With an increasing percentage of colorectal resections performed laparoscopically nowadays, there is more emphasis on training “before the job” on operative skills, including the comprehension of specific laparoscopic surgical anatomy. As integration of technical skills with correct interpretation of the anatomical image must be incorporated in laparoscopic training, a human specimen training model with special emphasis on surgical anatomy was developed.
The new embalming method Anubifix™ combines long-term high-quality embalming of human bodies with almost normal flexibility and plasticity, and the body can be kept operational as long as conventionally embalmed human specimens. A colorectal training model was created in a specimen in which anatomical landmarks of colorectal anatomy were permanently colored to explore laparoscopic colorectal anatomy in a skills training setting. Airtight closure of the abdominal wall permits the creation of pneumoperitoneum. Residents were asked to test the model by mobilizing the small and large bowels and expose the central vessels and ureters. Afterward they were asked to fill out an eight-item questionnaire about the model.
Eleven surgical residents in their first and second year of training participated. Responses to the questionnaire showed that a majority of residents considered the model to be representative of the real situation and superior to animal models or virtual reality simulators, and helped to improve the knowledge of three-dimensional anatomy and laparoscopic skills.
The new training model for laparoscopic colorectal surgery proved to be a high-quality tool, concentrating on laparoscopic colorectal anatomy in a skills training setting. We believe it may be a valuable adjunct to residency training programs based on the principle of “training before the job.”
Abdominal; Laparoscopic education; Training; Colorectal surgery; Gastrointestinal
Both “high tie” (HT) and “low tie” (LT) are well-known strategies in rectal surgery. The aim of this study was to compare colonic perfusion after HT to colonic perfusion after LT.
Patients undergoing rectal resection for malignancy were included. Colonic perfusion was measured with laser Doppler flowmetry, immediately after laparotomy on the antimesenterial side of the colon segment that was to become the afferent loop (measurement A). This measurement was repeated after rectal resection (measurement B). The blood flow ratios (B/A) were compared between the HT group and the LT group.
Blood flow was measured in 33 patients, 16 undergoing HT and 17 undergoing LT. Colonic blood flow slightly decreased in the HT group whereas the flow increased in the LT group. The blood flow ratio was significantly higher in the LT group (1.48 vs. 0.91; p = 0.04), independent of the blood pressure.
This study shows the blood flow ratio to be higher in the LT group. This suggests that anastomoses may benefit from better perfusion when LT is performed.
High tie; Low tie; Perfusion; Colorectal surgery; Anastomosis
Recently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy.
The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis).
In this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmann's procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmann's procedure and resection with primary anastomosis (DIVA-arm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVA-arm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and power = 90%) in favour of the patients with resection with primary anastomosis. Secondary endpoints for both arms are the number of days alive and outside the hospital, health related quality of life, health care utilisation and associated costs.
The Ladies trial is a nationwide multicentre randomised trial on perforated diverticulitis that will provide evidence on the merits of laparoscopic lavage and drainage for purulent generalised peritonitis and on the optimal resectional strategy for both purulent and faecal generalised peritonitis.
Nederlands Trial Register NTR2037
The existing literature regarding acute perforated diverticulitis only reports about short-term outcome; long-term following outcomes have not been assessed before. The aim of this study was to assess long-term quality of life (QOL) after emergency surgery for perforated diverticulitis.
Patients and Methods
Validated QOL questionnaires (EQ-VAS, EQ-5D index, QLQ-C30, and QLQ-CR38) were sent to all eligible patients who had undergone emergency surgery for perforated diverticulitis in five teaching hospitals between 1990 and 2005. Differences were compared between patients that had undergone Hartmann’s procedure (HP) or resection with primary anastomosis (PA) and also compared to a sex- and age-matched sample of healthy subjects.
Of a total of 340 patients, only 150 patients (44%) were found still alive in July 2007 (median follow-up 71 months). The response rate was 87%. In patients with PA, QOL was similar to the general population, whereas QOL after HP was significantly lower. The presence of a stoma was found to be an independent factor related to worse QOL. The deterioration in QOL was mainly due to problems in physical function and body image.
Survivors after perforated diverticulitis had a worse QOL than the general population, which was mainly due to the presence of an end colostomy. QOL may improve if these stomas are reversed or not be performed in the first place.
Perforated diverticulitis; Quality of life; Hartmann’s procedure; Primary anastomosis
Laparoscopic cholecystectomy (LC) is the most performed minimal invasive surgical procedure and has a relatively high complication rate. As complications are often revealed postoperatively, clear, accurate, and timely written operative notes are important in order to recall the procedure and start follow-up treatment as soon as possible. In addition, the surgeon’s operative notes are important to assure surgical quality and communication with other healthcare providers. The aim of the present study was to assess compliance with the Dutch guidelines for writing operative notes for LC.
Nine hospitals were asked to send 20 successive LC operative notes. All notes were compared to the Dutch guideline by two reviewers and double-checked by a third reviewer. Statistical analyses on the “not described” items were performed.
All hospitals participated. Most notes complied with the Dutch guideline (52–69%); 19–30% of items did not comply. Negative scores for all hospitals were found, mainly for lacking a description of the patient’s posture (average 69%), bandage (94%), blood loss (98%), name of the scrub nurse (87%), postoperative conclusion (65%), and postoperative instructions (78%). Furthermore, notes from one community hospital and two teaching hospitals complied significantly less with the guidelines.
Operative notes do not always fully comply with the standards set forth in the guidelines published in the Netherlands. This could influence adjuvant treatment and future patient treatment, and it may make operative notes less suitable background for other purposes. Therefore operative note writing should be taught as part of surgical training, definitions should be provided, and procedure-specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.
The supposed optimal treatment of perforated diverticulitis with generalized peritonitis has changed several times during the last century, but at present is still unclear.
The first cases of complicated perforated diverticulitis of the colon were reported in the beginning of the twentieth century. At that time the first therapeutic guidelines were postulated in which an initial nonresectional procedure was provided to be the safest plan of management. After many years in which resection had become standard practice, today, one century later, again (laparoscopic) nonresectional surgery is presented as a safe and promising alternative in treatment of complicated perforated diverticulitis. The question rises what had happened to close the circle?
This paper includes a historic summary of changing patterns in surgical strategies in perforated diverticulitis complicated by generalized peritonitis.
Perforated peptic ulcer (PPU), despite antiulcer medication and Helicobacter eradication, is still the most common indication for emergency gastric surgery associated with high morbidity and mortality. Outcome might be improved by performing this procedure laparoscopically, but there is no consensus on whether the benefits of laparoscopic closure of perforated peptic ulcer outweigh the disadvantages such as prolonged surgery time and greater expense.
An electronic literature search was done by using PubMed and EMBASE databases. Relevant papers written between January 1989 and May 2009 were selected and scored according to Effective Public Health Practice Project guidelines.
Data were extracted from 56 papers, as summarized in Tables 1–7. The overall conversion rate for laparoscopic correction of perforated peptic ulcer was 12.4%, with main reason for conversion being the diameter of perforation. Patients presenting with PPU were predominantly men (79%), with an average age of 48 years. One-third had a history of peptic ulcer disease, and one-fifth took nonsteroidal anti-inflammatory drugs (NSAIDs). Only 7% presented with shock at admission. There seems to be no consensus on the perfect setup for surgery and/or operating technique. In the laparoscopic groups, operating time was significant longer and incidence of recurrent leakage at the repair site was higher. Nonetheless there was significant less postoperative pain, lower morbidity, less mortality, and shorter hospital stay.
There are good arguments that laparoscopic correction of PPU should be first treatment of choice. A Boey score of 3, age over 70 years, and symptoms persisting longer than 24 h are associated with higher morbidity and mortality and should be considered contraindications for laparoscopic intervention.
Laparoscopic surgery; Perforated peptic ulcer; Omentoplasty; Review
Several studies have been performed to identify risk factors for abdominal wound dehiscence. No risk model had yet been developed for the general surgical population. The objective of the present study was to identify independent risk factors for abdominal wound dehiscence and to develop a risk model to recognize high-risk patients. Identification of high-risk patients offers opportunities for intervention strategies.
Medical registers from January 1985 to December 2005 were searched. Patients who had primarily undergone appendectomies or nonsurgical (e.g., urological) operations were excluded. Each patient with abdominal wound dehiscence was matched with three controls by systematic random sampling. Putative relevant patient-related, operation-related, and postoperative variables were evaluated in univariate analysis and subsequently entered in multivariate stepwise logistic regression models to delineate major independent predictors of abdominal wound dehiscence. A risk model was developed, which was validated in a population of patients who had undergone operation between January and December 2006.
A total of 363 cases and 1,089 controls were analyzed. Major independent risk factors were age, gender, chronic pulmonary disease, ascites, jaundice, anemia, emergency surgery, type of surgery, postoperative coughing, and wound infection. In the validation population, risk scores were significantly higher (P < 0.001) for patients with abdominal wound dehiscence (n = 19) compared to those without (n = 677). Resulting scores ranged from 0 to 8.5, and the risk for abdominal wound dehiscence over this range increased exponentially from 0.02% to 70.1%.
The validated risk model shows high predictive value for abdominal wound dehiscence and may help to identify patients at increased risk.
High-tie ligation is a common practice in rectal cancer surgery. However, it compromises perfusion of the proximal limb of the anastomosis. This anatomical study was designed to assess the value of low-tie ligation in order to obtain a tension-free anastomosis.
Materials and methods
Consecutive high- and low-tie resections were performed on 15 formalin-fixed specimens, with or without splenic flexure mobilization. If the proximal colon limb could reach the superior aspect of the symphysis pubis with more than 3 cm, the limb would be long enough for a tension-free colorectal anastomosis.
In 80% of cases, it was not necessary to perform high-tie ligation as sufficient length was gained with low-tie ligation. The descending branch of the left colic artery was the limiting factor in the other 20% of cases. Resecting half the sigmoid resulted in four times as many tension-free anastomoses after low-tie resection.
In the majority of cases, it was not necessary to perform high-tie ligation in order to create a tension-free anastomosis. Low-tie ligation was applicable in 80% of cases and might prevent anastomotic leakage due to insufficient blood supply of the proximal colon limb.
Vascular anatomy; Anastomosis; Inferior mesenteric artery; Rectal cancer
In the limited literature concerning abdominal wound dehiscence after laparotomy in children, reported incidences range between 0.2–1.2% with associated mortality rates of 8–45%. The goal of this retrospective case-control study was to identify major risk factors for abdominal wound dehiscence in the pediatric population.
Patients younger than aged 18 years who developed abdominal wound dehiscence in three pediatric surgical centers during the period 1985–2005 were identified. For each patient with abdominal wound dehiscence, four controls were selected by systematic random sampling. Patients with (a history of) open abdomen treatment or abdominal wound dehiscence were excluded as control subjects. Putative relevant patient-related, operation-related, and postoperative variables for both cases and control subjects were evaluated in univariate analyses and subsequently entered in multivariate stepwise logistic regression models to identify major independent predictors of abdominal wound dehiscence.
A total number of 63 patients with abdominal wound dehiscence and 252 control subjects were analyzed. Mean presentation of abdominal wound dehiscence was at postoperative day 5 (range, 1–15) and overall mortality was 11%. Hospital stay was significantly longer (p < 0.001) in the case group (median, 42 vs. 10 days). Major independent risk factors for abdominal wound dehiscence were younger than aged 1 year, wound infection, median incision, and emergency surgery. Incisional hernia was reported in 12% of the patients with abdominal wound dehiscence versus 3% in the control group (p = 0.001).
Abdominal wound dehiscence is a serious complication with high morbidity and mortality. Median incisions should be avoided whenever possible.
Laparoscopic surgery has become popular during the last decade, mainly because it is associated with fewer postoperative complications than the conventional open approach. It remains unclear, however, if this benefit is observed after laparoscopic correction of perforated peptic ulcer (PPU). The goal of the present study was to evaluate whether laparoscopic closure of a PPU is as safe as conventional open correction.
The study was based on a randomized controlled trial in which nine medical centers from the Netherlands participated. A total of 109 patients with symptoms of PPU and evidence of air under the diaphragm were scheduled to receive a PPU repair. After exclusion of 8 patients during the operation, outcomes were analyzed for laparotomy (n = 49) and for the laparoscopic procedure (n = 52).
Operating time in the laparoscopy group was significantly longer than in the open group (75 min versus 50 min). Differences regarding postoperative dosage of opiates and the visual analog scale (VAS) for pain scoring system were in favor of the laparoscopic procedure. The VAS score on postoperative days 1, 3, and 7 was significant lower (P < 0.05) in the laparoscopic group. Complications were equally distributed. Hospital stay was also comparable: 6.5 days in the laparoscopic group versus 8.0 days in the open group (P = 0.235).
Laparoscopic repair of PPU is a safe procedure compared with open repair. The results considering postoperative pain favor the laparoscopic procedure.
This study aims to increase knowledge of colorectal anastomotic leakage by performing an incidence study and risk factor analysis with new potential risk factors in a Dutch tertiary referral center.
All patients whom received a primary colorectal anastomosis between 1997 and 2007 were selected by means of operation codes. Patient records were studied for population description and risk factor analysis.
In total 739 patients were included. Anastomotic leakage (AL) occurred in 64 (8.7%) patients of whom nine (14.1%) died. Median interval between operation and diagnosis was 8 days. The risk for AL was higher as the anastomoses were constructed more distally (p = 0.019). Univariate analysis showed duration of surgery (p = 0.038), BMI (p = 0.001), time of surgery (p = 0.029), prophylactic drainage (p = 0.006) and time under anesthesia (p = 0.012) to be associated to AL. Multivariate analysis showed BMI greater than 30 kg/m2 (p = 0.006; OR 2.6 CI 1.3–5.2) and “after hours” construction of an anastomosis (p = 0.030; OR 2.2 CI 1.1–4.5) to be independent risk factors.
BMI greater than 30 kg/m2 and “after hours” construction of an anastomosis were independent risk factors for colorectal anastomotic leakage.
After-hours; Colorectal surgery; Anastomotic leakage; Body mass index
Consensus does not exist on the level of arterial ligation in rectal cancer surgery. From oncologic considerations, many surgeons apply high tie arterial ligation (level of inferior mesenteric artery). Other strategies include ligation at the level of the superior rectal artery, just caudally to the origin of the left colic artery (low tie), and ligation at a level without any intraoperative definition of the inferior mesenteric or superior rectal arteries.
Publications concerning the level of ligation in rectal cancer surgery were systematically reviewed. Twenty-three articles that evaluated oncologic outcome (n = 14), anastomotic circulation (n = 5), autonomous innervation (n = 5), and tension on the anastomosis/anastomotic leakage (n = 2) matched our selection criteria and were systematically reviewed. There is insufficient evidence to support high tie as the technique of choice. Furthermore, high tie has been proven to decrease perfusion and innervation of the proximal limb. It is concluded that neither the high tie strategy nor the low tie strategy is evidence based and that low tie is anatomically less invasive with respect to circulation and autonomous innervation of the proximal limb of anastomosis. As a consequence, in rectal cancer surgery low tie should be the preferred method.
Total mesorectal excision; Rectal cancer; High tie; Low tie; Central arterial ligation; Inferior mesenteric artery
Iatrogenic bile duct injury remains a current complication of laparoscopic cholecystectomy. One uniform and standardized protocol, based on the “critical view of safety” concept of Strasberg, should reduce the incidence of this complication. Furthermore, owing to the rapid development of minimally invasive surgery, technicians are becoming more frequently involved. To improve communication between the operating team and technicians, standardized actions should also be defined. The aim of this study was to compare existing protocols for laparoscopic cholecystectomy from various Dutch hospitals.
Fifteen Dutch hospitals were contacted for evaluation of their protocols for laparoscopic cholecystectomy. All evaluated protocols were divided into six steps and were compared accordingly.
In total, 13 hospitals responded—5 academic hospitals, 5 teaching hospitals, 3 community hospitals—of which 10 protocols were usable for comparison. Concerning the trocar positions, only minor differences were found. The concept of “critical view of safety” was represented in just one protocol. Furthermore, the order of clipping and cutting the cystic artery and duct differed. Descriptions of instruments and apparatus were also inconsistent.
Present protocols differ too much to define a universal procedure among surgeons in The Netherlands. The authors propose one (inter)national standardized protocol, including standardized actions. This uniform standardized protocol has to be officially released and recommended by national scientific associations (e.g., the Dutch Society of Surgery) or international societies (e.g., European Association for Endoscopic Surgery and Society of American Gastrointestinal and Endoscopic Surgeons). The aim is to improve patient safety and professional communication, which are necessary for new developments.
The median laparotomy is frequently used by abdominal surgeons to gain rapid and wide access to the abdominal cavity with minimal damage to nerves, vascular structures and muscles of the abdominal wall. However, incisional hernia remains the most common complication after median laparotomy, with reported incidences varying between 2-20%. Recent clinical and experimental data showed a continuous suture technique with many small tissue bites in the aponeurosis only, is possibly more effective in the prevention of incisional hernia when compared to the common used large bite technique or mass closure.
The STITCH trial is a double-blinded multicenter randomized controlled trial designed to compare a standardized large bite technique with a standardized small bites technique. The main objective is to compare both suture techniques for incidence of incisional hernia after one year. Secondary outcomes will include postoperative complications, direct costs, indirect costs and quality of life.
A total of 576 patients will be randomized between a standardized small bites or large bites technique. At least 10 departments of general surgery and two departments of oncological gynaecology will participate in this trial. Both techniques have a standardized amount of stitches per cm wound length and suture length wound length ratio's are calculated in each patient. Follow up will be at 1 month for wound infection and 1 year for incisional hernia. Ultrasound examinations will be performed at both time points to measure the distance between the rectus muscles (at 3 points) and to objectify presence or absence of incisional hernia. Patients, investigators and radiologists will be blinded during follow up, although the surgeon can not be blinded during the surgical procedure.
The STITCH trial will provide level 1b evidence to support the preference for either a continuous suture technique with many small tissue bites in the aponeurosis only or for the commonly used large bites technique.
Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects.
A randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included.
A clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach.
Trial registration number: NCT01111253
Results of both methods of gastric closure (omental and biodegradable patch) were similar suggesting that a biodegradable patch glued to the outside of the stomach may be a viable alternative for closure of perforations of the digestive tract.
The current treatment of perforated peptic ulcers is primary closure, supported by the application of an omental patch. It is difficult and time consuming to perform this procedure by laparoscopic surgery, largely because of the required suturing. It was our aim to develop and test a new method of closure for gastric perforation that is similar in efficacy and safety to a traditional repair. This technique could have utility in laparoscopic repair, as it does not require sutures or mobilization of the omentum.
The new method, called the “stamp” method consists of closure of the perforation by gluing a biodegradable patch made of lactide-glycolide-caprolacton (LGC, Polyganics, B.V. Groningen, The Netherlands) on the outside of the stomach. It was compared with the omental patch procedure. Perforations were made in the stomach of 20 rats and closed by either method (10 rats in each group). The rats were followed for 10 weeks.
No complications were seen in any of the rats. In both groups, histological degradation of the patch by giant cells started at week 2. No signs of inflammation existed in either group. Signs of closure of the mucosa were seen after 2 weeks, and the muscular layer started to regenerate after 8 weeks in both groups.
Results of both methods were similar, which means that treatment of a gastric perforation through the application of a biodegradable patch to the outside of the stomach is a feasible option and might even be an interesting technique for closure of other perforations in the digestive tract.
Gastric perforation; Laparoscopy; Biodegradable patch