Conventional Abdominal Approach Research Articles

A combined abdominal and transanal minimally invasive (TAMIS) approach in redo anastomoses for severe refractory rectal strictures.

Anastomotic stricture following anterior resection is an uncommon but challenging problem. Endoscopic dilatation and transanal endoscopic surgery (TES) are proven methods of treatment. However, a small proportion of patients repeatedly fail transanal local therapy for underlying reasons of tension, insufficient blood supply or irradiated tissue, eventually necessitating a complete anastomotic excision. We aimed to combine transanal minimally invasive surgery (TAMIS) with an abdominal approach in redo anastomoses for severe refractory anastomotic strictures. For the TAMIS phase, we use a Lonestar® retractor with a GelPOINT® Path transanal access platform. A circumferential full thickness rectotomy is performed and the dissection is continued proximally in the mesorectal fascial plane past the strictured segment to meet the abdominal dissection or until the peritoneal cavity is entered, facilitating mobilization of the rectum. The abdominal phase is performed as usual with sufficient mobilization of the left colon to enable tension-free redo anastomosis. An accompanying video demonstrates this technique. Two patients with refractory anastomotic strictures following a previous low anterior resection underwent the procedure. One patient had laparoscopy followed by TAMIS and the other had TAMIS followed by laparotomy. Both cases were performed by surgeons experienced in laparoscopy and TES. One patient had postoperative ileus which resolved conservatively. Both anastomoses were widely patent on follow-up. TAMIS combined with a conventional abdominal approach offers significant technical advantages over a totally abdominal approach for the definitive management of patients with severe anastomotic strictures refractory to first-line methods of therapy. The operator should already be proficient with TES.

Comparison of Minimally Invasive Surgery versus Laparotomy for Surgical Staging of Endometrial Carcinoma: A Retrospective Study

Introduction: Endometrial carcinoma is one of the commonest gynaecological cancer in developed countries as well as developing countries. The mainstay of initial treatment of endometrial carcinoma is surgical staging which may be performed by either the conventional abdominal approach or by minimally invasive route i.e. laparoscopic or robotic.
 Objectives: The purpose of this study was to compare and evaluate the surgical staging, safety and clinical benefits of minimally invasive surgeries versus. laparotomy in patients with endometrial cancer.
 Methodology: We retrospectively analyzed 105 patients with endometrial cancer over a period of five years and compared the outcome of total hysterectomy with pelvic and para-aortic lymphadenectomy by abdominal, laparoscopic approach or robotic-assisted surgery. Comparison was done with respect to operative time, blood loss, number of lymph nodes retrieved, length of hospital stay, intraoperative and postoperative complications. The data were analyzed using paired “t”- test / Wilcoxon signed rank test ,χ2 - test, Pearson correlation coefficient “r” whenever found suitable. P value of less than 0.05 was considered as statistically significant.
 Result: There was no statistically significant difference seen in the baseline characteristics like age and BMI between the two groups. The laparotomies were done in a shorter time than the minimally invasive approach (p<0.001). The amount of blood loss (p=0.002), and the duration of hospital stay (p<0.001) was significantly less in the minimally invasive surgery group than the laparotomies. Not much difference in the lymph node retrieval was observed between the two arms (p=0.614). The number of complications were almost similar in both the groups.
 Conclusion: Minimally invasive surgery for surgical staging of endometrial carcinoma is feasible and effective than laparotomy. The amount of blood loss and duration of hospital stay is seen much lesser with MIS than laparotomy.

DOP27 Transanal minimally invasive surgery (TAMIS): A novel approach for treatment of pouch failure

Abstract Background Many different pouch failure (PF) indications and procedures are known. In literature, different types of PF are randomly classified and often stacked together due to complexity. Transanal minimally invasive surgery (TAMIS) is becoming increasingly popular for redo-surgery due to greater accessibility and visibility in complex pelvic surgery compared with the conventional abdominal approach. We aimed to evaluate the efficacy of TAMIS in patients with PF. Methods This retrospective study includes all consecutive patients over 18-year old with an ileal pouch-anal anastomosis (IPAA) and PF that were managed with TAMIS between July 2014 and July 2019. Patient characteristics, operative indications, perioperative outcomes and short-term follow-up (FU) are described using a suggested subclassification for surgical-related PF (Figure 1). Results Forty-six procedures were completed in 42 patients, predominantly male (66.7%) with a median age of 44.6 (range 22.0–70.8) years. Initial IPAA indications were familial adenomatous polyposis (n = 11), medical refractory ulcerative colitis (UC) (n = 29) or other (n = 2). Seven (24.1%) UC patients turned out to have Crohn’s disease (CD). Reasons for PF were septic complications (n = 18), retained rectum (n = 3), outlet problems (n = 8) (with megapouch: n = 5), inlet problems (n = 6), cuff problems (n = 8) and refractory pouchitis with unknown aetiology (n = 3). Twenty-three pouch redo’s (16 remodelling, 7 new pouches), 5 sleeve advancements, 4 cuff excisions, 1 posterior pouchpexy, and 13 pouch excisions were recorded. Five pouch excisions were performed in CD patients. Five procedures were fully completed transanally, and 41 were a combined transabdominal (with 32 open and 9 laparoscopic) and TAMIS approach. None were converted to an open procedure. Apart from the patients with a pouch excision, 9 ended up with a permanent ileostomy, although technical success was achieved in 4 of those. Six permanent ileostomies were in patients with a redo-pouch (3 remodelling, 3 new pouches), 2 after sleeve advancement and 1 after cuff excision. Major morbidity (Clavien-Dindo ≥3) occurred after 17 procedures (37.0%), 14 within 1 month after surgery with a median FU of 17.9 (0.9–41.6) months. There was no peri-operative mortality. Conclusion TAMIS for PF after IPAA is technically feasible with acceptable short-term outcomes. Peri-operative morbidity is high and reflects the complexity of these procedures. Success after PF procedures is difficult to interpret due to a wide range of possible outcomes such as technical success, conversion rate and number of patients with a permanent stoma. The PF subclassification makes the complex problem and surgical management of PF comprehensible.

Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

BackgroundLocal excision of early rectal tumors as a rectal preserving treatment is gaining popularity, especially since bowel cancer screening programs result in a shift towards the diagnosis of early stage rectal cancers. However, unfavorable histological features predicting high risk for recurrence within the “big biopsy” may mandate completion total mesorectal excision (cTME). Completion surgery is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcomes compared to primary TME. Transanal approach potentially improves outcome of completion surgery for rectal cancer. The aim of this study was to compare radical completion surgery after local excision for rectal cancer by the transanal approach (cTaTME) with conventional abdominal approach (cTME).MethodsAll consecutive patients who underwent cTaTME for rectal cancer between 2012 and 2017 were case-matched with cTME patients, according to gender, tumor height, preoperative radiotherapy, and tumor stage. Surgical, pathological, and short-term postoperative outcomes were evaluated.ResultsIn total, 25 patients underwent completion TaTME and were matched with 25 patients after cTME. Median time from local excision to completion surgery was 9 weeks in both groups. In the cTaTME and cTME groups, perforation of the rectum occurred in 4 and 28% of patients, respectively (p = 0.049), leading to poor specimen quality in these patients. Number of harvested lymph nodes was higher after cTaTME (median 15; range 7–47) than after cTME (median 10; range 0–17). No significant difference was found in end colostomy rate between the two groups. Major 30-day morbidity (Clavien–Dindo≥ III) was 20 and 32%, respectively (p = 0.321). Hospital stay was significantly longer after cTME.ConclusionTaTME after full-thickness excision is a promising technique with a significantly lower risk of perforation of the rectum and better specimen quality compared to conventional completion TME.

Laparoscopic Versus Laparotomic Surgical Staging for Early-Stage Ovarian Cancer: A Case-Control Study

Study ObjectiveTo evaluate the oncologic outcomes of patients with early-stage ovarian cancer (eOC) managed by laparoscopy or laparotomy in a single high-volume gynecologic cancer center. DesignRetrospective case-control study (Canadian Task Force classification II-2). SettingCatholic University of the Sacred Hearth, Rome, Italy. PatientsData of consecutive women with eOC undergoing comprehensive laparoscopic staging between 2007 and 2013 were matched with a cohort of patients undergoing open surgery between 2000 and 2011. Four-year survival outcomes were analyzed using the Kaplan-Meier method. Measurements and ResultsSixty women undergoing staging via laparoscopy were compared with a cohort of 120 patients undergoing open surgery. Baseline characteristics were similar between groups. Seventy percent of patients underwent adjuvant platinum based chemotherapy without differences between the 2 groups. Operative time (p = .01), estimated blood loss (p = .032), and median hospital stay (p = .001) were higher in patients submitted to laparotomic versus laparoscopic staging. As of October 2015, median duration of follow-up was 38 months (range, 24 -48), recurrent disease was documented in 16 patients (13.3%) in the laparotomic group and in 5 patients (8.3%) in the laparoscopic group (p = .651), without differences in the pattern of recurrence presentation. Four-year progression-free survival (PFS) and overall survival (OS) rates were 89% and 92% in the laparoscopic group, respectively, and 81% and 91% in the laparotomic group, without any statistical significant difference between the groups (4-year PFS p = .651; 4-year OS p = .719). ConclusionThe findings of the present study suggests that in the surgical treatment of FIGO stage I ovarian cancer, laparoscopy is associated with equivalent oncologic outcome compared with a conventional abdominal approach.

Impact of the Thoracoabdominal Approach on Peri‐ and Postoperative Outcomes of Hepatectomy for Hepatocellular Carcinoma

Resection of hepatocellular carcinoma (HCC) located in the right liver often requires hepatic mobilization. However, exposure of the HCC may be restricted when using the conventional abdominal approach (AA). In such cases, a thoracoabdominal approach (TA) can provide a good operating field. Although several studies have reported on the TA for hepatectomy for HCC, none have been published since 2003. Accordingly, this issue seemed to have been resolved, based on the advantages of this approach. However, surgical instruments are constantly improving and hepatectomy may be possible without the TA. Data were retrospectively collected from 284 consecutive patients who underwent primary hepatectomy for HCC located in the right liver between January 1991 and December 2009. We compared the perioperative outcomes between patients who underwent the TA (n=111) and those who underwent the AA (n=173). Patient characteristics of both groups were comparable. The morbidity rate (Clavien grade≥1) was significantly greater with the TA than with the AA (64.2 vs. 49.2%, p=0.01), as was operative time (median=370 vs. 315 min, p=0.001) and hospital stay (median=25 vs. 21 days, p=0.005). There were no differences in hospital mortality or overall or disease-free survival. The TA provides no additional benefits over the AA in terms of safety and postoperative outcomes. We recommend that the TA should be used in exceptional circumstances because it resulted in a higher morbidity rate and longer operative time and postoperative hospitalization compared with the AA.

Transanal mucosectomy for endorectal pull-through in Hirschsprung’s disease: comparison of abdominal, extraanal and transanal approaches

The authors compared the clinical outcome between laparoscopically assisted endorectal pull-through (EPT) with an extraanal approach (EA) and conventional abdominal approach (AB) in Hirschsprung's disease (HD), and found that the former approach was less invasive and can provide a better clinical outcome. Recently, they introduced transanal approach (TA) without laparoscopical assistance and compared the clinical outcomes of these three approaches. In the period between 1990 and 1997, 20 cases of HD underwent EPT with AB (Group A), between 1998 and 2001, 21 cases underwent EPT with EA (Group E), and between 2004 and 2005, eight cases underwent EPT with TA (Group T). There was no difference in age and weight distribution among three groups. Clinical outcome was assessed 3 years after surgery. The operation time in Groups A, E and T was comparable (4.9 +/- 0.8, 5.2 +/- 0.8 and 4.3 +/- 0.8 h), whereas blood loss (98 +/- 52, 36 +/- 30 and 36 +/- 30 ml) and the incidence of postoperative complications requiring surgical intervention (25, 0 and 0%) was significantly lower in Groups E and T compared with Group A. The incidence of postoperative enteritis (25, 29 and 13%) was lower in Group T compared with Groups A and E. In Group E, two cases had persistent constipation, which required anorectal myotomy. Voluntary defecation (>once/2 days) was comparable among the groups (70, 87 and 88%). Soiling (small amount of involuntary passage of stool) was significantly less frequent in Groups E and T (45, 14 and 0%). EPT with perineal approaches is less invasive and can provide a better clinical outcome than EPT with AB in terms of postoperative soiling. Compared with EA and TA, EA tended to develop stagnant enteritis or residual constipation.

Sentinel Lymph Node Identification and Radical Hysterectomy with Lymphadenectomy in Early Stage Cervical Cancer: Laparoscopy Versus Laparotomy

Study Objective To estimate the feasibility and results of sentinel lymph node identification and radical hysterectomy with pelvic lymphadenectomy entirely completed by laparoscopy versus laparotomy in early stage cervical cancer. Design Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). Setting Acute care, teaching hospital. Patients From September 2000 through January 2005, 50 consecutive patients with International Federation of Gynecology and Obstetrics stage IA 2, IB 1, and IIA disease less than 4 cm underwent radical hysterectomy and lymphadenectomy with intraoperative sentinel lymph node biopsy. Interventions The operation was performed entirely by laparoscopy in 20 patients and using the conventional abdominal approach in 30. Feasibility of sentinel lymph node identification, surgical morbidity, overall survival, and recurrence rate–free survival in both groups were compared. Measurements and Main Results The overall detection rate of the sentinel lymph node was 100% (false negative 0%). A mean of 2.50 sentinel nodes/patient was detected in the laparotomy group compared with a mean of 2.55 nodes in the laparoscopic group (p = .874). Bifurcation of the right common iliac artery was the most frequent nodal location. Blood loss and length of stay were significantly lower in the laparoscopic group, but surgical time was significantly longer. The median follow-up was 35 months (range 5–57) in the laparotomy group and 22.5 (range 2–52) in the laparoscopic group. Differences in overall survival and disease-free survival were not observed. Conclusion Sentinel lymph node identification and radical hysterectomy in the initial treatment of early stage cervical cancer can be performed safely by laparoscopy with lower morbidity and overall survival and recurrence-free survival similar to standard laparotomy.

1065: Hydrocolonosonography

Ultrasonography of colon by conventional abdominal approach is frequently frustrating. Gas content within gut lumen can make visibility difficult and even impossible. Hydrocolonic sonography is a development of the conventional ultrasonographic examination of abdomen that has recently been shown to be effective in the assessing the colon wall, lumen and surroundings. Patients had an exclusively low-residue diet during the previous day of examination. Laxative tablets were advised to take at night.

Analysis of survival after laparoscopic-assisted vaginal hysterectomy compared with the conventional abdominal approach for early-stage endometrial carcinoma: A review of the literature

Study objective To assess potential differences in perioperative features and survival between laparoscopic-assisted vaginal hysterectomy and conventional transabdominal hysterectomy in stage I endometrial cancer. Design Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). Setting Acute-care, teaching hospital. Patients A total of 370 patients undergoing hysterectomy and bilateral salpingo-oophorectomy with surgical staging for primary treatment for clinical stage I endometrial cancer from January 1995 through June 2001. Intervention Clinical outcomes and survival in patients treated with laparoscopic-assisted vaginal hysterectomy (n = 55) and hysterectomy using the conventional abdominal approach (n = 315) were compared. Measurements and main results Baseline characteristics and histopathologic variables were similar in both groups. A total of 91.4% of patients underwent pelvic lymphadenectomy and 49.7% paraaortic lymphadenectomy. The median follow-up was 38.1 months. Blood loss, blood transfusions required, and length of stay were significantly lower in the laparoscopic group, but surgical time was significantly longer. The mean number of pelvic and aortic nodes recovered was higher in the laparoscopic group (p <.001). Differences in overall and recurrence-free survival rates were not observed. Conclusion Surgical staging of early-stage endometrial cancer by laparoscopic-assisted vaginal hysterectomy is feasible, with lower perioperative morbidity and shorter hospital stay compared with transabdominal hysterectomy. Prognosis and survival were not affected by the laparoscopic vaginal approach to hysterectomy.

Laparoskopisch-assistierte vaginale versus abdominale Operationstechnik bei Patientinnen mit Endometriumkarzinom - Eine prospektiv randomisierte Studie

Purpose: We compared a laparoscopic-vaginal with a conventional abdominal approach for treatment of patients with endometrial cancer. Patients and Methods: Between Julyl995 and May 2001 98 patients with endometrial cancer FIGO stage I-III were randomized to laparoscopic-assisted simple or radical vaginal hysterectomy or simple or radical abdominal hysterectomy with or without lymph node dissection. Results: 52 patients were treated in the laparoscopic versus 46 patients in the laparotomy group. Lymph node dissection was performed in 36 patients by laparoscopy and in 38 patients by laparotomy. Blood loss, transfusion rates, long term complications and duration of hospital stay were significantly lower in the laparoscopic group. Yield of pelvic and para-aortic lymph nodes, duration of surgery, and incidence of intra- and postoperative complications were similar for both groups. Overall- and recurrence-free survival did not differ significantly for both groups. Conclusion: The laparoscopic-vaginal approach for treatment of endometrial cancer is associated with lower perioperative and long-term morbidity compared with the conventional abdominal approach.

Laparoscopic-Assisted Vaginal versus Abdominal Surgery in Patients with Endometrial Cancer—A Prospective Randomized Trial

Objective.We compared a laparoscopic-vaginal approach with the conventional abdominal approach for treatment of patients with endometrial cancer.Method. Between July 1995 and August 1999, 70 patients with endometrial cancer FIGO stage I–III were randomized to laparoscopic-assisted simple or radical vaginal hysterectomy or simple or radical abdominal hysterectomy with or without lymph node dissection.Results. Thirty-seven patients were treated in the laparoscopic versus 33 patients in the laparotomy group. Lymph node dissection was performed in 25 patients by laparoscopy and in 24 patients by laparotomy. Blood loss and transfusion rates were significantly lower in the laparoscopic group. Yield of pelvic and para-aortic lymph nodes, duration of surgery, and incidence of postoperative complications were similar for both groups. Overall and recurrence-free survival did not differ significantly for both groups.Conclusion. The laparoscopic-vaginal approach for treatment of endometrial cancer is associated with lower perioperative morbidity compared with the conventional abdominal approach.