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Introduction: We introduced the robotic NICE procedure for left-sided colorectal resection in 2018 in which the entire procedure is performed without loss of pneumoperitoneum and without an abdominal wall incision by performing natural orifice-assisted transrectal extraction of the specimen and intracorporeal anastomosis. We compare the results of the NICE procedure versus conventional laparoscopic resection, which was our standard approach prior to 2018. Methods: A matched pair case–control study compared patients following the NICE procedure versus those who underwent laparoscopic left-sided colorectal resection with conventional extracorporeal-assisted technique. Cases were performed at an Academic Medical Center and recorded in a prospective database to analyze perioperative outcomes. Results: From a total cohort of 352 patients, 83 were matched in each group. When comparing the NICE procedure vs. the Extracorporeal-Assisted laparoscopic group, there were no significant differences in age (58.5 vs. 59.3 years old), sex (47 vs. 42 Female), body mass index (27.4 vs. 27.5 kg/m2), ASA, diagnosis, or type of surgery. Operative time (198.8 vs. 197.7 min), blood loss (56.0 vs. 53.3 ml), intraoperative complications (0.0% vs. 0.0%), and conversion rates (0.0% vs. 0.0%) were similar in both groups. The NICE procedure was associated with significantly earlier return of bowel function (40.7 vs. 23.6 h), shorter length of stay (3.1 vs. 2.2 days), and lower total opioid use (94.6 vs. 70.5 morphine milligram equivalents). Overall, there were no differences in postoperative abscess formation, complications, readmission, or reoperation rates. Conclusion: When compared to conventional laparoscopic resection, the NICE procedure is associated with short-term benefits including earlier recovery and less opioid use without increased operative time or increased risk of complications. Multicenter studies are recommended to validate benefits and limitations of this technique. [ABSTRACT FROM AUTHOR]

Background: Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery.Methods: The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach.Results: A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group.Conclusions: Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider. [ABSTRACT FROM AUTHOR]

Background: Single-incision laparoscopic surgery (SILS) is safe and feasible for benign and malignant colorectal diseases. SILS offers several patient-related benefits over multiport laparoscopy. However, its use in obese patients has been limited from concerns of technical difficulty, oncologic compromise, and higher complication and conversion rates. Our objective was to evaluate the feasibility and efficacy of SILS for colectomy in obese patients.Methods: Review of a prospective database identified patients undergoing elective colectomy using SILS from 2009 to 2014. They were stratified into obese (BMI ≥ 30 kg/m(2)) and non-obese cohorts (BMI < 30 kg/m(2)) and then matched on patient characteristics, diagnosis, and operative procedure. Demographic and perioperative outcome data were evaluated. The primary outcome measures were operative time, length of stay (LOS), and conversion, complication, and readmission rates for each cohort.Results: A total of 160 patients were evaluated-80 in each cohort. Patients were well matched in demographics, diagnosis, and procedure variables. The obese cohort had significantly higher BMI (p < 0.001) and ASA scores (p = 0.035). Operative time (176.9 ± 64.0 vs. 144.4 ± 47.2 min, p < 0.001) and estimated blood loss (89.0 ± 139.5 vs. 51.6 ± 38.0 ml, p < 0.001) were significantly higher in the obese. There were no significant differences in conversion rates (p = 0.682), final incision length (p = 0.088), LOS (p = 0.332), postoperative complications (p = 0.430), or readmissions (p = 1.000) in the obese versus non-obese. Further, in malignant cases, lymph nodes harvested (p = 0.757) and negative distal margins (p = 1.000) were comparable across cohorts.Conclusions: Single-incision laparoscopic colectomy in obese patients had significantly longer operative times, but comparable conversion rates, oncologic outcomes, lengths of stay, complication, and readmission rates as the non-obese cohorts. In the obese, where higher morbidity rates are typically associated with surgical outcomes, SILS may be the ideal platform to optimize outcomes in colorectal surgery. With additional operative time, the obese can realize the same clinical and quality benefits of minimally invasive surgery as the non-obese. [ABSTRACT FROM AUTHOR]

Background: Single-incision laparoscopic surgery (SILS) is safe and feasible for benign and malignant colorectal diseases. SILS has comparable or improved outcomes compared to multiport laparoscopy but technical limitations when operating in the pelvis. To address these limitations, we developed an innovative SILS+1 approach using a single Pfannenstiel incision for pelvis access with one additional umbilical port. Our goal was to compare outcomes for SILS and SILS+1 in lower abdominal and pelvic colorectal surgery.Methods: Review of a prospectively maintained database identified patients who underwent an elective reduced port laparoscopic lower abdominal/pelvic colorectal procedure from 2009 to 2014. Cases were stratified by approach: SILS versus SILS+1 then matched 1:2 on age, gender, body mass index (BMI), comorbidity, and procedure. Demographic, perioperative, and postoperative outcome variables were evaluated. The main outcome measures were operative time, conversion rate, length of stay, complication, morbidity, and mortality rates.Results: One hundred thirty-two reduced port AR/LAR patients were evaluated-44 SILS and 88 SILS+1. The groups were similar in age, gender, BMI, and ASA class. The primary diagnosis in both cohorts was diverticulitis (90.9 % SILS, 87.5 % SILS+1), and main procedure performed an anterior rectosigmoidectomy (86.4 % SILS, 88.2 % SILS+1). Significantly more SILS+1 patients had previous abdominal surgery (p = 0.01). The operative time was significantly shorter in SILS+1 (mean 166.6 [SD 48.4] vs. 178.0 [SD 70.0], p = 0.03). The conversion rate to multiport or open surgery was also significantly lower with SILS+1 compared to SILS (1.1 vs. 11.4 %, p = 0.02). Postoperatively, the length of stay across the groups was similar. SILS trended towards higher complication and readmission rates (NS). There were no unplanned reoperations or mortality in either group.Conclusions: SILS+1 facilitates pelvic and lower abdominal colorectal surgery, with shorter operative times and lower conversion rates. The additional port improved visualization and outcomes without any impact on length of stay, readmission, or complication rates. [ABSTRACT FROM AUTHOR]

Purpose. We present our experience with laparoscopic colorrhaphy as definitive surgical modality for the management of colonoscopic perforations. Methods. Over a 17-month period, we assessed the outcomes of consecutive patients presenting with acute colonoscopic perforations. Patient characteristics and perioperative parameters were tabulated. Postoperative outcomes were evaluated within 30 days following discharge. Results. Five female patients with a mean age of 71.4 ± 9.7 years (range: 58-83), mean BMI of 26.4 ± 3.4 kg/m2 (range: 21.3-30.9), and median ASA score of 2 (range: 2-3) presented with acute colonoscopic perforations. All perforations were successfully managed through laparoscopic colorrhaphy within 24 hours of development. The perforations were secondary to direct trauma (n = 3) or thermal injury (n = 2) and were localized to the sigmoid (n = 4) or cecum (n = 1). None of the patients required surgical resection, diversion, or conversion to an open procedure. No intra- or postoperative complications were encountered. The mean length of hospital stay was 3.8 ± 0.8 days (range: 3-5). There were no readmissions or reoperations. Conclusion. Acute colonoscopic perforations can be safely managed via laparoscopic primary repair without requiring resection or diversion. Early recognition and intervention are essential for successful outcomes. [ABSTRACT FROM AUTHOR]

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Purpose: Single-incision laparoscopic colectomy (SILC) is an emerging procedure in the field of minimally invasive colon and rectal surgery. The purpose of this study was to evaluate the safety and feasibility of this procedure. Methods: Between July 2009 and April 2010, SILC was performed for 35 patients presenting with pathology of the colon. Surgical procedures included right hemicolectomy, sigmoid resection, and total colectomy. Demographic data, intraoperative parameters, and short-term postoperative outcomes were assessed. Results: Thirty two of the 35 patients (91.4%) underwent successful completion of SILC while 3 patients required laparoscopic modifications. The mean incision length was 3.4 cm with a range of 2-6 cm. The mean total operative time (OT) for right, left, and total colectomies was 158.8 ± 31.8 min, 127.0 ± 37.1 min, and 216.3 ± 72.6 min, respectively. Overall, the OT was not significantly different between patients with a body mass index (BMI) ≥25 kg/m (147.9 ± 47.9 min) compared to those with a BMI <25 kg/m (123.1 ± 40.9 min). In the subset of patients with malignant disease, the mean lymph node extraction was 23.5 ± 12.0 and all margins were negative. There were no intraoperative complications, and the overall mean length of hospital stay was 2.9 ± 1.0 days (range 2-6 days). The postoperative morbidity rate was 11.4%. Conclusions: Single-incision laparoscopic colectomy is a safe and feasible procedure for benign and malignant diseases of the colon. This modality can be successfully applied for various colorectal procedures without conversion to open surgery, resulting in a short length of hospital stay and a minimal short-term complication rate. [ABSTRACT FROM AUTHOR]

Background: Robotic-assisted laparoscopic surgery (RALS) is evolving as an important surgical approach in the field of colorectal surgery. We aimed to evaluate the learning curve for RALS procedures involving resections of the rectum and rectosigmoid. Methods: A series of 50 consecutive RALS procedures were performed between August 2008 and September 2009. Data were entered into a retrospective database and later abstracted for analysis. The surgical procedures included abdominoperineal resection (APR), anterior rectosigmoidectomy (AR), low anterior resection (LAR), and rectopexy (RP). Demographic data and intraoperative parameters including docking time (DT), surgeon console time (SCT), and total operative time (OT) were analyzed. The learning curve was evaluated using the cumulative sum (CUSUM) method. Results: The procedures performed for 50 patients (54% male) included 25 AR (50%), 15 LAR (30%), 6 APR (12%), and 4 RP (8%). The mean age of the patients was 54.4 years, the mean BMI was 27.8 kg/m, and the median American Society of Anesthesiologists (ASA) classification was 2. The series had a mean DT of 14 min, a mean SCT of 115.1 min, and a mean OT of 246.1 min. The DT and SCT accounted for 6.3% and 46.8% of the OT, respectively. The SCT learning curve was analyzed. The CUSUM learning curve was best modeled as a parabola, with equation CUSUM in minutes equal to 0.73 × case number − 31.54 × case number − 107.72 ( R = 0.93). The learning curve consisted of three unique phases: phase 1 (the initial 15 cases), phase 2 (the middle 10 cases), and phase 3 (the subsequent cases). Phase 1 represented the initial learning curve, which spanned 15 cases. The phase 2 plateau represented increased competence with the robotic technology. Phase 3 was achieved after 25 cases and represented the mastery phase in which more challenging cases were managed. Conclusions: The three phases identified with CUSUM analysis of surgeon console time represented characteristic stages of the learning curve for robotic colorectal procedures. The data suggest that the learning phase was achieved after 15 to 25 cases. [ABSTRACT FROM AUTHOR]

Background: Robotic-assisted laparoscopic surgery has recently gained enthusiasm for application in colorectal surgery. We present the safety and feasibility of using the da Vinci robotic system for the surgical treatment of sigmoid diverticulitis. Methods: Between August 2008 and November 2009, robotic-assisted laparoscopic anterior rectosigmoid resection (RALS-AR) for diverticulitis was performed in 24 consecutive patients. Demographic data, intraoperative parameters, and postoperative outcomes were assessed. Results: RALS-AR was performed in 14 male (58.3%) and 10 female (41.7%) patients with a diagnosis of recurrent diverticulitis. The mean patient age and BMI were 49.8 ± 9.3 years (range = 30-62 years) and 29.9 ± 6.3 kg/m (range = 15.9-46.9 kg/m), respectively. Disease stratification identified 15 cases of uncomplicated (62.5%) and 9 cases of complicated (37.5%) disease. The procedures required 14.1 ± 6.7 min (range = 6-30 min) for robotic docking, 100.5 ± 31.0 min (range = 50-180 min) for surgeon console time, and 224.2 ± 47.1 min (range = 150-330 min) for the total operative time. Robotic docking and surgeon console time represented 51.9% of the total operative time. A primary colorectal anastomosis was fashioned with avoidance of colostomy in all patients. There were no significant intraoperative complications, and none of the procedures required conversion to open, hand-assisted, or conventional laparoscopic technique. The length of hospital stay was 3.4 ± 2.6 days (range = 2-14 days), and the postoperative complication rate was 12.5% ( n = 3). There were no anastomotic leaks, secondary surgical interventions, or hospital readmissions. Conclusions: Robotic-assisted laparoscopic technique is a safe and feasible option for the surgical treatment of diverticulitis. The approach may be offered to patients with uncomplicated or complicated disease, and it results in a short hospital stay and low complication rate. [ABSTRACT FROM AUTHOR]

Background: Single-incision laparoscopic colorectal surgery is an emerging modality. We incorporated this technique as an alternative to hand-assisted laparoscopic surgery. We investigated intraoperative and short-term outcomes following single-incision laparoscopic colectomy compared with hand-assisted laparoscopic colectomy.Methods: Between July and November 2009, single-incision colorectal procedures were performed and matched to hand-assisted procedures based on five criteria: gender, age, body mass index, pathology, and type of procedure. Demographic, intraoperative, and postoperative data were assessed.Results: Twenty-four pairs of patients with a mean age of 55.1 years and mean body mass index of 28.5 kg/m(2) were matched. The majority of cases (79.2%) were right hemicolectomies. The ranges of incision length were 2-6 cm (single incision) and 5-11 cm (hand-assisted). Mean operating time was significantly longer for single-incision procedures (143.2 min) compared with hand-assisted procedures (112.8 min), p < 0.0004. There was no significant difference in the groups regarding conversions or intraoperative complications (p < 0.083 and p < 1.0, respectively). Mean length of stay for the single-incision approach (2.7 days) was significantly shorter compared with the hand-assisted approach (3.3 days), p < 0.02.Conclusion: Single-incision laparoscopic colectomy is a safe and feasible alternative to hand-assisted laparoscopic surgery. Although the technique required longer operative time, it resulted in smaller incision size and significantly shorter length of hospitalization. [ABSTRACT FROM AUTHOR]

Introduction. Single-incision laparoscopic colectomy (SILC) is a viable and safe technique; however, there are no single-institution studies comparing outcomes of SILC for colon cancer with well-established minimally invasive techniques.We evaluated the shortterm outcomes following SILC for cancer compared to a group of well-established minimally invasive techniques. Methods. Fifty consecutive patients who underwent SILC for colon cancer were compared to a control group composed of 50 cases of minimally invasive colectomies performed with either conventional multiport or hand-assisted laparoscopic technique. The groups were paired based on the type of procedure. Demographics, intraoperative, and postoperative outcomes were assessed. Results. With the exception of BMI, demographics were similar between both groups. Most of the procedures were right colectomies (n = 33) and anterior resections (n = 12). There were no significant differences in operative time (127.9 versus 126.7 min), conversions (0 versus 1), complications (14% versus 8%), length of stay (4.5 versus 4.0 days), readmissions (2% versus 2%), and reoperations (2% versus 2%). Oncological outcomes were also similar between groups. Conclusions. SILC is an oncologically sound alternative for the management of colon cancer and results in similar short-term outcomes as compared with well-established minimally invasive techniques. [ABSTRACT FROM AUTHOR]