A prospective randomized study of multimodal analgesia combined with single injection transversus abdominis plane block versus epidural analgesia against postoperative pain after laparoscopic colon cancer surgery.

PURPOSE: Transversus abdominis plane (TAP) block is a safe, effective, and promising analgesic procedure, but TAP block only cannot overcome postoperative pain. We conducted a prospective randomized study to evaluate postoperative pain control using multimodal analgesia (MA) combined with a single injection TAP block compared with epidural analgesia (EA) after laparoscopic colon cancer surgery. METHODS: Sixty-seven patients scheduled for elective laparoscopic colon cancer surgery were enrolled in this study and randomized into EA and MA groups. The primary endpoint was the frequency of additional analgesic use until postoperative day (POD) 2. The VAS score, blood pressure, time to bowel movement, time to mobilization, postoperative complications, and length of hospital stay were also compared between the two groups. RESULTS: Sixty-four patients (EA group, n = 33; MA group, n = 31) were analyzed. The patient characteristics did not differ markedly between the two groups. The frequency of additional analgesic use was significantly lower in the MA group than in the EA group (P < 0.001), whereas the VAS score did not differ markedly between the two groups. The postoperative blood pressure on the day of surgery was significantly lower in the MA group than in the EA group (P = 0.016), whereas urinary retention was significantly higher in the EA group than in the MA group (P < 0.001). CONCLUSION: MA combined with a single injection TAP block after laparoscopic colon cancer surgery may be comparable to EA in terms of analgesia and superior to EA in terms of urinary retention.

Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program.

BACKGROUND: The aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery. METHODS: One hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients' satisfaction with pain management were also assessed. RESULTS: We observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups. CONCLUSION: TEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected.

The use of ultrasound in central vascular ligation during laparoscopic right-sided colon cancer surgery: technical notes.

BACKGROUND: Complete mesocolic excision (CME) with central vascular ligation (CVL) requires the surgeon to sharply dissect the mesocolon and approach the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) for ligation of the supplying vessels relating to right-sided colon cancer at their origin. Even with preoperative images, it can still be challenging to identify these structures during laparoscopic surgery because of various intraoperative conditions. The aim of this study was to assess the efficacy of intraoperative ultrasound (IOUS) for identification of blood vessels during right-sided colon cancer surgery. METHODS: We performed IOUS on 19 patients diagnosed with right-sided colon cancer at our institution, in January-October 2020. Preoperatively, a three-dimensional computed tomography (3D-CT) angiogram was obtained for the majority of patients to visualize the SMA, SMV, and their respective branches. The running position of the ileocolic artery (ICA) and right colic artery (RCA) related to the SMV and the presence of the middle colic artery were identified and compared using preoperative 3D-CT, IOUS, and intraoperative findings. RESULTS: Nineteen patients [seven men and 12 women with a mean age of 73.9 ± 8.4 years (range 58-82 years)] were studied, including some with a body mass index of > 30 kg/m2, locally advanced cancer, and severe adhesion. There were IOUSs that detected the SMA, SMV, and their tributaries in all patients. The positional relationships between the SMV and the ICA and RCA revealed by IOUS were consistent with the preoperative and intraoperative findings. CONCLUSION: IOUS is a safe, feasible, and reproducible technique that can assist in detecting the branching of the SMA and SMV during CME with CVL in laparoscopic right-sided colon cancer surgery, regardless of individual conditions.

Retroileal anastomosis in hand-assisted laparoscopic left colectomy: experience at a single institution.

BACKGROUND: Left hemicolectomy and complicated sigmoid colectomy require an anastomosis between the transverse colon and rectum. Generous mobilization will typically allow the colon to reach to the rectum. However, despite full mobilization of the splenic flexure and extensive work on the mesentery, there are cases in which reach to the pelvis is still an issue. Retroileal routing of the colon is one technique for overcoming such a reach problem and achieving a tension-free anastomosis. Performing retroileal routing using laparoscopic techniques has been reported rarely, and to date, there are no data on this technique when performed in a hand-assisted laparoscopic fashion. This study aimed to describe the feasibility of doing a retroileal routing using a hand-assisted laparoscopic technique. METHODS: This was a retrospective chart review of patients who underwent a colon or rectal resection, either open or laparoscopic, with a pelvic anastomosis, by a single colorectal surgeon at an academic institution between 2008 and 2015 with a focus on the immediate and long-term postoperative complications, estimated blood loss, and operating room time for patients having an operation that included retroileal routing for construction of a colorectal anastomosis. RESULTS: A total of 340 patients fit inclusion criteria and of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon to the colorectal anastomosis. Postoperative morbidity included intubation for CO2 retention in one patient and a RLL effusion in another patient; there were no anastomotic leaks. Long-term morbidities included two ventral hernias at 2 years postoperatively. Mean operating room time was 208 min. There were no 30- or 90-day mortalities. CONCLUSIONS: Hand-assisted laparoscopic retroileal routing is a feasible and safe technique in accomplishing a tension-free colorectal anastomosis when proximal colon length makes standard routing of the colon to the rectum an issue.

Transversus abdominis plane block for postoperative pain relief after hand-assisted laparoscopic colon surgery: a randomized, placebo-controlled clinical trial.

BACKGROUND: Although hand-assisted laparoscopic surgery (HALS) offers patients smaller surgical incisions, they still experience pain. Currently, there is no consensus on the optimal analgesic package for patients undergoing HALS. The aim of this prospective, randomized, double-blinded, placebo-controlled clinical trial was to evaluate the effect of transversus abdominis plane (TAP) block on postoperative pain control (pain score and analgesic use) and other outcomes in colon cancer patients undergoing hand-assisted laparoscopic left hemicolectomy. METHODS: Sixty-four patients with colon cancer scheduled for an elective colon resection were enrolled in this study. Patients were randomized into two groups to receive either TAP block using 20 mL of 0.375% ropivacaine (TAP block group: 32 patients) or 20 mL of 0.9% normal saline infusion (placebo group: 32 patients). Anaesthetic and surgical techniques were standardized. Twenty-four-hour postoperative analgesia was maintained by continuous infusion of 0.1-0.9 µg/kg/h fentanyl and intravenous injection of ketorolac. The primary outcome of the study was postoperative pain control (pain score and analgesic use). Pain was assessed using numeric rating scale at 2, 4, 8, 12, and 24 h after surgery at rest and during movement. Secondary outcomes included the time to resumption of intestinal function and the length of hospital stay. The data of the two groups were compared using Mann-Whitney U test. All statistical tests were two-tailed at a significance level of 0.05. RESULTS: The patients' mean age was 60.50 ± 6.77 years, and 68.75% of patients were males. The mean body mass index was 26.23 ± 4.83 kg/m2. The TAP block group had lower pain scores after surgery at 2, 4, and 12 h at rest (p < 0.05), at 2 and 4 h during movement (p < 0.01) and used less fentanyl and ketorolac than the placebo group (p < 0.01). The mean time to resumption of intestinal function was shorter in the TAP block group than that in the placebo group (p < 0.0001). The mean length of hospital stay was by 2.7 days shorter in the TAP block group than in the placebo group (p = 0.001). CONCLUSIONS: The ultrasound-guided TAP block given during hand-assisted laparoscopic colon surgery as part of a multimodal analgesic regimen is a feasible and effective technique for postoperative analgesia in colon cancer patients and significantly reduces both pain experienced by patients and short-term postoperative analgesic use and promotes early ambulation. Future studies are needed to determine the efficacy and costs/benefits of the ultrasound-guided TAP block in HALS.

Robotic colectomy with intracorporeal anastomosis is feasible with no operative conversions during the learning curve for an experienced laparoscopic surgeon developing a robotics program.

The benefits of performing a colectomy robotically instead of laparoscopically have not conclusively been demonstrated. Evaluation of studies is limited by sample size, retrospective design, heterogeneity of operative techniques, sparse adjustment for learning curve, and mixed results. Consequently, adoption of robotic colectomy by surgeons has been expectedly slow. The objectives of the study were to compare the outcomes of robotic colectomy to laparoscopic colectomy for patients with right-sided tumors undergoing a standardized completely intracorporeal operation and to examine the impact of prior experience with laparoscopic right colectomies on the performance of robotic right colectomies. Retrospective review of outcomes of consecutive patients undergoing a robotic right colectomy (robot) compared to those undergoing laparoscopic colectomy (LAP). LAP patients were further subdivided into a group during the learning curve (LC) and after the learning curve (post-LC). Data collected included operative time (OT), conversion to laparotomy, lymph nodes harvested (LN), length of stay (LOS), 30-day morbidity, and mortality. Comparison of continuous and categorical variables was assessed with the independent samples t test and Chi-square test, respectively. Data are expressed as mean ± SD, and significance defined as p < 0.05. 122 patients underwent robot (n = 21), LAP (n = 101), LC (n = 51), or post-LC (n = 50). OT was decreased for post-LC compared to LC (198 vs. 228 min). There were no conversions in robot and five with LAP. Morbidity was similar for robot (14%) compared to LAP (22%), LC (24%), or post-LC cases (20%). Median LOS was similar for robot vs. LAP (3 vs. 5 days). Robot had greater mean LN yield vs. LAP (19 vs. 14, p = 0.02). The initial outcomes with completely intracorporeal colectomy achieved robotically were equivalent to results during or after LC for laparoscopic resection. Proficiency gained with LAP seems to positively impact the initial results with the robot.

The Difficult Colorectal Polyp.

Difficult colorectal polyps represent lesions that pose a challenge to traditional endoscopic snare polypectomy. These polyps have historically been managed by surgical resection. Currently, several less invasive options are available to avoid colectomy. Repeat colonoscopy and snare polypectomy by an expert endoscopist, endoscopic mucosal resection, endoscopic submucosal dissection, and combined endoscopic and laparoscopic surgery have been developed to remove difficult polyps without the need for formal surgical resection. Patients with rectal polyps have the advantage of additional transanal minimally invasive techniques to enhance their resectability. Today, most colorectal polyps can be managed without the need for formal surgical resection.

Laparoscopic right hemicolectomy for a patient with idiopathic retroperitoneal fibrosis: A case report.

A 62-year-old man with abdominal pain and lumbago was admitted to our hospital. Blood examination revealed renal insufficiency, and CT revealed retroperitoneal fibrosis causing bilateral hydrocele and ureteral compression. A colonoscopy was performed to rule out secondary retroperitoneal fibrosis due to malignancies, and this imaging revealed an ascending colon cancer. Laparoscopic right hemicolectomy with lymphadenectomy and retroperitoneal biopsy were performed. The retroperitoneum was filled with hard, white fibrous tissue, which made it difficult to mobilize the right mesocolon from the retroperitoneum. Devascularization performed before mobilization allowed for a safe and oncologically feasible procedure. Histologically, there were no malignant cells in the retroperitoneal tissue. The patient has been without colon cancer reoccurrence for 4 years. When the surgical challenges that distinguish these patients from ordinary cases are recognized preoperatively, laparoscopic colectomy may be a feasible option for patients with colorectal cancer with idiopathic retroperitoneal fibrosis.

Severe cellulitis and abdominal wall emphysema following laparoscopic colonic surgery: A case report.

Abdominal wall emphysema is a common complication of laparoscopic surgery. This condition is usually harmless; however, if an infection occurs, it can develop into a serious condition such as necrotizing fasciitis. We report a case of a 51-year-old woman suffering from severe cellulitis that spread from an area of abdominal wall emphysema after laparoscopic surgery for sigmoid colon cancer. Recognizing this complication, early diagnosis, and prompt treatment are cornerstones for successful management of this potentially fatal disease.