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Transversus abdominis plane (TAP) block is considered a reliable locoregional technique for pain control after laparoscopic colorectal surgery. However, no clear benefit of TAP block over wound infiltration has been demonstrated by the current literature. This multicenter randomized clinical trial tested the non-inferiority of wound infiltration (WI) compared to WI plus laparoscopic-assisted TAP block (L-TAP). All patients with colorectal cancer and diverticular disease scheduled for laparoscopic resection at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, Verona, Italy and at the Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University, Daegu, Korea, between April 2018 and March 2019 were considered for the trial. Patients were randomly allocated to either the WI group or the WI plus L-TAP group in a 1:1 allocation ratio. In total, 108 patients entered the study and 102 patients were analyzed; 50 patients received WI plus L-TAP and 52 patients received WI. The primary end point was the efficacy in pain control at 6 h measured according to Numeric Rating Scale (NRS). Secondary aims evaluated pain control at 12, 24, 48 and 72 h and other short-term results related to pain management. Estimation of pain intensity at 6 h was comparable between the two groups (p = 0.16) with a mean (95% CI) difference in pain scores of 0.94 (− 0.13 to 2.02). No differences in pain scores were observed at other interval times or considering analgesic consumption, return of bowel function, postoperative complications and length of hospital stay. This study suggests that adding TAP block to WI does not affect pain control, amount of analgesics and other short-term outcomes. NCT03376048 ( https://www.clinicaltrials.gov ).

Lateral pelvic lymph node dissection (LPND) is a challenging procedure due to its technical difficulty and higher incidence of surgical morbidity. We compared short-term outcomes between laparoscopic and robotic LPND in patients with rectal cancer. Between May 2006 and December 2014, prospectively collected data from consecutive patients undergoing robotic or laparoscopic total mesorectal excision (TME) with LPND were retrospectively compared. Patients’ demographics, perioperative outcomes, functional results, and initial oncologic outcomes were analyzed. Fifty and 35 patients underwent robotic or laparoscopic TME with LPND, respectively. Bilateral LPND was performed in 10 patients (20%) in the robotic group and 6 (17.1%) in the laparoscopic group. For unilateral pelvic dissection, the mean operative time was not significantly different between groups (robotic vs. laparoscopic group, 41.0 ± 15.8 min vs. 35.3 ± 13.4 min; P = 0.146), but the EBL was significantly lower in the robotic group (34.6 ± 21.9 mL vs. 50.6 ± 23.8 mL; P = 0.002). Two patients (4.0%) in the robotic group and 7 (20.0%) in the laparoscopic group underwent Foley catheter reinsertion for urinary retention postoperatively (P = 0.029). The mean number of harvested lateral pelvic lymph nodes (LPNs) was 6.6 (range 0–25) in the robotic group and 6.4 (range 1–14) in the laparoscopic group. Pathologic LPN metastatic rate was not different between groups (robotic vs. laparoscopic group, 28.0 vs. 41.2%; P = 0.243). During the median follow-up of 26.3 months, overall recurrence rate was not different between groups (robotic vs. laparoscopic group, 30.0 vs. 31.2%; P = 0.850). Three patients (6.0%) in the robotic group and 4 (11.4%) in the laparoscopic group developed local recurrence (P = 0.653). Robotic TME with LPND is safe and feasible with favorable short-term surgical outcomes.

Lateral pelvic lymph node dissection (LPND) is a technically demanding procedure. Consequently, there is a possibility of incomplete dissection of lateral pelvic lymph nodes (LPNs). We aimed to identify metastatic LPNs intraoperatively in real-time under dual guidance of fluorescence imaging and 3D lymphovascular reconstruction, and then to remove them completely. Rectal cancer patients who were scheduled to undergo LPND after preoperative chemoradiotherapy (CRT) were prospectively enrolled. We traced changes in suspected metastatic LPNs during preoperative CRT and defined them as index LPNs on post-CRT imaging studies. For fluorescence imaging, indocyanine green (ICG) at a dose of 2.5 mg was injected transanally around the tumor before the operation. For 3D reconstruction images, each patient underwent preoperative axial CT scan with contrast (0.6 mm slice thickness). These images were then manipulated with OsiriX. Index LPNs and essential structures in the pelvic sidewall, such as the obturator nerve, were reconstructed with abdominal arteries from 3D volume rendering. All surgical procedures were performed via laparoscopic or robotic approach. From March to July 2017, ten rectal cancer patients underwent total mesorectal excision with LPND after preoperative CRT under dual image guidance. Bilateral LPND was performed in five patients. All index LPNs among ICG-bearing lymph nodes were clearly identified intraoperatively by matching with their corresponding 3D images. Pathologic LPN metastasis was confirmed in four patients (40.0%) and in five of the 15 dissected pelvic sidewalls (33.0%). All metastatic LPNs were identified among index LPNs. Four (80.0%) of the five metastatic LPNs were located in the internal iliac area. Index LPNs among ICG-bearing lymph nodes in pelvic sidewall were clearly identified and completely removed by matching with their corresponding 3D reconstruction images. Further studies and long-term oncologic outcomes are required to determine the real impact of dual image guidance in LPND.

The aim of this study was to compare the long-term outcomes of robot-assisted right colectomy (RAC) with those for conventional laparoscopy-assisted right surgery (LAC) for treating right-sided colon cancer. The enthusiasm for the robotic techniques has gained increasing interest in colorectal malignancies. However, the role of robotic surgery in the oncologic safety has not yet been defined. From September 2009 to July 2011, 71 patients with right-sided colonic cancer were randomized in the study. Adjuvant therapy and postoperative follow-up were similar in both groups. The primary and secondary endpoints of the study were hospital stay and survival, respectively. Data were analyzed by intention-to-treat principle. The RAC and LAC groups did not differ significantly in terms of baseline clinical characteristics. Compared with the LAC group, RAC was associated with longer operation times (195 min vs. 129 min, P

In recent decades, a combination of cytoreductive surgery and intraperitoneal chemotherapy has yielded improvements in the survival of patients with peritoneal carcinomatosis. Laparoscopic cytoreductive surgery and intraperitoneal chemotherapy comprise a challenging and rarely reported surgical procedure. Between November 2004 and February 2010, 29 patients underwent cytoreductive surgery and early postoperative intraperitoneal chemotherapy for peritoneal carcinomatosis secondary to colorectal cancer. Of the 29 patients, 15 underwent laparoscopic surgery and 14 underwent open surgery. The patient characteristics did not differ significantly between the two groups. Synchronous peritoneal carcinomatosis with a primary tumor was more common in the laparoscopic group, and the Gilly stage of peritoneal carcinomatosis was found more frequently in the open group. Complication rate and hospital stay were less in the laparoscopic group. However, the outcomes for the patients undergoing the combined treatment were similar between the two groups with respect to completeness of cytoreduction, operation morbidity, and overall survival. The laparoscopic group had a cytoreduction completeness of 86.7 % and an operative morbidity of 13.3 %. Operative mortality occurred for one patient after open surgery. Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy can be performed safely for selected patients with peritoneal carcinomatosis from colorectal cancer to a limited extent. Further studies with longer follow-up periods and larger numbers of patients are warranted to confirm the study findings.

To evaluate the technical feasibility, safety, and oncological outcomes of laparoscopic extended lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) in patients with advanced low rectal cancer. A review of a prospectively collected database at Kyungpook National University Hospital from May 2003 to September 2009 revealed a series of 16 consecutive laparoscopic TME with LPLD patients with preoperative diagnosis of lateral node metastasis. Data regarding patient demographics, operating time, perioperative blood loss, surgical morbidity, lateral lymph node status, functional outcome, and mid-term oncologic result were analyzed. In all 16 patients, the procedures were completed without conversion to open surgery. During the study period, robot-assisted laparoscopic LPLD was performed in two patients. Mean operative time was 321.9 min (range 220–510 min). The mean number of lateral lymph nodes harvested was 9.1 (range 3–19), and a total of nine patients (56.2%) had lymph node metastases. Postoperative mortality and morbidity were 0 and 31.2%, respectively. Recovery after the procedure was rapid, and mean hospital stay was 9.9 days (range 7–14 days). With median follow-up of 38 months, among nine patients who were lateral pelvic node positive, one patient experienced pelvic side-wall local recurrence (11.2%). Laparoscopic TME with LPLD is safe and feasible, with the advantage of a minimally invasive approach. Prospective controlled study comparing laparoscopy and conventional open surgery with long-term follow-up evaluation is needed to confirm the authors’ initial experience.

In recent years, robot-assisted surgery using the da Vinci System® has been proposed as an alternative to traditional open or laparoscopic procedures. The aim of this study was to compare the short-term outcomes for open, laparoscopic, and robot-assisted rectal resection for cancer. Two hundred sixty-three patients with rectal cancer who underwent curative resection between 2007 and 2009 were included. Patients were classified into an open surgery group (OS, n = 88), a laparoscopic surgery group (LAP, n = 123), and a robot-assisted group (RAP, n = 52). Data analyzed include operating time, length of recovery, methods of specimen extraction, quality of total mesorectal excision, and morbidity. The mean operating time was 233.8 ± 59.2 min for the OS group, 158.1 ± 49.2 min for the LAP group, and 232.6 ± 52.4 min for the RAP group (p

Although the vagina is considered a viable route during laparoscopic surgery, a number of concerns have led to a need to demonstrate the safety of a transvaginal approach in colorectal surgery. However, the data for transvaginal access in left-sided colorectal cancer are extremely limited, and no study has compared the clinical outcomes with a conventional laparoscopic procedure.We compared the clinical outcomes of totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) with those of the conventional laparoscopic approach with minilaparotomy (LAP) for anastomosis construction and specimen retrieval in left-sided colorectal cancer.Fifty-eight patients underwent TVSE between October 2006 and July 2011 and were matched by age, surgery date, tumor location, and tumor stage with patients who underwent conventional LAP for left-sided colorectal cancer.Operative time was significantly longer in the TVSE group (149.3 ± 39.8 vs. 131.9 ± 41.4 min; p = 0.023). Patients in the TVSE group experienced less pain (pain score 4.9 ± 1.6 vs. 5.8 ± 1.9; p = 0.008), shorter time to passage of flatus (2.2 ± 1.1 vs. 2.7 ± 1.2 days; p = 0.026), and higher satisfaction with the cosmetic results (cosmetic score 8.0 ± 1.4 vs. 6.3 ± 1.5; p = 0.001). More endolinear staplers for rectal transection were used in the LAP group (1.2 ± 0.5 vs. 1.1 ± 0.2; p = 0.021). Overall morbidities were similar in both groups; however, three wound infections only occurred in the LAP group. After a median follow-up of 34.4 (range 11-60) months, no transvaginal access-site recurrence occurred. The 3-year disease-free survival was similar between groups (91.5 vs. 90.8%; p = 0.746).Transvaginal access after totally laparoscopic anterior resection is safe and feasible for left-sided colorectal cancer in selected patients with better short-term outcomes.

Although early rehabilitation programs have been reported to be effective after laparoscopic colectomy, there is no report of the efficacy of rehabilitation programs after rectal cancer surgery. This study was designed to evaluate the efficacy of an early rehabilitation program after laparoscopic low anterior resection for mid or low rectal cancer in a randomized, controlled trial.Ninety-eight patients who had undergone a laparoscopic low anterior resection with defunctioning ileostomy were randomized on a 1:1 basis to an early rehabilitation program (n = 52) or conventional care (n = 46). The primary endpoint was recovery rate at 4 days postoperatively. The secondary endpoints were recovery time, postoperative hospital stay, complications, readmission rates, pain on a visual analogue scale, and quality of life (QOL) according to Short Form 36.The recovery rates were not different in both groups (rehabilitation, 25 % vs. conventional, 13 %, p = 0.135). Recovery time and postoperative hospital stay was similar between the groups (rehabilitation, 137 h [107-188] vs. conventional, 146.5 h [115-183], p = 0.47; 7.5 days [7-11] vs. 8.0 days [7-10], p = 0.882). The complication rates did not differ between the two groups, but more complications were noted in the rehabilitation program group (42.3 vs. 24.0 %, p = 0.054), which was related to postoperative ileus (28.8 vs. 13.0 %, p = 0.057) and acute voiding difficulty (19.6 vs. 4.7 %, p = 0.032). There was no readmission within 1 month of surgery. Pain and QOL were similar in both groups.This randomized trial did not show that an early rehabilitation program is beneficial after laparoscopic low anterior resection. Our results confirm that postoperative ileus and acute voiding difficulty are major obstacles to fast-track surgery for mid or low rectal cancer. This study was registered (registration number NCT00606944).

A robotic system (da Vinci(®) Surgical System, Intuitive Surgical Inc., Sunnyvale, CA, USA) has technical advantages over conventional laparoscopic surgery because it increases the precision and accuracy of anatomical dissection. The present study aimed to compare the short-term outcomes between robot-assisted intersphincteric resection (ISR) and laparoscopic ISR for distal rectal cancer.Patients who underwent robot- or laparoscopy-assisted ISR for rectal cancer between March 2008 and July 2011 were included in this retrospective comparative study. Perioperative and postoperative data, including complications and early functional outcomes, were analyzed between the two groups. Functional outcomes were evaluated using the Wexner scoring system, the International Prostate Symptom Score, and the 5-item version of the International Index of Erectile Function.A total of 40 patients underwent robot-assisted and 40 underwent laparoscopic ISR. The mean operative time was significantly longer in the robotic group than in the laparoscopic group (235.5 vs. 185.4 min; p0.001). Transabdominal ISR, in which intersphincteric dissection is completed in the pelvic cavity, was performed more with robotic assistance than with laparoscopic surgery (8 vs. 2 cases; p = 0.043). No difference was observed between groups regarding postoperative morbidity and pathological outcomes. The robot-assisted group showed a trend toward less postoperative blood loss and early recovery of functional outcomes.Robot-assisted surgery was safe and effective for ISR of distal rectal cancer and showed surgical outcomes similar to those of the latest laparoscopic ISR. The favorable results of the robot-assisted ISR included reduced adaptation time, alleviated difficulty of perineal phase, and early recovery of functional outcomes in this analysis of short-term clinical outcomes.

The preemptive intravenous and intraperitoneal application of local anesthetics is known to improve the postoperative outcome in abdominal surgery. The aim of this study was to compare the analgesic effect of intravenous lidocaine injection to that of intraperitoneal lidocaine instillation in patients who were undergoing laparoscopic appendectomy (LA).Sixty-eight patients who were undergoing LA for unperforated appendicitis were randomly divided into three groups. Group IP (the intraperitoneal instillation group) received intraperitoneal instillation of lidocaine and intravenous normal saline injection. Group IV (the intravenous injection group) received intravenous lidocaine injection and intraperitoneal instillation of normal saline. In group C (the placebo control group), normal saline was given both intravenously and intraperitoneally. The visual analog scale (VAS) of pain scores was measured after surgery. The needs for additional intravenous fentanyl were evaluated and the integrated fentanyl consumption (PCA delivered + additional fentanyl) was assessed. The incidence of shoulder tip pain and postoperative nausea and vomiting (PONV) were noted.Reduction of the VAS score and of fentanyl consumption was noted in the IV and IP groups and compared to that of group C (P0.05). The shoulder tip pain and PONV were reduced in groups IP and IV compared to that in group C (P0.05). However, no significant differences were found between the IP and IV groups for all the studied variables. There was no adverse effect from intravenous lidocaine throughout the study.Intravenous lidocaine injection is as effective as intraperitoneal instillation for reducing pain and fentanyl consumption. The major benefit of intravenous injection is that this is an easily and universally applicable procedure compared to that of intraperitoneal instillation. Lidocaine intravenous administration is a better alternative for reducing the pain of patients who are undergoing laparoscopic surgery.

Laparoscopic salvage surgery for colorectal cancer is a novel but technically challenging option for surgeons. The aim of this study was to evaluate the feasibility and safety of laparoscopic surgery in patients with recurrent or metachronous colorectal cancer in comparison with an open approach.The data used in this study were obtained from databases, the data of which were collected prospectively from January 1996 to February 2010. Data pertaining to patients, operations, and short-term outcomes were analyzed and compared between open and laparoscopic salvage groups.Among the 3,425 patients studied, colorectal cancer recurred in 565 patients (16.5%) and 41 patients had colorectal salvage operations. Twenty-six patients with recurrence underwent open surgery and 15 cases underwent laparoscopic surgery. The short-term outcomes of the laparoscopic group were comparable with those of the open surgery group or were partly favorable. The five-year disease-free interval and overall survival of recurrent cancer patients were not significantly different from those of the open patients. Metachronous colorectal cancer occurred in 13 patients (0.38%), 5 of whom had open surgery and 6 had laparoscopic salvage. The only significant difference between the groups was a shorter operating time for the laparoscopic group. Late in the study, four patients in the laparoscopic recurrent group and one patient in the metachronous group were converted to open surgery.Laparoscopic surgery yielded short-term outcomes that were comparable to those of conventional open surgery, in both recurrent and metachronous colorectal cancer patients. Thus, minimally invasive salvage approaches should be considered as a treatment option for the recurrent and the metachronous colorectal cancer patient.