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Laparoscopic colorectal surgery 30 years in China: what we learned

Journal of Surgery Concepts & Practice.2023;28(3):181-185. doi:10.16139/j.1007-9610.2023.03.001

Since 1993, the first laparoscopic radical surgery for colon cancer was carried out in China, laparoscopic colorectal surgery in China has embarked on a new journey, and has now entered its 30th year. Looking back on the 30 years history of laparoscopic colorectal surgery, it is hoped that through the window of laparoscopic colorectal surgery, from the establishment of a series of key technologies in its initial stage, to the development of training systems, and even the further development of innovative technologies and technology platforms, to review the trajectory in the development of laparoscopic surgery in China, and to think from multiple dimensions, so as to gain experience, guide current practice, and look forward to the future development.

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Influence of neoadjuvant radiotherapy combined with immunotherapy on minimally invasive surgeries for rectal cancer

Yingchi YANG ; Kai PANG ; Zhongtao ZHANG

Journal of Surgery Concepts & Practice.2023;28(3):186-189. doi:10.16139/j.1007-9610.2023.03.002

The current domestic and international guidelines recommend neoadjuvant chemoradiation or total neoadjuvant therapy followed by radical surgery for mid-low locally advanced rectal cancer. In recent years, the significant efficacy of immune checkpoint inhibitors has been recognized for patients with microsatellite instability-high/mismatch repair deficiency. The latest researchs show that in the neoadjuvant therapy of microsatellite stability/mismatch repair proficient rectal cancers, combining immune checkpoint inhibitors with radiotherapy can also achieve significant tumor regression, which is expected to usher in a new era of neoadjuvant therapy for rectal cancer. Even so, surgery remains pivotal in the current multidisciplinary diagnosis and treatment modelity for rectal cancer. However, it can be foreseen that a more significant preoperative tumor regression will greatly promote the widespread use of minimally invasive surgery. The minimally invasive surgery for rectal cancer represented by transanal endoscopic microsurgery, transanal total mesorectal excision, laparoscopic total mesorectal excision plus removal of specimens through natural cavity is hopeful to be further promoted and become the standard surgery in the era of radiotherapy combined with immunotherapy for rectal cancer.

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Function-preserving laparoscopic resection of pancreatic head and duodenal papilla tumors

Pan GAO ; Yunqiang CAI ; Bing PENG

Journal of Surgery Concepts & Practice.2023;28(3):190-196. doi:10.16139/j.1007-9610.2023.03.003

In recent years, with the development of minimally invasive instruments,equipment and the progress of surgical techniques, minimally invasive pancreatic surgery has entered an era of rapid development. Function-preserving laparoscopic resection of pancreatic head and duodenal papilla tumors including laparoscopic duodenum-preserving pancreatic head resection (LDPPHR), laparoscopic pancreatic head tumor enucleation and laparoscopic transduodenal ampullary resection(LTDAR) have also been used in clinical practice. However, the anatomy and surgical procedures are extremely complicated. Many surgeons lack the experience in this field. So far, these procedures have rarely used in clinical practice. In this article, we introduced the current status, problems and countermeasures of these surgical procedures, to promote the development of function-preserving laparoscopic pancreatic head and duodenal papilla tumor resection surgery.

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Meticulous surgical techniques for endoscopic thyroid surgery

Bin WANG ; Ming QIU

Journal of Surgery Concepts & Practice.2023;28(3):197-201. doi:10.16139/j.1007-9610.2023.03.004

The refinement of thyroid surgery has become a standardized requirement and a symbol of improved technical level in thyroid surgery. Endoscopic equipment magnifies the surgical field of view in high definition, making it more conducive to perform the surgery meticulously. Here we explored the key points of refined surgery based on the technical points of endoscopic thyroid surgery. We also focused on the establishment of endoscopic operation space, exposure of thyroid tumors, and protection of key organs and tissues. With regard to the establishment of endoscopic operation space, the separation of subcutaneous layer should show the view of “red sky and yellow ground”, which means the gap between the platysma muscle and the deep layer of the superficial fascia. The subcutaneous dissection area should be present as “long tunnel, small cavity”, and the shape from the bilateral sternoclavicular joints to the bilateral areola, which seems like the fan-shape with “thin neck and wide bottom”. With regard to the exposure of thyroid tumors, the key technical points include the dissociating and traction of anterior cervical muscles. Three spaces [the median space (the white line space of the neck), the inner space (the space between the thyroid surgical capsule and the anterior cervical muscles) and the outer space (the space between the anterior cervical muscles and the sternocleidomastoid muscle)] need to be fully dissociated. Furthermore, the assistant with special sutures or hooks to fully dissociate the anterior cervical space and the use of a reasonable grasping method as well as a suitable energy platform to prevent thyroid bleeding. With regard to the protection of key organs and tissues, nerve monitoring technology helps to find and locate the recurrent laryngeal nerve. In addition, careful manipulation at the entrance to the larynx is the key to avoid the damage of recurrent laryngeal nerve. Lymph negative imaging techno-logy helps to identify the parathyroid gland. Accurate identification of the anatomical type of the parathyroid gland and meticulous dissection of the intermembrane space of the parathyroid gland is benefit to protect the blood supply of the parathyroid gland in situ. To achieve the refinement and minimally invasive surgery, it is necessary to improve the surgical instruments and materials. What is more important, surgeons should update their surgical concepts, be well acquainted with anatomical relationships and constantly improve surgical techniques.

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Controversy over the medial border of lymph node dissection during CME/D3 surgery of right colon cancer

Yueming SUN ; Dongsheng ZHANG

Journal of Surgery Concepts & Practice.2023;28(3):202-207. doi:10.16139/j.1007-9610.2023.03.005

Radical surgery is the most important treatment for colon cancer. The development and application of complete mesentery excision (CME)/D3 lymph node dissection has promoted the standardization of surgical techniques for colon cancer. Right colon cancer surgery is relatively complicated, and is a research hotspot currently. The issues involved the range of lymph node dissection, the range of bowel resection, and the method of bowel reconstruction. The medial border of lymph node dissection for right colon cancer is one of the controversies. The left side of the superior mesenteric vein is generally considered to be the medial border of CME/D3 dissection in right colon cancer surgery. However, with the in-depth development of related research, some scholars believed that the left side of the superior mesenteric artery should be used as the medial border for lymph node dissection. This approach is more consistent with the principle of CME, and can achieve complete lymph node dissection. However, its clinical significance still needs to be evaluated with further research. This article discusses the selection of medial border of lymph node dissection for right colon cancer, hoping to provide reference for clinical practice.

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Current status of minimally invasive surgery of gastroesophageal reflux disease

Aikebaier· ; Aili ; Yusujiang· ; Tusuntuoheti ; Kelimu· ; Abudureyimu

Journal of Surgery Concepts & Practice.2023;28(3):208-214. doi:10.16139/j.1007-9610.2023.03.006

Gastroesophageal reflux disease (GERD) is one of the common gastrointestinal diseases. The treatment options for GERD includes lifestyle changes, medication, and surgery. With the development of surgical technology, minimally invasive surgery has become more and more widely used in clinical practice due to its advantages such as less trauma and rapid postoperative recovery. Laparoscopic fundoplication is the standard surgical treatment for GERD. Due to the postoperative complications of laparoscopic fundoplication, a variety of new alternative minimally invasive surgery methods, which are expected to provide new treatment options for GERD patients, have emerged recently. Surgical minimally invasive procedures include magnetic sphincter augmentation (MSA), bariatric surgery, and lower esophageal sphincter electric stimulating therapy (LES-EST). Endoscopic minimally invasive procedures include transoral incisionless fundoplication (TIF), Stretta radiofrequency ablation, and anti-reflux mucosectomy (ARMS). This article mainly describes the current status of minimally invasive surgical treatment of GERD.

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Minimally invasive surgery facilitates surgical treatment of obesity and metabolic diseases

Xianjue HUANG ; Qiyuan YAO

Journal of Surgery Concepts & Practice.2023;28(3):215-219. doi:10.16139/j.1007-9610.2023.03.007

The prevalence and social burden of obesity and metabolic diseases are increasing. Multidisciplinary diagnosis and treatment, including surgical treatment, can effectively improve the condition of obesity and metabolic diseases. With the developing and updating of minimally invasive surgical techniques and concepts, traditional open transabdominal bariatric surgery has been replaced by laparoscopic surgery. The emergence of new technologies such as 4K high-definition laparoscopy, single-port bariatric surgery, robot-assisted surgery, and endoscopic bariatric surgery has further contributed to the safe, effective, and individualized treatment of obesity and metabolic diseases.

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Prevention and treatment of anastomotic leakage after laparoscopic anterior resection of low rectal cancer

Yang LUO ; Ming ZHONG

Journal of Surgery Concepts & Practice.2023;28(3):220-225. doi:10.16139/j.1007-9610.2023.03.008

Anastomotic leakage (AL) is one of the inevitable and severe complications after laparoscopic-assisted anterior resection of low rectal cancer. With the improvement of surgical technology and cognitive concept, the position of sigmoid-rectal anastomosis is becoming lower and lower, and the problem of AL is more challenging. Preventive stoma is currently a common method to deal with AL, but over-reliance on stoma and the stoma-related complications have also troubled surgeons. Based on years of practical experience, we summarized how to avoid unnecessary stoma through the risk assessment scale, and how to detect and deal with AL in the early stage of laparoscopic-assisted anterior resection of low rectal cancer.

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Current status of high-positioned digestive tract reconstruction after laparoscopic proximal stomach and lower esophagus resection through the abdominal-left diaphragmatic approach for adenocarcinoma of esophagogastric junction

Wenqing HU ; Yinhao YANG ; Peng CUI ; Wei WEI

Journal of Surgery Concepts & Practice.2023;28(3):226-232. doi:10.16139/j.1007-9610.2023.03.009

In recent years, the rising incidence of adenocarcinoma of esophagogastric junction (AEG) and the subsequent surge in early detections have transformed the surgical treatment of AEG into a topic of substantial interest. The anatomical positioning of AEG, combined with the unique nature of its tumor biology, which encompasses two distinct surgical domains, the thoracic and abdominal cavities, has sparked numerous debates regarding the selection of treatment strategies. The comprehensiveness of lymph node dissection and the safety of digestive tract reconstruction are instrumental in shaping these strategies. The laparoscopic abdominal transhiatal (TH) approach offers a balance of addressing both these conside-rations. It ensures the oncological safety of inferior mediastinal lymph node dissection, while simultaneously performing abdominal lymph node dissection. This approach becomes a prime choice for AEG when the esophageal invasion length is ≤ 4 cm.When implementing the TH approach, surgeons have the ability to either augment the inferior mediastinal space or establish a direct connection between the abdomen and the left thoracic cavity by performing a strategic opening of the left diaphragm. Such a maneuver circumvents the need for traditional thoracotomy, thus enlarging the operating space and enhancing the surgical field of view. This method reduces chest trauma and enables a clearer and more comprehensive removal of inferior mediastinal lymph nodes. Moreover, ample operating space and sufficient esophageal dissection make high digestive tract reconstruction in the mediastinum or left thoracic cavity safer and more feasible. Our center has dubbed this approach the abdominal-left diaphragmatic (ALD) approach. Functional digestive tract reconstructions such as side overlap esophagogastrostomy （SOFY） anastomosis and double-flap technique can be progressively applied to a higher anastomosis plane through the ALD approach. Consequently, the ALD approach expands the indications for digestive tract reconstruction, ensures operational safety, and maintains an effective anti-reflux effect simultaneously.

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Practice of single-port and reduced-port laparoscopic gastric cancer surgery in China

Su YAN ; Minhua ZHENG

Journal of Surgery Concepts & Practice.2023;28(3):233-239. doi:10.16139/j.1007-9610.2023.03.010

The application and development of laparoscopic surgery for gastric cancer has experienced a history of more than two decades, from exploratory development to clinical validation, and then to large-scale clinical studies. Gra-dually, laparoscopic gastric cancer surgery has been supported by high-level evidence. Laparoscopic surgery is progressively recommended as one of the alternative treatment for gastric cancer and is widely performed in gastric cancer surgery worldwide, especially in East Asia, such as Japan, Korea and China. Single-port and reduced-port laparoscopic surgery was first performed for cholecystectomy and appendectomy, is becoming more popular among gastrointestinal surgeons due to its minimally invasive outcomes and better cosmetic effects. However, the clinical application of single-port and reduced-port laparoscopic surgery for gastric cancer is still in the exploratory stage. The results of initially observational studies have shown that single-port and reduced-port laparoscopic surgery have potential advantages in terms of cosmetic results and enhanced recovery after surgery compared with the conventional five-port laparoscopic surgery for gastric cancer. But its surgical safety and feasibility are still not confirmed by high-level evidence of evidence-based medicine.

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