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J W Milsom

Publications and source records attributed to J W Milsom.

At least 55 records · Page 3Linked to original sources
PubMed1997

Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients.

BACKGROUND: Despite improvement in surgical techniques and stapling devices during the last 10 years, colorectal anastomoses are still prone to leakage. The purpose of this study was to assess the performance and safety of stapled anastomoses in rectal surgery and to identify factors that influence the occurrence of anastomotic leaks. STUDY DESIGN: A review was undertaken of 1,014 patients who underwent stapled anastomoses to the rectum or anal canal for colorectal cancer or benign disease between 1989 and 1995 in a tertiary care institution. Indications for operations, comorbidities at admission, preoperative bowel preparation, stapler size, intraoperative events, associated surgical procedures, and clinical outcomes were tested for any association with anastomotic leak. RESULTS: A double stapled technique was used in 154 patients and a conventional single stapler technique was used in 860. Postoperative mortality was 1.6%, and the overall morbidity was 18.4%. Clinically apparent anastomotic leak developed in 29 patients (2.9%). Anastomotic dehiscence occurred in 22 of 284 patients (7.7%) after low stapling (within 7 cm from the anal verge) and in 7 of 730 patients (1%) after high stapling (p < 0.001). Diabetes mellitus, use of pelvic drainage, and duration of surgery were significantly related to the occurrence of anastomotic leak by the univariate analysis. Multivariate regression analysis identified an anastomotic distance from the anal verge within 7 cm as the only variable related to the occurrence of postoperative leak (p < 0.001). CONCLUSION: Low anastomoses were associated with a leak rate greater than with high colorectal anastomoses. We conclude that anastomoses to the rectum using the circular stapler can be done with low mortality and morbidity.

Adolescent↗
PubMed1996

Development of a reliable colorectal cancer liver metastasis model.

UNLABELLED: The liver is the most frequent and most fatal site of distant spread of colorectal cancer. Most current animal models of liver metastases utilize direct liver or intravascular injection (dissimilar to mechanisms of metastasis) or immunosuppression to establish metastases. AIM: The aim of this study was to develop a reliable rat model of liver metastases in immunocompetent hosts, whereby metastases spread hematogenously as in colorectal cancer. METHODS: WB-2054 is a poorly differentiated colon adenocarcinoma induced by 1,2 DMH in a WF x BN F1 hybrid rat. WB-2054-M0, Ml, M2, M3, and M4 are successive metastatic variant cell lines obtained through serial application of the Fidler hypothesis. WF x BN F1 rats were inoculated intrasplenically with 1 x 10(6)(M0) or 5 x 10(6)(M0-M4) cells; the spleen was left intact. Animals were evaluated 4 to 12 weeks postinjection and, if no metastases were found, reexplored 1-2 weeks later. Animals with liver metastases were sacrificed, and full abdominal and thoracic zoopsy was performed. Livers were excised and serially sectioned, to determine size, number, and location of liver metastases, and studied histologically to confirm the nature of the metastases. RESULTS: 44% (4/9), 80% (8/10), 86% (65/76), 94% (34/36), and 100% (65/65) of animals inoculated with the M0, M1, M2, M3, and M4 cell lines, respectively, developed liver metastases. Metastases were uniformly spread throughout all lobes of the livers. CONCLUSION: We have developed an extremely hepatotrophic metastatic colorectal cancer cell line. Intrasplenic injection of WB-2054-M4 cells is a reliable model for producing colorectal cancer liver metastases without the need for immunosuppression and should prove valuable in colorectal liver metastasis experiments.

Adenocarcinoma↗
PubMed1996

Laparoscopic techniques for fecal diversion.

UNLABELLED: Although the role of laparoscopic techniques in performing major colorectal resections is unclear, laparoscopy may be well suited for fecal diversion procedures because no resection and minimal tissue dissection is required. PURPOSE: This report reviews our initial experience with laparoscopic stoma procedures to assess safety and efficacy. METHODS: Using a simple two-cannula technique, 24 such procedures (16 loop ileostomies, 6 end sigmoid colostomies, 1 transverse, and 1 sigmoid loop colostomy) were attempted. Indications for diversion were rectovaginal fistula (7), perianal sepsis (7), incontinence (4), advanced rectal or colon carcinoma (4), and complicated pelvic infection (2). There were 15 females and 9 males with a median age of 44 (range, 25-88) years. RESULTS: Median operative time was 60 (range, 20-120) minutes, and median blood loss was 50 (range, 0-150) ml. There were no intraoperative complications. One case was converted to a laparotomy because of dense adhesions. Median time to passage of both flatus and stool was one (range, 1-3) day for ileostomy patients, two (range, 2-4) for flatus, and 3 (range, 2-6) days for stool after colostomy. Median time to discharge was 6 (range, 2-28) days and was often delayed by the primary disease process or ostomy teaching. One major postoperative complication, a pulmonary embolism, occurred eight days after operation in a patient with near obstructing, widely metastatic colon carcinoma. This patient later died of pulmonary failure. All stomas have functioned well, with no revisions required. CONCLUSIONS: Laparoscopic fecal diversion procedures can be performed safely, simply, and effectively. Apparent advantages over standard techniques are avoidance of a laparotomy, while maintaining the ability to precisely identify and orient the pertinent bowel segment and rapid return of bowel function.

Adult↗
PubMed1996

Intraoperative laparoscopic liver ultrasonography for staging of colorectal cancer. Initial experience.

PURPOSE: This study was undertaken to evaluate the feasibility of intraoperative laparoscopic ultrasonography (ILUS) to completely scan all anatomic segments of the liver through a single port site during laparoscopic resection for colorectal cancer. METHODS: ILUS was performed in patients who were undergoing laparoscopic colorectal cancer surgery using the following approach: 1) presence of a radiologist in the operating room; 2) introduction of the probe through a single cannula site; 3) standardized sequence of four probe positions on liver surface; 4) identification of all major vascular/biliary hepatic structures as a guideline to scan all parenchymal segments of the liver. RESULTS: Twenty-two patients who were undergoing laparoscopic colorectal cancer surgery were prospectively enrolled. Computed tomography (CT) scan films were available for an immediate comparative analysis in the first 12 cases. Mean duration of the procedure was 10 (range, 5-15) minutes. All major vascular and biliary structures were identified in all patients. Sixteen focal abnormalities were identified by ILUS, and ten focal abnormalities were identified by CT scan in the same seven patients. In one patient, detection of a suspected metastasis not seen by preoperative CT scan led to conversion of the surgical procedure to a laparotomy. CONCLUSIONS: ILUS is a safe and expeditious technique that permits scanning of all anatomic liver parenchyma segments through a single cannula site. Because intraoperative palpation of the liver is not possible during laparoscopic colorectal cancer surgery, ILUS should probably be a standard component of the curative laparoscopic colorectal cancer operation.

Adult↗
PubMed1996

Right colonic arterial anatomy. Implications for laparoscopic surgery.

PURPOSE: Hemorrhagic complications can be a major cause of conversion and/or morbidity during laparoscopic intestinal surgery. The limited exposure currently provided in laparoscopic intestinal resection demands a precise knowledge of mesenteric vascular anatomy to avoid such complications and to expedite the procedure. Most surgical texts depict a "normal pattern" of arterial supply to the right colon consisting of three arterial branches (ileocolic artery, right colic artery, and middle colic artery) arising independently from the superior mesenteric artery (SMA). Based on previous reports and clinical observations, we hypothesized that the right colic artery arises infrequently from the SMA, and most commonly, there are only two colonic arteries arising independently from the SMA. METHODS: We performed detailed dissections of the SMA in 56 human cadavers. RESULTS: We found the ileocolic artery in all of our cases and the middle colic artery in 55 of 56 cadavers but only six cases of a right colic artery emanating directly from SMA. CONCLUSIONS: Our data, combined with review of published anatomic studies, lead us to conclude that in the vast majority of cases there are only two independent branches arising from SMA that supply the large intestine, the ileocolic and the middle colic arteries. The right colic artery directly arising from SMA is unusual (10.7 percent). This knowledge may help lower the risk of vascular complications during laparoscopic intestinal surgery.

Adult↗
PubMed1996

Reoperative rates for Crohn's disease following strictureplasty. Long-term analysis.

BACKGROUND: In Crohn's disease, ten-year reoperative recurrence rates after resection range from 30 to 53 percent. To determine the effect of strictureplasty on reoperative "recurrence" rates, experience at a single tertiary care institution was reviewed. PATIENTS AND MATERIALS: Records of all patients who underwent strictureplasty for Crohn's disease from June 1984 to July 1994 at a tertiary care institution were reviewed. Data collected included duration of disease, medical and surgical history related to Crohn's disease, indications for strictureplasty, and longterm outcome. RESULTS: One hundred sixty-two patients (87 male) underwent 191 operations for a total of 698 strictureplasties (Heineke-Mikulicz, 617; Finney's, 81). Mean number of strictureplasties was three, and mean patient age was 36 years. No mortality occurred. Cumulative five-year incidence of reoperative recurrence was 28 percent (95 percent confidence interval, 18.8-37.2 percent), with a median follow-up of 42 (range, 1-120) months. Obstructive symptoms were relieved in 98 percent of patients. To determine whether any difference in reoperative rates exists between patients who have strictureplasty alone and those who have strictureplasty with bowel resection, we divided patients in two groups, those receiving strictureplasty alone and those undergoing stricutreplasty plus resection. For patients treated by strictureplasty alone (Group A, n = 52; 32 percent), cumulative reoperative rate at five years was 31 +/- 9.6 (+/-standard error) and for patients with concomitant bowel resection (Group B, n = 110; 68 percent), it was 27.2 +/- 5.4 (+/-standard error). No statistical difference was present between these two groups. Of patients undergoing strictureplasty alone (Group A), operative recurrence was managed by new stricutreplasty in seven, by restricutreplasty in two, and by bowel resection in one. Among patients in Group B (strictureplasty and concomitant bowel resection), new strictureplasty was performed in 11, restrictureplasty in 6, and bowel resection in 9. CONCLUSION: Strictureplasty is a safe and effective procedure for Crohn's disease in selected patients. Reoperative rates are comparable with resective surgery, and most recurrences occur at new sites.

Adolescent↗
PubMed1996

Preliminary experience with laparoscopic intestinal surgery for Crohn's disease.

BACKGROUND: Laparoscopic techniques are being applied to the surgical management of various intestinal conditions, but few reports describe their use with Crohn's disease. PATIENTS AND METHODS: Over a 2-year period, 31 selected patients with Crohn's disease underwent laparoscopic intestinal surgery: 18 women and 13 men, with a median age of 39 years (range 22 to 79). Indications for operation included: primary terminal ileitis (13); recurrent ileitis (2); Crohn's colitis (3); rectovaginal fistula (6); and severe perianal disease (7). Resections were laparoscopically assisted with division of mesentery and anastomosis performed extracorporeally. Diversion procedures were performed using a two-cannula technique. RESULTS: Twenty-five of 31 procedures were completed laparoscopically: loop ileostomy or colostomy (12); ileocecectomy (10); segmental colon resection (2); and total abdominal colectomy with ileorectal anastomosis (1). Six cases were converted to conventional surgery secondary to extensive adhesions from prior surgery (2) or severe inflammation (4). No case was converted because of intraoperative complication. Median operative time for diversion procedures was 53 minutes (range 20 to 90) and for resections 195 minutes (range 90 to 380). Median blood loss was 100 mL (range 10 to 500), and there were no intraoperative complications. Only 1 postoperative complication occurred: a myocardial infarction. Median times to passage of flatus and bowel movement were both 3 days (range 1 to 6). Median time to discharge was 6 days (2 to 21) for diversion patients, and 6 days (3 to 7) for resected patients. CONCLUSIONS: Laparoscopic intestinal surgery, both for resection and diversion, is feasible and safe for the management of selected patients with Crohn's disease. To determine if real advantages exist for laparoscopy in the surgical treatment of Crohn's disease, further study is needed.

Adult↗
PubMed1996

Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial.

OBJECTIVE: The authors assess the effect of surgical margin width on recurrence rates after intestinal resection of Crohn's Disease (CD). BACKGROUND: The optimal width of margins when resecting DC of the small bowel is controversial. Most studies have been retrospective and have had conflicting results. METHODS: Patients undergoing ileocolic resection for CD (N = 152) were randomly assigned to two groups in which the proximal line of resection was 2 cm (limited resection) or 12 cm (extended resection) from the macroscopically involved area. Patients also were classified by whether the margin of resection was microscopically normal (category 1), contained nonspecific changes (category 2), were suggestive but not diagnostic for CD (category 3), or were diagnostic for CD (category 4). Recurrence was defined as reoperation for recurrent preanastomotic disease. RESULTS: Data were collected on 131 patients. Median follow-up time was 55.7 months. Disease recurred in 29 patients: 25% of patients in the limited resection group and 18% of patients in the extended resection group. In the 90 patients in category 1 with normal tissue, recurrence occurred in 16, whereas in the 41 patients with some degree of microscopic involvement, recurrence occurred in 13. Recurrence rates were 36% in category 2, 39% in category 3, and 21% in category 4. No group differences were statistically at the 0.01 level. CONCLUSION: Recurrence of CD is unaffected by the width of the margin of resection from macroscopically involved bowel. Recurrence rates also do not increase when microscopic CD is present at the resection margins. Therefore, extensive resection margins are unnecessary.

Adult↗
PubMed1995

Postoperative intestinal motility following conventional and laparoscopic intestinal surgery.

OBJECTIVES: To evaluate the influence of conventional vs laparoscopic right-sided colectomy on postoperative motility of the stomach, small bowel, and large bowel, and to study the effects on postoperative intestinal motility of anesthesia only and of laparotomy vs laparoscopy only. DESIGN: Prospective randomized study in a canine model. SETTING: Animal research laboratory. ANIMALS: Twelve mongrel dogs weighting 23.4 to 29.6 kg. INTERVENTIONS: (1) Laparotomy or laparoscopy and (2) 1 week after complete recovery from the first procedure, right-sided colectomy with ileocolic anastomosis using conventional or laparoscopic techniques. End points of the study were (1) the postoperative time until the electrical response activity of the stomach, small intestine, and large intestine returned to a normal interdigestive pattern and (2) the time until first postoperative bowel movement occurred. RESULTS: Median time until return to normal interdigestive pattern of myoelectrical activity after laparoscopic colectomy was about 40% less than after conventional colectomy (P < .05). Time until first bowel movement was 27% reduced (P < .05). CONCLUSIONS: Recovery from postoperative ileus following laparoscopic surgery is more rapid than after conventional surgery in the canine model. Confirmatory human studies should be performed.

Animals↗
PubMed1995

Safety of urgent restorative proctocolectomy with ileal pouch-anal anastomosis for fulminant colitis.

PURPOSE: Subtotal colectomy with ileostomy is the operation of choice for patients with fulminant colitis. Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is preferred for patients who undergo elective surgery for ulcerative colitis. We retrospectively evaluated the safety of RPC with IPAA in patients with a moderate form of fulminant colitis. METHODS: A chart review of 737 patients who underwent RPC with IPAA for ulcerative and indeterminate colitis from 1983 through 1992 was performed. Moderate fulminant colitis was defined as acute disease requiring hospitalization and parenteral steroid therapy, but without hypotension (systolic blood pressure, < 100 mmHg), tachycardia (> 120 beats/min), or megacolon. RESULTS: Twelve patients with moderate fulminant colitis underwent urgent surgery (1.6 percent). They had been treated preoperatively for 5.1 +/- 2.3 days with intravenous high-dose steroids, total parenteral nutrition, and antibiotics. These patients had a shorter length of disease (P = 0.01), lower hemoglobin, hematocrit, and albumin (P = 0.001), and higher temperature (P = 0.002) and leukocyte count (P = 0.007) than patients undergoing elective surgery. No early septic complications occurred, although perianal abscess occurred in one patient and pouch-anal fistula in another patient, 13 and 14 months after surgery, respectively. CONCLUSION: In carefully selected, hemodynamically stable patients with fulminant colitis and without megacolon, RPC with IPAA can be safely performed.

Acute Disease↗
PubMed1995

Use of laparoscopic techniques in oncologic right colectomy in a canine model.

BACKGROUND: The purpose of this study was to evaluate the feasibility of laparoscopic oncologic righ colectomy (RC) with intraperitoneal ileocolic anastomosis (ICA) in a canine model. METHODS: In 21 dogs a laparoscopic RC with transection of the main right colic artery and removal of adjacent lymph nodes (LN) was carried out using an Nd:YAG contact laser and endoscopic stapler. Two weeks after surgery, all animals were killed. The number of remaining right colon mesenteric LN, length of remaining right colic artery, bursting pressure (BP) of ICA, and postoperative morbidity were evaluated. RESULTS: No major intraoperative complications were recorded. One dog died of pneumonia and heartworms. There were no postoperative septic or anastomotic complications. All dogs passed feces within the first 24 h postoperatively. Median operative time was 135 min (range 105-180 min). Length of remaining right colic artery after oncologic resection was 4.5 mm (range 3-7 mm), the number of remaining LN was 0, and the median anastomotic BP was 232 mm Hg (range 132-312 mm Hg). CONCLUSION: Oncologic resection of the right colon with high vascular ligation, wide mesenteric clearance of LN, and intraperitoneal anastomosis is feasible and safe in a canine model.

Anastomosis, Surgical↗
PubMed1995

Ileal pouch-anal anastomoses complications and function in 1005 patients.

BACKGROUND: Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become an established surgery for patients with chronic ulcerative colitis and familial adenomatous polyposis. PURPOSE: The authors report the results of an 11-year experience of restorative proctocolectomy and IPAA at a tertiary referral center. METHODS: Chart review was performed for 1005 patients undergoing IPAA from 1983 through 1993. Preoperative histopathologic diagnoses were ulcerative colitis (n = 858), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 75), and miscellaneous (n = 10). Information was obtained regarding patient demographics, type and duration of diseases, previous operations, and indications for surgery. Data were collected on surgical procedure and postoperative pathologic diagnosis. Early (within 30 days after surgery) and late complications were noted. Follow-up included an annual function and quality-of-life questionnaire, physical examination, and biopsies of the pouch and anal transitional zone. RESULTS: Of the 1005 patients (455 women), postoperative histopathologic diagnoses were as follows: ulcerative colitis (n = 812), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 54), Crohn's disease (n = 67), and miscellaneous (n = 10). During a mean follow-up time of 35 months (range 1-125 months), histopathologic diagnoses were changed for 25 patients. The overall mortality rate was 1% (n = 10 patients, early = 4, late = 6); one death (0.1%) was related to pouch necrosis and sepsis. The overall morbidity rate was 62.7% (1218 complications in 630 patients; early, n = 27.5%; late, n = 50.5%). Septic complication and reoperation rates were 6.8% and 24%, respectively. The ileal pouch was removed in 34 patients (3.4%), and it is nonfunctional in 11 (1%). Functional results and quality of life were good to excellent in 93% of the patients with complete data (n = 645) and are similar for patients with ulcerative colitis, familial adenomatous polyposis, indeterminate colitis, and Crohn's disease. Patients who underwent operations from 1983 through 1988 have similar functional results and quality of life compared with patients who underwent operations after 1988. CONCLUSION: Restorative proctocolectomy with an IPAA is a safe procedure, with low mortality and major morbidity rates. Although total morbidity rate is appreciable, functional results generally are good and patient satisfaction is high.

Adenomatous Polyposis Coli↗
PubMed1995

Role of laparoscopic techniques in colorectal cancer surgery.

Laparoscopic intestinal resection is a relatively new application of endoscopic technology that has evolved as a direct result of the successes and benefits seen with laparoscopic gallbladder surgery. Currently acceptable and feasible laparoscopic intestinal resections include those for diagnostic procedures, fecal diversion, Crohn's disease, diverticulitis, familial polyposis, rectal prolapse, and palliative colorectal cancer surgery. However, the efficacy of laparoscopic resection for curative cancer surgery remains a topic of much debate. Issues surrounding curative laparoscopic oncologic resection include the ability to perform an acceptable oncologic resection, the question of morbidity and mortality compared to conventional surgery, and the problem of port site recurrences. Thus, at present, curative laparoscopic oncologic surgery must be conducted within the framework of a prospective, randomized clinical trial, which includes full informed patient consent.

Colonic Neoplasms↗
PubMed1995

Surgical anatomy of the celiac artery and portal vein of the rat.

The study of liver function and diseases requires detailed knowledge of the regional anatomy of and surgical approach to the vascular supply of the liver. The objective of this study was to systematically describe the regional anatomy of the circulation to the rat liver to facilitate the planning and performance of future studies of the liver in this animal. Twelve adult rats underwent general anesthesia and vivisection of the celiac axis and portal vein using an operating microscope. The major vessels of these vascular systems were evaluated for their origin, course, relationship with neighboring structures, diameter, and length. All vessels were easily visualized by a ventral approach after mobilization of the intermediate lobe of the liver and its papillary process. The origin and course of the major vessels are similar to those of humans, and variability in vessel origin was identified in this small number of animals. Median vessel diameters were between 0.5 and 1 mm (range, 0.25 to 1 mm) for the celiac artery and its branches, and 3 mm for the portal vein (range, 2 to 3 mm). Median vessel length was between 3 and 7 mm (range, 2 to 8 mm) for the celiac artery and its branches, and 7 mm for the portal vein (range, 4 to 8 mm). The anatomic description obtained in this study is important for the appropriate selection of vessels for cannulation or ligation during study design, as well as vessel isolation during performance of the study. The diameter and length of vessels are important in the selection of appropriately sized catheters and perivascular devices.

Animals↗
PubMed1994

Monopolar electrosurgery and Nd:YAG Contact Laser in laparoscopic intestinal surgery.

In a prospective randomized study using a canine model, we compared the use of monopolar electrosurgery (EC) (n = 23) and the Nd:YAG Contact Laser (CL) (n = 21) on intra- and postoperative morbidity in laparoscopic large-bowel resection. In EC, cutting was performed with scissors and coagulation was performed with electrosurgery. In CL, cutting and coagulation were carried out with the Nd:YAG Contact Laser. Laparoscopic oncologic right colectomy with intraperitoneal ileocolic stapled anastomosis was performed in all dogs. Intraoperative smoke development, difficulty of dissection, hemostasis, and postoperative adhesions were judged using a five-point score. Two weeks after surgery, all dogs were sacrificed and zoopsy was carried out. Three dogs died postoperatively from pneumonia and one from an anastomotic leak. There were no other postoperative complications. Operative time was 135 min (range 105-180) in the CL group and 145 min (range 60-210) in the EC group. Intraoperative smoke development, difficulty of dissection, and postoperative amount of adhesions were not different between groups (P > 0.05). Hemostasis in the CL group (median score of 1, range 1-2) was significantly better (P = 0.01) than in the EC group (median score of 2, range 1-5). Scissors and electrosurgery as well as Nd:YAG Contact Laser can be used successfully in intestinal laparoscopic surgery. Although the use of the Contact Laser did not cause less postoperative morbidity than the conventional method, there was significantly better hemostasis using the Nd: YAG Contact Laser.

Animals↗
PubMed1994

Animal models as educational tools in laparoscopic colorectal surgery.

Laparoscopic colectomies have been shown to be feasible in patients with low morbidity. Thus, many surgeons, as they begin to perform laparoscopic surgery on other areas of the abdomen, may consider performing laparoscopic colectomies. Although certain basic skills like suturing and knot tying can be practiced in training models, the preclinical performance of intraperitoneal bowel mobilization and anastomosis, dissection of mesentery, and control of bleeding can only be practiced and perfected in live animal models. We describe several laparoscopic intestinal techniques in porcine and canine models. Through use of these procedures, the surgeon can learn to handle intraperitoneal organs atraumatically, to achieve hemostasis, to dissect mesentery with lymphadenectomy and high ligation of major vessels, and to accomplish a variety of intraperitoneal anastomoses. Acquisition of these skills is essential in the quest to perform successful laparoscopic intestinal surgery. These skills cannot be learned in inanimate training models.

Anastomosis, Surgical↗
PubMed1994

Laparoscopic oncologic proctosigmoidectomy with low colorectal anastomosis in a cadaver model.

The purpose of this study was to demonstrate that a standardized approach to laparoscopic proctosigmoidectomy in a cadaver model with (1) initial proximal ligation of the inferior mesenteric (IM) vascular pedicle, (2) complete mobilization of the splenic flexure, and (3) intraperitoneal stapled colorectal anastomosis can be accomplished in complete accordance with oncologic surgical principles. Using nine cadavers in the fresh state, six abdominal wall cannulas were placed so as to allow good access to the left colon and rectum. After identifying the left ureter and gonadal vessel, the IM pedicle was divided close to the aorta and the left mesocolon was separated from the retroperitoneal structures. The sigmoid colon was transected at the proximal resection line with an endoscopic stapler; then the splenic flexure and descending colon were completely mobilized. The rectum was freed circumferentially, dissected first posteriorly, laterally, and anteriorly, and then transected in its middle portion with an endoscopic stapler. The specimen was removed through a widened left-lower-quadrant trocar incision and the anvil of a circular endoscopic stapler was placed into the proximal colon extraperitoneally. An intraperitoneal laparoscopic colorectal anastomosis was performed using a double-stapled technique. The median length of specimen was 53 cm (range 45-80 cm) and the median number of removed lymph nodes was 15 (range 11-20). A careful abdominal autopsy was carried out in all cadavers. Length of remaining inferior mesenteric artery was smaller than 1.5 cm in all cases and only one remaining lymph node (3 mm in diameter) was found adjacent to the IMA in one subject. No damage to either ureter occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗