Intracorporeal Ileocolic Anastomosis Research Articles

A standardized stepwise approach to minimally invasive ileocolic anastomosis: Tips and tricks for laparoscopic and robotic surgery.

Intracorporeal anastomosis has been associated with earlier recovery of postoperative bowel function, shorter length of stay and lower surgical site infection rates. The aim of this work is to describe a step-by-step standardized technique for intracorporeal ileocolic and ileosigmoid anastomosis suitable for laparoscopic and robotic colectomy. Each step of the technique is illustrated using a composite collection of three operative patient videos. Two procedures were performed robotically and one was laparoscopic. Tips are provided to construct a two-layer anastomosis (both posteriorly and anteriorly). The procedures are presented in stepwise fashion, discussing the advantages and feasibility of the technique. The standardized technique described herein was used in three patients for this report, of whom two underwent right colectomy and one subtotal colectomy for cancer. The median operating time was 255 (206-333)min. There were no intraoperative complications. No major postoperative complications or 30-day readmissions occurred. The median length of stay was 4 (3-5)days. The described technique of a two-layer anastomosis can be used with any available minimally invasive approach. It is safe and feasible. Using a standardized approach, the technique can be easily taught and mastered, optimizing operating times and reducing adverse events.

Bowel function after laparoscopic right hemicolectomy: a randomized controlled trial comparing intracorporeal anastomosis and extracorporeal anastomosis

BackgroundThe laparoscopic right hemicolectomy is the standard surgical treatment for right-sided colon cancer. The continuity of the digestive tract is restored through ileocolic anastomosis which can be performed extracorporeally or intracorporeally. The study aimed to compare both anastomotic techniques in laparoscopic right hemicolectomy.Materials and methodsA single-blinded two-armed randomized control trial with 1:1 parallel allocation carried out from 2016 to 2020 in a single center. The follow-up period was 30 days. Compared interventions involved extracorporeal and intracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy. The main outcome of the study was bowel recovery measured as the time to the first stool. Other outcomes involved the time to the first flatus, morbidity, and duration of surgery.ResultsOne hundred and seventeen patients undergoing a laparoscopic right hemicolectomy with curative intent were eligible for the trial. Eight patients refused to participate. One hundred and two patients were analyzed, 52 in the intracorporeal group and 50 in the extracorporeal group. The groups did not differ in terms of cancer stage or body mass index, but did differ in age and sex. Intracorporeal anastomosis was associated with a shorter time to the first stool than extracorporeal, 32.8 h (26.0–43.7) vs. 41.7 (35.9–50.0), p = 0.017. There was no significant difference in the time to the first flatus, 30 h (23.2–42.3) vs. 26.6 h (21.8–37.3), p = 0.165. Similarly, overall complications did not differ (EC 12/50 vs. IC 10/52, p = 0.56). There were no differences in length of surgery, 190 min (150–230) and 190 min (180–220), p = 0.55.ConclusionIntracorporeal ileocolic anastomosis following laparoscopic right hemicolectomy results in slightly faster bowel recovery, with no differences in morbidity and duration of surgery.

Right colectomy with intracorporeal anastomosis for cancer: a prospective comparison between robotics and laparoscopy.

Robotics in right colectomy are still under debate. Available studies compare different techniques of ileocolic anastomosis but results are non-conclusive. Our study aimed to compare intraoperative outcomes, and short-term postoperative results between robotic and standard laparoscopic right colectomies for cancer with intracorporeal anastomosis (ICA) fashioned with the same technique. All consecutive patients scheduled for laparoscopic or robotic right hemicolectomies with ICA for cancer in two hospitals, one of which is a tertiary care centre, were prospectively enrolled in our prospective observational study, from April 2018 to December 2019. ICA was fashioned with the same stapled hand-sewn technique. Continuous and categorical variables were analysed using t test and chi-squared test as required. Statistical significance was set at p < 0.05. Forty patients underwent laparoscopic surgery, and 48 underwent robotic right colectomy and were included in the intention-to-treat analysis. Operative time was not statistically different between the two groups (robotic group 265.9min vs laparoscopic group 254.2min, p = 0.29). The robotic group had a significantly shorter time for stump oversewing (ileum reinforcement: robotic group 9.3min vs laparoscopic group 14.2min, p < 0.001; colon reinforcement: robotic 7.7. min, laparoscopy 13.9min, p < 0.001) and for ICA (robotic 31.6min vs laparoscopy 43.0, p < 0.001). One patient underwent extracorporeal anastomosis in the robotic group. The short-term outcomes were comparable between standard laparoscopic and robotic right colectomies with ICA. The limitation of the study is its small sample size and the fact that it was done in two institutions under the supervision of one person. Our data demonstrate that intracorporeal ileocolic anastomosis is safe, and faster and easier with robotic systems. Robotics can facilitate more challenging ICA in minimally invasive surgery.

Extracorporeal versus intracorporeal anastomosis in laparoscopic right hemicolectomy for cancer

Introduction This study aimed at assessing the long-term oncological outcomes of intracorporeal ileocolic anastomosis (ICA) for laparoscopic right hemicolectomy for colon cancer compared with extracorporeal anastomosis (ECA). Material and methods We performed a retrospective analysis of 149 consecutive patients who underwent laparoscopic right hemicolectomy for colon cancer between January 2006 and December 2012. Results Eighty and 69 patients underwent intracorporeal and ECA, respectively. The two groups were demographically comparable. ICA exhibited a significantly shorter operative time (p < .0001), while local relapse and length of hospital stay did not significantly differ among the groups (p = .724 and .310, respectively). There was no significant difference in median number of retrieved lymph node. The overall survival and the disease-free survival at five years did not significantly differ among the groups. Conclusions Intracorporeal ICA can reduce operative time and is associated with similar postoperative and long-term oncological outcomes compared to the ECA technique.

Does laparoscopic intracorporeal ileocolic anastomosis decreases surgical site infection rate? A propensity score-matched cohort study.

Foreshortened mesentery or thick abdominal wall constitutes a rationale for laparoscopic intracorporeal ileocolic anastomoses (ICA). The aim of this study was to compare intracorporeal to extracorporeal ICA in terms of surgical site infections in patients with Crohn's ileitis and overweight patients with right colon tumors. This was a prospective propensity score-matched cohort study enrolling consecutive patients with Crohn's terminal ileitis and overweight patients with right colon tumors undergoing elective laparoscopic right colon resection with intracorporeal or extracorporeal ICA. Propensity score matching with a 1:1 ratio was employed to compare diagnosis-matched patients for age, BMI, ASA, and previous abdominal surgery. Overall, 453 patients were enrolled: 233 intracorporeal vs. 220 extracorporeal. Propensity score matching left 195 intracorporeal and 195 extracorporeal patients comparable for age (p = 0.294), gender (p = 0.683), ASA (p = 0.545), BMI (p = 0.079), previous abdominal surgery (p = 0.348), and diagnosis (p = 0.301). Conversion rates (5.1 vs. 3.6%; p = 0.457) and intraoperative complications (1 vs. 2.1%; p = 0.45) were similar. Overall morbidity (5.1 vs. 12.8%; p = 0.008) and re-intervention rates (3.1 vs. 8.7%; p = 0.029) were significantly higher in extracorporeal patients. Anastomotic leak rates (0.5 vs. 1.5%; p = 0.623) did not differ. Incisional SSI rate was significantly higher in extracorporeal patients (p = 0.01). Laparoscopic intracorporeal ICA reduced incisional SSI rates as compared to its extracorporeal counterpart.

Robotic right hemicolectomy: Analysis of 108 consecutive procedures and multidimensional assessment of the learning curve

PurposeSurgeons tend to view the robotic right colectomy (RRC) as an ideal beginning procedure to gain proficiency in robotic general and colorectal surgery. Nevertheless, oncological RRC, especially if performed with intracorporeal ileocolic anastomosis confectioning, cannot be considered a technically easier procedure. The aim of this study was to assess the learning curve of the RRC performed for oncological purposes and to evaluate its safety and efficacy investigating the perioperative and pathology outcomes in the different learning phases. MethodsData on a consecutive series of 108 patients undergoing RRC with intracorporeal anastomosis between June 2011 and September 2015 at our institution were prospectively collected to evaluate surgical and short-term oncological outcomes. CUSUM (Cumulative Sum) and Risk-Adjusted (RA) CUSUM analysis were performed in order to perform a multidimensional assessment of the learning curve for the RRC surgical procedure. Intraoperative, postoperative and pathological outcomes were compared among the learning curve phases. ResultsBased on the CUSUM and RA-CUSUM analyses, the learning curve for RRC could be divided into 3 different phases: phase 1, the initial learning period (1st–44th case); phase 2, the consolidation period (45th–90th case); and phase 3, the mastery period (91th–108th case). Operation time, conversion to open surgery rate and the number of harvested lymph nodes significantly improve through the three learning phases. ConclusionsThe learning curve for oncological RRC with intracorporeal anastomosis is composed of 3 phases. Our data indicate that the performance of RRC is safe from an oncological point of view in all of the three phases of the learning curve. However, the technical skills necessary to significantly reduce operative time, conversion to open surgery rate and to significantly improve the number of harvested lymph nodes were achieved after 44 procedures. These data suggest that it might be prudent to start the RRC learning curve by treating only benign diseases and to reserve the performance of oncological resection to when at least the initial learning phase has been completed.

Intracorporeal ileocolic anastomosis in patients with laparoscopic right hemicolectomy.

Since the introduction of laparoscopic colorectal surgery, there has been a controversy between creating an intracorporeal or extracorporeal ileocolic anastomosis in right hemicolectomy. The purpose is to report our experience in intracorporeal anastomosis following right hemicolectomy in both malignant and benign pathologies. A retrospective review of a prospectively collected database was conducted at Virgen de la Arrixaca Clinical University Hospital (Murcia) between January 2000 and April 2014. The study includes all surgery patients who received a laparoscopic right hemicolectomy with an intracorporeal ileocolic anastomosis. The criteria for exclusion were conversion to open surgery during the procedure due to technical difficulties during dissect. Tumours considered T4 were not excluded, nor were stage IV patients or those with a history of previous abdominal surgery. There were 173 patients (63 females) aged 67 (range 14-91) years, with body mass index of 27 (17-52) kg/m(2) and ASA 1:2:3:4 of 12:78:68:15; 41% had previous abdominal surgery and 70% had a pre-existing comorbidity. Operating time was 142 (60-270) min. Specimen extraction site incision length was 8.1 (6-11.1) cm. Conversion rate was 9.2%, and there were 39 complications (22.54%) and 9 reoperations (5.2%). Readmission rate was 5.2%. Length of stay was 5.7 (1-35) days. The intracorporeal procedure is a safe and feasible alternative for creating an ileocolic anastomosis. It involves a similar rate of complications and may prevent some of the drawbacks presented by extracorporeal anastomosis.

Intracorporeal ileocolic anastomosis: a review

This study is a narrative review of the current literature regarding intracorporeal ileocolic anastomosis in laparoscopic right colon resection for benign or malignant diseases of the right colon and terminal ileum. The search strategy included Medline, Embase, CINAHL, ACP Journal Club, and Cochrane databases with laparoscopic right colectomy and intracorporeal anastomosis as keywords. All retrieved references were screened by two independent blinded reviewers. Thirteen papers including 611 patients undergoing laparoscopic right colon resection with intracorporeal ileocolic anastomosis for benign or malignant diseases of the right colon and terminal ileum were identified. There were eight case series and five case control studies. Anastomoses were fashioned as antiperistaltic or isoperistaltic, totally stapled or stapled/handsewn. The mesenteric defect was mostly left open. Overall operating time ranged from 53 to 360 min. The most common specimen extraction site locations were periumbilical, suprapubic, or transvaginal with a median incision length ranging from 3 to 6 cm. The overall rate of surgical site infection was 2.7 %. The anastomotic leak rates varied from 0 to 8.5 %. Postoperative mortality was 0.12 %. Intracorporeal ileocolic anastomosis following laparoscopic resection of the right colon is not commonly performed, but offers potential benefits if carried out by experienced surgeons in selected patients.

Short- and long-term outcomes of intracorporeal versus extracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy for colon cancer

We assessed the short- and long-term outcomes of intracorporeal ileocolic anastomosis (IA) in laparoscopic right hemicolectomy for colon cancer compared with extracorporeal anastomosis (EA). A retrospective chart review of 86 consecutive patients who underwent laparoscopic right hemicolectomy for colon cancer from March 2005 to June 2010 was performed. There were 51 and 35 patients who underwent intracorporeal and extracorporeal anastomosis, respectively. The two groups were demographically comparable. The conversion rate to open surgery was 8.6 % in the EA group, but none in the IA group (p = 0.064). There was no significant difference in operative time, estimated blood loss, complications (intra-abdominal abscess, anastomotic leak, ileus, and wound infection), and length of hospital stay between the groups. There was no perioperative mortality in both groups. There was no significant difference in median number of retrieved lymph node. The overall survival and the disease-free survival at 3 years were not different between the groups. Compared with the extracorporeal anastomosis technique, intracorporeal ileocolic anastomosis produces comparable short- and long-term outcomes in laparoscopic right hemicolectomy for colon cancer.

Extracorporeal versus intracorporeal ileocolic anastomosis

This nonsystematic review was performed to evaluate the literature that pertains to laparoscopic right colectomy, focusing on extracorporeal versus intracorporeal ileocolic anastomosis. The literature search was performed using PubMed to investigate the current status of research on 3 topics: (1) laparoscopic right colectomy with extracorporeal anastomosis, (2) laparoscopic right colectomy with intracorporeal anastomosis, and (3) comparisons of the 2 techniques. Each topic was reviewed, and the most relevant articles were selected for each subheading. Current literature is bringing to the forefront new evidence that laparoscopic right colectomy with intracorporeal anastomosis can be performed within a comparable time frame as extracorporeal anastomosis and with similar complication rates. Recent reports have presented evidence in which the entire operation is performed intracorporeally by a medial-to-lateral approach with comparable results to those observed in the surgery performed with extracorporeal anastomosis. The advantages of intracorporeal anastomosis are that mobilization of the transverse colon is not necessary, the anastomosis is performed away from the abdominal wall, and there is decreased potential for adhesion formation and a smaller extraction site. Potential disadvantages include intra-abdominal colotomy, requirement of laparoscopic suturing skills, and longer operative time.

Laparoscopic right colon resection with intracorporeal anastomosis

This study was performed to evaluate short-term clinical outcomes of laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon. This was a retrospective study of selected patients who underwent laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon for tumors or Crohn's disease by a single surgeon from July 2002 through June 2012. Data were retrieved from an Institutional Review Board-approved database. Study end point was postoperative adverse events, including mortality, complications, reoperations, and readmissions at 30 days. Antiperistaltic side-to-side anastomoses were fashioned laparoscopically with a 60-mm-long stapler cartridge and enterocolotomy was hand-sewn intracorporeally in two layers. Values were expressed as medians (ranges) for continuous variables. There were 243 patients (143 females) aged 61 (range = 19-96) years, with body mass index of 29 (18-43) kg/m(2) and ASA 1:2:3:4 of 52:110:77:4; 30 % had previous abdominal surgery and 38 % had a preexisting comorbidity. There were 84 ileocolic resections with ileo ascending anastomosis and 159 right colectomies with ileotransverse anastomosis. Operating time was 135 (60-220) min. Estimated blood loss was 50 (10-600) ml. Specimen extraction site incision length was 4.1 (3-4.4) cm. Conversion rate was 3 % and there was no mortality at 30 days, 15 complications (6.2 %), and 8 reoperations (3.3 %). Readmission rate was 8.7 %. Length of stay was 4 (2-32) days. Pathology confirmed Crohn's disease in 84 patients, adenocarcinoma in 152, and other tumors in 7 patients. Laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon resulted in a favorable outcome in selected patients with Crohn's disease or tumors of the right colon.

Robotic right colectomy for cancer with intracorporeal anastomosis: short-term outcomes from a single institution

Laparoscopic surgery for colon cancer has widely accepted as safe and effective. However, few studies report outcomes on robotic right colon resection with confectioning of the intracorporeal ileocolic anastomosis. This study aims to evaluate the feasibility and safety of robotic right colon resection with intracorporeal ileocolic anastomosis (RRCIA) in patients with cancer. Data of consecutive series of 20 patients undergoing RRCIA between June 2011 and May 2012 at our institution were prospectively collected in order to evaluate surgical and oncological short-term outcomes. Seven males and 13 females were operated of RRCIA during the study period. Mean age is 66.7years. The mean overall operative time was 327.5min (255-485), and the robot time was 286min (range 225-440min). No conversion to open or laparoscopy occurred. The mean specimen length was 32.7cm (range 26-44cm), and the mean number of harvested lymph nodes was 17.6 (range 14-21). During the 30 postoperative days, only one complication occurred, consisting in an infection of surgical specimen extraction wound. The RRCIA is a feasible and safe for patients with right colon cancer, also in terms of intraoperative oncological outcomes.

Laparoscopic right hemicolectomy with intracorporeal anastomosis

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.