To evaluate the impact of routine intraoperative endoscopy (IOE) on postoperative anastomotic bleeding of laparoscopic anterior resection (LAR) for rectal cancer, and to investigate the value of the IOE in terms of prevention and treatment of postoperative anastomotic bleeding.Medical records of the 279 cases of LAR from January 2006 to December 2011 were retrospectively analyzed, of which postoperative anastomotic bleeding occurred in 18. Univariate analysis was taken to determine the possible influencing factors of the bleeding. Then related influencing factors were put into the multivariate logistic regression analysis to ultimately determine the independent influencing factors of anastomotic bleeding. The efficacy of treatments to the anastomotic bleeding was also evaluated.The incidence of anastomotic bleeding after LAR is 6.5% (18/279).The rates of anastomotic bleeding in lower tumor location group and upper tumor location group were 9.2% (16/173) and 1.9% (2/106), respectively, as in intraoperative colonoscopy and nonintraoperative colonoscopy group were 3.3% (5/151), and 10.2% (13/128), respectively. Comparing the location of the tumor, the coefficient of regression and relative risk value for lower tumor were 1.564 and 4.776. Comparing the intraoperative colonoscopy and nonintraoperative colonoscopy group, the value for intraoperative colonoscopy group were -1.085 and 0.338. Sex, age, tumor stage, pathologic type, and preventive ileostomy had no relevance with the anastomotic bleeding. In 18 cases of the anastomotic bleeding, 7 received conservative treatments, 9 underwent endoscopic treatment, and 2 underwent reoperation. All the 18 cases had reached hemostasis.IOE is an independent protective factor of anastomotic bleeding after LAR. Endoscopic hemostasis is recommended for an anastomotic bleeding after LAR for rectal cancer with a stapling technique.
Colon cancer is one of the most common malignancies of the alimentary tract, and one main metastatic route is lymph node metastasis. Thorough dissections of regional lymph nodes is one of the core surgical treatment of right colon cancer. D3 lymphadenectomy and complete mesocolic excision (CME) are generally accepted surgical methods for right colon cancer, which can improve the standardization of surgery, improve the quality of tumor resection, and provide more lymph nodes dissectal. Colon cancer of hepatic flexure is likely to have metastasis of the infrapyloric lymph nodes (No.206), which are not regional lymph nodes. Lymph node dissection of No.206 group belongs to extended right hemicolectomy, which involves many vascular variations and complicated peripheral anatomical structure. The theory of fascial surgery provides surgeons with anatomic basis and a clear understanding of the anatomical structure of the infrapyloric region, which is an important theoretical basis for the thorough dissection of lymph nodes in No.206 group, and can completely remove the mass, regional lymph nodes and adipose connective tissue, so as to achieve the goal of non-bleeding surgery. Lymph nodes in No.206 group were dissected, not just the visible lymph nodes, but the entire lymph nodes and lymphatic vessels in the region, including adipose tissue. Extended right hemicolectomy requires higher surgical techniques. The survival benefits of extended right hemicolectomy are not supported by high-level evidence. It is still controversial whether the infrapyloric lymph node dissection should become routine for colon cancer of hepatic flexure. In this article, the metastasis and dissection of infrapyloric lymph node in colon cancer of hepatic flexure is elucidated.结肠癌是最常见的消化道恶性肿瘤之一，最主要转移方式是淋巴结转移，彻底清扫区域淋巴结是右半结肠癌外科治疗的核心之一。D(3)根治术和完整结肠系膜切除术（CME）是目前较为公认的右半结肠癌的手术方法，可以提高手术的规范性和肿瘤切除的质量，并提供更多的淋巴结清扫数目。目前，部分研究发现结肠肝曲癌有可能出现幽门下淋巴结（No.206）转移，No.206淋巴结属于非区域淋巴结，清扫No.206淋巴结属于右半结肠癌扩大根治术。右半结肠癌扩大根治术涉及的血管变异多、周围解剖结构关系复杂。膜解剖理论给外科医生提供了解剖学基础，清晰认识幽门下区域解剖结构，是彻底清扫No.206淋巴结的重要理论基础，可以完整地切除肿块、相应区域淋巴结和脂肪结缔组织，实现无出血手术的目标。清扫No.206淋巴结，并非单纯切除肉眼可见淋巴结，而是把连同脂肪组织在内的、该区域整个淋巴结和淋巴管一并切除。右半结肠癌扩大根治术对手术技术要求较高，扩大清扫术带来的生存获益尚缺少高级别证据支持。而且关于结肠肝曲癌幽门下淋巴结清扫的远期疗效，目前研究资料尚少，缺乏具有说服力的临床研究，有待临床多中心前瞻性研究的开展，来证实结肠肝曲癌扩大根治术的疗效。.
Objective:To evaluate the recurrence and complications of laparoscopic hernia repair.Methods:The clinical da ta of52patients(67procedures)admitted between Oct1993and Oct2001undergoing laparoscopic hernia repair were an alyzed retrospectively.There were48TAPP performed in37patients and19TEP performed in15patients.The cases were followed up for8～24months,with a median of18months.Results:The recurrence rate was4.5%.Emphysema,transient neurapraxia and seroma ranked the first3postoperative complications in laparoscopic hernia repair,their inci dence being43.3%,17.9%and9.0%respectively.The operative time was68.6min±40.5min,the hospital stay was7.1d±2.0d.Conclusions:The laparoscopic hernia repair is a safe and tension free technique.A thorough understanding of the anatomy of the pre peritoneal space is essential in an attempt to reduce recurrence and post operative complications.
Laparoscopy is believed to play an important role in the treatment for colorectal cancer and is now extensively applied across the world. Although the safety and feasibility of laparoscopic colorectal surgery has been verified by several randomized controlled trials, intraoperative hemorrhage is still a challenge for clinicians, which could lead to conversion to laparotomy or increased mortality. In this article we discuss the strategy for prevention and management of hemorrhage in laparoscopic colorectal surgery in terms of anatomy and surgical skills.
Objective
To investigate clinical effect of the cephalo-medial to lateral and traditional medial-to-lateral approaches for laparoscopic radical resection of rectal cancer.
Methods
The retrospective cohort study was adopted. The clinical data of 82 patients with rectal cancer who underwent laparoscopic radical resection of rectal cancer at the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between June 2015 and October 2015 were collected. Thirty patients undergoing cephalo-medial to lateral approach and 52 patients undergoing traditional medial-to-lateral approach were respectively allocated into the CML group and ML group. Cephalo-medial to lateral approach procedures included that peritoneum at surface of the abdominal aorta located at the cephalic inferior mesenteric artery (IMA) was excised and then opening the left Toldt space. Observation indexes: (1) operation situations: operation time, time to open the left Toldt space, time of lymph node dissected around IMA, volume of intraoperative blood loss, number of lymph node dissected, number of No.253 lymph node dissected, distance to distal resection margin, (2) postoperative situations: postoperative complications, duration of postoperative hospital stay, (3) follow-up situations: postoperative survival, tumor recurrence and metastasis. Patients were followed up by outpatient examination and telephone interview up to April 2016. Measurement data with normal distribution were presented as ±s and comparison between groups was analyzed using the t test. Count data were analyzed using the chi-square test.
Results
(1) Operation situations: 82 patients underwent successful laparoscopic radical resection of rectal cancer, without conversion to open surgery and perioperative death. Time to open the left Toldt space was (8±6)minutes in the CML group. Operation time, time of lymph node dissected around IMA, volume of intraoperative blood loss, number of lymph node dissected, number of No.253 lymph node dissected and distance to distal resection margin were (107±24)minutes, (9±6)minutes, (91±27)mL, 18.1±7.0, 3.5±2.2, (2.5±0.9)cm in the CML group and (102±15)minutes, (15±4)minutes, (94±26)mL, 16.2±5.7, 1.6±0.7, (2.6±1.8)cm in the ML group, respectively, with no statistically significant difference in operation time, volume of intraoperative blood loss, number of lymph node dissected and distance to distal resection margin between the 2 groups (t=1.079, -0.455, 1.368, -0.150, P>0.05) and with statistically significant differences in time of lymph node dissected around IMA and number of No.253 lymph node dissected between the 2 groups (t=-4.264, -4.268, P 0.05). (3) Follow-up situations: 82 patients were followed up for 6-10 months with a median time of 8 months, without the occurrence of tumor recurrence and metastasis and tumor-related death.
Conclusion
Compared with traditional medial-to-lateral approach, cephalo-medial to lateral approach is safe and feasible for laparoscopic radical resection of rectal cancer, and it cannot extend the operation time, with an advantage of No.253 lymph node dissection.
Key words:
Rectal neoplasms; Total mesorectal excision; Surgical approach; Laparoscopy
Background: To investigate the application value of 4K high definition (HD) in laparoscopic gastrectomy by comparing the short-term outcomes and subjective perception with three-dimensional (3D) and HD vision systems. Materials and Methods: A retrospective study was conducted between September 2018 and February 2019; a total of 87 patients who underwent laparoscopic gastrectomy were enrolled and divided into three groups in terms of different type of vision system used for surgery: 4K, 3D, and HD. Demographic and clinicopathological data as well as short-term outcomes were collected and analyzed. A questionnaire survey was completed by the team of surgeons to evaluate the subjective perception of different vision systems. Results: There was no significant difference in gender, body mass index, age, American Society of Anesthesiologists (ASA) score and history of abdominal surgery, tumor location as well as type of operation, and anastomosis between the 4K, 3D, and HD groups. All patients underwent laparoscopic gastrectomy without conversion to laparotomy. There was no difference between the three groups regarding operation time (4K versus 3D versus two-dimensional (2D), 183.60 ± 52.5 versus 189.69 ± 69.87 versus 211.00 0 ± 49.33, P = .145) and estimated blood loss (4K versus 3D versus 2D, 123.60 ± 119.51 versus 150.62 ± 105.46 versus 129.00 ± 103.57, P = .602), no difference was found in time to first flatus and postoperative hospital stay between the three groups. No significant difference was found in postoperative complications between the three groups. As for pathological results, there was no difference in tumor size and tumor-node-metastasis (TNM) stage. In 4K group, the number of lymph node harvested was 32.60 ± 10.28, no difference was found compared with that of 3D (29.81 ± 8.94) and HD groups (27.69 ± 10.96). The score of group 3D was the lowest concerning asthenopia and motion sickness. On the contrary, 3D group achieved the highest score in topographical orientation and depth description. 4K group was graded the highest in terms of control co-ordination of visual angle, visual acuity, radiance, resolution ratio and frames, and refresh rate. HD group was graded significantly lower in sense of control compared with that of 4K and 3D group. No significant difference was found in color resolution and contrast. Conclusions: In conclusion, the short-term effect of 4K HD laparoscopic system is comparable with that of HD and 3D laparoscopy, whereas 4K could reduce adverse effect than traditional instrument and improve quality of surgery. The Clinical Trial Registration number is NCT01441336.
This study aimed to assess the feasibility and long-term outcome of laparoscopic total mesorectal excision for middle and lower rectal cancer. Retrospective assessment was performed on 612 patients with middle and low rectal cancer in the surgery department of our hospital. Three-hundred and three patients underwent laparoscopic total mesorectal excision (LTME), and 309 patients underwent open TME (OTME). All the data regarding patient details, operative variables and the short- and long-term outcomes were collected and compared. The sphincter-preserving rates of the two groups were similar. The conversion rate in LTME was 2.31% (seven cases). Fourteen cases (6.67%) of protective diverting stoma were fashioned in the LTME group compared with 57 cases (26.64%) in the OTME group. The postoperative morbidity was the same in these two groups, while the postoperative period until bowel movement and hospital discharge was shorter in the LTME group (P < 0.01). The median follow-up period was 34 (6–81) months for the LTME group and 36 (6–81) months for the OTME group. Local recurrence rates, the five-year disease-free survival rate and the five-year overall survival rate showed no difference between the two groups. Laparoscopic surgery is feasible and safe in patients with middle and lower rectal caner and can provide favorable short-term and long-term outcomes.
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