Robotic versus laparoscopic colectomy

Background This study compared the experience and cost of the DaVinci Robotic system and laparoscopy for colon resections. Methods For this study, 30 consecutive robotic and 27 consecutive laparoscopic colectomies were divided into right and sigmoid colectomies for analysis. Comparisons included indications for surgery, gender, age, body mass index (BMI), estimated blood loss (EBL), length of operation, length of hospital stay (LOS), complications, operating room (OR) cost, OR personnel cost, OR supply cost, OR time cost, and total hospital cost. Results The comparison groups were similar in indications for surgery, gender, age, BMI, EBL, and LOS. The right colectomies included 17 robotic and 15 laparoscopic procedures. An intracorporeal anastomosis was performed in the robotic cases, and an extracorporeal anastomosis was performed in the laparoscopic cases. The total case time was 218.9 min for the robotic and 169.2 min for the laparoscopic procedures (p = 0.002). The total hospital cost was $9,255 for the robotic and $8,073 for the laparoscopic procedures (p = 0.430). The total OR cost was $5,823 for the robotic and $4,339 for the laparoscopic procedures (p < 0.000). The sigmoid colectomies included 13 robotic and 12 laparoscopic procedures. The robotic and laparoscopic cases were managed in similar sequence. The total case time was 225.2 min for the robotic and 199.4 min for the laparoscopic procedures (p = 0.128). The total hospital cost was $12,335 for the robotic and $10,697 for the laparoscopic procedures (p = 0.735). The total OR cost was $6,059 for the robotic and $4,974 for the laparoscopic procedures (p = 0.068). The complications in the robotic groups were more numerous, but were not attributable to equipment. Conclusions The comparison groups were similar. The robotic cases were significantly longer for right colectomies because of the intracorporeal anastomosis instead of the extracorporeal anastomosis performed in the laparoscopy cases. Every cost category was higher for the robotic cases. The right colectomies showed significant increases in total OR cost, OR personnel cost, OR supply cost, and OR time cost. The sigmoid colectomies had significant increases in OR personnel cost and OR supply cost. The total hospital cost was higher for the robotic groups, but the difference was not statistically significant.     

Increasing the number of attacks increases the conversion rate in laparoscopic diverticulitis surgery

Background  This study aimed to determine whether the number of diverticulitis or complicated diverticulitis episodes affects the conversion rate or postoperative complication rate in elective laparoscopic sigmoid colectomy. Methods  In this study, 216 charts were reviewed for baseline characteristics, diverticulitis history, and intra- and postoperative complications. Analysis was performed with the Student’s t-test, the chi-square test, and Fisher’s exact tests. Results  Of 216 sigmoid colectomies, 151 were laparoscopic, 19 were converted, and 46 were open. Baseline characteristics were similar for patients with zero to two and those with three or more inpatient diverticulitis attacks. Patients with uncomplicated diverticulitis had a higher rate of conversion after three or more inpatient episodes (2.6% vs 25%; p = 0.04). There was no difference in operative times or postoperative complication rates. Patients with a history of abscess had a 23% chance of conversion. Those with no abscess history had an 8% chance of conversion (p = 0.02). In general, converted procedures required more time than open procedures but were associated with decreased hospital length of stay (LOS) and a decreased rate of postoperative ileus. Conclusion  Multiple inpatient diverticulitis attacks and a history of abscess were associated with laparoscopic conversion. Converted procedures required more time than open procedures, but had reduced LOS and postoperative ileus. Laparoscopic sigmoid colectomy can be attempted safely for patients with three or more inpatient attacks or a history of complicated diverticulitis.     

Laparoscopic converted to open colectomy: predictors and outcomes from the Nationwide Inpatient Sample

Background

Early in their learning curve, surgeons need to appropriately select patients to avoid conversion from laparoscopic to an open colectomy.

Methods

Using the Nationwide Inpatient Sample, laparoscopic and laparoscopic converted to open colectomies performed between 2002 and 2007 were compared. We evaluated patient and institutional characteristics to find significant predictors and outcomes of conversion.

Results

Between 2002 and 2007, the rate of conversion was high, ranging from 35.7% to 38.0%. Multivariate predictors of conversion included obesity, diverticulitis, inflammatory bowel disease, constipation, metastatic disease, nonelective admission, left or transverse colectomy, intraoperative complication, lower socioeconomic status, uninsured status, and rural hospital location. A colectomy for benign colon polyps was less likely to be converted. Conversion to an open colectomy did not increase inpatient mortality.

Conclusions

Predictors of conversion from open to laparoscopic colectomy were found from a national database reflecting all US laparoscopic colectomies. Conversion did not increase inpatient mortality.     

Telerobotic surgery for right and sigmoid colectomies: 30 consecutive cases

Background This study aimed to evaluate the feasibility of using a robotic assistant for colon resections. This report describes the experience, advantages, and disadvantages of using the DaVinci system for a colectomy on the basis of 30 consecutive cases managed by a minimally invasive surgery fellowship–trained surgeon. Methods Data were prospectively collected on 30 consecutive colectomies performed using the DaVinci system from September 2002 to March 2005. Results A total of 13 sigmoid colectomies with splenic flexure mobilization and 17 right colectomies were performed for 14 men and 16 women. The preoperative diagnoses for the procedures were cancer (n = 5), diverticulitis (n = 8), polyps (n = 16), and carcinoid (n = 1). The right colectomies required 29.7 ± 6.7 min (range, 22–44 min) for the port setup, 177.1 ± 50.6 min (range, 103–306 min) for the robot, and 218.9 ± 44.6 min (range, 167–340 min) for the total case. The length of stay was 5.2 ± 5.8 days (range, 2–27 days). The robot portion was 80.9% of the total case time. The sigmoid colectomies required 30.1 ± 9.6 min (range, 15–50 min) for the port setup, 103.2 ± 29.4 min (range, 69–165 min) for the robot, and 225.2 ± 37.1 min (range, 147–283 min) for the total case. The hospital length of stay was 6.0 ± 7.3 days (range, 3–30 days). The robot portion was 45.8% of the total case time. Six complications occurred: left hip paresthesia, cecal injury, anastomotic leak, patient slipped from the operating table after the robotic portion of the case, transverse colon injury, and return of a patient to the office with urinary retention. Two sigmoid colectomies were converted to laparotomy. The specific advantages and disadvantages of using the DaVinci system for colectomies are discussed. Conclusions The 30 consecutive cases demonstrated the technical feasibility of using the DaVinci system for a colectomy. The longevity of the DaVinci system’s use for colectomy will be determined by comparison of its cost and outcomes with those for conventional laparoscopic colectomy.     

Factors associated with complications of open versus laparoscopic sigmoid resection for diverticulitis.

BACKGROUND: This study critically reviews sigmoid colon resection for diverticulitis comparing open and laparoscopic techniques. METHODS: We conducted a retrospective review of all open and laparoscopic cases of diverticulitis between 1992 and 2001. Data analyzed included the following: indications for operation, postoperative complications, and incidence of laparoscopic conversion to laparotomy. Major and minor complications were analyzed in relation to patients' preoperative diagnosis, age, presence or absence of splenic flexure mobilization, length of stay, and laparoscopic sigmoid resection versus open sigmoid resection. RESULTS: Over a 10-year period, 166 resections for diverticulitis were performed including 126 open cases and 40 laparoscopic cases. No significant differences existed in patient characteristics between the groups. Major complications occurred in 14% of patients, and the laparoscopic conversion rate was 20%. The presence of abscess, fistula, or stricture preoperatively was associated with a higher complication rate only in patients > or =50 years old undergoing open sigmoid resection. The length of stay between patients undergoing laparoscopic resection was significantly less than in patients having open resection. CONCLUSION: Advanced laparoscopic sigmoid resection is an alternative to open sigmoid resection in patients with diverticulitis and its complications. Open sigmoid resection in patients >50 years may have a higher complication rate in complicated diverticulitis when compared with laparoscopic sigmoid resection (all patient ages) and open sigmoid resection (patients <50 years old). Regarding complications, no difference existed between the length of stay in patients with open vs. laparoscopic resection.     

Laparoscopic versus open sigmoid colectomy for diverticulitis

This study compared laparoscopic with open sigmoid colectomy for patients with a diagnosis of diverticulitis. Increased use of less invasive techniques makes it vitally important to evaluate outcomes of these techniques as compared with standard open procedures. Patients undergoing sigmoid colectomy for diverticulitis without hemorrhage (code 56211) between January 1997 and December 2001 were reviewed. Two groups were identified: those undergoing open sigmoid colectomy and those undergoing laparoscopic sigmoid colectomy; American Society of Anesthesiologists (ASA) scores, operative time, intensive care unit (ICU) and hospital length of stay, morbidity/mortality, and hospital charges were compared. During the study period 271 sigmoid colectomies were performed for diverticulitis without hemorrhage: 56 laparoscopically and 215 with the standard open technique. Four patients required conversion from laparoscopic to open colectomy. Mean ASA scores were: open group 2.4; laparoscopic group, 1.9 (P < 0.001). Mean operative times were: laparoscopic group, 170 +/- 45 minutes; open group, 140 +/- 49 minutes (P < 0.001). In the open group 39 patients required transfer to the ICU; one patient in the laparoscopic group required transfer to the ICU. Average hospital lengths of stay for the open and laparoscopic groups were 9.06 and 4.12 days, respectively (P < 0.001). Complications were recorded in 57 (27%) of 215 patients who underwent an open procedure versus 5 (9%) of 56 patients who underwent laparoscopic sigmoid colectomy (P < 0.01). There were three deaths in the open group and none in laparoscopic group. Average total hospital charges were 25,700 dollars for open sigmoid colectomy and 17,414 dollars for laparoscopic colectomy. Laparoscopic sigmoid colectomy compares favorably with open sigmoid colectomy for patients with a diagnosis of diverticulitis.     

Laparoscopic colectomy: indications for conversion to laparotomy.

HYPOTHESIS: Although experience with laparoscopic colectomy continues to accumulate, criteria for patient selection for the procedure have yet to be developed. We propose that review of indications for conversion to laparotomy during laparoscopic colectomy should define some of the current technical limitations of the procedure. This information may facilitate development of selection criteria for laparoscopic colon and rectal surgery. DESIGN: Single-institution retrospective medical records review. SETTING: Tertiary referral center. PATIENTS: Two hundred patients who underwent laparoscopic colon surgery, in 47 (23.5%) of whom the procedure was converted to laparotomy. INTERVENTIONS: A registry of 200 patients who have undergone laparoscopic colon surgery was analyzed. Medical records of 47 patients whose procedure was converted were reviewed to assess indications for conversion and identify factors contributing to the need for conversion. RESULTS: Between July 1, 1991, and September 30, 1998, 200 laparoscopic colon procedures were performed: 78 ascending colectomies, 74 descending or sigmoid colectomies, 14 diverting stomas, and 34 "other procedures." The 200 patients were divided into 4 cohorts of 50 consecutive patients to analyze changes with time. The conversion rate was statistically greater in the first quarter (18 patients [36.0%]) than in subsequent quarters (16.0%; P <.05). The rate of conversion to laparotomy for segmental resection of the ascending and descending colon (31/153 [20.3%]) has been equivalent and less than the conversion rate for other procedures (16/33 [48.5%]; P <.05). The distribution of patients by operative indication has been fairly constant. The indication for operation has not influenced the need for conversion. The indications for conversion were technical problems in 15 patients (hypercarbia, unclear anatomy, and stapler misfire), laparoscopic complications in 9 patients (bleeding, cystotomy, and enterotomy), and problems that exceeded the limits of laparoscopic dissection in 23 patients (phlegmon, adhesions, obesity, and adjacent organ involvement by cancer). CONCLUSIONS: Our conversion rate has decreased during our experience, and currently the need for conversion to laparotomy is most frequently caused by situations such as excessive tumor bulk, adhesions, and diverticular phlegmon that exceed the technical limitations of laparoscopic dissection. Colorectal reanastomosis following a Hartmann resection and procedures involving resection of the distal rectum are unlikely to be successfully completed. Although obesity accentuates the technical limitations of laparoscopic dissection, it is an infrequent cause for conversion to laparotomy.     

Laparoscopic total abdominal colectomy in the acute setting

We report results from a single surgeon’s 10-year team experience with laparoscopic total abdominal colectomy. We review our series, which includes a large subgroup of ill, high-risk patients with acute colitis requiring urgent surgery. From 1993 to 2003, we performed 65 laparoscopic total abdominal colectomies. All patients referred for total abdominal colectomy were offered the laparoscopic approach. We prospectively collected the following data on all patients: demographics, surgical indications, preoperative status, duration of surgery, intraoperative blood loss, operative complications, length of stay, subsequent operations, patient satisfaction, and lessons learned from our team experience. Preoperative diagnoses included ulcerative colitis (n = 55), Crohn’s colitis (n = 3), colonic inertia (n = 4), and familial adenomatous polyposis (n = 3). Among the patients with inflammatory bowel disease, 70% of cases were performed on ill patients, refractory to medical management, requiring urgent surgery. This subgroup was managed with laparoscopic total abdominal colectomy and Brooke ileostomy, with ileoanal pouch anastomosis deferred. Operative times were long, ranging from 6 to 11 hours. Mean intraoperative blood loss was 200 ml. Mean length of stay was 4.3 days and ranged from 2 to 13 days. There were no conversions to open surgery and there were no deaths. Complications occurred in 12% of patients and included intra-abdominal abscess (n = 2), wound infection (n = 3), stoma stenosis (n = 1), and incisional hernia (n = 2). Postoperative patient satisfaction was high. Subsequent operations, including restorative proctectomy, were also performed laparoscopically. Laparoscopic total abdominal colectomy is technically challenging and requires a team approach but offers patients significant benefit in length of stay and surgical recovery. This operation can be effectively used with minimal morbidity in difficult, ill patients requiring urgent surgery. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation). The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Uniformed Services University, the Department of the Air Force, or the Department of Defense.     

Factors and consequences of conversion in laparoscopic sigmoidectomy for diverticular disease

BACKGROUND: The disadvantages of laparoscopic elective sigmoidectomy for diverticular disease include the risk of conversion to open operation and longer operative time. The aim of this study was to analyse the causes and consequences of conversion in 168 consecutive patients who underwent a laparoscopically assisted colectomy between January 1994 and June 2001. METHODS: Data were collected prospectively to analyse the causes and consequences of conversion to open surgery in terms of postoperative morbidity and patient recovery. RESULTS: Postoperative mortality, morbidity, conversion and reoperation rates were zero, 21.4 per cent (n = 36), 14.3 per cent (n = 24) and 3.0 per cent (n = 5) respectively. The reasons for conversion were presence of intraperitoneal adhesions and/or inflammatory pseudotumour (n = 21), an intraoperative diagnosis of sigmoid cancer (n = 1), hypercapnia (n = 1) and abdominal bleeding (n = 1). Three preoperative factors were associated with a significant higher risk of conversion: surgical expertise, the presence of sigmoid stenosis or fistula, and the severity of diverticulitis on pathological examination. Morbidity was no different between laparoscopic sigmoidectomy (30 of 144; 20.8 per cent) and converted procedures (six of 24; 25.0 per cent). Open conversion was associated with a longer operative time and significantly delayed patient recovery and hospital discharge. CONCLUSION: Surgical experience and severe diverticular disease are predictive factors for conversion in laparoscopic elective sigmoidectomy. Even if necessary, conversion does not increase the morbidity rate.     

Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer

The authors examined the impact of the laparoscopic approach on the early outcome of resected colon carcinomas. The role of laparoscopic techniques in the treatment of colon carcinomas is questionable. Previous studies have suggested technical feasibility of surgical resections of these cancers by laparoscopic means and have implied a benefit to laparoscopic technique for patients undergoing colorectal resections. A prospective, randomized study was conducted comparing laparoscopic assisted colectomy (LAC) open colectomy (OC) for colon cancer. We present the preliminary results in relation to the short-term outcome and judge the feasibility of the laparoscopic procedure to as a way of performing accurate oncologic resection and staging. Benefit has been demonstrated with LAC in this setting. Passing flatus, oral intake, and discharge from hospital occurred earlier in LAC- than OC-treated patients The mean operative time was significantly longer in the LAC group than in the OC group. The overall morbidity was significantly lower in the LAC group. No significant differences were observed between both groups in the number of lymph nodes removed or the pathological stage following the Astler-Coller modification of the Dukes classification. The laparoscopic approach improves the short-term outcome of segmental colectomies for colon cancer. However, the further follow-up of these patients will allow us to answer in the near future whether or not the LAC may influence the long-term outcome.Presented at the annual meeting of the Society of American Gastrointestinal Surgeons (SAGES), Orlando, FL, USA, 11–14 March 1995     

Laparoscopic colectomy is cheaper than conventional open resection

OBJECTIVE: International randomized trials have endorsed the routine use of laparoscopic techniques in colorectal surgery. The authors hypothesize that the overall care pathway in minimal access resection was cheaper than conventional open resection. METHOD: This was a case-matched study of consecutive patients undergoing laparoscopic resection between July 2005 and February 2006. Intraoperative (costs, duration, incision length) and postoperative [morbidity, length of stay (LOS), readmission] parameters were examined. Institutional retrospective open controls and national validated figures were used for costings. RESULTS: Thirty-five laparoscopic and 53 open resections were evaluated. Median LOS was 5 days in the laparoscopic group vs 12 in the open group (P = 0.001). There were two conversions (5.7%) and two readmissions. Mean operative cost of laparoscopic resection was 1557.08 euros, therefore 2.4 bed days need to be saved to recoup the increased cost compared with open resection. The actual median save is 7 days (P = 0.031). A mean of 4591.38 euros and 7 bed days per case is saved by performing the resection laparoscopically. Subgroup analysis of laparoscopic resections clearly demonstrates similar trends. CONCLUSION: The institutional saving is over 150,000 euros and 245 bed days during the study period. Despite higher operative spending, laparoscopic colorectal resections are significantly cheaper than conventional open resections.     

Comparison of Laparoscopic vs Open Sigmoid Colectomy for Benign and Malignant Disease at Academic Medical Centers

Few studies have examined outcomes of laparoscopic and open sigmoid colectomy performed at US academic centers. Using ICD-9 diagnosis and procedural codes, data was obtained from the University HealthSystem Consortium (UHC) Clinical Database of 10,603 patients who underwent laparoscopic or open sigmoid colectomy for benign and malignant disease between 2003–2006. A total of 1,092 patients (10.3%) underwent laparoscopic sigmoid colectomy. Laparoscopic sigmoid colectomy was associated with a significantly shorter length of stay (5.4 vs 7.4 days), lower overall complication rate (19.7 vs 26.0%), lower 30-day readmission rate (3.4 vs 4.6), and a lower hospital cost ($13,814 vs $15,626). When a subset analysis of malignant and benign groups was performed, a significantly shorter length of stay in both the malignant laparoscopic group (6.4 ± 6.4 vs 7.8 ± 6.6 days) and in the benign laparoscopic groups (5.1 ± 3.5 vs 7.2 ± 7.6) exists. A lower wound complication rate (2.1 vs 5.5%, malignant and 4.0 vs 6.1, benign) is also evident. Laparoscopic sigmoid colectomy was associated with a shorter length of stay, less complications, and a lower 30-day readmission rate. The shorter length of stay and wound infection rate maintain significance when comparing laparoscopic vs open sigmoid resections for malignant and benign disease. Presented at the 48th annual meeting of the Society for Surgery of the Alimentary Tract at Digestive Disease Weak, Washington, DC, May 21st 2007. The information contained in this article was based on the Clinical Data Base provided by the University HealthSystem Consortium.     

Laparoscopic colonic resection in inflammatory bowel disease: minimal surgery,minimal access and minimal hospital stay

Objective Laparoscopic surgery for inflammatory bowel disease (IBD) is technically demanding but can offer improved short‐term outcomes. The introduction of minimally invasive surgery (MIS) as the default operative approach for IBD, however, may have inherent learning curve‐associated disadvantages. We hypothesise that the establishment of MIS as the standard operative approach does not increase patient morbidity as assessed in the initial period of its introduction into a specialised unit, and that it confers earlier postoperative gastrointestinal recovery and reduced hospitalisation compared with conventional open resection. Method A case–control study was undertaken on laparoscopic resection (LR) vs open colon resection (OR) for IBD. The LR group was collated prospectively and compared with a pathologically matched historical control set. Outcomes measured included: postoperative length of stay, time to normal bowel function and postoperative morbidity. Statistical analysis was performed using spss . Results Twenty‐eight patients were investigated (14 LR, 14 OR). The two groups were matched for type of operation, type of disease and age. There were no conversions in the LR group. Morbidity and readmissions did not differ significantly between the groups. Those undergoing laparoscopic resection had a quicker return to diet (median 2 vs 4 days; P = 0.000002), time to first bowel motion (2 vs 4 days; P = 0.019) and shorter postoperative length of stay (5.5 vs 12.5; P = 0.0067). Conclusion These findings support the routine use of MIS for the elective surgical management of IBD in our department. Patients undergoing laparoscopic colectomies for IBD can expect faster return of gastrointestinal function and shorter hospitalisation.     

The learning curve for laparoscopic colectomy: experience of a surgical fellow in an university colorectal unit

Background  This study aimed to evaluate the learning curve for laparoscopic colectomy of a surgical fellow in an university colorectal unit using a structured training protocol. Methods  This study analyzed the data from 100 consecutive patients who had laparoscopic colectomy performed by a surgical fellow between 11/2004 and 12/2007. The structured training protocol required the fellow to assist more than 40 laparoscopic colectomies before embarking on his first case. Rectosigmoidectomy was prioritized during the initial experience. Operative times were analyzed to represent the learning curve. Other outcome data including conversion and operative outcome were also evaluated. Results   The following procedures were performed: 49 rectosigmoidectomies, 38 right colon resections, and 13 other resections. Median operative time was 150 min, and conversion rate was 1%. Overall postoperative morbidity rate was 28% (major morbidity 3%). Three patients required early reoperation. There was no operative death. Median hospital stay was 8 days. Operative times reached their lowest point at period of cases 45–50, and remained relatively stable afterwards. Comparing the first 50 and second 50 cases, the only difference observed was more frequent presence of a supervisor in the theater in the first 50 cases (74% versus 52%, p = 0.02), while the other parameters including types of procedures, postoperative recovery, hospital stay, and morbidity rate were not different. Conclusions   Our results indicated that laparoscopic colectomy training can be safely performed under a structured protocol. The surgeon can perform laparoscopic colectomies more independently after 50 cases, without jeopardizing the clinical outcome.     

Laparoscopic colorectal surgery – results from 200 patients

OBJECTIVE: Laparoscopic surgery is increasingly being performed for benign and malignant colorectal disease. This study examines the short-term results in a consecutive series of laparoscopic colorectal procedures performed over 2 years. METHOD: A prospective database was established for all elective patients undergoing laparoscopic colorectal surgery by one surgeon. The main outcome measures assessed were operative duration, conversion rate, length of hospital stay, morbidity and mortality and lymph node harvest. RESULTS: Two hundred and thirty-one consecutive patients were referred for elective colorectal surgery, with 18 patients excluded from laparoscopic surgery. Thirteen patients had nonresective laparoscopic colorectal procedures for endometriosis and have been excluded from the series. Of 200 patients who underwent a laparoscopic colorectal procedure, 114 (57%) were female, the median age was 67 years (inter-quartile range (IQR) 57-76), and there were 116 malignancies. The most common operations were anterior resection and sigmoid colectomy (n = 82), right hemicolectomy (n = 62) and left hemicolectomy (n = 12). The median operating time was 120 min (IQR 90-150) and 10 patients (5%) required conversion to open surgery. The median lymph node harvest in malignancies was 21 nodes (IQR 15-30) and no positive resection margins were found. There were two deaths and 29 significant complications (14.5%), with seven patients requiring re-operations because of postoperative complications. The median postoperative hospital stay was 4 days (IQR 3-6) and 13 patients (6.5%) were re-admitted within 30 days of hospital discharge. CONCLUSION: Laparoscopic colorectal surgery is possible for most benign and malignant conditions, with low conversion and complication rates, as well as short hospital stay.     

Early introduction of laparoscopic sigmoid colectomy during residency

BACKGROUND: Laparoscopic sigmoid colectomy for benign diseases is becoming the standard of care. However, few residency programmes incorporate the procedure. This study evaluated the safety and feasibility of the early introduction of laparoscopic sigmoid colectomy during residency. METHODS: From a database of consecutive laparoscopic sigmoid colectomies collected prospectively over 6 years, those for cancer and primary open sigmoid colectomies were excluded. Surgeons were categorized into five levels of experience in colonic surgery. Patient demographics, operative data, complications and conversion rates were assessed. RESULTS: A total of 262 sigmoid colectomies were performed by 13 surgeons. American Society of Anesthesiologists grade and diverticular disease classification were similar across the five experience levels. There were no significant differences in morbidity, mortality or readmission rates between experience levels. However, operative time (230 versus 145 min, P < 0.001) intraoperative blood loss (200 versus 100 ml, P < 0.001) and conversion rate (13.6 versus 2.1 per cent, P = 0.002) all decreased with increasing surgical experience (trainee versus trainer). CONCLUSION: It is safe and feasible to introduce laparoscopic sigmoid colectomy to a structured residency.     

Initial experience with 150 cases of laparoscopic assisted colectomy.

BACKGROUND: Despite multiple reports of large series in the literature over the past decade, laparoscopic assisted colectomy (LAC) has not received widespread acceptance by the surgical community. Critics of LAC note concerns regarding unproved benefits and increased complexity of the procedures. The authors report their initial experience with 150 procedures. METHODS: A retrospective review of 150 consecutive LACs was performed by the authors. RESULTS: Mean operative time for completed LAC, converted procedures, right, and sigmoid resections were 164 minutes, 203 minutes, 121 minutes, and 177 minutes, respectively. Twenty-two patients had additional concurrent laparoscopic procedures. Thirty-nine patients had undergone previous abdominal surgery. The conversion rate was 12%. Mean length of stay for all patients was 4.5 days. There were 8 major and 16 minor complications. There were no port site metastases. Major complications and conversion rate decreased from the first 50 cases to the last 50 cases. CONCLUSIONS: LAC can be safely performed with superior quality of life outcomes in comparison with open colectomy. The authors believe that LAC will eventually become the gold standard for colon resection. The learning curve is discussed as an ongoing process, rather than a set number of procedures.     

Laparoscopic restoration of intestinal continuity after Hartmann's procedure

BACKGROUND: Colostomy closure after a Hartmann's procedure typically requires a laparotomy. It also carries the risk of significant morbidity including anastomotic leak, wound infection, and incisional hernia. The aim of this study was to review our experience with laparoscopic restoration of intestinal continuity after Hartmann's procedure. METHODS: After institutional review board approval, we retrospectively reviewed the medical records of patients undergoing laparoscopic colostomy reversal between July 1997 and July 2004. RESULTS: Twenty-two patients were identified; all patients had left colon colostomies. A laparoscopic technique was used in 21 patients, and 1 patient underwent hand-assisted colostomy reversal concurrently with right radical nephrectomy. The laparoscopic approach was successful in 20 cases, and there were 2 conversions to open (9%) secondary to dense adhesions around the rectal stump. The mean time to closure of the colostomy was 168 days (range 69-385 days). The mean operative time was 158 minutes (range 84-356 minutes). The estimated blood loss averaged 114 mL (range 30-250 mL). The average length of hospitalization was 4.2 days (range 2-6 days). Bowel function returned on an average of 3.5 days (range 2-5 days). Three patients (14%) developed postoperative wound infections. There were no anastomotic leaks and no mortality. At a mean follow-up of 14.7 months, the only long-term complication has been a small hernia at a colostomy site. CONCLUSIONS: Laparoscopic colostomy reversal after Hartmann's procedure can be performed with low morbidity and a short hospital stay. The need for conversion to open surgery is uncommon despite patients' previous surgeries. A laparoscopic approach to colostomy takedown is safe and feasible and may result in a reduction in complications and length of stay as has been seen with other minimally invasive procedures.     

Laparoscopic colon surgery for benign disease: a comparison to open surgery.

BACKGROUNDS AND OBJECTIVES: There remains a debate in the literature about the advisability of laparoscopic surgery for malignant disease of the colon. Current prospective studies will hopefully answer this question. However, for benign diseases of the colon, we believe laparoscopic surgery offers many advantages including decreased postoperative pain, early discharge from the hospital, and early return to normal activities. We retrospectively reviewed our experience with laparoscopic colectomies for benign disease to see whether these procedures could be done safely and if the proposed advantages could be realized. METHODS: Thirty-eight laparoscopic colon resections performed for benign disease were compared to 39 open colon resections with respect to operating times, length of hospital stay, estimated blood loss, days until first postoperative bowel movement, and complications. RESULTS: The laparoscopic colon resection group had decreased length of stay, less blood loss, earlier return of bowel function, and an equivalent number of complications. Laparoscopic cases did take an average of 24 minutes longer. CONCLUSION: The use of laparoscopic colon surgery for benign disease not only affords the patient the advantage of the laparoscopic approach, but also allows the surgeon to gain experience while awaiting the results of ongoing trials for laparoscopic colon surgery in malignant disease.     

Are transverse colon cancers suitable for laparoscopic resection?

Background The large randomized trials reporting on laparoscopic versus open colon surgery for cancer have all excluded patients with transverse colon cancer lesions. This study was undertaken to review our experience with surgery for curable transverse colon cancer. Methods A database of 938 laparoscopic colon resections performed between April 1991 and September 2004 was reviewed. Of 514 procedures for cancer, stage IV disease, mid to low rectal cancers, and total colectomies were excluded. On an intent-to-treat basis, outcomes of surgery for transverse colon lesions (TC) were compared with outcomes of segmental colon resections for other lesions (OC). Results A total of 22 TC were resected compared with 285 OC. Patients with TC were similar to patients with OC in age, gender, weight, and body mass index (BMI). Cancer stage was equivalent between patients with TC (9 Stage I, 7 Stage II, 6 Stage III) and OC (66 Stage I, 126 Stage II, 93 Stage III, p = 0.170) as was tumor size. Patients with TC underwent 9 transverse colectomies, 12 extended right hemicolectomies, and 1 extended left hemicolectomy. Patients with OC underwent 126 right hemicolectomies, 24 left hemicolectomies, and 135 sigmoid colectomies or anterior resections. There were no differences in conversion rate (18.2% vs. 13.3%, p = 0.752) or in intraoperative (9% vs. 8%, p = 0.814) or postoperative (41% vs. 30%, p = 0.418) complications. Operating time was longer with TC (209 ± 63 min vs. 176 ± 60 min, p = 0.042) and lymph node harvest was higher (15.3 ± 11.6 vs. 10.8 ± 7.6, p = 0.011). At a median followup of 17.2 months and 17.1 months, respectively, there were two (9%) recurrences after resection of TC and 17 (6%) recurrences after resection of OC. Conclusions Laparoscopic resection of transverse colon cancers is technically feasible and not associated with a significantly higher rate of complications or conversions or with impaired oncologic outcomes compared with patients having segmental laparoscopic resections for other colon cancers. Operating time is longer. Presented at the 13th International Congress of the European Association for Endoscopic Surgery, Venice, Italy, June 2–4, 2005