The approach to various surgical procedures can vary by both surgeon and institution, with variations in technique to achieve a successful outcome. Surgeons employ principles of dissection and perioperative management based on training, theory, published literature, anecdotal experiences, and advances in technique. Employing new techniques requires a process of cognitive and technical training, as well as the appropriate proctorship, thereby shortening the learning curves and allowing for the safe integration and implementation into one’s practice [1, 2]. In recognizing the need to structure the evidence and training for new techniques, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has instituted the Masters Program for deliberate and lifelong learning [3]. It incorporates the most recent published evidence, societal guidelines and training pathways to provide surgeons with a curriculum and forum tailored for a successful and safe introduction of technical advances for their patients. As one of the 8 SAGES Masters program clinical pathways, the Colorectal Task Force has identified three anchoring procedures that will be the focus of the Masters program. These include the laparoscopic right colectomy [4], laparoscopic left/sigmoid colectomy for uncomplicated disease and complex disease and intracorporeal anastomosis for minimally invasive right colectomies.

In this article, the SAGES Colorectal taskforce has identified 10 seminal articles for the laparoscopic left/sigmoid colectomy anchoring procedure based on a systematic review of the literature predominantly using Web of Science. The rationale behind this approach was to identify the most impactful articles in the literature that focus on surgical technique, clinical effectiveness, and outcomes. This manuscript provides a summary of these 10 seminal articles as they pertain to key procedural principles in a minimally invasive approach to a left-sided and sigmoid colectomy for uncomplicated benign and malignant disease. With the supplemented knowledge of clinical considerations, technical approaches and expected clinical outcomes, SAGES members will be more effectively able to implement these minimally invasive techniques into practice.

Materials and methods

A systematic literature review was performed in April 2018 and updated in March 2022, for all articles published on the topic of laparoscopic left and sigmoid colectomy in uncomplicated disease. Using the Web of Science and Google Scholar, the top 30 articles with the highest citation index were selected and sent via email to 30 members of the SAGES Colorectal Task Force for review. Each article was rated on its importance by 28 responding task force members and the top 10 most-impactful articles selected based on consensus. Task Force members were assigned to perform an in-depth review of these articles and summarize them using a structured outline addressing specific questions about each paper: (1) Why is this paper a top 10 article? (2) What is unique about this paper? (3) Why is it important to read this paper before you do the relevant procedure? (4) What has been the impact of this paper in the field? (5) What are the study findings? (6) What are the strengths and limitations of the paper? and (7) What are the conclusions of the article? These summaries were subsequently compiled, reviewed by the task force and SAGES leadership and are presented here.

Results

The Citation Index for the top 10 seminal articles selected for the Colorectal Pathway laparoscopic left and sigmoid colectomy anchoring procedures ranged from 1.0 to 33.38 on Google Scholar, and from 1.0 to 47.5 on Web of Science (Table 1). The articles presented here include differential technical approaches to benign and malignant left sided and sigmoid disease, clinical outcomes with disease-specific approaches, techniques to minimize procedural morbidity, predictors of outcomes in large patient cohorts, and an understanding of the learning curve. They are presented here in order of 1 to 10 per the reviewer’s rank, with 1 being the highest rank.

Table 1 Citation Metrics for the Top 10 Left Colectomy Articles (Search performed April 2018, updated April 2022)
Full size table
  1. 1.

    Rickard et al. (2017): Three steps and a join: a simple guide to right- and left-sided medial to lateral laparoscopic colorectal surgery [5].

Techniques of left sided mobilization vary by surgeon; options for standardization of techniques can result in an improvement in outcomes and a more seamless introduction of new techniques to surgical trainees. Stratifying the approach into a standardized set of individualized steps can assist in the on-boarding of laparoscopic techniques in one’s practice. This article was included as one of the Top 10 articles for this anchoring procedure as it provides a comprehensive technical and stepwise approach to the medial to lateral dissection in a right and left hemicolectomy. The individual stratified components of the procedure allow for an ease of incorporation in one’s practice by focusing on each step of the technique in a stepwise fashion.

The article stratifies left hemicolectomy procedures into three standardized steps focusing on complete mobilization of the left and sigmoid colon off retroperitoneal structures in conjunction with other maneuvers such as routine splenic flexure mobilization to ensure a tension-free anastomosis. Additionally, a detailed stepwise video of the technique is provided that offers a simple, well-defined, systematic approach to medial–lateral dissection. The three technical components of the procedure include: (1) Medial mobilization and ligation of the inferior mesenteric vein (IMV) at the inferior border of pancreas with a medial to lateral dissection of the descending mesocolon off of the retroperitoneum. Additionally, the inferior mesenteric artery (IMA) is ligated at its root after successful identification of the left ureter; (2) Lateral mobilization of the descending and sigmoid colon to the splenic flexure allowing for complete detachment of the splenic flexure and descending colon/mesocolon from the inferior border of the pancreas to the level of the IMA; (3) Presacral mobilization of the proximal rectum and mesorectum to the appropriate distal transection margin with subsequent skeletonization of the rectum at this level and stapling.

The objective of this article was to present the results of a case series when this standardized approach was used by 20 senior colorectal surgeon trainees and 20 general surgery registrars. Of 568 laparoscopic anterior resections, there were 5 anastomotic leaks (0.9%). The strengths of this paper include its large sample size collected prospectively with a standardized three-step stratification to the procedure and an associated instructional video. The limitations include the fact that this is a single institution case series with the associated limitations of non-randomized studies. Additionally, the authors do not list any of the other potential complications.

In summary, the techniques provided would be especially helpful in establishing a routine approach to a left-sided dissection, but also provides management options for patients with phlegmon in the sigmoid colon or a large amount of retroperitoneal inflammation. In these cases, these findings may prevent an adequate medial–lateral or lateral- medial mobilization at the level of the pelvic brim. As such, proceeding from a less involved area first can assist with identification and preservation of anatomy. Ultimately, this simplified and demonstrably feasible approach to a medial to lateral dissection of the colon with video supplementation is an excellent demonstration tool for surgeons practicing a left colectomy, with demonstrable safety in an academic setting.

  1. 2.

    Milone, Milone (2017) Segmental left colectomy: a modified caudal-to-cranial approach [6].

  2. 3.

    Masoni et al. (2013) Preservation of the inferior mesenteric artery via laparoscopic sigmoid colectomy performed for diverticular disease: real benefit or technical challenge: a randomized controlled clinical trial [7].

Patients undergoing anterior or low anterior resection for benign disease may not necessarily benefit from high ligation of the IMA, usually performed to maximize lymph node retrieval in cases of malignancy or to reduce tension on pelvic anastomoses. Additionally, there may be implications on colonic and genitourinary function related to the injury to the hypogastric nerve plexus. From a practical standpoint, in patients with significant mesocolic phlegmonous changes, such as in diverticular disease or Crohn’s colitis, mesocolon-sparing approaches are likely to facilitate a laparoscopic approach. The above two studies were combined and included in the Top 10 articles to provide insight on the technical aspects and evidence-based outcomes of a mesocolon-sparing surgical approach, often used in cases of benign disease.

The objective of Milone et al. article [6] was to provide a video demonstration of the mesocolon and IMA-preserving technique, while Masoni et al. [7] focused on demonstrating the results of this approach in the context of a randomized controlled trial (RCT).

Milone et al. [6] describe the technical steps of the approach which involves mobilizing the colon from its lateral attachments, effectively straightening the colon and mesocolon between the proximal and distal transection margins. This is followed by stapling of the rectum distally with progressive ligation of the mesocolon proximally along the colon-mesocolon interface so as to preserve the origin of the IMA. This technique offers a unique approach to a left colectomy in benign disease with preservation of major vascular structures and hypogastric nerve bundles. Furthermore, it expedites completion of the resection with little concern for major intraoperative complications of bleeding or injury to genitourinary structures (e.g., the left ureter). Milone et al. report having performed this technique in 21 patients with benign sigmoid lesions, with no anastomotic leaks but 2 cases (10%) of anastomotic bleeding.

The results of the multicentered RCT on the same technique performed by Masoni et al. [7] provides stronger evidence of the efficacy of this technique. Patients undergoing laparoscopic sigmoid colectomy for Hinchey 1–3 diverticulitis were randomizing in a 1:1 fashion to either division of the IMA proximal to the left colic artery (high ligation) or to an intra-mesocolic dissection and ligation, with 107 patients in each group. The primary outcome for which the sample size was powered was postoperative defecatory disorder (PDD). Other scores that were assessed included the Wexner Fecal Incontinence score (FIS), the Wexner constipation score (CS) as well as the standard SF-36 quality of life questionnaires. Furthermore, the authors use an objective measure, specifically anal manometry. In assessing PDD, a significantly higher rate of constipation, fragmented evacuation and alternating bowel function was identified in patients with high ligation of the IMA relative to the IMA preservation group. With respect to incontinence, lower rates of incontinence to liquid stool and flatus as well as rates of wearing a pad and overall lifestyle alteration, were identified in the IMA preservation group; no assessment was performed of overall Wexner FIS. Furthermore, several components of the CS were demonstrated to be worse in the high ligation group, such as decreased defecation frequency, incomplete defecation and unsuccessful defecation, amongst others. No significant differences in anorectal manometric findings were identified.

The findings of this prospective randomized study with a relatively high sample size provide strong evidence of the potential benefits of an intramesocolic and IMA preserving approach on defecatory function following left-colectomy and sigmoid resection. Although this study identified functional benefits, a recent systematic review and meta-analysis did not identify a statistically significant difference in the risk of anastomotic leak between the two groups [15]. The main limitation of the study is that PDD is not a commonly used metric for defecatory dysfunction in other publications, hence the results could not be validated in other studies. In addition, the study identified differences in components of the FIS, CS and SF-36 between treatment groups, but did not assess for differences in the overall score of each scoring tool. Finally, no information regarding short and long-term complications of these procedures were provided.

In summary, these two articles provide a technical description of mesocolon/IMA sparing approach to a left colectomy, with evidence to support its feasibility and improved functional outcomes relative to left colectomy with high ligation of the IMA.

  1. 4.

    Williams et al. (2021) Utility of intra-operative flexible sigmoidoscopy to assess colorectal anastomosis: a systematic review and meta-analysis [8].

Intraoperative identification of anastomotic defects by way of air-leak testing has been assessed in the literature with proposed benefits to patient-centered outcomes. In one of the initial articles on the topic, a 6-year institutional cohort of almost 1000 patients, Ricciardi et al. reported an 8% rate of intraoperatively identified air-leaks in tested left sided anastomoses, with a nearly 50% decrease in the likelihood of anastomotic leak with negative leak testing [16]. This and other papers describe why this is a critical step in the procedure, as well as the implications of an abnormal test on the incidence of postoperative anastomotic leak. Mitchem et al. have gone further and described the fate of air-leak positive anastomoses based on management with various approaches such as diversion, suture repair or complete revision [17]. The article by Williams et al. was selected as a Top 10 article as it provides a synthesis of the comparative evidence of the benefits of intraoperative flexible endoscopic (IFE) techniques in anastomotic assessment and interrogation during left-sided resections.

The objective of this study was to perform a systematic review and meta-analysis of the published literature comparing outcomes with the use of IFE in left-sided colorectal resections compared to conventional institutional approaches such as traditional air leak testing (often with the introduction of a syringe transanally) or no testing at all. Eight studies were identified published between 1993 and 2019 with 1792 patients included, 884 in the IFE group and 908 in the control arm. Two primary outcome measures were assessed: anastomotic leak and anastomotic bleeding. The pooled analysis found IFE was associated with an increase in the detection of an anastomotic leak with an Odds Ratio 5.21 (95% CI 1.95–13.97; p < 0.001) with an associated protective effect on the risk of an anastomotic leak (OR 0.45; 95% CI 1.95–13.97; p = 0.006). Additionally, this effect was also preserved when comparing syringe-based air leak testing with IFE (OR 0.39; 95% CI 0.20–0.76, p = 0.006).

The strength of this article lies mostly in its large sample size and demonstrating a comparative estimate with non-endoscopic forms of leak testing. The main limitation of the study is that the individual studies were nonrandomized, and therefore subject to selection bias. Furthermore, in single centers, it is difficult to imagine a persistence of equipoise between IFE and no leak testing, once the benefits of this form of leak testing have been tried and tested. Other studies have also highlighted the benefits of the complete revision of anastomoses in the presence of a positive air-leak test with relatively low rates of subsequent anastomotic leaks, as well as the advantages of this routine practice in assessing both anastomotic integrity and hemostasis [16, 17]. Unfortunately, most of these studies addressing the management of anastomotic leaks have been non-comparative.

In conclusion, the article impresses on the reader the benefits of intraoperative assessment of left-sided colorectal anastomoses in identifying and addressing anastomotic leaks as well as anastomotic bleeding.

  1. 5.

    Midura et al. (2015) Risk factors and consequences of anastomotic leak after colectomy: a national analysis [9].

The multifactorial nature of the etiology of anastomotic leaks has been extensively assessed in the published literature. Reported rates of anastomotic leaks following colectomy are quite variable (2–25%), likely due to the heterogeneity of procedures reported (colon vs. rectal) and the definition of AL (radiological vs. clinical) used in the literature. This complication is known to negatively impact functional and oncologic outcomes, in addition to a known heavy financial burden on the institution and healthcare system at large. Stratifying risks into modifiable and non-modifiable for pre-operative optimization and risk mitigation is crucial to ensuring the best possible outcomes. The article by Midura et al. [9] is included as a Top 10 article as it provides surgeons with an understanding of the frequency of anastomotic leaks following left and right-sided colectomy and related risk factors.

The objective of this article was to evaluate the frequency, predictors and outcomes of anastomotic leaks following colectomy using the American College of Surgeons' National Quality Improvement Program (ACS-NSQIP) database. This database is unique in that it uses a standardized definition of anastomotic leak by trained data abstractors to ensure consistency and reliability of the definition. In addition, the ACS-NSQIP database includes a large data set from a variety of patients, surgeons, and hospitals, which allows for an overall assessment of this complication without the biases of single-institution reports. Personal audits of independent series will also allow for comparisons to be performed against nationwide rates of AL.

A retrospective analysis of 13,684 patients who underwent ileocecal, segmental or anterior resection with or without fecal diversion was conducted using the 2012 NSQIP database. The primary outcome was incidence of anastomotic leaks, including leaks that did not require intervention, those that required percutaneous drainage or reoperation. A multivariable logistic regression model was constructed to identify significant predictors of anastomotic leaks. The overall anastomotic leak rate was 3.8%; when stratified, the leak rate for laparoscopic and open anterior resections were 4.2% and 4.7%, respectively. Male sex (OR 1.37), pre-operative steroid use (OR 1.6), smoking (OR 1.56), open approach (OR 1.71), operative time > 3 h (OR 1.50), and preoperative chemotherapy (OR 1.60) were associated with an increased risk of anastomotic leaks; a diverting ileostomy was associated with a decreased risk of anastomotic leak (OR 0.55). Anastomotic leak was associated with poor postoperative outcomes including increased length of hospital stay, readmission rates and 30-days mortality. There was also a 37-fold increased likelihood of needing a repeat procedure when an anastomotic leak occurred following the primary procedure (p < 0.001).

The strength of this study is the large sample size as well as the validated nature of this nationwide database with standardized definitions of an anastomotic leak. The reported leak rate was lower than rates reported in the literature, likely related to the voluntary nature of ACS-NSQIP participation, and results being driven by hospitals with a particular interest and expertise in colorectal surgery. The risk factors identified have broad, yet statistically significant confidence intervals and should be interpreted in the context of the study methodology that included both right and left sided resections in their predictive models. That being said, the stratified leak rates only differed by ~ 2%, which shouldn’t significantly affect the conclusions, but may explain the width of the confidence intervals. Additionally, open surgery was found to be predictive of the likelihood of an anastomotic leak; readers should be cognizant of the fact that open procedures are often reserved for the more difficult surgical cases not amenable to laparoscopy, that are inherently more predisposed to complications. Further limitations are related to the retrospective collection of data that is subject to miscoding or omission of variables.

In conclusion, this article provides surgeons with a broad understanding of both modifiable (steroid use, smoking, and preoperative chemotherapy) and non-modifiable risk factors for anastomotic leaks in colorectal surgery. Surgeons can likely utilize pre-habilitative programs to optimize patient risks in addressing these predictors of anastomotic leaks. Furthermore, the information provided is highly beneficial in counselling discussions with patients when consenting for these procedures to better highlight their perioperative risk of this complication and associated outcomes.

  1. 6.

    Schlussel et al. (2017). Location is everything: The role of splenic flexure mobilization during colon resection for diverticulitis [10].

Splenic flexure mobilization is a fundamental skill for any general surgeon performing left-sided colonic resection to ensure reach of the proximal colonic conduit during colorectal reconstruction. There are several components to a complete splenic flexure mobilization including ligation of the IMV, takedown of omental and splenocolic attachments, adequate retroperitoneal mobilization of the proximal descending mesocolon and takedown of the pancreatic attachments of the distal transverse and proximal descending mesocolon. This article was included in the Top 10 articles as it identifies factors predictive of a need for splenic flexure mobilization during elective sigmoid and left colectomy for diverticulitis. It analyzes the effect of splenic flexure mobilization on multiple postoperative outcomes.

The objective of this article was to assess a cohort of 208 patients undergoing elective sigmoid and left colectomy for diverticulitis and evaluate the role of selective splenic flexure mobilization and its impact on postoperative outcomes. The authors merged extracted institutional preoperative and postoperative data from the ACS-NSQIP with a detailed data abstraction of the patient record. In addition, preoperative CT scans were reviewed to obtain details about the location of the diverticular disease (sigmoid vs descending colon). Factors predictive of a need for splenic flexure mobilization were identified, and postoperative outcomes were compared between patients who did vs those who did not undergo splenic flexure mobilization. Risk adjustment was performed for both analyses with multivariable logistic regression modeling.

Splenic flexure mobilization was performed in approximately half of the colectomies performed for diverticulitis (113 of 208; 54%) and added a median of 46 min to the procedure operative time. By multivariable analysis, a laparoscopic approach (OR 2.4; 95% CI 1.1–5.0; p = 0.02) and diverticulitis in the descending colon (OR 7.4; 95% CI 3.4–16; p < 0.01) were associated with the need for splenic flexure mobilization. No other patient or surgeon factors were predictive. Most notably, obesity, age, and colorectal fellowship training by the operating surgeon were not associated with completion of splenic flexure mobilization. Splenic flexure mobilization was associated with a trend toward an increased composite rate of minor morbidity (OR 2.8; 95% CI 1.8–5; p = 0.05) but was not associated with major complications or any other singular complication. Anastomotic leak was not directly assessed but two proxies of leak, organ space surgical site infection (splenic flexure mobilization 4.6% vs no splenic flexure mobilization 2.4%; p = 0.34) and reoperation (none in either group) were not significantly different.

The main strength of this article is that it provides evidence that splenic flexure mobilization is a safe and feasible option. Other strengths of the paper include its large sample size and detailed clinical and radiologic description of the location of diverticulitis. Surgeons can therefore adapt preoperative planning re operative time, intraoperative tasks and expected outcomes based on the need for splenic flexure mobilization, tailored to the patient’s specific profile. With respect to limitations, while the study design captured several variables, some important covariates, including a history of previous abdominal surgery are missing. Finally, the dataset is subject to selection bias, with final decision-making regarding splenic flexure mobilization based on surgical judgement.

In summary, this paper offers two important conclusions for surgeons performing elective sigmoid and left colectomy for diverticulitis. First, a splenic flexure mobilization should be anticipated with disease present in the descending colon, and when a laparoscopic approach is planned. Second, completion of a splenic flexure mobilization confers minimal added significant risk for major morbidity but may be associated with an increase in minor morbidity.

  1. 7.

    Bonnet et al. (2012). High tie versus low tie vascular ligation of the inferior mesenteric artery in colorectal cancer surgery: impact on the gain in colon length and implications on the feasibility of anastomoses [11].

Similar to the issue related to achieving adequate length and reach of the proximal colonic conduit during left-sided colorectal resections with splenic flexure, the implications of height of IMA ligation needs to be clarified. From an oncologic standpoint, high ligation allows for retrieval of the IMA nodal package but also puts the patient at risk of injury to the superior hypogastric nerve plexus, with associated risk of retrograde ejaculation. Low IMA ligation allows for the preservation of the left colic artery and theoretical increased vascularity of the proximal colonic conduit. In the HIGHLOW RCT that compared high vs low IMA ligation in patients undergoing laparoscopic low anterior resection for rectal cancer, high ligation was associated with more genitourinary dysfunction with no differences in AL rates between the groups [18]. However, a meta-analysis of randomized and non-randomized comparative studies demonstrated a significantly increased risk of anastomotic leaks in the high IMA ligation group (OR = 1.33; 95% CI 1.10–1.62; p = 0.004) [19].

The article by Bonnet et al. was included in the list of the Top 10 articles for laparoscopic left and sigmoid colectomy pathway as it objectively measures the impact of high vs low IMA ligation on the length of left colonic conduit that can be mobilized using a cadaveric model. This article provides an anatomic foundation for expectations and recommendations regarding the length of left colon that can be mobilized based on high (root of IMA) or low (1 cm distal to the origin of the left colic artery) IMA ligation [11].

The objective of this paper was to demonstrate how high versus low tie IMA ligation impacts the length of proximal bowel that can be mobilized after sigmoid resection, and the feasibility of performing a tension-free colorectal and coloanal anastomosis after a total mesorectal excision (TME) using fresh cadavers. Stratifications of high (root of the IMA) or low (1 cm distal to the origin of the left colic artery) IMA ligation were performed with a high ligation of the IMV. In addition, the feasibility of constructing colorectal anastomoses at the sacral promontory, and coloanal anastomoses in a straight or coloanal J pouch configuration after TME, based on IMA ligation pattern was also evaluated.

The study included 30 fresh cadavers randomly assigned to high-tie (n = 15: high IMA and IMV ligation) and low-tie (n = 15; low IMA and high IMV ligation, with subsequent assessment of left colic artery ligation) groups. After mobilization of the left colon including splenic flexure mobilization, sigmoidectomy was performed followed by TME. After sigmoid resection, the distance from the distal margin of the colon to the lower edge of the pubic symphysis was recorded after each vessel transection to evaluate length gain. After TME, the proximal bowel was placed in the pelvic cavity in contact with the sacrum and a determination was made of whether the distal edge of the colon reached the pelvic floor in a tension-free manner to perform a straight or a coloanal J pouch-anastomosis. High tie IMA and IMV ligations were found to provide a 10 cm increase in colon length in comparison with low IMA and high IMV ligation. If a low tie IMA ligation was performed, high IMV ligation did not result in significant further length gain; therefore, there was no identifiable added benefit to ligating the IMV at the lower border of the pancreas in these cases. If more colonic length was needed after low IMA ligation, division of the left colic artery provided a gain in length for the proximal colon conduit that was similar to that obtained with high tie IMA/IMV ligation.

The strengths of the manuscript include the randomized nature of the study, using comparable cadavers with regards to age, BMI, and gender. A standardized technique of dissection was used. The main limitation of the study was that vascularization of the proximal bowel and clinical outcomes after different levels of vessel transection could not be assessed in a cadaver model; essentially the study only assesses issues related to reach and tension on the colorectal and coloanal anastomoses. In addition, although fresh cadavers were used, the elasticity and bulk of the colon and mesocolon may not have replicated real life clinical scenarios. Actual colorectal or coloanal anastomoses were not constructed, as the authors used a surrogate of reach (pubic symphysis); despite this, the incremental increase in colonic length achieved with these various ligation maneuvers serve as a solid foundation for clinical practice.

In conclusion, this well-designed cadaveric study provides a fundamental understanding of expected gains in length of the proximal colonic conduit with various combinations of IMV ligation with high and low ligations of the IMA. The results were assessed in the context of a sigmoidectomy and reach for a colorectal anastomosis, as well as a subsequent TME and a coloanal anastomosis. Optimal additional length was achieved with a high ligation of the IMA and ligation of the IMV at the inferior border of the pancreas.

  1. 8.

    Leraas et al. (2017). Hand-Assisted Laparoscopic Colectomy Improves Perioperative Outcomes Without Increasing Operative Time Compared to the Open Approach: a National Analysis of 8791 Patients [12].

Hand-assisted surgical techniques can be a useful adjunct for surgeons initiating their laparoscopic experience and with various intra-abdominal pathologies such as complicated diverticulitis. Additionally, authors should be aware of the benefits of techniques such as HALS in purely laparoscopic procedures when considering a conversion to open surgery. This manuscript was included as a Top 10 article for the laparoscopic left and sigmoid colectomy pathway as it compares short-term postoperative outcomes of hand-assisted laparoscopic vs open colectomy in a large ACS-NSQIP cohort. The authors provide a well-performed regression analysis assessing patient predictors associated with an increased likelihood of using a hand-assisted laparoscopic surgical approach (HALS) during colorectal surgical procedures.

Given the potential role of HALS techniques in avoiding an open approach, the objective of the authors was to assess the short-term postoperative outcomes with a HALS approach and evaluate whether this approach improved postoperative outcomes of an open approach. The retrospective study is based on the 2012–2013 data set of the ACS-NSQIP colectomy procedure-targeted database, identifying patients who underwent an elective colectomy either open (OC) or with HALS. The authors use propensity-score matching techniques to account for selection bias associated with the dataset. In doing so, the authors are able to match patients in each of the OC and HALS groups by clinical, disease and treatment factors. These included age, sex, race, BMI, indication (neoplastic, benign, IBD), year of operation, American Society of Anesthesiologists (ASA) classification, bowel preparation status, and extent of surgery. Multivariate models to identify the odds of various outcomes with each procedure were also performed.

A total of 8791 patients were included (2707 open, 6084 HALS); after matching in a 1:1 fashion using a nearest neighbor method, 1747 patients were included in each group. HALS was associated with a decreased incidence of overall complications (13.6 vs 21.5%, p < 0.001), wound complications (8.8 vs 13.8%, p < 0.001) and AL (3.1 vs 4.7%, p = 0.014), in addition to lower rates of transfusion requirement (5.0 versus 10.7%, p < 0.001) and postoperative ileus (8.8 versus 18.0%, p < 0.001). There was a shorter length of stay in patients treated using a HALS approach (median 4 versus 6 days, p < 0.001) with a lower incidence of readmissions (6.9 versus 11.4%, p < 0.001), and with no evident increase in required operative time (median 148 versus 150 min, p = 0.111). After multivariate modelling, significant predictors of using a HALS approach were found to be male patients (OR 1.17), increasing BMI (OR 1.01 per unit increase in BMI), benign indications (OR 1.48) and total abdominal colectomy (OR 10.39).

Similar to other large database studies, the strength of this article lies in its ability to provide the reader with an understanding and expectation of the benefits afforded by a HALS approach with respect to patient-centered and resource-based outcomes. This procedure can often be used as a bridging technique to maintain a minimally invasive focus, either in one’s initial experience with minimally invasive surgery, or during a technically challenging laparoscopic procedure that necessitates some additional assistance, prior to converting to open. Although not eliminated, the propensity-score matching approach helps mitigate some of the concerns with selection bias inherent to retrospective studies of this nature. Ultimately, large prospective randomized studies would best account for this; that being said, the authors maximize the potential utility of this dataset with sound methodologic techniques. An additional limitation readers should be aware of is the heterogenous nature of this dataset given the inclusion of both right and left sided surgical procedures. It’s important for the reader and surgeon to remain cognizant of the advantages of a HALS approach, but also that an open technique will at times be necessary for the safe completion of the procedure.

In summary, this article provides surgeons utilizing a minimally invasive approach to colon resections with supportive evidence for the utility of a HALS approach to avoid open surgery. The authors suggest improved intraoperative and postoperative outcomes when comparing a HALS approach to OC, further supporting this technique as a beneficial approach in the armamentarium of the minimally invasive surgeon.

  1. 9.

    Braga et al. (2010). Randomized clinical trial of laparoscopic versus open left colonic resection [13].

Laparoscopic surgery for colon cancer has been assessed in a number of prospective randomized trials such as the COST [20] and COLOR [21] trials, although these studies were generalized to all sites of colonic resections. The article by Braga and colleagues [13] was included in the Top 10 list of articles for left colectomy as it represents a well-designed prospective, randomized trial, comparing short and long-term outcomes of laparoscopic vs open left colectomy, as well as differences in cost and quality of life measures.

The primary objective of this study was to compare short-term outcomes (complications, length of stay, operative time) as well as long term outcomes (morbidity, quality of life scores) between the laparoscopic and open approaches for left colectomy for cancer. A standardized surgical approach and postoperative treatment care pathway were followed for all patients. Patients with advanced cancer, or significant comorbidities were excluded from the study. The authors randomized 268 patients to a laparoscopic (n = 134) or open left colectomy (n = 134). Operative time was longer in the laparoscopic group, but postoperative complications were not significantly different between the groups (p = 0.094). The laparoscopic group had a shorter length of stay (7 vs 8.7 days, p = 0.002) than the open group, which translated into net savings despite longer operative time and utilization of more surgical instruments. In the short-term, (6 months or less) patients in the laparoscopic group had higher quality of life (QOL) scores, but there were no differences between the groups at one-year or any of the later time-points. Long term complications were similar between the two groups with equivalent overall survival (66% open vs. 72% laparoscopic; p = 0.321).

The article has had a major impact in clinical practice as it provides level 1 evidence in support of short-term benefits of a laparoscopic approach for left sided colon resections. Some of the original critiques of larger RCTs had been the heterogeneity of right and left sided resections included. The homogenous group in this study provides further support for the laparoscopic approach in patients with left colon cancers. Furthermore, the laparoscopic approach has been studied for its effects on long-term outcomes with no clinically or statistically significant difference in disease-free survival [22].

The strengths of this study include the prospective randomized methodology in addition to standardization of procedures and surgical teams as well as postoperative care pathways.

Furthermore, the study being conducted at a single-institution increases the reliability of the cost analyses. The relative long length of hospital stay reflects pre-Enhanced Recovery after Surgery (ERAS) protocols. The main.

In summary, this is a well-conducted trial providing level 1 evidence that laparoscopic left colectomy for cancer is not only safe, but results in improved short-term outcomes and QOL scores relative to open surgery.

  1. 10.

    Tekkis et al. (2005). Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections [14].

In initiating a minimally invasive practice in colorectal surgery, it is important to be aware of the learning curve for specific procedures in order to have realistic expectations regarding one’s own learning curve, and need for advanced training, coaching and/or proctoring. This manuscript provides an excellent overview of the learning curve involved in achieving technical adequacy and mastery in laparoscopic colorectal resections. It provides realistic expectations for those learning these new techniques and makes a call for improved training and simulation. This manuscript was selected as a Top 10 article as it represents one of the few studies of the learning curve in laparoscopic colorectal surgery, benefiting from a high volume of cases performed by a number of surgeons of various levels of experience.

The objective of the article was to use risk-adjusted CUSUM methodology (Cumulative Sum of the Means) to assess the institutional learning curve for laparoscopic colorectal resections. Nine hundred colectomies were divided into left-sided (443) and right-sided resections (457) performed by four surgeons. Surgeon-specific (conversion rates and operative time) and patient-centered outcomes (complication rates and readmission) were collected. Conversion was defined as early or unplanned transition to an open procedure or use of an extraction site > 10 cm. The conversion rate to open surgery was 8.1% for right-sided and 15.3% for left-sided resections. The CUSUM model demonstrated a learning curve of 55 cases for right-sided and 62 cases for left-sided resections based on conversion rates. Six factors were found to be predictive of conversion including ASA grade (OR 1.63 per unit increase), BMI (OR 1.07 per unit increase), left-sided colectomy (OR 1.1), presence of an intra-abdominal abscess (OR 5.0) or fistula (OR 4.6), with the only variable found to be protective for conversion being operative experience (OR 0.9 per 10 cases of experience). Using a risk-adjusted technique, there was a 5.1-fold increase for conversion in the first 25 cases, and a 3.8-fold increase for risk of conversion for the second 25 cases, (cases 25–50). The authors did not identify a significant learning curve based on 30-days readmission or postoperative complication rates. Operative time was found to be significantly associated with operative experience, age, BMI, and gender but was not different with left versus right colectomy.

Strengths of the paper include the large sample size from a single institution and the CUSUM statistical methods used to determine the learning curve. Limitations include the fact that this is a single institution experience with most cases performed by 4 surgeons with a wide range between the maximum and minimum number of cases performed (258). A sensitivity analysis with individual surgeon learning curves might have demonstrated how these rates can also vary based on each surgeon’s individual experience and training.

In summary, this manuscript demonstrates that the learning curve for laparoscopic colectomy is significant, but not insurmountable, and demonstrates a need for new training strategies. It also suggests that conversion rates and operative time continue to improve throughout the operative experience. The article provides a realistic expectation of the number of cases needed to reach the learning curve for right and left-sided laparoscopic colorectal procedures. It also informs surgeons of anticipated conversion rates during surgeons’ early clinical practice.

Conclusions

Learning a new surgical technique requires cognitive and technical skills development (1). To accomplish this, surgeons will typically search the literature and various published multimedia adjuncts for resources that will help them improve these skills. A structured learning pathway, such as the one developed by the SAGES MASTERS program, can be very useful to surgeons learning a new technique or improving the technique they are already using in their practice. The above 10 seminal articles provide important and fundamental information to be cognizant of when attempting to develop one’s understanding of a procedure, or even to further optimize one’s skillset in a procedure already performed. These papers present a stratified approach to left colectomy in uncomplicated disease, technical variations and the associated outcome with a mesocolon-sparing approach in benign disease, technical maneuvers to optimize the length of reach of the proximal colon, in addition to a demonstration of the importance of splenic flexure mobilization, the benefits of a HALS approach in select cases and the overall importance of one’s knowledge of the learning curve in taking on minimally invasive techniques. The authors believe that reading these seminal articles will help surgeons optimize their learning curve, current technique, and outcomes of minimally invasive left and sigmoid colon resections in uncomplicated disease.