Laparoscopic right hemicolectomy with intracorporeal anastomosis

Abstract

Dear Editor, Dr. Ho may have planned to write a scientific paper on an innovative surgical technique. I applaud Dr. Ho’s decision, as section editor, to invite Dr. Yamaguchi’s comment, which elevates the debate to a scientific level [1]. However, there are a number of methodological aspects of Dr. Ho’s publication that can give the wrong take-home message. These aspects, outlined below, may not be readily understood by inexperienced readers. Although there is certainly a need for innovation in surgery, it is beneficial to the patients that innovation happens in accordance with the rules of evidence [2]. As Dr. Ho’s technique is performed by a single surgeon, the reproducibility of his results is debatable, or at best, unknown. Other authors have previously emphasized how standardization and sequential execution are essential to outcomes and safety in surgical technique [3]. Ho sends a different message; he does it his way: lateral-to-medial! medial-to-lateral! It is dangerous as readers can get the wrong message. Laparoscopic right colectomy with intracorporeal anastomosis is no news to the well-informed reader. I agree with Dr. Ho that intracorporeal anastomosis is advantageous compared with extracorporeal. Potential advantages of intracorporeal anastomosis include: (1) anastomosing away from the abdominal wall could reduce surgical-site infection rates; (2) no manipulation of abdominal cavity by the surgeon could reduce creation of adhesions and possibly rates of adhesive small bowel obstruction; (3) a 50% reduction in the abdominal wall incision for specimen extraction could lead to clinically relevant benefits; and (4) laparoscopic visualization during the creation of the anastomosis could reduce unrecognized twisting of the terminal ileum mesentery. Nevertheless, I have the following concerns regarding Dr. Ho’s choice to promote totally stapled intracorporeal ileocolic anastomosis. Potential disadvantages of totally stapled intracorporeal ileocolic anastomoses include: (1) leads to an everted anastomosis with potential for increased risk of complications as opposed to its handsewn inverted counterpart; (2) requires usage of 60 mm long cartridge for side-to-side ileocolic stapling as it inevitably excises tissue and thereby potentially reduces the size of the anastomosis; (3) most likely requires an additional port if performed on the transverse colon; (4) does not obviate the need for intracorporeal suturing as stay stitches are required to ensure safe stapler application on the enterocolotomy; (5) may require multiple firings depending on the size of the enterocolotomy or whether the previous stapled line is being excised; and (6) leads to higher costs due to additional cartridges. An alternative option to totally stapled intracorporeal ileocolic anastomosis is to handsew the enterocolotomy [4]. Without standardization of a surgical technique and proof of reproducibility by others, Dr. Ho’s ‘‘How I do it’’ paper lacks external validity.