Abstract

Even with considerable operator experience and expertise, surgical access from the abdomen to the mid and low rectum and mesorectum can be difficult, especially in male and obese patients. This holds true whether the approach from above is performed by laparoscopy or laparotomy. While conventional operations that include extirpation of the anal canal and sphincters of course incorporate a perineal approach for the lowermost aspect of the proctectomy, their efficiency in cephalad extension is limited by difficulties in access and visualization. Recently, the concepts behind transanal endoscopic microsurgery/operation (TEM/TEO), natural orifice translumenal endoscopic surgery (NOTES), and confined-access/single-port laparoscopy have synergized to proffer a novel in-line endoscopic approach to the lowermost portion of the rectum in the form of a transanal-transrectal portal either alone or in combination with an abdominal component. This can be done in concert with or without sphincter excision and should both enhance the quality of the surgical specimen and minimize the potential for collateral damage in dissection. While clinical experience is developing, this operative access can already be appreciated both from a technical evolutionary and a clinical benefit perspective and is evidently consistent with the oncological principles of package total mesorectal excison (TME) for neoplasia. Furthermore, while specific “ideal” devices evolve, the essential base technological components and access platforms are now widely available while the necessary skillsets either already exist or are readily attained. This state-of-the-art review aims to illustrate the principles behind what appears likely to be the next major laparoendoscopic advance in operative practice for the colorectal and pelvic surgeon.

Abstract

Clinical results comparing intermittent intraoperative neuromonitoring (Int-IONM) and continuous IONM (Cont-IONM) for recurrent laryngeal nerve protection are lacking. Int-IONM has been routinely applied in thyroid resection since January 2008. Cont-IONM was added in November 2008 (ISIS; Inomed, Emmendingen, Germany). Rates of vocal cord palsies (VCPs) and the corresponding IONM signals of both methods are compared. Int-IONM was applied in 458 patients and Cont-IONM in 667 patients. Early postoperative VCPs were diagnosed in 4.0% (34/850 NaR) of the Int-IONM group and in 2.9% (34/1184 NaR) of the Cont-IONM group (p = n.s.). The permanent palsy rate was 0.7% (n = 6) for the Int-IONM group, while all VCPs of the Cont-IONM group except one recovered within 1 to 5 months (p = 0.01). First mobilizing the gland is an early risk point for loss of signal (LOS) in 19.1% of cases. VCPs were identified in 58.8% to 85.3% by intraoperative LOS. Recognition of the nerve-threatening surgical action is significantly better for Cont-IONM (67.7% vs. 20.6%; p = 0.0008). In this clinical setup the Cont-IONM method reduces permanent VCP rates significantly in comparison with Int-IONM. The continuous evaluation of signals during the various dissection steps reduces and limits irreversible damage and allows the surgeon to pay increased attention to the functioning of the nerve.

Abstract

The management of gastric gastrointestinal stromal tumors (GIST) is complex. Local tumor resection with disease-free resection margins without lymphadenectomy is the treatment of choice for primary non-metastatic tumors. This can be achieved with several techniques including wedge resection, transgastric resection, partial gastrectomy, total gastrectomy, and multivisceral resection. Open and minimally invasive surgical approaches can be considered. We describe the technical steps of the aforementioned procedures in relation to tumor size, tumor location (especially at or near the gastro-esophageal junction or pylorus), pattern of exophytic or intraluminal growth, adherence to surrounding structures, and other tumor-associated factors. Challenging situations in gastric surgery for GISTs are also discussed and categorized according to a classification of intraoperative complexity (1 [easy] to 4 [very difficult]). On the basis of this classification, we divided all patients with an indication for gastric GIST surgery into appropriate groups.