Laparoscopic Right Hemicolectomy Research Articles

Single-Center Experiences: A Comparison of Intracorporeal and Extracorporeal Anastomosis Outcomes in Right Hemicolectomy.

Background Anastomosis formed in minimally invasive laparoscopic right hemicolectomy (LRH) may be achieved intra-corporeally (ICA) or extra-corporeally (ECA). This study compared the return of bowel function and other associated early patient outcomes and morbidity rates after an ICA or ECA in LRH. Methodology The study conducted a single-center retrospective cohort study of elective LRH from January 2021 to September 2023. Patient demographics, surgical techniques, and outcomes were analyzed using IBM SPSS Statistics for Windows, Version 29.0 (IBM Corp.,Armonk, NY). Results Ninety participants underwent LRH, and the anastomotic type was evenly distributed - with male patients comprising 53 (58.9%) of the total. The mean age was 64 (standard deviation [SD] ±16.8) years, and the median body mass index (BMI) was 27.0 (interquartile range [IQR] = 7.8). The mean follow-up period was 5.1 (SD ± 6.0) months. Univariate analysis showed that ICA had a shorter time for return of bowel function (P < 0.01). Additionally, ICA was associated with lower pain scores (P < 0.01), low morbidity (P = 0.02), and shorter hospital stays (P = 0.01). When comparing ICA to ECA, no significant difference was observed for procedure duration (P = 0.13), anastomotic leak (AL,P = 1.00), surgical-site infections (P = 0.36), lymph node yield (P = 0.26), and any-cause mortality. Multivariate logistic regression, controlling for statistically insignificant confounding factors, revealed that ECA was significantly and independently associated with increased time to first flatus (odds ratio [OR] 2.3, P = 0.01) and higher average postoperative pain (OR 1.5, P = 0.02) compared to ICA. Conclusions This single-center experience showed that ICA is associated with a quicker return to normal bowel function and low morbidity outcomes. ICA participants were positively associated with clinically relevant and health economics outcomes of shorter hospital stays without significantly adding to the procedure's duration times or compromising principles of oncological resection yield.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy for overweight colon cancer patients: a case-control study.

Either extracorporeal anastomosis (EA) or intracorporeal anastomosis (IA) could be selected for digestive reconstruction in laparoscopic right hemicolectomy (LRH). However, whether LRH with IA is feasible and beneficial for overweight right-side colon cancer (RCC) is unclear. This study aims to investigate the feasibility and advantage of IA in LRH for overweight RCC. Forty-eight consecutive overweight RCC patients undergoing LRH with IA were matched with 48 consecutive cases undergoing LRH with EA. Both clinical and surgical data were collected and analyzed. The incidence of postoperative complications was 20.8% (10/48) in the EA group and 14.6% (7/48) in the IA group respectively, with no statistical difference. Compared to the EA group, patients in the IA group revealed faster gas (40.2 + 7.8h vs. 45.6 + 7.9h, P = 0.001) and stool discharge (4.0 + 1.2 d vs. 4.5 + 1.1 d, P = 0.040), shorter assisted incision (5.3 + 1.3cm vs. 7.5 + 1.2cm, P = 0.000), and less analgesic used (3.3 + 1.3 d vs. 4.0 + 1.3 d, P = 0.012). There were no significant differences in operation time, blood loss, or postoperative hospital stays. In the IA group, the first one third of cases presented longer operation time (228.4 + 29.3min) compared to the middle (191.0 + 35.0min, P = 0.003) and the last one third of patients (182.2 + 20.7min, P = 0.000). LRH with IA is feasible and safe for overweight RCC, with faster bowel function recovery and less pain. Accumulation of certain cases of LRH with IA will facilitate surgical procedures and reduce operation time.

Deep learning-based vessel automatic recognition for laparoscopic right hemicolectomy.

In laparoscopic right hemicolectomy (RHC) for right-sided colon cancer, accurate recognition of the vascular anatomy is required for appropriate lymph node harvesting and safe operative procedures. We aimed to develop a deep learning model that enables the automatic recognition and visualization of major blood vessels in laparoscopic RHC. This was a single-institution retrospective feasibility study. Semantic segmentation of three vessel areas, including the superior mesenteric vein (SMV), ileocolic artery (ICA), and ileocolic vein (ICV), was performed using the developed deep learning model. The Dice coefficient, recall, and precision were utilized as evaluation metrics to quantify the model performance after fivefold cross-validation. The model was further qualitatively appraised by 13 surgeons, based on a grading rubric to assess its potential for clinical application. In total, 2624 images were extracted from 104 laparoscopic colectomy for right-sided colon cancer videos, and the pixels corresponding to the SMV, ICA, and ICV were manually annotated and utilized as training data. SMV recognition was the most accurate, with all three evaluation metrics having values above 0.75, whereas the recognition accuracy of ICA and ICV ranged from 0.53 to 0.57 for the three evaluation metrics. Additionally, all 13 surgeons gave acceptable ratings for the possibility of clinical application in rubric-based quantitative evaluations. We developed a DL-based vessel segmentation model capable of achieving feasible identification and visualization of major blood vessels in association with RHC. This model may be used by surgeons to accomplish reliable navigation of vessel visualization.

Laparoscopic Right Hemicolectomy for Inflammatory Bowel Disease: Is Intracorporeal Anastomosis Feasible? A Retrospective Cohort Comparison Study.

Background: Inflammatory bowel disease (IBD) affects all ages and backgrounds, and many individuals require surgical intervention during their disease course. The adoption of laparoscopic techniques in this patient population has been slow, including intracorporeal anastomosis (ICA). The aim of our study was to determine if ICA was feasible and safe in patients with IBD undergoing laparoscopic right hemicolectomy (LRHC). Methods: This is a retrospective, single institution cohort study of elective and emergent cases of LRHC at a single academic center. Patients included underwent LRHC or ileocolic resection for IBD. Exclusion criteria: conversion to laparotomy, resection without anastomosis, or unconfirmed diagnosis of IBD. Main outcomes studied were anastomotic leak rate, surgical site infection (SSI), postoperative length of stay, 30-day readmission/reoperation, and operative time. Secondary outcomes were incisional hernia rates and rates of disease recurrence. Results: A total of 70 patients were included, 12 underwent ICA and 58 extracorporeal anastomosis. Anastomotic leak rate (intracorporeal 8.3% [n = 1], extracorporeal 8.6% [n = 5], P = .97), and SSI rates (intracorporeal 0%, extracorporeal 6.9% [n = 4], P = .36) were similar. Mean postoperative length of stay, rates of 30-day readmission/reoperation and diagnosis of hernia at 1 year were not significantly different. Rates of IBD recurrence and location of recurrence at 1 year were similar. However, operative time was significantly longer in those undergoing ICA (intracorporeal 187 minutes versus extracorporeal 139 minutes, P = < .05). Conclusions: ICA is a safe option in patients with IBD undergoing LRHC.

The value of mesenteric closure after laparoscopic right hemicolectomy: a scoping review

ObjectiveTo evaluate the prognostic impact and describe suturing tools of mesenteric closure after laparoscopic right hemicolectomy (LRH).MethodsPubMed, Embase, Cochrane library, Web of Science, and Scopus databases, were searched and publications relating to mesenteric closure data and tools were extracted. Search terms: “Mesenteric Defects” and “Mesenteric Closure” were used, and manual searches of eligible articles from literature reference lists performed.ResultA total of 7 publications were identified. 5 focused on prognostic impact and 4 referred to tools for mesenteric closure, two of which concerned both prognostic data and tools. All studies related to prognostic impact were single center with “low” modified GRADE quality. A high degree of heterogeneous was found.ConclusionThe evidence from current research does not support routine closure of mesenteric defects. Use of a polymer ligation clip has produced favorable results in a small sample size trial and further investigation is merited. A large randomized controlled trial is still warranted.

Does 3D laparoscopic video technology affect long-term survival in right hemicolectomy for cancer compared to standard 2D? A propensity score study.

There are few studies focused on the short-term results of laparoscopic right hemicolectomy performed with 2D (two-dimension) or 3D (three-dimension) video technology and none on the oncologic effects. The aim of the study was to assess the long-term results of laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis using 3D or 2D video in patients with right colon cancer with at least three years of oncologic follow-up. Data from patients undergoing laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis for cancer in an 11-year period (June 2008-June 2019) and ≥ 3years of follow-up were prospectively collected. Surgical procedures were performed by two expert laparoscopic surgeons. 111 patients were included in the study: 56 (50.5%) in the 3D group and 55 (49.5%) in the 2D group. Tumor stage and number of lymph nodes harvested were similar. Overall and disease-free survival were not different in the two groups. Local recurrence occurred in none of the patients, and distant metachronous metastases were similar in the two groups. A propensity score weighting approach was used to account for potential confounding related to patients' nonrandom allocation to the 2 groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach. Laparoscopic 3D technology allows similar oncological results as 2D vision in LRH with intracorporeal anastomosis. Larger prospective randomized studies might confirm these results in the long-term follow-up.

The fundamentals of laparoscopic surgery in general surgery residency: fundamental for junior residents' self-efficacy.

Implementation of the Fundamentals of Laparoscopic Surgery (FLS) by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has served a need for educational structure for laparoscopic skill within General Surgery training since 2004. This study looks at how FLS affects resident self-efficacy (SE) with laparoscopic procedures. We conducted a national survey, linked to the 2020 American Board of Surgery In-Training Examination (ABSITE), in which 9275 residents from 325 US General Surgery Training Programs participated. The online survey included multimodal questions that analyzed whether participants felt they could perform the most commonly-logged laparoscopic operationsamong residents [Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), Laparoscopic Right Hemicolectomy (LRH), Diagnostic Laparoscopy (DL)] without faculty assistance. This used a 5-point scaled assessment, ranging from "not able to" to "definitely able to." Multivariate analyses determined if completion of FLS made a difference for resident self-efficacy, stratified by post-graduate year (PGY). At the time of the survey, 2300 reported completion of FLS. The percentage of FLS completion increased from PGY1 to PGY5 (4.2% n = 59 vs 85.8% n = 893). PGY1 residents who completed FLS, from 48 diverse institutions, demonstrated the most significant increases in SE (p < 0.05) with significantly higher perceived self-efficacy in LA (p = 0.001) and LRH (p = 0.012). PGY2 and PGY3 residents indicated increased SE in DL (p = 0.037, p = 0.015, respectively), based on FLS completion. These FLS effects were less evident in the more senior classes. Completion of FLS arguably has the greatest benefits for more junior residents, as it establishes a foundation of laparoscopic knowledge and skill, upon which further residency training can build. Successful completion of the curriculum and assessment offered by the Fundamentals of Laparoscopic Surgery leads to greater sense of ability in early trainees.

Priority Management of Henle Trunk in Cranial-to-Caudal Approach for Laparoscopic Right Hemicolon Cancer Surgery.

This study aimed to compare the short-term clinical efficacy between prior and traditional approach of Henle trunk in laparoscopic right hemicolectomy (LRH) for right colon cancer. A total of 161 patients underwent LRH for right colon cancer between June 2018 and December 2020 by the same group of physicians. The prior approach of Henle trunk (priority group) was used in 82 patients and traditional approach in 79 (traditional group). The demographics and clinicopathological characteristics were recorded and retrospectively analyzed. As compared to the traditional group, the mean blood loss reduced significantly [73.84 ± 17.31 mL vs. 83.42 ± 30.16 mL; P = 0.001], the operation time was markedly shorter [151.35 ± 6.75 min vs. 159.13 ± 18.85 min; P = 0.014], and the intraoperative vascular injury rate was significantly lower [6.1% (5/82). vs. 17.7% (14/79); P = 0.022]. There were no significant differences in the postoperative complications, first exhaust time, first defecation time, drainage time, postoperative hospital stay, quality evaluation of surgical specimens and pathological findings between two groups. Our study shows that the priority management of Henle trunk in the LRH for right colon cancer is a safe and feasible procedure with less blood loss, shorter operation time and lower intraoperative vascular injury rate.

Complete Mesocolic Excision with Central Vascular Ligation during Laparoscopic Right Hemicolectomy: Technical Notes

In this article we describe the surgical technique of the Complete Mesocolic Excision (CME) with Central Vascular Ligation (CVL) during laparoscopic right hemicolectomy (LRH) with intracorporeal anastomosis, as performed in our current surgical practice. The preparation of the patient, the operating room, the position of the surgeons, equipment and trocar placement are described in detail. The procedure is divided into well-defined steps, and each one is meticulously described.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: a retrospective cohort study of anastomotic complications.

Laparoscopic right hemicolectomy (LRH) can be performed with an intracorporeal anastomosis (IA) or extracorporeal anastomosis (EA). It is not clear which technique is best. This study evaluated the impact of each anastomosis technique on perioperative safety and postoperative evolution. We performed a retrospective study at a tertiary colorectal surgery center. All patients who had an elective LRH from 2015 to 2019 were analyzed according to the anastomosis technique used. In total, 285 patients were included in the study. IA was performed in 64 patients (22.5%). Mean operative time was longer in the patients with IA (IA, 160±31 minutes vs. EA, 138±42 minutes; P<0.001). No differences were observed in intraoperative complications, time to first bowel movement, length of stay, reoperation, or rehospitalization. Time to first flatus was longer in the patients with IA (P=0.049). At 30 days after surgery, there were no differences in the frequency of anastomotic leak (IA, 0% vs. EA, 2.3%; P=0.59), bleeding (IA, 3.1% vs. EA, 2.7%; P>0.99), or intraabdominal abscess (IA, 0% vs. EA, 0.5%; P>0.99). During follow-up, we noted more incisional hernias in patients with EA (IA, 1.6% vs. EA, 11.3%; P=0.01) and a trend toward more hernia in patients with EA in multivariate analysis (hazard ratio, 7.13; P=0.06). Anastomosis technique had no influence on recurrence. For LRH, both IA and EA are safe, with a low incidence of complications when performed by experienced surgeons. IA may be associated with a lower incidence of incisional hernia.

Does cranial-medial mixed dominant approach have a unique advantage for laparoscopic right hemicolectomy with complete mesocolic excision?

BACKGROUNDComplete mesocolic excision (CME) with central vascular ligation (CVL) was proposed by Hohenberger in 2009. The CME principle has gradually become the technical standard for colon cancer surgery. How to achieve CME with CVL in laparoscopic right hemicolectomy (LRH) is controversial, and a unified standard approach is not yet available. In recent years, the authors’ team has integrated the theory of membrane anatomy, tried to combine the cephalic approach with the classic medial approach (MA) for technical optimization, and proposed a cranial-medial mixed dominant approach (CMA).AIMTo explore the feasibility of operational approaches for LRH with CME.METHODSIn this retrospective cohort study, the clinical data of 57 patients with right-sided colon cancer (TNM stage I, II, or III) who underwent LRH with CME from January 2016 to June 2020 were collected and summarized. There were 31 patients in the traditional MA group and 26 in the CMA group.RESULTSThere were no significant differences in baseline data between the two groups. The operation was shorter and the number of lymph nodes dissected was higher in the CMA group than in the MA group, but there was no significant difference in the number of positive lymph nodes, intraoperative blood loss, postoperative exhaust time, feeding time, postoperative hospital stay or postoperative complication incidence.CONCLUSIONOur study shows that the CMA is a safe and feasible procedure for LRH with CME and has a unique advantage.

Laparoscopic Right Hemicolectomy With Complete Mesocolic Excision and Central Vascular Ligation Using a Right Colon Rotation Technique (Flip-Flap Method).

Background: Laparoscopic right hemicolectomy (Lap-RHC) with complete mesocolic excision (CME) and central vascular ligation (CVL) is technically challenging. A standardized procedure is thus needed to minimize technical hazards. Technique: We have developed the "flip-flap method," comprising repeated inversion and restoration of the mobilized right colon according to the anatomical complexity and vascularity in Lap-RHC, and showed that this technique is safe, feasible, and useful in terms of CME and CVL. Our study included 30 consecutive patients who underwent Lap-RHC using the flip-flap method between April 2018 and December 2020. The short-term surgical outcomes suggested this method was safe and feasible. We report herein the surgical procedure for this flip-flap method. The hepatic flexure is mobilized, then the ileocecal vessels are divided, and the cecum is separated from the retroperitoneal space. The mobilized right colon is rotated to the left of the superior mesenteric vein, continuing to separate the mesentery from right to left, and the right colic vessels are divided. If division of the right colic vessels is technically difficult, the inverted right colon is restored to its original position, and the right colon vessels are divided. Finally, the transverse mesenteric fat is dissected along the left edge of the superior mesenteric artery to the inferior border of the pancreas. Conclusions: We consider that the most useful point of this technique is the ability to develop an optimal operative field according to the anatomical complexity and vascularity of the individual, securing CME without unexpected bleeding or damage to other organs.

International survey among surgeons on laparoscopic right hemicolectomy: the gap between guidelines and reality.

IntroductionTo assess the current approaches and perioperative treatments of laparoscopic right hemicolectomy (LRHC) and to highlight similarities and differences with international guidelines and scientific evidence, we conducted a survey for surgeons across the globe.MethodsAll digestive and colorectal surgeons registered with the database of the Research Institute against Digestive Cancer (IRCAD) were invited to take part in the survey via email and through the social media networks of IRCAD.ResultsThere were a total of 440 respondents from 78 countries. Most surgeons worked in the European region (38.6%) followed by the Americas (34.1%), the Eastern Mediterranean region (13.0%), the South-East Asian region (5.9%), the Western Pacific region (4.8%), and Africa (3.2%) respectively. Over half of the respondents performed less than 25% of right hemicolectomies laparoscopically where 4 ports are usually used by 68% of the surgeons. The medial-to-lateral, vessel-first approach is the approach most commonly used (74.1%). The most common extraction site was through a midline incision (53%) and an abdominal drain tube is routinely used by 52% of the surgeons after surgery. A total of 68.6% of the responding surgeons perform the majority of the anastomoses extracorporeally. Finally, we found that the majority of responders (60.7%) routinely used mechanical bowel preparations prior to LRHC.ConclusionRegarding several topics related to LRHC care, a discrepancy was observed between the current medical practice and the recommendations from RCTs and international guidelines and significant regional differences were observed.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-022-09044-w.

Robotic versus laparoscopic right hemicolectomy: a case-matched study

The current gold standard surgical treatment for right colonic malignancy is the laparoscopic right hemicolectomy (LRH). However, laparoscopic surgery has limitations which can be overcome by robotic surgery. The benefits of robotics for rectal cancer are widely accepted but its use for right hemicolectomy remains controversial. The aim of this study was to compare outcomes in patients undergoing robotic right hemicolectomy (RRH) and LRH in a university teaching hospital. Demographic, perioperative and postoperative data along with early oncological outcomes of patients who underwent RRH and LRH with extracorporeal anastomosis (ECA) were identified from a prospectively maintained database. A total of 70 patients (35 RRH, 35 LRH) were identified over a 4-year period. No statistically significant differences in estimated blood loss, conversion to open surgery, postoperative complications, anastomotic leak, 30-day reoperation, 30-day mortality, surgical site infection or lengths of stay were demonstrated. Surgical specimen quality in both groups was favourable. The mean duration of surgery was longer in RRH (p < < 0.00001). A statistically significant proportion of RRH patients had a higher BMI and ASA grade. The results demonstrate that RRH is safe and feasible when compared to LRH, with no statistical difference in postoperative morbidity, mortality and early oncological outcomes. A difference was noted in operating time, however was influenced by training residents in docking the robot and a technically challenging cohort of patients. Operative time has shortened with further experience. Incorporating an intracorporeal anastomosis technique in RRH offers the potential to improve outcomes compared to LRH.

A novel and simple technique to close the enterotomy after intracorporeal anastomosis in laparoscopic right hemicolectomy.

We developed a new technique to reduce the length of the enteric defect to be closed during intracorporeal anastomosis in laparoscopic right hemicolectomy (LRH), also avoiding the need to suture the first part of the anastomosis in a deep space with an acute angle. From January 2017, after the ileo-colic anastomosis was completed, an additional stapler cartridge was applied starting at the colonic rim and including the small bowel part of the anastomosis. The isoperistaltic fashion of the ileo-colonic anastomosis was maintained. The remaining defect left to be closed was 2-3cm. We compared the results of the novel technique with those of the 'standard' closure (full-length enterotomy). In the last 30months, this technique was successfully used in 32 patients (Group A), compared with 33 patients (2012-2016) operated with 'standard' closure (Group B). Age, BMI and post-operative stage distribution were similar. The mean operative time was 175.2min (± 36.7) in Group A and 165.9min (± 42.5) in Group B (p = ns), with 53.1% and 27.3% of associated procedures (cholecystectomy, ovariectomy, etc.), respectively (p < 0.05). Overall morbidity rate was 28.1% and 30.3% (Group A vs Group B, p = ns), with no anastomotic bleeding/leak in either group. This technique, which simplifies the closure of the enteric defect after LRH with intracorporeal anastomosis is safe, reproducible and easy to learn. It might help more surgeons to perform a fully laparoscopic procedure in right hemicolectomy, offering the advantages of intracorporeal anastomosis to their patients.

Current status and trend of laparoscopic right hemicolectomy for colon cancer.

Laparoscopic right hemicolectomy (LRH) is utilized worldwide as one of the standard surgical treatments for right‐sided colon cancer. However, there have been issues concerning its applicability, techniques, and trend. The present study aimed to elucidate the current status and trend of LRH by reviewing literature focusing on important issues associated with this surgery. Based on previous studies, LRH most likely provides better short‐term outcomes and similar oncological outcomes compared to open surgery. Despite the increasing use of robotic approach in this surgery, it seems to have always been associated with longer operative times and greater hospital cost with limited advantage. Intracorporeal anastomosis seems to improve short‐term outcomes, such as quicker recovery of bowel function, compared to extracorporeal anastomosis. However, it does not contribute to shorter hospital stay. With regard to dissection technique, various approaches, and landmarks have been advocated to overcome the technical difficulty in LRH. This difficulty is likely to be caused by anatomical variation, especially in venous structures. The superiority of one approach or landmark over another is still argued about due to the lack of large‐scale prospective studies. However, deep understanding both of anatomical variation and characteristics of each approach would be of extreme importance to minimize adverse effects and maximize patient benefit after LRH.

Robotic vs laparoscopic right colectomy – the burden of age and comorbidity in perioperative outcomes: An observational study

BACKGROUNDSeveral studies have shown the safety, feasibility and oncologic adequacy of robotic right hemicolectomy (RRH). Laparoscopic right hemicolectomy (LRH) is considered technically challenging. Robotic surgery has been introduced to overcome this technical limitation, but it is related to high costs. To maximize the benefits of such surgery, only selected patients are candidates for this technique. In addition, due to progressive aging of the population, an increasing number of minimally invasive procedures are performed on elderly patients with severe comorbidities, who are usually more prone to post-operative complications.AIMTo investigate the outcomes of RRH vs LRH with regard to age and comorbidities.METHODSWe retrospectively analyzed 123 minimally invasive procedures (68 LRHs vs 55 RRHs) for right colon cancer or endoscopically unresectable adenoma performed in our Center from January 2014 until September 2019. The surgical procedures were performed according to standardized techniques. The primary clinical outcome of the study was the length of hospital stay (LOS) measured in days. Secondary outcomes were time to first flatus (TFF) and time to first stool evacuation. The robotic technique was considered the exposure and the laparoscopic technique was considered the control. Routine demographic variables were obtained, including age at time of surgery and gender. Body mass index and American Society of Anesthesiologists physical status were registered. The age-adjusted Charlson Comorbidity Index (ACCI) was calculated; the tumor-node-metastasis system, intra-operative variables and post-operative complications were recorded. Post-operative follow-up was 180 d.RESULTSLOS, TFF, and time to first stool were significantly shorter in the robotic group: Median 6 [interquartile range (IQR) 5-8] vs 7 (IQR 6-10.5) d, P = 0.028; median 2 (IQR 1-3) vs 3 (IQR 2-4) d, P < 0.001; median 4 (IQR 3-5) vs 5 (IQR 4-6.5) d, P = 0.005, respectively. Following multivariable analysis, the robotic technique was confirmed to be predictive of significantly shorter hospitalization and faster restoration of bowel function; in addition the dichotomous variables of age over 75 years and ACCI more than 7 were significant predictors of hospital stay. No outcomes were significantly associated with Clavien-Dindo grading. Sub-group analysis demonstrated that patients aged over 75 years had a longer LOS (median 6 -IQR 5-8- vs 7 -IQR 6-12- d, P = 0.013) and later TFF (median 2 -IQR 1-3- vs 3 -IQR 2-4- d, P = 0.008), while patients with ACCI more than 7 were only associated with a prolonged hospital stay (median 7 -IQR 5-8- vs 7 -IQR 6-14.5- d, P = 0.036).CONCLUSIONRRH is related to shorter LOS when compared with the laparoscopic approach, but older age and several comorbidities tend to reduce its benefits.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: results from the CLIMHET study group.

Laparoscopic right hemicolectomy (LRHC) is increasingly performed for the treatment of right colon disease. Nevertheless, standardization of the surgical technique regarding the performance of intracorporeal (IC) or extracorporeal (EC) anastomosis is lacking. The purpose of this study was to compare short-term postoperative outcomes in patients who had laparoscopic right colectomy either with IC or EC. This was a retrospective, non-randomized and multicenter study conducted from January 2005 to December 2015 on the CLIMHET study group cohort from five tertiary centers in France. Data were collected for all patients with LRHC to compare patient characteristics, intraoperative data and postoperative outcomes in terms of medical and surgical complications, duration of hospitalization and mortality. A multivariate analysis was performed to compare the results in the two groups. Of the 597 patients undergoing LRHC, 150 had IC and 447 had EC. The incidence of medical complications (cardiac, vascular, and pulmonary complications) was lower in the IC group than in the EC group (13 vs 20%, p = 0.049). This difference remained significant in multivariate analysis after adjusting to field characteristics and patient histories (p = 0.009). Additionally, a shorter hospital stay (7 vs 8days, p = 0.003) was observed in the IC group as compared to the EC group. This difference remained significant in favor of the IC group in multivariate analysis (p = 0.029). There was no difference between the groups as regards: surgical complications (p = 0.76), time of mobilization (p = 0.93), reintervention rate (p = 1) and 90-day mortality (p = 0.47). Our results show that IC anastomosis in LRHC is associated with fewer medical complications and shorter hospital stays compared to EC anastomosis.

Successful patient-oriented surgical outcomes in robotic vs laparoscopic right hemicolectomy for cancer - a systematic review.

Minimally invasive surgical approaches for cancer of the right colon have been well described with significant patient and equivalent oncological benefits. Robotic surgery has advanced in its ability to provide multi-quadrant abdominal access, leading the surgical community to widen its application outside of the pelvis to other abdominal compartments. Globally it is being realized that a patient's surgical episode of care is becoming the epicentre of cancer treatment. In order to establish the role of robotic surgery in a patient's episode of care, 'successful patient-oriented surgical' parameters in right hemicolectomy for malignancy were measured. The objective was to examine the rates of successful patient-oriented surgical outcomes in robotic right hemicolectomy (RRH) compared to laparoscopic right hemicolectomy (LRH) for cancer. A systematic search of MEDLINE (Ovid: 1946-present), PubMed (NCBI), Embase (Ovid: 1966-present) and Cochrane Library was conducted using PRISMA for parameters of successful patient-oriented surgical outcomes in RRH and LRH for malignancy alone. The parameters measured included postoperative ileus, anastomotic complication, surgical wound infection, length of stay (LOS), incisional hernia rate, conversion to open, margin status, lymph node harvest and overall morbidity and mortality. There were 15 studies which included 831 RRH patients and 3241 LRH patients, with a median age of 62-74years. No study analysed the concept of successful patient-oriented surgical outcomes. There was no significant difference in the incidence of postoperative ileus, with less time to first flatus in RRH (2.0-2.7days, compared with 2.5-4.0days, P<0.05). Anastomotic leak rate in one study reported a significant increase in LRH compared to RRH (P<0.05, 0% vs 8.3%). Significantly decreased LOS following RRH was outlined in six studies. One study reported a significantly higher rate of incisional hernias following LRH with extracorporeal anastomoses compared to RRH with intracorporeal anastomoses. Overall rates of conversion to open surgery were less with RRH (0%-3.9% vs 0%-18%, P<0.001, 0.05). One study outlined significantly higher rates of incomplete resection with an open right hemicolectomy compared with minimally invasive laparoscopic and robotic resections, with positive margin rates of 2.3%, 0.9% and 0% respectively (P<0.001). Two studies reported significantly higher lymph node harvest in RRH (P<0.05). Overall morbidity and 30-day mortality were comparable in both approaches. Thirty-day morbidity and mortality were comparable between the two approaches, with patients undergoing RRH having lower anastomotic complications, increased lymph node harvest, and reduced LOS, conversion to open and incisional hernia rates in a number of studies. There are limited data on surgical approach and impact on quality of life and what patients deem successful surgical outcomes. There is a further need for a randomized controlled trial examining successful patient-oriented outcomes in right hemicolectomy for malignancy.

Comparison of the short-term efficacy of modified intermediate approach and traditional intermediate approach in laparoscopic radical right hemicolectomy

Objective To compare and analyze the short-term efficacy of modified intermediate laparoscopic right hemicolectomy (LRHC) and traditional intermediate laparoscopic right hemicolectomy (LRHC) in patients with colon cancer. Methods Eighty-four patients with colon cancer treated by laparoscopic right hemicolectomy(LRHC) from March 2014 to March 2018 in the General Surgery department of Guangzhou Hospital of Traditional Chinese Medicine were randomly divided into two groups.The control group was treated with traditional intermediate approach, while the improved group was treated with improved intermediate approach centering on the anterior pancreatic head region, with 42 cases in each group.The two groups of operations and related complications were statistically analyzed and compared. Results Compared to the control group, the improved group had less estimated mean blood loss((39.5±11.6) ml vs.(86.3±13.7) ml, t=11.124, P 0.05). Conclusion Modified intermediate approach LRHC for colon cancer patients not only reduces the amount of bleeding and operation time, but also significantly reduces the rate of intraoperative vascular injury. Key words: Colon cancer; Laparoscopic right hemicolectomy; Modified medial approach