Open low anterior resection (LAR) and abdomino-perineal resections (APR) are not easy procedures, esp. in tight male pelvises. The laparoscopic approach gave us a tool dramatically improving the exposure and making the whole mesorectal excision significantly easier. As frequently in situations like that, we were quite hopeful (and meanwhile biased towards believeing) that the advantages in the laparoscopic LAR and APR would translate in better oncological outcomes.
Dr. Fleshman (Dallas, Texas) was one of the most vocal proponents of the laparoscopic approach and wanted to prove it. He recently published a very well designed study:
This is such good news that I couldn't resist starting with it. :)
I wrote twice aboutthis topic and not only my opinion didn't change, I noticed that the general perception regarding NOTES is meanwhile clearly negative. Even people who are usually more open to new approaches share this position now.
Surgeons need new challenges though and the Single Incision Laparoscopic Surgery (SILS) is offering some. Recently I was on Grand Rounds where a general surgeon from a private practice shared his thoughts and experience with the auditorium about SILS. I was hoping that he would focus more on review of the (still scarcely) available data. He decided to just present some of his cases though: just cholecystectomies.
About a year ago I wrote about a transgastric approach in some gastroenterological experiments. What happened in this year? Well, there is a development! Let us take a look at a paper published last year in Nature Clinical Practice Gastroenterology & Hepatology - a magazine belonging to the Nature publishing group. This posting is a review of the still veterinary experiments regarding the "natural orifice transluminal endoscopic surgery" (NOTES).
This time the paper is written better. The authors are medical guys who are obviously still in the euphory in front of the possibility to perform "operations" as endoscopists. Though they started thinking about things like indications, complications and techniques.
For me the interest in NOTES-publications remain still in the question about the indication and the risks of this experiment. Therefore I don't want to discuss the other parts of the paper. Also, I will compare the transluminal with the laparoscopic approach only and not with the open surgery, because the laparoscopy is what NOTES competes with.
In the beginning of most medical books, one can read that the medicine (and of course the surgery) is an ever growing field. Now we know that the laparoscopic cholecystectomy is a good idea, whereas the laparoscopic hernia repair may not be that of a one. Common sense doesn't need much trials. Therefore I dare to share some thoughts about a recent discussions concerning minimizing the "Minimally Invasive Surgery".
A very interesting trial was published in the current issue of Archives of Surgery. The conclusion is:
Video game skill correlates with laparoscopic surgical skills. Training curricula that include video games may help thin the technical interface between surgeons and screen-mediated applications, such as laparoscopic surgery. Video games may be a practical teaching tool to help train surgeons.
In discussions with colleagues we compared many times the endoscopy (gastroscopy and colonoscopy) with a video game. The students found this talks very funny.
Now we have the "proof"!
So, dear surgeons, take a good computer machine and play! Play for the sake of your patients! :)
This is a somehow old (mid 2004) but nevertheless important multicenter trial which aroused my interest due to the fact that I do laparoscopically (hand)assisted colectomies.
The conclusion is:
...the rates of recurrent cancer were similar after laparoscopically assisted colectomy and open colectomy, suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.
Though, "no advantage of laparoscopically assisted surgery was evident with respect to either all stages of cancer or high-risk subgroups".
The collecting of data for the trial began 1994. Therefore the new, hand assisted approach in the laparoscopic surgery, could not be considered.