Simplifying three-stage colon resections.

PURPOSE: Hand-assisted laparoscopic colectomy has traversed three phases of distinct development. This review was designed to trace the evolution of hand-assisted colectomy from an infrequently used technique to a clinically useful surgical approach to diseases of the colon and rectum. METHODS: This review compiles previously reported and published experiences with hand-assisted laparoscopic colectomy. RESULTS: During the first phase of development of hand-assisted laparoscopic colectomy, surgeons explored what could be accomplished by a hand inserted into the abdomen through the specimen extraction site as an adjunct to laparoscopic techniques. Case reports and small trials found that manually assisted laparoscopic techniques permitted more rapid completion of laparoscopic-assisted colectomies. In the second phase, surgeons used early devices that facilitated the insertion of the surgeon's hand into the abdomen and helped to maintain the pneumoperitoneum. Larger series and small, randomized trials indicated a time-saving advantage to hand-assisted techniques and similar short-term outcomes as laparoscopic-assisted colectomies. In the current third phase, surgeons are using a new generation of hand-access devices that extend the options for hand-assisted techniques. These devices, like earlier devices, facilitate hand insertion, protect the wound, act as the retrieval site for the specimen, and serve as the portal for construction of extracorporeal anastomoses. In addition, these new devices can serve as laparoscopic trocar sites. This permits selective use of hand-assisted and laparoscopic-assisted techniques at various times in the same operation. These new devices have not undergone clinical trials, and therefore, a final appraisal must await future publication of outcomes. CONCLUSIONS: Hand-assisted laparoscopic colectomy has evolved into a clinically useful surgical technique. New devices facilitate the performance of these operations and permit the surgeon to switch between hand-assisted and laparoscopic techniques.

Colectomy↗

PubMed2004

[Simulation of a colon carcinoma: diuretic-induced ulcerative-stricturing ischemic colitis].

HISTORY AND ADMISSION FINDINGS: A 49-year-old man was admitted to hospital with lower gastro-intestinal bleeding. He complained of fatigue, weight loss and bloody stools for a few days. There was no history of abdominal pain, but he had irregular bowel movements for some weeks with alternating constipation and diarrhea. He regularly took furosemide and ACE inhibitors for hypertension. The abdominal investigation was unremarkable. INVESTIGATIONS: Laboratory investigations showed a significant anemia (Hb 6,3 g/dl), WBC, C-reactive protein and lactic acid were normal, carcino-embryonic antigen was 38 ng/ml and thus increased (normal value: < 5 ng/ml). Colonoscopy revealed a circular stricturing and ulcerating tumor at 70 cm, which looked highly suspicious for malignancy and could not be passed endoscopically. Biopsies showed high-grade dysplasia and colon contrast x-ray confirmed a stricturing tumor. TREATMENT AND COURSE: Laparotomy was performed for a bleeding colon carcinoma. However, besides multiple inflammatory-stenosing strictures of different parts of the right colon, no tumor was found. Perfusion of the small and large bowel was normal. A right colectomy was performed and multiple deep ulcerations and strictures were found inside the resected colon. A cecal ulceration was the origin of the bleeding. After stopping furosemide intake no further bleeding or colonic ulceration occurred. CONCLUSION: This is an unusual case of drug related non-occlusive, ulcerative-stricturing, ischemic colitis, masquerading as colonic cancer. Although diuretic-induced non-occlusive ischemic colitis is a very rare finding, it should be taken into account in young patients with ischemic colitis, when other risk factors have been excluded and intake of diuretics is reported.

Colectomy↗