Laparoscopic-assisted Surgery Research Articles

Gastrectomia parcial videoassistida para câncer gástrico precoce

INTRODUÇÃO: É considerado câncer do estômago precoce aquele que ocorre limitado à mucosa ou submucosa da parede gástrica, independentemente da presença de metástases. Apesar de alta prevalência, o câncer gástrico é de diagnóstico tardio, pois na maioria dos casos quando precoce possui apresentação silenciosa. Assim, muitas vezes, através de um exame complementar realizado por outras causas, incidentalmente identifica-se a sua presença proporcionando tratamento de forma precoce e menos invasiva. Atualmente, a cirurgia minimamente invasiva, através da videolaparoscopia, apresenta-se cada vez mais como solução para diminuir-se a incidência de complicações pós-cirúrgicas, assim como melhorar a qualidade da recuperação pós-operatória. OBJETIVO: Verificar o grau de evidência relacionado às vantagens e desvantagens inerentes a utilização da gastrectomia videoassistida para o tratamento do câncer gástrico precoce. MÉTODO: Foram utilizados os descritores: câncer, estômago, cirurgia laparoscópica, para pesquisa no PubMed (www.pubmed.com), na Bireme (www.bireme.br) e na Cochrane BVS (http://cochrane.bvsalud.org). A seguir foram selecionados os artigos pertinentes relacionados à abordagem cirúrgica videoassistida para o tratamento do câncer gástrico precoce. CONCLUSÃO: É possível evidenciar-se que o uso da videolaparoscopia para o tratamento do câncer gástrico precoce, mesmo que em parte do ato operatório, tem potencial para diminuir as complicações relacionadas às gastrectomias parciais.

Sources of bias in non-randomized comparative studies of surgical procedures

Introduction Although non randomized comparative studies provide weak evidence for the effectiveness of health interventions, the surgical literature is dominated by these studies. Non randomized studies are prone to selection and measurement biases that exaggerate estimates of the effectiveness of surgical procedures. We sought to quantify the extent of bias associated with characteristics of non randomized studies of surgical procedures. Methods We identified English language studies comparing laparoscopic-assisted and conventional surgery for colon cancer that estimated surgical complications as an outcome measure. A single reviewer determined study eligibility and extracted the data. Subgroup meta-analyses for five study characteristics were performed using R. Summary odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated using random-effects models. Results 155 comparative studies were identified from 6,261 abstracts. Sixty-three studies that provided an estimate of surgical complications were included. The summary OR for surgical complications associated with laparoscopic-assisted surgery in 21 randomized controlled trials was 0.76 (95% CI 0.62-0.94). The summary OR for surgical complications associated with laparoscopic-assisted surgery in 42 non randomized studies was 0.70 (95% CI 0.64-0.76). Studies with consecutively recruited controls and studies with matched controls estimated a larger benefit of laparoscopic-assisted surgery on complications than studies without these characteristics (see Table). Studies with concurrent controls and systematic assessment of outcomes estimated smaller benefits of laparoscopic-assisted surgery.Characteristics of non randomized studies (n=42)Characteristic presentCharacteristic absentOR ⁎ 95% CIOR ⁎ 95% CIProspective data collection0.670.60-0.760.680.52-0.89Consecutive recruitment of patients0.620.52-0.740.740.66-0.82Concurrent (vs historical) controls0.700.64-0.760.610.22-1.63Matching of groups0.520.35-0.780.710.66-0.78Systematic outcome assessment0.760.72-0.800.600.49-0.74⁎Favoring laparoscopic-assisted surgery Conclusions Among non randomized studies comparing surgical complications after laparoscopic-assisted and conventional surgery for colon cancer, use of matched controls is strongly associated with exaggerated estimates of safety.

Totally laparoscopic Billroth II( gastrectomy without intracorporeal hand-sewn sutures

To evaluate the safety and feasibility of a novel totally laparoscopic Billroth II gastrectomy. Twelve gastric cancer patients underwent totally laparoscopic D2 dissection without intracorporeal hand-sewn sutures in the Xijing Hospital of Fourth Military Medical University between May 2011 and July 2011. In this technique, circular stapling device was used for gastrojejunostomy, and an Endo GIA was used to close the incision at the greater curvature of the stomach. After the completion of the anastomosis, a side-to-side anastomosis (jejunum-afferent loop or jejunum-efferent loop) was performed using an Endo-GIA. No patients required conversion to laparoscopy-assisted or open surgery. The operative time was 196.0±19.3 min, and the blood loss was 169.5±28.8 ml. The number of lymph node harvested was 25.1±3.3. The proximal resection margin and distal resection margin were 8.8±2.4 cm and 6.9±5.5 cm, respectively. The mean time to the first postoperative flatus was 3.1±1.3 days. The length of hospital stay was 4.5±1.9 days. This technique is simple and quick. There is no need for laparoscopic hand-sewn suturing. It is safe to perform for totally laparoscopic gastrectomy and reconstruction.

Laparoscopic-assisted Proximal Gastrectomy in an Obese Patient With Gastric Cancer and Myasthenia Gravis

The patient is a 61-year-old man who had previously undergone an extended thymectomy for myasthenia gravis. Endoscopic examination during a routine follow-up visit revealed early gastric cancer in the proximal portion of the stomach. To undergo resection the patient received general and epidural anesthesia. The conditions were unfavorable for laparoscopic-assisted surgery because he had a body mass index of 33 and muscle relaxants could not be used. Pneumoperitoneum was induced with carbon dioxide, and the abdominal wall was lifted. An adequate working space was secured in the upper abdomen and proximal gastrectomy was successfully performed.

Use of SAND Balloon Catheter for Laparoscopic Management of Extremely Large Ovarian Cysts

The objective of the study was to assess the feasibility and outcome of laparoscopic surgery for management of extremely large ovarian cysts using the SAND balloon catheter. From January 2006 to December 2009, 25 patients with large cystic adnexal tumors underwent laparoscopic-assisted surgery using the SAND balloon catheter. Median (range) patient age was 43 (20–68) years, body mass index was 25 (19–32), mass size was 26 cm (15–60 cm), duration of the surgical procedure was 60 (30–300) minutes), and blood loss was 30 (10–100) mL. There were no major surgical complications. Intra-abdominal leakage of cyst fluid was observed in only 1 case (4%). With proper patient selection, the SAND balloon catheter can be extremely useful in laparoscopic removal of very large adnexal masses, without intraperitoneal spillage.

Short-term and medium-term clinical outcomes of laparoscopic-assisted and open surgery for colorectal cancer: a single center retrospective case-control study

BackgroundLaparoscopic procedure is a rapid developed technique in colorectal surgery. In this investigation we aim at assessing the diversities of short-term and medium-term clinical outcomes of laparoscopic-assisted versus open surgery for colorectal cancer.MethodsA total number of 519 patients with non-metastatic colorectal cancer were enrolled for this study. The patients underwent either laparoscopic-assisted surgery (LAP) (n = 254) or open surgery (OP) (n = 265). Surgical techniques, perioperative managements and clinical follow-ups were standardized. Short-term perioperative data and medium-term recurrence and survival were compared and analyzed between the two groups.ResultsThere were no differences in perioperative parameters between the two groups except in regards to a trend of faster recovery in laparoscopic procedures. There was no statistically significant difference in postoperative complications, reoperation rate, or perioperative mortality. Statistically significant differences in a faster return of gastrointestinal function and shorter hospital stay were identified in favor of laparoscopic-assisted resection. In colon and rectal cancer cases separately, the overall survival, cancer-free survival and recurrence rate were similar in two groups. There was also no tendency of significant differences in overall survival, cancer-free survival and recurrence in stage I-II and stage III patients in two cancer categories between the two groups, respectively. pT, lymph node metastasis, and clinical stage were independent predictors of overall death risk, while pT, pN, lymph node metastasis and clinical stage were found to be the independent predictors of recurrence risk in enrolled patients database.ConclusionsLaparoscopic-assisted procedure has more benefits on postoperative recovery, while has the same effects on medium-term recurrence and survival compared with open surgery in the treatment of non-metastatic colorectal cancer.

Robotic versus laparoscopic surgery for rectal cancer and cost-effectiveness analysis

Innovation in technology is crucial for improving healthcare. Robotic technology in surgical practice [1] and nextgeneration sequencing (NGS) platforms in genomics research [2] represent the most promising technological advances for improving clinical outcomes of patients with complex diseases such as cancer. However, technological innovation in healthcare is an important driver of cost growth. Very often, physicians and patients seeking the best treatment embrace new modes of treatment before there is evidence-based clinical utility of new medical devices. It is obvious that comparative-effectiveness research (CER) is required before new medical devices, diagnostics or novel drugs are incorporated into clinical practice [3]. Robotic surgical devices allow a surgeon at a console to operate remote-controlled robotic arms, which may facilitate the performance of laparoscopic procedures. Laparoscopic surgery, in turn, is associated with shorter hospital stays than open surgery, as well as with less postoperative pain and scarring, lower risks of infection and need for blood transfusion, and better aesthetic result. All these advantages can be termed as better short-term quality of life (QOL). Evidence for the superiority of laparoscopic versus open surgery has already been documented for colon cancer, and there is also a trend for similar benefits in patients with rectal cancer and gastric cancer [4–9]. However, there is still no evidence that robotic-assisted surgery significantly improves outcomes and reduces adverse effects as compared with laparoscopic-assisted surgery, while by contrast it appears that it is associated with higher costs. The hypothesis that more appropriate and precise total mesorectal excision (TME) can lead to higher complete cancer resection (R0), lower rates of local and locoregional recurrence, and improved survival with robot-assisted surgery compared with laparoscopic resection [10] requires data from CER, which remain scarce. In the November issue of Surgical Endoscopy, Bianchi and colleagues [11] address the question of potential shortterm benefits of robotic versus laparoscopic surgery in the treatment of patients with middle or lower rectal adenocarcinoma. The authors analysed the data of 50 patients with proven middle/lower rectal adenocarcinoma who all underwent minimally invasive TME either with a four-arm Da Vinci S robot (Intuitive Surgical, Sunnyvale, CA, USA) (n = 25) or with laparoscopic technique (n = 25). The groups were well balanced. Most patients underwent anterior resections (74%) and the remaining underwent abdominoperineal resections (26%), while about half of patients received preoperative (neoadjuvant) chemotherapy. There was no significant difference in median operating time, first bowel movement, median hospital stay or complications between the two groups. Extent of lymphadenectomy as measured by the median number of lymph nodes examined was similar (18 vs. 17). Distal resection margins were disease free in both groups, but circumferential margin was involved in one patient (4%) of the laparoscopic group. There was only one conversion to laparotomy. The authors conclude that robotic TME for rectal cancer is feasible with similar short-term oncologic and QOL outcomes compared with laparoscopic TME. They note that whether the greater manoeuvrability and visibility afforded by the robotic approach can result in better outcomes than those of laparoscopic surgery can be answered by future, more systematic studies considering also the costs of robotic-assisted surgery. C. Hottenrott (&) Chirurgische Klinik, St. Elisabethenkrankenhaus, Ginnheimer Strase 3, 60487 Frankfurt, Germany e-mail: info@gastricbreastcancer.com

Efficacy of robotic-assisted surgery in colorectal cancer: A systematic review and meta-analysis.

e14125 Background: Laparoscopic assisted colorectal surgery is an accepted mode of treatment for colorectal cancer. The addition of robotics has been reported by some to improve technical aspects o...

Functional outcomes according to the size of the gastric remnant and type of reconstruction following laparoscopic distal gastrectomy for gastric cancer

In gastric cancer, various methods of gastric resection and reconstruction have been devised according to the location of the primary tumor and the depth of invasion. The functional outcomes of patients treated by laparoscopy-assisted or totally laparoscopic distal gastrectomy were compared with respect to the approach, size of the remnant stomach, and type of reconstruction. Patients who required distal gastrectomy to treat early-stage cancer between May 2000 and December 2008 were treated by one of the four following procedures: Billroth Type I (B-1) reconstruction for 1/2 remnant stomach (1/2B1ML) or B-1 for 1/3 remnant stomach (1/3B1ML), through a mini-laparotomy following laparoscopy-assisted surgery; intra-corporeal B-1 for 1/2 remnant stomach (1/2 B1IC); or intra-corporeal Roux-en-Y for 1/3 remnant stomach (1/3RYIC). The primary outcome measure was digestive function, assessed by body weight, food intake, and degree of abdominal symptoms. The secondary outcome was morbidity. The 1/2B1ML (n=27) and 1/2B1IC (n=56) groups were significantly superior to the 1/3 resection groups in terms of the preservation of body weight. The 1/3B1ML (n=29) and 1/3RYIC (n=64) groups were associated with significantly decreased food intake compared with the 1/2B1ML group. Endoscopy revealed a greater incidence of esophagitis and gastritis among the 1/3B1ML patients compared with the 1/3RYIC patients. There were no operative deaths, and no differences in morbidity between the groups. Patients with early-stage cancer actually benefit from 1/2 gastrectomy rather than the typical 2/3 gastrectomy. B-1 reconstruction is appropriate for patients with large gastric remnants, and intra-corporeal reconstruction in experienced hands is associated with no apparent disadvantages, while offering a favorable cosmetic result.

Pelvic dimensions as a predictor of difficulty in laparoscopic surgery for rectal cancer

Laparoscopic surgery for rectal cancer is thought to be a technically more difficult operation than laparoscopic colectomy. Data from the Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) trial showed that circumferential resection margin positivity was greater in the laparoscopic group (12%) than in the open surgery group (6%) undergoing anterior resection, although this difference was not significant [1]. In contrast, many nonrandomized studies, including ours, have suggested that laparoscopic surgery for rectal cancer is safe and feasible with careful case selection and expertise [2, 3]. The recent randomized Comparison of Open versus laparoscopic surgery for mid and low REctal cancer After Neoadjuvant chemoradiotherapy (COREAN) trial showed that laparoscopic surgery after preoperative chemoradiotherapy for mid and low rectal cancer is safe and that the quality of oncologic resection is similar to that of open surgery [4]. Because the future may see increasing demand for laparoscopic surgery to treat rectal cancer, a better understanding of the factors associated with the difficulty of laparoscopic surgery is important for surgeons, especially those learning these operations for proper case selection. In the December issue of Surgical Endoscopy, Killeen et al. [5] examined the influence of pelvic dimensions measured by magnetic resonance imaging (MRI) on difficulties in laparoscopic surgery for rectal cancer. Operative time was used as a measurement of operative difficulty. Univariate analysis showed that a less acutely curved sacrum and a larger sagittal pelvic outlet were significantly correlated with longer operative time, especially for a pelvis with a narrow intertuberous distance. Although Killeen et al. [5] introduced our study as supportive of their findings, indeed, we came to different conclusions [6]. We showed by multivariate analysis that narrower pelvic outlet together with higher body mass index, shorter tumor distance from the anal verge, and advanced tumor depth was independently predictive of longer operative time in laparoscopic total mesorectal excision (TME) with intracorporeal rectal transection and double-stapling technique (DST) anastomosis. There may be some reasons for the different conclusions. First, the total number of patients analyzed in the study of Killeen et al. [5] was small (n = 25). Second, multivariate analysis including patientand tumor-related factors other than pelvic dimensions was not performed in their study. Third, they evaluated the total operative time as dependent variable, and patients who underwent either laparoscopic anterior resection or abdominoperineal resection were included. However, excluding the procedures outside the pelvis might be necessary for accurate analysis of the influence that pelvic dimensions has on difficulties in laparoscopic surgery for rectal cancer because pelvic dimensions influence the procedures more directly after the pelvic cavity is reached. We also have reported that narrow pelvic dimensions were not associated with overall postoperative morbidity and anastomotic leakage [6]. On the contrary, larger pelvic outlet was independently predictive of anastomotic leakage [6]. Considering these results, we concluded in our T. Akiyoshi (&) M. Ueno Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan e-mail: takashi.akiyoshi@jfcr.or.jp

Simultaneous laparoscopic hand-assisted hepatectomy and splenectomy for liver cancer with hypersplenism: Report of a case

Hepatocellular carcinoma accompanied by portal hypertension and hypersplenism is difficult to treat medically and surgically due to pancytopenia and the development of collateral circulation. In this study, we were able to safely and simultaneously perform a laparoscopically-assisted splenectomy and partial hepatectomy. The characteristics of this procedure include: (1) the shared use of a medial wound made through laparoscopically-assisted surgery; (2) improved safety for manipulating areas that were difficult to observe with a camera in a case of splenomegaly; (3) a preventive ligation of the splenic artery; (4) improved hemostatic function using LigaSure Impact; and (5) hemorrhage control through manual manipulations and the Pringle maneuver during liver parenchymal transection. The surgery was safely performed using the above points.

Laparoscopy for recurrent Crohn’s disease: how do the results compare with the results for primary Crohn’s disease?

To assess the feasibility and outcomes of reoperative laparoscopic-assisted surgery for recurrent Crohn's disease compared with index laparoscopic resections. A retrospective analysis of a prospectively maintained database was performed from 2001 to 2008 on patients who had primary laparoscopy (group I) or reoperative laparoscopy for Crohn's disease (group II). Data collection included demographic and surgical data, and postoperative outcomes. One hundred and thirty patients were included in this study, distributed as follows: group I, 80 patients with a mean age of 35 years; and group II, 50 patients with a mean age of 42 years. Preoperative American Society of Anesthesiologists score and body mass index were similar in both groups. Patients in group II had a longer period of disease (15.5 vs 8.9 years in groups I and II, respectively; P = 0.0002). Immunosuppressive therapy had been utilized in 66 (82.5%) and in 42 (84%) patients in groups I and II, respectively. Ileocolic resection was the most commonly performed procedure in both groups (82%), followed by subtotal colectomy. Conversion rates were 18.7 and 32% in groups I and II, respectively (P = 0.09). The mean operative time (182 vs 201 min) and mean blood loss (161 vs 202 ml) were not significantly different (P > 0.05); however, the overall incisional length was significantly longer in group II (6.7 vs 11.4 cm, P = 0.045). A stoma was created in 17 and 16% of patients in groups I and II, respectively. Overall, early postoperative complications were not statistically significantly different between the two groups (P > 0.05); anastomotic leak occurred in four (5%) and one (2%) patients (P = 0.65), and abdominal abscess in three (3.75%) and four (8%) patients (P = 0.56), in groups I and II, respectively. Reoperative rates were 10 and 6% (P = 0.53), and mean hospital stay was similar in groups I and II respectively (6.7 vs 7.5 days, respectively; P = 0.3266). There was no mortality. The results of laparoscopic-assisted resection for recurrent Crohn's disease are similar to those for primary resection.

Subcutaneous Metastases After Laparoscopic-assisted Partial Hepatectomy for Hepatocellular Carcinoma

We reported an unusual case with subcutaneous seeding of hepatocellular carcinoma 12 months after laparoscopic-assisted partial hepatectomy. A 69-year-old woman with hepatitis-C-related liver cirrhosis was found to have hepatocellular carcinoma on routine sonographic examination. The tumor located superficially in the left lateral segment. She received laparoscopic-assisted partial hepatectomy for the tumor in February 2002. She was uneventful after the surgery and serum α-fetoprotein level dropped from 1217 to 275 ng/mL in 3 months. Serum α-fetoprotein level was found to rise 9 months after surgery and a subcutaneous tumor appeared over the surgical wound 12 months after surgery. Resection of lesion showed hepatocellular carcinoma. To our knowledge, seeding of hepatocellular carcinoma on surgical wound has rarely, if ever, been reported after laparoscopic-assisted surgery. The patient died of disseminated recurrence 20 months after the surgery. This case reminded us the risk of tumor seeding after laparoscopic-assisted partial hepatectomy.

Laparoscopy-assisted appendectomy through an umbilical port in children

We report surgical techniques for single-incision laparoscopy-assisted surgery (SILAS) in the treatment of pediatric acute appendicitis. We performed SILAS in 15 cases of acute appendicitis between January and September of 2009. SILAS is a surgical method that involves making the incision at the umbilicus, inserting a wound retractor XS, suspending the abdominal wall with a hook, and appendectomy with the same procedures as conventional appendectomy. SILAS appendectomy was performed in all 15 cases with the exception of one case where one 3-mm port was added. Compared to open appendectomy, blood loss was significantly lower and postoperative hospitalization time was shorter, although there was no significant decrease in operative time, or postoperative fasting time. No postoperative complications, such as wound infection, intestinal obstruction, intra-abdominal abscess, or bleeding, were encountered. SILAS was safely performed and is superior to open appendectomy with regard to cosmetic outcome.

A case of pubic bone endometriosis treated by laparoscopy-assisted surgery

A case of pubic bone endometriosis treated by laparoscopy-assisted surgery

Hand-assisted laparoscopic colorectal surgery: Initial experience of a single surgeon

Background/Aim:As totally laparoscopic colorectal surgery is considered challenging and technically demanding with a long steep learning curve, we adopted hand-assisted laparoscopic colorectal surgery as a bridge to totally laparoscopic assisted colorectal surgery. This prospective study aims to highlight the initial experience of a single surgeon with this technique.Materials and Methods:A prospective analysis of the first 25 cases of hand-assisted laparoscopic colorectal resections which were performed by a single surgeon over a 15-month period. There were 15 males and 10 females with a mean age of 55.5 (range 20-82) years.Results:The indication in majority of cases was cancer (76%). The procedures consisted of 18 (72%) various colectomies and 7 (28%) anterior resections. The operative time ranged between 110-400 (mean 180) min. There was one conversion (4%) and the mean operative blood loss was 80 (range 60-165) ml. The number of lymph nodes retrieved in the cancer cases was 5-31 (mean 15) nodes. The mean length of hospital stay was five (range 3-10) days. The total number of short-term complications was six (24%) and there was one death due to anastomatic leak and multiorgan failure. Long-term complications after a maximum follow up of 30 months were two incisional hernias at the hand port site, but none of the patients developed adhesive small bowel obstruction or late anastomotic stricture. Currently all our colorectal procedures are conducted laparoscopically.Conclusion:Hand-assisted laparoscopic colorectal procedures are easy to learn as a good bridge to master totally laparoscopic colorectal surgery.

Deep-tissue Injury During Laparoscopy-assisted Rectal Surgery in the Lithotomy Position

当院で経験した手術体位による仙骨部deep tissue injury（DTI）について報告する．当施設では2004年1月から2008年12月までに砕石位で直腸切除術を82例施行し，4例に大臀筋の圧挫を経験した．4症例ともに男性の下部直腸癌で，腹腔鏡補助下に手術を受け，手術時間は9時間25分～11時間と長かったが，術中血圧は安定していた．翌日には全例が臀部に違和感または痛みを自覚しており，翌日のCPKが6,927，3,133，1,913IU/Lと異常高値であった（1例データなし）．2例は2週間後のMRIで仙骨関節周囲の両側大臀筋腫大，皮下浮腫を指摘され，他の2例は術後2～3か月目のCTで片側の仙腸周囲の大臀筋腫大を指摘された．皮膚障害は軽度で，大臀筋壊死を伴うDTIと診断した．砕石位を多用する直腸癌手術や腹腔鏡補助下手術では，術中のDTIは注意を要する合併症の一つと考えられた．

Long-term Oncologic Outcomes of Laparoscopic Resection for Colorectal Cancer

See Article on Page 64-70 Several large randomized trials comparing laparoscopic versus open resection for colon cancer have demonstrated that the laparoscopic-assisted colectomy can be an acceptable alternative to an open colectomy for colon cancer [1-4]. These trials suggested similar oncologic outcomes (local recurrence and overall survival) for laparoscopic-assisted and open colectomies. In addition, laparoscopic-assisted resection may be associated with a shorter hospital stay with no difference in intra-, peri- and postoperative complications. To date, however, the laparoscopic resection for rectal cancer has not gained level-1 evidence in surgical practice. A subset analysis of the UK Medical Research Council (MRC) trial, Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC), reported a 34% conversion rate with 59% morbidity during the first 30 days after laparoscopic surgery for rectal cancer. Laparoscopic procedures for rectal cancer are regarded as technically demanding because a total mesorectal excision (TME) and autonomic nerve preservation are prerequisites for functional and oncological safety. In Korea, the laparoscopic resection for colorectal cancer was introduced by some pioneering surgeons in the early 1990's and currently, it is growing in popularity. In this issue, Lee et al. reported the long term oncologic outcomes for 303 patients who underwent a laparoscopic resection for colorectal cancer (colon, 115; rectum, 188). The recurrence rate was 2.2% for colon cancer and 4.4% for rectal cancer. The five-year overall and disease-free survival rates were 86.1% and 89.8% for colon cancer and 68.6% and 74.5% for rectal cancer, respectively. The authors concluded that laparoscopic surgery for colorectal cancer is a good alternative method to open surgery, with tolerable oncologic long-term results. The oncologic outcomes in their study are comparable to those of a conventional open resection for colorectal cancer, even when compared to those of high-volume, leading cancer centers. The results of this study can stimulate a surge in applications of laparoscopy in the field of colorectal cancer surgery. However, as with open surgery, the safety and the benefits of laparoscopy still lie with the surgeons, who must develop competency along a personal learning curve that assures proper patient selection, technical performance, and a low conversion rate. In addition, surgeons who have already overcome the learning curve and attained proficiency should endeavor to develop and establish systematic teaching programs for young surgeons, including surgical residents and fellows.

Single-Port Transumbilical Laparoscopic-Assisted Adnexal Surgery

To evaluate the efficiency and feasibility of single-port access transumbilical laparoscopic-assisted surgery in patients with large (>8cm) adnexal tumors and to present our initial experience. Twenty-two patients with presumably benign adnexal tumors who have undergone single-port access transumbilical laparoscopic-assisted surgery were enrolled. The procedure was performed using the method of exteriorization and extracorporeal surgery of adnexal tumors outside the abdominal cavity under laparoscopic guidance with preservation of as much ovarian tissue as possible. In each case, a homemade single-port device was inserted into the abdomen through a 2-cm umbilical incision. The clinical characteristics and operative outcomes of these patients were reviewed. Twenty of 22 cases were completed successfully. The one failed case required an additional trocar for adequate adhesiolysis, and the other case needed intraperitoneal drainage. The median operating time was 50 minutes (range, 35 to 120), and the estimated blood loss was 38mL (range, 10 to 300). Cyst rupture occurred in 2 cases, but there were no major postoperative complications. Single-port access transumbilical laparoscopic-assisted surgery for benign and relatively large adnexal tumors is feasible and could be an alternative to convention open laparotomy or laparoscopic surgery.

Favorable outcomes with laparoscopic surgery for rectal cancer

Liakakos et al. [1] concluded from a retrospective series of1,057 selected patients studied by Miyajima et al. [2] thatlaparoscopic surgery for rectal cancer is safe. Althoughcohort studies have shown safety, the most important out-comes such as disease-free survival and the recurrence rateneed to be demonstrated in prospective randomized con-trolled trials before laparoscopic surgery is accepted as thestandard approach.Laparoscopic resection of colonic cancer is proved to besafe, with no difference in long-term oncologic outcomecompared with open surgery [3–5]. However, long-termoutcome data after laparoscopic surgery for rectal cancerstill are not available.Only 5 years ago, the first study investigating the qualityof the mesorectal dissection with 25 patients was published[6]. The first randomization was done in the conventionalversus laparoscopically-assisted surgery in ColorectalCancer (CLASICC) trial with 253 patients treated withlaparoscopic surgery. The conversion rate at the beginningof the trial was 34%, which decreased to 16% during thesixth year of the study [5]. This high conversion rate in arelatively small study group was due the experience curveeffect.Miyajima et al. [2] concluded that laparoscopy is fea-sible and safe for selected patients with rectal cancer, withfavorable short- and mid-term outcomes after a mean fol-low-up period of 30 months. This retrospective study, notintended to be a comparison between open and laparo-scopic surgery, was reported without long-term outcomedata. Therefore, as stated by Liakakos et al. [1], more dataare needed from randomized controlled trials, if feasible, tosupport the hypothesis of better oncologic outcomes forclosed rather than open surgery for rectal cancer.Currently, several multicenter randomized controlledtrials comparing laparoscopic and open surgery for rectalcancer are registered (Clinicaltrials.gov) and recruitingpatients, including the laparoscopic-assisted resection oropen resection in treating patients with Stage IIA, StageIIIA, or Stage IIIB rectal cancer (NCT00726622) trial bythe American College of Surgeons (estimated primarycompletion date, August 2010) and the Phase II trial toevaluate laparoscopic surgery for Stage 0/1 rectal carci-noma (Lap RC), NCT00635466 (estimated study comple-tion date, 2016).In addition, the comparing laparoscopic and open sur-gery for rectal cancer (COLOR II) trial (NCT00297791)will fulfil the profound need for a well-designed and per-formed randomized trial. Recently, this COLOR II trialfinished randomization of 1,100 patients. The short-termresults will be presented by the colorectal cancer laparo-scopic or open resection study group on a short notice.The primary end point of the COLOR II trial is thelocoregional recurrence rate 3 years postoperatively. Untilthese data become available, we believe that open totalmesorectal excision must be regarded as the gold standardtreatment for rectal cancer.