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Mesenteric closure following right colectomy remains controversial and, following the advent of laparoscopic surgery, many surgeons do not routinely close the mesentery after colorectal resection. Nevertheless, especially after the introduction of operations such as right colectomy with complete mesocolic excision and ileocolic resections with extensive mesentery removal for Crohn's disease, the wide mesenteric defect resulting from the dissections can certainly expose the patients to complications such as internal hernias or volvuli. In general, mesenteric closure requires intracorporeal suturing. We describe a simple technique for the closure of the mesentery after surgical resection using polymer-ligating clips. This novel technique seems to minimize the time, effort and risk inherent to the procedure, even after large mesenteric excisions.

Background The aim of this study was to compare the short-term outcomes of the duodenum-first multidirectional approach (DMA) in laparoscopic right colectomy with those of the conventional medial approach to assess its safety and feasibility. Methods This retrospective study enrolled 120 patients who had laparoscopic surgery for right-sided colon cancer in our institution between April 2013 and December 2019. Fifty-four patients underwent colectomy using the multidirectional approach; among these, 20 underwent the DMA and 34 underwent the caudal-first multidirectional approach (CMA). Sixty-six patients underwent the conventional medial approach. Complications within 30 days of surgery were compared between the groups. Results There were 54 patients in the multidirectional group [29 females, median age 72 years (range 36–91 years)] and 66 in the medial group [42 females, median age 72 years (range 41–91 years)]. Total operative time was significantly shorter in multidirectional approach patients than conventional medial approach patients (208 min vs. 271 min; p = 0.01) and significantly shorter in patients who underwent the DMA compared to the CMA (201 min vs. 269 min; p p Conclusions The DMA in laparoscopic right colectomy is safe and feasible and can achieve R0 resection with a shorter operative time than the conventional medial approach, even in patients with advanced tumors.

Background The transvaginal natural orifice specimen extraction (NOSE) approach for right-side colon surgery has been proven to exhibit favorable short-term outcomes. However, thus far, no study has reported the advantages of transrectal NOSE for right-side colon surgery. The aim of this study was to compare the technical feasibility, safety, and short-term outcomes of minimally invasive right hemicolectomy using the transrectal NOSE method and those of conventional mini-laparotomy specimen extraction. Methods A study was conducted on consecutive patients who had minimally invasive right hemicolectomy either for malignancy or benign disease at Chang Gung Memorial Hospital, Linkou, Taiwan, between January 2017 and December 2018. The patients were divided into two groups: conventional surgery with specimen extraction using mini-laparotomy and NOSE surgery. Surgical outcomes, including complications, postoperative short-term recovery, and pain intensity, were analyzed. Results We enrolled 297 patients (151 males, mean age 64.9 ± 12.8 years) who had minimally invasive right hemicolectomy. Of these 297 patients, 272 patients had conventional surgery with specimen extraction through mini-laparotomy and 25 patients had NOSE surgery (23 transrectal, 2 transvaginal). The diagnosis of colon disease did not differ significantly between the conventional and NOSE groups. Postoperative morbidity and mortality rates were comparable. The postoperative hospital stay was significantly (p = 0.004) shorter in the NOSE group (median 5 days, range 3–17 days) than in the conventional group (median 7 days, range 3–45 days). Postoperative pain was significantly (p = 0.026 on postoperative day 1 and p = 0.002 on postoperative day 2) greater in the conventional group than in the NOSE group. Conclusions NOSE was associated with acceptable short-term surgical outcomes that were comparable to those of conventional surgery. NOSE results in less postoperative wound pain and a shorter hospital stay than conventional surgery. Larger studies are needed

The da Vinci Single-Port (SP) robot is a novel platform designed to facilitate single-incision robotic surgery (rSILS). The objective of this study was to describe our initial experience using this platform for SP robotic (SPr) right colectomy. Under a Food and Drug Administration-regulated feasibility study and Institutional Review Board approval, a patient with cecal adenocarcinoma underwent an SPr right colectomy. The primary endpoint was the safety and feasibility of the first SPr right colectomy performed in the USA. Secondary endpoints included perioperative metrics, morbidity and mortality. An SPr Standard right colectomy was performed through a 4-cm single incision without the need for conversion or additional port placement. Estimated blood loss was 100 mL and there were no intraoperative complications. The robot was docked once with a docking time of 19 min. Total console time was 116 min and operative time was 219 min. The patient tolerated clear liquids on postoperative day (POD) 0 and a low-residue diet on POD 1. The patient had flatus and a bowel movement on POD 1. She was discharged home on POD 3. Final pathology showed pT3N0 cecal adenocarcinoma with negative margins and 0/24 lymph nodes positive for disease. Our initial experience demonstrates that an SPr right colectomy is feasible and can be safely completed. We completed an oncologic resection of a cecal adenocarcinoma without complications. The SP robot facilitates the utilization of robotic technology in a single-incision platform to perform colorectal procedures and offers promising benefits in the advancement of robotic surgery.

Background: Minimally invasive colectomy has become the standard for treatment of colonic disease in many centers. Restoration of bowel continuity following resection can be achieved by intracorporeal (IC) or extracorporeal (EC) anastomosis. The aim of this systematic review was to assess the outcomes of IC compared to EC anastomosis in minimally invasive right colectomy. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic literature search for studies assessing the outcome of IC and EC anastomosis in laparoscopic and robot-assisted right colectomy was conducted. The primary outcome of this review was postoperative complications. Secondary outcomes included operative time, blood loss, length of stay, conversion to open surgery, and bowel recovery. Results: Twenty-five studies including 4450 patients were evaluated. 47.7% of patients had IC anastomosis and 52.3% had EC anastomosis. The weighted mean length of extraction site incision in the IC group was shorter than the EC group. The EC group had significantly higher odds of conversion to open surgery (OR 1.87, 95% CI 1–3.45, p = 0.046), total complications (OR 1.54, 95% CI 1.05–2.11, p = 0.007), anastomotic leakage (AL) (OR 1.95, 95% CI 1.4–2.7, p = 0.003), surgical site infection (SSI) (OR 1.69, 95% CI 1.4–2.6, p = 0.002), and incisional hernia (OR 3.14, 95% CI 1.85–5.33, p < 0.001) compared to the IC group. Both groups had similar rates of ileus, small bowel obstruction, bleeding, and intra-abdominal infection. Conclusion: IC anastomosis was associated with significantly shorter extraction site incisions, earlier bowel recovery, fewer complications, and lower rates of conversion, AL, SSI, and incisional hernia than has the EC anastomosis.

Laparoscopic right hemicolectomy (LRHC) is increasingly performed for the treatment of right colon disease. Nevertheless, standardization of the surgical technique regarding the performance of intracorporeal (IC) or extracorporeal (EC) anastomosis is lacking. The purpose of this study was to compare short-term postoperative outcomes in patients who had laparoscopic right colectomy either with IC or EC. This was a retrospective, non-randomized and multicenter study conducted from January 2005 to December 2015 on the CLIMHET study group cohort from five tertiary centers in France. Data were collected for all patients with LRHC to compare patient characteristics, intraoperative data and postoperative outcomes in terms of medical and surgical complications, duration of hospitalization and mortality. A multivariate analysis was performed to compare the results in the two groups. Of the 597 patients undergoing LRHC, 150 had IC and 447 had EC. The incidence of medical complications (cardiac, vascular, and pulmonary complications) was lower in the IC group than in the EC group (13 vs 20%, p = 0.049). This difference remained significant in multivariate analysis after adjusting to field characteristics and patient histories (p = 0.009). Additionally, a shorter hospital stay (7 vs 8 days, p = 0.003) was observed in the IC group as compared to the EC group. This difference remained significant in favor of the IC group in multivariate analysis (p = 0.029). There was no difference between the groups as regards: surgical complications (p = 0.76), time of mobilization (p = 0.93), reintervention rate (p = 1) and 90-day mortality (p = 0.47). Our results show that IC anastomosis in LRHC is associated with fewer medical complications and shorter hospital stays compared to EC anastomosis.

BACKGROUND: The aim of our study was to evaluate the short-term outcomes of totally laparoscopic right colectomy, in particular to compare the incidence of leakage of the ileocolic anastomosis after either single-layer (SL) or double-layer (DL) enterotomy closure. METHODS: From March 2010 to July 2014, 162 patients underwent laparoscopic right colectomy with intracorporeal ileocolic anastomosis. The enterotomy was closed with either SL (77 patients) or DL technique (85 patients). Short-term outcomes in both groups were retrospectively analyzed. RESULTS: Median time to perform the ileocolic anastomosis was similar in the two groups (17 min in SL versus 20 min in DL, p = 0.109). DL closure was associated with a significantly lower incidence of anastomotic leakage (1.2 % in DL vs 7.8 % in SL, p = 0.044). Shorter hospital stay was also observed in the DL group. CONCLUSIONS: Adoption of DL closure of the enterotomy resulted in significantly improved outcome. We strongly recommend a double-layer closure technique when performing an intracorporeal enterocolic anastomosis.

Cecal volvulus is a rare clinical entity with an average incidence of 2.8–7.1 per million people per year, accounting for 1–2% of all large bowel obstructions. Cecal bascule is the rarest type of cecal volvulus, accounting for 5–20% of all cases. Although several case reports have been published, there is no consensus regarding its diagnosis and treatment. The aim of this study was to review the literature on cecal bascule in order to summarize the etiopathogenesis, clinical features, diagnosis, and treatment options. The PubMed, MEDLINE, and Scopus databases were systematically searched by two independent authors. Cecal bascule was defined as anterior displacement of the distended cecum on the ascending colon without any torsion. The etiopathogenesis, clinical features, diagnosis, and treatment options were analyzed. Nineteen previously published papers reporting on 26 patients were included. The mean age of patients from previously reported cases was 55.1 ± 19.2 years, and 54% of all patients were males. Presenting symptoms included abdominal pain in 16 (61%), distension in 22 (84%), and vomiting in eight patients (30%). The mean time to diagnosis was 3.6 ± 2.6 days. The extent of surgery varied from cecopexy to right colectomy. There was no postoperative mortality. Cecal bascule recurred one 1 year after index surgery in one patient. Cecal bascule is a rare clinical entity, which is mostly encountered in patients with peritoneal adhesions, mobile cecum, bowel dysfunction, and cecal displacement. In patients with recurrent or persistent abdominal pain and distension, cecal bascule should be considered. The majority of these patients require surgical management.

This study is a narrative review of the current literature regarding intracorporeal ileocolic anastomosis in laparoscopic right colon resection for benign or malignant diseases of the right colon and terminal ileum. The search strategy included Medline, Embase, CINAHL, ACP Journal Club, and Cochrane databases with laparoscopic right colectomy and intracorporeal anastomosis as keywords. All retrieved references were screened by two independent blinded reviewers. Thirteen papers including 611 patients undergoing laparoscopic right colon resection with intracorporeal ileocolic anastomosis for benign or malignant diseases of the right colon and terminal ileum were identified. There were eight case series and five case control studies. Anastomoses were fashioned as antiperistaltic or isoperistaltic, totally stapled or stapled/handsewn. The mesenteric defect was mostly left open. Overall operating time ranged from 53 to 360 min. The most common specimen extraction site locations were periumbilical, suprapubic, or transvaginal with a median incision length ranging from 3 to 6 cm. The overall rate of surgical site infection was 2.7 %. The anastomotic leak rates varied from 0 to 8.5 %. Postoperative mortality was 0.12 %. Intracorporeal ileocolic anastomosis following laparoscopic resection of the right colon is not commonly performed, but offers potential benefits if carried out by experienced surgeons in selected patients.

This nonsystematic review was performed to evaluate the literature that pertains to laparoscopic right colectomy, focusing on extracorporeal versus intracorporeal ileocolic anastomosis. The literature search was performed using PubMed to investigate the current status of research on 3 topics: (1) laparoscopic right colectomy with extracorporeal anastomosis, (2) laparoscopic right colectomy with intracorporeal anastomosis, and (3) comparisons of the 2 techniques. Each topic was reviewed, and the most relevant articles were selected for each subheading. Current literature is bringing to the forefront new evidence that laparoscopic right colectomy with intracorporeal anastomosis can be performed within a comparable time frame as extracorporeal anastomosis and with similar complication rates. Recent reports have presented evidence in which the entire operation is performed intracorporeally by a medial-to-lateral approach with comparable results to those observed in the surgery performed with extracorporeal anastomosis. The advantages of intracorporeal anastomosis are that mobilization of the transverse colon is not necessary, the anastomosis is performed away from the abdominal wall, and there is decreased potential for adhesion formation and a smaller extraction site. Potential disadvantages include intra-abdominal colotomy, requirement of laparoscopic suturing skills, and longer operative time.

Background: The aim of this study was to ascertain the impact of injury to the superior mesenteric nerve plexus caused by right colectomy with D3 extended mesenterectomy as performed in the prospective multicenter trial: “Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-detector Computed Tomography” in which all soft tissue surrounding the superior mesenteric vessels from the level of the middle colic artery to that of the ileocolic artery was removed. Methods: Bowel function and gastrointestinal quality of life in two consecutive cohorts that underwent right colectomy with and without D3 extended mesenterectomy were compared. Main outcome measures were the Diarrhea Assessment Scale (DAS) and Gastrointestinal Quality of Life Index (GIQLI). The data were collected prospectively through telephone interviews. Results: Forty-nine patients per group, comparable for age, sex, length of bowel resected but with significantly shorter follow-up time in the experimental group, were included. There was no difference in total DAS scores, subscores or additional questions except for higher bowel frequency scores in the D3 group (p = 0.02). Comparison of total GIQLI scores and subscales showed no difference between groups. Regression analysis with correction for confounding factors showed 0.48 lower bowel frequency scores in the D2 group (p = 0.022). Within the D3 group presence of jejunal arteries cranial to the D3 dissection area showed 1.78 lower DAS scores and 0.7 lower bowel frequency scores. Conclusions: Small bowel denervation after right colectomy with D3 extended mesenterectomy leads to increased bowel frequency but does not impact gastrointestinal quality of life. Individual anatomical variants can affect postoperative bowel function differently despite standardized surgery. acceptedVersion

The study aim was to provide data on pattern and length of crossing of the ileocolic artery (ICA) and right colic artery (RCA) with the superior mesenteric vein (SMV). Specimens from 30 fresh human cadavers underwent corrosion casting. Methylacrylate was injected into the SMV and superior mesenteric artery (SMA). Length of crossing was measured with a scaleable ruler and copper wire. Values are mean (SD; range). ICA was present in all specimens and crossed posterior to the SMV in 19 (63.33%) of 30 specimens. Length of crossing was 17.01 (7.84; 7.09–42.89) mm. RCA was present in 19 (63.33%) of 30 specimens. RCA crossed anterior to SMV in 16 (84.21%) of 19 specimens. Length of crossing was 20.63 (8.09; 6.3–35.7) mm. ICA was always present, crossed posterior to SMV in 60% of specimens with a crossing length of 17 mm. RCA was present in 63% of specimens, crossed anterior to the SMV in 84% of specimens with a crossing length of 20 mm. Clinical implications include arterial length left behind with main nodes, arterial bleeding and safety of laparoscopic access.

The last 2 issues of Techniques in Coloproctology present 2 examples of the technique referred to as complete mesocolic excision (CME). Shin and colleagues report in the current issue on a series of 168 patients with stages II and III colon carcinoma treated with laparoscopic CME, who achieved a remarkable overall survival of 89.6 % after a median follow-up of almost 5 years [1]. In their recently published experience, Storli and colleagues compared the results of resection for stage I–II colon carcinoma in 1 community hospital in which CME was used with results obtained in 2 control hospitals using standard surgical technique [2]. After a median follow-up of 50.2 months, the use of CME was associated with significantly improved 3-year overall survival and disease-free survival, while the difference in cancer-specific survival was not statistically significant. Both series, in different ways, pose the question of whether the technique of colonic dissection should be revisited to incorporate the principles of CME. The technique has been popularized by Hohenberger and colleagues who described the removal of colon cancer with ligation of vascular pedicles at their origin and preservation of the mesocolic investment of the removed specimen to minimize tumor spread. The principles of CME are intended to replicate in colon carcinoma the principles of total mesorectal excision, which have been associated with significant improvement of oncologic outcomes in rectal cancer and have been replicated in several centers throughout the world. In this respect, it is important to point out that CME requires a substantial technical dexterity when compared with standard technique, especially when using a laparoscopic approach. For example, a right colectomy with CME requires mobilization of the duodenum with the head of the pancreas and the mesenteric root to allow full exposure of the superior mesenteric vessels [3]. Pathological studies on the specimens resulting from such procedures have indicated advantages in surrogate metrics of oncologic benefits, namely preservation of the mesocolic envelope, increased lymph node retrieval and increased size of the removed specimen. However, the extent of the actual oncologic advantages deriving from CME remains unclear. For example, a study specifically assessing the impact of pathology grading of colon cancer surgical resection failed to demonstrate improved overall survival associated with mesocolic plane surgery, except for the subset of patients with stage III disease and did not report on cancer-specific survival [4]. On the other hand, the series, which did report improved cancer-specific outcomes after the introduction of CME when compared with an earlier time period, might not have adequately considered the influence on cancer outcomes of improved pathology staging and unequal use of chemotherapy treatments over time [3]. Storli and colleagues also reported a statistically marginal improvement in cancer-specific survival associated with CME as opposed to other important oncologic end points such as disease-free and overall survival. While lack of statistical power in the assessment of an individual end point is possible, an alternative explanation could be a difference in the comorbidity rate in the two groups, disproportionally accounting for the increased mortality noted in the standard group, as could be suggested by the 8.6 % in—hospital mortality after standard colonic resections compared with 2.9 % in the CME group. In the absence of reported data on comorbidity, this can only remain a L. Stocchi (&) Desk A30, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA e-mail: stocchl@ccf.org

Because of its technical difficulty, totally laparoscopic right colectomy with intracorporeal anastomosis is performed only by a small number of surgeons and most of them use a laparoscopic-assisted technique with extracorporeal anastomosis. This systematic review aims to evaluate differences in outcomes of patients undergoing right laparoscopic colectomy, either with intracorporeal or extracorporeal anastomosis. Electronic databases were searched for studies published between 1991 and 2012. Randomized controlled trials and case-control studies comparing intracorporeal to extracorporeal anastomosis in laparoscopic right colectomy were included in the systematic review. Meta-analytical models were used to evaluate anastomotic leak rate and short-term overall morbidity. Defined primary outcomes of interest were operating time, conversion rate, return of bowel function, anastomotic leak rate, and length of hospital stay. Randomized controlled trials were not found, confirming the paucity of the literature on this topic. Six case-control studies were identified involving 484 patients undergoing right laparoscopic colectomy, 272 with intracorporeal and 212 with extracorporeal anastomosis. Best outcomes seem to be associated with totally laparoscopic right colectomy with intracorporeal anastomosis, especially in terms of return of bowel function, length of hospital stay, and cosmetic results. However, our meta-analysis did not show a significant difference between the two techniques in terms of anastomotic leak rate (OR 0.98; 95 % CI 0.30-3.15) or for short-term overall morbidity (OR 0.68; 95 % CI 0.41-1.12). Comparative analysis of outcomes is in favor of intracorporeal anastomosis. However, the meta-analysis results do not allow us to draw definitive conclusions. Further prospective randomized trials are necessary to confirm our findings.

The purpose of this study was to evaluate the 5-year survival of patients with colon adenocarcinoma that underwent elective or emergency curative surgical treatment. Between 1993 and 1998, 80 patients underwent a potentially curative colonic resection based on mobilisation along anatomic planes. Among the patients, 26 underwent right colectomy, 3 transverse colectomy, 13 left colectomy and 38 sigmoidectomy. All patients classified as TNM stage III underwent adjuvant chemotherapy. The Kaplan–Meier method was used to analyse survival. Overall 5-year survival was 69.5%. Patient’s sex and age, mucinous characteristics of the tumour and tumour location did not significantly affect survival. Patients with higher Duke’s classification and TNM stage had significantly worse 5-year survival (p=0.025 and p=0.007, respectively). Although patients with good tumour differentiation had the highest 5-year survival, this difference was not statistically significant (p=0.211). The treatment of colon adenocarcinoma with curative resection by the end of the 20th century is accompanied with acceptable rates of overall 5-year survival.

Transverse abdominal wall incisions are favoured as part of enhanced recovery programmes. We explored the use of rectus-preserving extraction site incisions in laparoscopic right colectomy. The approach involved minimal anterior abdominal wall disruption with preservation of the rectus abdominis muscle: the rectus abdominis muscle extraction site (RAMES). In 15 patients, a RAMES was used electively in right colectomy for malignancy. The median wound length was 6 cms. There was no clinical or radiological evidence of incisional herniation in the 15 patients at 12-month and in the 12 survivors at 24-month follow-up. An anatomical dissection at specimen extraction site reduces early incisional herniation rates and should be of benefit in the longer term.

Dear Editor, Dr. Ho may have planned to write a scientific paper on an innovative surgical technique. I applaud Dr. Ho’s decision, as section editor, to invite Dr. Yamaguchi’s comment, which elevates the debate to a scientific level [1]. However, there are a number of methodological aspects of Dr. Ho’s publication that can give the wrong take-home message. These aspects, outlined below, may not be readily understood by inexperienced readers. Although there is certainly a need for innovation in surgery, it is beneficial to the patients that innovation happens in accordance with the rules of evidence [2]. As Dr. Ho’s technique is performed by a single surgeon, the reproducibility of his results is debatable, or at best, unknown. Other authors have previously emphasized how standardization and sequential execution are essential to outcomes and safety in surgical technique [3]. Ho sends a different message; he does it his way: lateral-to-medial! medial-to-lateral! It is dangerous as readers can get the wrong message. Laparoscopic right colectomy with intracorporeal anastomosis is no news to the well-informed reader. I agree with Dr. Ho that intracorporeal anastomosis is advantageous compared with extracorporeal. Potential advantages of intracorporeal anastomosis include: (1) anastomosing away from the abdominal wall could reduce surgical-site infection rates; (2) no manipulation of abdominal cavity by the surgeon could reduce creation of adhesions and possibly rates of adhesive small bowel obstruction; (3) a 50% reduction in the abdominal wall incision for specimen extraction could lead to clinically relevant benefits; and (4) laparoscopic visualization during the creation of the anastomosis could reduce unrecognized twisting of the terminal ileum mesentery. Nevertheless, I have the following concerns regarding Dr. Ho’s choice to promote totally stapled intracorporeal ileocolic anastomosis. Potential disadvantages of totally stapled intracorporeal ileocolic anastomoses include: (1) leads to an everted anastomosis with potential for increased risk of complications as opposed to its handsewn inverted counterpart; (2) requires usage of 60 mm long cartridge for side-to-side ileocolic stapling as it inevitably excises tissue and thereby potentially reduces the size of the anastomosis; (3) most likely requires an additional port if performed on the transverse colon; (4) does not obviate the need for intracorporeal suturing as stay stitches are required to ensure safe stapler application on the enterocolotomy; (5) may require multiple firings depending on the size of the enterocolotomy or whether the previous stapled line is being excised; and (6) leads to higher costs due to additional cartridges. An alternative option to totally stapled intracorporeal ileocolic anastomosis is to handsew the enterocolotomy [4]. Without standardization of a surgical technique and proof of reproducibility by others, Dr. Ho’s ‘‘How I do it’’ paper lacks external validity.