Intracorporeal Anastomosis Research Articles

SJLA_2024_A2: Laparoscopic Colectomy with Lymph Node Navigation and Intracorporeal Anastomosis using Double Indocyanine Green Technique

Introduction: In laparoscopic colectomy for colorectal cancer, appropriate lymph node dissection and prevention of anastomotic leak are very important. Indocyanine green (ICG) images obtained through the laparoscopic procedure helped visualize lymphatic drainage vessels and inform decision-making to determine the vessels. Intracorporeal anastomosis has advantages such as earlier recovery of postoperative bowel function, shorter length of wound incision, reduction of intestinal mobilization range, and fewer incisional hernias. Background: We report the surgical technique and short-term results of 48 patients who underwent laparoscopic colectomy and intracorporeal anastomosis using the double ICG fluorescence technique from July 2020 to September 2023. Methods: Two injections of ICG (0.75 mg ×2) into the proximal and distal subserosa of the tumor preceded the surgical procedure after pneumoperitoneum. Intraoperative lymph node mapping by the Stryker1588, 1688AIM camera imaging system was visualized. Laparoscopic colectomy was performed according to the Complete Mesocolic Excision and Central Vascular Ligation concepts. Complete intracorporeal anastomosis was performed by a functional end-to-end or overlap or Delta anastomosis. After anastomosis, ICG (12.5 mg) was injected intravenously to check the intestinal blood perfusion at the anastomosis site. Results: Forty-eight patients (Sex; male: 23 and female: 25) (Tumor location; C: 20, A: 11, T: 8, D: 7, S:2) (pStage0:2, I:15, II: 16, III:10, and IV:5) were underwent. The median age was 74. median body mass index was 23. Median number of dissected lymph nodes was 18. The median operative time was 246 min. The median wound length was 3.5 cm. The median postoperative hospital stay was 7 days. Visualization of lymphatic flow was observable in 24 of 28 cases (85.7%). The transection line was changed in 2/48 cases (4.1%) after ICG fluorescence angiography. There were no intraoperative complications, and two patients had postoperative paralytic ileus. Discussion: We introduce a novel technique of double ICG administration during laparoscopic colon resection for colon cancer that enables improved lymphadenectomy and warrants the extent of intestinal resection. It contains the intrinsic solution to the potential risks related to more intense dissection for extended lymphadenectomy. This is an immediate assessment of blood supply to the anastomosed intestinal walls. ICG fluorescence has immanent advantages as a result of its very low toxicity, high sensitivity, fast feedback, and absence of radiation. It is helpful to determine the extent of a bowel resection and can avoid leaving positive lymph nodes behind. It was revealed that ICG accurately evaluates the blood supply to anastomotic sites in real time and can detect organ ischemia before reconstruction is performed. This is particularly useful in laparoscopic surgery, as detection of impaired blood supply is difficult and even more for intracorporeal anastomosis. Lower anastomotic leak and reoperation rates were revealed with the use of ICG in several studies. Lymph nodes’ metastases are the most important prognostic factor in colon cancer, which has a poor prognosis and high recurrence. The use of ICG in the identification of lymph flow and lymphadenectomy basin in colon cancer patients has been previously reported. Lymph drainage of the transverse colon is complicated, and understanding this lymphatic drainage system is difficult, making ICG fluorescence particularly useful in right-sided and splenic flexure colon cancer patients. Conclusion: ICG fluorescence lymphangiography in laparoscopic colectomy for colon cancer allows visualization of lymphatic flow and may complement more reliable lymph node dissection. In addition, the evaluation of intestinal perfusion using ICG contributes to the reduction of anastomotic leakage and enables safer intracorporeal anastomosis.

A Case of Colon Cancer Close to the Sigmoid-Descending colon Junction in which Laparoscopic Colectomy was Performed with Intracorporeal Anastomosis while Avoiding Splenic Flexure Mobilization

A Case of Colon Cancer Close to the Sigmoid-Descending colon Junction in which Laparoscopic Colectomy was Performed with Intracorporeal Anastomosis while Avoiding Splenic Flexure Mobilization

Double-loop reconstruction after laparoscopic gastrectomy for gastric cancer.

Gastric cancer (GC) constitutes a major health problem. In addition to the popularity of laparoscopic gastrectomy, many reconstructive procedures have been reported in the literature. Surgical resection and lymphatic dissection determine long-term survival; however, the election of a reconstruction procedure determines the postoperative quality of life for patients with GC. At present, no consensus exists regarding the optimal reconstructive procedure. A new reconstructive approach was recently adopted at our center. Laparoscopic distal or total gastrectomy with D2 lymphadenectomy and a so called 'double-loop' reconstruction method with intracorporeal mechanical anastomosis was performed in our patients and we describe the technical note and outcome. The intuition in its use comes from the packaging of gastric bypasses in bariatric surgery. The double-loop method is a valid simplification of the traditional technique of construction of the Roux-limb that could increase the feasibility and safety in performing a full laparoscopic intracorporeal reconstruction with greater ergonomics for the surgeon.

Laparoscopic radical transverse colectomy with transrectal specimen extraction: A novel natural orifice specimen extraction procedure: A case report.

Transverse colon cancer accounts for about 10% of all colonic cancers. The resection of cancers in the transverse colon is technically more challenging, compared with other cancer locations in the colon because the variable anatomy of the middle colic vessels demands excellent surgical skills and the anatomical location of the transverse colon is related to major organs. We report a novel laparoscopic technique for the first time used in surgery of transverse colon cancer which combines a total intracorporeal anastomosis with natural orifice specimen extraction to solve the problems of traditional laparoscopic surgery. A 48-year-old male patient, whose diagnosis was transverse colon adenocarcinoma, was admitted to the hospital. The surgery was performed in accordance with the procedure of totally laparoscopic right hemicolectomy and the specimen was extracted by opening the rectum. Natural orifice specimen extraction surgery has many advantages, including less pain, better cosmesis and minimising risks of complications and also has comparable long-term outcomes compared to conventional laparoscopic surgery.

Intracorporeal vs extracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy

Introduction: Anastomotic leak after ileocolic anastomosis influences morbidity and mortality of a patient. Therefore, protection of ileocolic anastomosis is of paramount importance in laparoscopic right hemicolectomy. Methods: A retrospective study of seventy-nine patients who belong to American Society of Anaesthesiologists physical status classification class 1 and 2 who had undergone laparoscopic right hemicolectomy due to caecal or ascending colonic pathologies were selected for the study. A comparison between the two groups of patients who had undergone intracorporeal vs extracorporeal ileocolic anastomosis was done with regards to occurrence of anaestomotic leaks, paralytic ileus, duration of hospital stay and duration taken to tolerate a soft tissue. All patients were managed in high dependency units with optimum facilities under fast-track category. Every patient was under patient-controlled analgesia for pain control. Results: Of the 79 patients studied, 40 had intracorporeal anastomosis (ICA) whereas 39 had extracorporeal anastomosis (ECA). Age range of the patients was 40 - 75 years. Out of the 40 patients who had ICA, only one patient developed anastomotic leak and out of those who had ECA, 3 patients had anastomotic leaks (p=0.36). Two out of 3 patients who had anaestomotic leaks following the ECA, underwent lower midline laparotomies to rectify the leak. Four (4/40, 40%) patients in ICA group and 6 (6/39, 60%) patients in the ECA group had developed post op paralytic ileus (p=0.52). Average durations of hospital stay were 4 and 5 respectively for ICA and ECA groups and both groups were able to tolerate a soft diet on post operative day 2. Conclusions: ICA has improved the outcome of ileocolic anastomosis in the studied group of patients compare to ECA, although the observed differences between the two groups were not statistically significant.

Robotic Versus Laparoscopic Right Hemicolectomy For Cancer

Background: Laparoscopic right colectomy is regarded technically difficult especially with intracorporeal anastomosis, and in obese patients. Robotic surgery may offer a solution to these limitations. Our aim is to evaluate the results of robotic right hemicolectomy for cancer compared to traditional laparoscopy. Methods: Retrospective study including all patients who underwent elective laparoscopic or robotic right hemicolectomy for cancer from January 2009 till August 2011.We analyzed the preoperative, operative and pathological criteria, postoperative outcomes and follow up. Results: We had 48 patients (M: F of 1.3:1), 34 laparoscopic, 14 robotic comparable as regards ASA grade BMI and co-morbid conditions. The site of lesions were; cecum=18, ascending colon=24, hepatic flexure=7 (one patient had 2 synchronous tumors). There were no statistically significant differences in the total operative time or amount of blood loss or hospital stay between both groups. No open conversion in the robotic group compared to 2 in the laparoscopic group. There was a statistically significant difference in the number of lymph nodes retrieved; 21.1±10 in the robotic group compared to 16.4±4.8 in the laparoscopic group (P value=0.0320). In the laparoscopic group we performed extracorporeal mechanical anastomosis in 24 cases (70%) and in the robotic group intracorporeal manual anastomosis in 9(64%). In the laparoscopic group there were 3 anastomosis related complications: 2 bleedings and one major leak, none in the robotic group. We had a single mortality in the laparoscopic group from advanced disease. Short term follow up revealed no relapses in neither groups. Conclusion: Robotic hemicolectomy for right colon cancer appears as a safe and effective technique with less anastomosis related complications and better patient outcome with comparable oncological result

Safe implementation of robotic right colectomy with intracorporeal anastomosis.

The robotic platform can overcome technical difficulties associated with laparoscopic colon surgery. Transitioning from laparoscopic right colectomy with extracorporeal anastomosis (ECA) to robotic right colectomy with intracorporeal anastomosis (ICA) is associated with a learning phase. This study aimed at determining the length of this learning phase and its associated morbidity. We retrospectively analyzed all laparoscopic right colectomies with ECA (n = 38) and robotic right colectomies with ICA (n = 67) for (pre)malignant lesions performed by a single surgeon between January 2014 and December 2020. CUSUM-plot analysis of total procedure time was used for learning curve determination of robotic colectomies. Non-parametric tests were used for statistical analysis. Compared to laparoscopy, the learning phase robotic right colectomies (n = 35) had longer procedure times (p < 0.001) but no differences in anastomotic leakage rate, length of stay or 30-day morbidity. Conversion rate was reduced from 16 to 3 percent in the robotic group. This study provides evidence that robotic right colectomy with ICA can be safely implemented without increasing morbidity.

Laparoscopic Intracorporeal Anastomosis.

Given the progression of laparoscopic surgery, questions continue to arise as to the ideal technique for a laparoscopic colectomy. The most debated of these questions is whether it is best to complete an intracorporeal (ICA) or extracorporeal (ECA) intestinal anastomosis. Here, we review the literature to date and report the equivalent safety and efficacy of ICA and ECA for laparoscopic right colectomy. However, these studies also indicate that when completed, ICA may prove beneficial with respect to earlier return of bowel function, less postoperative pain, shorter incision length, and reduced risk of wound infections. For this, we present the tips and tricks for completing all forms of laparoscopic ICAs during laparoscopic colectomy.

The success rate of robotic natural orifice intracorporeal anastomosis and transrectal extraction (NICE procedure) in a large cohort of consecutive unselected patients

BackgroundThe Robotic NICE procedure is a total intracorporeal natural orifice approach in which specimen extraction and anastomosis is accomplished without an abdominal wall incision other than the port sites themselves. We aim to present the success rate of the NICE procedure in a large cohort of unselected consecutive patients presenting with colorectal disease using a stepwise and reproducible robotic approach.MethodsConsecutive patients who presented with benign or malignant disease requiring left-sided colorectal resection and anastomosis between May 2018 and June 2021 were evaluated. Data abstracted included demographic, clinical data, disease features, intervention data, and outcomes data. The main outcome was success rate of Intracorporeal anastomosis (ICA), transrectal extraction of specimen (TRSE), and conversion rate.ResultsA total of 306 patients underwent NICE procedure. Diverticulitis was the main diagnosis (64%) followed by colorectal neoplasm (27%). Median operative time was 219 min, and the median estimated blood loss was 50 ml. ICA was achieved in all cases (100%). TRSE was successfully achieved in 95.4% of cases. In 14 patients (4.6%), an abdominal incision was required due to inability to extract a bulky specimen through the rectum. There overall postoperative complications rate was 12.4%. Eight patients (2.6%) experienced postoperative ileus. There were no superficial or deep surgical site infection (SSI). Eleven patients (3.6%) developed organ SSI space including 5 patients with intra-abdominal abscess and 4 patients with anastomotic leak. There was one mortality (0.3%) due to toxic megacolon from resistant Clostridium difficile. The 30-day reoperation rate was 2.9% (n = 9) including six patients presenting with organ space SSI and three patients with postoperative obstruction at the diverting loop ileostomy site.ConclusionThe NICE procedure is associated with a very high success rate for both intracorporeal anastomosis and transrectal specimen extraction in a large cohort of unselected patients.

Surgical site infection after intracorporeal anastomosis for left-sided colon cancer: study protocol for a non-inferiority multicenter randomized controlled trial (STARS)

BackgroundSurgical site infection (SSI), as one of the most common hospital-acquired infection, is usually associated with increased morbidity, mortality, and health care burden. SSI is a significant perioperative complication after colon cancer surgery, particularly for left-sided colon cancer. This paper describes the background and design of the “Surgical Site Infection after intracorporeal anastomosis for Left-sided Colon Cancer: study protocol for a non-inferiority multicenter Randomized Controlled Trial (STARS).” The STARS trial aims to compare the incidence of SSI after intracorporeal anastomosis and extracorporeal anastomosis after radical resection of colon cancer and to explore the risk factors of SSI.MethodsA total of 354 left colon cancer patients from 8 hospitals in China will be enrolled in this multi-center randomized controlled study. The primary outcome of this study is the incidence of SSI 30 days after left-sided colon cancer surgery. Secondary outcome measures include operation time, blood loss, conversion rate, incidence of perioperative complications, completeness of resection, number of lymph nodes collected and postoperative recovery characteristics, 3-year disease-free survival, and 5-year overall survival. The first patient was enrolled in January 2021.DiscussionTo our knowledge, this is the first prospective multicenter study to investigate whether there is a difference in the SSI incidence after intracorporeal and extracorporeal anastomosis for left-sided colon cancer in China. The results may provide more evidence that supports performing total laparoscopic left-sided colon cancer surgery.Trial registrationThe trial has been registered on ClinicalTrials.gov website (ID: NCT04201717). Registered on September 22, 2020

Establishment of a new practical telesurgical platform using the hinotori™ Surgical Robot System: a preclinical study.

AimThe recent development of new surgical robots and network telecommunication technology has opened new avenues for robotic telesurgery. Although a few gastroenterological surgeries have been performed in the telesurgery setting, more technically demanding procedures including gastrectomy with D2 lymphadenectomy and intracorporeal anastomosis have never been reported. We examined the feasibility of telesurgical robotic gastrectomy using the hinotori™ Surgical Robot System in a preclinical setting.MethodsFirst, the suturing time in the dry model was measured in the virtual telesurgery setting to determine the latency time threshold. Second, a surgeon cockpit and a patient unit were installed at Okazaki Medical Center and Fujita Health University, respectively (approximately 30 km apart), and connected using a 10-Gbps leased optic-fiber network. After evaluating the feasibility in the dry gastrectomy model, robotic distal gastrectomies with D2 lymphadenectomy and intracorporeal B-I anastomosis were performed in two porcine models.ResultsThe virtual telesurgery study identified a latency time threshold of 125 ms. In the actual telesurgery setting, the latency time was 27 ms, including a 2-ms telecommunication network delay and a 25-ms local information process delay. After verifying the feasibility of the operative procedures using a gastrectomy model, two telesurgical gastrectomies were successfully completed without any unexpected events. No fluctuation was observed across the actual telesurgeries.ConclusionShort-distance telesurgical robotic surgery for technically more demanding procedure may be safely conducted using the hinotori Surgical Robot System connected by high-speed optic-fiber communication.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00423-022-02710-6.

Enterotomy Closure after Minimally Invasive Distal Gastrectomy with Intracorporeal Anastomosis: A Multicentric Study

Introduction: Despite progressive improvements in technical skills and instruments that have facilitated surgeons performing intracorporeal gastro-jejunal and jejuno-jejunal anastomoses, one of the big challenging tasks is handsewn knot tying. We analysed the better way to fashion a handsewn intracorporeal enterotomy closure after a stapled anastomosis. Methods: All 579 consecutive patients from January 2009 to December 2019 who underwent minimally invasive partial gastrectomy for gastric cancer were retrospectively analysed. Different ways to fashion intracorporeal anastomoses were investigated: robotic versus laparoscopic approach; laparoscopic high definition versus three-dimensional versus 4K technology; single-layer versus double-layer enterotomies. Double-layer enterotomies were analysed layer by layer, comparing running versus interrupted suture; the presence versus absence of deep corner suture; and type of suture thread. Results: Significantly lower rates of bleeding (p = 0.011) and leakage (p = 0.048) from gastro-jejunal anastomosis were recorded in the double-layer group. Barbed suture thread was significantly associated with reduced intraluminal bleeding and leakage rates both in the first (p = 0.042 and p = 0.010) and second layer (p = 0.002 and p = 0.029). Conclusions: Double-layer sutures using barbed suture thread both in first and second layer to fashion enterotomy closure result in lower intraluminal bleeding and anastomotic leak rates.

Laparoscopic right colectomies with intracorporeal compared to extracorporeal anastomotic techniques are associated with reduced post-operative incisional hernias.

BackgroundOwing to important differences in surgical technique, laparoscopic right colectomy with intracorporeal (ICA) compared to extracorporeal (ECA) anastomotic technique may result in improved patient outcomes. We aimed to compare both techniques according to incisional hernias and other pertinent perioperative characteristics, post-operative complications, and oncologic quality markers. MethodsAll adult patients undergoing laparoscopic right colectomies between 2015 and 2020 at a single institution were included. ICA and ECA techniques were compared based on selected outcomes using univariable and multivariable statistical analyses, as appropriate. Subgroup analyses were restricted to patients with neoplastic indications for surgery and non-urgent operations.ResultsA total of 517 patients met inclusion criteria, of which 139 (26.9%) underwent ICA and 378 (73.1%) underwent ECA. ICA and ECA patients had similar baseline characteristics. At two years of follow-up, a lower proportion of ICA patients developed a hernia at the extraction incision (1.5% vs. 7.1%, p = 0.02) and ICA was associated with an 80% reduction in extraction incision hernias (aHR 0.20, p = 0.03). These results were stable through subgroup and sensitivity analyses. Median operative time was longer in the ICA group (186 min vs. 135 min, p < 0.001), but the gap in operative time narrowed during the study period. Median length of stay was one calendar day shorter in the ICA group (3 days vs. 4 days, p = 0.007) and ICA was associated with a 13% decrease in the length of stay (aRR 0.87, p = 0.02). The incidence of superficial wound infections, anastomotic leaks and re-interventions was lower in ICA patients, but this difference was not statistically significant. 90-day unscheduled visits, readmissions, and mortalities were similar across both groups, as were oncologic outcomes.ConclusionLaparoscopic right colectomies with intracorporeal anastomoses are associated with a reduction in incisional hernias and shorter hospital lengths of stay without compromising on patient safety or oncologic principles.Graphical abstract Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-022-09585-0.

Robotic-Assisted Laparoscopic Sigmoidectomy with Transrectal Specimen Extraction for Recurrent Diverticulitis

Natural orifice specimen extraction is a surgical technique that is defined as the removal of a surgical specimen from a natural orifice with intracorporeal anastomosis. Natural orifice specimen extraction is defined by the site of extraction and has been performed via the vagina, anal canal, rectum, colon, and mouth. The primary benefit of this technique is reduced trauma at the access point due to avoidance of mini laparotomy, used to facilitate specimen extraction in conventional laparoscopy. This technique has been associated with less postoperative pain, lower analgesic requirement, faster return of bowel function, and fewer incisional hernias, as well as an improved cosmetic result. Use of the robotic platform allows for deep pelvic dissection, which is challenging to impossible with laparoscopic instruments. Here, we report a case of recurrent diverticulitis in the setting of complex abdominal surgical history managed by robotic-assisted laparoscopic sigmoidectomy with transrectal specimen extraction.

Is there a superior anastomosis technique in right hemicolectomy? Clinical outcome analysis and survey of long-term quality of life and functional outcome of intracorporeal versus extracorporeal anastomosis techniques in laparoscopic and open surgery

Objectives: Laparoscopic right hemicolectomy with complete mesocolic excision has become the focus of scientific interest in recent years. There are technical differences with regard to the anastomosis which may influence long-term function and quality of life. The aim of this study was to compare short- and long-term functional outcomes of three groups (open surgery versus laparoscopic surgery with intracorporeal anastomosis versus laparoscopic surgery with extracorporeal anastomosis).

Medium-term oncological outcomes of totally laparoscopic colectomy with intracorporeal anastomosis for right-sided and left-sided colon cancer: propensity score matching analysis

BackgroundThis retrospective study aimed to compare long-term oncological outcomes between laparoscopic-assisted colectomy (LAC) with extracorporeal anastomosis (EA) and totally laparoscopic colectomy (TLC) with intracorporeal anastomosis (IA) for colon cancers, including right- and left-sided colon cancers.MethodsPatients with stage I–III colon cancers who underwent elective laparoscopic colectomy between January 2013 and December 2017 were analyzed retrospectively. Patients converted from laparoscopic to open surgery and R1/R2 resection were excluded. Propensity score matching (PSM) analysis (1:1) was performed to overcome patient selection bias.ResultsA total of 388 patients were reviewed. After PSM, 83 patients in the EA group and 83 patients in the IA group were compared. Median follow-up was 56.5 months in the EA group and 55.5 months in the IA group. Estimated 3-year overall survival (OS) did not differ significantly between the EA group (86.6%; 95% confidence interval (CI), 77.4–92.4%) and IA group (84.8%; 95%CI, 75.0–91.1%; P = 0.68). Estimated 3-year disease-free survival (DFS) likewise did not differ significantly between the EA group (76.4%; 95%CI, 65.9–84.4%) and IA group (81.0%; 95%CI, 70.1–88.2%; P = 0.12).ConclusionTLC with IA was comparable to LAC with EA in terms of 3-year OS and DFS. TLC with IA thus appears to offer an oncologically feasible procedure.

Extracorporeal versus intracorporeal anastomosis for right colon cancer surgery.

Laparoscopic right colectomy is currently considered the standard treatment for right colon cancer. After excision of the right colon, minimally invasive options for ileocolonic anastomosis include extracorporeal anastomosis (EA) and intracorporeal anastomosis (IA). However, the choice of anastomotic technique remains debated. As the entire IA is performed in the abdominal cavity, it is known for its advantages of a faster intestinal recovery and small incision. However, IA is time-consuming and technically difficult, limiting its widespread use. Recently, the robotic approach has increased the adoption of intracorporeal anastomotic techniques owing to the benefits of endowrist-articulated instruments and staplers. Except for a small incision and faster bowel recovery, the outcomes of the two anastomoses methods are inconsistent. To date, there has been no clear conclusion regarding whether IA or EA should be used to treat right colon cancer. This review aimed to investigate the current evidence relating to intraoperative outcomes and short-term postoperative results between both anastomotic approaches.

A novel method of anvil placement of circular stapler for esophagojejunostomy in laparoscopic total gastrectomy for gastric cancer: results of consecutive 200 cases.

Laparoscopic total gastrectomy for gastric cancer is still a demanding operation because of technical difficulties, especially of intracorporeal esophago-jejunal anastomosis. We introduced a newly designed method of anvil placement of circular stapling devices (CS) for laparoscopic esophagojejunostomy (EJS). A small incision was made on the anterior wall of the stomach, from which the anvil was inserted into the stomach and proceeded to the thoracic esophagus. Then, the abdominal esophagus was transected by a linear stapler, and the anvil into the esophagus was drawn back to the esophageal stump by pulling out the cotton tape pre-attached to the anvil. Intracorporeal EJS by Roux-en-Y reconstruction was performed by CS inserted into the abdominal cavity from the umbilical wound. A total of consecutive 200 gastric cancer patients underwent laparoscopic total gastrectomy using this method. There was no operative mortality. Anastomotic complications occurred in 12 cases (6.0%): 9 cases of stenosis (4.5%) and 3 cases of bleedings (1.5%). Anastomotic leakage was not observed. As for non-anastomotic complications, there occurred 2 pulmonary complications (1.0%), 3 pancreatic leakages (1.5%), and 8 bowel obstructions due to internal hernia (4.0%). With a median follow-up period of 47.1months, 5-year overall survival for assessable patients (n = 193) was 60.3% (95% CI 52.6-67.2). The total rate of peritoneal recurrence was 9.8%. Our new method of anvil placement for laparoscopic EJS with CS is safe and feasible with favorable survival outcomes. It eliminates the need for suturing, and will promote the clinical application of laparoscopic total gastrectomy for gastric cancer. UMIN000046119.

Comparison of short-term and medium-term outcomes between intracorporeal anastomosis and extracorporeal anastomosis for laparoscopic left hemicolectomy

BackgroundFew studies have evaluated the feasibility and safety of intracorporeal anastomosis (IA) for left hemicolectomy. Here, we aimed to investigate the potential advantages and disadvantages of laparoscopic left hemicolectomy with IA and compare the short- and medium-term outcomes between IA and extracorporeal anastomosis (EA).MethodsWe retrospectively analyzed 133 consecutive patients who underwent laparoscopic left hemicolectomies from July 2016 to September 2019 and categorized them into the IA and EA groups. Patients with stage 4 disease and conversion to laparotomy or those lost to follow-up were excluded. Postoperative outcomes between IA and EA groups were compared. Short-term outcomes included postoperative pain score, bowel function recovery, complications, duration of hospital stay, and pathological outcome. Medium outcomes included overall survival and disease-free survival for at least 2 years.ResultsAfter excluding ineligible patients, the remaining 117 underwent IA (n = 40) and EA (n = 77). The IA group had a shorter hospital stay, a shorter time to tolerate liquid or soft diets, and higher serum C-reactive protein level on postoperative day 3. There was no difference between two groups in operative time, postoperative pain, specimen length, or nearest margin. A 2-year overall survival (IA vs. EA: 95.0% vs. 93.5%, p = 0.747) and disease-free survival (IA vs. EA: 97.5% vs. 90.9%, p = 0.182) rates were comparable between two groups.ConclusionsLaparoscopic left hemicolectomy with IA was technically feasible, with better short-term outcomes, including shorter hospital stays and shorter time to tolerate liquid or soft diets. The IA group had higher postoperative serum C-reactive protein level; however, no complications were observed. Regarding medium-term outcomes, the overall survival and disease-free survival rates were comparable between IA and EA procedures.

Intracorporeal or extracorporeal ileocolic anastomosis after laparoscopic right colectomy: cost analysis of the Torino trial.

Intracorporeal (IIA) and extracorporeal anastomosis (EIA) are two well-established techniques for restoration of bowel continuity after laparoscopic right colectomy (LRC). Since no economic analysis comparing the two different anastomotic techniques has been performed yet, it is still unclear if IIA can reduce perioperative costs. The aim of the study was to compare costs of LRC with IIA or EIA for right-sided colon neoplasm. This is a cost analysis of a single-institution double-blinded randomized controlled trial comparing the outcomes of LRC with IIA and LRC with EIA in patients with a right-sided colon neoplasm. All direct in-hospital costs related to patient's admission were recorded (intraoperative costs: operative room, surgical tools, blood units-postoperative costs: hospital stay, laboratory and microbiology analyses, diagnostic services, analgesic drugs and antibiotic therapy, blood units, reoperation-outpatient costs: post-discharge wound medications). This trial was registered with ClinicalTrials.gov, Number NCT03045107. A total of 140 patients were randomized and analyzed. Mean overall costs in the IIA group exceeded 349€ the mean overall costs of the EIA group (7926.87 ± 4617.23€ vs. 7577.45 ± 6131.17€; P = 0.704). A mean extra charge of 608€ regarding total intraoperative costs was recorded in the IIA group (3058.84 ± 897.42€ vs. 2450.15 ± 558.90€; P < 0.001). The cost of surgical instruments resulted in 542€ additional charge per patient in the IIA group compared to EIA group (1782.74 ± 541.26€ vs. 1240.55 ± 384.09€; P < 0.001). The mean cost of operative room occupancy was comparable in IIA and EIA group: 1276.09 ± 514.94€ vs. 1209.60 ± 422.80€ (P = 0.405). No significant differences were observed in postoperative costs and in outpatient costs. This economic analysis showed that IIA and EIA after LRC had similar overall costs, even though there were intraoperative extra costs of IIA.