Intersphincteric Exploration With Ligation of Intersphincteric Fistula Tract or Attempted Closure of Internal Opening for Acute Anorectal Abscesses.

BACKGROUND: Acute anorectal abscesses of cryptoglandular origin are commonly managed by incision and drainage, which results in fistula development in up to 73% of cases, requiring subsequent definitive fistula surgery. However, given that fistula tracts may already be present at the initial presentation, primary closure of the tract as secondary prevention of fistula formation, using ligation of intersphincteric fistula tract, may be useful. OBJECTIVE: This study aims to examine the feasibility and outcomes of performing intersphincteric exploration with ligation of intersphincteric fistula tract or attempted closure of internal opening for acute anorectal abscesses. DESIGN: This is a retrospective study of patients with acute anorectal cryptoglandular abscesses who underwent surgery between January 2014 and December 2016. SETTINGS: The patients were treated at a tertiary referral center in Thailand. PATIENTS: Eighty-six patients with acute anorectal abscesses without previous surgery were included. INTERVENTIONS: Intersphincteric dissection was performed. Further surgical intervention was dependent on the intersphincteric findings. MAIN OUTCOME MEASURE: The main outcome measure was the 90-day healed rate. RESULTS: Of the 86 patients, 3 had low intersphincteric abscesses, 26 had low transsphincteric abscesses, 25 had anterior high transsphincteric abscesses, 27 had posterior high transsphincteric abscesses, and 5 had high intersphincteric abscesses. Ligation of intersphincteric fistula tract was successfully performed in 66 patients with an identifiable intersphincteric tract. Intersphincteric exploration with attempted closure of the internal opening was performed in the remaining 20 patients. The success rates were 86% and 70%. Unidentified internal opening and intersphincteric pathology were risk factors for nonhealing. No patients reported fecal incontinence postoperatively. LIMITATIONS: The limitation of this study is its retrospective nature and that all operations were performed by a single surgeon; therefore, the results may vary according to the individual surgeon's expertise. CONCLUSIONS: Fistula tract formation was found in most cases of acute anorectal abscesses. Definitive surgery using this strategy provides promising results. See Video Abstract at http://links.lww.com/DCR/B451. EXPLORACIN INTERESFINTRICA CON LIGADURA DEL TRAYECTO EN LA FSTULA INTERESFINTRICA O INTENTO DE CIERRE DEL ORIFICIO INTERNO EN ABSCESOS ANORRECTALES AGUDOS: ANTECEDENTES:Los abscesos anorrectales agudos de origen criptoglandular, comúnmente se manejan mediante incisión y drenaje, lo que resulta en el desarrollo de una fístula hasta en un 73% de los casos, requiriendo posteriormente cirugía definitiva de la fístula. Sin embargo, dado que los trayectos de la fístula ya pueden estar inicialmente presentes, puede ser útil el cierre primario del trayecto, como prevención secundaria en la formación de la fístula, mediante la ligadura del trayecto de la fístula interesfintérica.OBJETIVO:El estudio tiene como objetivo, examinar la viabilidad y los resultados en realizar exploración interesfintérica, con ligadura del trayecto de fístula interesfintérica o intento de cierre del orificio interno para abscesos anorrectales agudos.DISEÑO:Se trata de un estudio retrospectivo de pacientes con abscesos criptoglandulares anorrectales agudos, que fueron operados entre enero de 2014 y diciembre de 2016.AJUSTES:Los pacientes fueron tratados en un centro de referencia terciario en Tailandia.PACIENTES:Se incluyeron 86 pacientes con abscesos anorrectales agudos, sin cirugía previa.INTERVENCIONES:Se realizó disección interesfintérica. La intervención quirúrgica adicional dependió de los hallazgos interesfintéricos.PRINCIPALES MEDIDAS DE RESULTADO:La principal medida de resultado, fue la tasa de cicatrización a 90 días.RESULTADOS:De los 86 pacientes, hubo 3 abscesos interesfintéricos bajos, 26 abscesos transesfintéricos bajos, 25 abscesos transesfintéricos anteriores altos, 27 abscesos transesfintéricos posteriores altos y 5 abscesos interesfintéricos altos. La ligadura del tracto de la fístula interesfintérica, con tracto interesfintérico identificable, se realizó con éxito en 66 pacientes. Se realizó exploración interesfintérica, con intento de cierre del orificio interno en los 20 pacientes restantes. Las tasas de éxito fueron 86% y 70% respectivamente. Orificio interno no identificado y patología interesfintérica, fueron factores de riesgo para la falta de cicatrización. Ningún paciente reportó incontinencia fecal posoperatoria.LIMITACIONES:La limitación de este estudio, es su naturaleza retrospectiva y que todas las operaciones fueron realizadas por un solo cirujano, por lo tanto, los resultados pueden variar según la experiencia de cada cirujano.CONCLUSIONES:En la mayoría de los casos de abscesos anorrectales agudos, se encontró formación de trayectos fistulosos. La cirugía definitiva con esta estrategia, proporciona resultados prometedores. Consulte Video Resumen en http://links.lww.com/DCR/B451.

Ligation of Intersphincteric Fistula Tract for Fistula in Ano: Lessons Learned From a Decade of Experience.

BACKGROUND: Ligation of intersphincteric fistula tract is a well-described sphincter-preserving technique for the management of fistula in ano. In 2007, we reported our early experience demonstrating a primary success rate of 94.4%. These findings have since been supported by several short-term studies, but long-term results and secondary cure rates after ligation of intersphincteric fistula tract failure remain unknown. OBJECTIVE: This study aims to report a 10-year experience of ligation of intersphincteric fistula tract with extended long-term follow-up. DESIGN: Retrospective analysis of single-center data from May 2006 to October 2010 was performed. SETTINGS: This study was conducted at a large tertiary hospital in Bangkok, Thailand. PATIENTS: All patients with primary or recurrent fistula in ano who underwent a ligation of intersphincteric fistula tract procedure were included. Patients with malignancy, incontinent patients, and patients with rectovaginal fistula were excluded. MAIN OUTCOME MEASURES: Healing as defined by the absence of symptoms with no visible external opening on clinical examination. Follow-up was continued until May 2016. RESULTS: In total, 251 patients were identified, with a primary healing rate of 87.65% at a median follow-up of 71 months. The healing rates for low transsphincteric, intersphincteric, high transsphincteric, semihorseshoe, and horseshoe fistulas were 92.1%, 85.2%, 60.0%, 89.0%, and 40.0%. Of the 42 patients who had an unhealed fistula after previous non-ligation of intersphincteric fistula tract surgery, 38 (90.48%) healed after the first attempt at ligation of intersphincteric fistula tract. There were 31 patients with unhealed fistulas after the first ligation of intersphincteric fistula tract. Of these, 3 healed spontaneously, and the rest underwent either repeat ligation of intersphincteric fistula tract, fistulotomy (if the recurrence was intersphincteric), or simple curettage (if no internal opening was found). Ultimately, only 2 of the original 251 patients remained unhealed, and there was no change in subjective continence status after surgery. LIMITATIONS: This study was limited by its retrospective design. CONCLUSION: Ligation of intersphincteric fistula tract is an effective technique for the treatment of fistula in ano, including recurrent or unhealed fistula after other procedures. See Video Abstract at http://links.lww.com/DCR/A387.

Marsupialization for simple fistula in ano: a randomized controlled trial.

BACKGROUND: Marsupialization of anal fistulotomy results in less raw-surface wound and may improve postoperative outcomes. The present study was designed to test the benefit of marsupialization for simple fistula in ano. MATERIAL AND METHOD: This was a randomized controlled study conducted at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Fifty patients with simple uncomplicated fistula in ano were allocated into either fistulotomy group or fistulotomy with marsupialization group. Patients with complex fistula in ano, prior incontinence, immuno-compromised status and bleeding tendency were excluded from the present study. The postoperative pain score, the pain score after the first defecation, total amount of the analgesic usage and complications were evaluated. Recurrence was also assessed RESULTS: There was no difference in the postoperative pain score between the treatment groups. However, there was a significant difference (p = 0.017) in the number of patients who needed pethidine injection (4 patients of the fistulotomy with marsupialization group versus 13 patients of the fistulotomy group). There was no statistical significant difference in the pain score after the first defecation and the amount of paracetamol usage in seven days. Five complications were found only in the fistulotomy group but the significant level was marginal (p = 0.0501). There was no recurrence of thefistula and none of the patients developed anal incontinence after the surgery. CONCLUSION: Marsupialization for anal fistulotomy is safe. This technique helps to improve the postoperative outcomes.

Internal sphincter myectomy for adult Hirschsprung's disease: a single institute experience.

OBJECTIVE: Adult Hirschsprungs disease is a rare disease and frequently misdiagnosed as the long-standing refractory constipation. Almost all cases have short or ultra-short aganglionic segment of distal rectum. The clinical features are different from those in childhood when the diseased segment is long. Amongst the few successful operations that have been used to treat this condition, internal sphincter myectomy has been proposed as a simple and low morbidity procedure, but only a few literatures reported the results. The present study aimed to evaluate the outcomes of anorectal myectomy in adult Hirschsprung's disease. MATERIAL AND METHOD: All medical records of adult Hirschsprung's disease between January 1, 1997 and April 30, 2008 were retrospectively reviewed The histological criteria for diagnosis were increase in the number of cholinergic nerve fibers in the lamina propria, muscularis mucosae, and submucosa, and the absence of ganglia in the submucosa. All cases underwent internal sphincter myectomy as the first operation. Post-operative complications, number of defecation per week, and the need for a second operation were studied. RESULTS: Seven patients met the criteria. All patients had the long history of constipation. Anorectal myectomy was performed as the first operation in all cases. Four patients (57%) had good results, without complication and no further operation was needed up to the last follow-up (26-86 months). Two cases underwent subtotal and total colectomy after myectomy to achieve good results eventually. Only one patient had a poor result after Left colectomy and Total proctocolectomy with ileal pouch anal anastomosis. CONCLUSION: Internal sphincter myectomy, the simple and complication-free procedure, provides the satisfactory outcomes for adult Hirschsprung's disease. This technique should be the first operation for this condition.

Sacrectomy for primary sacral tumors.

PURPOSE: En bloc resection with adequate margins has provided a chance for cure of primary sacral tumors. However, high sacral lesions are challenging because of the complexity of the surgical approach. The aims of this study were to describe a modification in technique and to evaluate the outcomes. METHODS: This is a study of eight sacrectomies performed at King Chulalongkorn Memorial Hospital between February 2000 and July 2007. Cadaveric dissections were carried out prior to surgery. We have modified the technique by ligation of the branches of the external iliac veins, resulting in "isolation" of the external iliac veins. Spinopelvic reconstruction was performed for total and extended total sacrectomy. Closure of the sacral defect was done with use of the Hartmann stump and the gluteus maximus flaps. RESULTS: Two total sacrectomies, one extended total sacrectomy, and five subtotal S1 sacrectomies were performed. En bloc resection with adequate margins was achieved in all patients. The patient who underwent extended total sacrectomy and one patient who underwent total sacrectomy had nonunion requiring removal of the spinopelvic instrumentation. Five patients who underwent subtotal sacrectomy were ambulating well postoperatively, except for one who had an S1 fracture after falling. No sacral hernias were observed. None of the patients developed recurrence of the primary tumor. Mean follow-up time was four years. CONCLUSIONS: Sacrectomy for primary sacral tumors can be safely conducted, achieving tumor-free margins and acceptable functional and long-term outcomes.

A comparison of early postoperative results between urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids and elective closed hemorrhoidectomy.

OBJECTIVE: To compare the perioperative complications, analgesics requirement, and length of hospital stay between patients undergoing urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoid and elective closed hemorrhoidectomy. RESEARCH DESIGN: Retrospective, comparative study. MATERIAL AND METHOD: All records of the patients who underwent urgent and elective hemorrhoidectomy between January 2000 and December 2005 were reviewed. Perioperative complications (bleeding, urinary retention, post-operative thrombosis, and wound dehiscence), analgesic requirement, and length of hospital stay were analyzed. STATISTICS: Chi-Square Test and Mann-Whitney U Test. RESULTS: From 1440 patients, 1184 patients met the inclusion criteria. All were done with closed technique. The indication for urgent hemorrhoidectomy was prolapsed thrombosed hemorrhoid in 416 patients (group 1). The indication for elective hemorrhoidectomy were grade 3 and 4 internal hemorrhoid, external hemorrhoid or combined hemorrhoid in 768 patients (group 2). There was no statistically significant difference in urinary retention and bleeding complication between two groups; 31 patients (7.5%) in group 1 and 69 patients (8.9%) in group 2 experienced urinary retention p = 0.426, five patients (1.2%) in group 1 and 10 patients (1.3%) in group 2 had postoperative bleeding, p = 1.000). On the second postoperative week, wound dehiscence was found in nine patients (2.2%) from group 1 and 15 patients (2%) from group 2. On the fourth week, all the wounds were completely healed without granulation or stricture formation. Post-operative meperidine requirement was significantly lower in the urgent hemorrhoidectomy group (0.84 +/- 0.71 vs. 0.99 + 0.81 mg/kg, p < 0.001). Post-operative length of hospital stay were not statistically different (1.017 +/- 0.129 vs. 1.016 +/- 0.124, p = 0.107). CONCLUSION: Urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids may be a preferable option for patients suffering from this condition.

Effects of preoperative endoanal ultrasound on functional outcome after anal fistula surgery.

OBJECTIVE: Endoanal ultrasound (EAUS) is a recommended preoperative investigation for fistula-in-ano (FiA) which aims to provide the best chance of healing and preservation of continence function. This study aims are (1) to assess effect of EAUS on functional outcome and (2) to determine factors associated with clinical outcomes after FiA surgery. DESIGN: Retrospective analysis of subjects with cryptogenic FiA between January 2011 and December 2016, in a tertiary hospital, was performed by comparing EAUS and no-EAUS groups. Postoperative change in St. Mark's faecal incontinence severity score (cFISS=FISS at 6 months after surgery-FISS before surgery) were compared. General linear model was used to determine factors associated with cFISS. Binary logistic regression was used to assess factors related to clinical outcomes. A p-value of <0.05 is considered significant. RESULTS: We enrolled 339 subjects; 109 (M:F 91:18, mean age 41.7±13.6 years) of 115 in EAUS group and 230 in no-EAUS group (M:F 195:35, mean age 42.6±13.0 years). There were higher proportions of recurrent cases (24.8% vs 13.9%, p=0.014) and complex FiA (80.7% vs 50.4%, p=0.001) in EAUS group. Postoperative FISS (mean±SE) were increased in both groups; preoperative versus postoperative FISS were 0.36±0.20 versus 0.59±0.25 in EAUS group (p=0.056) and 0.31±0.12 versus 0.76±0.17 in no-EAUS group (p<0.001). EAUS had significant effects on cFISS in both univariate analysis, F(1,261)=4.053, p=0.045; and multivariate analysis, F(3,322)=3.147, p=0.025, Wilk's Lambda 0.972. Other associated factors included recurrent fistula (F(3,322)=0.777, p=0.007, Wilk's Lambda 0.993) and fistula classification (F(3,322)=16.978, p<0.001, Wilk's Lambda 0.863). After a mean follow-up of 33.6±28.6 weeks, success rate was 63.3%(EAUS) and 60% (no-EAUS), p=0.822. Factors associated with clinical outcomes were fistula complexity, number of tracts, recurrence, number of previous surgery and type of operations. Accuracy of EAUS was 90.8% and not related to clinical outcomes (p=0.522). CONCLUSION: EAUS had favourable effects on functional outcome after FiA surgery while multiple factors were associated with clinical outcomes. EAUS is useful, accurate, inexpensive and can be the first tool for planning of complex and recurrent FiA.

Multimedia article. Laparoscopic restorative proctocolectomy with small McBurney incision for ileal pouch construction without protective ileostomy.

PURPOSE: Restorative proctocolectomy is a standard treatment for colorectal diseases over decades. At present, this technique is frequently performed via minimal invasive approach. Most reported techniques of laparoscopic restorative proctocolectomy involved a Pfannenstiel incision for the major part of the operation to be performed openly; a double-stapled pouch anal anastomosis technique and protective ileostomy. This study was designed to demonstrate the modification of this technique. METHODS: This was a retrospective study of seven patients (4 had ulcerative colitis and 3 had familial adenomatous polyposis) who underwent laparoscopic restorative proctocolectomy at King Chulalongkorn Memorial Hospital between September 2004 and February 2007. The details of the procedure are shown in the video. The techniques involve the following: full mobilization of entire colon and rectum using medial to lateral approach, division of submesenteric arcades for ileal pouch elongation with preservation of three to four inner most arcades of distal ileum segment and preservation of both superior mesenteric and ileocolic trunk, ileal pouch construction via a small (3-4 cm) McBurney incision, transanal mucosectomy with removal of the entire rectum and colon transanally, and handsewn ileal pouch-anal anastomosis. None of the patients underwent protective ileostomy. RESULTS: Mean surgical time was 360 (270-510) minutes, and median blood loss was 230 (100-400) ml. There were neither conversions nor intraoperative surgical complications. However, one patient developed small-bowel obstruction, which was successfully treated by laparoscopic approach. Anastomotic leakage was not found in this series. All patients have good control of their bowel movement as well as a very good cosmetic result during the follow-up period. CONCLUSIONS: Laparoscopic restorative proctocolectomy with small McBurney incision for ileal pouch construction, without protective ileostomy, is technically feasible and safe.

New concept of ileocecal junction: intussusception of the terminal ileum into the cecum.

AIM: To prove that the terminal ileum is intussuscepted into the cecum creating the ileocecal junction, contrary to previous valvular concept which has been widely believed. METHODS: This study is based on gross and microscopic examinations of fresh specimens derived from colonic operations (right hemicolectomy or subtotal colectomy). Data compiled from observing and dissecting of specimens of seven patients are used to examine both gross and microscopic appearance of ileocecal junction. RESULTS: Intussusception of the terminal ileum was found in every specimen. However, the length of intussusception was different in each specimen. CONCLUSION: Gross and microscopic appearance studies suggest that the terminal ileum is intussuscepted into the cecum.

Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract.

OBJECTIVE: To describe a new technique for fistula-in-ano surgery aimed at total sphincter preservation, and evaluate the preliminary results concerning non-healing and intact anal function. MATERIAL AND METHOD: A prospective observational study in eighteen fistula-in-ano patients treated by ligation of intersphincteric fistula tract (LIFT) technique, from January to June 2006. RESULTS: Fistula-in-ano in seventeen patients healed primarily (94.4%). There was one non-healing case (5.6%). The mean healing time was four weeks. None had disturbances in clinical anal continence. CONCLUSION: The early outcome of the LIFT technique is quite impressive. Results warrant a larger study with long-term evaluation. This technique has the potential to become a viable option for fistula-in-ano surgery.

Closed vs ligasure hemorrhoidectomy: a prospective, randomized clinical trial.

OBJECTIVE: To compare the operative time, postoperative complications, and analgesic requirement between closed hemorrhoidectomy and Ligasure hemorrhoidectomy. MATERIAL AND METHOD: The study was conducted in a prospectively randomized controlled fashion. Forty-seven patients with grade 3 or 4 hemorrhoids plus external component or skin tag were operated on by either hemorrhoidectomy with Ligasure (24 patients) or closed hemorrhoidectomy (23 patients). One patient in each group was lost to follow up. The operative time, postoperative verbal numeric pain score, analgesic requirement, bleeding, and wound dehiscence between the two groups were compared Unpaired t-tests, Mann-Whitney U tests, or Fisher's Exact tests were used where appropriate. RESULTS: Demographic and clinical data between two groups were comparable. Operative time for the Ligasure hemorrhoidectomy was significantly shorter than the closed hemorrhoidectomy group (21.70 +/- 11.76 vs 35.68 +/- 14.25 min, p < 0. 001), while the number of resected hemorrhoids in the study group were 2.91 versus 2.18 in the control group. However, there were no differences in post-operative pain score, analgesic requirement, bleeding, or wound dehiscence between the two groups. CONCLUSION: Ligasure hemorrhoidectomy is superior to closed hemorrhoidectomy in terms of reducing the operative time without affecting postoperative complications.

Outcome of familial adenomatous polyposis: a retrospective study.

BACKGROUND: Familial adenomatous polyposis (FAP) is characterized by the presence of numerous colorectal adenomatous polyps that progress to colorectal cancer if left untreated. Following colorectal cancer, periampullary cancer and aggressive desmoid tumor are also the common causes of death. The purpose of the present study was to describe the clinical course of FAP patients. MATERIAL AND METHOD: The authors conducted a retrospective study of 31 FAP patients who were treated at King Chulalongkorn Memorial Hospital (KCMH) between March 2000 and March 2006. Demographic data, family history, symptoms, extracolonic manifestations, operative procedures, pathologic findings, and postoperative results were collected. RESULTS: Two patients were excludedfrom the present study. The average age of the 29 patients was 33.48 years with the sex ratio (male/female) of 0.93. Seventeen of the 29 patients (58.6%) had a family history of FAP Sixteen of 29 patients were discovered with colorectal cancer with a mean age of34.56 years. Mucous bloody stool was the most common presenting symptom and most of the patients with this symptom (11/13) already had colorectal cancer Gastroduodenal polyps and desmoid tumor were common extracolonic manifestations. The most common operative procedure was restorative proctocolectomy with ileal J pouch (RPC). Wound infection and gut obstruction were the frequent complications. Functional outcomes of patients with RPC were good. The mean age ofpatients with colon cancer was older than the mean age ofpatients without colon cancer However, there was no significant difference between the two groups. The sex ratio and family history of FAP were not statistically different. No significant differences were found in surgical procedures and postoperative complications. On the follow up period, two patients in the later group died of desmoid tumor and pancreatic cancer while seven patients in the former group died of metastatic colon cancer and one with desmoid tumor CONCLUSION: The proportion ofpatients who were discovered with colorectal cancer in the present study was high with young age onset of cancer Moreover, patients in this group had poorer outcome compared to the group of patients without colorectal cancer; of which, metastatic colorectal cancer was the major cause of death. This result may be due to aggressiveness and advanced stage of disease at the first diagnosis.

Preoperative capecitabine with pelvic radiotherapy for locally advanced rectal cancer (phase I trial).

OBJECTIVE: Phase I multicenter study defined the maximal tolerated dose (MTD), dose-limiting toxicity (DLT) and safety profile of capecitabine in combination with preoperative radiation for patients with locally advanced rectal cancer (LARC). MATERIAL AND METHOD: Patients were treated with oral capecitabine (700, 800, 900, 1000, 1100 and 1200 mg/m2 twice daily continuously) plus preoperative whole pelvic irradiation (45-46 Gy in 23-25 fractions over 5-6 weeks). Surgery was performed at the median of 42 days after chemoradiation treatment. RESULTS: Twenty-seven patients were in this trial. Eighteen patients (3 per dose level) had received capecitabine from 700 mg/m2 twice daily to the highest dose level of 1200 mg/m2 twice daily. There were no grade 3/4 DLTs during dose escalation, a further nine patients were included at the highest capecitabine dose. Two of the twelve patients (16%) receiving capecitabine 1200 mg/m2 twice daily developed grade 3 diarrhea and discontinued treatment. There were no other grade 3/4 adverse events. After capecitabine chemoradiation, 24 of 27 patients (89%) received definite surgery. Primary and lymph node down staging occurred in ten patients (42%). Sphincter-sparing surgery was performed in seven patients (26%) and abdominal-perineal resection was performed in 17 patients (63%). CONCLUSION: Preoperative capecitabine chemoradiation based on continuous daily capecitabine is very well tolerated in patients with LARC. The authors did not reach the MTD in the present study.

Laparoscopic versus open surgery for rectosigmoid and rectal cancer.

OBJECTIVES: The aim of this study was to evaluate feasibility and safety of laparoscopic surgery for rectosigmoid cancer and rectal cancer. MATERIAL AND METHOD: Twenty four patients who underwent laparoscopic surgery for rectosigmoid cancer or rectal cancer were retrospectively evaluated. Results were compared with those of 25 patients who had open surgery at the same period. The procedures of both groups were anterior resection, low anterior resection, coloanal anastomosis, abdominoperineal resection and subtotal colectomy. RESULTS: The mean operative time was significantly increased in the laparoscopic group. However, this group showed faster recovery of bowel function. There were no differences in the distal margin and yield of harvested lymph nodes of resected specimens. Although anastomotic leakage was comparable between 2 groups, surgical wound infection was significantly higher in open surgery group. CONCLUSION: Laparoscopic surgery for rectosigmoid cancer and rectal cancer is feasible and can be performed safely with comparable oncological clearance.

Perineum push-up device to facilitate transabdominal suturing of the lower rectum.

Pressure on the perineum by the fist facilitates the placement of sutures into the rectal remnant, but put the assisting surgeon on an awkward and strenuous posture. The perineum push-up device to facilitate transabdominal suturing of the lower rectum was invented. The assisting surgeon can push up the perineum more comfortably with his abdominal wall or thigh. The device was tested in fifteen patients. The average distance that can be pushed up is 4.2 cm, which is a significant distance, facilitating in the maneuver of the distal rectal stump.

The new laparoscopic proctocolectomy training (in soft cadaver).

OBJECTIVES: The purpose of the present study was to evaluate the quality of preservation (tissue plane, named vessels identification, consistency of colon and rectum), quality of performing procedures, difficulties and problems and finally the satisfaction of surgeons in laparoscopic proctocolectomy in soft cadaver. SETTING: Colorectal Division, Department of Surgery and Surgical Training Center Department of Anatomy, Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study MATERIAL AND METHOD: 10 soft cadavers were scheduled for laparoscopic proctocolectomy. The procedures (colon-rectum mobilization and named vessels identification) were performed by 14 experienced surgeons (8 colorectal surgeons) and assisted by surgical residents. The quality of preservation, successfulness and the satisfaction in performing the procedures were recorded using questionnaires for evaluation. RESULTS: The preservation was very good in every aspect especially tissue plane between colon, mesocolon and retroperitoneum which was clearly dissected, same asfasciapropria of rectum. The named vessels and the tissue consistency were very well preserved and tolerated to laparoscopic equipment handling. The surgeons were satisfied with the tissue handling and dissections. There were two difficulties, the first was air leakage but simply corrected with purse string suture and the second was unflavored smell which was not concerned. Laparoscopic proctocolectomy could be completely performed in soft cadaver. CONCLUSION: Laparoscopic proctocolectomy could be performed in soft cadavers with great satisfaction. Repeated practice is possible, so the surgeons can gain their experiences outside the operating theatre. This success may shorten the learning curve and may be the new era in cadaver-based training.

Minimally invasive surgery training in soft cadaver (MIST-SC).

OBJECTIVES: The purpose of this study was to evaluate the surgical anatomy, tissue plane, organ consistency of soft cadaver and the possibility of minimally invasive surgery training in soft cadaver. SETTING: Surgical Training Center. Department of Anatomy and Department of Surgery Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study. MATERIAL AND METHOD: 2 soft cadavers were scheduled for fully laparoscopic surgery in upper gastrointestinal, colorectal, hepatopancreatobiliary and solid organs surgery. All the procedures were performed by the experienced surgical staffs and assisted by surgical staffs and/or surgical residents. The surgical anatomy, tissue plane, organ consistency and the satisfactory in performing the procedures were recorded for evaluation. RESULTS: The surgical anatomy, the tissue consistency the anatomical plane were very well preserved with mean score of 4.72 +/- 0.45. All the surgeons were satisfied with the findings, the mean score was 4.97 +/- 0.18. All the plan procedures were completely performed with great satisfactory results. CONCLUSION: The Minimally Invasive Surgery Training in Soft Cadaver (MIST-SC) was feasible with great satisfactory. This successful integration of basic and advanced laparoscopic procedures into the soft cadaver setting would be the next step in evolution of MIS training.