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Background: With the optimization of neoadjuvant treatment regimens, the indications for intersphincteric resection (ISR) have expanded. However, limitations such as unclear surgical field, impaired anal function, and failure of anal preservation still exist. Transanal total mesorectal excision can complement the drawbacks of ISR. Therefore, this study combined these two techniques and proposed transanal endoscopic intersphincteric resection (taE-ISR), aiming to explore the value of this novel technique in anal preservation for ultra-low rectal cancer., Material and Methods: Four high-volume centres were involved. After 1:1 propensity score-matching, patients with ultra-low rectal cancer underwent taE-ISR ( n =90) or ISR ( n =90) were included. Baseline characteristics, perioperative outcomes, pathological results, and follow-up were compared between the two groups. A nomogram model was established to assess the potential risks of anal preservation., Results: The incidence of adjacent organ injury (0.0% vs. 5.6%, P =0.059), positive distal resection margin (1.1% vs. 8.9%, P =0.034), and incomplete specimen (2.2% vs. 13.3%, P =0.012) were lower in taE-ISR group. Moreover, the anal preservation rate was significantly higher in taE-ISR group (97.8% vs. 82.2%, P =0.001). Patients in the taE-ISR group showed a better disease-free survival ( P =0.044) and lower cumulative recurrence ( P =0.022) compared to the ISR group. Surgery procedure, tumour distance, and adjacent organ injury were factors influencing anal preservation in patients with ultra-low rectal cancer., Conclusion: taE-ISR technique was safe, feasible, and improved surgical quality, anal preservation rate and survival outcomes in ultra-low rectal cancer patients. It held significant clinical value and showed promising application prospects for anal preservation., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Right hemicolectomy is the standard treatment for right-sided colon cancer. There is variation in the technical aspects of performing right hemicolectomy as well as in short-term outcomes. It is therefore necessary to explore best clinical practice following right hemicolectomy in expert centres., Methods: This snapshot study of right hemicolectomy for colon cancer in China was a prospective, multicentre cohort study in which 52 tertiary hospitals participated. Eligible patients with stage I-III right-sided colon cancer who underwent elective right hemicolectomy were consecutively enrolled in all centres over 10 months. The primary endpoint was the incidence of postoperative 30-day anastomotic leak., Results: Of the 1854 patients, 89.9 per cent underwent laparoscopic surgery and 52.3 per cent underwent D3 lymph node dissection. The overall 30-day morbidity and mortality were 11.7 and 0.2 per cent, respectively. The 30-day anastomotic leak rate was 1.4 per cent. In multivariate analysis, ASA grade > II (P < 0.001), intraoperative blood loss > 50 ml (P = 0.044) and D3 lymph node dissection (P = 0.008) were identified as independent risk factors for postoperative morbidity. Extracorporeal side-to-side anastomosis (P = 0.031), intraoperative blood loss > 50 ml (P = 0.004) and neoadjuvant chemotherapy (P = 0.004) were identified as independent risk factors for anastomotic leak., Conclusion: In high-volume expert centres in China, laparoscopic resection with D3 lymph node dissection was performed in most patients with right-sided colon cancer, and overall postoperative morbidity and mortality was low. Further studies are needed to explore the optimal technique for right hemicolectomy in order to improve outcomes further., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

Background: Although laparoscopic inguinal hernia repair (LIHR) is widely performed worldwide, few studies have focused on the procedure in female patients. This study investigated the characteristics and outcomes of female patients with inguinal hernias who underwent LIHR., Materials and Methods: This study retrospectively analyzed the data of 7380 patients with inguinal hernia admitted to the General Surgery Department of Ruijin Hospital and underwent LIHR from January 2001 to December 2020. The clinical characteristics, surgical outcomes, and complications were assessed., Results: In total, 572 female patients were enrolled in this study. The proportion of femoral hernias in female patients was higher in women than in male patients (17.4% vs. 0.3%, respectively). Mesothelial cysts of the round uterine ligament (MCURL) were noted in 74 patients. The mean age of patients with MCURL was lower than that of patients without MCURL (46.4 vs. 55.6, P =0.018). Seventy cases (93.3%) of MCURL were resected laparoscopically, and 5 cases were resected through an auxiliary small incision. The round ligament was cut off in 335 patients and preserved in 237. No significant differences were observed in the number of hospitalization days, recurrence rates, or complications between the transection and preservation groups. None of the cases were converted to laparotomy, and no recurrence was noted during follow-up., Conclusion: LIHR is safe and feasible in female patients. Treatment of femoral hernia, MCURL, and the round ligament of the uterus should be carefully considered during LIHR in female patients., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Conventional laparoscopic-assisted right hemicolectomy requires a small abdominal incision to extract the specimen, which becomes an important source of postoperative complications and impairs perioperative experience. Transvaginal natural orifice specimen extraction surgery (NOSES VIIIA) avoids this small incision by extracting the specimen through the vagina. Here we describe the design of a multicenter, open-label, parallel, noninferior, phase III randomized controlled trial (NCT05495048). The aim of this study is to confirm that the NOSES VIIIA procedure is not inferior to small-incision assisted right hemicolectomy in long-term oncological efficacy. A total of 352 female patients with right colon adenocarcinoma/high-grade intraepithelial neoplasia will be randomly assigned to the NOSES VIIIA arm and the small-incision arm in a 1:1 ratio. The primary end point of this trial is 3 year disease-free survival. Clinical Trial Registration: NCT05495048 (ClinicalTrials.gov).

Background: The aim of this study was to compare the pathological and perioperative outcomes of extracorporeal versus intracorporeal anastomosis after laparoscopic transverse colon cancer resection., Methods: In this retrospective study, patients from seven institutions in China who underwent laparoscopic resection of transverse colon cancer between 2019 and 2021 were selected and included. Either extended right hemicolectomy or transverse colectomy/extended left hemicolectomy was performed. The clinical characteristics and the pathological and perioperative outcomes were compared between patients undergoing extracorporeal or intracorporeal anastomosis. Resection margin lengths were measured on formalin-fixed specimens and an inadequate margin was defined as less than 4.2 cm between the division and the tumour. The outcome of interest was the prevalence of specimens with an inadequate margin. Length of incision, bowel function recovery, hospital stay, early postoperative pain (first day after surgery), 30-day complications, and nodal harvest were investigated as secondary outcomes., Results: Of 411 patients treated during the study interval, 370 patients with transverse colon cancer were included (23.2 per cent treated with intracorporeal anastomosis and 76.8 per cent treated with extracorporeal anastomosis). The prevalence of specimens with inadequate margins was lower in the intracorporeal anastomosis group compared with the extracorporeal anastomosis group in patients undergoing extended right hemicolectomy (P = 0.045) and in patients undergoing transverse colectomy/extended left hemicolectomy (P = 0.030). In multivariate analysis, extracorporeal anastomosis (OR 2.94 (95 per cent c.i. 1.33 to 6.49), P = 0.008) and transverse colectomy/extended left hemicolectomy (OR 1.75 (95 per cent c.i. 1.03 to 2.96), P = 0.038) were independent risk factors for specimens with an inadequate margin. Intracorporeal anastomosis was associated with a shorter incision length (P < 0.001), an earlier recovery of bowel function (P = 0.035), a shorter postoperative hospital stay (P = 0.042), less early postoperative pain (P < 0.001), a longer specimen length (P = 0.042), a longer resection margin (P = 0.007), and a greater lymph node harvest (P = 0.036). There was no statistically significant difference in 30-day complications., Conclusion: Patients with transverse colon cancer have better perioperative outcomes, fewer margins of less than 4.2 cm, and larger lymph node harvests when the anastomosis is performed intracorporeally. Further studies are needed to confirm these findings., Registration Number: NCT05061199 (www.clinicaltrials.gov)., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

Background: Current studies did not draw definitive conclusions on comparison of intracorporeal anastomosis (ICA) with extracorporeal anastomosis (ECA) in laparoscopic right colectomy. Whether the intraperitoneal contamination induced by ICA can result in higher risk of postoperative abdominal infection remains unclear. This study was aimed to compare the short-term outcomes, especially the risk of abdominal infection after ICA versus ECA., Methods: This was an observational cohort study as a secondary analysis of a randomized controlled trial (RCT)-RELARC trial (NCT02619942). The patients enrolled in the RELARC trial were diagnosed with primary colon adenocarcinoma without distant metastasis and underwent radical laparoscopic right colectomy between Jan 2016 and Dec 2019. In our study the patients who converted to open surgery in RELARC trial were excluded. The short-term outcomes were compared between ICA and ECA. The primary endpoint was abdominal infection. The inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) was used for adjusting the potential confounders., Results: This study enrolled 975 patients with 119 patients undergoing ICA and 856 patients undergoing ECA. The incidence of abdominal infection was higher in ICA group (9.2% versus 1.5%, RR from IPTW = 5.7 (95%CI: 2.6-12.6), P < 0.001) as well as the incidence of wound infection (14.3% vs 3.3%, RR from IPTW = 5.0 (95%CI: 2.9-8.6), P < 0.001). ICA was associated with higher incidence of Clavien-Dindo (CD) grade I and II complications (CD-I: 15.1% versus 6.8%, RR from IPTW = 2.4 (95%CI: 1.5-3.9), P < 0.001; CD-II: 26.9% versus 8.2%, RR from IPTW = 3.6 (95%CI: 2.5-5.1), P < 0.001) but similar incidence of CD-III ~ IV complications compared to ECA (3.4% vs 2.1%, RR from IPTW = 1.2 (95%CI: 0.4-4.0), P = 0.73). In ICA group, choosing another incision rather than lengthening main port site decreased the incidence of wound infection although without statistical significance (17.3% (14/81) versus 7.9% (3/38), crude RR = 2.2 (95%CI: 0.7-7.2), P = 0.17)., Conclusion: ICA is likely to be associated with higher risk of abdominal infection and CD-I ~ II complications., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Introduction: In the case of right-sided transverse colon cancer (RTCC) and hepatic flexure colon cancer (HFCC), there is a potential connection of lymph drainage between mesentery and greater omentum. However, most previous reports have been limited case series with No. 206 and No. 204 lymph node (LN) dissection for RTCC and HFCC., Methods and Analysis: The InCLART Study is a prospective observational study aiming to enrol 427 patients with RTCC and HFCC treated at 21 high-volume institutions in China. The prevalence of infrapyloric (No. 206) and greater curvature (No. 204) LN metastasis and short-term outcomes will be investigated in a consecutive series of patients with T2 or deeper invasion RTCC or HFCC, following the principle of complete mesocolic excision with central vascular ligation. Primary endpoints were performed to identify the prevalence of No. 206 and No. 204 LN metastasis. Secondary analyses will be used to estimate prognostic outcomes, intraoperative and postoperative complications, the consistency of preoperative evaluation and postoperative pathological results of LN metastasis., Ethics and Dissemination: Ethical approval for the study has been granted by the Ruijin Hospital Ethics Committee (approval number: 2019-081) and has been or will be approved successively by each participating centre's Research Ethics Board. The findings will be disseminated in peer-reviewed publications., Trial Registration Number: ClinicalTrials.gov Registry (NCT03936530; https://clinicaltrials.gov/ct2/show/NCT03936530)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine the morbidity, mortality, and pathologic outcomes of transanal total mesorectal resection (taTME) versus laparoscopic total mesorectal excision (laTME) among patients with rectal cancer with clinical stage I to III rectal cancer below the peritoneal reflection., Background: Studies with sufficient numbers of patients allowing clinical acceptance of taTME for rectal cancer are lacking. Thus, we launched a randomized clinical trial to compare the safety and efficacy of taTME versus laTME., Methods: A randomized, open-label, phase 3, noninferiority trial was performed at 16 different hospitals in 10 Chinese provinces. The primary endpoints were 3-year disease-free survival and 5-year overall survival. The morbidity and mortality within 30 days after surgery, and pathologic outcomes were compared based on a modified intention-to-treat principle; this analysis was preplanned., Results: Between April 13, 2016, and June 1, 2021, 1115 patients were randomized 1:1 to receive taTME or laTME. After exclusion of 26 cases, modified intention-to-treat set of taTME versus laTME groups included 544 versus 545 patients. There were no significant differences between taTME and laTME groups in intraoperative complications [26 (4.8%) vs 33 (6.1%); difference, -1.3%; 95% confidence interval (CI), -4.2% to 1.7%; P =0.42], postoperative morbidity [73 (13.4%) vs 66 (12.1%); difference, 1.2%; 95% CI, -2.8% to 5.2%; P =0.53), or mortality [1 (0.2%) vs 1 (0.2%)]. Successful resection occurred in 538 (98.9%) versus 538 (98.7%) patients in taTME versus laTME groups (difference, 0.2%; 95% CI, -1.9% to 2.2%; P >0.99)., Conclusions: Experienced surgeons can safely perform taTME in selected patients with rectal cancer., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Aim: Lateral pelvic lymph node dissection (LPND) is a technically challenging procedure, and the safety and feasibility of laparoscopic LPND remains undetermined. Here, we compared the short- and long-term survival outcomes of laparoscopic LPND with those of open LPND., Methods: From January 2012 to December 2019, locally advanced middle-low rectal cancer patients with clinical evidence of lateral pelvic lymph node metastasis (LPNM) who underwent total mesorectal excision with LPND at three institutions were included. Propensity score matching was used to minimize selection bias. The short-term and oncological outcomes of open and laparoscopic LPND were compared., Results: Overall, 384 patients were enrolled into the study including 277 and 107 patients who underwent laparoscopic and open LPND, respectively. After matching, patients were stratified into laparoscopic (n = 100) and open (n = 100) LPND groups. Patients in the laparoscopic LPND group had a shorter operation time (255 vs. 300 min, p = 0.001), less intraoperative blood loss (50 vs. 300 ml, p < 0.001), lower incidence of postoperative complications (32.0% vs. 15.0%, p = 0.005), shorter postoperative hospital stay (8 vs. 14 days, p < 0.001), and excision of more lateral pelvic lymph nodes (9 vs. 7, p = 0.025) than those in the open LPND group. The 3-year overall survival (p = 0.581) and 3-year disease-free survival (p = 0.745) rates were similar between the groups, and LPNM was an independent predictor of survival., Conclusion: Laparoscopic LPND is technically safe and feasible with favourable short-term results and similar oncological outcomes as open surgery in selected patients., (© 2022 Association of Coloproctology of Great Britain and Ireland.)

Background: Chylous ascites (CA) after laparoscopic D3 lymphadenectomy for right colon cancer is not rare. However, the risk factors for CA have not been fully explored. Few studies have investigated the effect of CA on long-term prognosis., Methods: The clinical data of patients with right colon cancer who underwent laparoscopic D3 lymphadenectomy in five centers from January 2013 to December 2018 were retrospectively collected. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with CA. Then, the long-term prognosis of patients with and without CA was compared by propensity score matching and Kaplan-Meier survival analysis., Results: The incidence of CA was 4.4% (48/1090). Pathological T stage (p = 0.025), dissection along the left side of the superior mesenteric artery (p < 0.001) and the number of retrieved lymph nodes (p < 0.001) were independent risk factors for CA. After propensity score matching, 48 patients in the CA group and 353 patients in the non-CA group were enrolled. Kaplan-Meier survival analysis indicated that CA was not associated with overall survival (p = 0.454) and disease-free survival (p = 0.163). In patients with stage III right colon cancer, there were no significant differences in overall survival (p = 0.501) and disease-free survival (p = 0.254)., Conclusions: Pathological T stage, number of retrieved lymph nodes, and left side dissection along the superior mesenteric artery were independent risk factors for CA after laparoscopic D3 lymphadenectomy. CA does not impair the oncological outcomes of patients., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Recent interest in laparoscopic right colectomy with D3 lymphadenectomy for right colon cancer, has raised renewed attention to the anatomic variations of the gastrocolic trunk of Henlé (GTH). Understanding the vascular structure of the GTH region for individual patients should improve surgical outcomes. The goal of this nationwide multicenter study (Anatomical Classification of Henlé's Trunk in Laparoscopic Right Hemi-colectomy (HeLaRC) trial) was to study the anatomic patterns of the GTH region, to clarify the implications of GTH in laparoscopic right colectomy with D3 lymphadenectomy (D3-RC) and analyze their clinical significance., Methods: We enrolled 583 patients from 26 centers across China who underwent D3-RC. The number of tributaries, length and types of GTH constitutions and their influence on intra-operative data were investigated. A nomogram score (based on the length of GTH, body mass index (BMI), tumor location, T stage and type of GTH (type I vs. non-type I) was established to assess the potential hazard of bleeding., Results: The GTH was found in 567 patients (97.3%). The distribution of GTH types was 0 (14.1%, n = 80), I (53.3%, n = 302), II (27.0%, n = 153), III (5.6%, n = 32). Of note, the type I GTH, T1 stage and tumor location at ileocecal or ascending colon were correlated with shorter exposure time of the GTH region (P < 0.0001). Short length of GTH (P = 0.002) and tumor location (transverse colon vs. non transverse colon) (P = 0.003) were correlated with the amount of GTH bleeding during the surgery. Nomogram discrimination was good (C-index: 0.72 (95% CI: 0.64, 0.80)). The dissection plane was better in patients with type I GTH than with other types (P = 0.023)., Conclusion: GTH pattern variations may affect surgical outcomes in patients undergoing D3-RC. Better recognition of GTH anatomy might lead to a safer operation with better oncologic quality., (Copyright © 2022 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: To investigate the application value of 4K high definition (HD) in laparoscopic gastrectomy by comparing the short-term outcomes and subjective perception with three-dimensional (3D) and HD vision systems. Materials and Methods: A retrospective study was conducted between September 2018 and February 2019; a total of 87 patients who underwent laparoscopic gastrectomy were enrolled and divided into three groups in terms of different type of vision system used for surgery: 4K, 3D, and HD. Demographic and clinicopathological data as well as short-term outcomes were collected and analyzed. A questionnaire survey was completed by the team of surgeons to evaluate the subjective perception of different vision systems. Results: There was no significant difference in gender, body mass index, age, American Society of Anesthesiologists (ASA) score and history of abdominal surgery, tumor location as well as type of operation, and anastomosis between the 4K, 3D, and HD groups. All patients underwent laparoscopic gastrectomy without conversion to laparotomy. There was no difference between the three groups regarding operation time (4K versus 3D versus two-dimensional (2D), 183.60 ± 52.5 versus 189.69 ± 69.87 versus 211.00 0 ± 49.33, P  = .145) and estimated blood loss (4K versus 3D versus 2D, 123.60 ± 119.51 versus 150.62 ± 105.46 versus 129.00 ± 103.57, P  = .602), no difference was found in time to first flatus and postoperative hospital stay between the three groups. No significant difference was found in postoperative complications between the three groups. As for pathological results, there was no difference in tumor size and tumor-node-metastasis (TNM) stage. In 4K group, the number of lymph node harvested was 32.60 ± 10.28, no difference was found compared with that of 3D (29.81 ± 8.94) and HD groups (27.69 ± 10.96). The score of group 3D was the lowest concerning asthenopia and motion sickness. On the contrary, 3D group achieved the highest score in topographical orientation and depth description. 4K group was graded the highest in terms of control co-ordination of visual angle, visual acuity, radiance, resolution ratio and frames, and refresh rate. HD group was graded significantly lower in sense of control compared with that of 4K and 3D group. No significant difference was found in color resolution and contrast. Conclusions: In conclusion, the short-term effect of 4K HD laparoscopic system is comparable with that of HD and 3D laparoscopy, whereas 4K could reduce adverse effect than traditional instrument and improve quality of surgery. The Clinical Trial Registration number is NCT01441336.

Importance: Preventing anastomotic leakage (AL) is crucial for colorectal surgery. Some studies have suggested a positive role of transanal drainage tubes (TDTs) in AL prevention after low anterior resection, but this finding is controversial., Objective: To assess the effect of TDTs in AL prevention after laparoscopic low anterior resection for rectal cancer., Design, Setting, and Participants: This multicenter randomized clinical trial with parallel groups (TDT vs non-TDT) was performed from February 26, 2016, to September 30, 2020. Participants included patients from 7 different hospitals in China who were undergoing laparoscopic low anterior resection with the double-stapling technique for mid-low rectal cancer; 576 patients were initially enrolled in this study, and 16 were later excluded. Ultimately, 560 patients were randomly divided between the TDT and non-TDT groups., Interventions: A silicone tube was inserted through the anus, and the tip of the tube was placed approximately 5 cm above the anastomosis under laparoscopy at the conclusion of surgery. The tube was fixed with a skin suture and connected to a drainage bag. The TDT was scheduled for removal 3 to 7 days after surgery., Main Outcomes and Measures: The primary end point was the postoperative AL rate within 30 days., Results: In total, 576 patients were initially enrolled in this study; 16 of these patients were excluded. Ultimately, 560 patients were randomly divided between the TDT group (n = 280; median age, 61.5 years [IQR, 54.0-68.8 years]; 177 men [63.2%]) and the non-TDT group (n = 280; median age, 62.0 years [IQR, 52.0-69.0 years]; 169 men [60.4%]). Intention-to-treat analysis showed no significant difference between the TDT and non-TDT groups in AL rates (18 [6.4%] vs 19 [6.8%]; relative risk, 0.947; 95% CI, 0.508-1.766; P = .87) or AL grades (grade B, 14 [5.0%] and grade C, 4 [1.4%] vs grade B, 11 [3.9%] and grade C, 8 [2.9%]; P = .43). In the stratified analysis based on diverting stomas, there was no significant difference in the AL rate between the groups, regardless of whether a diverting stoma was present (without stoma, 12 [5.8%] vs 15 [7.9%], P = .41; and with stoma, 6 [8.3%] vs 4 [4.5%], P = .50). Anal pain was the most common complaint from patients in the TDT group (130 of 280, 46.4%). Accidental early TDT removal occurred in 20 patients (7.1%), and no bleeding or iatrogenic colonic perforations were detected., Conclusions and Relevance: The results from this randomized clinical trial indicated that TDTs may not confer any benefit for AL prevention in patients who undergo laparoscopic low anterior resection for mid-low rectal cancer without preoperative radiotherapy., Trial Registration: ClinicalTrials.gov Identifier: NCT02686567.

Background: Opinions vary on the medial border of D3 lymphadenectomy for right colon cancer. Most surgeons place the medial border along the left side of the superior mesenteric vein, but some consider the left side of the superior mesenteric artery as the medial border., Objectives: This study investigated the clinical outcomes of laparoscopic D3 lymphadenectomy for right colon cancer with the medial border along the left side of superior mesenteric artery., Design: This was a retrospective study., Settings: The study was conducted in specialized colorectal cancer department of 5 tertiary hospitals., Patients: Patients receiving laparoscopic D3 lymphadenectomy for right colon cancer from January 2013 to December 2018 were included., Main Outcome Measures: After propensity score matching, 307 patients receiving laparoscopic D3 lymphadenectomy along the left side of the superior mesenteric artery were assigned to the superior mesenteric artery group and 614 patients were assigned to the superior mesenteric vein group. Univariate, multivariate, and Kaplan-Meier analyses were performed to assess the clinical data., Results: The short-term outcomes were similar between the 2 groups; however, the superior mesenteric artery group had a higher rate of chylous leakage (p < 0.001). More lymph nodes were harvested from the superior mesenteric artery group than from the superior mesenteric vein group (p = 0.001). The number (p = 0.005) of metastatic lymph nodes and the lymph node ratio (p = 0.041) in main nodes were both higher in the superior mesenteric artery group. The 2 groups had similar long-term survival, but the superior mesenteric artery group tended to show better disease-free survival in patients with stage disease III (p = 0.056)., Limitations: This was a retrospective, nonrandomized study., Conclusion: Laparoscopic D3 lymphadenectomy along the left side of the superior mesenteric artery, except for a higher rate of chylous leakage, had short-term outcomes comparable to the superior mesenteric vein group. The superior mesenteric artery group tended to achieve better disease-free survival in patients with stage III disease, but further study is required to better elucidate differences in these approaches because risks/benefits do exist., (Copyright © The ASCRS 2021.)

Background: To investigate feasibility of laparoscopic abdominoperineal resection with pelvic peritoneum closure (LAPR-PPC) for lower rectal cancer., Methods: LAPR-PPC has been used for lower rectal cancer in our institution since 2014. In this study, we retrospectively analyzed the data from 86 patients who underwent LAPR-PPC and compared with the data from 96 patients who underwent laparoscopic APR without PPC (LAPR) from January 2013 to December 2018., Results: The rate of perineal surgical site infection (SSI) (18.75% (18/96) vs. 5.81% (5/86), p < 0.01), delayed (> 4 weeks) perineal healing (12.50% (12/96) vs. 3.49% (3/86), p = 0.027), ileus (7.29% (7/96) vs 1.16% (1/86), p = 0.044), and postoperative perineal hernia (PPH, 5.21% (5/96) vs. 0% (0/86), p = 0.032) were significantly lower in LAPR-PPC group than LAPR group. The patients in LAPR-PPC group had shorter hospitalization time (21.32 ± 11.95 days vs. 13.93 ± 11.51 days, p < 0.01)., Conclusions: PPC procedure enabled the reduction in perineal wound complications, ileus, PPH, and consequently shortened hospitalization time. LAPR-PPC is beneficial for the patients with lower rectal cancer.

Background: As a key landmark during laparoscopic right colectomy, the classification and variation of the gastrocolic trunk of Henle (GTH) remains to be clarified. The aim of this nationwide multicenter study was to describe the characteristics of the GTH intra-operatively during laparoscopic right colectomies., Methods: Three hundred seventy-one patients who underwent laparoscopic right colectomies from January 2018 to March 2019 in 25 hospitals across China were enrolled in the study. The length of the GTH, the classification with a precise description of confluent tributaries, and other variations were analyzed., Results: Of the 371 patients, 363 had a GTH. The proportion of type-0, type-I, type-II, and type-III was 15.2% (n = 55), 54.8% (n = 199), 25.3% (n = 92), and 4.7% (n = 17), respectively. The average length of the GTH was 8.5 mm, ranging from 2 to 30 mm., Conclusions: This is the first multicenter study with a large sample by which the GTH was classified based on laparoscopic intraoperative observation. Variations in the GTH were classified into four types based on the number of colic drainage veins (right colic, superior right colic, middle colic, accessory middle colic, and ileocolic veins), among which the right colic vein was the most common. The length of the GTH was relatively short, and thus might carry a risk of bleeding. Further clinical data should be correlated with the characteristics of the GTH.

Background: Laparoscopy-assisted gastrectomy (LAG) has been proven to be feasible and oncologically safe for early gastric cancer. Despite the rapid increase in the number of LAG cases, there are few reports on the long-term outcomes of T4a (serosalinvasion) gastric cancer after LAG. The aim of the present study was to evaluate the long-term clinical outcomes in patients with stage T4a gastric cancer after laparoscopic gastrectomy., Materials and Methods: A total of 578 patients with gastric cancer were treated with LAG between February 2004 and December 2014. Among these patients, 224 patients were pathologically confirmed with T4a advanced gastric cancer. The clinical and follow-up data were retrospectively analyzed, the survival rates were estimated using the Kaplan-Meier method, and the risk factors for overall and disease-free survival (DFS) were evaluated by Cox regression., Results: Among these 224 patients, 129 patients were above 60 years old, and the male-to-female ratio was 157:67. Furthermore, among these patients, 125 patients received laparoscopy-assisted distal gastrectomy, whereas 99 patients received laparoscopy-assisted total gastrectomy. Forty (17.90%) patients experienced postoperative complications according to the Clavien-Dindo classification. Median follow-up time was 32 months. Recurrence was observed in 99 (44.20%) patients. The cumulative 5-year overall survival (OS) and DFS rates were 47.20% and 43.60%, respectively. The 5-year OS and DFS rates were 72.50% and 70.00% for stage N0, 57.00% and 53.90% for stage N1, 41.60% and 37.00% for stage N2, and 23.30% and 21.30% for stage N3, respectively. In the univariate analysis, tumor size, tumor location, N stage and metastatic lymph node ratio (MLR) were correlated with OS and DFS. The MLR was identified as an independent predictor for OS (P<0.05; hazard ratio=1.828; 95% confidence interval, 1.353-2.469) and DFS (P<0.05; hazard ratio=1.197; 95% confidence interval, 0.945-1.516)., Conclusions: The long-term outcomes of LAG for T4a (M0) gastric cancer were acceptable, compared with previous reports. Therefore, this treatment could be considered as an alternative operative approach for T4a gastric cancer. The MLR was an independent predictor for OS and DFS.

Background: To investigate the safety and feasibility of the completely medial access by page-turning approach (CMAP) for laparoscopic right hemi-colectomy., Methods: In this retrospective study, the data from 72 patients who underwent laparoscopic right hemi-colectomy with CMAP were analyzed and compared with data from 124 patients who underwent the conventional medial approach performed by the same surgical team from September 2011 to March 2017., Result: Complete mesocolic excision (CME) was achieved in 67 of 72 patients (93.1%) with laparoscopic CMAP. The average operation time, blood loss, and specimen length was 135.9 ± 28.3 min, 63.2 ± 32.2 ml, and 23.9 ± 4.7 cm, respectively. The number of lymph nodes harvested was 20.6 ± 7.7, the time-to-flatus was 2.5 ± 0.8 days, the time-to-fluid intake was 3.2 ± 0.8 days, and the average hospital stay was 8.9 ± 4.7 days. No intra-operative complications occurred in this study. The vessel-related complication and total post-operative complication rate was 2.78% (2/72) and 6.94% (5/72), respectively., Conclusions: Laparoscopic CMAP was an alternative approach for CME in laparoscopic right hemi-colectomy, which was proved safe and feasible for right colon cancer.

Background: Our objective was to investigate the clinical characteristics of laparoscopic repair for groin hernias in female patients., Study Design: The clinical data of 316 female patients (341 hernias) who underwent laparoscopic inguinal hernia repair at Shanghai Minimally Invasive Surgery Center between January 2001 and December 2015 was analyzed retrospectively. The operation-related data were to provide an overview of female groin hernias, preferred surgical approach, and the management of round ligament of uterus., Results: There were 274 transabdominal preperitoneal patch plastic repairs and 67 total extraperitoneal repairs performed on 257 and 59 patients, respectively. The median follow-up period was 48 months. Fifty-eight femoral hernias were noted in 52 patients, of which 18 femoral hernias were incarcerated. Cysts on the round ligament of uterus were found in 39 patients, and most of them underwent laparoscopic resection. Round ligaments of uterus were preserved in 152 patients and transected in 162 patients. The preservation group requires longer operation time and trickier surgical technique. None of the cases was converted to laparotomy. All patients returned to normal activity soon and no recurrence was noted during follow-up., Conclusions: Laparoscopic inguinal hernia repair is well adopted around the world. Meanwhile, there still remain questions to be discussed in female patients. Based on this study, the round ligament cyst could be resected while the operation. Either "open and suture" or keyhole technique will be available to preserve the round ligament of uterus.

Laparoscopic techniques are now well pervading in the treatment of inguinal hernia. This study aims to investigate the laparoscopic strategy for recurrent inguinal hernia repair. Laparoscopic technique was retrospectively applied to 330 patients with 352 recurrent inguinal hernias in the past 14 years. The surgical strategies were further evaluated. There were 22 cases with bilateral recurrent hernias, whereas the rest 308 cases with unilateral disorders. Patients were further categorized by previous repair approaches as high ligation, sclerotherapy, conventional suture repair, Lichtenstein repair, plug and patch repair, and preperitoneal repair. All cases were successfully repaired by laparoscopic approaches including transabdominal preperitoneal (TAPP) (288 cases), totally extraperitoneal (50 cases), and intraperitoneal onlay mesh (14 cases). The median operation duration was 39.5 ± 13.4 minutes. The average Visual Analog Scales score on postoperative day 1 was 2.4 ± 1.1. The median follow-up time was 36 (14-61) months. There was one case of recurrence during the follow-ups. One severe complication, i.e., bowel injury, was observed and cured, whereas other complications were as follows: 22 seroma, 8 urinary retention, 3 transient paresthesia, and 1 ileus. Laparoscopic procedures for recurrence inguinal hernia are safe and applicable. A surgeon can choose to reinforce the myopectineal orifice or only fix the hernia defect accordingly. The strategy of choosing TAPP and/or totally extraperitoneal depends on the type of previous repair, the exact anatomical position of the previous implanted mesh, and more importantly, the surgeon's experience. Moreover, the intraperitoneal onlay mesh technique can be regarded as a backup option for TAPP in certain cases.

Objective: To investigate the safety and feasibility of totally laparoscopic uncut Roux-en-Y anastomosis in the distal gastrectomy with D2 dissection for gastric cancer. We also summarized the preliminary experience of totally laparoscopic uncut Roux-en-Y anastomosis., Methods: A retrospective analysis was done in 51 cases of total laparoscopic uncut Roux-en-Y anastomosis in the distant gastrectomy with D2 dissection for gastric cancer in our hospital from September 2014 to December 2015., Results: All of 51 cases underwent total laparoscopic uncut Roux-en-Y anastomosis. All the procedures were performed successfully. There were neither conversions to open surgery nor intraoperative complications in all 51 cases. In this study, the median operative time was 170 (135-210) min and the median time of anastomosis was 27 (24-41) min. The blood loss was 60 (30-110) ml. The time to flatus and length of postoperative hospital stay were 2 (1-3) days, and 8 (7-12) days, respectively. The mean lymph node harvest was 34 (18-49). One anastomotic bleeding occurred postoperatively which was cured by conservative treatment. No major postoperative complication occurred, such as anastomotic leak, anastomotic stenosis, and Roux stasis syndrome. After a short-term follow-up, no recanalization or reflux gastritis was encountered by endoscopy., Conclusion: The totally laparoscopic uncut Roux-en-Y anastomosis in distal gastrectomy with lymph node dissection for gastric cancer is safe and feasible, with a very low rate of recanalization and reflux gastritis.

Introduction: Single port laparoscopy (SPL) and natural orifice transluminal endoscopic surgery (NOTES) are next-generation minimally invasive surgery (MIS) procedures which could further reduce patient trauma. Robotic assistance shows great potential in providing augmented motion precision and manipulation dexterity. This article reviews the robotic systems recently developed for SPL and NOTES., Material and Methods: A literature search was conducted based on Science Citation Index, Engineering Index, Medline, and PubMed databases., Results: Eleven robotic systems for SPL and six robotic systems for NOTES were identified. Structures and performances of these systems were reported. Special attention was directed to the systems using continuum mechanisms., Discussion and Conclusion: Regarding the structure aspect, the reviewed systems for SPL and NOTES all deploy a vision unit and at least two manipulation arms for surgical interventions through an access channel. To date, the smallest diameter of such a channel is 12 mm. Regarding the functionality aspect, only a few systems demonstrated results promising enough for animal or clinical studies in the near future. Surgical robots using dual continuum mechanisms achieved both design compactness and functional versatility. The characteristics suggest that the use of continuum mechanisms is worth exploring through future developments of surgical robots.

Objective: To evaluate the impact of routine intraoperative endoscopy (IOE) on postoperative anastomotic bleeding of laparoscopic anterior resection (LAR) for rectal cancer, and to investigate the value of the IOE in terms of prevention and treatment of postoperative anastomotic bleeding., Methods: Medical records of the 279 cases of LAR from January 2006 to December 2011 were retrospectively analyzed, of which postoperative anastomotic bleeding occurred in 18. Univariate analysis was taken to determine the possible influencing factors of the bleeding. Then related influencing factors were put into the multivariate logistic regression analysis to ultimately determine the independent influencing factors of anastomotic bleeding. The efficacy of treatments to the anastomotic bleeding was also evaluated., Results: The incidence of anastomotic bleeding after LAR is 6.5% (18/279).The rates of anastomotic bleeding in lower tumor location group and upper tumor location group were 9.2% (16/173) and 1.9% (2/106), respectively, as in intraoperative colonoscopy and nonintraoperative colonoscopy group were 3.3% (5/151), and 10.2% (13/128), respectively. Comparing the location of the tumor, the coefficient of regression and relative risk value for lower tumor were 1.564 and 4.776. Comparing the intraoperative colonoscopy and nonintraoperative colonoscopy group, the value for intraoperative colonoscopy group were -1.085 and 0.338. Sex, age, tumor stage, pathologic type, and preventive ileostomy had no relevance with the anastomotic bleeding. In 18 cases of the anastomotic bleeding, 7 received conservative treatments, 9 underwent endoscopic treatment, and 2 underwent reoperation. All the 18 cases had reached hemostasis., Conclusion: IOE is an independent protective factor of anastomotic bleeding after LAR. Endoscopic hemostasis is recommended for an anastomotic bleeding after LAR for rectal cancer with a stapling technique.

Objective: To discuss the learning curve of laparoscopy-assisted distal gastrectomy (LADG) with lymph node dissection and the oncological results and long-term outcomes of different periods in the learning stage., Patients and Methods: One hundred twenty-four patients with gastric cancer who received LADG with lymph node dissection from January 2004 to December 2009 were retrospectively reviewed and analyzed. They were divided into three groups (A-C) according to different operative date: 41 were in Group A (early), 41 in Group B (middle), and 42 in Group C (laer). There were no significant statistical differences among the three groups with respect to age, gender, early/advanced gastric cancer, Union for International Cancer Control stage, and lymph node dissection. Then the following items were compared in these groups: operative time, blood loss, number of lymph nodes harvested, postoperative complications, postoperative hospital stay, and long-term survival., Results: The operative time in Group A (235.0±50.3 minutes) was significantly longer than in Groups B (201.7±39.6 minutes) and C (199.0±44.7 minutes), but there was no significant difference between Groups B and C. The harvest of lymph nodes from Group A (11.0±5.5) was significantly less than from Groups B (16.3±9.2) and C (17.2±8.7), but there was no significant difference between Groups B and C. The postoperative hospital stay and complications, overall survival, and disease-free survival showed no difference among the three groups., Conclusions: The learning curve of gastrointestinal surgeons with experience of laparoscopic operation is about 40 cases. The oncological principles and long-term outcomes were not sacrificed during the learning stage.

Purpose: To investigate the applicability, safety, short-term and long-term outcomes of laparoscopic surgery in the treatment of right-sided colon carcinomas with D3 lymphadenectomy., Methods: Between June 2003 and September 2010, 324 patients with right-sided colon carcinoma underwent surgical treatment in the same hospital, 177 cases were treated by laparoscopic surgery (LRH group) and 147 cases by open surgery (ORH group). We performed a retrospective analysis of the differences between the two groups in terms of the clinical data., Results: There were no significant differences between the two groups in the demographic data; however, the recovery time was significantly shorter in the LRH group, the number of overall lymph nodes harvested and principle lymph nodes harvested in the LRH group was significantly higher than in the ORH group, the incidence of postoperative complications was 12.99 % in the LRH group and 22.45 % in the ORH group (P < 0.05), and the recurrence rate in the LRH group was lower than that in the ORH group, although the difference was not significant (15.25 vs 19.73 %). The cumulative overall survival for all stages at 1, 3 and 5 years in the LRH group (97.18, 83.73 and 70.37 %) were not significantly different compared to those in the ORH group (94.56, 77.84 and 66.97 %)., Conclusions: Laparoscopic-assisted right hemicolectomy with D3 lymphadenectomy for colon carcinomas is safe and effective, while it is also superior to open surgery regarding the short-term outcomes, and the long-term outcomes are similar to those of open surgery.

Objective: To explore the feasibilities between operational approaches for laparoscopic complete mesocolic excision (CME) to right hemicolon cancer., Methods: This prospective randomized controlled trial included patients admitted to a Shanghai minimally invasive surgical center to receive laparoscopic CME from September 2011 to January 2013 randomized into two groups: hybrid medial approach (HMA) and completely medial approach (CMA). The feasibilities and strategies of the two techniques were studied and compared. Furthermore, the operation time and vessel-related complications were designed to be the primary end points, and other operational findings, including the classification of the surgical plane and postoperative recovery, were designed to be the secondary end points for this study., Results: After screening, 50 cases were allocated to the HMA group and 49 to the CMA group. Within the HMA group, there were 48 cases graded with mesocolic plane and 2 with intramesocolic plane. For the CMA group, there were 42 cases graded with mesocolic plane and seven with intramesocolic plane. The differences between the two were insignificant, as were the number of lymph nodes retrieved. The mean±standard deviation total operation time for the CMA group was 128.3 ± 36.4 min, which was significantly shorter than that for the HMA group, 142.6 ± 34.8 min. For the CMA group, the time involved in central vessel ligations and laparoscopic procedures was 58.5 %, 14.1 and 81.2 ± 23.5 min, respectively, which were shorter than the HMA group. The vessel-related complication rate was significantly higher in the HMA group., Conclusions: Laparoscopic CME via the total medial approach is technically feasible after the precise identification of the surgical planes and spaces for the right hemicolon. The procedure has a shorter operation time and fewer vessel-related complications.

Objective: The purpose of this study was to evaluate the feasibility, the safety, and outcomes of renal replacement therapy with the laparoscopic technique for peritoneal dialysis (PD) catheter implantation with an intra-abdominal fixation., Methods: Medical records of 53 patients with end-stage renal disease who underwent laparoscopic PD catheter implantation with an intra-abdominal fixation in our department from December 2008 to October 2009 were reviewed retrospectively. Their surgical procedure, operative outcomes, postoperative complications, and follow-up outcomes were analyzed., Results: All patients underwent laparoscopic PD catheter implantation with an intra-abdominal fixation successfully. Neither conversion to open surgery nor major intraoperative complications were observed. The median operative time was 24.2±10.5 minutes. The operative cost was 837.3±107.0 US$. Two patients (3.8%) had catheter obstruction peritonitis 12 and 15 months after surgery, respectively, and both of them had the catheter removed., Conclusions: Laparoscopic PD catheter implantation with an intra-abdominal fixation of the catheter tip is feasible and safe. It had a low incidence of PD catheter migration and other PD-related postoperative complications with the benefit of minimal invasiveness, a shorter operation time, and quicker postoperative recovery.

Purposes: To study the feasibility, safety, and short-/long-term outcomes of laparoscopy-assisted right hemicolectomy with D3 lymphadenectomy for colon cancer., Methods: The clinical data of 177 cases that underwent laparoscopy-assisted radical right hemicolectomy with D3 lymphadenectomy for colon cancer between Jun 2003 and Sep 2010 was collected; the safety of operation, status of recovery, complication, oncological outcomes, and results of short-/long-term follow-up were analyzed., Results: No case died in this study; five cases (2.82 %) were converted to open surgery. Four cases (2.26 %) underwent hand-assisted laparoscopic right hemicolectomy. The average operation time was 133 ± 36 min, and the blood loss was 94 ± 34 ml. The average time for passage of flatus, liquid food eating, and hospitalization were 2.1 ± 0.7, 3.2 ± 0.5, and 10.4 ± 2.7 day, respectively. The total number of lymph nodes removed was 15.2 ± 10.1. Postoperative complications were observed in 23 of 177 patients (12.99 %). The median follow-up period was 54 months; port-site recurrence was observed in one patient; local recurrence was found in five cases (2.82 %); distant metastasis was found in 21 cases (11.86 %). The cumulative overall survival of all stages at 12, 36, 60, and 72 months was 97.18 %, 83.73 %, 70.37 %, and 68.99 %, respectively. The cancer-specific survival was 98.73 % (12 months), 87.81 % (36 months), and 80.17 % (60 months)., Conclusions: Laparoscopy-assisted right hemicolectomy with D3 lymphadenectomy can be successfully performed for right colon cancer with the advantages of minimally invasive surgery. Moreover, the results implied appropriate short- and long-term outcomes.

Background: Our objective was to investigate the feasibility of laparoscopic inguinal hernia repair during its developmental phases in China., Study Design: The clinical data of 2,056 patients (2,473 hernias) who underwent laparoscopic inguinal hernia repair at Shanghai Minimally Invasive Surgery Center between January 2001 and December 2011 were analyzed retrospectively. The operation priority was used to divide the patients into 7 groups for analysis of the learning curve., Results: There were 1,005 transabdominal preperitoneal patch plastic repairs (TAPP), 1,458 total extraperitoneal repairs (TEP), and 10 intraperitoneal onlay mesh repairs performed on 874, 1,175, and 7 patients, respectively. Median follow-up period was 60 months. The operation time and postoperative hospital stay for TEP were considerably shorter than those for TAPP. The complication rate for TEP, especially seroma, was considerably lower. Transabdominal preperitoneal patch plastic repair was performed in 81.4% of the recurrent inguinal hernias. Seven patients underwent unilateral intraperitoneal onlay mesh repair and 3 others underwent unilateral intraperitoneal onlay mesh repair and TAPP on the opposite. Most of patients with grade I and II hernias underwent TEP. The learning curve has demonstrated that more obstacles occurred in the earlier phase of the laparoscopic inguinal hernia repair training, supported by findings such as fewer cases performed annually, longer operation time, and higher incidence of complications and recurrence. These findings have improved as experience is accumulated through more operations. In addition, the ratios of TEP to TAPP and mesh nonfixation to fixation also evolved throughout the course of the study., Conclusions: Laparoscopic inguinal hernia repair is a feasible technique that can be popularized in China., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This study was designed to investigate the feasibility and technical strategies of laparoscopic complete mesocolic excision (CME) for right-hemi colon cancer., Methods: The clinical and pathological findings of 64 patients with right-hemi colon cancer who underwent laparoscopic CME between March 2010 and September 2011 were collected retrospectively. Among them, 35 cases were eligible for the final analysis through various screening factors. The quality of surgery also was assessed by reviewing the recorded video obtained through the operations in terms of specimen anatomic planes and completeness of the excised mesocolon., Results: Laparoscopic CME is focused on applying the concept of enveloped visceral and parietal planes during the operations. Laparoscopic approach proceeds with medial access where the dissection starts at ileocolic vessel before proceeds along with the superior mesenteric vessel. The access also emphasized en bloc resection of mesocolon without defections to the planes. Besides, lymph node resections at the root of ileocolic; right colic and middle colic vessels are necessary for ileocecum cancer. Cancers at the hepatic flexure requires further dissection of subpyloric lymph nodes and of greater omentum that is within 15 cm of the tumor and along the greater curvature. Thirty-five cases were evaluated as good plane. The median total number of central lymph nodes retrieved was 19 (range, 15-25) and central lymph node metastasis was found in 5 of all stage III cases. The median operation time was 2.6 h and the blood loss was 80 mL. The median time for passage of flatus and hospitalization were 2 and 12 days respectively. Complications were observed in three cases., Conclusions: CME is a novel concept for colon cancer surgery and might be a standard for the procedure. Laparoscopic CME with medial access is technically feasible and randomized trials are needed to evaluate its long-term outcomes.

Purpose: To evaluate laparoscopic gastric resection for gastrointestinal stromal tumors (GIST)., Methods: From June, 2003 to October, 2009, 56 patients with gastric GIST who underwent laparoscopic gastric resection were retrospectively reviewed, and their surgical procedure, perioperative outcomes, pathology, and follow-up outcomes were analyzed., Results: All patients underwent laparoscopic gastric resection successfully, including 33 laparoscopic wedge resections, 19 laparoscopic transgastric tumor-everting resections, 3 laparoscopic-assisted distal gastrectomies, and 1 laparoscopic-assisted endoscopic resection. The operative approaches performed were mostly based on the tumor location. No conversions were observed. The mean operative duration was 90 minutes (30 to 210 min), blood loss was 55 mL (5 to 180 mL), time for passage of flatus was 2 days (1 to 11 d), and the postoperative hospital stay was 7 days (3 to 13 d). The resection margin was microscopic negative. After 21.5 months (6 to 76 mo) of follow-up, there was no operative recurrence and metastasis., Conclusions: Laparoscopic gastric resection for selective cases of gastric GISTs is safe, feasible, and effective. Laparoscopic wedge resection procedure is the first choice for most GISTs located in fundus and anterior wall, laparoscopic transgastric tumor-everting resection procedure can be used in cases with the tumor located in esophagogastric junction area and in posterior wall of the stomach as well. For antral tumors, laparoscopic subtotal gastrectomy with gastrojejunostomy should be performed.

Objective: To evaluate laparoscopic radical gastrectomy for early gastric cancer., Methods: A total of 204 patients with early gastric cancer undergoing laparoscopic-assisted radical gastrectomy or open radical gastrectomy between October 2004 and December 2009 were retrospectively reviewed and analyzed. Patients were divided into laparoscopic group(LAP, n=78) and open group (OPEN, n=126). Operative time, blood loss, time to passage of flatus, postoperative hospital stay, complications and pathologic findings were compared between the two groups., Results: Compared to the OPEN group, operative time in the LAP group was significantly shorter[(202.9±45.6) min vs.(219.8±45.2) min, P<0.05], blood loss was less[(144.5±146.5) ml vs. (245.0±146.4) ml, P<0.05], time to passage of flatus was shorter[(3.1±1.1) d vs.(4.5±1.6) d, P<0.05], postoperative hospital stay was shorter[(10.8±1.2) d vs. (12.4±3.8) d, P<0.05]. However, the two groups were comparable with regard to postoperative complication rate(10.3% vs. 12.7%, P>0.05), proximal resection margin[(4.0±1.9) cm vs. (4.2±1.7) cm, P>0.05], distal resection margin [(3.6±1.7) cm vs. (3.5±1.8) cm, P>0.05], number of harvested lymph node(13.1±6.5 vs. 14.5±8.2, P>0.05). The median follow up was 22(2-64) months. There were no tumor recurrences or metastases in the LAP group. In the OPEN group, only 1 patient died from peritoneal metastasis. Total hospital costs between the two groups were similar(P>0.05)., Conclusion: Laparoscopic radical gastrectomy is a safe, feasible, effective, and less invasive surgery for early gastric cancer.

Background: Few studies evaluate the cost-effectiveness issues of laparoscopic anterior resection (LAR) for rectal cancer. This study evaluates direct and indirect costs of LAR and its long-term survival rate in rectal cancer patients., Material/methods: This prospective nonrandomized controlled trial included 2 endpoints (direct and indirect costs, and disease-free survival). From January 2003 to May 2005, rectal cancer patients admitted to our center were assigned to 2 groups: 87 patients underwent LAR (LAP), while 86 cases received open anterior resection (OPEN). The direct costs were prospectively evaluated. Main indirect cost is productivity loss. The data of direct costs, indirect costs, and the total costs were collected for the minimal cost analysis., Results: Disease-free survival at 65 months in the LAP group and the OPEN group was 78.2% and 74.7%; there was no significant difference between the groups. Median direct costs were not significantly different between the LAP and the OPEN groups. Indirect costs of the LAP group were significantly lower than those of the OPEN group, while total costs were not significantly different. Cost percentage for operations, medications, and hospitalization were 75.90%, 11.28%, and 2.18% in the LAP group; while in the operation group, they were 54.50%, 29.09%, and 3.35%., Conclusions: Total economic budget for a patient receiving LAR was not significantly increased compared with the conservative method owing to its technical predominance, oncologic safety, as well as frequent bed turnover.

This study aimed to assess the feasibility and long-term outcome of laparoscopic total mesorectal excision for middle and lower rectal cancer. Retrospective assessment was performed on 612 patients with middle and low rectal cancer in the surgery department of our hospital. Three-hundred and three patients underwent laparoscopic total mesorectal excision (LTME), and 309 patients underwent open TME (OTME). All the data regarding patient details, operative variables and the short- and long-term outcomes were collected and compared. The sphincter-preserving rates of the two groups were similar. The conversion rate in LTME was 2.31% (seven cases). Fourteen cases (6.67%) of protective diverting stoma were fashioned in the LTME group compared with 57 cases (26.64%) in the OTME group. The postoperative morbidity was the same in these two groups, while the postoperative period until bowel movement and hospital discharge was shorter in the LTME group (P < 0.01). The median follow-up period was 34 (6-81) months for the LTME group and 36 (6-81) months for the OTME group. Local recurrence rates, the five-year disease-free survival rate and the five-year overall survival rate showed no difference between the two groups. Laparoscopic surgery is feasible and safe in patients with middle and lower rectal cancer and can provide favorable short-term and long-term outcomes.

Aim: To analyze the clinical manifestations and risk factors of complications in laparoscopic low anterior resection (LAR) for rectal cancer patients., Methods: A series of 132 consecutive patients who received laparoscopic LAR for rectal cancer in our center were included. The etiology, diagnosis, treatment and prevention of rectal cancer were studied among the patients with surgery-related complications using both univariate and multivariate regression analysis., Results: No conversion to open surgery was observed and 5 cases converted to hand-assisted laparoscopic operation. The overall morbidity rate was 20.5%. Complications occurred during the operation in 7 patients (5.3%), within 30 postoperative days in 24 patients (18.2%), and within 3 mo in 2 patients (1.5%). The most significant complications were anastomotic leakage (9.1%) and anastomotic hemorrhage (5.3%). Size and location of tumor, pathological staging and preoperative nutrition were significant factors associated with LAR complications, while gender, age and pathological type showed no relevance. Binary logistics regression showed that the size and location of tumor, and pathological staging were independent factors of laparoscopic LAR. All the complications were treated during their onset of clinical manifestations by interventional or conservative therapy., Conclusion: Anastomotic leakage is a major complication in laparoscopic LAR. The complications may be associated with tumor size and site, and pathological stage. Interventional therapies are of value in the management of laparoscopic LAR complications.

Background: Morbidity of small intestinal disease is rare and the associated lesion is hard to be detected due to lack of specific manifestations and effective diagnostic approaches. Hematochezia and melena are the most common symptoms in small intestinal diseases. Hence, small intestinal disease is an important differential diagnosis when hematochezia or melena occurs, especially when gastric and colonic diseases are excluded. As the small intestinal lesion is hard to be located preoperatively, laparotomy used to be performed without a preoperative location. This might lead to related postoperative complications. With the development of laparoscopic technique, laparoscopic operations are more frequently applied to surgical disease, despite their benign or malignant nature. Generally, almost all kinds of small intestinal disease can be treated with laparoscopic surgery., Methods: Clinical data of 77 patients with small intestinal bleeding undergoing laparoscopic or laparoscopy-assisted operations from April 2003 to December 2008 were included, and their clinical information were analyzed retrospectively., Results: No intraoperative complication or conversion was observed in all cases. The mean operative time, mean estimated blood loss, and mean size of incision were 78.3 +/- 30.5 minutes, 17.5 +/- 9.8 mL, and 3.3 +/- 1.9 cm, respectively. Postoperative complications occurred in 4 patients, including 2 cases of adhesive ileus, 1 case of gastric retention, and 1 case of anastomotic bleeding. All of them were cured by nonoperative management. The mean flatus time was 2 days after operation and the mean postoperative hospital stay was 7 days. There was 1 case of gastrointestinal stromal tumor with local recurrence and hepatic metastasis. Four patients died from metastasis of malignant tumors during the follow-up from 2 to 70 months after operations. No trocar site or wound recurrences were noted., Conclusions: Laparoscopic treatment in small intestinal bleeding is feasible, safe, and minimally invasive. It may be widely used in the future for its good therapeutic outcomes and improved diagnostic chance in small intestinal bleeding diseases.

Background: There is still a debate about the utility of intraoperative cholangiography (IOC) or laparoscopic ultrasonography (LUS) for detection of occult choledocholithiasis during laparoscopic cholecystectomy (LC). The aim of this study was to assess the value of IOC combined with LUS for detection of occult common bile duct (CBD) stones at LC., Material/methods: From Dec 2002 to Aug 2006, 103 patients with moderate risk of CBD stones underwent IOC and LUS simultaneously during LC. The physician teams for the two different procedures were blinded by each other. The sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated by several contingency tables that cross-tabulated the results of each technique with those of the gold standard., Results: The success rate of IOC and LUS were 91.3% and 100% respectively and the time required for LUS was significantly shorter (P<0.01). The visualization of intrapancreatic part of CBD by IOC (97.3%) was significantly higher than LUS (73.8%). The sensitivities, specificities, accuracies, positive and negative predictive values, positive and negative likelihood rations identifying occult CBD stones were 75.0%, 98.7%, 92.2%, 95.5%, 91.4%, 57.7 and 0.253 by IOC, and 82.1%, 98.7%, 94.2%, 95.8%, 93.7%, 63.2 and 0.181 by IUS respectively. The McNemar test showed no significant difference between two methods. The sensitivity of IOC combined with LUS was 92.9%, which was greater than that of IOC and LUS taken separately., Conclusions: LUS is usually performed in case where IOC has failed or is contraindicated. The combination of both methods maximizes intraoperative detection of occult CBD stones and should at least be recommended as two complementary methods.

Laparoscopic resection of rectal cancer or gastric cancer has been advocated for the benefits of a reduced morbidity, a shorter treatment time, and similar outcomes. However, simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy for synchronous carcinoma of rectum and stomach are rarely documented in literature. Endoscopic examination revealed a synchronous carcinoma of rectum and stomach in a 55-year-old male patient with rectal bleeding and epigastric discomfort. He underwent a simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy with regional lymph nodes dissected. The operation time was 270 min and the estimated blood loss was 120 mL. The patient required parenteral analgesia for less than 24 h. Flatus was passed on postoperative day 3, and a solid diet was resumed on postoperative day 7. He was discharged on postoperative day 13. With the advances in laparoscopic technology and experience, simultaneous resection is an attractive alternative to a synchronous gastrointestinal cancer.

Background and Aims: Elderly patients have a high incidence of colorectal cancer, which may be associated with increased morbidity and mortality due to complex comorbidity and diminished cardiopulmonary reserves. The aims of this study were to compare the outcomes of laparoscopic colorectal cancer surgery with those observed in traditional open surgery in patients aged over 70 years., Methods: Between January 2003 and October 2004, 51 patients aged over 70 years with colorectal cancer, who underwent laparoscopic surgery (LAP group), were evaluated and compared with 102 controls (also over 70 years old) treated by traditional open surgery (OPEN group) in the same period. All patients were evaluated with respect to the American Society of Anesthesiologists (ASA) classification, surgery-related complications, and postoperative recovery., Results: No surgery-related death was observed in the LAP group, whereas two deaths occurred in the OPEN group for severe post-operative pulmonary infection and anastomotic leak, respectively. No pneumoperitoneum-related complications were observed in the LAP group; 2 (3.9%) patients required conversion to open surgery, because of the unexpectedly bulky tumor and severe adhesions in the abdominal cavity. With the increase in patients' age, increased ASA classification was observed. No significant differences were observed in gender, Dukes' staging or types of procedures between LAP and OPEN groups. The overall morbidity in the LAP group was significantly less than that of the OPEN group [17.6% (9/51) vs 37.3% (38/102), p=0.013]. Mean blood loss, time to flatus passage, and time to semi-liquid diet in the LAP group were significantly shorter than those of the OPEN group (90.7+/-49.9 vs 150.3+/-108.7 ml, 2.4+/-1.2 vs 3.5+/-2.9 d, 5.0+/-1.8 vs 5.9+/-1.2 d, respectively, p<0.05). No significant differences were observed in terms of mean operation time or hospital stay between LAP and OPEN groups., Conclusion: Laparoscopic colorectal cancer surgery in elderly patients with colon cancer has clinically significant advantages over traditional open surgery, and appears to be the ideal surgical choice for the elderly.

Background: Minimal access techniques have gained wide acceptance in surgical practice, but the role of laparoscopic pancreaticoduodenectomy is still controversial. Laparoscopic pancreaticoduodenectomy has seldom been described. In this report, we assessed the feasibility and safety of laparoscopic pancreaticoduodenectomy for ductal adenocarcinoma of the common bile duct., Case Report: According to imaging findings, a 71-year-old Chinese man was diagnosed with malignancy of the common bile duct, and successfully underwent laparoscopic pancreaticoduodenectomy in our center. The operation's safety, postoperative recovery, complications, oncological clearance, and short-term follow-up results of the patient are evaluated. No severe intraoperative or postoperative complications were observed. The operation time was 390 minutes, and the blood loss was about 50 ml; the flatus, time to resume early activity and hospital stay were 3, 4, and 30 days respectively. The patient remained well at a follow-up of 6 months., Conclusions: Laparoscopic pancreaticoduodenectomy can be performed feasibly and safely by surgeons with advanced laparoscopic skills, and could be considered for the treatment of common bile duct tumors.

Objective: To investigate the feasibility of the laparoscopic salvage surgery for locally recurrent rectal cancer., Methods: Seven cases with recurrent rectal carcinoma treated by laparoscopic salvage surgery from February 2004 to July 2005 were retrospectively analyzed. Among them, four were males and 3 females, and the median age was 60 years (range 37-74). Three cases of recurrence were after conventional anterior resection, 2 after laparoscopic-assist anterior resection, 1 after laparoscopic-assist Parks' procedure, and 1 with pars sacral fistula after per-sacral-local resection for three times. Image examination (CT scanning) was taken preoperatively to evaluate the locally recurrence and exclude the distant metastases. The laparoscopic-assist procedure with or without a hand-assist technique was used in this study., Results: Six cases with the recurrent lesion of central type were treated by salvage surgical procedure as follows: 3 laparoscopic-assist anterior resection, 1 laparoscopic-assist abdominoperineal resection, 1 laparoscopic-assist posterior exenteration, and 1 laparoscopic-assist proctocolectomy with a terminal ileum stoma. All of them were R0 resection confirmed by postoperative pathological examination. The other one with the lesion of combination type was treated with the procedure of laparoscopic-assist sigmoid colostomy. A hand-assist technique was used in 2 cases. The mean operation time, bleeding and hospital day was (211 +/- 13) min, (200 +/- 91) ml, and (15 +/- 10) d, respectively. No conversion and complication occurred., Conclusion: Laparoscopic salvage surgery for locally recurrent rectal cancer is safe and feasible when taken by experienced laparoscopic colorectal surgeon to the cases with the recurrent lesion of central type.

Aim: Laparoscopic surgery, especially laparoscopic rectal surgery, for colorectal cancer has been developed considerably. However, due to relatively complicated anatomy and high requirements for surgery techniques, laparoscopic right colectomy develops relatively slowly. This study was designed to compare the outcomes of laparoscopic right hemicolectomy (LRH) with open right hemicolectomy (ORH) in the treatment of colon carcinoma., Methods: Between September 2000 and February 2003, 30 patients with colon cancer who underwent LRH were compared with 34 controls treated by ORH in the same period. All patients were evaluated with respect to surgery-related complications, postoperative recovery, recurrence and metastasis rate, cost-effectiveness and survival., Results: Among 30 LRH, 2 (6.7%) were converted to open procedure. No significant differences were observed in terms of mean operation time, blood loss, post-operative complications, and hospital cost between LRH and ORH groups. Mean time for bowel movement, hospital stay, and time to resume early activity in the LRH group were significantly shorter than those in the ORH group (2.24+/-0.56 vs 3.25+/-1.29 d, 13.94+/-6.5 vs 18.25+/-5.96 d, 3.94+/-1.64 vs 5.45+/-1.82 d respectively, P<0.05). As to the lymph node yield, the specimen length and total cost for operation and drugs, there was no significant difference between the two groups. Local recurrence rate and metachronous metastasis rate had no marked difference between the two groups. Cumulative survival probability at 40 mo in LRH group (76.50%) was not obviously different compared to the ORH group (74.04%)., Conclusion: LRH in patients with colon cancer has statistically and clinically significant advantages over ORH. Thus, LRH can be regarded as a safe and effective procedure.

Objective To investigate the clinical characteristics and laparoscopic strategy of female inguinal hernia with cyst of round ligament of uterus. Methods The clinical data of 63 female patients of inguinal hernia with cyst of round ligament of uterus as cyst group admitted to our Department of Surgery, from January 2001 to December 2018 were analyzed retrospectively. The patients in cyst group were compared to contemporaneous 412 female patients of inguinal hernia without cyst as non-cyst group. Results The majority female patients of inguinal hernia with cyst of round ligament of uterus were youth with 87.3% of indirect hernia. There were 93.7% transabdominal preperitoneal(TAPP) repaire more than 6.3% total extraperitoneal repaire. The preservation rate of round ligament of uterus was 34.9% in cyst group and 46.4% in non-cyst group without significant difference statistically (P=0.086). However, the preservation rate of round li-gament of uterine of patients younger than 45 years in cyst group (47.1%) was less than that in non-cyst group (89.1%) and the difference was statistically significant (P0.05). Conclusions Female inguinal hernia with cyst of round ligament of uterus ws more seen in young women. TAPP could be used for exploration and definite diagnosis. Most cyst of round ligament of uterus can be resected during herniorrhaphy simultaneously. The difficulty in retaining round ligament of uterus increased when the cyst is present.

AIM: This study aimed to assess the safety and feasibility of laparoscopic curative resection for colorectal cancer through the clinical practice and basic research. MATERIAL AND METHODS: From September 2001 to September 2002, 47 patients with colorectal cancer were treated using laparoscopic approach, compared with 113 patients underwent traditional operation. The length of intestinal segment excised, size of tumour, clearance of lymph nodes, local recurrence and distant metastasis rate during the period of follow-up in both groups were compared. The other part of the study involved the detection of exfoliated tumour cells in the peritoneal washing before and after surgery; flushing of the instruments was performed in both groups and the results compared. For the laparoscopic cases, the filtrated liquid of CO2 pneumoperitoneum was also checked for tumour cells. RESULTS: No significant differences existed in tumour size, operative site and manner between the two groups. The exfoliated tumour cell was not detected in the CO2 filtrated liquid. Between both groups there was no difference in the incidence of exfoliated tumour cells in peritoneal washing before and after surgery as well as in the fluid used for flushing the instruments. The total number of lymph nodes harvested was 13.71±9.57 for the laparoscopic group and 12.10±9.74 for the traditional procedure. Similar length of colon was excised in both groups; this was (19.38±7.47) cm in the laparoscopic and (18.60±8.40) cm in the traditional groups. The distal margins of resection for rectal cancer were (4.19±2.52) cm and (4.16±2.00) cm respectively. The local recurrence rate was 2.13% (1/47) and 1.77% (2/113) with the distant metastasis rate 6.38% (3/47) and 6.19% (7/113) respectively. Both the statistics were comparable between the laparoscopic and traditional surgery for the colorectal cancer. CONCLUSIONS: Laparoscopic curative resection for colorectal cancer can be performed safely and effectively. In the treatment of colorectal malignancy, laparoscopic resection can achieve similar radicalilty as compared to the traditional laparotomy.