Laparoscopic Colon Resection Research Articles

Robotic Versus Laparoscopic Colorectal Resection: Are We There Yet?

Background: Laparoscopy-assisted surgery (LAS) for colorectal cancer (CRC) was first described in 1991 and robotic-assisted surgery (RAS) for CRC was first reported in 2002; robotic-assisted colorectal surgery (RACS) is becoming increasingly popular. However, data comparing its outcomes to other established techniques remain limited to small case series. Our primary goal was to review the mortality outcome difference between laparoscopic versus robotic elective colon resection at a small, community hospital.Study design: We conducted a retrospective review of 2089 patients at the South Atlantic division for cases who underwent robotic and laparoscopic colectomies at our division in 2014-2018. All cases were elective surgeries and analysis was performed within these two subgroups.Results: In this study, 306 patients underwent robotic colorectal surgery versus 1783 patients who underwent laparoscopic-assisted colorectal surgery. Readmission rate within 30 days of operation was significantly lower for laparoscopic-assisted colorectal resection (LACR) versus RACS (445.4% vs. 53.9%, p= 0.006). However, the length of hospital stay was significantly shorter for RACS with a median of three days (interquartile range {IQR}: 2-5) versus four days (IQR: 3-7) for LACR (p=0.0001). There were no significant differences between the two groups for post-operative incisional hernias, anastomotic leaks, post-operative pain control, surgical site infections, or rate of conversion to an open procedure.Conclusion: Our study showed a similar outcome between LACR and RACS for post-operative incisional hernias, anastomotic leaks, post-operative pain control, surgical site infections, and rate of conversion to an open procedure. Also, our study showed a readmission rate within 30 days of operation was significantly lower for LACR versus RACS. However, the length of hospital stay was significantly shorter for RACS with a median of three days when compared to LACR. Future research should focus on surgeon-specific variables, such as comfort, ergonomics, distractibility, and ease of use, as other ways to potentially distinguish robotic from laparoscopic colorectal surgery.

Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program

BackgroundThe aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery.MethodsOne hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients’ satisfaction with pain management were also assessed.ResultsWe observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups.ConclusionTEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected.

Defining a minimum hospital volume threshold for minimally invasive colon cancer resections

BackgroundLaparoscopic colectomy is considered the standard of care in colon cancer treatment when appropriate expertise is available. However, guidelines do not delineate what experience is required to implement this approach safely and effectively. This study aimed to establish a data-derived, hospital-level annual volume threshold for laparoscopic colectomy at which patient outcomes are optimized. MethodsThis evaluation included 44,157 stage I to III adenocarcinoma patients aged ≥40 years who underwent laparoscopic colon resection between 2010 and 2015 within the National Cancer Database. The primary outcome was overall survival, with 30- and 90-day mortality, duration of stay, days to receipt of chemotherapy, and number of lymph nodes examined as secondary. Segmented logistic and Cox regression models were used to identify volume thresholds which optimized these outcomes. ResultsIn hospitals performing ≥30 laparoscopic colectomies per year there were incremental improvements in overall survival for each additional resection beyond 30. Hospitals performing ≥30 procedures/year demonstrated improved 30-day mortality (1.3% vs 1.7%, P < .001), 90-day mortality (2.3% vs 2.9%, P < .001), and overall survival (84.3% vs 82.3%, P < .001). Those hospitals performing <30 procedures/year had no significant benefit in overall survival. Thresholds were not identified for any other outcomes. Results were comparable in colon cancer patients with stage IV or multiple cancers. ConclusionA high-volume hospital threshold of ≥30 cases/year for laparoscopic colectomies is associated with improved patient survival and outcomes. A minimum volume standard may help providers determine which approach is most suitable for their hospital’s practice as open procedures may yield better oncologic results in low volume settings.

Submucosal Giant Lipoma of the Colon as an Unusual Cause of Partial Intestinal Occlusion: Report on Seven Consecutive Cases.

Colonic lipomas begin to be symptomatic when they reach a certain size, although the presentation can vary. In this study, we aimed to evaluate our experiences with the management of patients who presented with symptomatic giant colonic lipomas. The data of 7 patients with single colonic lipoma were retrospectively reviewed. The following data were evaluated: age, gender, clinical and diagnostic findings, American Society of Anesthesiologists (ASA) score, operative findings, postoperative complications, mortality, hospital stay duration, and hospital readmission. The diagnosis of colonic lipoma was established by computed tomography (CT). In this study, 4 (57.1%) of 7 patients with colonic lipoma were female, and 3 (42.9%) were male. The mean age was 56.7 years (range, 45-69). The main symptoms were abdominal pain (100%), and constipation (71.4%). The findings of intestinal occlusion detected on CT confirmed the diagnosis in all patients. Colon lipoma was located in the ascending colon in 2 patients, in the hepatic flexure in 2 patients, in the transverse colon in 2 patients, and in the cecum in 1 patient. The surgical procedure was uneventful in all patients. Four (57.1%) patients underwent laparoscopic colonic resection, while in the remaining 3 (42.9%) patients, a laparotomy was performed. The mean operating time was 185.7 min (150-210). Length of stay was 7.1 days (6-10), with no mortality. The mean diameter of the lesions was 7.4 cm (6-9). At a 6-month follow-up, all patients were asymptomatic with no signs of recurrence. Although colon lipomas are rare, they are of great importance because they can be symptomatic and can be confused with colon malignancies in the differential diagnosis. Being able to make a definitive preoperative diagnosis will change the surgical strategy. A minimally invasive surgical approach should be employed to resect symptomatic colonic lipomas with an experienced surgical team in eligible patients whenever possible.

Possibilities of the indocyanine green dye application for evaluation of peculiarities of lymph outflow and metastasizing of colorectal cancer

Objective. Studying of velocity of prevalence of luminescent dye indocyanine green along lymphatic vessels in the large bowel surgery.&#x0D; Materials and methods. Estimation of procedure for coloring of tumoral substrate and lymphatic vessels while performance of oncological operations was conducted. We performed laparoscopic resection of sigmoid colon in 7 patients, suffering tumors, and anterior rectal resection in 5 patients, having tumors of upper ampullary part of rectum, using indocyanine green dye.&#x0D; Results. In Group I, consisting of 7 patients, surgical technique of no touch manipulations on the tumor before transection of feeding vessels (NTIT–operations) was applied, and in Group II, consisting of 5 patients, the tumor mobilization was done primarily. Application of indocyanine green dye helped a lot to establish localization and prevalence of the process in rectum.&#x0D; Conclusion. Application of fluorescent dye indocyanine green on tumoral substrate before doing ligation of feeding vessels raises possibility of the complication occurrence, consisting of the cancer cells dissemination in abdominal cavity. While performing laparoscopic procedures in resection of the large bowel tumors it is expedient to ligate the feeding vessels primarily, with secondary manipulation– to dissect and mobilize the tumoral substrate.

Laparoscopic wedge resection as an alternative to laparoscopic oncological colon resection for benign endoscopically unresectable colon polyps.

AimThe aim of this study was to investigate, by comparing clinical and histological outcomes, whether laparoscopic (hybrid) wedge resection (LWR) could be a less invasive and safe alternative to laparoscopic oncological colon resection (OCR) for patients with an endoscopically unresectable, suspected benign, colon polyp.MethodAll patients with an endoscopically unresectable colon polyp who were referred for surgery between 2009 and 2018 and without biopsy‐proven colon cancer were identified from a prospectively maintained database. Patients with macroscopic features of malignancy during endoscopy were excluded. Clinical and histological results for patients who underwent OCR or LWR were reviewed.ResultsOne hundred‐and‐twenty‐two patients were included. Ninety‐seven patients underwent OCR and 25 LWR. Major complications occurred in 16.7% (n = 16) of the OCR group compared with 4.0% (n = 1) of the LWR group (p = 0.06). In the OCR group the anastomotic leakage rate was 6.3% (n = 6) and the mortality rate 3.1% (n = 3). No anastomotic leakage or deaths occurred in the LWR group. The median length of hospital stay after OCR was 5 days [interquartile range (IQR) 5–9 days)] compared with 2 days (IQR 2–4 days) after LWR (p < 0.0001). Definite pathology showed a malignancy rate of 4.2% (n = 4) in the OCR group and 4.0% (n = 1) (without high‐risk features) in the LWR group.ConclusionThis study shows that LWR was associated with significantly lower complication rates and acceptable oncological risks compared with OCR. Therefore we suggest that LWR is a safe alternative treatment, next to other endoscopic options. The treatment that is most suitable for an individual patient should be discussed in a multidisciplinary meeting.

Quality of life after extended lymph node dissection for colon cancer

Aim: to evaluate the effect of the lymphadenectomy (LD) level on the quality of life (QoL) in patients who underwent laparoscopic colon resection for colon cancer.Patients and methods: the study included 86 patients who underwent surgery for colon cancer from January 2018 to August 2020. The patients were randomized in 2 groups: the main group — with D3 lymphadenectomy — 41 patients and the control group — with D2 — 45 patients. Two validated QoL questionnaires (QLQ-C30 v. 3.0, QLQ-CR29 v. 2.1) of the European Organization for Research and Treatment of Cancer (EORTC) were applied by the patients on the day before the surgery and on the 30th day after the surgery and were used for the further analysis.Results: there were no significant differences between the groups in gender, age, weight, height, BMI, assessment of functional and physical status according to the ASA and ECOG scales, incidence of comorbidities, tumor site, type and volume surgical of procedures. Regardless of the level of lymphadenectomy, the significant improvement in QoL after surgery was obtained (pQoLD3 = 0.005, pQoLD2 = 0.023) in both groups. The significant increase in the incidence of diarrhea by 2.65 times was detected after laparoscopic right hemicolectomies with extended lymphadenectomy (p = 0.042). Also, there was a significant 2.45 fold increase in the risk of developing erectile dysfunction (ED) after D3 lymphadenectomy in the patients who underwent laparoscopic resections of the left colon in the early postoperative period (p = 0.031).Conclusion: the analysis of physical, social functioning and symptomatic scales has established that in patients who underwent colon resection for cancer of the left colon erectile dysfunction occurred to a greater extent after D3 LD, whereas diarrhea was more likely to develop after resection of the right colon with D3 LD than with D2 LD.

Laparoscopic surgery for the treatment of colon cancer: the new standard?

Colon cancer is a major health problem worldwide with an overall 5-year survival rate of < 50%. Despite advances in the field of oncology proving that adjuvant chemotherapy may improve the outcome, the only treatment with curative intent is represented by surgical resection of the tumor. Over the past 30 years, surgical techniques for the treatment of colon cancer have improved considerably. Major doubts regarding the radicality of the resection and the long-term outcome have been overcome lately. The main objective of this study was to determine the feasibility of laparoscopic surgery for the treatment of colon cancer. Our goal with this paper was to conduct a narrative review of the literature about laparoscopic treatment in colon cancer and outline the essential principles of the procedure. We found that laparoscopic resection has advantages over open surgery. These advantages include a shorter hospital stay, reduced incidence of surgical site infection, earlier return of bowel movements, and less immune suppression. As surgical centers with higher volume have very low complication rates, patients proposed for laparoscopic colonic resection for cancer should be referred to these hospitals. Laparoscopic surgery is an important option in the radical treatment of colon cancer that can be used routinely and safely.

Early catheter removal after laparoscopic colonic resection: A propensity score matched analysis

Background: The actual impact of early urinary catheter (UC) removal within an ERAS protocol after minimally invasive colonic resection (MICR) was assessed in a propensity score matched cohort.Methods: A retrospective cohort study was conducted on 227 consecutive patients who underwent elective MICR and ERAS were divided in two groups according to early (E-UC) or late (L-UC) removal of UC. After application of propensity score matching, two groups of 76 patients each were compared for non-severe post-operative complications, total fluids administered (TVF) and length of stay (LOS). Recovery outcomes, urinary retention (UR) and urinary tract infections (UTI) were the secondary endpoints analysed.Results: The L-UC was characterized by a higher TVF and an increased rate of general complications. Post-operative LOS was one day shorter in the E-UC group, whilst UR and UTI rates were comparably low. Late UC removal was associated to a delayed deambulation and solid diet intake.Conclusions: Our data confirm that early UC removal after MICR is safe and effective in reducing minor complications and LOS. Delay in UC removal is associated with an increased amount of post-operative fluids infusion and delayed restore of deambulation and solid diet intake which could be responsible for higher general complication rate. Avoidance of UC in selected patients should be further investigated.

O65: C-MET PROTEIN AS A COLORECTAL CANCER BIOMARKER FOR FLUORESCENCE IMAGE-GUIDED SURGERY

Abstract Introduction The c-Met transmembrane protein is vital for cell differentiation and migration and is overexpressed in many gastrointestinal cancers. This study aimed to investigate a novel c-Met targeted peptide coupled to a fluorophore (EMI-137, Edinburgh Molecular Imaging Ltd.) for use in fluorescence image-guided colorectal cancer (CRC) surgery. Method A high c-Met expressing cell-line, HT29, was identified with temporary RNA suppression and used to develop a mouse xenograph CRC model. Tumours were allowed to grow to 10mm. EMI-137 was injected into the tail vein and biodistribution analysed using the IVIS system. Nine patients undergoing elective surgery for colon cancer received a single IV dose EMI-137 1-3 hours before surgery. Tumour and LN fluorescence was assessed with a prototype Karl Storz laparoscope. Intraoperative fluorescence was correlated with radiological and pathological TNM stage and tissue c-Met expression using immunohistochemistry. Result The HT29 xenograph CRC model demonstrated selective EMI-137 uptake and fluorescence 1- 6 hours post administration. Nine participants aged 67-77 years received EMI-137 106 minutes (S.D±17) before surgery. Marked background fluorescence was observed in all patients. 4/9 (44%) patients showed mild increase in tumour fluorescence over background. 5/9 patients had histological LN disease, but no fluorescent nodes were detected intraoperatively. There was no correlation with T-stage. At histopathological assessment 8/9 participants showed moderate or high tumour c-Met expression. 8/8 malignant LNs demonstrated high c-Met expression. Conclusion EMI-137 is specific for human c-Met in 2D and xenograph CRC models. EMI-137 is safe for human use but its utility is limited by insufficient tumour-to-background ratios. Take-home message This first-in-man study of a novel fluorescent peptide targeted to the c-Met receptor, found EMI-137 lacked the sensitivity and specificity to accurately map the tumour margins and lymph node burden in laparoscopic colonic cancer resection surgery.

Development of surgical concepts in rectal cancer resection and challenges in minimally invasive surgical proctectomy

Since the early 1900s there have been dramatic changes in the management of patients with rectal cancer. Surgical approaches initially performed for palliation, have now been adapted, modernised and undertaken as part of a multimodal approach. This has resulted in significant improvements in long-term oncological survival and patient quality of life. With the introduction of total mesorectal excision (TME) in the 1980's, and its global acceptance by the surgical community, local and distant disease-free survival in patients with rectal malignancy has significantly improved. Since the inception of minimally invasive surgery, laparoscopy has seen dramatic changes both in the evolution of technological advances and application in multiquadrant surgery for colorectal malignancy. Favorable short-term clinical benefits and long-term oncological equivalence from many multicentre randomized controlled trials in laparoscopic colonic cancer resection has led the colorectal surgical community to translate and adapt minimally invasive surgical (MIS) techniques for proctectomy in patients with rectal tumours. MIS proctectomy is technically challenging and is associated with a steep learning curve. Reported challenges in the literature continuously identify a group within three common themes which can be divided into patient/anatomical factors, tumour characteristics and the use of neoadjuvant therapies. Despite a large body of evidence highlighting efficacy of MIS in proctectomy, significant challenges exist in male patients with a narrow pelvis and distal tumors. Such patients are at increased risk of a poor surgical specimen, positive distal and circumferential resection margins (CRMs), and increased local recurrence. Despite advances in laparoscopy and robotic platforms, approaching such lesions from a “top down” approach expose the ongoing limitations to lower pelvic access. This technically challenging issue has led to the colorectal surgical community adopting previously taught MIS techniques to develop a “bottom up” transanal approach to TME, now known as transanal TME (taTME) in order to mitigate this increased margin risk.

LAPAROSCOPY IN THE TREATMENT OF COLONIC DIVERTICULAR BLEEDING

Summary. Objective. To analyze the experience of treatment of patients with diverticular disease of the colon, complicated by bleeding.&#x0D; Materials and methods. Analyzed the treatment of 221 patients, hospitalized in the Military Medical Clinical Center of the Southern region of Odessa, who underwent 263 surgeries for diverticular disease of the colon and its complications. Intestinal bleeding as a cause of hospitalization was noted in 17 (7.6 %) patients.&#x0D; Results and discussion. In 9 patients, bleeding was stopped by conservative methods. 8 patients underwent surgical treatment. The following surgical interventions were performed: laparoscopic left hemicolectomy (4), laparoscopic resection of the sigmoid colon (1), left hemicolectomy (3), righthemicolectomy (1). At laparoscopic left hemicolectomy the average duration of operation made (205 ± 12,5) min. The average duration of the postoperative period was (9.75 ± 1.2) days. The average duration of the postoperative period was (9.75 ± 1.2) days. With left-sided traditional hemicolec-tomy — the average duration of the operation — (215 ± 16.3) min, the average duration of the postoperative period — (14.5 ± 2.1) days.&#x0D; Conclusions. Our experience showed the relative duration of surgery in both laparoscopic and «traditional» open, the duration of the postoperative period with laparoscopic intervention is lower, the intensity of pain and recovery time of bowel function in the group of patients who also performed laparoscopic surgery. compared to traditional access operations.

CONSORT-epidural dexmedetomidine improves gastrointestinal motility after laparoscopic colonic resection compared with morphine: Retraction.

CONSORT-epidural dexmedetomidine improves gastrointestinal motility after laparoscopic colonic resection compared with morphine: Retraction.

Postoperative pain after intrathecal analgesia in laparoscopic liver resection: a retrospective chart review.

Intrathecal analgesia (IA) has been recommended by the enhanced recovery after surgery (ERAS) Society for laparoscopic colon resections; however, although IA is used in open liver resections, it has not been extensively studied in laparoscopic hepatobiliary surgery. This retrospective chart review was undertaken to explore postoperative pain within 48 hours among patients who underwent laparoscopic liver resections (LLR), receiving either IA with or without patient-controlled analgesia (IA±PCA) versus PCA alone. After ethics approval, charts were reviewed for adult patients who underwent LLR between January 2016 and April 2019, and had IA±PCA or PCA alone. Patients with any contraindication to IA with morphine, obstructive sleep apnea, body mass index >40 kg/m2, history of chronic pain, and/or history of drug use were excluded. Descriptive statistics used to describe postoperative pain levels at 48 hours by treatment group for each pain outcome. Of 111 patients identified, 79 patients were finally included; 22 patients had IA±PCA and 57 patients had PCA only. There were no statistically significant differences in baseline characteristics, use of non-opioid pain control, and postoperative complications between the two groups. IA use was associated with reduced postoperative opioid consumption (measured in oral morphine equivalents) compared to PCA alone (mean difference [95% confidence interval] -45.92 [-83.10 to -8.75]; P=0.016). IA has the potential to decrease postoperative opioid use for patients undergoing LLR, and appears to be safe and effective in the setting of LLR. These findings are consistent with the ERAS Society recommendations for laparoscopic colorectal surgery.

Laparoscopic versus Open Transverse-Incision Approach for Right Hemicolectomy: A Systematic Review and Meta-Analysis.

Background and Objectives: There is general agreement on the benefits of laparoscopy for treatment of rectal and left colon cancers, whereas findings regarding the comparison of laparoscopic and open right colonic resections are discordant. The aim of this systematic review and meta-analysis was to assess the outcomes and advantages of laparoscopic versus transverse-incision open surgery for management of right colon cancer. Materials and Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Comparative studies evaluating the results of laparoscopic and transverse-incision open right hemicolectomies were analyzed. The measured outcomes were mean operative time, time to feeding, duration of hospital stay, and number of lymph nodes harvested. Results: A total of 5 studies including 318 patients met the inclusion criteria. Meta-analysis revealed no differences in time to resume oral feeding, hospital stay, and number of lymph nodes harvested in between groups, but mean length of surgery was significantly longer in the laparoscopic group. Conclusion: These data confirm that the preferred approach to right hemicolectomy is yet unclear. Laparoscopy has a longer operative time than transverse-incision open surgery, and no significant short-term benefits were observed for the studied parameters. Well-designed randomized control trials (RCTs) might help to identify the differences between these two techniques for the surgical treatment of right colon cancer.

Intravenous Local Anesthetic Compared With Intraperitoneal Local Anesthetic in Laparoscopic Colectomy: A Double-blind Randomized Controlled Trial.

Controlling perioperative pain is essential to improving patient experience and satisfaction following surgery. Traditionally opioids have been frequently utilized for postoperative analgesia. Although they are effective at controlling pain, they are associated with adverse effects, including postoperative nausea, vomiting, ileus, and long-term opioid dependency.Following laparoscopic colectomy, the use of intravenous or intraperitoneal infusions of lidocaine (IVL, IPL) are promising emerging analgesic options. Although both techniques are promising, there have been no direct, prospective randomized comparisons in patients undergoing laparoscopic colon resection. The purpose of this study was to compare IPL with IVL. Double-blinded, randomized controlled trial of patients undergoing laparoscopic colonic resection. The 2 groups received equal doses of either IPL or IVL which commenced intra-operatively with a bolus followed by a continuous infusion for 3 days postoperatively. Patients were cared for through a standardized enhanced recovery after surgery program. The primary outcome was total postoperative opioid consumption over the first 3 postoperative days. Patients were followed for 60 days. Fifty-six patients were randomized in a 1:1 fashion to the IVL or IPL groups. Total opioid consumption over the first 3 postoperative days was significantly lower in the IPL group (70.9 mg vs 157.8 mg P < 0.05) and overall opioid consumption during the total length of stay was also significantly lower (80.3 mg vs 187.36 mg P < 0.05. Pain scores were significantly lower at 2 hours postoperatively in the IPL group, however, all other time points were not significant. There were no differences in complications between the 2 groups. Perioperative use of IPL results in a significant reduction in opioid consumption following laparoscopic colon surgery when compared to IVL. This suggests that the peritoneal cavity/compartment is a strategic target for local anesthetic administration. Future enhanced recovery after surgery recommendations should consider IPL as an important component of a multimodal pain strategy following colectomy.

Combined endoscopic-laparoscopic surgery (CELS) can avoid segmental colectomy in endoscopically unremovable colonic polyps: a cohort study over 10 years.

Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings. Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017). One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection. CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.

Elective Laparoscopic Cecopexy and Sigmoid Colon Resection (Sharon Operation) for Cecal and Sigmoid Volvulus: A Case Report

症例は66歳男性．S状結腸捻転に対して３回の内視鏡整復歴がある．今回，腹痛を主訴に救急要請し搬送されたが病院到着時に腹痛は改善傾向であった．CTではS状結腸捻転は否定的であった．盲腸が左上腹部位置しており，虚脱した上行結腸は十二指腸の足側を左側から右側へ走行し，造影効果の減弱を認め盲腸捻転と診断した．検査後に腹痛は消失したため自然に整復されたものと判断し，後日待機的手術を行った．術式はS状結腸捻転の再発防止のため左下腹部の小切開創からのS状結腸切除術，盲腸捻転の予防のため腹腔鏡下盲腸固定術とした．S状結腸捻転と盲腸捻転に対する緊急手術は血流障害を伴い開腹手術での腸管切除が余儀なくされることが多いが，本症例は待機手術が可能でありリスクと侵襲を軽減させるための工夫を行ったため報告する．

Robotic left colectomy with double indocyanine green guidance and intracorporeal anastomoses.

Radical surgery is the mainstay of treatment of colon cancer. Lymphatic drainage of splenic flexure colon cancer is variable, and the exact site of lymphatic dissection is uncertain. Hence, a true consensus of what kind of colectomy should be performed for tumours of the splenic flexure is lacking. Segmental left colectomy (splenic flexure colectomy) (extended), left colectomy as well as subtotal colectomy (extended right colectomy) all have their proponents. Robotic colectomy addresses the limitations of straight laparoscopic colon resections. We report our technique of single-docking totally robotic left hemicolectomy for splenic flexure adenocarcinoma using Da Vinci Xi® Surgical System (Intuitive Surgical, USA) with indocyanine green near-infrared fluorescence for the assessment of both the lymph nodes and intestinal blood flow in real time.

Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis

Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available. To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis. This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography-verified free air, were eligible. Those available for trial intervention (Hinchey stages <IV) were included in the long-term follow-up. Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization. The primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life. Of 199 randomized patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to colon resection. At the time of surgery, perforated purulent diverticulitis was confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-up was 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patients were lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 36% (n = 26) in the laparoscopic lavage group and 35% (n = 24) in the resection group (P = .92). Overall mortality was 32% (n = 23) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .36). The stoma prevalence was 8% (n = 4) in the laparoscopic lavage group vs 33% (n = 17; P = .002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36% (n = 26) vs 35% (n = 24; P = .92), respectively. Recurrence of diverticulitis was higher following laparoscopic lavage (21% [n = 15] vs 4% [n = 3]; P = .004). In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection. There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores between the groups. Long-term follow-up showed no differences in severe complications. Recurrence of diverticulitis after laparoscopic lavage was more common, often leading to sigmoid resection. This must be weighed against the lower stoma prevalence in this group. Shared decision-making considering both short-term and long-term consequences is encouraged. ClinicalTrials.gov Identifier: NCT01047462.