Quicker Return Of Bowel Function Research Articles

Laparoscopic Double Discoid Colorectal Resection for the Treatment of Two Distinct Deep Endometriotic Nodules

To show the surgical steps used to perform a laparoscopic double discoid colorectal resection for the excision of 2 distinct deep endometriotic nodules (DENs). Stepwise demonstration of the technique with narrated video footage. To date there is agreement that discoid resection should be the first choice procedure in patients eligible for surgical treatment with rectal, unifocal DENs measuring ≤ 3 cm [1-3]. For surgical management of lesions of the sigmoid colon, current international guidelines suggest to perform segmental resections [3]. Data on surgical treatment of multiple colorectal DENs separated by a great distance from each other are very limited, mostly owing to the rarity of such a diagnosis. In particular, there is paucity of data concerning the efficacy and safety of a double discoid resection for surgical management of distinct DENs found in the sigmoid colon and rectum [4]. In a context of multiple colorectal DENs, the decision-making process with respect to a double discoid excision must take into consideration both the distance between the 2 nodules and the nodules' distance from anal verge. When technically feasible, such organ-sparing surgery allows preserving the healthy bowel interposed between the endometriotic lesions, seeming to offer advantages in terms of quicker return of bowel function and better rectal functional outcomes than segmental colorectal resection. The patient was a 36-year-old woman experiencing drug treatment failure and presenting with refractory constipation, dyschezia, dysmenorrhea, dyspareunia, cyclical abdominal bloating, and chronic pelvic pain. Preoperative ultrasonography revealed the presence of an endometriotic nodule of 19×6×16 mm deeply infiltrating the tunica muscularis of the sigmoid colon. A second DEN was found at the level of the rectum, the latter measuring 19×5×12 mm and having a distance of 9 cm from the anal verge. Both the intestinal lesions resulted to have a circumferential extent of 30%. The distance between the 2 nodules was 15 cm. A 3-dimensional laparoscopy was performed. Sigmoid colon and rectal mobilization were performed according to our standardized technique [5-7]. A 31-mm circular stapler was used to excise first the nodule of the sigmoid colon. The stapler, in its closed position, was gently introduced into the rectum via the anus and then progressively advanced inside the large bowel up to the level of the sigmoid nodule. After correct positioning, the stapler was completely opened and the nodule was imbricate between the anvil and staple housing of the stapler. Then, the stapler was closed and fired. The procedure was repeated using a second 31 mm circular stapler to resect the rectal endometriotic nodule. The overall operative time was 90 minutes. The estimated blood loss was 5 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 3 days after surgery. The sigmoid colon and rectal endometriotic nodules measured, respectively, 20×6×15 mm and 20×5×12 mm on fresh unfixed specimens. Both nodules were found to have endometriosis-free surgical margins on definitive pathology. The operative technique displayed in this video may contribute to the standardization of a procedure, which could be included among the options available in the surgical armamentarium, to be used in selected cases of multiple colorectal DENs each having 3 cm or less in diameter. Surgeon experience and an adequate preoperative evaluation are of utmost importance to plan the operative strategy and have the best chance of surgical success.

Totally Laparoscopic Resection with Transanal Natural Orifice Specimen Extraction for Deep Endometriosis Infiltrating the Rectum

To show the surgical steps used to perform a totally laparoscopic segmental rectal resection, with intracorporeal anastomosis and transanal natural orifice specimen extraction (NOSE), in a context of deep endometriosis. Step-by-step video demonstration of the technique. Even though the combined use of intracorporeal anastomosis and NOSE has increasingly been investigated during the last decade, there is still lack of defined consensus, both in terms of patient eligibility and operative technique. In particular, experience with intracorporeal anastomosis and NOSE for treatment of deep rectal endometriosis is very limited. Preliminary reports have documented that a totally laparoscopic rectal resection is equally effective and safe compared with the conventional approach using an abdominal minilaparotomy for extracorporeal anastomosis and specimen retrieval. In comparison to the latter, intracorporeal anastomosis with NOSE seems to offer advantages in terms of less postoperative pain, fewer wound-related complications, better cosmetic results, quicker return of bowel function and shorter hospital stay. A 31-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. Preoperative ultrasonography showed partial obliteration of the Douglas' pouch due to a rectal endometriotic nodule of 42×12×18 mm in contiguity with a deeply infiltrating retrocervical lesion of 13×3×17 mm. The rectal nodule resulted in the infiltration of the tunica muscularis with a distance of 12 cm from the anal verge and a circumferential extent of 45%. A 3-dimensional laparoscopic system was used. Rectal mobilization was performed according to our standardized technique [1]. After determining the proximal and distal resection margins, the rectum was transected using a tissue sealing-device. The resected specimen was placed in a retrieval bag and pulled out through the anus. Proximal and distal resection lines were closed using a 60 mm linear endo-stapler, and a totally intracorporeal, side-to-end anastomosis was performed using a 29 mm circular stapler. The overall operative time was 85 minutes. The estimated blood loss was 10 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 5 days after surgery. The bowel endometriotic nodule measured 41×12×18 mm on the fresh unfixed specimen. Advanced surgical skills are needed to perform an effective and safe, totally laparoscopic rectal resection. The operative technique displayed in this video may contribute to the standardization of such surgical procedure. Accurate patient selection, including adequate preoperative evaluation, is of utmost importance for the best chance of surgical success.

Regional anesthesia: Epidurals, TAP blocks, or wound infiltration?

Regional anesthesia is an important part of Enhanced Recovery Pathways following colorectal surgery. By facilitating decreased opioid consumption, wound infiltration, blocks, and neuraxial anesthesia promote quicker return of bowel function and decreased side effects.

Elderly Patients Benefit From Enhanced Recovery Protocols After Colorectal Surgery

BackgroundEnhanced recovery protocols (ERAS) aim to decrease physiological stress response to surgery and maintain postoperative physiological function. Proponents of ERAS state these protocols decrease lengths of stay (LOS) and complication rates. Our aim was to assess whether elderly patients receive the same benefit as younger patients using ERAS protocols. MethodsWe queried patients from 2015 to 2017 at our institution with Enhanced Recovery in Surgery (ERIN) variables from the targeted colectomy NSQIP database. The patients were divided into sextiles and analyzed for readmission, LOS, return of bowel function, tolerating diet, mobilization, and multimodal pain management comparing the youngest sextile to the oldest sextile. ResultsTwo hundred sixty-two patients (73% colectomies) were enrolled in ERAS. When compared with the youngest sextile (age 19-43.8), the oldest sextile (age 71.4-92.5) had similar readmission rates at 9.8% versus 9.5% (P-value = 0.87), quicker return of bowel function, average 1.9 d versus 3.7 d (P-value < 0.01), and tolerated diet quicker, average POD 2.4 d versus 5.1 d (P-value < 0.01). There was a slight decrease in the use of multimodal pain management 88% versus 100% (P-value = 0.07), but mobilization on POD1 was slightly better in the elderly at 80% versus 78% (P-value = 0.76). Elderly patients enrolled in ERAS had an average LOS of 4.9 days versus 7.8 in the younger patients (P-value = 0.08). Among elderly non-ERAS patients average LOS was 14.6 days. ConclusionOverall, elderly patients fared better or the same on the ERIN variables analyzed than the younger cohort. ERAS protocols are beneficial and applicable to elderly patients undergoing colorectal surgery.

A prospective randomized trial of intravenous ketorolac vs. acetaminophen administered with opioid patient-controlled analgesia in gynecologic surgery

ObjectiveTo determine which non-narcotic analgesic, acetaminophen (Ofirmev®) or ketorolac (Toradol®), provides better post-operative pain control when combined with an opioid patient-controlled analgesia (PCA) pump. Secondary objectives include comparisons of the rates of ileus, post-operative bleeding, transfusions, and length-of-hospitalization (LOH). MethodsA prospective, randomized trial of acetaminophen (A) 1-g intravenous (IV) every 6-h or ketorolac (K) 15-mg IV every 6-h from post-operative day 1–3 in addition to an opioid PCA for patients undergoing benign or malignant gynecologic laparotomy procedures was performed. Abstracted data included pain levels via visual analogue pain scales (VAS), amount of narcotic used, hepatic enzyme levels, hemoglobin, urine output, blood transfusions, time to return of flatus and LOH. ResultsOne-hundred patients were accrued and underwent 55 benign gynecologic laparotomies and 45 cancer-related laparotomies. VAS pain levels (3.3 K, 3.5 A) and morphine PCA use (79.1 oral morphine equivalents [OME] K vs. 84.5 A) were not different, however dilaudid PCA usage was less by K patients (84.4 OME K and 136.8 OME A, p < 0.001). There was a significant hemoglobin change between the two groups (2.6 g K vs. 2 g A, p = 0.015), however blood transfusions were equal (28% K, 22% A, p > 0.05). Return of flatus was 2.7-days for K vs. 3.4-days for A (p = 0.011) and LOH was not different (4.4-days K vs. 5.1-days A, p = 0.094). ConclusionsBoth intravenous ketorolac and acetaminophen provide similar post-operative analgesia through VAS pain scales and total usage of morphine via PCA pumps. Use of ketorolac with dilaudid PCA was associated with less dependence on dilaudid and a quicker return of bowel function than acetaminophen, however length of stay and transfusion rates were not different.

Utility of robot-assisted radical cystectomy with intracorporeal urinary diversion for muscle-invasive bladder cancer.

Radical cystectomy remains the gold standard for treatment of muscle‐invasive bladder cancer. Robot‐assisted radical cystectomy has technical advantages over laparoscopic radical cystectomy and has emerged as an alternative to open radical cystectomy. Despite the advancements in robotic surgery, experience with total intracorporeal reconstruction of urinary diversion remains limited. Most surgeons have carried out the hybrid approach of robot‐assisted radical cystectomy and extracorporeal reconstruction of urinary diversion, as intracorporeal reconstruction of urinary diversion remains technically challenging. However, intracorporeal reconstruction of urinary diversion might potentially proffer additional benefits, such as decreased fluid loss, reduction in estimated blood loss and a quicker return of bowel function. The adoption of intracorporeal ileal neobladder reconstruction has hitherto been limited to high‐volume academic institutions. In the present review, we compare the totally intracorporeal robot‐assisted radical cystectomy approach with open radical cystectomy and robot‐assisted radical cystectomy + extracorporeal reconstruction of urinary diversion in muscle‐invasive bladder cancer patients.

Efficacy of Intravenous Acetaminophen in Length of Stay and Postoperative Pain Control in Laparoscopic Roux-en-Y Gastric Bypass Surgery Patients.

Background: Opiate-based pain medications may incur adverse effects following bariatric surgery. The aim of this study was to evaluate the efficacy of intravenous Acetaminophen (IVAPAP) on length of stay (LOS) after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery.Methods: This was a prospective, double-blind, randomized controlled trial conducted from October 2011 to March 2014 at a 416-bed teaching hospital. Eighty-nine total patients were included (control group, n = 45; treatment group, n = 44). Patients were administered either 1000 mg of IVAPAP or placebo every 6 h beginning preoperatively and continuing for four doses. LOS, total narcotic consumption, pain and nausea scores, time to return of flatus (ROF), and postoperative rescue pain medication used were measured during the first 24 h after surgery.Results: LOS was significantly decreased in the treatment group compared with control (2.72 days vs. 3.18 days; p = 0.03). There was significant reduction in time to ROF (1.87 days vs. 2.24 days; p = 0.04). Pain was significantly decreased in the first 2 postoperative hours in the treatment group (p = 0.02). Total opioid consumption, postoperative nausea scores, and use of rescue pain medications were not affected.Conclusions: The use of IVAPAP significantly decreases LOS following LRYGB, improves acute postoperative pain control, and mediates quicker return of bowel function.

Adoption rates for laparoscopy in colorectal surgery: why are they lagging behind?

During the last three decades, the laparoscopic revolution shook the world. The advantages of the laparoscopic approach compared to open surgery are indisputable: reduced post-operative pain, reduced suppression of pulmonary function, less wound complications, quicker return of bowel function, fewer adhesions, shortened hospital stay, earlier recovery, better cosmesis and reduced costs as compared to laparotomy (1-4). Understandably, laparoscopy now represents the standard approach for most surgical procedures, including appendectomies, cholecystectomies and bariatric procedures. However, colorectal surgeons have been late and slow to adopt the laparoscopic approach, as reflected in this current paper by Davis and colleagues (5). These findings further amplify the results of earlier publications.

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Surgery and Opioids: 71. Liposomal bupivacaine reduces narcotic consumption in adult deformity surgery

BACKGROUND CONTEXT Increasing public awareness of the dangers of narcotics use has prompted recent government legislation aimed at curtailing the crisis. Many of these new regulations are placing greater restrictions on the ability of physicians to prescribe narcotics with some laws penalizing surgeons for excessive utilization. Liposomal bupivacaine offers a potential alternative to heavy narcotics use postoperatively, but has demonstrated limited benefit in the literature to date. PURPOSE To determine if liposomal bupivacaine reduces postop narcotic use and length of stay in spinal deformity patients. STUDY DESIGN/SETTING Prospective, single-surgeon comparative cohort study. PATIENT SAMPLE Adults undergoing arthrodesis of seven or more levels for spinal deformity. OUTCOME MEASURES Visual Analog Scale (VAS), narcotic utilization, length of stay, perioperative complication rates. METHODS A total of 159 consecutive adults undergoing elective spinal fusion (mean age 54.2) for scoliosis or kyphosis by a single surgeon (MSC) received either peri-incisional injections of combined liposomal and standard bupivacaine (n=90, group L) or standard bupivacaine only (n=69, group C). There were no significant baseline demographic differences between the two groups. Postop pain scores (VAS), opioid use, length of stay, functional outcome and perioperative complications were recorded. IV and oral narcotic consumption from all sources were standardized to morphine-equivalent units. This study was performed completely independent of industry. RESULTS Patients receiving liposomal bupivacaine consumed 18.0% less morphine-equivalent units compared with the control group (259 vs. 316 mg) over their hospitalization. The liposomal group also transitioned off IV narcotics significantly faster, with 52.6% less IV use by postop day 3 compared with the control arm (12.0 vs. 25.4 mg, P=.03). However, this reduction in narcotic use did not significantly impact length of stay (L: 4.7 vs. C: 4.8), as our protocol requirement of return of bowel movements before discharge ended up being the limiting factor. There were also no significant differences in postop complication rates overall as well as specifically ileus (L: 7[7.8%] vs. C: 3[4.3%]) and superficial wound infection (L:1[1.1%] vs. C: 0). Functional outcome scores were also no different by 6 weeks postop. CONCLUSIONS Liposomal bupivacaine substantially reduces opioid requirements after adult spinal deformity surgery with no noticeable complications. However, the reduction in opioid use did not translate into quicker return of bowel function. FDA DEVICE/DRUG STATUS Liposomal Bupivacaine (Approved for this indication)

Natural orifice specimen extraction in colorectal surgery: patient selection and perspectives.

Over the past 30 years, colorectal surgery has evolved to include minimally invasive surgical techniques. Minimally invasive surgery is associated with reduced postoperative pain, reduced wound complications, earlier return of bowel function, and possibly shorter length of hospital stay. These benefits have been attributed to a reduction in operative trauma compared to open surgery. The need to extract the specimen in colorectal operations through a “mini-laparotomy” can negate many of the advantages of minimally invasive surgery. Natural orifice specimen extraction (NOSE) is the opening of a hollow viscus that already communicates with the outside world, such as the vagina or distal gastrointestinal tract, in order to remove a specimen. The premise of this technique is to reduce the trauma required to remove the specimen with the expectation that this may improve outcomes. Reduction in postoperative analgesic use, quicker return of bowel function, and shorter length of hospital stay have been observed in colorectal operations with NOSE compared to conventional specimen extraction. While the feasibility of NOSE has been demonstrated in colorectal surgery, failures of this technique have also been described. Selection of patients who can successfully undergo NOSE needs further investigation. This review aims to guide surgeons in appropriately selecting patients for NOSE in colorectal surgery. Patient and specimen characteristics are reviewed in order to define patient populations in which NOSE is likely to be successful. Randomized trials comparing NOSE to conventional specimen extraction in colorectal surgery tend to enroll patients with favorable characteristics (body mass index <30, American Society of Anesthesiologists class ≤3, specimen diameter <6.5 cm) and demonstrate improved outcomes. Adopters of NOSE should restrict using this technique to the populations in which feasibility has been defined in the literature. Wider application to other populations, particularly patients with body mass index >30 and those with significant comorbidities, requires further study.

MP59-01 IS RETRO THE WAY FORWARD? RETROPERITONEAL ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY: SINGLE INSTITUTION EXPERIENCE.

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy IV1 Apr 2017MP59-01 IS RETRO THE WAY FORWARD? RETROPERITONEAL ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY: SINGLE INSTITUTION EXPERIENCE. Muddassar Hussain, Joanne Oakley, Georg Muller, Amr Emara, and Neil Barber Muddassar HussainMuddassar Hussain More articles by this author , Joanne OakleyJoanne Oakley More articles by this author , Georg MullerGeorg Muller More articles by this author , Amr EmaraAmr Emara More articles by this author , and Neil BarberNeil Barber More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1817AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The majority of robotic-assisted renal surgery is performed via the transperitoneal route (T). Retroperitoneal robotic-assisted partial nephrectomy (R-RAPN) allows direct access to hilar structures and the posterolateral surface of the kidney. In the few comparative studies published, it has shown potential advantages. We review our institution's experience with RAPN. METHODS Data from all consecutive patients who underwent RAPN at our single institution between June 2010 and October 2016 were prospectively collected. Demographics, R.E.N.A.L. nephrometry score, and perioperative outcomes were evaluated and comparisons between R-RAPN and T-RAPN were made. RESULTS 258 patients (119 male, 139 female) underwent RAPN (232 R-RAPN vs 26 T-RAPN). The mean age was 59.7 vs 55.9 (SD±11.9 vs 8.9), mean body mass index was 28.9kg/m2 vs 29.0 (SD±5.5 vs 5.3), and median ASA was 2 (range 1-4 vs 1-3). The mean nephrometry score was 6.1 vs 6.5 (SD±1.7 vs 1.5), tumour size 30.6mm vs 26.8 (SD±12.7 vs 9.8), estimated blood loss 78.9mL vs 116.6 (SD±244.7 vs 178.4), and warm ischaemia time 20.4 minutes vs 20.0 (SD±6.9 vs 6.4). The mean operative time was 130 minutes vs 168 (SD±35.6 vs 32.2) [p<0.05] with a median hospital stay of a single overnight stay vs two. 1.7% patients required blood transfusions in the R-RAPN vs 3.8%. 1.3% cases were converted to robotic-assisted radical nephrectomy in the R-RAPN group vs 3.8% in the T-RAPN group and two cases were converted to open partial nephrectomy in the R-RAPN group. The rate of Clavien III or higher was 1.7% vs 3.8%. There were no renal cancer-related mortalities in this series. CONCLUSIONS The current series represents the largest single-institution series on R-RAPN, which accounts for 90% of our robotic partial nephrectomy experience. The retroperitoneal route allows direct access to the renal hilum with no requirement for bowel mobilisation. This approach has been shown to decrease operative times, opiate requirement, and allows for quicker return of bowel function. Furthermore, there does not appear to be any increase in perioperative complications using this approach. R-RAPN is an effective alternative to T-RAPN and can be safely and successfully applied to the majority of patients with tumours amenable to nephron preservation. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e780-e781 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Muddassar Hussain More articles by this author Joanne Oakley More articles by this author Georg Muller More articles by this author Amr Emara More articles by this author Neil Barber More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival?

Laparoscopic resection for colon and rectal cancer is associated with quicker return of bowel function, reduced postoperative morbidity rates and shorter length of hospital stay compared to open surgery, with no differences in long-term survival. Conversion to open surgery is reported in up to 30% of patients enrolled in randomized control trials comparing open and laparoscopic colorectal resection for cancer. In this review, reasons for conversion are anatomical-related factors, disease-related-factors and surgeon-related factors. Body mass index, local tumour extension and co-morbidities are independent predictors of conversion. The current evidence has shown that patients with converted resection for colon cancer have similar outcomes compared to patients undergoing a laparoscopic completed or open resection. The few studies that have assessed the outcomes after conversion of laparoscopic rectal resection reported significantly higher rates of complications and longer length of hospital stay in converted patients compared to laparoscopically treated patients. No definitive conclusions can be drawn when converted and open rectal resections are compared. Early and pre-emptive conversion appears to have more favourable outcomes than reactive conversion; however, further large studies are needed to better define the optimal timing of conversion. With regard to long-term oncologic outcome, overall and disease-free survival in the case of conversion in laparoscopic colorectal cancer surgery seems to be worse than those achieved in patients in whom resection was successfully completed by laparoscopy. Although a worse long-term oncologic outcome has been suggested, it remains difficult to draw a proper conclusion due to the heterogeneity of the long-term outcomes as well as the inclusion of both colon and rectal cancer patients in most of the studies. Therefore, we discuss the currently available evidence of the impact of conversion in laparoscopic resection for colon and rectal cancer on both short-term outcomes and long-term survival.

Severe complications related to central vascular resection: complete mesocolic resection vs traditional resection

RESULTS: Fifty six obese patients (mean age, 59.5 10 years) underwent RS or LS for rectal cancer. There were 29 and 27 patients in the RS and LS group, respectively. Both groups were comparable in terms of demographics, BMI (35 7 vs 35 5 kg/m, p1⁄40.71), co-morbidities, surgical and tumor characteristics. Comparison of the intraoperative findings revealed no significant differences including operative time (329 102 vs 295 81 min, p1⁄40.13), blood loss (434 612 vs 339 272 ml, p1⁄40.68), tumor distance to distal margin (4 2 vs 3 2 cm, p1⁄40.17), radial involvement (7% vs 7%, p1⁄40.99), conversion (3% vs 19%, p1⁄40.09), intraoperative complications (7% vs 0%, p1⁄40.49). Regarding postoperative outcomes, there were no significant differences regarding surgical site infections, sepsis, ileus, pulmonary and urinary complications. Other outcomes were also similar except that RS was associated with quicker return of bowel function (3 vs 4 days, p1⁄40.01) and shorter hospital stay (6 vs 7 days, p1⁄40.02).

The Role of Enhanced Recovery After Surgery for Rectal Cancer

The enhanced recovery after surgery (ERAS) programme is increasingly recognised as the standard of care for patients undergoing colonic cancer surgery, but its applicability to rectal surgery has been questioned. This article analyses the available evidence for the benefit of the individual ERAS elements, with particular reference to rectal surgery. Recent studies have demonstrated the feasibility of ERAS in rectal cancer surgery, and show a reduced length of stay and quicker return of bowel function compared with conventional postoperative care. Ongoing randomised trials will help to clarify the role of ERAS in the era of laparoscopic colonic and rectal cancer surgery.

Robotic retroperitoneal partial nephrectomy

Robotic-assisted renal surgery is being increasingly utilized; however, the majority of these are performed via a transperitoneal approach. Retroperitoneal robotic surgery is a relatively new technique allowing direct access to the posterolateral surface of the kidney, as well as posterior hilar structures. In this review, we summarize the most recent publications and review our experience of robotic retroperitoneal partial nephrectomy. The retroperitoneal approach has been successfully applied to robotic partial nephrectomy. The current series find this approach ideal for posterior and lateral renal masses, and technically feasible with the advances in robotic technology. The retroperitoneal approach has been shown to decrease operative times, narcotic need, and permit quicker return of bowel function. Furthermore, there does not appear to be any increase in perioperative complications using this approach. Since 2006, we have treated 68 patients using this approach. The mean age was 58.9 years, and mean preoperative tumor size 2.5 cm (range 1-5 cm). Mean operative and warm ischemia time were 125 min and 20.7 min, respectively. The majority of patients had renal cell carcinoma, with a 4.4% positive margin rate. The most common complication was an arterial pseudoaneurysm in 3 (4.4%) patients. The limited data using this technique offer an encouraging outlook on robotic retroperitoneal partial nephrectomy. The retroperitoneal approach permits direct access to the renal hilum, no need for bowel mobilization, and excellent visualization for posteriorly located renal masses.

Robotic retroperitoneal surgery

Robotic-assisted renal surgery is being increasingly utilized for various kidney diseases; however, the majority of these are performed via a transperitoneal approach. Retroperitoneal robotic surgery is a relatively new technique, which allows direct access to the posterolateral surface of the kidney, as well as posterior hilar structures. In this review, we summarize the most recent publications and review our experience of retroperitoneal robotic surgery. Retroperitoneal robotic surgery has been successfully applied to radical nephrectomy, partial nephrectomy and pyeloplasty. The current series, although few, find this approach ideal for posterior and lateral renal masses, and technically feasible with the advances in robotic technology. The retroperitoneal approach has been shown to decrease operative times, narcotic need and permit quicker return of bowel function. Furthermore, there does not appear to be any increase in perioperative complications using this approach. The limited data using this technique offer an encouraging outlook on robotic retroperitoneal surgery. The retroperitoneal approach permits direct access to the renal hilum, no need for bowel mobilization and excellent visualization for posteriorly located renal disease.

The role of carbohydrate drinks in preoperative nutrition for elective colorectal surgery

Traditionally, patients have been fasted from midnight on the night before elective surgery. With the advent of the enhanced recovery programme for elective colorectal surgery, there has been a major change in established practice with patients able to continue with clear fluids up to two hours prior to surgery and solids up to six hours prior to surgery. It has been suggested that nutritional supplements in the immediate pre-operative period enhance post-operative recovery. The aim of this review was therefore critically to appraise the evidence available regarding the use of pre-operative carbohydrate (CHO) supplements for elective colorectal surgery. A literature search was performed using: PubMed, MEDLINE(®), Athens and Google Scholar. The following keywords were used: 'pre-operative', 'carbohydrate supplements', 'enhanced recovery' and 'colorectal surgery', singly or in combination. To ensure an up-to-date literature search, the search was restricted to the last ten years. To maximise the search, backward chaining of reference lists from retrieved papers was also undertaken. Only English language articles were included. The use of CHO drinks pre-operatively in colorectal surgery is both safe and effective. There is no increased risk of aspiration and it results in a shorter hospital stay, a quicker return of bowel function and less loss of muscle mass. On the basis of this evidence, the use of pre-operative CHO drinks should be standard in elective colorectal patients. Further research is nevertheless required for those with diabetes mellitus.

Laparoscopic Colectomy for Crohn’s Colitis. A Large Prospective Comparative Study

IntroductionThe purpose of this study was to compare short-term outcomes of laparoscopic (LC) vs open colectomy (OC) in patients with Crohn’s colitis. Materials and MethodsWe collected data on all patients undergoing colectomy for primary or recurrent Crohn’s disease confined to the colon from July 2002 to August 2008. Patient and disease-specific characteristics and perioperative and short-term postoperative outcomes were prospectively collected and analyzed. ResultsA total of 125 patients underwent colectomy during the study period, 55 (44%) LC. There were six conversions (10.9%). Median operative time was shorter in the LC group (212 min, interquartile range (IQR) 180–315 LC vs 286 min, IQR 231–387 OC, p = 0.032). Estimated blood loss was less for the LC group (100 ml, IQR 90–250 LC vs 250 ml, IQR 100–400 OC, p = 0.002). Earlier return of bowel function was noted in the LC group (3 days vs 4 days, OC). Length of post-op stay was shorter in the LC group (6 days, IQR 5–8 vs 8 days, IQR 6–10 OC, p = 0.001). There was one death in the OC group. Postoperative complications occurred in eight (14.5%) LC patients vs 16 (22.9%) OC. Disease recurrence rate was 16%, 10.9% LC and 20% OC, respectively. ConclusionsLaparoscopic colectomy is a safe and effective technique in the hands of experienced surgeons. Benefits of laparoscopic colectomy in Crohn’s disease include reduced operative blood loss, quicker return of bowel function, and shorter hospital length of stay.

Robotic Radical Cystectomy: Where are We Today, Where will We be Tomorrow?

While open radical cystectomy remains the gold-standard treatment for muscle-invasive bladder cancer and high-risk non–muscle invasive disease, robotic assisted radical cystectomy (RARC) has been gaining popularity over the past decade. The robotic approach has the potential advantages of less intraoperative blood loss, shorter hospital stay, less post-operative narcotic requirement, quicker return of bowel function, and earlier convalescence with an acceptable surgical learning curve for surgeons adept at robotic radical prostatectomy. While short to intermediate term oncologic results from several small RARC series are promising, bladder cancer remains a potentially lethal malignancy necessitating long-term follow-up. This article aims to review the currently published literature, important technical aspects of the operation, oncologic and functional outcomes, and the future direction of RARC.

Establishment of a minimally invasive program at a Veterans' Affairs Medical Center leads to improved care in colorectal cancer patients

Background Despite significant advantages to patients, less than 5% of all colorectal surgeries for cancer are performed laparoscopically. A minimally invasive colorectal cancer program was created in our Veterans' Affairs hospital with the intent of increasing access and improving quality of patient care while maintaining patient safety and oncologic standards. Methods Sixty consecutive laparoscopic colorectal cancer resections and 60 age-matched open resections were identified. Our prospective database was queried for demographic, clinical outcomes, and oncologic data. Results Patients undergoing laparoscopic resections experienced a shorter hospital stay and a quicker return of bowel function. Both groups had similar intraoperative blood loss and surgical times. Laparoscopic resections achieved equivalent lymph node retrieval and resection completeness compared with open resections. Laparoscopic resections resulted in fewer wounds and fewer complications requiring reoperation. Conclusions Establishment of a minimally invasive colorectal cancer program in a Veterans Affairs Medical Center leads to increased access to laparoscopic colorectal resections and improved patient care while maintaining patient safety.