Anatomical framework for pre-operative planning of laparoscopic left-sided colorectal surgery: Potential relevance of the distance between the inferior mesenteric artery and inferior mesenteric vein.

BACKGROUND: The medial-to-lateral approach is favored by most colorectal surgeons for laparoscopic retroperitoneal dissection and mobilisation of the left colon. The peritoneal access window, i.e. the distance between the inferior mesenteric vein (IMV) and inferior mesenteric artery (IMA) must be large enough to perform the procedure safely and successfully. However, studies investigating the IMA-IMV distance and factors affecting this variable, are scarce. Therefore, we examined the IMA-IMV and D3-IMA distances to determine an anatomical framework on planning and adapting surgical therapy. BASIC PROCEDURES: The IMA-IMV and D3-IMA distances were retrospectively measured in 230 patients (127 Male/103 Female, Median Age=54.5) who had undergone pre-operative CT-scanning before laparoscopic left-sided colorectal surgery. Two observers rated the images and interrater reliability was calculated. Subgroup, simple and multiple linear regression analyses were performed in order to detect potential interaction between morphometric variables and IMA-IMV distance. MAIN FINDINGS: We demonstrated a significant correlation between the inferior margin of the duodenum and the origin of IMA. Determination of the IMA-IMV distance was simple and reproducible. Approximately 45% of patients undergoing laparoscopic colorectal procedures had a narrow distance (≤50mm). There was a sexual dimorphism in IMA-IMV distance, being consistently large in males. There were no other pre-operative factors which predicted whether the peritoneal dissection window for a medial-to-lateral approach was sufficient. CONCLUSIONS: Our results provide new data for a better understanding of metric variations in abdominal vascular structures and complement previous observations. In view of our results, we recommend pre-operative measurement of the IMA-IMV before colorectal surgery where the medial-to-lateral approach is planned. Given that a narrow distance may predict a difficult dissection, this factor should be taken into account to determine the optimal surgical approach in each patient.

Clinical outcome of short-term compression after sclerotherapy for telangiectatic varicose veins.

BACKGROUND: Sclerotherapy is considered to be the method of choice for the treatment of telangiectatic varicose veins (C1 veins). Whereas the use of compression stockings after sclerotherapy is recommended, little is known about the impact of compression on the outcome of sclerotherapy. The aim of this study was to assess the influence of compression on the outcome of injection sclerotherapy of C1 varicose veins. METHODS: There were 100 legs of 50 consecutive patients with chronic venous insufficiency (C1) included. After randomization per patient, both legs were treated with sclerotherapy in a predefined area of the thigh (measuring 100 cm2), followed by eccentric compression for 24 hours. Group A received no further compression, whereas group B was additionally equipped with compression stockings of 18 to 20 mm Hg above the ankle and continued wearing these for 1 week. Photodocumentation was performed before, 1 week after, and 4 weeks after sclerotherapy, and the clinical outcome was assessed at these postprocedure follow-up dates. The photographs were reviewed by an internal unblinded rater and an independent blinded external rater. RESULTS: There was no discernible difference between the groups in terms of clinical outcome or side effects after 4 weeks. Whereas inter-rater reliability was high, there was no correlation between the raters and patients in terms of outcome. In 55% of the treated legs, the patients deemed the result of the treatment to be good; in 27% of the treated legs, fair; and in 18%, poor. Postprocedure hyperpigmentation occurred in 13% of patients and was comparable in both groups. Compression therapy was found to be comfortable by the majority (58%) of patients. CONCLUSIONS: One week of postinterventional compression therapy had no clinical benefit compared with no compression.

Insufflation pressure above 25 mm Hg confers no additional benefit over lower pressure insufflation during posterior retroperitoneoscopic adrenalectomy: a retrospective multi-centre propensity score-matched analysis.

BACKGROUND: Insufflation pressures of or in excess of 25 mm Hg CO2 are routinely used during posterior retroperitoneoscopic adrenalectomy (PRA) in most centres. A critical analysis of the surgical literature provides limited evidence to support this strategy. OBJECTIVE: To determine whether high pressure (≥ 25 mm Hg) compared with lower pressure (< 25 mm Hg) retroperitoneoscopy reduces operating time and complications. METHODS: A multi-centre retrospective cohort study was performed using data collected over a period of almost one decade (1st November 2008 until 1st February 2018) from surgical centres in Germany. A total of 1032 patients with benign adrenal tumours were identified. We compared patients undergoing PRA with insufflation pressures of < 25 mm Hg (G20 group) versus ≥ 25 mm Hg (G25 group). A propensity score matching analysis was performed using BMI, tumour size and surgeon's experience as independent variables. The main outcomes were (1) the incidence of perioperative complications and (2) the length of operating time. RESULTS: The baseline patient characteristics were similar in both groups, with the exception of tumour size, BMI and surgeon's experience in PRA. After propensity score matching, perioperative outcomes, especially perioperative complications (3.7% vs. 5.5% in G20 and G25, respectively; p = 0.335) and operation duration (47 min vs. 45 min in G20 and G25, respectively; p = 0.673), did not significantly differ between the groups. CONCLUSION: Neither patient safety nor operative success was compromised when PRA was performed with insufflation pressures below 25 mm Hg. Prospective studies are required to determine whether an optimal insufflation pressure exists that maximizes patient safety and minimizes the risks of post-surgical complications. Nevertheless, our results call for a careful re-evaluation of the routine use of high insufflation pressures during PRA. In the absence of prospective data, commencing PRA with lower insufflation pressures, with the option of increasing insufflation pressures to counter intraoperative bleeding or exposition difficulties, may represent a reasonable strategy.