Specimen Extraction Site Research Articles

Rectal Eversion as an Anus-sparing Technique in Laparoscopic Low Anterior Resection With Double Stapling Anastomosis: Long-term Functional Results.

Rectal eversion (RE) is a natural orifice specimen extraction (NOSE) method that allows anus-sparing resection in very low rectal tumors. This study aims to share the long-term results of RE in laparoscopic rectal resection performed with double stapling anastomosis. A single-center retrospective cohort study was conducted for patients who underwent laparoscopic low anterior resection with RE. Age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, type of surgery, distance of the tumor to the dentate line, specimen extraction site, cancer stage, preoperative chemoradiotherapy, postoperative complications, and postoperative clinical follow-up findings were recorded. Incontinence was assessed using the Wexner score (WS). Low anterior resection syndrome (LARS) is determined by the LARS score. A 7-point Likert scale was used to evaluate the satisfaction of the patients. A total of 17 patients underwent resection by RE for rectal tumors. Of the 11 patients included in the study, 4 were female and 7 were male. The mean age was 66.09±15.04 years. The mean follow-up was 64.18±16.83 months. The mean tumor diameter was 3.1cm (range: 0.9 to 7.2cm). The mean distance of the tumor from the dentate line was 2.7cm (range: 1.2 to 5.6cm). No anastomotic leak was observed in any patient. One patient had an anastomotic stenosis and was treated with balloon dilatation. The median LARS score was 16 (range 0 to 32) and 64% of the patients had no LARS. Two patients had minor LARS and 2 patients had major LARS. The median Wexner score was 3.5 (range 0 to 14). The median Likert scale was 7 (range 5 to 7). It was found that 55% of the patients were extremely satisfied, 18% were satisfied, and 27% were slightly satisfied with their surgery. There were no dissatisfied patients. RE is a safe NOSE technique in laparoscopic double stapling anastomosis for rectal resection. There is a high level of long-term patient satisfaction with anus-sparing procedures via RE, even in the presence of various symptoms.

ASO Visual Abstract: Significance of Specimen Extraction Site in Minimizing Hernia Risk After Distal Pancreatectomy.

ASO Visual Abstract: Significance of Specimen Extraction Site in Minimizing Hernia Risk After Distal Pancreatectomy.

Significance of Specimen Extraction Site in Minimizing Hernia Risk After Distal Pancreatectomy.

Incisional hernia (IH) results in significant morbidity to patients and financial burden to healthcare systems. We aimed to determine the incidence of IH in distal pancreatectomy (DP) patients, stratified by specimen extraction sites. Imaging in DP patients in our institution from 2016 to 2021 were reviewed by radiologists blinded to the operative approach. Specimen extraction sites were stratified as upper midline/umbilical (UM) versus Pfannenstiel. IH was defined as fascial defect on postoperative imaging. Patients without preoperative and postoperative imaging were excluded. Of the 219 patients who met our selection criteria, the median age was 64 years, 54% were female, and 64% were White. The majority were minimally invasive (MIS) procedures (n=131, 60%), of which 52% (n=64) had a UM incision for specimen extraction, including 45 hand-assist and 19 purely laparoscopic procedures. MIS with Pfannenstiel incisions for specimen extraction was 48% (n=58), including 44 robotic and 14 purely laparoscopic procedures. Mean follow-up time was 16.3 months (standard deviation [SD] 20.8). Follow-up for MIS procedures with UM incisions was 16.6 months (SD 21.8) versus 15.5 months (SD 18.6) in the Pfannenstiel group (p=0.30). MIS procedures with UM incisions for specimen extraction had a 17.8 times increase in odds of developing an IH compared with MIS procedures with Pfannenstiel extraction sites (p=0.01). The overall odds of developing an IH increased by 4% for every month of follow-up (odds ratio 1.04; p<0.001). A Pfannenstiel incision should be performed for specimen extraction in cases with purely laparoscopic or robotic distal pancreatectomy, when feasible.

Effect of Specimen Extraction Site on Postoperative Incisional Hernia after Minimally Invasive Right Colectomy.

Incisional hernia (IH) is a known complication after colorectal surgery. Despite advances in minimally invasive surgery, colorectal surgery still requires extraction sites for specimen retrieval, increasing the likelihood of postoperative IH development. The objective of this study is to determine the effect of specimen extraction site on the rate of IH after minimally invasive right-sided colectomy for patients with available imaging. This is a retrospective multi-institutional cohort study at 2 large academic medical centers in the US. Adults who underwent right-sided minimally invasive colectomy from 2012 to 2020 with abdominal imaging available at least 1 year postoperatively were included in the analysis. The primary exposure was specimen extraction via a midline specimen extraction vs Pfannenstiel specimen extraction. The main outcome was the development of IH at least 1 year postoperatively as visualized on a CT scan. Of the 341 patients sampled, 194 (57%) had midline specimen extraction and 147 (43%) had a Pfannenstiel specimen extraction. Midline extraction patients were older (66 ± 15 vs 58 ± 16; p < 0.001) and had a higher rate of previous abdominal operation (99, 51% vs 55, 37%, p = 0.01). The rate of IH was higher in midline extraction at 25% (48) compared with Pfannenstiel extraction (0, 0%; p < 0.001). The average length of stay was higher in the midline extraction group at 5.1 ± 2.5 compared with 3.4 ± 3.1 days in the Pfannenstiel extraction group (p < 0.001). Midline extraction was associated with IH development (odds ratio 24.6; 95% CI 1.89 to 319.44; p = 0.004). Extracorporeal anastomosis was associated with a higher IH rate (odds ratio 25.8; 95% CI 2.10 to 325.71; p = 0.002). Patients who undergo Pfannenstiel specimen extraction have a lower risk of IH development compared with those who undergo midline specimen extraction.

The Incidence of Incisional Hernia after Colorectal Surgery Depends on the Extraction Site: A Cohort Analysis

Abstract Background Although minimally invasive surgery has reduced the incidence of incisional hernia in colorectal surgery, specimen extraction site still constitutes a risk for incisional hernia. Aims We aimed to analyse the incidence of incisional hernia according to the specimen extraction site. Methods We conducted a retrospective observational cohort study of consecutive patients who underwent elective laparoscopic colorectal surgery for colorectal cancer between 01.2013 and 12.2021. The primary outcome was the CT-proven incidence of incisional hernia at the level of the extraction site until the end of follow-up (12.2023). Patients with open surgery, previous hernia repair, reoperations during the study period or without imaging follow-up were excluded. Results One hundred and fifty-eight patients were included. One hundred and four patients (65,8 %) had an extraction site located on the midline, and 54 patients (34,2 %) had an extraction site which was off midline. The midline was preferably used as extraction site during right and transverse colectomy (96,5% and 100% respectively), and off midline was used in left hemicolectomy, sigmoid colectomy and anterior resection (60%, 88%, 93,8% respectively). The overall incidence of incisional hernia at the level of the extraction site was of 29,8 % (31 patients) when midline was chosen as the extraction site, and of 1,9% (1 patient) when the extraction site was off-midline (p-value&amp;lt;0,001). Seven patients (6,7%) required hernia repair in the midline group and no patient (0%) in the off-midline group (p-value=0.051). The mean follow-up was of 3.1+/-2.1 years. Uni-and multivariate logistic regression identified the choice of extraction site as a risk factor for incisional hernia (odds ratio: 22,5, 95%CI: 2,3-27,1, p-value: 0,03). Conclusion Choosing the midline as an extraction site exposes patients to the risk of incisional hernia. Fully minimally invasive colorectal resection using off-midline incision as extraction site should be encouraged.

Incisional hernias following robotic-assisted laparoscopic prostatectomy: does the extraction site matter?

The incidence of incisional hernia (IH) following robotic-assisted laparoscopic prostatectomy (RALP) varies widely within the literature (0.4-9.7%). Whilst small hernias may go unnoticed, the potential exists for bowel strangulation and subsequent emergency surgery. We suggest that the extraction site may influence the rate of IH. A retrospective chart review of a single surgeon RALP series was undertaken. One hundred charts were sampled, of which 69 had sufficient data to be analysed. Prior to July 2017, specimen extraction had been via the supra-umbilical port site. After this time, specimens were extracted via a Pfannenstiel incision. Of the 69 patients, 24 underwent RALP prior to July 2017. Three patients developed IH at the supra-umbilical port extended for extraction site in the pre-2017 group and three patients developed IH at the supra-umbilical port (not extraction) site in the post-2017 group. The rate of IH was almost double in the pre-July 2017 group (12.5% vs. 6.7%). No patient developed an incisional hernia at the Pfannenstiel site in the post-2017 group. In our series, no patient developed a hernia at the Pfannenstiel site. This is in keeping with the reported < 1% IH rate following Pfannenstiel specimen extraction. Given that incisional hernias are a known complication of robotic surgery, thought should be given to changing the site of specimen extraction site to lower the rate of incisional hernias and the morbidity associated with such.

205 Single-Centre Review on Incisional Hernia After Laparoscopic Anterior Resection: What Is the Ideal Incision for Specimen Extraction?

Abstract Aim Midline incision was reported as the common site of incisional hernia (IH) after hand-assisted laparoscopic anterior resection (LAR). There is no consensus on the ideal site for specimen extraction. Our aim was to compare the rate of IH at various specimen extraction sites at our institution. Method We retrospectively reviewed data of 90 cases of LAR from May 2015 to February 2018. Patients were divided into three groups such as Pfannenstiel, iliac fossa (ILF) and midline. Age, sex, BMI, diabetes, steroid use, smoking, wound infection, hernia, post-operative hospital stays (HS) and length of follow up (LOF) were compared among these groups. Results There were 13, 44 &amp; 33 patients in Pfannenstiel, ILF and midline groups. There was no significant difference in age, gender, BMI, smoking, steroid use, and mean LOF among groups. Patients in the ILF group had the highest prevalence of diabetes (27%), mean BMI of 28.91, rate of wound infection (16%), and incidence of incisional hernia (16%). The midline group had the highest mean age of 72.45 years and the longest HS of 11.45 days (p &amp;lt; 0.003). At 49-month follow up, none of the Pfannenstiel group developed wound infection or IH (0%). However, there was no strong association between hernia and type of incision (p 0.248). Conclusions Although Pfannenstiel incision was found to have the lowest rate of IH, the analysis was not significant due to the small sample. We suggest future studies to have larger samples with proper randomization to propose that Pfannenstiel is the ideal incision for specimen extraction.

Comparison of specimen extraction site and another site for protective loop ileostomy in laparoscopic low anterior rectal resection: a retrospective comparative study

BackgroundProtective loop ileostomy is commonly performed in laparoscopic low anterior rectal resection to prevent the serious complications of anastomotic fistula. It is usually created at the right lower quadrant of the abdomen and another wound is required for stoma. The study aimed to evaluate the outcomes of ileostomy at the specimen extraction site (SES) and another site (AS) beside the auxiliary incision.MethodsA retrospective analysis was conducted on 101 eligible patients with pathologically diagnosed adenocarcinoma of the rectum from January 2020 to December 2021 in the study center. According to whether the ileostomy was at the specimen extraction site, patients were divided into SES group (40 patients) and AS group (61 patients). Clinicopathological characteristics, the intraoperative details, and postoperative outcomes of the two groups were measured.ResultsUnivariate analysis showed that the operative time was significantly shorter and the blood loss was significantly less in the SES group than in the AS group during laparoscopic low anterior rectal resection, the time to first flatus was significantly shorter, and the pain was significantly less in the SES group than in the AS group during ileostomy closure. The postoperative complications were similar in both groups. Multivariable analysis showed that ileostomy at the specimen extraction site was a significant factor influencing the operative time and blood loss of rectal resection, and influencing the pain and the time to first flatus during ileostomy closure.ConclusionCompared to ileostomy at AS, protective loop ileostomy at SES was time-saving and less bleeding during laparoscopic low anterior rectal resection, and more quick to first flatus and less pain during stoma closure, and did not lead to more postoperative complications. The median incision of the lower abdomen and the left lower abdominal incision were both good sites for ileostomy.

Extraction Site in Minimally Invasive Colorectal Surgery.

The widespread adoption of minimally invasive colorectal surgery has led to improved patient recovery and outcomes. Specimen extraction sites remain a major source of pain and potential postoperative morbidity. Careful selection of the extraction site incision may allow surgeons to decrease postoperative pain, infectious complications, or rates of hernia formation. Options include midline, paramedian, transverse, Pfannenstiel, and natural orifice sites. Patient, disease, and surgeon-related factors should all be considered when choosing a site. This article will review different options for specimen extraction sites.

TU2.4 Synthesis review with meta-analysis on risk of incisional hernia following transverse versus vertical midline incision for specimen extraction in patients undergoing laparoscopic colorectal resections

Abstract Objective The objective of this article is to explore the risk of incisional hernia (IH) occurrence at the site of specimen extraction following laparoscopic colorectal resection (LCR), highlighting the comparison between transverse incision versus midline vertical abdominal incision. Method Analysis was conducted according to PRISMA guidelines. Systematic search of medical databases like MEBASE, MEDLINE and pubmed was performed to find all types of comparative studies reporting the incidence of IH at the specimen extraction site of transverse or vertical midline incision following LCR. The analysis of the pooled data was done using the RevMan statistical software. Result Twenty-five comparative studies (including 2 RCTs) on 10362 patients fulfilled the inclusion criteria. There were 4944 patIents in the transverse incision group and 5418 patients in the vertical midline incision group. In the random effects model analysis, the use of transverse incision for specimen extraction following LCR reduced the risk of IH development [odds ratio 0.30, 95% CI (0.19–0.49), z= 4.88, p=0.00001]. However, there was significant heterogeneity (Tau2 = 0.97; Chi2= 109.98, df = 24(p=0.00004; I2 = 78%) among included studies. Conclusion Transverse incision used for specimen extraction following LCR seems to reduce the risk of postoperative IH incidence compared to vertical midline abdominal incisions.

Does temporary ileostomy via specimen extraction site affect the short outcomes and complications after laparoscopic low anterior resection in rectal cancer patients? A propensity score matching analysis

PurposeThe purpose of the current study was to compare the outcomes of temporary stoma through the specimen extraction site (SSES) and stoma through a new site (SNS) after laparoscopic low anterior resection.MethodsThe rectal cancer patients who underwent laparoscopic low anterior resection plus temporary ileostomy were recruited in a single clinical database from Jun 2013 to Jun 2020. The SSES group and the SNS group were compared using propensity score matching (PSM) analysis.ResultsA total of 257 rectal cancer patients were included in this study, there were 162 patients in the SSES group and 95 patients in the SNS group. After 1:1 ratio PSM, there was no difference in baseline information (p > 0.05). The SSES group had smaller intraoperative blood loss (p = 0.016 < 0.05), shorter operation time (p < 0.01) and shorter post-operative hospital stay (p = 0.021 < 0.05) than the SNS group before PSM. However, the SSES group shorter operation time (p = 0.006 < 0.05) than the SNS group after PSM, moreover, there was no significant difference in stoma-related complications (p > 0.05). In the multivariate analysis, longer operation time was an independent factor (p = 0.019 < 0.05, OR = 1.006, 95% CI = 1.001–1.011) for the stoma-related complications.ConclusionBased on the current evidence, the SSES group had smaller intraoperative blood loss, shorter operation time and shorter post-operative hospital stay before PSM, and shorter operation time after PSM. Therefore, SSES might be superior than SNS after laparoscopic low anterior resection for rectal cancer patients.

Risk factors of incisional hernia at the umbilical specimen extraction site in patients with laparoscopic colorectal cancer surgery.

Incisional hernia (IH) is a frequent complication following laparoscopic colorectal surgery. The present study investigated the risk factors for IH after laparoscopic surgery for colorectal cancer. A retrospective study was conducted on 202 patients who underwent laparoscopic surgery for colorectal cancer. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with IH. The overall incidence of IH was 25.7% (52 of 202). The univariate analysis showed that female sex (P=0.004), a high body mass index (P<0.001), noncurrent smoking habit (P=0.043), low level of hemoglobin (P=0.035), high subcutaneous fat area (P<0.001), high visceral fat area (P=0.006), low skeletal muscle area (P=0.001), long distance between the inner edges of the rectus abdominis muscle (P=0.001), long protrusion of the peritoneum at the umbilical site (P<0.001), and lymph node metastasis (P=0.007) were significantly more frequent in the group with IH than in the group without it. The multivariate logistic regression analysis revealed an older age (10-year increments: odds ratio [OR], 1.576; 95% confidence interval [CI], 1.027-2.419; P=0.037), lymph node metastasis (OR, 2.384; 95% CI, 1.132-5.018; P=0.022) and lengthy protrusion of the peritoneum at the umbilical site (10-mm increments: OR, 5.555; 95% CI, 3.058-10.091; P<0.001) were independent risk factors for IH. Our findings suggest that older age, lymph node metastasis, and lengthy protrusion of the peritoneum at the umbilical site are risk factors for IH after laparoscopic surgery for colorectal cancer. An assessment using these factors before the operation and the implementation of countermeasures might help prevent IH.

High Rates of Incisional Hernia After Laparoscopic Right Colectomy With Midline Extraction Site.

Laparoscopic surgery aims at reducing wound complications and improving cosmetics, among other advantages. High rates of postoperative ventral hernia (POVH) are observed after laparoscopic-assisted colectomies. In a 2011 to 2016 retrospective study of all patients at Rabin Medical Center, we examined POVH prevalence after right hemicolectomy for neoplasia and correlation to specimen extraction site. We also compared laparoscopic-assisted colectomy to hand-assisted laparoscopic colectomy. Included were patients who had postoperative abdominal computed tomography or magnetic resonance imaging scan as part of their routine oncological follow-up to 6 months postsurgery. Patients were excluded for conversion to laparotomy, and prior abdominal surgeries after right colectomy and before follow-up computed tomography/magnetic resonance imaging scan. Demographic and surgical data were collected from patient electronic records, and scans reviewed for POVH by a designated radiologist. Of 370 patients, 138 (mean age 70.09 y, 58 males) were included: 54 (39.1%) were diagnosed with POVH, 42/72 (58.3%) at midline extraction site, and 12/66 (18.8%) at off-midline extraction sites (P<0.0001). Surgical site infections and patients positive for tumor metastasis were associated with higher POVH rates. Most (74%) POVHs were identified within 18 months postsurgery (P<0.0001). Body mass index, age, sex, diabetes mellitus, smoking, tumor size, lymph nodes positive for metastasis, and hand-assisted laparoscopic colectomy were not associated with POVH prevalence. High rates of radiologically diagnosed POVH were found after laparoscopic-assisted colectomy, with association to midline extraction site, surgical site infections, and positive tumor distant metastasis.

Protocol for the UK cohort study to investigate the prevention of parastomal hernia (the CIPHER study).

Abdominal surgery sometimes necessitates the creation of a stoma, which can cause future complications including parastomal hernia (PSH), an incisional hernia adjacent to and related to the stoma. PSH affects approximately 40% of patients within 2years of stoma formation. Complications of PSH reduce a patient's quality of life and can be severe (e.g. bowel obstruction). PSHs are difficult to manage and can recur after surgical repair. Therefore, it is very important to prevent a PSH. Surgeons create stomas in different ways and both patient and surgical factors are believed to influence the development of PSH. The aim of the CIPHER study is to investigate the influence of different surgical techniques on the development of PSH. The UK cohort study to investigate the prevention of parastomal hernia (the CIPHER study) aims to recruit 4000 patients undergoing elective or expedited surgery with the intention of forming an ileostomy or colostomy, irrespective of the primary indication for the planned surgery. For each patient, surgeons will describe their methods of trephine formation, mesh reinforcement of the stoma trephine, use of the stoma as a specimen extraction site and wound closure. The primary outcome will be incident PSH during follow-up, defined as symptoms of PSH (custom-designed questionnaire) and anatomical PSH, ascertained by independent reading of usual care CT scans. Secondary outcomes will include surgical site infection, the Comprehensive Complication Index, quality of life (EQ-5D-5L and SF-12), PSH repair and use of NHS resources. Results of the study will be submitted for publication in peer-reviewed journals. All publications relating to the results of CIPHER will use a corporate authorship, 'The CIPHER Study Investigators' with named writing committee members. The CIPHER study will be the first to investigate detailed surgical methods of stoma formation in a large, representative cohort of patients with a range of primary indications, both cancer and noncancer.

Bottom-up suprapubic approach for robotic right colectomy: technical aspects and preliminary outcomes.

Complete mesocolic excision (CME) for right colectomy increase the technical complexity of a laparoscopic approach especially when an intracorporeal anastomosis (IA) is associated. The robotic platform, with its intrinsic technical advantages, could potentially overcome the limitations of conventional laparoscopy. This study aimed to describe the robotic bottom-up technique and to evaluate short-terms outcomes of robotic right colectomy (RRC) with CME and IA. Data from patients who underwent RRC for cancer with bottom-up suprapubic approach from October 2016 to April 2020 were prospectively collected and retrospectively analyzed. Intraoperative outcomes and complications, conversion rate, 30-day postoperative outcomes, incisional hernia rate and pathological outcomes were the variables assessed. A total of 109 patients were submitted to bottom-up suprapubic approach for RRC with CME and IA during the study period. Mean operative time was 179 min, no intraoperative complications were observed, and the conversion rate was 3.6%. Mean postoperative stay was 4.6 days and the overall 30-day complication rate was 15.6%. Thirteen patients (12%) had minor complications, while major postoperative complications occurred in 4 patients (3.6%). Anastomotic leak was recorded in 1 patient (0.9%) and the 30-day re-admission rate was 0.9%. Mean number of harvested lymph nodes was 22.6. Incisional hernia rate at the specimen extraction site was 0.9%. Bottom-up approach for RRC with CME and IA carries a low rate of conversions, intraoperative and short-term postoperative complications.

Midline incision vs. transverse incision for specimen extraction is not a significant risk factor for developing incisional hernia after minimally invasive colorectal surgery: multivariable analysis of a large cohort from a single tertiary center in Korea.

Incisional hernia (IH) is a commonly encountered problem even in the era of minimally invasive surgery (MIS). Numerous studies on IH are available in English literature, but there are lack of data from the Eastern part of the world. This study aimed to evaluate the risk factors as well as incidence of IH by analyzing a large cohort collected from a single tertiary center in Korea. Among a total number of 4276 colorectal cancer patients who underwent a surgical resection from 2006 to 2019 in Korea University Anam Hospital, 2704 patients (2200 laparoscopic and 504 robotic) who met the inclusion criteria were analyzed. IH was confirmed by each patient's diagnosis code registered in the hospital databank based on physical examination and/or computed tomography findings. Clinical data including specimen extraction incision (transverse or vertical midline) were compared between IH group and no IH group. Risk factors of developing IH were assessed by utilizing univariable and multivariable analyses. During the median follow-up of 41months, 73 patients (2.7%) developed IH. Midline incision group (n = 1472) had a higher incidence of IH than that of transverse incision group (n = 1232) (3.5% vs. 1.7%, p = 0.003). The univariable analysis revealed that the risk factors of developing IH were old age, female gender, obesity, co-morbid cardiovascular disease, transverse incision for specimen extraction, and perioperative bleeding requiring transfusion. However, on multivariable analysis, specimen extraction site was not significant in developing IH and transfusion requirement was the strongest risk factor. IH development after MIS is uncommon in Korean patients. Multivariable analysis suggests that specimen extraction site can be flexibly chosen between midline and transverse incisions, with little concern about risk of developing IH. Careful efforts are required to minimize operative bleeding because blood transfusion is a strong risk factor for developing IH.

Postoperative Pain After Enhanced Recovery Pathway Robotic Colon and Rectal Surgery: Does Specimen Extraction Site Matter?

BACKGROUND: The current opioid crisis has motivated surgeons to critically evaluate ways to balance postoperative pain while decreasing opioid use and thereby reducing opioids available for community diversion. The longest incision for robotic colorectal surgery is the specimen extraction site incision. Intracorporeal techniques allow specimen extraction to be at any location. OBJECTIVE: This study was designed to determine whether the Pfannenstiel location is associated with less pain and opioid use than other abdominal wall specimen extraction sites. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted with a prospectively maintained colorectal surgery database (July 2018 through October 2019). PATIENTS: Patients with enhanced recovery robotic colorectal resections with specimen extraction were included. MAIN OUTCOME MEASURES: Propensity score weighting was used to derive adjusted rates for numeric pain scores, inpatient opioid use, opioids prescribed at discharge, opioid refills after discharge, and other related outcomes. For comparing outcomes between groups, p values were calculated using weighted χ2, Fisher exact, and t tests. RESULTS: There were 137 cases (70.9%) with Pfannenstiel extraction site incisions and 56 (29.0%) at other locations (7 midline, 49 off-midline). There was no significant difference in transversus abdominis plane blocks and epidural analgesia use between groups. Numeric pain scores, overall benefit of analgesia scores, inpatient postoperative opioid use, opioids prescribed at discharge and taken after discharge, and opioid refills were not significantly different between groups. Nonopioid pain analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentin) prescribed at discharge were significantly less in the Pfannenstiel group (90.19% vs 98.45%; p = 0.006). Postoperative complications and readmissions were not different between groups. LIMITATIONS: This study was conducted at a single institution. CONCLUSIONS: The Pfannenstiel incision as the specimen extraction site choice in minimally invasive surgery is associated with similar postoperative pain and opioid use as extraction sites in other locations for patients having robotic colorectal resections. Specimen extraction sites may be chosen based on patient factors other than pain and opioid use. See Video Abstract at http://links.lww.com/DCR/B495. DOLOR POSTOPERATORIO DESPUÉS DE VÍAS DE RECUPERACIÓN MEJORADA EN CIRUGÍA ROBÓTICA DE COLON Y RECTO: ¿IMPORTA EL LUGAR DE EXTRACCIÓN DE LA MUESTRA ANTECEDENTES: La actual crisis de opioides ha motivado a los cirujanos a evaluar críticamente, formas para equilibrar el dolor postoperatorio, disminuyendo el uso de opioides y por lo tanto, disminuyendo opioides disponibles para el desvío comunitario. La incisión más amplia en cirugía colorrectal robótica, es la incisión del sitio de extracción de la muestra. Las técnicas intracorpóreas permiten que la extracción de la muestra se realice en cualquier sitio. OBJETIVO: El estudio fue diseñado para determinar si la ubicación del Pfannenstiel está asociada con menos dolor y uso de opioides, a otros sitios de extracción de la muestra en la pared abdominal. DISEÑO: Estudio de cohorte retrospectivo. AJUSTES: Estudio de base de datos de cirugía colorrectal mantenida prospectivamente (7/2018 a 10/2019). PACIENTES: Se incluyeron resecciones robóticas colorrectales con recuperación mejorada y extracción de muestras. PRINCIPALES MEDIDAS DE RESULTADO: Se utilizó la ponderación del puntaje de propensión para derivar las tasas ajustadas para los puntajes numéricos de dolor, uso de opioides en pacientes hospitalizados, opioides recetados al alta, recarga de opioides después del alta y otros resultados relacionados. Para comparar los resultados entre los grupos, los valores p se calcularon utilizando chi-cuadrado ponderado, exacto de Fisher y pruebas t. RESULTADOS: Hubo 137 (70,9%) casos con incisiones en el sitio de extracción de Pfannenstiel y 56 (29,0%) en otras localizaciones (7 en la línea media, 49 fuera de la línea media). No hubo diferencias significativas en los bloqueos del plano transverso del abdomen y el uso de analgesia epidural entre los grupos. Las puntuaciones numéricas de dolor, puntuaciones de beneficio general de la analgesia, uso postoperatorio de opioides en pacientes hospitalizados, opioides recetados al alta y tomados después del alta, y las recargas de opioides, no fueron significativamente diferentes entre los grupos. Los analgésicos no opioides (acetaminofén, antiinflamatorios no esteroideos, gabapentina) prescritos al alta, fueron significativamente menores en el grupo de Pfannenstiel (90,19% frente a 98,45%, p = 0,006). Las complicaciones postoperatorias y los reingresos, no fueron diferentes entre los grupos. LIMITACIONES: Una sola institución. CONCLUSIÓN: La incisión de Pfannenstiel como sitio de extracción de la muestra en cirugía mínimamente invasiva, se asocia con dolor postoperatorio y uso de opioides similar, a otros sitios de extracción en pacientes sometidos a resecciones robóticas colorrectales. Sitios de extracción de la muestra, pueden elegirse en función de factores del paciente distintos al dolor y uso de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B495.)

Does the Choice of Extraction Site During Minimally Invasive Colorectal Surgery Change the Incidence of Incisional Hernia? Protocol for a Systematic Review and Network Meta-Analysis.

Background:Various sites are used for specimen extraction in oncological minimally invasive colorectal surgery. The objective is to determine if the choice of extraction site modulates the incidence of incisional hernia (IH).Methods/design:A systematic review will be performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. MEDLINE, Embase and CENTRAL will be searched to look for original studies reporting the incidence of IH after minimally invasive colorectal surgery. Studies will be excluded from the analysis if: 1) they do not report original data, 2) the outcome of interest (incidence of incisional hernia) is not clearly reported and does not allow to extrapolate and/or calculate the required data for network meta-analysis, 3) they include pediatric patients, 4) they include a patients’ population with a conversion rate to laparotomy >10%, 5) they do not compare at least two different extraction sites for the operative specimen, 6) they report patients who underwent pure (and not hybrid) natural orifice transluminal endoscopic surgery (NOTES). Network meta-analysis will be performed to determine the incidence of IH per extraction site.Discussion:By determining which specimen extraction site leads to reduced rate of IH, this systematic review and network meta-analysis will help colorectal surgeons to choose their extraction site and reduce the morbidity and costs associated with IH.Registration:The systematic review and meta-analysis protocol is registered in the International Prospective Register of Ongoing Systematic Reviews (PROSPERO) with number CRD42021272226.HighlightsVarious sites are used for specimen extraction in oncological minimally invasive colorectal surgery, and the choice of the site may probably modulate the incidence of incisional hernia.The present protocol aims to design a systematic review which will identify original studies comparing two extraction sites during minimally invasive colorectal surgery in terms of incidence of incisional hernia.Network meta-analysis will be performed to determine the incidence of IH per extraction site.

Midline incision as specimen extraction site: always to avoid? Single center experience about the use of enlarged umbilical trocar access

By the years several locations for specimen extraction site (SES) during laparoscopic surgery for colorectal disease have been proposed and many studies have focused their attention on outcomes and complications, but the 'best' SES has not yet been found. In this paper we describe our experience using the enlargement of umbilical trocar access as SES during laparoscopic colorectal surgery: at the end of the intracorporal phase we remove Hasson's trocar from the umbilicus, therefore the skin and fascial incision is enlarged up to 5-6 cm. In our work we considered 36 patients extracted from our database from 2017 with at least one year follow up. We don't report any skin closure dehiscence or surgical site infection (SSI) and in only one patient (2.7%) occurred incisional hernia (IH). The results of our study are good and an accurate wound closure at the end of the surgery and an optimal perioperative management are important to reach this goal. The enlargement of umbilical access could enable several post-operative advantages such as a fewer painful areas and a reduced number of incisions with a potential risk of SSI and incisional hernia compared to traditional SES options but further studies investigating that are needed. In the future other incisions will not be necessary except the normal trocar site ones.

Midline incision as specimen extraction site: always to avoid? Single center experience about the use of enlarged umbilical trocar access.

By the years several locations for specimen extraction site (SES) during laparoscopic surgery for colorectal disease have been proposed and many studies have focused their attention on outcomes and complications, but the "best" SES has not yet been found. In this paper we describe our experience using the enlargement of umbilical trocar access as SES during laparoscopic colorectal surgery: at the end of the intracorporal phase we removed Hasson's trocar from the umbilicus, therefore the skin and fascial incision is enlarged up to 5-6 cm. In our work we considered 36 patients extracted from our database from 2017 with at least one year follow-up. We do not report any skin closure dehiscence or surgical site infection (SSI) and in only one patient (2.7%) occurred incisional hernia (IH). The results of our study are good. Important to reach this goal are an accurate wound closure at the end of the surgery, and an optimal perioperative management. The enlargement of umbilical access could enable several postoperative advantages such as a fewer painful area, a reduced number of incisions with a potential risk of SSI, and incisional hernia compared to traditional SES options. However, further studies investigating that are needed. In the future, other incisions will not be necessary except the normal trocar site ones.