Symmetrical single-port +2 around the umbilicus (Tang style) laparoscopic total colectomy for refractory constipation

Symmetrical single-port +2 around the umbilicus (Tang style) laparoscopic total colectomy for refractory constipation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Symmetrical single-port +2 around the umbilicus (Tang style) laparoscopic total colectomy for refractory constipation Xuanyu Wei, Haokai Ma, Yutao Wang, Hao Ji, Yichao Ma, Chen Wei, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7958638/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and objective: This study aimed to evaluate the efficacy of the symmetrical single-port + 2 around the umbilicus laparoscopic (Tang style) total colectomy in the treatment of refractory constipation.. Methods From June 2023 to December 2024, 40 patients with refractory constipation underwent the symmetrical single-port + 2 around the umbilicus laparoscopic (Tang style) total colectomy. Preoperative assessments included modified colonic transit tests, defecography, physical examinations, and multiple standardized scales. Postoperative efficacy was evaluated via follow-up questionnaires at 3 and 6 months. Results At the 3-month follow-up, the mean weekly spontaneous bowel movements significantly increased from 2.68 ± 2.25 to 21.30 ± 7.24 (P < 0.01). Significant improvements were also observed in the PAC-QOL quality of life scale, Wexner constipation score, PHQ-9 depression scale, and GAD-7 anxiety scale (P < 0.01). At the 6-month follow-up, therapeutic effects remained stable, with a mean weekly spontaneous bowel movement frequency of 18.55 ± 5.48, along with sustained improvements in quality of life and psychological scores. No surgery-related mortality occurred. Three cases (7.5%) of minor complications or adverse events were reported, most of which resolved with conservative management. Patient satisfaction was 87.5% at 3 months and further improved to 92.5% at 6 months. Conclusions The symmetrical single-port + 2 around the umbilicus laparoscopic (Tang style) total colectomy is a safe and effective surgical approach for chronic refractory constipation, demonstrating significant and sustained improvements in bowel function, quality of life, and psychological well-being with minimal complications. refractory constipation total colectomy minimally invasive surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Constipation is a chronic gastrointestinal disorder with a high incidence rate, causing not only physical discomfort but also significant psychological distress [ 1 ] . Many patients rely on long-term medication to maintain bowel regularity, which can increase the risk of intestinal obstruction. Prolonged medical treatment also imposes a substantial economic burden on both patients and society [ 2 ] . When medical interventions fail, surgery is often considered the last resort. Chronic functional constipation is currently categorized into slow transit constipation, rectal outlet obstruction, and mixed constipation. Colectomy is the primary surgical treatment for slow transit constipation, which alleviates most symptoms but can lead to complications such as severe short-term diarrhea and long-term recurrent small bowel obstruction [ 3 , 4 ] . This may be related to the length and chosen location of colon resection and preservation. For rectal outlet obstruction, various surgical methods are available, with rectal suspension and rectal excision being the most common. Each of these treatments has advantages and disadvantages [ 5 – 7 ] . Long-term follow-up studies have shown that stapled trans-anal rectal resection (STARR) is a safe surgical method with a low recurrence rate, with main complications being pain, bleeding, and anal bleeding, though these occur infrequently [ 8 , 9 ] . Chronic refractory constipation often presents as mixed constipation, involving both slow colonic transit and outlet obstruction [ 10 ] . To address this, Li Lin developed a new surgical approach: subtotal colectomy combined with a modified Duhamel procedure, known as the Jinling procedure. This technique involves resecting most of the colon and appendix and performing a side-to-side anastomosis between the right colon stump and the rectum [ 11 ] . Long-term follow-up has demonstrated that the Jinling procedure significantly increases spontaneous defecation frequency and is widely endorsed by surgeons. However, challenges such as prolonged operation time, a high incidence of diarrhea, and significant surgical trauma remain [ 12 , 13 ] . Thus, optimizing treatment for intractable constipation while minimizing complications, surgical duration, and patient trauma is a key goal for surgeons. The aim of this study is to evaluate the efficacy and safety of the Symmetrical single-port + 2 around the umbilicus (Tang style) laparoscopic total colectomy in treating chronic refractory constipation from June 2023 to December 2024. forty patients, comprising 21 males and 19 females, were included in this study. Defecation frequency and daily life impacts were assessed using a questionnaire. The findings of this study may contribute to optimizing surgical strategies for chronic refractory constipation. Materials and Methods: The patient From June 2023 to December 2024, a total of 40 patients were diagnosed with chronic constipation based on the Rome IV criteria. The duration of the disease ranged from 2 to 40 years. All patients had been treated with irritating laxatives, including enema in 5 cases and traditional Chinese medicine or acupuncture in 25 cases, but no significant improvement was observed. Each patient was managed by the constipation multidisciplinary team at Northern Jiangsu People's Hospital. This team comprises specialists from gastrointestinal surgery, gastroenterology, clinical psychology, traditional Chinese medicine, rehabilitation physiotherapy, and nutrition. It is responsible for diagnosing, evaluating, and formulating personalized treatment plans for patients with chronic refractory constipation. The Ethics Committee of Subei People's Hospital in Jiangsu, China, approved the study protocol, and informed consent was obtained from all patients or their families. Diagnostic criteria Patients were enrolled if they met the following criteria: (1) Diagnosis of chronic constipation based on the Rome IV criteria, with a duration exceeding 2 years.. (2) Frequency of bowel movements less than 3 times per week for at least 3 months per year. (3) Modified colonic transit test indicating a colonic transit time greater than 72 hours, evidenced by significant contrast agent retention in abdominal X-rays 72 hours after barium ingestion. (Fig. 1) (4) Ineffectiveness of long-term standardized medical treatment. Patients were excluded if they met any of the following criteria: (1) Presence of organic gastrointestinal disease or cancer. (2) Endocrine or metabolic disorders, such as hypothyroidism, that could cause secondary constipation. (3) Gastrointestinal discontinuity resulting from surgery for other conditions. (4) Severe cardiovascular or cerebrovascular diseases that contraindicate surgery. Patient Assessment and Preoperative Examinations At the time of admission, each patient completed several relevant scales, including the Patient Assessment of Constipation Quality of Life (PAC-QOL), Wexner Constipation Score, Bristol Stool Scale, Generalized Anxiety Disorder Scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9) for depression screening. Patients also underwent various preoperative examinations, including constipation-specific assessments such as the modified colonic transit test, defecography, and anorectal manometry. Additionally, some patients underwent functional magnetic resonance imaging (fMRI) to detect the effects of constipation on brain function and structure [ 14 ] . Six months post-surgery, functional and structural improvements in corresponding brain regions were compared between the two groups. The PAC-QOL was developed in 2005 to assess the quality of life in patients with constipation. It consists of 28 items, including physical and psychological sensations, each scored on a 5-point scale ranging from 0 to 4. The total score ranges from 0 (indicating the best quality of life) to 112 (indicating the worst) [ 15 ] . The Wexner Constipation Score is used to evaluate the severity of constipation symptoms, with scores ranging from 0 to 30; higher scores indicate more severe constipation and this scale is widely utilized in clinical settings [ 16 ] . The Bristol Stool Scale helps to preliminarily determine colonic transit time by categorizing stool into seven distinct forms [ 17 ] . The GAD-7 and PHQ-9 scales were used to evaluate anxiety and depression levels, respectively, providing an initial assessment of the patient's psychological status. The psychological status of patients was initially evaluated using the standardized scales. If any abnormal scores were identified, a clinical psychologist provided appropriate psychological treatment. Surgical methods The symmetrical single-port + 2 around the umbilicus (Tang style) laparoscopic total colectomy is inspired by the concept of Chinese Tai Chi (Fig. 2). The Tang style design positions the navel as the center, with the two auxiliary ports representing the "fish eyes" of Tai Chi. The surgeon can perform a 360-degree rotation in the abdominal cavity around the navel, mimicking the rotational movement of Tai Chi. By adjusting the angle and the surgeon's standing position, this setup ensures optimal visualization and access to all areas of the abdominal and pelvic cavity with endoscopic instruments. All surgeries were performed by the same surgical team, led by a single surgeon. Following the induction of general anesthesia, each patient was placed in the lithotomy position. A transverse incision approximately 3 cm in length was made along the upper edge of the umbilicus. A disposable trocar puncture needle was used to establish pneumoperitoneum. Two additional laparoscopic ports were created symmetrically, each 10 cm from the umbilicus, in the left upper and right lower abdominal quadrants (Fig. 3). The patient was been Tredenlenberg position, and the surgeon stood on the patient's left side. Initially, a laparoscope was introduced to explore the abdominal cavity. The dissection of the colon began using a right caudal colic approach. Starting with the lower segment of the ileum and the root of the small intestine mesentery, the ileocecal region was mobilized. The right colon and hepatic flexure were separated from the lateral edge of the right colon along Toldt's fascia. At this point, gauze was placed along the medial border of the right colon as a marker. The patient's position was then adjusted to head elevated, allowing full exposure of the greater curvature of the stomach and the greater omentum. The greater omentum was dissected, taking care to avoid the left gastroepiploic artery and its branches. The gastrocolic ligament was then divided to expose the transverse colon. The transverse colon was mobilized from the hepatic flexure to splenic flexure, joining the previously dissected areas. Gauze was then used as a marker and operated from the root of the right mesocolon. The ileocolic and left colic arteries were ligated. At the root of the mesocolon, the right and left branches of the middle colic artery were also ligated, facilitating further mobilization of the transverse colon to the splenic flexure. The ileocecum, right colon, and transverse colon were then fully mobilized. The patient was repositioned with the head down, and the primary surgeon moved to the patient's right side. Using the sacral promontory as a landmark, a point approximately 10 cm above the peritoneal reflection, marking the junction of the sigmoid colon and rectum, was identified. The intestine was transected using a linear cutting stapler. Starting from the sigmoid stump, dissection proceeded along the mesenteric fold to mobilize the sigmoid and descending colon up to the splenic flexure. Ensuring the entire colon was mobilized. The colon was then gradually exteriorized from the abdominal cavity via the supraumbilical port, exposing the ileocecal region. The colon was resected, and a specimen was obtained by transecting the ileum approximately 5 cm above the ileocecal junction. Place the base of the intestinal anastomosis device onto the ileal stump. After the assistant had fully dilated the anus, the rectum was flushed with diluted iodophor. The residue in the intestinal cavity should be washed out to reduce the risk of postoperative anastomotic infection. An ileorectal anastomosis was performed within the abdominal cavity along the mesenteric direction. The anastomosis was reinforced using absorbable barbed sutures to prevent leakage. Finally, the mesenteric defect was sutured to prevent the formation of an internal hernia. Following irrigation of the abdominal cavity, an abdominal drainage tube was placed in the left upper quadrant and a pelvic drainage tube in the right lower quadrant. The abdominal incision was then closed, concluding the operation. The primary steps of the procedure were performed laparoscopically, as illustrated below (Fig. 4). Follow-up Patients were followed up via telephone at 3 months post-operation. A questionnaire survey was administered, including the same five scales used preoperatively: the Patient Assessment of Constipation Quality of Life (PAC-QOL), the Wexner Constipation Score, the Bristol Stool Scale, the Generalized Anxiety Disorder Scale (GAD-7), and the Depression Screening Scale (PHQ-9). Additionally, questions addressed the frequency and duration of bowel movements, use of laxatives or antidiarrheal agents, and occurrences of abdominal pain and bloating. Results Patient Characteristics According to the inclusion and exclusion criteria, a total of 40 patients with chronic refractory constipation were enrolled from June 2023 to December 2024. The cohort comprised 19 females and 21 males, with average age of 64.10 ± 12.26 years (range: 30–85 years). Of these patients, 16 (40.0%) had diabetes, 11 (27.5%) had hypertension, and 2 (5.0%) had a history of cancer. The average duration of constipation was approximately 9.88 ± 8.35 years (range: 2–40 years). The average BMI was 22.23 ± 2.73 kg/m 2 (range: 16–28 kg/m 2 ). Patient characteristics are detailed in Table 1 . The mean operating time was 170.13 ± 24.35 minutes (range: 120–240 minutes). The mean intraoperative blood loss was 37.75 ± 22.93 ml (range: 20–100 ml). The mean length of hospital stay was 12.08 ± 3.17 days (range: 7–21 days). The mean time of fasting after surgery was 2.95 ± 1.18 days (range: 2–6 days). Table1. Patient Characteristics Parameter N=40 Age at operation (y) 64.10±12.26 (30–85) Gender, n (%) Male 21 (52.5) Female 19 (4.75) Chronic disease, n (%) Diabetes 16 (40.0) Hypertension 11 (27.5) Cancer 2 (5.0) BMI (kg/m 2 ) 22.23±2.73 (16-28) Operation time (min) 170.13±24.35 (120–240) Fasting time after operation (d) 2.95±1.18 (2–6) Intraoperative blood loss (ml) 37.75±22.93 (20–100) Postoperative hospital stay (d) 12.08±3.17 (7–21) The data are presented as mean (range) Results of surgery Three months after surgery, the spontaneous bowel movements per week increased significantly from 2.68 ± 2.25 to 21.30 ± 7.24 (p < 0.001). The PAC-QOL score decreased from 63.45 ± 16.06 to 19.20 ± 5.67, the Wexner score of constipation decreased from 17.35 ± 3.77 to 7.83 ± 1.99, and the scores of depression (PHQ-9) and anxiety (GAD-7) also improved significantly (all p < 0.01). The patient satisfaction was 87.5%. Six months after operation, the curative effect remained stable, the defecation frequency (18.55 ± 5.48 times/week) and the scores were further optimized, and the satisfaction rate was increased to 92.5%. Complications and adverse events were reported in 3 patients, giving an overall morbidity rate of 7.5%. One patient experienced early postoperative diarrhea within 2 weeks, which was managed conservatively with probiotics and somatostatin and was not deemed a major complication. One patient developed postoperative abdominal bleeding and recovered after laparotomy. One patient had incision infection and recovered after dressing change. Preoperative and postoperative results are summarized in Table 2 . No recurrences of constipation were observed at 6 months post-surgery. Both constipation-related symptoms and psychological disorders showed improvement following the operation. (Fig. 5 – A&B) Follow-up included repeating the modified colonic transit test (Fig. 5 - C) and defecography (Fig. 5 - D), which demonstrated visual improvement. Postoperative pelvic floor electromyography was reviewed, showing improvement in some cases, as evidenced by changes in electromyography waveforms (Fig. 5 - E). Table2. Preoperative and Follow-Up Questionnaire Data Parameter Preoperative 3 months after operation 6 months after operation SCBM (per week) 2.68±2.25 21.30±7.24 18.55±5.48 PAC-QOL 63.45±16.06 19.20±5.67 17.95±5.14 Wexner 17.35±3.77 7.83±1.99 6.67±1.90 PHQ-9 4.88±3.84 1.70±2.63 1.40±2.44 GAD-7 4.23±1.92 1.35±1.92 1.10±1.65 The data are presented as AVG±SD *P＜0.05 Comparison of data before and 3 months after surgery. (A) Comparison of constipation related scales before and after surgery. (B) Comparison of psychological related scales before and after surgery. *P < 0.05. (C) Comparison of preoperative and postoperative modified colonic transit test. (D) Comparison of defecography before and after surgery. (E) Comparison of pelvic floor electromyography before and after surgery. Discussion In 1908, Arbuttnott Lane first proposed transabdominal surgery for chronic refractory constipation, which initially resulted in high mortality rates due to technical limitations [ 18 ] . However, with ongoing improvements, surgical success rates have increased. Sarli subsequently introduced subtotal colectomy combined with antiperistaltic cecorectal anastomosis, but long-term follow-up revealed no significant advantage over traditional ileorectal anastomosis [ 19 ] . Kalbassi further modified total colectomy by creating a pouch from the terminal ileum and anastomosing it with the rectal stump. Although this approach improved postoperative defecation frequency, it was associated with long-term refractory pelvic pain [ 20 ] . Our clinical experience and research findings suggest that the length of the rectal stump is a critical factor influencing severe diarrhea and recurrence. A rectal stump that is too short impairs fecal storage, leading to severe diarrhea or frequent bowel movements exceeding 10 times per day. Conversely, a too-long remaining large bowel increases the likelihood of constipation recurrence [ 21 , 22 ] . Based on clinical practice, we have found that the junction of the rectum and sigmoid colon is the most suitable site for intestinal separation. This approach not only addresses slow colonic transit but also preserves fecal storage function, resulting in relatively stable bowel movements post-surgery. After probiotics pretreatment, the frequency of defecation was maintained at 2–4 times per day for 3 months, and it would decrease and stabilize after 6 months. Chronic refractory constipation often involves both slow colonic transit and rectal obstruction. Simply removing the intestine without addressing these issues selectively is insufficient. Li Lin’s Jinling procedure has demonstrated favorable short-term and long-term results, though it is associated with more complications and a complex surgical process [ 12 , 13 ] . This approach results in longer operation times and a less favorable abdominal cosmetic outcome. To address these shortcomings, we modified the colectomy procedure to create the Symmetrical single-port + 2 around the umbilicus (Tang style) laparoscopic total colectomy. This method introduces significant innovations in surgical techniques and procedures to address constipation while minimizing operative time and trauma. To reduce operative time, we accessed the right Toldt space for dissociating the outer edge of the right hemicolon, greatly reducing the time needed [ 23 , 24 ] . Gauze markers were also placed to reduce the time required to find the anatomical location. During the separation of the medial border of the right hemicolon and transverse colon, we chose to separate from the mesocolon root, which is shorter and involves ligation of fewer large vessels. This shortens the procedure and reduces the risk of bleeding. We employed a single-port device with four operating holes, two of which accommodated laparoscopic access. We used a single-port set that contained four operating ports, two of which could accommodate laparoscopic passage. Plus operating on both sides of the hole and open surgery not big difference, whether the operating space, or vision space. Despite similar operative and visual spaces to open surgery, single-port operations can be challenging due to increased intensity and potential collisions, particularly for inexperienced surgeons. The large single port may cause the laparoscope to contact the sheath wall or abdominal wall, disrupting the surgical field. We recommend positioning the assistant higher along the edge of the single-hole device to minimize the impact on the operator’s handling, which presents a significant physical and technical challenge. To prevent complications such as anastomotic leakage or nonunion, we modified additional procedures. We preserve the superior rectal artery and the sigmoid artery during separation of the sigmoid colon from the left hemicolon [ 25 , 26 ] . I This ensures a robust blood supply to the anastomosis after ileum-rectum anastomosis. Additionally, proper alignment of the intestinal stump with the mesentery direction prevents ischemia and obstruction. After these precautions, the mesenteric hiatus is closed. This significantly reduces the risk of anastomotic leakage and mesenteric hiatus hernia. Finding the anastomotic stump under laparoscopy is a common challenge for gastrointestinal surgeons. We recommend using a stapler seat for suturing the purse-string after being buried in the intestinal stump. Reserve approximately 10 cm of suture outside the purse and avoid breaking all the threads. Different colored sutures are easier to locate under laparoscopy. Trimming excess sutures after successful stapler docking does not affect normal anastomosis. For rectal obstruction cases, we employ a specific approach. Before surgery, we perform blunt anal dilation to accommodate four or five fingers. First, the anal sphincter can be released so that the anus is fully relaxed. The second is to improve paradoxical contraction and relieve defecation obstruction. A third stimulation of the anus promotes the postoperative defecation reflex [ 27 – 29 ] . Unlike anal sphincterotomy, our method involves blunt dissection, preserving some muscle fibers. Some patients may experience postoperative fecal incontinence or difficulty with bowel control. This damage is reversible, and the anal sphincter generally repairs itself within a week. No cases of fecal incontinence were observed during follow-up, and outlet obstruction significantly improved. This approach effectively addresses excessive and paradoxical anal sphincter contraction. Additionally, this procedure is minimally invasive, requiring only three incisions, with the largest measuring 3 cm at the umbilicus. A week or so after the procedure, we removed the drain. By the time the patient was discharged, the abdominal incision had largely heal The drain was removed approximately one week post-procedure, and the abdominal incision was largely healed by discharge. However, this approach has limitations. Firstly, fecal traits significantly change after colectomy. Patients may experience prolonged periods of unformed or watery stools. Patients require extended probiotic use and dietary modifications to improve their condition. The limited sample size may introduce bias. Furthermore, the current follow-up period is only six months, leaving the long-term effects of the surgical treatment unclear. Conclusion In conclusion, this study demonstrates thatthe symmetrical single-port + 2 around the umbilicus laparoscopic (Tang style) total colectomy is a safe and effective minimally invasive procedure that significantly improves bowel function and quality of life in patients with refractory constipation. The procedure, performed through a concealed umbilical incision combined with two auxiliary ports (each < 5mm), offers advantages including minimal trauma, low blood loss (37.75 ± 22.93ml), and rapid recovery (time to first flatus 2.95 ± 1.18 days). Follow-up results showed a remarkable increase in spontaneous bowel movements from 2.68 ± 2.25/week preoperatively to 21.30 ± 7.24/week at 3 months, with sustained efficacy at 6 months (18.55 ± 5.48/week). Significant improvements were observed in quality of life, constipation symptoms, and psychological status, with patient satisfaction reaching 92.5%. Although complications occurred in 7.5% of cases, all were successfully managed conservatively. This technique combines minimally invasive advantages with durable therapeutic effects, making it an optimal choice for refractory constipation treatment. Declarations Competing Interest declaration All authors (Xuanyu Wei, Haokai Ma, Yutao Wang, Ji Hao, Yichao Ma, Chen Wei, Daorong Wang, and Dong Tang) declare that they have no conflicts of interest, financial or otherwise, related to the subject matter of this manuscript. This includes, but is not limited to, grants or funding, employment, affiliations, patents, inventions, honoraria, consultancies, royalties, stock options/ownership, or expert testimony. No spousal or familial financial interests are relevant to this work. This statement covers the past two years and the foreseeable future. Funding Declaration No source of funding Author Contribution Xuanyu Wei: Data curation, Investigation, Writing – original draft; Haokai Ma: Formal analysis, Investigation; Yutao Wang: Formal analysis; Hao Ji: Data curation; Yichao Ma: Formal analysis; Chen Wei: Formal analysis; Daorong wang, M.D.: Resources, Supervision; Dang Tang, M.D.: Conceptualization, Project administration, Resources, Supervision, Writing – review & editing. Data Availability Data sets generated during the current study are available from the corresponding author on reasonable request. The natural gas production data are available from Drilling Info but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. References Barberio B, Judge C, Savarino EV et al (2021) Global prevalence of functional constipation according to the Rome criteria: a systematic review and meta-analysis [J], vol 6. The lancet Gastroenterology & hepatology, pp 638–648. 8 Nag A, Martin SA, Mladsi D et al (2020) The Humanistic and Economic Burden of Chronic Idiopathic Constipation in the USA: A Systematic Literature Review [J]. Clin Exp Gastroenterol 13:255–265 Knowles CH, Grossi U, Chapman M et al (2017) Surgery for constipation: systematic review and practice recommendations: Results I: Colonic resection [J]. Colorectal Dis 19(Suppl 3):17–36 Tsimogiannis KE, Karlbom U, Lundin E et al (2019) Long-term outcome after segmental colonic resection for slow transit constipation [J]. Int J Colorectal Dis 34(6):1013–1019 Grossi U, Knowles CH, Mason J et al (2017) Surgery for constipation: systematic review and practice recommendations: Results II: Hitching procedures for the rectum (rectal suspension) [J]. Colorectal Dis 19(Suppl 3):37–48 Mercer-Jones M, Grossi U, Pares D et al (2017) Surgery for constipation: systematic review and practice recommendations: Results III: Rectal wall excisional procedures (Rectal Excision) [J]. Colorectal Dis 19(Suppl 3):49–72 Shi Y, Yu Y, Zhang X et al (2017) Transvaginal Mesh and Transanal Resection to Treat Outlet Obstruction Constipation Caused by Rectocele [J]. Med Sci monitor: Int Med J experimental Clin Res 23:598–605 Andreoli R, Zampieri N, Orlandi S et al (2024) Long time consequences after STARR procedure: Report of 15 years experience and medico-legal perspective [J]. Am J Surg 229:169–173 Guttadauro A, Chiarelli M, Maternini M et al (2018) Value and limits of stapled transanal rectal repair for obstructed defecation syndrome: 10 years-experience with 450 cases [J]. Asian J Surg 41(6):573–577 Ragg J, McDonald R, Hompes R et al (2011) Isolated colonic inertia is not usually the cause of chronic constipation [J]. Colorectal Dis 13(11):1299–1302 Zhu X, Li J, Fu T et al (2015) Laparoscopic-assisted subtotal colectomy combined with modified Duhamel procedure for mixed constipation [J]. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 19(1): e2014.00131 Ding W, Jiang J, Feng X et al (2014) Novel surgery for refractory mixed constipation: Jinling procedure - technical notes and early outcome [J]. Archives Med science: AMS 10(6):1129–1134 Li N, Jiang J, Feng X et al (2013) Long-term follow-up of the Jinling procedure for combined slow-transit constipation and obstructive defecation [J]. Dis Colon Rectum 56(1):103–112 Feng Y, Li G, Hu Y et al (2023) Magnetic resonance imaging and functional constipation [J]. 2(1) Marquis P, De La Loge C, Dubois D et al (2005) Development and validation of the Patient Assessment of Constipation Quality of Life questionnaire [J]. Scand J Gastroenterol 40(5):540–551 Agachan F, Chen T, Pfeifer J et al (1996) A constipation scoring system to simplify evaluation and management of constipated patients [J]. Dis Colon Rectum 39(6):681–685 Longstreth GF, Thompson WG, Chey WD et al (2006) Funct bowel disorders [J] Gastroenterol 130(5):1480–1491 Lane WA, Remarks ON THE RESULTS OF, THE OPERATIVE TREATMENT OF CHRONIC CONSTIPATION [J] (1908) BMJ 1(2455):126–130 Xie XY, Sun KL, Chen WH et al (2019) Surgical outcomes of subtotal colectomy with antiperistaltic caecorectal anastomosis vs total colectomy with ileorectal anastomosis for intractable slow-transit constipation [J]. Gastroenterol Rep 7(6):449–454 Kalbassi MR, Winter DC, Deasy JM (2003) Quality-of-life assessment of patients after ileal pouch-anal anastomosis for slow-transit constipation with rectal inertia [J]. Dis Colon Rectum 46(11):1508–1512 Johnston BJ, Clark DA, Warwick AM (2023) Long-term outcomes of total colectomy for severe constipation [J]. Colorectal Dis 25(6):1194–1201 Patton V, Balakrishnan V, Pieri C et al (2020) Subtotal colectomy and ileorectal anastomosis for slow transit constipation: clinical follow-up at median of 15 years [J]. Tech Coloproctol 24(2):173–179 Wedel T, Heimke M, Fletcher J et al (2023) The retrocolic fascial system revisited for right hemicolectomy with complete mesocolic excision based on anatomical terminology: do we need the eponyms Toldt, Gerota, Fredet and Treitz? [J]. Colorectal Dis 25(4):764–774 Schulte Am Esch J, Iosivan SI, Steinfurth F et al (2019) A standardized suprapubic bottom-to-up approach in robotic right colectomy: technical and oncological advances for complete mesocolic excision (CME) [J]. BMC Surg 19(1):72 Rausa E, Colletti G, Ciniselli CM et al (2023) Superior rectal artery preservation to reduce anastomotic leak rates in familial adenomatous polyposis patients treated with total colectomy and ileorectal anastomosis [J]. Tech Coloproctol 27(12):1327–1334 Allison AS, Bloor C, Faux W et al (2010) The angiographic anatomy of the small arteries and their collaterals in colorectal resections: some insights into anastomotic perfusion [J]. Ann Surg 251(6):1092–1097 Jumbi T, Kuria K, Osawa F et al (2019) The effectiveness of digital anal dilatation in preventing anal strictures after anorectal malformation repair [J]. J Pediatr Surg 54(10):2178–2181 Bharucha AE, Wald A, Enck P et al (2006) Functional anorectal disorders [J]. Gastroenterology 130(5):1510–1518 Hite M, Curran T (2021) Biofeedback for Pelvic Floor Disorders [J]. Clinics in colon and rectal surgery. 34(1):56–61 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7958638","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":543268528,"identity":"e4d536aa-0637-4e26-8183-0bccd1c303b2","order_by":0,"name":"Xuanyu Wei","email":"","orcid":"","institution":"Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Xuanyu","middleName":"","lastName":"Wei","suffix":""},{"id":543268529,"identity":"6ecd3820-e0c1-42c9-81b1-3600038f85eb","order_by":1,"name":"Haokai Ma","email":"","orcid":"","institution":"The Yangzhou Clinical Medicine College of Xuzhou Medical University, Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Haokai","middleName":"","lastName":"Ma","suffix":""},{"id":543268530,"identity":"a293d127-5dc7-42c9-a037-88a3bb2563d6","order_by":2,"name":"Yutao Wang","email":"","orcid":"","institution":"Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yutao","middleName":"","lastName":"Wang","suffix":""},{"id":543268531,"identity":"a1462610-9c3d-4746-b5d1-8b1b22817e73","order_by":3,"name":"Hao Ji","email":"","orcid":"","institution":"Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Ji","suffix":""},{"id":543268532,"identity":"083fc8d6-6c6c-4f7a-ae29-16cabf363df7","order_by":4,"name":"Yichao Ma","email":"","orcid":"","institution":"Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yichao","middleName":"","lastName":"Ma","suffix":""},{"id":543268533,"identity":"33b6eb8d-0346-423a-b417-51bb02c738a1","order_by":5,"name":"Chen Wei","email":"","orcid":"","institution":"Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Wei","suffix":""},{"id":543268534,"identity":"6aa3a88e-6944-40ea-83cb-e2a06806aff4","order_by":6,"name":"Daorong Wang","email":"","orcid":"","institution":"Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Northern Jiangsu People’s Hospital, The Yangzhou Clinical Medical College of Xuzhou Medical University, The Yangzhou School of Clinical Medicine of Dalian Medical University, The Yangzhou School of Clinical Medicine of Nanjing Medical University, Northern Jiangsu People's Hospital, Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Daorong","middleName":"","lastName":"Wang","suffix":""},{"id":543268535,"identity":"896d2bcb-f676-4e7f-94ce-7d5847c3d15b","order_by":7,"name":"Dong Tang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYBACfv72gw8+/rOp5ydai+SMM8mGM9jSEiQbiNVicCDBTJqH7XCCwQGibWk4kCbBw5OWZ3w8eQPDj4pthLXwMzcetpCQsCk2O/OsgLHnzG2ibEm8YWCQxrjtRo4BM2MbEVqAfjGQSEg4zLh5BglajCQOHDicuEGCWC3gQG5sSDOWAPrlIFF+AUXl478NNnL87ckbH/yoIEILEiAhahBaSNUxCkbBKBgFIwQAAFbLQsitzrAqAAAAAElFTkSuQmCC","orcid":"","institution":"Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Northern Jiangsu People’s Hospital, The Yangzhou Clinical Medical College of Xuzhou Medical University, The Yangzhou School of Clinical Medicine of Dalian Medical University, The Yangzhou School of Clinical Medicine of Nanjing Medical University, Northern Jiangsu People's Hospital, Nanjing University","correspondingAuthor":true,"prefix":"","firstName":"Dong","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2025-10-27 12:36:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7958638/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7958638/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96240145,"identity":"dc9170af-3349-4761-957a-53005c25d5f4","added_by":"auto","created_at":"2025-11-19 07:08:30","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9253,"visible":true,"origin":"","legend":"","description":"","filename":"9ae95db1df9f4ef39fe449003a25e1eb.json","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/0ff2f0bcf7f08241259a6a2b.json"},{"id":96239209,"identity":"1f0a2543-c469-4ca3-a244-c3f4cea1eeb1","added_by":"auto","created_at":"2025-11-19 07:05:30","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":17541,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/28ed797d5e2b14094c1d256f.docx"},{"id":95825576,"identity":"b00744d5-f451-4eae-bf24-7ed064dbc1af","added_by":"auto","created_at":"2025-11-13 11:09:15","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":17755,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/615244c5e3393885bedf12f7.docx"},{"id":95825580,"identity":"27baf018-fe3a-49a9-9890-8868bb3983a0","added_by":"auto","created_at":"2025-11-13 11:09:15","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77877,"visible":true,"origin":"","legend":"","description":"","filename":"9ae95db1df9f4ef39fe449003a25e1eb1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/e62bc72fed52599a7abe4c99.xml"},{"id":96239631,"identity":"28c9726d-3666-4651-bac0-0be33fe02506","added_by":"auto","created_at":"2025-11-19 07:07:13","extension":"xml","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75526,"visible":true,"origin":"","legend":"","description":"","filename":"9ae95db1df9f4ef39fe449003a25e1eb1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/e96b5bbb54d9d4a6aa557d84.xml"},{"id":95825581,"identity":"4fe1e54c-790f-4bb0-ada8-e8c5a83aadd7","added_by":"auto","created_at":"2025-11-13 11:09:15","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":86305,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/5405fdc0af405d1c3e41e9e3.html"},{"id":95825579,"identity":"48fc710a-bdf1-47b7-ab4f-bba82bc530bd","added_by":"auto","created_at":"2025-11-13 11:09:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":670954,"visible":true,"origin":"","legend":"\u003cp\u003eImproved transmission test. The patient was instructed to ingest 50 mL of barium, and abdominal radiographs were obtained at 6 and 72 hours. If gastric emptying and small intestinal transit are normal, the barium should reach the colonic segment within 6 hours. Normal colonic transit is indicated if the barium is completely excreted by 72 hours. (A) Normal colonic transit: The barium is fully excreted by 72 hours. (B) Slow transit constipation: A significant amount of barium remains in the colon at 72 hours. (C) Delayed rectal emptying constipation: Barium is retained at the rectal outlet and cannot be discharged by 72 hours. (D) Mixed constipation: At 72 hours, there is both substantial barium accumulation at the outlet and widespread barium distribution throughout the colon.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/4dc4b59917624930bc14acc2.png"},{"id":95825573,"identity":"67131e28-cf49-4eef-b050-8dd60f38f8fe","added_by":"auto","created_at":"2025-11-13 11:09:15","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27228,"visible":true,"origin":"","legend":"\u003cp\u003eTang style and Chinese Tai Chi.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/e6a7c24f175d312df655b5c6.jpg"},{"id":95825575,"identity":"64c36f68-0b49-44f8-be39-ed4699d294f3","added_by":"auto","created_at":"2025-11-13 11:09:15","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":284145,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative images. (A) A schematic diagram of the surgical procedure. (B) The resected colon specimen. (C) An abdominal photograph taken at the conclusion of the surgery.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/ad734cdd655b54316a3f67a8.jpg"},{"id":96239299,"identity":"3f8f61f9-3a32-42a9-861d-b1892a3be271","added_by":"auto","created_at":"2025-11-19 07:06:03","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":450309,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical Flow Chart. (A) Begin with the caudal approach to the right colon, starting from the lower ileum and the mesentery of the small intestine. (B) Place gauze along the descending duodenum as a marker, while protecting the duodenum and pancreas. (C) Mobilize the right colon upward along the right Toldt space. (D) Dissect the hepatic region of the right colon. (E) Incise the omentum along the lower edge of the stomach. (F) Continue to the right until reaching the gauze marker. (G) Dissect the gastrocolic mesocolon along the interstitial space. (H) Mobilize the colon to the splenic region. (I) Place gauze along the upper edge of the transverse colon to protect both the transverse colon and pancreas. (J) Identify two areas of hyaline fascia at the root of the right mesocolon, with the right colic artery located between them. Ligate the right colic artery. (K) Ligate the middle colic artery and vein at the root of the mesocolon. (L) Dissect to the left to the splenic region of the colon. (M) Transect the sigmoid colon approximately 10 cm from the peritoneal reflection. (N) Mobilize the sigmoid and left colon upward from the stump of the sigmoid colon along the mesenteric folds. (O) Once the colon is fully mobilized, remove it through a median abdominal incision. (P) Organize the ileal stump along the mesenteric direction and perform an ileorectal anastomosis. Finally, close the mesenteric hiatus.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/dc31f54bd54fdfa944cd0a9e.jpg"},{"id":96240063,"identity":"658d006e-171e-497d-864d-9787d1323a06","added_by":"auto","created_at":"2025-11-19 07:08:18","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":3993075,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of data before and 3 months after surgery. (A) Comparison of constipation related scales before and after surgery. (B) Comparison of psychological related scales before and after surgery. *P \u0026lt; 0.05. (C) Comparison of preoperative and postoperative modified colonic transit test. (D) Comparison of defecography before and after surgery. (E) Comparison of pelvic floor electromyography before and after surgery.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/f98e6feaab8627eb0faf13c9.png"},{"id":96920937,"identity":"00398cd0-615f-4274-aace-7f107700462e","added_by":"auto","created_at":"2025-11-27 14:15:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6751017,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7958638/v1/76e5f228-462d-48ee-8ff8-a90142b23da7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Symmetrical single-port +2 around the umbilicus (Tang style) laparoscopic total colectomy for refractory constipation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eConstipation is a chronic gastrointestinal disorder with a high incidence rate, causing not only physical discomfort but also significant psychological distress\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Many patients rely on long-term medication to maintain bowel regularity, which can increase the risk of intestinal obstruction. Prolonged medical treatment also imposes a substantial economic burden on both patients and society\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. When medical interventions fail, surgery is often considered the last resort. Chronic functional constipation is currently categorized into slow transit constipation, rectal outlet obstruction, and mixed constipation. Colectomy is the primary surgical treatment for slow transit constipation, which alleviates most symptoms but can lead to complications such as severe short-term diarrhea and long-term recurrent small bowel obstruction\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. This may be related to the length and chosen location of colon resection and preservation. For rectal outlet obstruction, various surgical methods are available, with rectal suspension and rectal excision being the most common. Each of these treatments has advantages and disadvantages\u003csup\u003e[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Long-term follow-up studies have shown that stapled trans-anal rectal resection (STARR) is a safe surgical method with a low recurrence rate, with main complications being pain, bleeding, and anal bleeding, though these occur infrequently\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eChronic refractory constipation often presents as mixed constipation, involving both slow colonic transit and outlet obstruction\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. To address this, Li Lin developed a new surgical approach: subtotal colectomy combined with a modified Duhamel procedure, known as the Jinling procedure. This technique involves resecting most of the colon and appendix and performing a side-to-side anastomosis between the right colon stump and the rectum\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Long-term follow-up has demonstrated that the Jinling procedure significantly increases spontaneous defecation frequency and is widely endorsed by surgeons. However, challenges such as prolonged operation time, a high incidence of diarrhea, and significant surgical trauma remain\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Thus, optimizing treatment for intractable constipation while minimizing complications, surgical duration, and patient trauma is a key goal for surgeons.\u003c/p\u003e\u003cp\u003eThe aim of this study is to evaluate the efficacy and safety of the Symmetrical single-port\u0026thinsp;+\u0026thinsp;2 around the umbilicus (Tang style) laparoscopic total colectomy in treating chronic refractory constipation from June 2023 to December 2024. forty patients, comprising 21 males and 19 females, were included in this study. Defecation frequency and daily life impacts were assessed using a questionnaire. The findings of this study may contribute to optimizing surgical strategies for chronic refractory constipation.\u003c/p\u003e"},{"header":"Materials and Methods:","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eThe patient\u003c/h2\u003e\n\u003cp\u003eFrom June 2023 to December 2024, a total of 40 patients were diagnosed with chronic constipation based on the Rome IV criteria. The duration of the disease ranged from 2 to 40 years. All patients had been treated with irritating laxatives, including enema in 5 cases and traditional Chinese medicine or acupuncture in 25 cases, but no significant improvement was observed. Each patient was managed by the constipation multidisciplinary team at Northern Jiangsu People's Hospital. This team comprises specialists from gastrointestinal surgery, gastroenterology, clinical psychology, traditional Chinese medicine, rehabilitation physiotherapy, and nutrition. It is responsible for diagnosing, evaluating, and formulating personalized treatment plans for patients with chronic refractory constipation. The Ethics Committee of Subei People's Hospital in Jiangsu, China, approved the study protocol, and informed consent was obtained from all patients or their families.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eDiagnostic criteria\u003c/h3\u003e\n\u003cp\u003ePatients were enrolled if they met the following criteria:\u003c/p\u003e\n\u003cp\u003e(1) Diagnosis of chronic constipation based on the Rome IV criteria, with a duration exceeding 2 years..\u003c/p\u003e\n\u003cp\u003e(2) Frequency of bowel movements less than 3 times per week for at least 3 months per year.\u003c/p\u003e\n\u003cp\u003e(3) Modified colonic transit test indicating a colonic transit time greater than 72 hours, evidenced by significant contrast agent retention in abdominal X-rays 72 hours after barium ingestion. (Fig.\u0026nbsp;1)\u003c/p\u003e\n\u003cp\u003e(4) Ineffectiveness of long-term standardized medical treatment.\u003c/p\u003e\n\u003cp\u003ePatients were excluded if they met any of the following criteria:\u003c/p\u003e\n\u003cp\u003e(1) Presence of organic gastrointestinal disease or cancer.\u003c/p\u003e\n\u003cp\u003e(2) Endocrine or metabolic disorders, such as hypothyroidism, that could cause secondary constipation.\u003c/p\u003e\n\u003cp\u003e(3) Gastrointestinal discontinuity resulting from surgery for other conditions.\u003c/p\u003e\n\u003cp\u003e(4) Severe cardiovascular or cerebrovascular diseases that contraindicate surgery.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003ePatient Assessment and Preoperative Examinations\u003c/h3\u003e\n\u003cp\u003eAt the time of admission, each patient completed several relevant scales, including the Patient Assessment of Constipation Quality of Life (PAC-QOL), Wexner Constipation Score, Bristol Stool Scale, Generalized Anxiety Disorder Scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9) for depression screening. Patients also underwent various preoperative examinations, including constipation-specific assessments such as the modified colonic transit test, defecography, and anorectal manometry. Additionally, some patients underwent functional magnetic resonance imaging (fMRI) to detect the effects of constipation on brain function and structure\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Six months post-surgery, functional and structural improvements in corresponding brain regions were compared between the two groups. The PAC-QOL was developed in 2005 to assess the quality of life in patients with constipation. It consists of 28 items, including physical and psychological sensations, each scored on a 5-point scale ranging from 0 to 4. The total score ranges from 0 (indicating the best quality of life) to 112 (indicating the worst)\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. The Wexner Constipation Score is used to evaluate the severity of constipation symptoms, with scores ranging from 0 to 30; higher scores indicate more severe constipation and this scale is widely utilized in clinical settings\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. The Bristol Stool Scale helps to preliminarily determine colonic transit time by categorizing stool into seven distinct forms\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The GAD-7 and PHQ-9 scales were used to evaluate anxiety and depression levels, respectively, providing an initial assessment of the patient's psychological status. The psychological status of patients was initially evaluated using the standardized scales. If any abnormal scores were identified, a clinical psychologist provided appropriate psychological treatment.\u003c/p\u003e\n\u003ch3\u003eSurgical methods\u003c/h3\u003e\n\u003cp\u003eThe symmetrical single-port\u0026thinsp;+\u0026thinsp;2 around the umbilicus (Tang style) laparoscopic total colectomy is inspired by the concept of Chinese Tai Chi (Fig.\u0026nbsp;2). The Tang style design positions the navel as the center, with the two auxiliary ports representing the \"fish eyes\" of Tai Chi. The surgeon can perform a 360-degree rotation in the abdominal cavity around the navel, mimicking the rotational movement of Tai Chi. By adjusting the angle and the surgeon's standing position, this setup ensures optimal visualization and access to all areas of the abdominal and pelvic cavity with endoscopic instruments.\u003c/p\u003e\n\u003cp\u003eAll surgeries were performed by the same surgical team, led by a single surgeon. Following the induction of general anesthesia, each patient was placed in the lithotomy position. A transverse incision approximately 3 cm in length was made along the upper edge of the umbilicus. A disposable trocar puncture needle was used to establish pneumoperitoneum. Two additional laparoscopic ports were created symmetrically, each 10 cm from the umbilicus, in the left upper and right lower abdominal quadrants (Fig.\u0026nbsp;3). The patient was been Tredenlenberg position, and the surgeon stood on the patient's left side. Initially, a laparoscope was introduced to explore the abdominal cavity. The dissection of the colon began using a right caudal colic approach. Starting with the lower segment of the ileum and the root of the small intestine mesentery, the ileocecal region was mobilized. The right colon and hepatic flexure were separated from the lateral edge of the right colon along Toldt's fascia. At this point, gauze was placed along the medial border of the right colon as a marker. The patient's position was then adjusted to head elevated, allowing full exposure of the greater curvature of the stomach and the greater omentum. The greater omentum was dissected, taking care to avoid the left gastroepiploic artery and its branches. The gastrocolic ligament was then divided to expose the transverse colon. The transverse colon was mobilized from the hepatic flexure to splenic flexure, joining the previously dissected areas. Gauze was then used as a marker and operated from the root of the right mesocolon. The ileocolic and left colic arteries were ligated. At the root of the mesocolon, the right and left branches of the middle colic artery were also ligated, facilitating further mobilization of the transverse colon to the splenic flexure. The ileocecum, right colon, and transverse colon were then fully mobilized. The patient was repositioned with the head down, and the primary surgeon moved to the patient's right side. Using the sacral promontory as a landmark, a point approximately 10 cm above the peritoneal reflection, marking the junction of the sigmoid colon and rectum, was identified. The intestine was transected using a linear cutting stapler. Starting from the sigmoid stump, dissection proceeded along the mesenteric fold to mobilize the sigmoid and descending colon up to the splenic flexure. Ensuring the entire colon was mobilized. The colon was then gradually exteriorized from the abdominal cavity via the supraumbilical port, exposing the ileocecal region. The colon was resected, and a specimen was obtained by transecting the ileum approximately 5 cm above the ileocecal junction. Place the base of the intestinal anastomosis device onto the ileal stump. After the assistant had fully dilated the anus, the rectum was flushed with diluted iodophor. The residue in the intestinal cavity should be washed out to reduce the risk of postoperative anastomotic infection. An ileorectal anastomosis was performed within the abdominal cavity along the mesenteric direction. The anastomosis was reinforced using absorbable barbed sutures to prevent leakage. Finally, the mesenteric defect was sutured to prevent the formation of an internal hernia. Following irrigation of the abdominal cavity, an abdominal drainage tube was placed in the left upper quadrant and a pelvic drainage tube in the right lower quadrant. The abdominal incision was then closed, concluding the operation. The primary steps of the procedure were performed laparoscopically, as illustrated below (Fig.\u0026nbsp;4).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eFollow-up\u003c/h3\u003e\n\u003cp\u003ePatients were followed up via telephone at 3 months post-operation. A questionnaire survey was administered, including the same five scales used preoperatively: the Patient Assessment of Constipation Quality of Life (PAC-QOL), the Wexner Constipation Score, the Bristol Stool Scale, the Generalized Anxiety Disorder Scale (GAD-7), and the Depression Screening Scale (PHQ-9). Additionally, questions addressed the frequency and duration of bowel movements, use of laxatives or antidiarrheal agents, and occurrences of abdominal pain and bloating.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient Characteristics\u003c/h2\u003e\n \u003cp\u003eAccording to the inclusion and exclusion criteria, a total of 40 patients with chronic refractory constipation were enrolled from June 2023 to December 2024. The cohort comprised 19 females and 21 males, with average age of 64.10\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26 years (range: 30\u0026ndash;85 years). Of these patients, 16 (40.0%) had diabetes, 11 (27.5%) had hypertension, and 2 (5.0%) had a history of cancer. The average duration of constipation was approximately 9.88\u0026thinsp;\u0026plusmn;\u0026thinsp;8.35 years (range: 2\u0026ndash;40 years). The average BMI was 22.23\u0026thinsp;\u0026plusmn;\u0026thinsp;2.73 kg/m\u003csup\u003e2\u003c/sup\u003e (range: 16\u0026ndash;28 kg/m\u003csup\u003e2\u003c/sup\u003e). Patient characteristics are detailed in \u003cstrong\u003eTable\u0026nbsp;1\u003c/strong\u003e. The mean operating time was 170.13\u0026thinsp;\u0026plusmn;\u0026thinsp;24.35 minutes (range: 120\u0026ndash;240 minutes). The mean intraoperative blood loss was 37.75\u0026thinsp;\u0026plusmn;\u0026thinsp;22.93 ml (range: 20\u0026ndash;100 ml). The mean length of hospital stay was 12.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.17 days (range: 7\u0026ndash;21 days). The mean time of fasting after surgery was 2.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18 days (range: 2\u0026ndash;6 days).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable1.\u0026nbsp;\u003c/strong\u003ePatient Characteristics\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003eN=40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eAge at operation (y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e64.10\u0026plusmn;12.26 (30\u0026ndash;85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eGender, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e21 (52.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e19 (4.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eChronic disease, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003e\u0026nbsp;Diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e16 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003e\u0026nbsp;Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e11 (27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003e\u0026nbsp;Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e2 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e22.23\u0026plusmn;2.73 (16-28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eOperation time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e170.13\u0026plusmn;24.35 (120\u0026ndash;240)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eFasting time after operation (d)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e2.95\u0026plusmn;1.18 (2\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003eIntraoperative blood loss (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e37.75\u0026plusmn;22.93 (20\u0026ndash;100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.3544%;\"\u003e\n \u003cp\u003ePostoperative hospital stay (d)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6456%;\"\u003e\n \u003cp\u003e12.08\u0026plusmn;3.17 (7\u0026ndash;21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eThe data are presented as mean (range)\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eResults of surgery\u003c/h3\u003e\n\u003cp\u003eThree months after surgery, the spontaneous bowel movements per week increased significantly from 2.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25 to 21.30\u0026thinsp;\u0026plusmn;\u0026thinsp;7.24 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The PAC-QOL score decreased from 63.45\u0026thinsp;\u0026plusmn;\u0026thinsp;16.06 to 19.20\u0026thinsp;\u0026plusmn;\u0026thinsp;5.67, the Wexner score of constipation decreased from 17.35\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77 to 7.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99, and the scores of depression (PHQ-9) and anxiety (GAD-7) also improved significantly (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The patient satisfaction was 87.5%. Six months after operation, the curative effect remained stable, the defecation frequency (18.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.48 times/week) and the scores were further optimized, and the satisfaction rate was increased to 92.5%. Complications and adverse events were reported in 3 patients, giving an overall morbidity rate of 7.5%. One patient experienced early postoperative diarrhea within 2 weeks, which was managed conservatively with probiotics and somatostatin and was not deemed a major complication. One patient developed postoperative abdominal bleeding and recovered after laparotomy. One patient had incision infection and recovered after dressing change.\u003c/p\u003e\n\u003cp\u003ePreoperative and postoperative results are summarized in \u003cstrong\u003eTable\u0026nbsp;2\u003c/strong\u003e. No recurrences of constipation were observed at 6 months post-surgery. Both constipation-related symptoms and psychological disorders showed improvement following the operation. (Fig.\u0026nbsp;5 \u0026ndash; A\u0026amp;B)\u003c/p\u003e\n\u003cp\u003eFollow-up included repeating the modified colonic transit test (Fig.\u0026nbsp;5 - C) and defecography (Fig.\u0026nbsp;5 - D), which demonstrated visual improvement. Postoperative pelvic floor electromyography was reviewed, showing improvement in some cases, as evidenced by changes in electromyography waveforms (Fig.\u0026nbsp;5 - E).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable2.\u003c/strong\u003e Preoperative and Follow-Up Questionnaire Data\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e3 months after operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e6 months after operation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003eSCBM (per week)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003e2.68\u0026plusmn;2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e21.30\u0026plusmn;7.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e18.55\u0026plusmn;5.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003ePAC-QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003e63.45\u0026plusmn;16.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e19.20\u0026plusmn;5.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e17.95\u0026plusmn;5.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003eWexner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003e17.35\u0026plusmn;3.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e7.83\u0026plusmn;1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e6.67\u0026plusmn;1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003ePHQ-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;3.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e1.70\u0026plusmn;2.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e1.40\u0026plusmn;2.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003eGAD-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8543%;\"\u003e\n \u003cp\u003e4.23\u0026plusmn;1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e1.35\u0026plusmn;1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.1457%;\"\u003e\n \u003cp\u003e1.10\u0026plusmn;1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe data are presented as AVG\u0026plusmn;SD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;*P＜0.05\u003c/p\u003e\n\u003cp\u003eComparison of data before and 3 months after surgery. (A) Comparison of constipation related scales before and after surgery. (B) Comparison of psychological related scales before and after surgery. *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. (C) Comparison of preoperative and postoperative modified colonic transit test. (D) Comparison of defecography before and after surgery. (E) Comparison of pelvic floor electromyography before and after surgery.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn 1908, Arbuttnott Lane first proposed transabdominal surgery for chronic refractory constipation, which initially resulted in high mortality rates due to technical limitations\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. However, with ongoing improvements, surgical success rates have increased. Sarli subsequently introduced subtotal colectomy combined with antiperistaltic cecorectal anastomosis, but long-term follow-up revealed no significant advantage over traditional ileorectal anastomosis\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Kalbassi further modified total colectomy by creating a pouch from the terminal ileum and anastomosing it with the rectal stump. Although this approach improved postoperative defecation frequency, it was associated with long-term refractory pelvic pain\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Our clinical experience and research findings suggest that the length of the rectal stump is a critical factor influencing severe diarrhea and recurrence. A rectal stump that is too short impairs fecal storage, leading to severe diarrhea or frequent bowel movements exceeding 10 times per day. Conversely, a too-long remaining large bowel increases the likelihood of constipation recurrence\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. Based on clinical practice, we have found that the junction of the rectum and sigmoid colon is the most suitable site for intestinal separation. This approach not only addresses slow colonic transit but also preserves fecal storage function, resulting in relatively stable bowel movements post-surgery. After probiotics pretreatment, the frequency of defecation was maintained at 2\u0026ndash;4 times per day for 3 months, and it would decrease and stabilize after 6 months.\u003c/p\u003e\u003cp\u003eChronic refractory constipation often involves both slow colonic transit and rectal obstruction. Simply removing the intestine without addressing these issues selectively is insufficient. Li Lin\u0026rsquo;s Jinling procedure has demonstrated favorable short-term and long-term results, though it is associated with more complications and a complex surgical process\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. This approach results in longer operation times and a less favorable abdominal cosmetic outcome. To address these shortcomings, we modified the colectomy procedure to create the Symmetrical single-port\u0026thinsp;+\u0026thinsp;2 around the umbilicus (Tang style) laparoscopic total colectomy. This method introduces significant innovations in surgical techniques and procedures to address constipation while minimizing operative time and trauma. To reduce operative time, we accessed the right Toldt space for dissociating the outer edge of the right hemicolon, greatly reducing the time needed\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Gauze markers were also placed to reduce the time required to find the anatomical location. During the separation of the medial border of the right hemicolon and transverse colon, we chose to separate from the mesocolon root, which is shorter and involves ligation of fewer large vessels. This shortens the procedure and reduces the risk of bleeding. We employed a single-port device with four operating holes, two of which accommodated laparoscopic access. We used a single-port set that contained four operating ports, two of which could accommodate laparoscopic passage. Plus operating on both sides of the hole and open surgery not big difference, whether the operating space, or vision space. Despite similar operative and visual spaces to open surgery, single-port operations can be challenging due to increased intensity and potential collisions, particularly for inexperienced surgeons. The large single port may cause the laparoscope to contact the sheath wall or abdominal wall, disrupting the surgical field. We recommend positioning the assistant higher along the edge of the single-hole device to minimize the impact on the operator\u0026rsquo;s handling, which presents a significant physical and technical challenge.\u003c/p\u003e\u003cp\u003eTo prevent complications such as anastomotic leakage or nonunion, we modified additional procedures. We preserve the superior rectal artery and the sigmoid artery during separation of the sigmoid colon from the left hemicolon \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. I This ensures a robust blood supply to the anastomosis after ileum-rectum anastomosis. Additionally, proper alignment of the intestinal stump with the mesentery direction prevents ischemia and obstruction. After these precautions, the mesenteric hiatus is closed. This significantly reduces the risk of anastomotic leakage and mesenteric hiatus hernia. Finding the anastomotic stump under laparoscopy is a common challenge for gastrointestinal surgeons. We recommend using a stapler seat for suturing the purse-string after being buried in the intestinal stump. Reserve approximately 10 cm of suture outside the purse and avoid breaking all the threads. Different colored sutures are easier to locate under laparoscopy. Trimming excess sutures after successful stapler docking does not affect normal anastomosis. For rectal obstruction cases, we employ a specific approach. Before surgery, we perform blunt anal dilation to accommodate four or five fingers. First, the anal sphincter can be released so that the anus is fully relaxed. The second is to improve paradoxical contraction and relieve defecation obstruction. A third stimulation of the anus promotes the postoperative defecation reflex\u003csup\u003e[\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. Unlike anal sphincterotomy, our method involves blunt dissection, preserving some muscle fibers. Some patients may experience postoperative fecal incontinence or difficulty with bowel control. This damage is reversible, and the anal sphincter generally repairs itself within a week. No cases of fecal incontinence were observed during follow-up, and outlet obstruction significantly improved. This approach effectively addresses excessive and paradoxical anal sphincter contraction. Additionally, this procedure is minimally invasive, requiring only three incisions, with the largest measuring 3 cm at the umbilicus. A week or so after the procedure, we removed the drain. By the time the patient was discharged, the abdominal incision had largely heal The drain was removed approximately one week post-procedure, and the abdominal incision was largely healed by discharge.\u003c/p\u003e\u003cp\u003eHowever, this approach has limitations. Firstly, fecal traits significantly change after colectomy. Patients may experience prolonged periods of unformed or watery stools. Patients require extended probiotic use and dietary modifications to improve their condition. The limited sample size may introduce bias. Furthermore, the current follow-up period is only six months, leaving the long-term effects of the surgical treatment unclear.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study demonstrates thatthe symmetrical single-port\u0026thinsp;+\u0026thinsp;2 around the umbilicus laparoscopic (Tang style) total colectomy is a safe and effective minimally invasive procedure that significantly improves bowel function and quality of life in patients with refractory constipation. The procedure, performed through a concealed umbilical incision combined with two auxiliary ports (each \u0026lt;\u0026thinsp;5mm), offers advantages including minimal trauma, low blood loss (37.75\u0026thinsp;\u0026plusmn;\u0026thinsp;22.93ml), and rapid recovery (time to first flatus 2.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18 days). Follow-up results showed a remarkable increase in spontaneous bowel movements from 2.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25/week preoperatively to 21.30\u0026thinsp;\u0026plusmn;\u0026thinsp;7.24/week at 3 months, with sustained efficacy at 6 months (18.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.48/week). Significant improvements were observed in quality of life, constipation symptoms, and psychological status, with patient satisfaction reaching 92.5%. Although complications occurred in 7.5% of cases, all were successfully managed conservatively. This technique combines minimally invasive advantages with durable therapeutic effects, making it an optimal choice for refractory constipation treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cdiv\u003e\n\u003ch2\u003eCompeting Interest declaration\u003c/h2\u003e\n\u003cp\u003eAll authors (Xuanyu Wei, Haokai Ma, Yutao Wang, Ji Hao, Yichao Ma, Chen Wei, Daorong Wang, and Dong Tang) declare that they have no conflicts of interest, financial or otherwise, related to the subject matter of this manuscript. This includes, but is not limited to, grants or funding, employment, affiliations, patents, inventions, honoraria, consultancies, royalties, stock options/ownership, or expert testimony. No spousal or familial financial interests are relevant to this work. This statement covers the past two years and the foreseeable future.\u003c/p\u003e\n\u003ch2\u003eFunding Declaration\u003c/h2\u003e\n\u003cp\u003eNo source of funding\u003c/p\u003e\n\u003c/div\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eXuanyu Wei: Data curation, Investigation, Writing \u0026ndash; original draft; Haokai Ma: Formal analysis, Investigation; Yutao Wang: Formal analysis; Hao Ji: Data curation; Yichao Ma: Formal analysis; Chen Wei: Formal analysis; Daorong wang, M.D.: Resources, Supervision; Dang Tang, M.D.: Conceptualization, Project administration, Resources, Supervision, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData sets generated during the current study are available from the corresponding author on reasonable request. The natural gas production data are available from Drilling Info but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBarberio B, Judge C, Savarino EV et al (2021) Global prevalence of functional constipation according to the Rome criteria: a systematic review and meta-analysis [J], vol 6. The lancet Gastroenterology \u0026amp; hepatology, pp 638\u0026ndash;648. 8\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNag A, Martin SA, Mladsi D et al (2020) The Humanistic and Economic Burden of Chronic Idiopathic Constipation in the USA: A Systematic Literature Review [J]. Clin Exp Gastroenterol 13:255\u0026ndash;265\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKnowles CH, Grossi U, Chapman M et al (2017) Surgery for constipation: systematic review and practice recommendations: Results I: Colonic resection [J]. Colorectal Dis 19(Suppl 3):17\u0026ndash;36\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsimogiannis KE, Karlbom U, Lundin E et al (2019) Long-term outcome after segmental colonic resection for slow transit constipation [J]. Int J Colorectal Dis 34(6):1013\u0026ndash;1019\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrossi U, Knowles CH, Mason J et al (2017) Surgery for constipation: systematic review and practice recommendations: Results II: Hitching procedures for the rectum (rectal suspension) [J]. Colorectal Dis 19(Suppl 3):37\u0026ndash;48\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMercer-Jones M, Grossi U, Pares D et al (2017) Surgery for constipation: systematic review and practice recommendations: Results III: Rectal wall excisional procedures (Rectal Excision) [J]. Colorectal Dis 19(Suppl 3):49\u0026ndash;72\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShi Y, Yu Y, Zhang X et al (2017) Transvaginal Mesh and Transanal Resection to Treat Outlet Obstruction Constipation Caused by Rectocele [J]. Med Sci monitor: Int Med J experimental Clin Res 23:598\u0026ndash;605\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndreoli R, Zampieri N, Orlandi S et al (2024) Long time consequences after STARR procedure: Report of 15 years experience and medico-legal perspective [J]. Am J Surg 229:169\u0026ndash;173\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuttadauro A, Chiarelli M, Maternini M et al (2018) Value and limits of stapled transanal rectal repair for obstructed defecation syndrome: 10 years-experience with 450 cases [J]. Asian J Surg 41(6):573\u0026ndash;577\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRagg J, McDonald R, Hompes R et al (2011) Isolated colonic inertia is not usually the cause of chronic constipation [J]. Colorectal Dis 13(11):1299\u0026ndash;1302\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhu X, Li J, Fu T et al (2015) Laparoscopic-assisted subtotal colectomy combined with modified Duhamel procedure for mixed constipation [J]. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 19(1): e2014.00131\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDing W, Jiang J, Feng X et al (2014) Novel surgery for refractory mixed constipation: Jinling procedure - technical notes and early outcome [J]. Archives Med science: AMS 10(6):1129\u0026ndash;1134\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi N, Jiang J, Feng X et al (2013) Long-term follow-up of the Jinling procedure for combined slow-transit constipation and obstructive defecation [J]. Dis Colon Rectum 56(1):103\u0026ndash;112\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeng Y, Li G, Hu Y et al (2023) Magnetic resonance imaging and functional constipation [J]. 2(1)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarquis P, De La Loge C, Dubois D et al (2005) Development and validation of the Patient Assessment of Constipation Quality of Life questionnaire [J]. Scand J Gastroenterol 40(5):540\u0026ndash;551\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgachan F, Chen T, Pfeifer J et al (1996) A constipation scoring system to simplify evaluation and management of constipated patients [J]. Dis Colon Rectum 39(6):681\u0026ndash;685\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLongstreth GF, Thompson WG, Chey WD et al (2006) Funct bowel disorders [J] Gastroenterol 130(5):1480\u0026ndash;1491\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLane WA, Remarks ON THE RESULTS OF, THE OPERATIVE TREATMENT OF CHRONIC CONSTIPATION [J] (1908) BMJ 1(2455):126\u0026ndash;130\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXie XY, Sun KL, Chen WH et al (2019) Surgical outcomes of subtotal colectomy with antiperistaltic caecorectal anastomosis vs total colectomy with ileorectal anastomosis for intractable slow-transit constipation [J]. Gastroenterol Rep 7(6):449\u0026ndash;454\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKalbassi MR, Winter DC, Deasy JM (2003) Quality-of-life assessment of patients after ileal pouch-anal anastomosis for slow-transit constipation with rectal inertia [J]. Dis Colon Rectum 46(11):1508\u0026ndash;1512\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJohnston BJ, Clark DA, Warwick AM (2023) Long-term outcomes of total colectomy for severe constipation [J]. Colorectal Dis 25(6):1194\u0026ndash;1201\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatton V, Balakrishnan V, Pieri C et al (2020) Subtotal colectomy and ileorectal anastomosis for slow transit constipation: clinical follow-up at median of 15 years [J]. Tech Coloproctol 24(2):173\u0026ndash;179\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWedel T, Heimke M, Fletcher J et al (2023) The retrocolic fascial system revisited for right hemicolectomy with complete mesocolic excision based on anatomical terminology: do we need the eponyms Toldt, Gerota, Fredet and Treitz? [J]. Colorectal Dis 25(4):764\u0026ndash;774\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchulte Am Esch J, Iosivan SI, Steinfurth F et al (2019) A standardized suprapubic bottom-to-up approach in robotic right colectomy: technical and oncological advances for complete mesocolic excision (CME) [J]. BMC Surg 19(1):72\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRausa E, Colletti G, Ciniselli CM et al (2023) Superior rectal artery preservation to reduce anastomotic leak rates in familial adenomatous polyposis patients treated with total colectomy and ileorectal anastomosis [J]. Tech Coloproctol 27(12):1327\u0026ndash;1334\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAllison AS, Bloor C, Faux W et al (2010) The angiographic anatomy of the small arteries and their collaterals in colorectal resections: some insights into anastomotic perfusion [J]. Ann Surg 251(6):1092\u0026ndash;1097\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJumbi T, Kuria K, Osawa F et al (2019) The effectiveness of digital anal dilatation in preventing anal strictures after anorectal malformation repair [J]. J Pediatr Surg 54(10):2178\u0026ndash;2181\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBharucha AE, Wald A, Enck P et al (2006) Functional anorectal disorders [J]. Gastroenterology 130(5):1510\u0026ndash;1518\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHite M, Curran T (2021) Biofeedback for Pelvic Floor Disorders [J]. Clinics in colon and rectal surgery. 34(1):56\u0026ndash;61\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"refractory constipation, total colectomy, minimally invasive surgery","lastPublishedDoi":"10.21203/rs.3.rs-7958638/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7958638/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and objective:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the efficacy of the symmetrical single-port + 2 around the umbilicus laparoscopic (Tang style) total colectomy in the treatment of refractory constipation..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom June 2023 to December 2024, 40 patients with refractory constipation underwent the symmetrical single-port + 2 around the umbilicus laparoscopic (Tang style) total colectomy. Preoperative assessments included modified colonic transit tests, defecography, physical examinations, and multiple standardized scales. Postoperative efficacy was evaluated via follow-up questionnaires at 3 and 6 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the 3-month follow-up, the mean weekly spontaneous bowel movements significantly increased from 2.68 ± 2.25 to 21.30 ± 7.24 (P \u0026lt; 0.01). Significant improvements were also observed in the PAC-QOL quality of life scale, Wexner constipation score, PHQ-9 depression scale, and GAD-7 anxiety scale (P \u0026lt; 0.01). At the 6-month follow-up, therapeutic effects remained stable, with a mean weekly spontaneous bowel movement frequency of 18.55 ± 5.48, along with sustained improvements in quality of life and psychological scores. No surgery-related mortality occurred. Three cases (7.5%) of minor complications or adverse events were reported, most of which resolved with conservative management. Patient satisfaction was 87.5% at 3 months and further improved to 92.5% at 6 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe symmetrical single-port + 2 around the umbilicus laparoscopic (Tang style) total colectomy is a safe and effective surgical approach for chronic refractory constipation, demonstrating significant and sustained improvements in bowel function, quality of life, and psychological well-being with minimal complications.\u003c/p\u003e","manuscriptTitle":"Symmetrical single-port +2 around the umbilicus (Tang style) laparoscopic total colectomy for refractory constipation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 11:09:10","doi":"10.21203/rs.3.rs-7958638/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"38d1d891-9653-4629-b452-59b60f0d0fb9","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-27T11:08:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-13 11:09:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7958638","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7958638","identity":"rs-7958638","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}