Minimally invasive surgery for rectal cancer: Are we there yet?

Laparoscopic colon surgery for select cancers is slowly evolving as the standard of care but minimally invasive approaches for rectal cancer have been viewed with significant skepticism. This procedure has been performed by select surgeons at specialized centers and concerns over local recurrence, sexual dysfunction and appropriate training measures have further hindered widespread acceptance. Data for laparoscopic rectal resection now supports its continued implementation and widespread usage by expeienced surgeons for select patients. The current controversies regarding technical approaches have created ambiguity amongst opinion leaders and are also addressed in this review.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide.Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy(total mesorectal excision).This has traditionally been performed transabdominally through an open incision.Over the last thirty years,minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach.There are currently three resective modalities that complement the traditional open operation:(1)Laparoscopic surgery;(2)Robotic surgery;and(3)Transanal total mesorectal excision.In addition,there are several platforms to carry out transluminal local excisions(without lymphadenectomy).Evidence on the various modalities is of mixed to moderate quality.It is unreasonable to expect a randomized comparison of all options in a single trial.This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks,recovery and complications,oncological and functional outcomes.

Complete mesocolic excision and central vascular ligation in colorectal cancer in the era of minimally invasive surgery

Since the 19th century,appropriate lymphadenectomy has been considered a cornerstone of oncologic surgery and one of the most important prognostic factors.This approach can be applied to any surgery for gastrointestinal cancer.During surgery for colon and rectal cancer,an adequate portion of the mesentery is removed together with the segment of bowel affected by the disease.The adequate number of lymph nodes to be removed is standardized and reported by several guidelines.It is mandatory to determine the appropriate extent of lymphadenectomy and to balance its oncological benefits with the increased morbidity associated with its execution in cancer patients.Our review focuses on the concept of“complete mesenteric excision(CME)with central vascular ligation(CVL),”a radical lymphadenectomy for colorectal cancer that has gained increasing interest in recent years.The aim of this study was to evaluate the evolution of this approach over the years,its potential oncologic benefits and potential risks,and the improvements offered by laparoscopic techniques.Theoretical advantages of CME are improved local-relapse rates due to complete removal of the intact mesocolic fascia and improved distance recurrence rates due to ligation of vessels at their origin(CVL)which guarantees removal of a larger number of lymph nodes.The development and worldwide diffusion of laparoscopic techniques minimized postoperative trauma in oncologic surgery,providing the same oncologic results as open surgery.This has been widely applied to colorectal cancer surgery;however,CME entails a technical complexity that can limit its wide minimally-invasive application. This review analyzesresults of these procedures in terms of oncological outcomes, technical feasibilityand complexity, especially within the context of minimally invasive surgery.

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 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 < 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 < 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 < 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P < 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.

Lymph node metastasis in early gastric cancer with submucosal invasion:Feasibility of minimally invasive surgery

AIM:To explore the feasibility of pertorming minimally invasive surgery(MIS)on subsets of submucosal gastric cancers that are unlikely to have regional lymph node metastasis. METHODS:A total of 105 patients underwent radical gastrectomy with lymph node dissection for submucosal gastric cancer at our hospital from January 1995 to December 1995.Besides investigating many clinicopathological features such as tumor size,gross appearance,and differentiation, we measured the depth of invasion into submucosa minutely and analyzed the clinicopathologic features of these patients regarding lymph node metastasis. RESULTS:The rate of lymph node metastasis in cases where the depth of invasion was<500 μm,500-2 000 μm,or >2 000 μm was 9%(2/23),19%(7136),and 33%(15/46), respectively(P<0.05).In univariate analysis,no significant correlation was found between lymph node metastasis and clinicopathological characteristics such as age,sex,tumor location,gross appearance,tumor differentiation,Lauren's classification,and lymphatic invasion.In multivariate analysis, tumor size(>4 cm vs≤2 cm,odds ratio=4.80, P=0.04)and depth of invasion(>2 000 μm vs ≤500 μm, odds ratio=6.81,P=0.02)were significantly correlated with lymph node metastasis.Combining the depth and size in cases where the depth of invasion was less than 500 μm, we found that lymph node metastasis occurred where the tumor size was greater than 4 cm.In cases where the tumor size was less than 2 cm,lymph node metastasis was found only where the depth of tumor invasion was more than 2 000 μm. CONCLUSION:MIS can be applied to submucosal gastric cancer that is less than 2 cm in size and 500 μm in depth.

Recent advances in the management of rectal cancer: No surgery, minimal surgery or minimally invasive surgery

Over the last decade,with the acceptance of the need for improvements in the outcome of patients affected with rectal cancer,there has been a significant increase in the literature regarding treatment options available to patients affected by this disease.That treatment related decisions should be made at a high volume multidisciplinary tumor board,after pre-operative rectal magnetic resonance imaging and the importance of total mesorectal excision(TME)are accepted standard of care.More controversial is the emerging role for watchful waiting rather than radical surgery in complete pathologic responders,which may be appropriate in 20%of patients.Patients with early T1 rectal cancers and favorable pathologic features can be cured with local excision only,with transanal minimal invasive surgery(TAMIS)because of its versatility and almost universal availability of the necessary equipment and skillset in the average laparoscopic surgeon,emerging as the leading option.Recent trials have raised concerns about the oncologic outcomes of the standard"top-down"TME hence transanal TME(Ta TME"bottom-up")approach has gained popularity as an alternative.The challenges are many,with a dearth of evidence of the oncologic superiority in the long-term for any given option.However,this review highlights recent advances in the role of chemoradiation only for complete pathologic responders,TAMIS for highly selected early rectal cancer patients and Ta TME as options to improve cure rates whilst maintaining quality of life in these patients,while we await the results of further definitive trials being currently conducted.

Transanal minimally invasive surgery using laparoscopic instruments of the rectum:A review

Transanal minimally invasive surgery(TAMIS)was first described in 2010 as an alternative to transanal endoscopic microsurgery(TEM).The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and earlystage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery.TAMIS has a shorter learning curve,reduced device setup time,flexibility in instrument use,and versatility in application than TEM.Also,TAMIS shows similar results in a view of the operation time,conversion rate,reoperation rate,and complication to TEM.For these reasons,TAMIS is an easily accessible,technically feasible,and cost-effective alternative to TEM.Overall,TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons.As TAMIS becomes more broadly utilized such as pelvic abscess drainage,rectal stenosis,and treatment of anastomotic dehiscence,the acquisition of appropriate training must be ensured,and the continued assessment and assurance of outcome must be maintained.

Laparoscopic right radical hemicolectomy: Central vascular ligation and complete mesocolon excision vs D3 lymphadenectomy - How I do it?

In colon cancer surgery,ensuring the complete removal of the primary tumor and draining lymph nodes is crucial.Lymphatic drainage in the colon follows the vascular supply,typically progressing from pericolic to paraaortic lymph nodes.While NCCN guidelines recommend the removal of 10-12 lymph nodes for ade-quate oncological resection,achieving complete oncological resection involves more than just meeting these numerical targets.Various techniques have been developed and studied over time to attain optimal oncological outcomes.A key technique central to this goal is identifying the ileocolic vessels at their origin from the superior mesenteric vessels.Complete excision of the visceral and parietal mesocolon ensures the intact removal of the specimen,while D3 lymphade-nectomy targets all draining regional lymph nodes.Although these principles emphasize different aspects,they ultimately converge to achieve the same goal of complete oncological resection.This article aims to simplify the surgical steps that align with the principle of central vascular ligation and mesocolon mobilization while ensuring adequate D3 dissection.

Mammotome微创旋切术治疗乳腺不可触及微小病灶的效果

目的:探讨Mammotome(MMT)微创旋切术治疗乳腺不可触及微小病灶的临床效果。方法:选择2021年1月—2023年5月于九江市第三人民医院行手术根治的100例乳腺不可触及微小病灶患者。根据不同手术方式将其分为对照组(n=40)和观察组(n=60);观察组采用超声引导下MMT微创旋切术治疗,对照组采用常规开放式乳腺肿块切除术治疗。比较两组手术相关指标、住院时间、瘢痕大小、术后疼痛情况、并发症发生情况;随访6个月,比较两组末次随访时复发情况及满意度。结果:观察组术中出血量、切口愈合时间、住院时间及瘢痕大小均优于对照组,术后疼痛程度轻于对照组,差异均有统计学意义(P<0.05)。两组并发症发生率比较,差异无统计学意义(P>0.05);随访6个月,两组复发率比较,差异无统计学意义(P>0.05);观察组总满意度为96.67%,高于对照组的72.50%,差异有统计学意义(P<0.05)。结论:MMT微创旋切术治疗乳腺不可触及微小病灶的手术创伤小、操作简单、并发症少、疗效满意,术后乳房外形美学满意度高,在良性乳腺不可触及微小病灶的诊治中具有重要应用价值。

超声引导下Mammotome微创旋切术治疗乳腺良性结节的有效性及安全性

目的:探讨乳腺良性结节患者采用超声引导下麦默通(Mammotome)微创旋切术治疗的有效性及安全性。方法:选取2020年3月—2022年12月瑞昌市人民医院收治的80例乳腺良性结节患者,以随机数字表法分成研究组(n=40)与对照组(n=40)。对照组给予常规开放切除术治疗,研究组给予超声引导下Mammotome微创旋切术治疗。对两组临床指标、瘢痕形态、乳房外观美学及并发症发生情况进行比较。结果:与对照组比较,研究组手术时间更短,术中出血量更少,术后1 d视觉模拟评分法(VAS)评分更低,差异均有统计学意义(P<0.05);研究组术后3个月温哥华瘢痕量表(VSS)评分均较对照组更低,差异均有统计学意义(P<0.05);研究组乳房外观美学优良率(100%)较对照组(85.00%)更高,差异有统计学意义(P<0.05);研究组(5.00%)并发症发生率较对照组(22.50%)更低,差异有统计学意义(P<0.05)。结论:超声引导下Mammotome微创旋切术治疗乳腺良性结节能够降低术后疼痛感,减轻对乳房外观美学的影响,降低并发症发生率。

超声引导下Mammotome系统在乳腺外科中的应用

目的探讨Mammotome微创旋切系统对乳腺病灶的诊断和治疗价值。方法对30例36处直径0.5-2.0cm乳腺病灶进行B超引导下Mammotome微创旋切。结果29处乳腺纤维瘤,4处乳腺腺病,3处浸润性导管癌,术后1例小血肿形成,平均每处旋切15次(2-50次),用时30mi(n20-60min)。结论B超引导下Mammotome微创旋切操作简易安全,创伤小,对直径<2.0cm乳腺病灶可微创切除并获得明确的病理诊断。

Mammotome微创旋切系统在乳腺肿瘤诊治中的应用

目的评估在B超引导下Mammotome微创旋切系统对乳腺病灶诊断与治疗的临床价值。方法在B超引导下对104例乳腺肿物病人行Mammotome微创旋切除术,并评价其手术效果。结果104例138处乳腺病灶均经Mammotome微创旋切术获明确诊断,良性病变也同时获得治疗。除术后有1例病人残腔形成血肿外,无其他并发症。结论B超引导下Mammotome微创旋切术具有微创、安全的优点。Mammotome微创旋切系统较传统手术及空心针活检具有不可比拟的优越性,特别是对于乳腺多发良性病变的年轻女性患者具有广阔的应用前景。

超声引导下Mammotome旋切系统在乳腺纤维腺瘤中的应用

目的探讨超声引导下应用Mammotome旋切系统在乳腺纤维腺瘤中的应用价值。方法2007年1月～2008年10月,对183例266个乳腺良性肿瘤进行超声引导下Mammotome微创旋切术,直径4～25 mm,其中≤10 mm 73个,10～20 mm148个,≥20 mm45个。结果266个乳腺病灶均被Mammotome微创旋切系统完全切除,平均旋切15次(5～44次),手术时间26 min(10～60 min)。2例轻度皮下淤血,余无并发症。瘢痕长2.5～4 mm,隐蔽。183例随访2～22个月,平均12个月,均应用超声检查,BI-RADS评级Ⅰ～Ⅱ级,未提示局部复发。结论应用Mammotome微创旋切系统切除适当大小乳腺纤维腺瘤,可完全切除病灶并获得理想美容学效果,并发症少。多发纤维腺瘤的手术经验尚需进一步探索总结。

微创旋切系统在乳腺肿瘤诊疗中的应用:EnCor与Mammotome的对比研究

目的探讨EnCor在乳腺肿瘤诊治上的临床应用价值。方法 2009年1～6月,应用微创旋切系统EnCor或Mammotome对96例114处乳腺肿瘤<3 cm者行超声引导下肿物切除、活检,其中应用EnCor 62处,Mammotome 52处,比较两组的切除率、术后并发症等。结果病灶完整切除率、活检组织病理满意率、美容满意率、并发症等的比较,两种真空微创旋切系统没有明显差异。EnCor组手术时间明显短于Mammotome组[(10.0±5.8)min vs.(15.0±8.6)min,t=-3.364,P=0.001]。在3个及以上肿瘤的切除中,EnCor组3例均无须更换旋切刀,而Mammotome组2例均需更换旋切刀。结论EnCor在乳腺肿瘤的诊治上也是一个安全可靠的微创旋切活检系统,尤其适用于多发实性占位病灶。

超声引导下Mammotome微创旋切系统在乳腺肿瘤诊治中的应用

目的:探讨B超引导下Mammotome微创旋切系统对乳腺病灶的诊断价值,并探索其用于乳腺纤维腺瘤微创手术的可行性。方法:对289例430处乳腺病灶进行B超引导下Mammotome微创旋切术,通过病理检查与随访评价其对乳腺病灶的诊治效果。结果:Mammotome微创手术操作成功率达100%。皮肤伤口微小,仅3～5mm。无严重并发症。临床及超声诊断为乳腺纤维腺瘤者均在超声实时监控下完全予以切除。92例144处术后6个月～5年获得随访,其中89例141处经临床B超随访复查均未见“复发”迹象,肿瘤被完全切除率为97.9%(141/144)。对可疑病灶及Ⅲ期乳腺癌均取材满意,并能作出明确诊断。结论:B超引导下的Mammotome微创旋切系统对乳腺不同病灶均能作出明确诊断;对小纤维腺瘤成功进行微创切除术,创伤和皮肤伤口小,效果满意,对其他良性小病灶也可避免不必要的手术活检。

B超引导下Mammotome微创旋切技术在乳腺良性肿块外科治疗应用研究

目的:探讨B超引导下Mammotome微创旋切技术在乳腺良性肿块外科治疗当中的应用价值。方法:在B超引导下应用Mammotome微创旋切系统对35例病人38个乳房良性肿块施行微创旋切术,并进行随访3个月。结果:所有肿块均被准确、完全切除。每个肿块的切除时间平均15 min,皮肤切口0.3～0.5 cm,无手术并发症发生。结论:B超引导下Mammotome微创旋切系统切除乳房良性肿块,操作简易、准确、创伤小,外观效果好,是一项值得推广的乳腺微创技术。

Mammotome微创旋切系统在女性乳腺肿瘤中的应用价值

目的探讨Mammotome微创旋切系统在女性乳腺肿瘤疾病中的应用价值。方法分析女性乳腺肿瘤疾病患者173例,在超声引导下对患者行Mammotome微创旋切术切除病灶。结果 173例女性乳腺肿瘤患者共切除291个肿瘤病灶,良性肿瘤病灶259个以乳腺纤维腺瘤(67.35%)为主,恶性乳癌病灶32个以浸润性导管癌(9.97%)为主。Mammotome微创旋切术后患者满意度高,复查肿瘤病灶清除率100%且无复发迹象,术后不良事件以出现血肿为主,发生率为2.92%。结论 Mammotome微创旋切系统对女性乳腺肿瘤清除有很好的临床应用价值,而且术后不良事件发生率小。

Mammotome微创活检术在临床不可触及乳腺微小病灶诊断中的应用

目的探讨Mammotome微创活检术在临床不可触及乳腺微小病灶诊断中的应用价值。方法对42例乳腺影像学检查异常但临床未触及肿块的患者应用Mammotome旋切系统微创活检，检查后21例行开放手术，对照分析术后病理诊断结果。结果42例患者应用Mammotome微创活检系统取样均成功，无严重并发症，微创活检病理诊断为乳腺癌8例，良性病变34例。21例行开放手术的患者中，20例术后病理诊断与Mammotome微创活检病理诊断结果一致，敏感性88．9％，特异性100％。未行开放手术的21例患者随访6～12个月，复查超声及乳腺钼靶x线摄片未见异常。结论Mammotome微创活检具有微创、安全的特点，敏感性和特异性较高，可作为诊断临床不可触及乳腺影像学微小病灶的首选方法。

Mammotome真空辅助旋切系统在乳腺良性肿块微创切除中的应用

目的探讨超声引导下Mammotome真空辅助旋切系统对乳腺良性病灶进行微创切除的治疗价值。方法2005年10月至2006年12月,对82例患者218个超声检查诊断为良性的乳腺病灶在超声引导下进行Mammotome切除术,对其进行回顾性分析,评价其在乳腺微创外科的应用价值。结果全部肿块均顺利切除,术后病理学诊断全部为良性,患者第2天可恢复上肢正常活动。术后3,6个月接受复查,乳腺外形及皮肤感觉正常,超声未发现病灶残留,术后切口瘢痕不明显。结论应用超声引导下Mammotome切除术对乳腺良性病灶可进行完整切除,具有微创、美观、术后对触觉无影响、操作简单、安全等优点,是一种值得推广的微创手术方法。

B超引导下Mammotome微创旋切术和传统开放手术对于乳腺不可触及病灶的疗效对比

目的 全面系统比对B超引导下的Mammotome微创旋切除术和传统开放式手术治疗乳腺不可触及病灶的效果和安全性。方法 选择2009年2月~2014年3月于广州军区总医院乳腺外科接受治疗的300例女性患者共388处不可触及病灶或肿块为研究对象,分为两组,其中,观察组255例患者共333处乳腺不可触及病灶施行B超引导下的Mammotome微创旋切术,同期对照组45例患者共55处乳腺肿块施行传统开放式手术。术后1个月随访,术后3个月行彩超复查。整个过程观察并记录手术结果、病理结果和随访结果。所得数据采用统计学软件SPSS 17.0进行分析处理。结果 观察组患者的切口长度、术中出血量、愈合时间、术后瘢痕大小和乳房变形现象均明显优于对照组,差异有统计学意义（P〈0.05）;观察组和对照组患者的术后满意度分别为94.1%和40.0%,差异有统计学意义（P〈0.05）。结论 B超引导下Mammotome微创旋切术不但诊断灵敏度高、专属性强,且疗效理想、操作简便,具有创伤小、安全性高的显著优势,临床上可作为治疗乳腺不可触及病灶的首选方案。