Postoperative Complications Associated with Laparoscopy-assisted Colectomy

Abstract: The intraoperative and postoperative complications of laparoscopic colectomy were analyzed in a consecutive series of 69 cases in our experience. The final histological diagnosis of these patients was adenoma of the colon in eight, carcinoma of the colon and rectum in 59, leiomyoma of the colon in one and Crohn's disease in one. The TIMM staging of the carcinomas in our series was Tis in four, T1 in 20, T2 in 10 and T3 in 25 cases. Conversion to open surgery was necessary in four of the 69 cases. The reasons for conversion were bleeding in two, adhesion in one and malignant invasion to the bladder in one. Major postoperative complications occurred in the four cases in whom a reoperation was carried out. These included perforation of the colon, pancreatic fistula, ileus and bleeding. Among the 11 minor postoperative complications, wound infection was the most frequent and occurred in six cases. There were no operative or postoperative deaths. The postoperative observation period ranged from one month to 4¹/₂ years. There was only one case with a possible local recurrence who had a CEA level of 34 ng/ml. In this patient, no findings of port site recurrence were detected. We thus consider laparoscopic-assisted colectomy, when done by technically well experienced surgeons, to be an effective and curative procedure for the treatment of colorectal carcinoma. However, in view of our complication rate, both sufficient training and experience with the techniques required to perform a laparoscopic colectomy are important for the future development of this procedure.     

Laparoscopic Total Colectomy: An Evolutionary Experience

Purpose Laparoscopic total abdominal colectomy and total proctocolectomy are technically challenging operations. Advances in minimally invasive techniques, including sleeveless hand-assist devices, may influence performance of these procedures. This study was designed to evaluate the results of laparoscopic total colectomy and to compare the hand-assisted approach with straight laparoscopy. Methods Sequential patients undergoing hand-assisted and straight laparoscopic total abdominal colectomy and total proctocolectomy from 1997 to 2004 were identified from a single institution prospective database involving four colorectal surgeons, of which three had limited laparoscopic experience. Patient characteristics, perioperative parameters, and outcomes were assessed. Results A total of 130 patients were analyzed. Sixty-nine patients underwent total abdominal colectomy (hand-assisted 17 vs. straight laparoscopic 52), and 61 underwent total proctocolectomy (hand-assisted 28 vs. straight laparoscopic 33). For both total abdominal colectomy and total proctocolectomy, the hand-assisted and straight laparoscopic groups were well matched. Although no differences were observed in operative blood loss and intraoperative complications, hand assistance resulted in fewer overall conversions to open (1/45 (2.2 percent) vs. 6/85 (7.1 percent); P < 0.01), with no conversions in the total abdominal colectomy group (0 vs. 9.6 percent; P = 0.05). There was a trend toward reduced operative time with hand assistance, and nonlaparoscopic staff surgeons performed a greater proportion of the hand-assisted cases (22.2 vs. 10.6 percent; P < 0.05). Conclusions Laparoscopic total colectomy is technically feasible and safe. With a significant reduction in conversions and a greater proportion of cases performed by nonlaparoscopic surgeons, there was an evolutionary shift to a hand-assisted technique. A hand-assisted approach may be a useful alternative to a straight laparoscopic approach for this technically challenging operation. Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. Dr. Marcello is a consultant for Applied Medical, Ethicon Endo-Surgery, Olympus, and Valleylab. He has received honoraria from each company.     

Hand-Assisted Laparoscopic Colectomy: Evolution to a Clinically Useful Technique

PURPOSE: Hand-assisted laparoscopic colectomy has traversed three phases of distinct development. This review was designed to trace the evolution of hand-assisted colectomy from an infrequently used technique to a clinically useful surgical approach to diseases of the colon and rectum.METHODS: This review compiles previously reported and published experiences with hand-assisted laparoscopic colectomy.RESULTS: During the first phase of development of hand-assisted laparoscopic colectomy, surgeons explored what could be accomplished by a hand inserted into the abdomen through the specimen extraction site as an adjunct to laparoscopic techniques. Case reports and small trials found that manually assisted laparoscopic techniques permitted more rapid completion of laparoscopic-assisted colectomies. In the second phase, surgeons used early devices that facilitated the insertion of the surgeons hand into the abdomen and helped to maintain the pneumoperitoneum. Larger series and small, randomized trials indicated a time-saving advantage to hand-assisted techniques and similar short-term outcomes as laparoscopic-assisted colectomies. In the current third phase, surgeons are using a new generation of hand-access devices that extend the options for hand-assisted techniques. These devices, like earlier devices, facilitate hand insertion, protect the wound, act as the retrieval site for the specimen, and serve as the portal for construction of extracorporeal anastomoses. In addition, these new devices can serve as laparoscopic trocar sites. This permits selective use of hand-assisted and laparoscopic-assisted techniques at various times in the same operation. These new devices have not undergone clinical trials, and therefore, a final appraisal must await future publication of outcomes.CONCLUSIONS: Hand-assisted laparoscopic colectomy has evolved into a clinically useful surgical technique. New devices facilitate the performance of these operations and permit the surgeon to switch between hand-assisted and laparoscopic techniques.     

Review of 500 single incision laparoscopic colorectal surgery cases- Lessons learned

Single incision laparoscopic surgery(SILS) is a minimally invasive platform with specific benefits over traditional multiport laparoscopic surgery. The safety and feasibility of SILS has been proven, and the applications continue to grow with experience. After 500 cases at a high-volume, single-institution, we were able to standardize instrumentation and operative steps, as well as develop adaptations in technique to help overcome technical and ergonomic challenges. These technical adaptations have allowed the successful application of SILS to technically difficult patient populations, such as pelvic cases, inflammatory bowel disease cases, and high body mass index patients. This review is a frame of reference for the application and wider integration of the single incision laparoscopic platform in colorectal surgery.     

Review of single incision laparoscopic surgery in colorectal surgery

As surgical techniques continue to move towards less invasive techniques,single incision laparoscopic surgery(SILS),a hybrid between traditional multiport laparoscopy and natural orifice transluminal endoscopic surgery,was introduced to further the enhanced outcomes of multiport laparoscopy. The safety and feasibility of SILS for both benign and malignant colorectal disease has been proven. SILS provides the potential for improved cosmesis,postoperative pain,recovery time,and quality of life at the drawback of higher technical skill required. In this article,we review the history,describe the available technology and techniques,and evaluate the benefits and limitations of SILS for colorectal surgery in the published literature.     

Standardized Laparoscopic Intracorporeal Right Colectomy for Cancer: Short-Term Outcome in 111 Unselected Patients

Purpose  This study was designed to evaluate the impact of a standardized laparoscopic intracorporeal right colectomy on the short-term outcome of patients with neoplasia. Methods  Consecutive patients with histologically proven right colon neoplasia underwent a standardized laparoscopic intracorporeal right colectomy with medial to lateral approach encompassing ten sequential steps: 1) ligation of ileocolic vessels, 2) identification of right ureter, 3) dissection along superior mesenteric vein, 4) division of omentum, 5) division of right branch of middle colic vessels, 6) transection of transverse colon, 7) mobilization of right colon, 8) transection of terminal ileum, 9) ileocolic anastomosis, 10) delivery of specimen. Values were medians (ranges). Results  From July 2002 to June 2005, 111 laparoscopic intracorporeal right colectomies were attempted with a 5.4 percent conversion rate. There were 57 women and 54 men, aged 64.9 (range, 40–85) years, with body mass index of 33 (range, 20–43), American Society of Anesthesiology score of 2 (range, 2–4), 36.9 percent comorbidities, and 37.8 percent previous abdominal surgery. The indication for surgery was cancer in 109 patients. Operative time was 120 (range, 80–185) minutes. Estimated blood loss was 69 (range, 50–600) ml. Overall length of skin incisions was 66 (range, 60–66) mm; 29 (range, 2–41) lymph nodes were harvested. Length of stay was four (range, 2–30) days. Complication rate was 4.5 percent. Conclusions  A standardized laparoscopic intracorporeal right colectomy resulted in a favorable short-term outcome in unselected patients with neoplasia of the right colon. Poster presentation at the meeting of the American College of Surgeons, Chicago, Illinois, October 8 to 12, 2006.     

Laparoscopic upper gut surgery

Australian surgeons have been prominent in the introduction, development, and consolidation of laparoscopic surgery of the upper gut. In doing this, some of the very best principles of surgical innovation have been in evidence: preliminary animal work in which to test hypotheses and techniques, followed by careful application and documentation in the clinical setting, randomized clinical trials and finally academic reporting and ongoing development. This review documents the introduction of laparoscopic surgery for gastroesophageal reflux, hiatus hernia, achalasia, gastroesophageal malignancy, obesity, and a range of emergency conditions in Australia. Those involved are regarded as world leaders in their field. A vital component of this success has been the close cooperation between surgeons and gastroenterologists within the Gastroenterological Society of Australia.     

Portal Vein Thrombosis After Laparoscopic Sigmoid Colectomy for Diverticulitis

Portal vein thrombosis is a very uncommon complication after laparoscopic surgery. Although only one case of portal vein thrombosis has been reported after laparoscopic colectomy, there are several reports of mesenteric vascular occlusion after other laparoscopic procedures. We present a case of portal vein thrombosis in a patient with no other demonstrable hypercoagulable states or risk factors, who underwent an uneventful laparoscopic sigmoid colectomy. Because alteration in coagulation may occur after establishing a pneumoperitoneum, we suggest that heparin prophylaxis may be advisable to avoid these kinds of complications, especially if a past history of coagulable disorders is present.     

Laparoscopic hepatectomy for liver tumors: proposals for standardization

Background/purpose

We draw on our experience with laparoscopic hepatectomy (LH) to present recommendations for standardization of LH for the treatment of liver tumors.

Methods

At our center, 90 LHs were performed from April 1993 to January 2008. These were divided equally into early cases and late cases, and short-term postoperative results were compared. Forty-nine of the LH procedures were total-laparoscopic procedures, 16 were hand-assisted procedures, and 25 were laparoscopy-assisted procedures. The tumors were malignant in 76 cases and benign in 14 cases.

Results

Among late cases, the numbers of malignant tumors and tumors located in the posterosuperior region of the liver (Segments VII, VIII, and IVb) were significantly higher than among early cases; however, operative blood loss and postoperative hospital stay were significantly lower in the late cases (158.9 ± 213.4 vs. 377.6 ± 421.2 cc, P = 0.007; and 8.7 ± 3.6 vs. 15.3 ± 8.7 days, P = 0.0001, respectively). No operative deaths occurred in either group.

Conclusions

Although LH does have a steep learning curve, we believe that it can be standardized and provide a less invasive surgical option—with no reduction in disease curability—for the treatment of liver tumors in selected patients.     

Systematic review and meta-analysis on laparoscopic pancreatic resections for neuroendocrine neoplasms (PNENs)

Introduction: The safety of laparoscopic resections (LPS) of pancreatic neuroendocrine neoplasms (PNENs) has been well established in the literature.

Areas covered: Studies conducted between January 2003 and December 2015 that reported on LPS and open surgery (OPS) were reviewed. The primary outcomes were the rate of post-operative complications and the length of hospital stay (LoS) after laparoscopic and open surgical resection. The rate of recurrence was the secondary outcome. Eleven studies were included with a total of 907 pancreatic resections for PNENs, of whom, 298 (32.8%) underwent LPS and 609 (67.2%) underwent open surgery. LPS resulted in a significantly shorter LoS (p < 0.0001) and lower blood loss (p < 0.0001). The meta-analysis did not show any significant difference in the pancreatic fistula rate, recurrence rate or post-operative mortality between the two groups.

Expert commentary: LPS is a safe approach even for PNENs and it is associated with a shorter LoS.     

Laparoscopic distal pancreatectomy as the total biopsy of the pancreas: tool of minimally invasive surgery

Because of recent progress in imaging modalities, the opportunities to detect pancreatic cystic neoplasms are increasing. However, serous cystadenoma is still uncommon. We report a case of serous cystadenoma treated by laparoscopic distal pancreatectomy. A 52-year-old woman presented with mild upper abdominal pain. Dynamic computed tomography (CT) revealed a solitary cystic lesion 3?cm in diameter in the pancreatic tail. Endoscopic ultrasound showed a honeycomb pattern, indicative of serous cystadenoma. To obtain the final diagnosis of the tumor, we performed laparoscopic distal pancreatectomy. A histopathological study showed microcystadenoma with no evidence of malignancy.     

Current status of laparoscopic surgery of the pancreas

Laparoscopic surgery of the pancreas remains, other than for certain clear indications, primarily investigational. However, in the past few years, laparoscopic therapy for pancreatic diseases has made significant strides and will undoubtedly contribute increasingly to the care of the surgical patient with pancreatic disease. This review discusses the current status of minimally invasive surgical therapy of pancreatic diseases and reviews the current literature. There are four major areas of clinical and laboratory investigation, including diagnostic laparoscopy for staging of pancreatic cancer, laparoscopic palliation of unresectable pancreatic cancer, laparoscopic management of pancreatic pseudocyst, and laparoscopic partial pancreatectomy (pancreaticoduodenectomy, distal pancreatectomy, and enucleation for islet cell tumors). The increased sensitivity of staging laparoscopy with laparoscopic ultrasound as a staging modality in the diagnosis of previously unrecognized metastatic disease from pancreatic cancer is clearly the most utilitarian application of laparoscopic technology in this patient population. Additionally, a natural extension of staging laparoscopy with laparoscopic ultrasound is the ability to improve the quality of life for the patient with unresectable pancreatic cancer by palliating the biliary and gastrointestinal obstruction and the debilitating pain, without the need for and morbidity of open laparotomy. Laparoscopic internal drainage of pancreatic pseudocysts remains early in its development but appears to have potential benefit from application of minimal access techniques. And laparoscopic partial pancreatectomy, both pancreaticoduodenectomy, and, to a lesser degree, distal pancreatectomy, remain primarily investigational without clearly established benefits from the use of minimal access techniques.     

Laparoscopic inversion esophagectomy: simplifying a daunting operation

Minimally invasive esophageal resection is a technically demanding procedure that may reduce patient morbidity and improve convalescence when compared with the open approach. Despite these proposed advantages, the minimally invasive approach has not been widely embraced and is routinely performed in only a few specialized centers around the world. The laparoscopic inversion esophagectomy attempts to eliminate some of the technical obstacles inherent in this procedure by simplifying the transhiatal mediastinal dissection, facilitating vagal preservation, and enhancing safety. We present a case of a 37-year-old man who underwent laparoscopic inversion esophagectomy for Barrett's esophagus with high-grade dysplasia. Immediate and long-term outcome measures are being prospectively gathered in order to establish the ultimate value of this procedure.     

Laparoscopic staging in selected patients with colorectal liver metastases as a prelude to liver resection

Background: Careful selection of patients with colorectal liver metastases for liver resection should minimize the risk of unnecessary laparotomy due to unresectable disease. The impact of staging laparoscopy with laparoscopic ultrasonography (LapUS) on clinical decision making in selected patients with potentially resectable colorectal liver metastases was evaluated. Patients and methods: Staging laparoscopy with or without LapUS was performed in 77 of 415 consecutive patients (19%) with colorectal liver metastases deemed potentially resectable following liver-specific CT and/or MRI scanning. Retrospective analysis of prospectively collected data compared clinical outcomes with those in whom laparoscopy had been deferred in favour of laparotomy. Results: Staging laparoscopy was successful in 76 of 77 patients (99%). Adverse events occurred in three patients (4%): bowel injury n=2; late port site metastasis, n=1. Laparoscopic staging identified factors precluding curative resection in 16 patients (21%), thus averting unnecessary laparotomy. Of the 57 patients (74%) staged laparoscopically who underwent surgical exploration, 7 patients (12%) were unresectable and liver resection was achieved in 50 (88%). Discussion: Laparoscopic staging remains useful in detecting occult intra- and extra-hepatic tumour in selected patients with potentially operable colorectal liver metastases.     

Laparoscopy Assisted Colectomy with Extracorporeal Anastomosis

Abstract: Laparoscopy assisted colectomy with extracorporeal anastomosis was carried out in five patients. In three patients, the lesions were carcinoma with submucosal invasion and the histological results of the polypectomy specimen indicated the necessity of the subsequent colectomy. In the other two patients the lesions were either adenoma or carcinoma in adenoma. Under pneumoperitoneum, mobilization of the colon was performed using the laparoscopic technique. In three patients the mesenteric vessels of a segment of the colon were ligated and divided extracorporeally. In two patients the mesenteric vessels were clipped and divided intracorporeally. In all cases, extracorporeal resection of the colon and hand suture anastomosis were performed. Surgery time ranged from 3 hours and 20 minutes to 4 hours and 50 minutes. No postoperative complications were experinced. Four patients began to walk on the first postoperative day. Postoperative administration of analgesics was needed in four patients for two days or less after the operation. In all but one case, bowel sounds were audible from the first post-operative day onwards. In only one patient was the postoperative recovery delayed. Although sufficient future studies should be accumulated to confirm the advantages of this procedure, we can expect that laparoscopy assisted colectomy will become a useful procedure for benign and early malignant lesions in which colonoscopic removal was not possible or was suspected to be insufficient. (Dig Endosc 1944; 6 : 52–58)     

Hand-assisted Laparoscopic Colorectal Surgery: Initial Experience of a Single Surgeon

Background/Aim:

As totally laparoscopic colorectal surgery is considered challenging and technically demanding with a long steep learning curve, we adopted hand-assisted laparoscopic colorectal surgery as a bridge to totally laparoscopic assisted colorectal surgery. This prospective study aims to highlight the initial experience of a single surgeon with this technique.

Materials and Methods:

A prospective analysis of the first 25 cases of hand-assisted laparoscopic colorectal resections which were performed by a single surgeon over a 15-month period. There were 15 males and 10 females with a mean age of 55.5 (range 20-82) years.

Results:

The indication in majority of cases was cancer (76%). The procedures consisted of 18 (72%) various colectomies and 7 (28%) anterior resections. The operative time ranged between 110-400 (mean 180) min. There was one conversion (4%) and the mean operative blood loss was 80 (range 60-165) ml. The number of lymph nodes retrieved in the cancer cases was 5-31 (mean 15) nodes. The mean length of hospital stay was five (range 3-10) days. The total number of short-term complications was six (24%) and there was one death due to anastomatic leak and multiorgan failure. Long-term complications after a maximum follow up of 30 months were two incisional hernias at the hand port site, but none of the patients developed adhesive small bowel obstruction or late anastomotic stricture. Currently all our colorectal procedures are conducted laparoscopically.

Conclusion:

Hand-assisted laparoscopic colorectal procedures are easy to learn as a good bridge to master totally laparoscopic colorectal surgery.     

Colovesical Fistula: Not a Contraindication to Elective Laparoscopic Colectomy

PURPOSE Traditionally, diverticular fistula was thought to be a contraindication for laparoscopic colectomy. The advent of hand-assisted laparoscopy has allowed repair of a diverticular fistula to be technically feasible laparoscopically. We present our experience with laparoscopic colectomy in patients with diverticular fistulas.METHODS Patients with colovesical or colovaginal fistulas secondary to diverticular disease were consecutively entered into a database over a five-year period. All operations were electively performed by a single group of colorectal surgeons. Patient demographics, American Society of Anesthesiologists classification, type of surgery, operating time, hospital length of stay, and early and late complications were recovered by chart review. These results were then compared to results from a group of patients who had undergone elective laparoscopic colectomy for recurrent diverticulitis during the same period by the same group of surgeons.RESULTS Altogether, 40 consecutive operations for diverticular fistulas were performed, 36 of which were started laparoscopically (90 percent). The average patient age was 65 years and the average American Society of Anesthesiologists class was 2. Patient demographics were similar among the group with recurrent diverticulitis (n = 149). The average hospital stay was 6.2 days for the fistula group and 4.4 days in the recurrent diverticulitis group. The average operating time was 220 minutes for the fistula group vs. 176 minutes for the uncomplicated group (P < 0.002). The conversion rate was significantly higher in the fistula group (25 percent vs. 5 percent, P < 0.001). There were no postoperative anastomotic leaks or bleeding episodes requiring reoperation in the fistula group.CONCLUSIONS Diverticular fistula should no longer be considered a contraindication for laparoscopic colectomy. These cases are more complex, as evidenced by the longer operating times and higher conversion rates when compared with resections for uncomplicated recurrent diverticulitis. Although the length of hospital stay was longer for patients who underwent laparoscopic colectomy for diverticular fistula, those whose operations were completed laparoscopically had the same outcome as patients with uncomplicated disease. We anticipate that minimally invasive surgery will become the standard of care for colovesical fistula, as it now is for uncomplicated diverticular disease.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

Laparoscopic major hepato-biliary-pancreatic surgery: formidable challenge to standardization

Introduction

Although laparoscopic colorectal or gastric surgery has become widely accepted as a superior alternative to conventional open surgery, the surgical management of hepato-biliary-pancreatic disease has traditionally involved open surgery. Recently, many reports have described laparoscopic partial liver resection, lateral segmentectomy, and distal pancreatectomy. However, laparoscopic major hepato-biliary-pancreatic surgery, such as hepatic lobectomy and pancreaticoduodenectomy, has not been widely developed because of technical difficulties.

Methods

We describe our experience with laparoscopic major hepato-biliary-pancreatic surgery, including right hepatectomy using hilar Glissonean pedicle transaction, and pylorus-preserving pancreaticoduodenectomy.

Conclusion

Although our experience is limited, and randomized study is necessary to elucidate the appropriate indications for and effects of the present procedures, we believe that laparoscopic major hepato-biliary-pancreatic surgery can be feasible, safe, and effective in highly selected patients, and that it will be one of the standard therapeutic options for carefully selected patients with hepato-biliary-pancreatic disease.     

Laparoscopic liver resection: a systematic review

Background

Outcomes of laparoscopic liver resection (LLR) are not clarified. The objective of this article is to depict the state of the art of LLR by means of a systematic review of the literature.

Methods

Studies about LLR published before September 2008 were identified and their results summarized.

Results

Indications for laparoscopic hepatectomy do not differ from those for open surgery. Technical feasibility is the only limiting factor. Bleeding is the major intraoperative concern, but, if managed by an expert surgeon, do not worsen outcomes. Hand assistance can be useful in selected cases to avoid conversion. Patient selection must take both tumor location and size into consideration. Potentially good candidates are patients with peripheral lesions requiring limited hepatectomy or left lateral sectionectomy; their outcomes, including reduced blood loss, morbidity, and hospital stay, are better than those of their laparotomic counterparts. The same advantages have been observed in cirrhotics. Laparoscopic major hepatectomies and resections of postero-superior segments need further evaluation. The results of LLR in cancer patients seem to be similar to those obtained with the laparotomic approach, especially in cases of hepatocellular carcinoma, but further analysis is required.

Conclusions

Laparoscopic liver resection is safe and feasible. The laparoscopic approach can be recommended for peripheral lesions requiring limited hepatectomy or left lateral sectionectomy. Preliminary oncological results suggest non-inferiority of laparoscopic to laparotomic procedures.