The common incisions for transabdominal specimen retrieval after laparoscopic colorectal surgery are lower quadrant, midline, or transverse suprapubic incision. This study was designed to evaluate a novel method of specimen extraction after totally laparoscopic proctocolectomies. We retrospectively studied seven women patients from 2004 to 2007. The indication for surgery was familial polyposis coexisting with adenocarcinoma of the upper rectum. A totally laparoscopic proctocolectomy with ileal pouch-anal anastomosis was successfully performed for all cases. The entire specimen was extracted via a transvaginal route. The mean age of the patients was 49.5 years, and mean body mass index was 25.3 kg/m2. The mean operating time was 222.5 minutes, and average blood loss was 172 ml. The average hospital stay was 25.5 days. Postoperative complications included ileus (n = 1), pouchitis (n = 1), and deep vein thrombosis (n = 1). The vaginal wound had healed completely by the first follow-up. There was no mortality. Our technique of transvaginal retrieval effectively prevents wound-related complications by completely eliminating minilaparotomies for specimen retrieval. It could be called “Natural Orifice Specimen Extraction,” or N.O.S.E. We stress the need for innovations in specimen extraction, for which importance is not given by surgeons.

An Innovative Technique for Colorectal Specimen Retrieval: A New Era of “Natural Orifice Specimen Extraction” (N.O.S.E)

PURPOSE: The common incisions for transabdominal specimen retrieval after laparoscopic colorectal surgery are lower quadrant, midline, or transverse suprapubic incision. This study was designed to evaluate a novel method of specimen extraction after totally laparoscopic proctocolectomies. METHODS: We retrospectively studied seven women patients from 2004 to 2007. The indication for surgery was familial polyposis coexisting with adenocarcinoma of the upper rectum. A totally laparoscopic proctocolectomy with ileal pouch-anal anastomosis was successfully performed for all cases. The entire specimen was extracted via a transvaginal route. RESULTS: The mean age of the patients was 49.5 years, and mean body mass index was 25.3 kg/m 2 . The mean operating time was 222.5 minutes, and average blood loss was 172 ml. The average hospital stay was 25.5 days. Postoperative complications included ileus (n=1), pouchitis (n=1), and deep vein thrombosis (n=1). The vaginal wound had healed completely by the first followup. There was no mortality. CONCLUSIONS: Our technique of transvaginal retrieval effectively prevents wound-related complications by completely eliminating minilaparotomies for specimen retrieval. It could be called “Natural Orifice Specimen Extraction,” or N.O.S.E. We stress the need for innovations in specimen extraction, for which importance is not given by surgeons.

ORIGINAL CONTRIBUTION An Innovative Technique for Colorectal Specimen Retrieval: A New Era of "Natural Orifice Specimen Extraction" (N.O.S.E)

Die laparoskopische Rektumkarzinomresektionen hat eine den offenen Verfahren vergleichbare Morbiditat und onkologische Sicherheit bei jedoch deutlich hoherer Morbiditat nach Konversion. Zu den onkologischen Langzeitergebnisse nach Konversion liegen keine Daten vor. Vom 01.01.2000–31.12.2002 in einer Beobachtungsstudie erfasste Patienten mit kurativ reseziertem Rektumkarzinom wurden hinsichtlich der postoperativen Morbiditat, Letalitat, des tumor- und lokalrezidivfreien Uberlebens nach laparoskopischer vs. konvertierter vs. offener Resektion verglichen. Von 7189 Patienten wurden 237 (3,3%) laparoskopisch (ITT) reseziert. Diese Patienten hatten signifikant haufiger T1/2-Tumore (p<0,001) in fruheren UICC-Stadien (p<0,001) als die offen resezierten. Die Konversionsrate betrug 14,8% (n=35). Die Konversionsgruppe hatte signifikant mehr intraoperative (p<0,001) und allgemeine postoperative Komplikationen (p=0,003) sowie die hochste Gesamtmorbiditat (p=0,031) im Vergleich zur laparoskopischen und offenen Resektion. Nach einem medianen Follow-up von 30.1 Monaten zeigten die konvertierten Patienten die hochste 5-J-Lokalrezidivrate (16.0%). Nach laparoskopischer sowie offener Resektion betrug diese 3.3% resp. 12.4% (p=0.082). Die tumorfreie 5-J-Uerlebensrate war vergleichbar (p=0.585). Die laparoskopische Rektumkarzinomresektion bietet gegenuber der offenen Resektion vergleichbare onkologische Ergebnisse, jedoch ist nach Konversion das fruhpostoperative und das onkologische Langzeit-Outcome schlechter. Bei Konversionsraten um 15% ist eine strenge Patientenselektion und Durchfuhrung der laparoskopischen Resektion an Zentren zu fordern.

Operative Behandlung von Rektumkarzinomen im Vergleich

Familial adenomatous polyposis (FAP) is a dominantly inherited syndrome. Risk of cancer begins to increase after age 20 years if not treated. The purpose of this study was to evaluate the feasibility and short- and long-term outcomes after laparoscopic prophylactic surgery for FAP. Fifty-five patients with FAP were identified through the Hereditary Colorectal Tumor Registry from 2003 to 2009. Patients with laparoscopic total colectomy (TC)/IRA or proctocolectomy (TPC)/ileal pouch-anal anastomosis IPAA were included. Patients with previous colon or abdominal major surgery, malignancy, and desmoids before surgery were excluded. Main outcomes were: 30 days anastomotic leak and pouch failure; long-term desmoids and malignant recurrence. Of the 55 patients, 32 were men, median age was 28 years, and mean body mass index was 23. Median follow-up time was 36 (range, 5–77) months. Forty-four patients had laparoscopic TC/IRA and ten had laparoscopic TPC/IPAA. One patient was converted to open surgery and received an open TPC/IPAA. Incision length was 7 (range, 5–14) cm. Anastomotic leak was 3 (5.4%: 2 laparoscopic and 1 open), and pouch failure was 0. Median postsurgical length of stay was 7 (range, 4–24) days. Desmoids occurred in three patients (5.4%), and there was no malignant recurrence within the follow-up period. Pathology revealed severe dysplasia in ten patients and adenocarcinoma in nine (8 laparoscopic and 1 open). Long-term small-bowel obstruction was 2 (3.6%). One mortality due to liver metastases occurred at 24 months. Laparoscopic prophylactic treatment of FAP appears to be safe and feasible and may be an appealing alternative to open surgery. If the goal of prophylactic FAP surgery is to avoid cancer occurrence, laparoscopic surgery could be an important advancement.

Laparoscopic colectomy and restorative proctocolectomy for familial adenomatous polyposis.

BACKGROUND: Laparoscopic colorectal procedures for the treatment of benign disorders are increasingly appreciated and have become the standard procedure for e.g. surgical treatment for recurrent diverticulitis. METHODS: Data show that even laparoscopic surgery for left sided colon cancer is seen as oncologically equal to the classic open resection. Laparoscopic resections offer several benefits e.g. minimal impairment of gastrointestinal and pulmonary functions, lower immunosuppression, shorter hospital stay, and faster reconvalescence. RESULTS: However, laparoscopic resections for rectal cancer are still discussed controversially as concerns are raised in terms of oncologic radicality, port-site metastases, autonomic nerve preservation, and completeness of total mesorectal excision especially in obese male patients with a tight pelvis. CONCLUSIONS: The clinical reality and several studies demonstrate that laparoscopic rectal surgery for cancer is oncologically feasible, lymph node dissection is equivalent to open surgery, and the incidence of port-site recurrence is not increased compared to wound recurrence in conventional laparotomy.

Laparoscopic resection for rectal cancer

Laparoscopic colorectal resections offer several benefits postoperatively, including minimal impairment of gastrointestinal and pulmonary function, less immunosuppression, shorter hospital stay and improved reconvalescence. Since the introduction of laparoscopic surgery for the therapy of curable colorectal cancer, some concern was voiced in terms of oncologic radicality, the issue of port-site metastases and tumor cell distribution. However, the clinical reality has demonstrated that oncologic radicality is equivalent to open surgery, and the incidence of port-site metastases is not increased when compared to wound recurrence at the laparotomy site. Focusing on colon and rectum, various indications of laparoscopic-endoscopic 'rendezvous' procedures exist including laparoscopic-assisted endoscopic transluminal resection, endoscopic-assisted wedge or anatomical resections, and, finally, intraoperative tumor location by colonoscopy to achieve oncologic resection margins in laparoscopic curative resections. In terms of colorectal curative resections, long-term results provide level I evidence that laparoscopic surgery for colon cancer is oncologically adequate and can be performed with equivalent morbidity and mortality rates when compared to conventional surgery. In terms of rectal cancer, no level I evidence is available. However, short-term data from experienced centers do not report inferior oncologic outcome particularly related to laparoscopic total mesorectal excision.

/pdf/current-status-of-laparoscopic-therapy-of-colorectal-cancer-17ux61ox7s.pdf

Current status of laparoscopic therapy of colorectal cancer.

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Current status of laparoscopic therapy of colorectal cancer.