Incidence of Symptomatic Internal Hernia following Minimal Invasive colorectal surgery: A Single Center Experience

Laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant diseases. Recent reviews suggest that the incidence of symptomatic internal hernias after laparoscopic colorectal resection is from 0.39 to 0.65%. Unlike in open surgery, laparoscopic closure of a mesenteric defect is inherently challenging as inadvertent injury to the marginal vessels may compromise blood supply to the anastomosis. For these reasons, many surgeons leave the defect open during laparoscopic surgery. But this may lead to development of post-operative internal hernia through the defect. This is a retrospective study where we included 149 patients who underwent laparoscopic/ robotic colorectal surgeries from March 2019 to March 2020. Data pertaining for following variables were collected which included age, sex, indication for surgery, location of the pathology, splenic flexure mobilization. The incidence of internal hernia among these patients were calculated and assessed using SPSS 20. Incidence of internal hernia was found to be 0.67% which was diagnosed and treated on the 18th post-operative day of initial surgery. Internal hernia is a rare but important complication of laparoscopic/robotic colorectal surgery with a high mortality rate if not diagnosed early. Defect closure is still controversial during the initial surgery and probably not indicated for all patients and depends on surgeon’s preference.

Visceral obesity enhances inflammatory response after laparoscopic colorectal resection

Aims: C-reactive protein (CRP) is commonly used for monitoring Surgical Stress Response (SSR) and detecting post-operative infectious complications. However, high CRP values can be associated to patient-related factors independently from complications. The aim of this study was to assess the relationship between visceral obesity (VO) and SSR after laparoscopic colorectal resection. Methods: Visceral adipose tissue (VAT) area was measured at CT images for 357 patients who underwent elective laparoscopic colorectal resection at our institution. Post-operative outcomes and CRP values were compared between VO and non-VO groups, defined according to VAT cut-offs. Univariate and multivariate analyses were conducted for factors affecting SSR. ROC curves were constructed to assess the most appropriate CRP values for identifying infectious complications in the VO and non-VO populations. Results: In the final cohort, 62.2% of patients were classified as VO. No differences were seen in post-operative outcomes and infectious complications. VO was associated with higher CRP values on post-operative day (POD)1, POD2, POD3, and POD5, considering both the overall cohort and patients without infectious complications. A positive correlation was found between VAT and CRP values on all PODs, and VO independently predicted increased CRP on POD1-3 in patients without infectious complications but not in those who developed complications. ROC curves analysis for POD3 CRP showed comparable accuracy for detection of infectious complications in both groups, though the optimal cut-off value was higher in VO group (154 vs. 136 mg/dl). Conclusions: Although VO is not associated to increased complications after laparoscopic colorectal resection, it independently predicts increased SSR risk. To achieve accurate identification of infectious complications, different cut-off values of POD3 CRP shall be used in VO and non-VO patients.

Preoperative Immunonutrition vs. Standard Dietary Advice in Normo-Nourished Patients Undergoing Fast-Track Laparoscopic Colorectal Surgery

Immunonutrition (IN) appears to reduce infective complications and in-hospital length of stay (LOS) after major gastrointestinal surgery, but its use in normo-nourished patients is still controversial. The primary aim of this comparative observational study was to evaluate if pre-operative IN reduces in-hospital stay in patients undergoing laparoscopic colorectal resection for cancer under an enhanced recovery after surgery (ERAS) program. The influence of IN on time to first bowel movements, time to full oral diet tolerance, number and type of complications, reasons of prolonged LOS and readmission rate was evaluated as secondary outcome. Patients undergoing ERAS laparoscopic colorectal resection between December 2016 and December 2019 were reviewed. Patients who have received preoperative IN (group A) were compared to those receiving standard dietary advice (group B). Mean in-hospital LOS was significantly shorter in patients receiving preoperative IN than standard dietary advice (4.85 ± 2.25 days vs. 6.06 ± 3.95 days; p < 0.0492). No differences in secondary outcomes were observed. Preoperative IN associated with ERAS protocol in normo-nourished patients undergoing laparoscopic colorectal cancer resection seems to reduce LOS.