Hand-assisted laparoscopic surgery for complex gallstone disease: A report of five cases

AIM:To describe the use of hand-assisted laparoscopic surg-ery(HALS) as an alternative to open conversion for complex gall-stone diseases, including Mirizzi syndrome (MS) and mimic MS. METHODS: Five patients with MS and mimic MS of 232 consecutive patients undergoing laparoscopic cholecyst-ectomies were analyzed. HALS without a hand-port device was performed as an alternative to open conversion if the anatomy was still unclear after the neck of the gallbladder was reached. RESULTS: HALS was performed on three patients with MS type I and 2 with mimic MS owing to an unclear or abnormal anatomy, or an unusual circumstance in which an impacted stone was squeezed out from the infundibulum or the aberrant cystic duct impossible with laparoscopic approach. The median operative time was 165 min (range, 115-190 min). The median hand-assisted time was 75 min (range, 65-100 min). The median postoperative stay was 4 d (range, 3-5 d). The postoperative course was uneventful, except for 1 patient complicated with a minor incision infection. CONCLUSION: HALS for MS type I and mimic MS is safe and feasible. It simplifies laparoscopic procedure, and can be used as an alternative to open conversion for complex gallstone diseases.

Controversy of hand-assisted laparoscopic colorectal surgery

Laparoscopically assisted colorectal procedures are time-consuming and technically demanding and hence have a long steep learning curve. In the technical demand, surgeons need to handle a long mobile organ, the colon, and have to operate on multiple abdominal quadrants, most of the time with the need to secure multiple mesenteric vessels. Therefore, a new surgical innovation called hand-assisted laparoscopic surgery (HALS) was introduced in the mid 1990s as a useful alternative to totally laparoscopic procedures. This hybrid operation allows the surgeon to introduce the non-dominant hand into the abdominal cavity through a special hand port while maintaining the pneumoperitoneum. A hand in the abdomen can restore the tactile sensation which is usually lacking in laparoscopic procedures. It also improves the eye-to-hand coordination, allows the hand to be used for blunt dissection or retraction and also permits rapid control of unexpected bleeding. All of those factors can contribute tremendously to reducing the operative time. Moreover, this procedure is also considered as a hybrid procedure that combines the advantages of both minimally invasive and conventional open surgery. Nevertheless, the exact role of HALS in colorectal surgery has not been well defined during the advanced totally laparoscopic procedures. This article reviews the current status of hand-assisted laparoscopic colorectal surgery as a minimally invasive procedure in the era of laparoscopic surgery.

Performance in the Fundamentals of Laparoscopic Surgery: Does it reflect global rating scales in the Objective Structured Assessment of Technical Skills in porcine laparoscopic surgery?

Objective:To correlate the utility of the Fundamentals of Laparoscopic Surgery(FLS)manual skills program with the Objective Structured Assessment of Technical Skills(OSATS)global rating scale in evaluating operative performance.Methods:The Asian Urological Surgery Training and Educational Group(AUSTEG)Laparoscopic Upper Tract Surgery Course implemented and validated the FLS program for its usage in laparoscopic surgical training.Delegates’basic laparoscopic skills were assessed using three different training models(peg transfer,precision cutting,and intra-corporeal suturing).They also performed live porcine laparoscopic surgery at the same workshop.Live surgery skills were assessed by blinded faculty using the OSATS rating scale.Results:From March 2016 to March 2019,a total of 81 certified urologists participated in the course,with a median of 5 years of post-residency experience.Although differences in task time did not reach statistical significance,those with more surgical experience were visibly faster at completing the peg transfer and intra-corporeal suturing FLS tasks.However,they took longer to complete the precision cutting task than participants with less experience.Overall OSATS scores correlated weakly with all three FLS tasks(peg transfer time:r=0.331,r^(2)=0.110;precision cutting time:r=0.240,r^(2)=0.058;suturing with intracorporeal knot time:r=0.451,r^(2)=0.203).Conclusion:FLS task parameters did not correlate strongly with OSATS globing rating scale performance.Although FLS task models demonstrated strong validity,it is important to assimilate the inconsistencies when benchmarking technical proficiency against real-life operative competence,as evaluated by FLS and OSATS,respectively.

Identification of clinical subphenotypes of sepsis after laparoscopic surgery

Objective:Some patients exhibit septic symptoms following laparoscopic surgery,leading to a poor prognosis.Effective clinical subphenotyping is critical for guiding tailored therapeutic strategies in these cases.By identifying predisposing factors for postoperative sepsis,clinicians can implement targeted interventions,potentially improving outcomes.This study outlines a workflow for the subphenotype methodology in the context of laparoscopic surgery,along with its practical application.Methods:This study utilized data routinely available in clinical case systems,enhancing the applicability of our findings.The data included vital signs,such as respiratory rate,and laboratory measures,such as blood sodium levels.The process of categorizing clinical routine data involved technical complexities.A correlation heatmap was used to visually depict the relationships between variables.Ordering points were used to identify the clustering structure and combined with Consensus K clustering methods to determine the optimal categorization.Results:Our study highlighted the intricacies of identifying clinical subphenotypes following laparoscopic surgery,and could thus serve as a valuable resource for clinicians and researchers seeking to explore disease heterogeneity in clinical settings.By simplifying complex methodologies,we aimed to bridge the gap between technical expertise and clinical application,fostering an environment where professional medical knowledge is effectively utilized in subphenotyping research.Conclusion:This tutorial could primarily serve as a guide for beginners.A variety of clustering approaches were explored,and each step in the process contributed to a comprehensive understanding of clinical subphenotypes.

Application value of machine learning models in predicting intraoperative hypothermia in laparoscopic surgery for polytrauma patients

BACKGROUND Hypothermia during laparoscopic surgery in patients with multiple trauma is a significant concern owing to its potential complications.Machine learning models offer a promising approach to predict the occurrence of intraoperative hypothermia.AIM To investigate the value of machine learning model to predict hypothermia during laparoscopic surgery in patients with multiple trauma.METHODS This retrospective study enrolled 220 patients who were admitted with multiple injuries between June 2018 and December 2023.Of these,154 patients were allocated to a training set and the remaining 66 were allocated to a validation set in a 7:3 ratio.In the training set,53 cases experienced intraoperative hypothermia and 101 did not.Logistic regression analysis was used to construct a predictive model of intraoperative hypothermia in patients with polytrauma undergoing laparoscopic surgery.The area under the curve(AUC),sensitivity,and specificity were calculated.RESULTS Comparison of the hypothermia and non-hypothermia groups found significant differences in sex,age,baseline temperature,intraoperative temperature,duration of anesthesia,duration of surgery,intraoperative fluid infusion,crystalloid infusion,colloid infusion,and pneumoperitoneum volume(P<0.05).Differences between other characteristics were not significant(P>0.05).The results of the logistic regression analysis showed that age,baseline temperature,intraoperative temperature,duration of anesthesia,and duration of surgery were independent influencing factors for intraoperative hypothermia during laparoscopic surgery(P<0.05).Calibration curve analysis showed good consistency between the predicted occurrence of intraoperative hypothermia and the actual occurrence(P>0.05).The predictive model had AUCs of 0.850 and 0.829 for the training and validation sets,respectively.CONCLUSION Machine learning effectively predicted intraoperative hypothermia in polytrauma patients undergoing laparoscopic surgery,which improved surgical safety and patient recovery.

First experience in laparoscopic surgery in low and middle income countries: A systematic review

BACKGROUND Laparoscopic surgery has reduced morbidity and mortality rates,shorter post-operative recovery periods and lower complication rates than open surgery.It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources.However,introducing laparoscopic surgery in low-and-middle-income countries(LMIC)can be expensive and requires resour-ces,equipment,and trainers.AIM To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources.METHODS MEDLINE,EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC.Included studies were published between 1996 and 2022 with full text available in English.Exclusion criteria were studies considering only open surgery,ear,nose,and throat,endoscopy,arthro-scopy,hysteroscopy,cystoscopy,transplant,or bariatric surgery.RESULTS Ten studies out of 3409 screened papers,from eight LMIC were eligible for inclusion in the final analysis,totaling 2497 patients.Most reported challenges were related to costs of equipment and training programmes,equipment pro-blems such as faulty equipment,and access to surgical kits.Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff.The benefits of introducing laparoscopic surgery were economic and clinical,including a reduction in hospital stay,complications,and morbidi-ty/mortality.The introduction of laparoscopic surgery also provided training opportunities for junior doctors.CONCLUSION Despite financial and technical challenges,many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients.While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported,more support is critically required,in particular regarding training.

Single incision laparoscopic surgery for hepatocellular carcinoma

Single incision laparoscopic liver resection(SILLR)is the most recent develop-ment in the laparoscopic approach to the liver.SILLR for hepatocellular carci-noma(HCC)has developed much more slowly than multiport LLR.So far,195 patients completed SILLR for HCC.In this paper,we reviewed all published papers about SILLR for HCC and discussed the feasibility of the SILLR,peri and postoperative findings,tricks of patient selection and whether SILLR compromise the oncological principles.

Laparoscopic vs open surgery for gastric cancer: Assessing time, recovery, complications, and markers

BACKGROUND Gastric cancer(GC)is one of the most common cancers worldwide.Morbidity and mortality have increased in recent years,making it an urgent issue to address.La-paroscopic radical surgery(LRS)is a crucial method for treating patients with GC;However,its influence on tumor markers is still under investigation.The data of 194 patients treated at Chongqing University Cancer Hospital bet-ween January 2018 and January 2019 were retrospectively analyzed.Patients who underwent traditional open surgery and LRS were assigned to the control(n=90)and observation groups(n=104),respectively.Independent sample t-tests andχ2 tests were used to compare the two groups based on clinical efficacy,changes in tumor marker levels after treatment,clinical data,and the incidence of posto-perative complications.To investigate the association between tumor marker levels and clinical efficacy in patients with GC,three-year recurrence rates in the two groups were compared.RESULTS Patients in the observation group had a shorter duration of operation,less in-traoperative blood loss,an earlier postoperative eating time,and a shorter hospital stay than those in the control group(P<0.05).No significant difference was observed between the two groups regarding the number of lymph node dissections(P>0.05).After treatment,the overall response rate in the control group was significantly lower than that in the observation group(P=0.001).Furthermore,after treatment,the levels of carbohydrate antigen 19-9,cancer antigen 72-4,carcinoembryonic antigen,and cancer antigen 125 decreased significantly.The observation group also exhibited a significantly lower incidence rate of postoperative complications compared to the control group(P<0.001).Additionally,the two groups did not significantly differ in terms of three-year survival and recurrence rates(P>0.05).CONCLUSION LRS effectively treats early gastric cancer by reducing intraoperative bleeding,length of hospital stays,and postoperative complications.It also significantly lowers tumor marker levels,thus improving the short-term prognosis of the disease.

Influence of reduced-port laparoscopic surgery on perioperative indicators, postoperative recovery, and serum inflammation in patients with colorectal carcinoma

BACKGROUND Conventional five-port laparoscopic surgery,the current standard treatment for colorectal carcinoma(CRC),has many disadvantages.AIM To assess the influence of reduced-port laparoscopic surgery(RPLS)on perioperative indicators,postoperative recovery,and serum inflammation indexes in patients with CRC.METHODS The study included 115 patients with CRC admitted between December 2019 and May 2023,52 of whom underwent conventional five-port laparoscopic surgery(control group)and 63 of whom underwent RPLS(research group).Comparative analyses were performed on the following dimensions:Perioperative indicators[operation time(OT),incision length,intraoperative blood loss(IBL),and rate of conversion to laparotomy],postoperative recovery(first postoperative exhaust,bowel movement and oral food intake,and bowel sound recovery time),serum inflammation indexes[high-sensitivity C-reactive protein(hs-CRP),tumor necrosis factor-α(TNF-α),and interleukin-6(IL-6)],postoperative complications(anastomotic leakage,incisional infection,bleeding,ileus),and therapeutic efficacy.RESULTS The two groups had comparable OTs and IBL volumes.However,the research group had a smaller incision length;lower rates of conversion to laparotomy and postoperative total complication;and shorter time of first postoperative exhaust,bowel movement,oral food intake,and bowel sound recovery;all of which were significant.Furthermore,hs-CRP,IL-6,and TNF-αlevels in the research group were significantly lower than the baseline and those of the control group,and the total effective rate was higher.CONCLUSION RPLS exhibited significant therapeutic efficacy in CRC,resulting in a shorter incision length and a lower conversion rate to laparotomy,while also promoting postoperative recovery,effectively inhibiting the inflammatory response,and reducing the risk of postoperative complications.

Surgical outcomes of hand-assisted laparoscopic liver resection vs. open liver resection: A retrospective propensity scorematched cohort study

Objective: Hand-assisted laparoscopic liver resection has the advantages of open and laparoscopic surgeries.There is still lack of comparison of surgical outcomes between hand-assistied laparoscopic liver resection(HALLR)and open liver resection(OLR). This study compared the surgical outcomes of the two approaches between wellmatched patient cohorts.Methods: Patients who received liver resection during January 2014 and October 2017 in Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College were included in this retrospective study. Propensity score matching(PSM) was performed to reduce selection bias between the two groups. Operation and short-term surgical outcomes were compared between the well matched groups.Results: During this period, 232 patients with a median age of 55.1 years old received OLR, while 49 patients with a median age of 54.7 years old received HALLR. Compared with HALLR group, OLR group has a higher proportion in male patients(190/232, 81.9% vs. 34/49, 69.4%, P=0.048) and lower albumin(43.2±4.5 vs. 44.8±3.7,P=0.020). After PSM, 49 patients from each group were included in the following analysis. Two groups were well balanced in their baseline characteristics, liver functions, preoperative treatments, abdominal surgery history, and surgical difficulty. None perioperative mortality was observed in both groups. Operation time and postoperative complications were similar in two groups(P=0.935, P=0.056). The HALLR group showed less bleeding amount(177.8±217.1 mL vs. 283.1±225.0 mL, P=0.003) and shorter postoperative stay period(6.9±2.2 d vs. 9.0±3.5 d,P=0.001).Conclusions: We demonstrated that hand-assisted laparoscopic surgery is feasible and safe for liver resection,including some difficult cases. HALLR can provide better bleeding control and faster recovery after surgery.

Hand-assisted laparoscopic restorative proctocolectomy for ulcerative colitis

AIM To evaluate the utility of hand-assisted laparoscopic restorative proctocolectomy(HALS-RP) compared with the conventional open procedure(OPEN-RP).METHODS Fifty-one patients who underwent restorative total proctocolectomy with rectal mucosectomy and ileal pouch anal anastomosis between January 2008 and July 2015 were retrospectively analyzed.Twentythree patients in the HALS-RP group and twentyfour patients in the OPEN-RP group were compared.Four patients who had purely laparoscopic surgery were excluded.Restorative total proctocolectomy was performed with mucosectomy and a hand-sewn ilealpouch-anal anastomosis.Preoperative comorbidities,intraoperative factors such as blood loss and operative time,postoperative complications,and postoperative course were compared between two groups.RESULTS Patients in both groups were matched with regards to patient age,gender,and American Society of Anesthesiologists score.There were no significant differences in extent of colitis,indications for surgery,preoperative comorbidities,and preoperative medications in the two groups.The median operative time for the HALS-RP group was 369(320-420) min,slightly longer than the OPEN-RP group at 355(318-421) min; this was not statistically significant.Blood loss was significantly less in HALS-RP [300(230-402) m L] compared to OPEN-RP [512(401-1162) m L,P = 0.003].Anastomotic leakage was noted in 3 patients in the HALS-RP group and 2 patients in the OPEN-RP group(13% vs 8.3%,NS).The rates of other postoperative complications and the length of hospital stay were not different between the two groups.CONCLUSION HALS-RP can be performed with less blood loss and smaller skin incisions.This procedure is a feasible technique for total proctocolectomy for ulcerative colitis.

Effect of simulating training of the fundamentals of laparoscopic surgery on the attitude of operating room nurses students:an intervention study

Objective:Clinical education plays a key role in preparing students for patient care.Laparoscopy is one of the most important minimally invasive surgeries(MISs)wherein surgical technologists are responsible for camera navigation and assistant surgeons are responsible for peg transfer.Therefore,it is necessary to improve the attitude of the operating room students toward these skills during their study period.The present study was conducted to determine the effect of simulating training in the fundamentals of laparoscopic surgery(FLS)on the attitude of the operating room students.Methods:This interventional study was conducted on 28 operating room students of Iran University of Medical Sciences in 2019.The census sampling method was used.The data-collection tool included the“Intrinsic motivation inventory(IMI)questionnaire.”The educational intervention was carried out in theoretical(booklet design)and practical(simulation)sections.Data analysis was carried out using descriptive and inferential analyses including the paired t-test,Mann–Whitney U test,and independent t-test.The collected data were analyzed using R and SPSS software.P-value<0.05 was considered as the significant level.Results:The mean±SD of the participants'age was 22.93±2.14 years,and the majority of them were women(67.9%).There was a significant difference in the mean scores of students'attitudes toward the FLS before and after the educational intervention(P<0.001)in all dimensions(interest,perceived competence,perceived choice,and tension).There was also a significant correlation between gender and interest dimension(P=0.005).Conclusions:The results of the present study showed that simulating the training FLS curriculum positively affects students'attitudes.Therefore,the researchers suggest that for creating a positive attitude,increasing students'interest in laparoscopic surgery,and ensuring a more effective presence in the operating room,this training should be considered in the operating room curriculum.

Hand-assisted laparoscopic splenectomy is a useful surgical treatment method for patients with excessive splenomegaly: A metaanalysis

BACKGROUND Hand-assisted laparoscopic splenectomy(HALS) can help overcome the drawbacks of laparoscopic splenectomy(LS) while maintaining its advantages.AIM To evaluate the efficacy and advantages of HALS for splenomegaly.METHODS The relevant literature was reviewed using the PubMed, EMBASE, Cochrane,Ovid Medline, and Wanfang databases to compare the clinical outcomes of HALS and LS. Odds ratios or mean differences were calculated with 95% confidence intervals for fixed-effects and random-effects models. Overall, 754 patients from16 trials who met the inclusion criteria were selected.RESULTS In pure splenectomy, blood loss volume(P < 0.001) and conversion rate(P =0.008) were significantly lower in the HALS group than in the LS group.Conversely, for splenomegaly, the operative time(P = 0.04) was shorter and blood loss volume(P < 0.001) and conversion rate(P = 0.001) were significantly lower in the HALS group than in the LS group. However, no significant difference was observed in hospital stay length, blood transfusion, time to food intake, complications, or mortality rate between the two groups. Moreover, in splenectomy and devascularization of the upper stomach(DUS), the operative time(P = 0.04) was significantly shorter and blood loss volume(P < 0.001) andconversion rate(P = 0.05) were significantly lower in the HALS + DUS group than in the LS + DUS group. However, no significant difference was observed in hospital stay length, timing of diet, and complications between the two groups.CONCLUSION HALS is an ideal surgical treatment method for splenomegaly because it can maximize the benefits for patients while maintaining the advantages of LS.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage(AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Laparoscopic and robot-assisted laparoscopic digestivesurgery:Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Single-incision laparoscopic surgery for biliary tract disease

Single-incision laparoscopic surgery(SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy(SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials(RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration(CBDE) methods have been used for more than one hundred years, laparoscopic CBDE(LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and singleincision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.

Total mesorectal excision for mid and low rectal cancer: laparoscopic vs robotic surgery

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer.METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision (TME) with curative intent between January 2008 and December 2014 (robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage&#x02005;I-III disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared.RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME (L-TME) and 342 min for robotic TME (R-TME) (P &#x0003c; 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. The patients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients (8 d for L-TME and 6 d for R-TME, P &#x0003c; 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group (18 for R-TME, 11 for L-TME, P &#x0003c; 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P &#x0003c; 0.001). The three-year overall survival and disease-free survival rates were similar between groups.CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.

Five-year long-term outcomes of laparoscopic surgery for colon cancer

AIM:To perform a meta-analysis to answer whether long-term recurrence rates after laparoscopic-assisted surgery are comparable to those reported after open surgery.METHODS:A comprehensive literature search of the MEDLINE database,EMBASE database,and the Cochrane Central Register of Controlled Trials for the years 1991-2010 was performed.Prospective randomized clinical trials(RCTs)were eligible if they included patients with colon cancer treated by laparoscopic surgery vs open surgery and followed for more than five years.RESULTS:Three studies involving 2147 patients reported long-term outcomes based on five-year data and were included in the analysis.The overall mortality was similar in the two groups(24.9%,268/1075 in the laparoscopic group and 26.4%,283/1072 in open group).No significant differences between laparoscopic and open surgery were found in overall mortality during the follow-up period of these studies[OR(fixed) 0.92,95%confidence intervals(95%CI):0.76-1.12,P=0.41].No significant difference in the development of overall recurrence was found in colon cancer patients,when comparing laparoscopic and open surgery [2147 pts,19.3%vs 20.0%;OR(fixed)0.96,95% CI:0.78-1.19,P=0.71].CONCLUSION:This meta-analysis suggests that laparoscopic surgery was as efficacious and safe as open surgery for colon cancer,based on the five-year data of these included RCTs.

Single-incision laparoscopic colorectal surgery for cancer: State of art

A number of clinical trials have demonstrated that the laparoscopic approach for colorectal cancer resection provides the same oncologic results as open surgery along with all clinical benefits of minimally invasive surgery. During the last years, a great effort has been made to research for minimizing parietal trauma, yet for cosmetic reasons and in order to further reduce surgery-related pain and morbidity. New techniques, such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy (SIL) have been developed in order to reach the goal of &#x0201c;scarless&#x0201d; surgery. Although NOTES may seem not fully suitable or safe for advanced procedures, such as colectomies, SIL is currently regarded as the next major advance in the progress of minimally invasive surgical approaches to colorectal disease that is more feasible in generalized use. The small incision through the umbilicus allows surgeons to use familiar standard laparoscopic instruments and thus, perform even complex procedures which require extraction of large surgical specimens or intestinal anastomosis. The cosmetic result from SIL is also better because the only incision is made through the umbilicus which can hide the wound effectively after operation. However, SIL raises a number of specific new challenges compared with the laparoscopic conventional approach. A reduced capacity for triangulation, the repeated conflicts between the shafts of the instruments and the difficulties to achieve a correct exposure of the operative field are the most claimed issues. The use therefore of this new approach for complex colorectal procedures might understandingly be viewed as difficult to implement, especially for oncologic cases.

Postoperative ileus: Impact of pharmacological treatment,laparoscopic surgery and enhanced recovery pathways

Almost all patients develop postoperative ileus (POI) after abdominal surgery.POI represents the single largest factor influencing length of stay (LOS) after bowel resection,and has great implications for patients and resource utilization in health care.New methods to treat and decrease the length of POI are therefore of great importance.During the past decade,a substantial amount of research has been performed evaluating POI,and great progress has been made in our understanding and treatment of POI.Laparoscopic procedures,enhanced recovery pathways and pharmacologic treatment have been introduced.Each factor has substantially contributed to decreasing the length of POI and thus LOS after bowel resection.This editorial outlines resource utilization of POI,normal physiology of gut motility and pathogenesis of POI.Pharmacological treatment,fast track protocols and laparoscopic surgery can each have significant impact on pathways causing POI.The optimal integration of these treatment options continues to be assessed in prospective studies.