Laparoscopic Anterior Rectal Resection Research Articles

Intracorporal isoperistaltic linear colorectal “side-to-side” (overlap) anastomosis: invention concept and primary results

AIM: to present the primary experience of performing intracorporeal linear colorectal anastomosis using the “overlap” technique in laparoscopic anterior rectal resection. MATERIALS AND METHODS: the study presents the outcomes of intracorporeal linear “overlap” anastomosis in patients who underwent laparoscopic anterior rectal resection between October 2023 and February 2024. The results were evaluated based on various parameters including operation time, the postoperative morbidity rate (by Clavien-Dindo scale), conversion rates, hospital stay, quality of life by SF-36 questionnaire 30 days after surgery. RESULTS: the linear “overlap” anastomosis was done in 10 patients (5 females), aged 62.0 ± 9.03 years and BMI of 27.5 ± 7.2 kg/m2. No intraoperative complications occurred. One patient developed a seroma at the incision site (Clavien–Dindo I). The first bowel movement was at 1 (0–3) days after surgery. The post-op hospital stay was 5.7 ± 1.9 days. CONCLUSION: primary results demonstrate the simplicity and safety of intracorporeal linear “overlap” anastomosis technique. The further advanced study is justified.

A commentary on '"Dumpling suture method" versus traditional suture method of protective loop ileostomy in laparoscopic anterior rectal resection with specimen extraction through stoma incision: a retrospective comparative cohort study'.

A commentary on '"Dumpling suture method" versus traditional suture method of protective loop ileostomy in laparoscopic anterior rectal resection with specimen extraction through stoma incision: a retrospective comparative cohort study'.

'Dumpling suture method' versus traditional suture method of protective loop ileostomy in laparoscopic anterior rectal resection with specimen extraction through stoma incision: a retrospective comparative cohort study.

A diverting loop ileostomy (DLI) is performed in laparoscopic anterior rectal resection (LAR) surgery at high risk of anastomotic fistula. Minimally invasive surgery promotes postoperative recovery and cosmetics. To reduce abdominal trauma, specimen extraction through stoma incision (EXSI) is usually performed to avoid auxiliary abdominal incision with enlarged stomal incision. The traditional suture method (TSM) reduces the incision size by suturing the ends of the enlarged incision, leading to peristomal incisions and a higher risk of stomal complications. The study aimed to introduce the dumpling suture method (DSM) of PLI and compare this new method with TSM. The authors propose a novel stoma suture technique, which utilized a method of skin folding suture to reduce the enlarged incision size. A retrospective analysis was conducted on 71 consecutive patients with rectal cancer who underwent LAR-DLI with EXSI, and the intraoperative details and postoperative outcomes of the two groups were measured. The DSM group showed a lower stomal complication rate (10.3 vs. 35.7%, P=0.016) than that of the TSM group. The scores of DET (Discoloration, Erosion, Tissue overgrowth), stomal pain, quality of life were all significantly lower in DSM group than in TSM group. In multivariate analysis, DSM was an independent protective factor for stoma-related complications. Operative time, time to first flatus, defecation and eat, nonstomal related postoperative complications were similar in both groups. DSM utilizes a method of skin folding suture to reduce the enlarged incision size, which is safe and effective in reducing the incidence of peristomal skin infections and stomal complications. This procedure offers a novel suturing approach for loop ileostomy with enlarged incision, effectively reducing the postoperative trauma and incidence of stomal complications.

Pelvic Floor Peritoneum Closure Reduces Severe Postoperative Complications in Rectal Cancer Patients After Laparoscopic Anterior Rectal Resection.

Laparoscopic anterior rectal resection (LAR) is a commonly performed surgery for rectal cancer patients. Pelvic floor peritoneum closure (PC), a vital procedure in conventional anterior rectal resection, is not routinely performed in LAR. A total of 1118 consecutive patients with rectal cancer receiving LAR were included in this retrospective study. Patients were allocated into the PC group and the non-PC group. The occurrence of postoperative complications was compared between the 2 groups. Influential factors in anastomotic leakage (AL) were explored using univariate and multivariate logistic regression. There was no difference between the groups in terms of baseline characteristics. The occurrence of postoperative complications was similar between the groups. The PC group had significantly shorter postoperative hospitalization and longer operation duration compared with the non-PC group. The occurrences of Clavien-Dindo (CD) III-IV complications, CD III-IV AL, and reoperation were significantly lower in the PC group than the non-PC group. PC and a protective ileostomy were independent protective factors for CD III-IV AL. PC could reduce the occurrence of CD III-IV complications, especially CD III-IV AL, and the rate of secondary surgery, especially in patients with a lower body mass index and patients who did not receive protective ileostomies.

Outcomes of anastomosis of mechanically prepared bowel vs. mechanically unprepared bowel in laparoscopic anterior resection in adult patients with rectal cancer

Introduction: The limited literature supporting the utilization of mechanical bowel preparation (MBP) for patients undergoing laparoscopic anterior resection of rectum (LAR) remains a notable issue. This study was conducted to examine the clinical consequences of anastomosis in rectal surgery with MBP compared to cases where MBP is not utilized (no-MBP) in the context of LAR.Methods: This is a retrospective comparative study conducted in the professorial surgical wards of Teaching Hospital Karapitiya (THK). Rectal cancer patients (n=306) participated in the study, including 151 MBP patients and 155 no-MBP patients where the postoperative complications and mortality rates were compared.Results: The anastomotic leakage rate was 2.6% (n=4) in the no-MBP group and 6.0% (n=9) in the MBP group, (p=0.143). Postoperative paralytic ileus rate was 18.5% (n=28) and 5.8% (n=9) in the MBP group and no-MBP group respectively displaying a statistically significant difference (p=0.001). Wound infection, pneumonia, urinary tract infection, and cardiac complication rates also were higher in the MBP group. Overall mortality rate was 1.3% (n=3) in no-MBP group and 2.0% (n=2) in MBP group. Conclusions: The evidence concludes that MBP increases post-operative complications. Therefore, prophylactic MBP in LAR has not been proven to benefit patients. However, further research is necessary to understand the comparative effects of MBP versus no preparation comprehensively.

Transatmospheric ileal stoma manometry can be applied for the early detection of stoma outlet obstruction.

Stoma outlet obstruction (SOO) is a common complication of diverting ileostomy and usually detected at the advanced stage when the intestine is obviously obstructed. The objective of this study is to explore the efficacy of transatmospheric ileal stoma manometry (TISM) in early detection of SOO before the manifestation of intestinal obstruction. A single-center prospective study was performed in patients scheduled to undergo reversal ileostomy and laparoscopic anterior rectal resection and diverting ileostomy in Second Affiliated Hospital of Zhejiang University School of Medicine from 1st July 2022 to 31st December 2022. The stoma pressure was measured by TISM at different time points. The mean stoma pressure of the 30 patients before reversal ileostomy was 5.21 cmH2O which was considered as normal standard of stoma pressure, and ranged from 1.2 to 8.56 cmH2O. After excluding two patients with anastomotic leakage, a total of 38 patients who were subjected to laparoscopic anterior rectal resection and diverting ileostomy were further included in this study. The incidence of anastomotic leakage was 5% and that of SOO was 12.5%. The mean postoperative obstruction time was 5.2 (3-7) days and the mean time from elevated stoma pressure to diagnosed as SOO was 2.8 (2-4) days in the five patients who developed SOO. The pressure measured at the third stoma manometry time point (second day after return of gut function) (10.23 vs. 6.04 cmH2O, p<0.001) and the postoperative hospital stay (10 vs. 8.49 days, p=0.028) showed significantly difference between the SOO and non-SOO groups. The pressures measured at the first time point (before return of gut function) (4 vs. 4.49 cmH2O, p=0.585), the second time point (the day of return of gut function) (6.8 vs. 5.62 cmH2O, p=0.123), and the fourth time point (discharge day) (5.88 vs. 5.9 cmH2O, p=0.933) showed no significant difference in both groups. TISM can be utilized for early detection of SOO and can be incorporated as a novel diagnostic method together with abdominal CT scan to realize the goal of ERAS.

The Prevalence of Back Pain in Patients Operated on Due to Colorectal Cancer Depending on the Type of Surgical Procedure Performed

Purpose: Low back pain presents a serious challenge for numerous medical specialties. The purpose of this study was to assess disability due to low back pain in patients operated on due to colorectal cancer depending on the type of surgery performed. Methods: This prospective observational study was carried out in the period of July 2019 through March 2020. Included in the study were patients with colorectal cancer for scheduled surgeries including anterior resection of rectum (AR), laparoscopic anterior resection of rectum (LAR), Hartmann’s procedure (HART), or abdominoperineal resection of rectum (APR). The Oswestry Low Back Pain Disability Questionnaire was used as the research tool. The study patients were surveyed at three time points: before surgery, six months after surgery, and one year after surgery. Results: The analysis of study results revealed that an increase in the degree of disability and functioning impairment occurred in all groups between time points I and II, with the differences being statistically significant (p &lt; 0.05). The inter-group comparative analysis of the total Oswestry questionnaire scores revealed statistically significant differences, with the impairment of function being most severe within the APR group and least severe within the LAR group. Conclusion: The study results showed that low back pain contributes to impaired functioning of patients operated on due to colorectal cancer regardless of the type of procedure performed. A reduction in the degree of disability due to low back pain was observed one year after the procedure in patients having undergone LAR.

Necrotizing Fasciitis as an Early Postoperative Complication of Non-perforated Non-metastatic Rectal Cancer: Case Report and a Review of the Literature

Background: Necrotizing fasciitis is a life-threatening condition characterized by a rapid onset and aggressive degradation of the patient’s condition due to its fair prognosis. The brisk rate of necrotizing fasciitis evolution often makes diagnosing and treating it difficult, thus becoming fatal and incompatible with life. Case report: The authors report a rare case of a 62 years old woman, who had undergone a laparoscopic anterior rectal resection intervention. The patient presented stable with no co-morbidities. She had suffered different gastrointestinal symptoms during the last 2 months such as anorexia, diarrhea, and abdominal discomfort. She had also lost 6 kg in a 2-month time period. Imaging examinations (contrast CT) detected a rectal tumor stage CT4a N1 M0. No bowel perforations were detected. The team faced no perioperative complications. Later that day, she referred to having moderated pain around the surgical wounds that developed two days later with pain and mild diffuse hematoma in the left flank. This developed into necrotizing fasciitis and despite all the efforts she had an exitus lethalis on the 9 th postoperative day. Conclusions: Necrotizing fasciitis still remains a challenge to many specialists. In the context of malignancies, it is sometimes seen as a complication of perforated colon tumors. However, cases such as this, represent a challenge to many doctors due to their insidious characteristics. That is why it is important to search further into the mechanisms of this pathology. Keywords: necrotizing fasciitis, colorectal cancer, postoperative complication. DOI: 10.7176/ALST/96-01 Publication date: December 31 st 2022

Polypoid arteriovenous malformation of the rectum: A case report

BackgroundIntestinal arteriovenous malformation is an abnormal connection between arteries and veins that bypasses the capillary system and may be a cause of significant lower gastrointestinal bleeding. On endoscopy, arteriovenous malformations are usually flat or elevated, bright red lesions. Overall, rectal localization of arteriovenous malformations is rare. The same may be said about polypoid shape arteriovenous malformations. Herein, we present a case of a large rectal polypoid arteriovenous malformations.MethodsClinical, diagnostic, and treatment modalities of the patient were reviewed. Pre- and post-operative parameters were collected and analyzed. The clinical English literature is also reviewed and discussedResultsA 60-year-old female patient was admitted to our emergency department for rectorrhagia and anemia. Rectoscopy revealed a polypoid lesion in the rectum and the biopsy showed fibrosis, necrosis areas, and hyperplastic glands. A total body contrast-enhanced computed tomography (CT) was performed revealing a parietal pseudonodular thickening with concentric growth and contrast enhancement, extending for about 53 mm. The mass wasn't removed endoscopically due to concentric growth, sessile implant, and submucosal nature. The patient underwent an uneventful laparoscopic anterior rectal resection. The postoperative hospitalization was free of complications. Histology showed the presence of a polypoid AVM composed of dilated arteries, veins, capillaries, and lymphatics, engaging the submucosa, muscularis, and subserosa layer.ConclusionAfter a review of the current English literature, we found only one case of rectal polypoid AVM. The scarcity of documented cases encumbers optimal diagnostic and treatment approaches.

Features to Prevent Failed Hardware Colorectal Anastomoses in Laparoscopic Rectal Resections

The aim of research was to study proper results of laparoscopic anterior rectal resection using intraoperative measures to prevent failure of hardware colorectal anastomoses in patients with rectal tumor.Material and methods. Out of 68 patients included in the study, colorectal anastomotic leakage occurred clinically only in 2 cases (2.9%, class A and B) and required no further surgical interventions. When evaluating the risk of colorectal anastomosis failure in each specific case, it is necessary to consider pre- and intraoperative risk factors. Formation of colorectal anastomosis with one angular end of the rectal stump followed by immersion; additional strengthening of the anastomosis zone with interrupted serous-muscular sutures; adequate drainage of the pelvic cavity (the most effective - transperineal presacral) are intraoperative methods that reduce the risk of failed hardware colorectal anastomoses.Results. Out of 68 operated patients, colorectal anastomosis failure occurred clinically only in 2 cases (2.9%, class A and B) and did not require repeated surgical intervention. When assessing the risk of colorectal anastomosis failure in each specific case, it is necessary to take into account pre-and intraoperative risk factors. Formation of a colorectal anastomosis with one angular end of the rectal stump, followed by its immersion; additional strengthening of the anastomosis zone with nodular serous-muscular sutures; adequate drainage of the pelvic cavity (most effectively - trans-interventional presacral) - intraoperative methods that reduce the risk of failure of hardware colorectal anastomoses.Conclusion. Reasonable doubts in the intraoperative evaluation of the blood supply to the end section of the descending colon, viability of the colorectal anastomosis, presence of 3 or more risk factors, low position of anastomosis (less than 10 cm from the outer end of the anal canal) indicate the necessity to form preventive transversostomy.

Management of postoperative complications during laparoscopic anterior rectal resection.

Laparoscopic anterior resection (LAR) is currently a routine practice in specialized high-volume centers, with equivalent oncological outcomes in historical, open surgery. Appropriate pelvic dissection can be measured by the adequacy of circumferential margin (CRM) and distal margin, both are risk factors of local recurrence. Among the various operative procedures for colorectal cancer, low anterior resection (LAR) for rectal cancer is one of the most demanding procedures because it requires resection of cancer with surrounding mesorectal tissue and reconstruction with anastomosis in the narrow pelvis while preserving the autonomic nerves of the urogenital organs particularly in the male pelvis. Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, and asymptomatic patients infected with COVID-19 submitted to elective could be at higher risk which sometimes result in postoperative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential to prevent it. The importance of some risk factors such as age, nutrition status of the patient, experience of the surgeon and many other factors that influence outcome of colorectal surgery which could be modified preoperatively to prevent postoperative complications. In the other hand long term postoperative complications may promote tumor recurrence and decrease survival. The aims of this review are to provide an overview of the current literature on postoperative complications of rectal surgery and to describe risk factors and strategies to prevent, treat or reduce complications.

Is routine splenic flexure mobilization always necessary in laparotomic or laparoscopic anterior rectal resection? A systematic review and comprehensive meta-analysis.

Splenic flexure mobilization (SFM) is one of the most difficult steps in laparoscopic colorectal surgery and its role is harshly debated. Some surgeons considered it routinely necessary to obtain a safe anastomosis and to respect oncologic criteria; for others SFM is frequently unnecessary, not ensuring the aspects mentioned above and increasing the risk of morbidity (splenic, bowel and vessels injury, lengthened procedure). We performed a systematic review and a comprehensive meta-analysis, without any language restriction, about the peri-operative and post-operative outcomes (anastomotic leakage, intra-operative complication, conversion rate, operative time, post-operative bleeding, intra-abdominal collection, prolonged ileus, wound infection, anastomotic stricture, overall complications, hospital stay, re-operation, post-operative mortality, R0 margin resection, local recurrence) in patients undergoing elective anterior rectal resection (ARR) with or without SFM, both in laparotomic (LT) and laparoscopic (LS) approach. Fourteen studies were meta-analyzed with a total amount of 42,221 patients. The comprehensive meta-analysis shows that the mobilization or the preservation (SFP) of the splenic flexure does not statistically influence the incidence of colorectal anastomotic leakage, conversion rate, post-operative bleeding, intra-abdominal collection, prolonged ileus, wound infection, anastomotic stricture, overall complications, hospital stay, re-operation, R0 margin resection, and local recurrence results. The operative time is significantly longer in every group of patients undergoing SFM. The incidence of intra-operative complication is statistically increased in overall patients and also in the LS subgroup of patients undergoing SFM, in which also higher incidence of wound infection and re-operation is shown. The meta-analysis shows that SFM may be considered not necessary to ensure better peri-operative and post-operative outcomes in both LT and LS ARR.

A modified technique of transanal specimen extraction in the laparoscopic anterior rectal resection for upper rectal or lower sigmoid colon cancer: a retrospective study

BackgroundIn recent years, natural orifice specimen extraction surgery (NOSES) has become a field of special interest for colorectal surgeons. Some researchers have reported transanal specimen extraction in the laparoscopic anterior rectal resection, including intersphincteric resection (ISR) and rectal eversion-resection. However, these surgical procedures have certain limitations. Based on the proven expertise in laparoscopic surgery, our center has developed a modified technique of transanal specimen extraction. The aim of this study was to investigate the safety and feasibility of a modified technique of transanal specimen extraction in the laparoscopic anterior rectal resection.MethodsFrom January 2011 to January 2014, the patients with upper rectal or lower sigmoid colon cancer who had undergone laparoscopic anterior rectal resection with specimen extraction by a modified transanal technique were enrolled in the observation group, and the patients who had undergone laparoscopic anterior rectal resection with specimen extraction via an abdominal incision by the same surgeons during the same period were enrolled in the control group.ResultsA total of 36 patients were included in the observation group and 128 patients were included in the control group. There were no significant differences (P > 0.05) between the two groups in terms of the mean operative time [144 ± 10 min vs. 141 ± 11 min], mean intraoperative blood loss [63 ± 6 ml vs. 61 ± 7 ml], and the mean time to anal exhaust [67 ± 7 h vs. 65 ± 8 h]. However, there were significant differences (P < 0.05) between the two groups in terms of the mean postoperative Visual Analogue Scale (VAS) pain scores [3.4 ± 1.1 vs. 4.5 ± 1.2], mean postoperative hospital stay [6.0 ± 1.1 days ± vs. 7.2 ± 1.2 days], and incidence of postoperative complications (4/36 vs. 15/128). Long-term follow-up results showed that there was no significant difference (P > 0.05) between the two groups in terms of the 3- or 5-year overall survival.ConclusionsThe modified technique of transanal specimen extraction in the laparoscopic anterior rectal resection fulfilled the principle of no-neoplasm touch technique, with advantages, such as minimal trauma, rapid recovery, and fewer complications. Long-term follow-up results also showed satisfactory oncological outcomes.

Advances in the application of prophylactic ostomy in radical resection of rectal cancer

: Despite of technological improvements in surgical equipment, anastomotic leakage (AL) after anterior rectal resection is still the most important and common complication in laparoscopy and open surgery. According to reports, the clinically obvious leakage rate after laparoscopic anterior rectal resection is 3–19%. AL is associated with high morbidity and mortality, and usually requires re-operation with stoma creation. It significantly increases the length of hospital stay and rehabilitation costs. For a long time, there has been controversy about the role of protective stomas, and there are still controversies. Some authors recommend the routine use of temporary stomas to reduce the incidence and incidence of AL. On the contrary, other authors discourage the regular use of temporary stomas, and preferring selective use. For these authors, a protective stoma can only reduce the catastrophic clinical consequences of AL and decrease the burden of stoma-related complications. The conventional method of temporarily using the stoma reduces the advantages of the laparoscopic technique, so it is advisable to use it selectively. The difficulty in choosing to use temporary stoma is related to the necessity of effective anastomotic cracking risk stratification, which is not yet available today. In this article, we reviewed literatures regarding the indications of prophylactic ostomy, stoma-associated complications, timing of reversal, and surgical complications, aimed at providing useful summary of experience for early stoma closure, and thus reduce stoma-associated complications and ultimately improve the quality of life of patients.

CORRELATION BETWEEN THE LEVEL OF COLORECTAL ANASTOMOSIS AND ANORECTAL FUNCTION.

SUMMARYAnterior rectal resection is a standard surgical procedure for treating carcinomas of rectum and distal sigmoid colon. In many cases of anterior rectal resection, postoperatively some level of fecal incontinence may occur. The aim of our study was to evaluate the impact of the colorectal anastomosis level on anorectal functional disorder. In our prospective study, the participants were patients diagnosed with carcinoma of rectum or distal sigmoid colon. All patients underwent standard open or laparoscopic anterior rectal resection. Six months after the surgery, the function of anorectum was evaluated in all participants. Finally, 38 patients were analyzed, including 13/38 (34.2%) patients with high rectal anastomosis, 11/38 (28.9%) with mid rectal anastomosis and 14/38 (36.8%) with low rectal anastomosis. Patients with a lower level of anastomosis had a statistically significantly greater number of stools, higher urgency and discrimination impairment, more pronounced solid, liquid and gas incontinence, and greater need for diapers (p<0.05 all). Therefore, patients with lower anastomosis had a statistically significant impairment of their quality of life and higher Wexner score (p<0.001 for both analyses). Our study results suggested reduced neorectal capacity to be the main pathophysiological factor for the development of postoperative anorectal function impairment.

Single vs. double purse-string anastomosis during laparoscopic low anterior rectal resection (SINGLE\u2013DOUBLE trial): study protocol for a randomized controlled trial

BackgroundAn inappropriate anastomosis method during laparoscopic anterior rectal resection can increase the risk of anastomotic complications and affect surgical, economic, and oncological outcomes. The aim of this study is to compare the incidence of anastomotic complications and the surgical, economic, and oncological outcomes following single versus double purse-string anastomosis during laparoscopic total mesorectal excision (TME) for low rectal cancer.Methods/designThis randomized controlled trial (the SINGLE–DOUBLE study) will randomly assign middle and low rectal adenocarcinoma patients to receive either single or double purse-string anastomosis during laparoscopic low anterior rectal resection. Patients will be eligible for inclusion only if they (1) have adenocarcinoma confirmed by preoperative colonoscopy and biopsy, (2) have a tumor situated less than 12 cm from the anal verge, (3) do not have the anal sphincter involved, and (4) do not have distant metastases. The primary endpoint measure will be the incidence of anastomotic complications (leakage, narrowing, and bleeding). The secondary endpoints will be surgical, economic, and oncological outcomes. A total of 500 patients will be enrolled in the study. Sample size calculation was based on previous reports and our retrospective analysis.DiscussionThis randomized single-center controlled trial is expected to demonstrate which anastomosis method (single or double purse-string anastomosis) is better for reducing complications and improving prognosis in rectal cancer patients undergoing laparoscopic TME for low or middle rectal cancer.Trial registrationRegistration number: ChiCTR1800016116. Protocol Registration Receipt: May 13, 2018.

Surgical treatment of rectal cancer with a Retzius shunt: a case report

BackgroundA case of a short circuit (Retzius shunt) from the inferior mesenteric vein (IMV) to the inferior vena cava (IVC) without accompanying portal hypertension due to liver cirrhosis is rare.Case presentationAn 83-year-old woman who was followed after surgery for thyroid and breast cancer was incidentally found to have rectal cancer on computed tomography (CT). Preoperative three-dimensional CT showed a venous malformation forming a short circuit (Retzius shunt) from the IMV to the IVC. Laparoscopic anterior rectal resection was performed. Operative findings included the Retzius vein crossing the abdominal aorta and the inferior mesenteric artery (IMA) to the IVC and a number of engorged vessels in the mesentery. The Retzius vein and IMA were clipped without major bleeding, and tumor-specific mesorectal excision was then performed. The patient’s postoperative clinical course was good, and she was discharged without complications.ConclusionsPreoperative imaging enabled identification of an unexpected rare disease, thus reinforcing the importance of preoperative imaging.

A case of laparoscopic high anterior resection of rectosigmoid colon cancer associated with a horseshoe kidney using preoperative 3D-CT angiography

BackgroundHorseshoe kidney is a congenital malformation in which the bilateral kidneys are fused. It is frequently complicated by other congenital malformations and is often accompanied by anomalies of the ureteropelvic and vascular systems, which must be evaluated to avoid iatrogenic injury. We report a case of laparoscopic high anterior resection of rectosigmoid colon cancer associated with a horseshoe kidney using preoperative 3D-CT angiography.Case presentationA 52-year-old Japanese man with lower abdominal pain underwent lower endoscopy, revealing a type 2 lesion in the rectosigmoid colon. He was diagnosed with rectosigmoid colon cancer with multiple lung metastases and a horseshoe kidney on computed tomography (CT) scan. Three-dimensional (3D)-CT angiography showed an aberrant renal artery at the isthmus from 3 cm under the inferior mesenteric artery (IMA) branch of the aorta. Laparoscopic anterior rectal resection was performed. During the operation, the inferior mesenteric artery, left ureter, left gonadal vessels, and hypogastric nerve plexus could be seen passing over the horseshoe kidney isthmus and were preserved. The left branch of aberrant renal artery that was close to IMA was also detected and preserved.ConclusionTo prevent intraoperative misidentification, 3D-CT angiography should be performed preoperatively to ascertain the precise positional relationships between the extra renal arteries and the kidney. We always must consider anomalous locations of renal vessels, ureter, gonadal vessels, and lumbar splanchnic nerve to avoid laparoscopic iatrogenic injury in patients with a horseshoe kidney.

"High or low Inferior Mesenteric Artery ligation in Laparoscopic low Anterior Resection: study protocol for a randomized controlled trial" (HIGHLOW trial).

BackgroundThe position of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision can affect genito-urinary function, bowel function, oncological outcomes, and the incidence of anastomotic leakage. Ligation to the inferior mesenteric artery at the origin or preservation of the left colic artery are both widely performed in rectal surgery. The aim of this study is to compare the incidence of genito-urinary dysfunction, anastomotic leak and oncological outcomes in laparoscopic anterior rectal resection with total mesorectal excision with high or low ligation of the inferior mesenteric artery in a controlled randomized trial.Methods/designThe HIGHLOW study is a multicenter randomized controlled trial in which patients are randomly assigned to high or low inferior mesenteric artery ligation during laparoscopic anterior rectal resection with total mesorectal excision for rectal cancer. Inclusion criteria are middle or low rectal cancer (0 to 12 cm from the anal verge), an American Society of Anesthesiologists score of I, II, or III, and a body mass index lower than 30. The primary end-point measure is the incidence of post-operative genito-urinary dysfunction. The secondary end-point measure is the incidence of anastomotic leakage in the two groups. A total of 200 patients (100 per arm) will reliably have 84.45 power in estimating a 20% difference in the incidence of genito-urinary dysfunctions. With a group size of 100 patients per arm it is possible to find a significant difference (α = 0.05, β = 0.1555). Allowing for an estimated dropout rate of 5%, the required sample size is 212 patients.DiscussionThe HIGHLOW trial is a randomized multicenter controlled trial that will provide evidence on the merits of the level of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision in terms of better preserved post-operative genito-urinary function.Trial registrationClinicalTrials.gov Identifier: NCT02153801Protocol Registration Receipt 29/5/2014.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-014-0537-5) contains supplementary material, which is available to authorized users.

Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial.

Anastomotic leakage following anterior rectal resection is the most important and most commonly faced complication of laparoscopy and open surgery. To prevent this complication, the construction of a preventing stoma is usually adopted. It is not easy to decide whether to construct a protective stoma in patients with a medium risk of anastomotic leakage. In these patients, ghost ileostomy (GI), a pre-stage ileostomy that can be externalized and opened if needed, has proved useful. We conducted a prospective, randomized, controlled study to evaluate the advantages of GI in laparoscopic rectal resection. All patients with surgical indications for laparoscopic rectal resection who were at medium risk for anastomotic leakage from January 2007 to January 2013 were included and were randomly divided in 2 groups. All of the patients were subjected to laparoscopic anterior rectal resection with the performance of GI (group A) or without the construction of any protective stoma (group B). The presence and severity of clinically evident postoperative anastomotic leakage and other postoperative complications and reinterventions were investigated. Of the 55 patients allocated to group A, 3 experienced anastomotic leakage compared with 4 in group B. The patients with GI experienced a lower severity of anastomotic leakage and shorter hospitalization compared with the patients in group B. None of the patients with GI and anastomotic leakage required laparotomy to treat the dehiscence. The use of GI in laparoscopic rectal resections in patients at medium risk for anastomotic leakage was useful because it allowed for the avoidance of stoma creation in all of the patients, thus reducing the number of stomas performed, improving the quality of life of the patients and preserving, in most cases, the benefits gained by laparoscopy.