Abstract. In this study, a total of 108 patients with primary colorectal cancer who underwent hybrid 2-port hand-assisted laparoscopic surgery (HALS) were classified as 58 patients with colon cancer and 50 patients with rectal cancer. The mean operating time, mean blood loss, postoperative complications, and mean postoperative hospital stay were compared between the two groups. In patients who underwent colon cancer surgery, the mean operating time was 2 h and 26 min, the mean blood loss was 166.3 ml, and the postoperative complications were wound infection in 5/58 patients (8.6%), postoperative ileus in 3 patients (5.2%), and anastomotic stricture in 1 patient (1.7%). There was no anastomotic leakage and no conversion to conventional open laparotomy. The mean postoperative hospital stay was 12.6 days. In patients who underwent rectal cancer surgery, the mean operating time was 3 h and 38 min, the mean blood loss was 238.8 ml, and the postoperative complications consisted of wound infection in 6/50 patients (12.0%), anastomotic leakage in 3/35 patients (8.6%), anastomotic stricture in 3/47 patients (6.4%), postoperative ileus in 3/50 patients (6.0%), and conversion to conventional open laparotomy in 1/50 patients (2.0%). A covering stoma was constructed during surgery in 12/47 patients (25.5%). The mean postoperative hospital stay was 19.1 days. These results suggest that hybrid 2-port HALS (Mukai's operation) could become a standard method for the treatment of colorectal cancer, and that the long-term outcome should be compared in detail with that of standard laparotomy in the future. IntroductionLess invasive surgery such as laparoscopy-assisted colorectal surgery (LACS) has become popular in recent years, and its indications have expanded markedly from additional resection in patients with stage I colorectal cancer to radical resection in patients with stage II/III cancer and palliative surgery for patients with advanced stage IV disease (1-5). Unlike Western countries, where hand-assisted laparoscopic surgery (HALS) and hybrid HALS combined with open manipulation are performed (6-9), the main type of surgery employed in Japan is pure LACS with 5-6 ports including a camera port for manipulation and a small incision of 35-45 mm (10-12). However, at least 3 surgeons experienced with smooth camera operation are required for pure LACS since the operation is mostly performed by the operator and first assistant manipulating four forceps. Pure LACS has the following disadvantages compared with ordinary open laparotomy: i) poor palpation/tactile sensation, ii) limited applicability with respect to large and heavy tumors, ii) difficulty in assessing the total operating field, iv) a longer operating time as laparoscopic manipulation while observing the monitor is the main procedure, and v) a requirement to acquire specific skills and pass the certification exam in Japan. In addition, LACS cannot become the standard operation even at a relatively large general hospital since it requires several experienced surgeons to s...

Abstract. To safely avoid the construction of a covering stoma in patients with advanced lower rectal cancer undergoing laparoscopy assisted colorectal surgery (LACS), we added circumferential manual reinforcing sutures via the transanal approach at the site of mechanical anastomosis. In June 2008, LACS was performed for a tumor of 6 cm in longer diameter in the Rb region of the lower rectum ~5 cm from the anal verge. After intraperitoneal coloproctal anastomosis was performed in the pelvis by the double stapling technique (DST), reinforcement was provided by manual trans-anal suturing (trans-anal reinforcing sutures: TARS). A covering stoma was constructed because this was a high-risk case. Complications such as mild wound infection and stoma trouble occurred, and the patient was discharged after conservative therapy. In June 2008, LACS was performed for a tumor of 5 cm in longer diameter in the Ra region of the lower rectum ~7 cm from the anal verge. After intraperitoneal colorectal anastomosis was performed in the pelvis by DST, TARS were added to avoid a covering stoma. Minor leakage occurred postoperatively, but this was controlled conservatively and the patient was discharged. In patients having surgical treatment of advanced lower rectal cancer, good results were obtained by adding circumferential reinforcing sutures via the trans-anal approach at the site of ultra-low anastomosis after DST.

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Abstract. During the initial emergency operation, a temporary loop colostomy (TLC) was constructed at the oral border of the region for subsequent radical resection. Then, radical surgery was performed by hybrid 2-port HALS (Mukai's operation) using the TLC as the hand access site. Left hemicolectomy was done in three patients, sigmoidectomy in two cases, low anterior resection in one case, and Hartmann's operation in one case. Radical surgery was not done in one patient with multiple distant metastases. The mean operating time was 3 h and 7 min (ranging from 1 h and 55 min to 3 h and 47 min), the mean blood loss was 146.4 ml (7-354 ml), the mean duration from TLC to HALS was 11.3 days (8-16 days), and the mean hospital stay after HALS was 13.9 days (9-20 days). Mild wound infection occurred postoperatively in 2/7 patients and ileus occurred in one patient. However, there was no anastomotic leakage/stricture or conversion to conventional laparotomy. These results suggest that 2-stage treatment (Mukai's method with Mukai's operation) is also applicable to large obstructing left colon or rectal cancers. This method is safe, less invasive, and achieves excellent results, including a good cosmetic outcome. IntroductionIn recent years, minimally invasive laparoscopy-assisted colorectal surgery (LACS) has become common, and its indications have expanded considerably from additional resection for early stage I colorectal cancer to radical curative resection of advanced stage II/III cancer and palliative surgery for stage IV patients (1-5). Unlike Western countries, where hand-assisted laparoscopic surgery (HALS) and hybrid-HALS combined with surgery under direct vision are popular (6-9), pure LACS performed via 5-6 ports together with a small incision of 35-45 mm has become the mainstream procedure in Japan (10,11). However, the use of pure LACS is limited in patients with complete bowel obstruction due to left colon cancer, which is an oncologic emergency, and those who need partial resection of tumors infiltrating other organs such as the bladder. In addition, it has been pointed out that the operating time is relatively long (5,(12)(13)(14). In order to solve these problems, we devised hybrid 2-port HALS (Mukai's operation), which involves HALS using a small incision of 45-55 mm as the hand access site, combined with manipulation under direct vision (15). The features of this surgical procedure include the following: i) full grasping manipulation, as well as palpation, can be done with the left hand, enabling protective and smooth handling of even large and heavy tumors; ii) there is little difficulty for anesthesiologists and operating room staff since the procedure is an extension of conventional laparotomy and takes less time than pure LACS and; iii) it is less demanding for surgeons and less time is required to master the procedure, a supervised surgeon who only has experience of standard laparotomy is able to perform it without difficulty. Due to such advantages, hybrid 2-port HALS is applicable to all colorect...

Our previous study demonstrated that the pT2 and pT3-4 gallbladder carcinomas can be classified into two groups, i.e. infiltrative growth type (IG type) and destructive growth type (DG type) and that the DG type is associated with poor differentiation, aggressive infiltration, and decreased postoperative survival. The present study focused on the clinicopathologic significance of laminin-5γ2 chain expression as an indicator of local aggressiveness and Ki-67 labeling index (Ki-67 LI) as an indicator of the cell proliferation activity of gallbladder carcinoma. Ki-67 LI was higher in the DG type (26.3%) than in the IG type (21.4%), and the rate of high-grade cell proliferation cases (Ki-67 LI ≧ 30%) was high in the DG type (P = 0.012). Gallbladder carcinoma cases with high Ki-67 LI were significantly associated with poorly differentiation (P = 0.089) and distant lymph node metastasis (P = 0.079). Laminin-5γ2 expression patterns of gallbladder carcinoma were divided into two distinct types, extracellular staining and cytoplasmic staining. The extracellular staining was subclassified into two groups, basement membrane staining and stromal staining. In the basement membrane staining, laminin-5γ2 was present in the basement membranes surrounding neoplastic glandular structures. The basement membrane staining of laminin-5γ2 was more frequent in the IG type (40%) than in the DG type (12.9%) (P = 0.025). The stromal staining was more frequent in the DG type. Furthermore, the stroma-positive group was more closely associated with decreased overall survival than the stroma-negative group (P = 0.028). The cytoplasmic staining was not significantly correlated with invasion pattern in gallbladder carcinoma (P = 0.545). Univariate analysis demonstrated that laminin-5γ2 stromal staining is a predictor of lymphatic invasion, venous invasion, neural invasion, the mode of subserosal infiltration, and lymph nodal status. Multivariate analysis revealed the mode of subserosal infiltration is the strongest predictor of stromal invasion (P = 0.068). In conclusion, high-grade cell proliferation and stromal laminin-5γ2 staining were significantly correlated with a wall-invasion pattern of aggressive gallbladder carcinoma indicating destructive growth (DG type).In a previous study, we subclassified the pT2 and pT3-4 gallbladder carcinomas into two groups, i.e. infiltrative growth type (IG type) and destructive growth type (DG type), and the DG type was significantly associated with poor differentiation, aggressive infiltration, vascular invasion, lymph node metastasis, and decreased postoperative survival (38). Therefore, subclassification of the IG/DG growth