineal resection (n = 10), right colectomy (n = 56), rectopexia (n = 21), colectomy (n = 8), palliative procedure (n = 8) and stoma reversal (n = 8). The overall mortality rate was 0.4%; intra- and post-operative complication rates were 5.4% and 16%, respectively; and the reoperation rate was 9%. Conversion to open surgery was necessary in 9% of cases. A positive learning curve was found for low anterior resections with a significant decrease in duration of surgery over the course of the study period. CONCLUSION: RAL colorectal surgery can be performed as a standard procedure for most colorectal procedures. Appropriate staff education, surgical plan and quality assessment are necessary and we recommend a credentialing system for robotic surgery certification. Future randomized clinical trials should be performed to evaluate the short- and long-term results in these patients. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Safe laparoscopic colorectal surgery performed by trainees.

OBJECTIVES: Laparoscopic surgery for colorectal cancer is safe, but there have been hesitations to implement the technique in all departments. One of the reasons for this may be suboptimal learning possibilities since supervised trainees have not been allowed to do the operations to an adequate extent for the technique to spread. We routinely plan all operations as laparoscopic procedures and most cases are done by supervised trainees. The present study therefore presents the results of operations performed by trainees compared with results obtained by experienced laparoscopic surgeons. DESIGN: Data for all patients who underwent elective colorectal cancer surgery in 2009 were recorded. Surgeries performed by laparoscopic inexperienced surgeons were compared with the outcome of surgery performed by laparoscopic experienced surgeons. These results were also compared with nationwide data extracted from the national database. SETTING: A university teaching department of surgery. PARTICIPANTS: A total of 131 patients underwent colorectal elective surgery in 2009 in the department. RESULTS: Of the 131 operations, 60% were performed by trainees supervised by experienced laparoscopic colorectal surgeons. The trainees performed a total of 70% of all colonic procedures and 43% of all rectal resections. There were no statistically significant differences between the inexperienced and experienced laparoscopic surgeons with regards to short-term outcome other than increased duration of surgery for colonic resections (198 vs 140 min, p = 0.005). Thus, we found no difference regarding length of stay, conversion to laparotomy, intraoperative bleeding or complications, postoperative complications, or 30-day mortality. CONCLUSIONS: Our data suggest that laparoscopic surgery for colorectal cancer can be performed safely by supervised trainees with good short term results. Therefore, a high volume of operations with an educational potential can easily be maintained when going from open to laparoscopic surgery as the standard operative technique for colorectal cancer in a university department of surgery.

[Good results after Hartmann's operation for rectal cancer in high risk patients]. / Gode resultater efter Hartmanns operation for cancer recti hos højrisikopatienter.

INTRODUCTION: The purpose of this study was to evaluate the incidence of per- and postoperative complications of low anterior resection and Hartmann's operation (HO) for rectal cancer. The study was performed in a department with a high frequency of HO. MATERIAL AND METHODS: Patients who had undergone low anterior resection (LA) or HO for rectal cancer at the Department of Surgery, Gentofte Hospital, between 1 January 2001 and 31 December 2007. RESULTS: A total of 187 patients were operated using LA or HO technique during this period. LA was performed in 103 patients and HO in 84 patients. ASA-scores were significantly higher for patients who underwent HO (p = 0.0066). There was no significant difference in complication rates between the two groups (p = 0.385). The 30-day mortality rate was 3.2% (n = 6) for all patients, and it was not significantly different between the two groups (HO 3.6% (n = 3) and LA= 2.9% (n = 3), p = 1). One ASA III patient who underwent LA died from anastomotic leakage whereas no ASA III patients operated with HO died. There was no significant difference between the groups for any other per- and postoperative complication. CONCLUSION: In this material, HO rather than LA seems to be the safer choice for high risk rectal cancer patients with ASA > 3 in terms of mortality rate compared with the national index.

Increased risk of anastomotic leakage with diclofenac treatment after laparoscopic colorectal surgery.

BACKGROUND: Over a period our department experienced an unexpected high frequency of anastomotic leakages. After diclofenac was removed from the postoperative analgesic regimen, the frequency dropped. This study aimed to evaluate the influence of diclofenac on the risk of developing anastomotic leakage after laparoscopic colorectal surgery. METHODS: This was a retrospective case-control study based on 75 consecutive patients undergoing laparoscopic colorectal resection with primary anastomosis. In period 1, patients received diclofenac 150 mg/day. In period 2, diclofenac was withdrawn and the patients received an opioid analgesic instead. The primary outcome parameter was clinically significant anastomotical leakage verified at reoperation. RESULTS: 1/42 patients in the no-diclofenac group compared with 7/33 in the diclofenac group had an anastomotic leakage after operation (p = 0.018). In a multivariate regressional analysis, none of the recorded factors were significantly associated with the frequency of anastomotical leakages when diclofenac treatment was omitted from the model. CONCLUSIONS: We found an increased number of clinically significant anastomotic leakages in patients receiving oral diclofenac for postoperative analgesia. There is an urgent need to test our hypothesis in prospective randomized clinical trials and to examine whether our findings can be extended to open surgery and to other NSAIDs.

Prevention of parastomal hernia by placement of a polypropylene mesh at the primary operation.

INTRODUCTION: Parastomal hernias occur frequently after placement of a permanent colostomy. Preliminary reports have shown a beneficial effect of placing a mesh at the primary operation to prevent the formation of a parastomal hernia. We studied the safety and prophylactic effect of placing a newly designed polypropylene mesh in an onlay position at the primary operation. METHODS: This was a prospective study that included 25 patients scheduled for elective colorectal surgery. Risk factors for development of parastomal hernia were recorded before surgery. A prepared lasercut polypropylene mesh with six "arms" was placed in an onlay position. Immediate and long-term complications were evaluated by an experienced stoma nurse and a surgeon. Abdominal ultrasound was performed at 6 and 12 months follow-up. Parastomal hernia was defined as both clinical and ultrasonographic signs of protrusion in the vicinity of the stoma. RESULTS: The median follow-up time was 12 (range, 2-26) months. One patient died eight days after surgery. Of the 24 patients included, none had infections or immediate complications after surgery. Two patients had minor complications necessitating a local revision of one of the mesh arms. No other long-term complication was found. Two patients had signs of parastomal hernia at 6 and 12 months follow-up, respectively. CONCLUSIONS: Placement of a polypropylene mesh in an onlay position at the primary operation is a safe procedure and probably results in a low risk of parastomal hernia occurrence.

No-trocar laparoscopic stoma creation.

Creation of an intestinal stoma may be necessary in a wide variety of colorectal diseases of both benign and malignant character. Open and laparoscopic techniques can be used for the fecal diversion. We report a case of a patient with a diverticulitis of the sigmoid colon with abscess formation and fistulation to the abdominal wall and vagina. Owing to severe comorbidity, a permanent fecal diversion was prepared. We performed a laparoscopic no-trocar technique. Only 1 incision, at the planned stoma site, was used. The abdominal wall was elevated with gaspers, no pneumoperitoneum or trocars were used. The laparoscope and reuseable laparoscopic graspers were introduced through the stoma site to correctly identify and grasp a loop of the terminal ileum. Finally, the loop ileostomy was placed on a bar. This laparoscopic technique is a valid alternative to standard laparoscopic stoma creation. Different techniques for stoma creation are discussed.