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Background: Benefits of minimally invasive surgical approaches to diverticular disease are limited by conversion to open surgery. A comprehensive analysis that includes risk factors for conversion may improve patient outcomes.Methods: The US Premier Healthcare Database was used to identify patients undergoing primary elective sigmoidectomy for diverticular disease between 2013 and September 2015. Propensity-score matching was used to compare conversion rates for laparoscopic and robotic-assisted sigmoidectomy. Patient, clinical, hospital, and surgeon characteristics associated with conversion were analyzed using multivariable logistic regression, providing odds ratios for comparative risks. Clinical and economic impacts were assessed comparing surgical outcomes in minimally invasive converted, completed, and open cases.Results: The study population included 13,240 sigmoidectomy patients (8076 laparoscopic, 1301 robotic-assisted, 3863 open). Analysis of propensity-score-matched patients showed higher conversion rates in laparoscopic (13.6%) versus robotic-assisted (8.3%) surgeries (p < 0.001). Greater risk of conversion was associated with patients who were Black compared with Caucasian, were Medicaid-insured versus Commercially insured, had a Charlson Comorbidity Index ≥ 2 versus 0, were obese, had concomitant colon resection, had peritoneal abscess or fistula, or had lysis of adhesions. Significantly lower risk of conversion was associated with robotic-assisted sigmoidectomy (versus laparoscopic, OR 0.58), hand-assisted surgery, higher surgeon volume, and surgeons who were colorectal specialties. Converted cases had longer operating room time, length of stay, and more postoperative complications compared with minimally invasive completed and open cases. Readmission and blood transfusion rates were higher in converted compared with minimally invasive completed cases, and similar to open surgeries. Differences in inflation-adjusted total ($4971), direct ($2760), and overhead ($2212) costs were significantly higher for converted compared with minimally invasive completed cases.Conclusions: Conversion from minimally invasive to open sigmoidectomy for diverticular disease results in additional morbidity and healthcare costs. Consideration of modifiable risk factors for conversion may attenuate adverse associated outcomes. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to evaluate the feasibility and safety of a more versatile rectosigmoid nodulectomy technique using a linear stapler. Methods: Case series. Setting: tertiary care (reference center for endometriosis surgery). Patients: Sixty-one consecutive patients who were operated on between January 2006 and February 2013. Intervention: anterior rectal wall nodulectomy technique using sequential bites of the linear stapler. Measurements: Perioperative complications were recorded, and a condition-specific bowel dysfunction quality of life questionnaire (Rome III-Constipation) was applied pre-operatively and post-operatively during the first week of April 2013. Design classification: Canadian Task Force III Results: A total of 61 patients were submitted to the intervention. After a mean follow-up period of 1.83 years (.25-7.1 ± 1.97), no post-operative fistula or leakage was observed. In addition, no cases of rectal stenosis or bowel obstruction were recorded, and two patients were excluded for not answering the post-operative questionnaire. According to the Rome III questionnaire, constipation symptoms improved significantly in 12 out of 17 questions. No patient reported worsening of symptoms in question. Conclusions: Linear stapler resection is a safe alternative to segmentar resection for endometriotic nodules on the anterior rectal wall. [ABSTRACT FROM AUTHOR]

Background: Elective laparoscopic sigmoid resection for diverticulitis has proven short-term benefits, but little data are available from prospective randomized trials regarding long-term outcome, quality of life, and functional results. Methods: Of 113 patients randomized to undergo laparoscopic (LAP) versus open (OP) sigmoid resection for diverticulitis, 105 (93%, LAP = 54, OP = 51) patients were examined and answered the Gastrointestinal Quality of Life Index (GIQLI) questionnaire, with a median follow-up of 30 (range, 9-63) months after surgery. Results: Incisional hernias were detected in five (9.8%) patients in the OP group versus seven (12.9%) in the LAP group, P = 0.84). Overall satisfaction with the operation on a scale of 0 (very poor) to 10 (excellent) was 9 (range, 2-10) in the OP group versus 9 (range, 2-10) in the LAP group ( P = 0.78). Median GIQLI score was 115 (range, 57-144) in the OP group versus 110 (range, 61-134) in the LAP group ( P = 0.17). Overall satisfaction with the cosmetic aspect of the scar on a scale of 0 (very poor) to 10 (excellent) was 8 (range, 1-10) in the OP group versus 9 (range, 0-10) in the LAP group ( P = 0.01). Finally, median hospital cost (including reoperations for hernias) was 11,606 (5,230-147,982) CHF in the LAP group versus 12,138 (6,098-39,786) CHF in the OP group ( P = 0.47). Conclusions: Both open and laparoscopic approaches for sigmoid resection achieve good long-term results in terms of gastrointestinal function, quality of life, and patients' satisfaction. Significant long-term benefits of laparoscopic surgery are restricted to cosmetic (ClinicalTrials.gov protocol #NCT00453830). [ABSTRACT FROM AUTHOR]

Background: The clinical application of natural orifice transluminal endoscopic surgery (NOTES) for sigmoidectomy is associated with several difficulties that need to be overcome before wider clinical application of the procedure. The purpose of this study was to evaluate the technical feasibility and safety of transgastric sigmoidectomy in a survival animal model, as well as to evaluate the safety and usability of a custom paired magnetic intraluminal device, which we developed for the NOTES procedure. Methods: Survival experiments were conducted on 24-33-kg dogs. After anesthesia, a gastrotomy was created using double-channel endoscope, and peritoneoscopy was performed. The sigmoid colon was retracted laterally using paired magnetic intraluminal device, the mesocolon was dissected, and the branch vessel was sealed. The anvil was placed into the descending colon through anus. A proximal and distal colonic transection was then performed. The circular stapler was passed through the anus and performed end-to-end anastomosis. Afterwards the specimen was removed through gastrotomy, and the gastric incision was closed. Postoperatively, all dogs were recovered and monitored for well-being during convalescence. Reexploration was practiced under anesthesia 2 weeks after surgery for evaluation of intra-abdominal complications, and intra-peritoneal cultures for microorganism. Results: The mean operative time was 141 (range, 122-157) min. There were no complications or physical evidence of sepsis or bowel obstruction during the observation period. Only one dog exhibited decreased body weight, decreasing to 20.4 kg from 22.4 kg after surgery; all of the other dogs exhibited increased body weight. We observed no evidence of peritonitis, intra-abdominal abscess, bleeding, or organ injury on reexploration conducted on day 14 after surgery. Conclusions: Transgastric NOTES sigmoidectomy is a safe operation technique as evaluated in a dog model. The paired magnetic intraluminal device that was used in this study was useful to avoid an abdominal incision for retracting the sigmoid colon. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic sigmoidectomy has become the standard procedure in elective surgery for recurrent diverticular disease. To realize further benefits of this minimal invasive procedure and to offer less postoperative pain, shorter recovery time, reduced complications, and improved cosmetic results, attempts are being made to minimize the number of necessary skin incisions for trocar positioning. One method is to use only one port for laparoscopic access to perform diverticular-related elective sigmoidectomies. Methods: Between 7 July and 4 August 2009, 10 consecutive patients were referred for partial left colon resection due to multiple episodes of diverticulitis. In all cases, access to the abdomen was achieved through a 2- to 2.5-cm single incision via the umbilicus followed by insertion of the single-incision laparoscopic surgery (SILS™) port system. Outcomes such as change in the procedural method, operative time, postoperative complications, and length of stay were recorded. Results: Of the 10 consecutive sigmoidectomies, 9 were performed successfully with the SILS™ procedure using only one incision in the umbilicus. No mortalities or major complications were noted. The median operating time was 120 min, and the median postoperative hospital stay was 7 days. Conclusion: As an alternative to the standard laparoscopic procedure, single-incision laparoscopic sigmoidectomy via the umbilicus is technically feasible and effective. This attractive procedure aims to increase the patient's comfort further after abdominal surgery. [ABSTRACT FROM AUTHOR]

Laparoscopic surgery demands mastery of a steep learning curve. Defining a learning curve in laparoscopic surgery is useful for planning training programs or clinical trials. This study aimed to define the learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer by evaluating early surgical outcome data from three colorectal surgeons. This study analyzed data from 138 consecutive patients undergoing laparoscopic sigmoidectomy for curable sigmoid colon cancer performed by three colorectal surgeons between May 2001 and November 2006. The learning curve for each surgeon were generated using the moving average method to assess changes in operation time and cumulative sum (CUSUM) analysis to assess changes in failure rates [(failure = conversion to open surgery, major perioperative complication, or failure to harvest an adequate number of lymph nodes (<12 nodes)]. Learning curves generated with the moving average method indicated that the operation time reached a steady state after 42 cases for surgeon A, 35 cases for surgeon B, and 30 cases for surgeon C. The overall open conversion rate was 2.9%. There was only one laparoscopy-related perioperative major complication (0.7%). An inadequate number of lymph nodes was harvested in 10 cases (7.2%): 6 (10.5%) for surgeon A, 1 (2.4%) for surgeon B, and 3 (7.7%) for surgeon C. Learning curves generated using CUSUM analysis based on a 90% success rate showed that adequate learning occurred after 10 cases for surgeon A, 17 cases for surgeon B, and 5 cases for surgeon C. Pertinent learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer can be generated using the moving average method and CUSUM analysis. These results are likely to be useful in designing laparoscopic training programs and clinical trials aimed at investigating outcomes of laparoscopic colorectal cancer surgery. [ABSTRACT FROM AUTHOR]

Natural orifice translumenal endoscopic surgery (NOTES) continues to evolve. This study investigated the feasibility and outcome of performing localized sigmoidectomy in its entirety via NOTES. A survival study of five male minipigs (mean weight, 30 kg) was conducted. After anesthesia, a gastrotomy was created by a per os double-channel endoscope, and full peritoneoscopy was performed. A Berci needle then was inserted transparietally to allow maintenance and monitoring of the pneumoperitoneum. Using a transanal probe to facilitate intestinal retraction, the mesentery was dissected with instruments worked through the channels of the transgastric endoscope. The anvil of a circular stapler then was passed per anum into the colon above the point of intended transection. A penetrating transrectal trocar was placed to allow entry of a linear stapler into the peritoneum through a colotomy, and the sigmoid was cross-stapled proximally. The strut of the anvil then was snugged into a colotomy made at this staple line. The specimen was delivered via the anus by a “pull-through” technique. The distal sigmoidal margin was cross-stapled extracorporeally, ensuring that the colotomy was included within the specimen. Retrograde passage of the circular stapler head per anus allowed colocolonic reanastomosis by its mating with the anvil already in situ. The gastrotomy was closed with a previously validated prosthesis. Postoperatively, all the animals were recovered and monitored for well-being during convalescence. Endoscopy (gastroscopy and sigmoidoscopy), laparoscopy, and laparotomy were performed on postoperative day 14 as follow-up measures. Each operation was satisfactorily completed. The mean operative time was 76 min (range, 44–95 min). All the animals prospered postoperatively. Follow-up examination showed full healing of all anastomoses and gastrotomy sites. There was no evidence of luminal stricturing, peritonitis, or intraabdominal sepsis in any animal. Using this experimental model, colonic resection and reanastomosis can be performed safely within the NOTES format. [ABSTRACT FROM AUTHOR]

With available laparoscopic and endoscopic instruments/technology a standard radical sigmoid resection is feasible and safe using transvaginal minilaparoscopic-assisted natural orifice surgery (MA-NOS). The intervention was a transvaginal MA-NOS sigmoidectomy in a 78-year-old woman with a sigmoid adenocarcinoma. Maintaining triangulation the surgeon positioned himself at the right side of the patient and used the transvaginal trocar for dissection and stapling of both the inferior mesenteric vessels and the upper rectum. The colonic resection was performed extracorporeally in the conventional fashion and was followed by an intra-abdominal endoscopically assisted stapled anastomosis. Advantages of minimally invasive surgery seemed to be enhanced with this hybrid laparoscopic approach. Postoperative course was uneventful. All oncological principles governing resection and management were accomplished and the pathology examination confirmed a T3N1 lesion. The patient was discharged on the fourth postoperative day. Transvaginal MA-NOS radical sigmoidectomy is a feasible and oncologically safe procedure. MA-NOS is a realistic option for avoiding the need of assisting incisions and related morbidity in the laparoscopic resection of large intra-abdominal lesions. Combined hybrid laparoscopic NOS in humans (MA-NOS) currently provides a safe and reliable way of defining future clinical applications and advantages of NOS and NOTES. Additionally, it stimulates the active development and evaluation of the underpinning technologies and instrumentation. [ABSTRACT FROM AUTHOR]

Background: We undertook a retrospective multicenter study of elective laparoscopic sigmoidectomy for diverticulitis in order to assess the safety and the results of the procedure performed by a large number of surgeons.Materials and Methods: Between January 1998 and April 1999, the French Society of Laparoscopic Surgery recruited retrospectively 179 patients from 10 surgical units, operated on for elective laparoscopic sigmoidectomy. There were 94 men and 85 women with a mean age of 58 years (range, 30-82). The indications for surgery were acute attacks in 123 cases, complicated diverticulitis in 47 cases, and miscellaneous in 9 cases.Results: The performed procedure was a successful laparoscopic assisted sigmoidectomy in 154 cases (with totally intracorporeal anastomosis in 136 cases and hand-sewn anastomosis via small incision in 18 cases). The mean operation time was 223 min +/- 79 (range, 100-480). There was no mortality and 23 complications occurred in 23 patients (14.9%). Postoperative ileus lasted 2.5 +/- 0.9 days (range, 1-6), and oral intake started after 3.3 +/- 1.3 days (range, 1-12). The mean postoperative stay was 9.3 days (range, 4-50). Conversion to laparotomy was necessary in 25 cases (13.9%). The essential causes of conversion were obesity, severe adhesions, and colonic inflammation. The mean postoperative stay for the 25 converted patients was 13 +/- 8.5 days (range, 7-42).Conclusion: Elective laparoscopic sigmoidectomy for diverticulitis is feasible and is safe. The complication and mortality rates are similar to those observed after open procedures. For experienced surgical teams, laparoscopic colonic resection is a good approach for selected patients suffering from symptomatic diverticulitis. [ABSTRACT FROM AUTHOR]

Background: A newly available, laparoscopic 5-mm bipolar vessel sealing device promises substantial advantages over the 10-mm instrument. This study compared the safety as well as the technical and surgical aspects of these different tools.Methods: For this study, 30 consecutive patients undergoing laparoscopic left-sided colectomy were prospectively randomized for the 5-mm LigaSure or The 10-mm LigaSure. The patients' demographics were analyzed together with their intraoperative and postoperative parameters, and the instruments were assessed by the surgeons with a standardized questionnaire.Results: The two groups were comparable and demonstrated similar mean operation times, blood losses, and hospital stays. The 5-mm LigaSure was applied in more operation steps and resulted in fewer bleeding episodes and less lens cleaning. Monopolar scissors were used less frequently in the 5-mm group, thus minimizing cauteric lesions and their complications (0 in the 5-mm group vs 2 in the 10-mm group). Overall satisfaction with the 5-mm LigaSure was significantly higher (8.4 +/- 0.18 vs 6.9 +/- 0.41 out of 10; p = 0.002), with significant advantages in terms of dissection capacity, visibility, and handling.Conclusion: The 5-mm LigaSure is as secure and fast as the larger 10-mm device and compares favorably in terms of finer dissection as well as trocar flexibility and handling. Therefore, it can be used safely in laparoscopic colorectal surgery. [ABSTRACT FROM AUTHOR]

Background: Transumbilical single-incision laparoscopic surgery is an emerging concept that could offer excellent cosmetic results []. The authors describe an index case of curatively intended resection of early-stage sigmoid colon cancer using this technique [, ]. Methods: A 75-year-old woman with a body mass index of 24 underwent surgery by two colorectal surgeons who had hundreds of experiences with laparoscopic colorectal surgery. Three 5-mm ports were placed linearly in the vertical 2-cm skin incision in the umbilicus. Almost all the procedures were performed with usual laparoscopic instruments such as a 5-mm flexible laparoscope and the Harmonic ACE (Ethicon Endo-Surgery, Cincinnati, OH, USA). Also, the operative procedures were much the same as in usual laparoscopic surgery. The sigmoid colon was mobilized using a medial approach. Then the root of the superior rectal artery and inferior mesenteric vein were divided using the EnSeal tissue sealing and hemostasis system (SurgRx, Inc. Redwood City, CA, USA). Low-profile trocars were mandatory to minimize interferences among instruments. The rectum was divided 5 cm distal to the lesion with one firing of an endoscopic stapler. The specimen was extracted through a 2-cm transumbilical laparotomy. End-to-side anastomosis using a circular stapler was performed intraabdominally, and air tightness was confirmed by the anastomotic leak test. Results: The operative time was 192 min. There was no intra- or postoperative morbidity. Altogether, 20 cm of sigmoid was resected with negative tumor margins, and 14 lymph nodes were harvested. The patient started receiving meals and was discharged on postoperative days 2 and 7, respectively. The final pathology showed Tis, N0, M0, stage 0. The scar was invisible at 1 month. Conclusion: Single-incision laparoscopic colectomy is feasible and safe for selected patients and gives a favorable cosmetic result. By well-trained surgeons, this technique could be a realistic option for colorectal cancer surgery. [ABSTRACT FROM AUTHOR]