Laparoscopic colorectal surgery

Background: This study was performed to prospectively assess the results of our first 140 consecutive patients who underwent laparoscopic or laparoscopic-assisted colorectal operations. Methods: The parameters studied included the type and length of procedure, intra- and postoperative complications, conversion to open surgery, and length of ileus and hospitalization. Results: 140 laparoscopic and laparoscopic-assisted procedures were performed between May 1991 and January 1995. The mean patient age was 48 (range 12–88) years; there were 78 males and 62 females. Indications for surgery included inflammatory bowel disease in 47, colorectal carcinoma in 19, diverticular disease in 17, polyps in 16, familial polyposis in 7, colonic inertia in 7, fecal incontinence in 11, sigmoidocele in 3, irradiation proctitis in 3, rectal prolapse in 2, intestinal lymphoma in 2, and miscellaneous conditions in 6. The procedures included 38 total abdominal colectomies (TAC) (ileoanal reservoir 28, ileorectal anastomosis 8 and end ileostomy 2); 70 segmental resections of the colon, small bowel, and rectum; 18 diverting stoma creations; 10 reversal of Hartmann's procedures; and 4 other procedures. In 15 cases, the laparoscopic procedure was converted to a laparotomy (11%); 31 patients (22%) sustained 37 complications, which included: enterotomies (7), hemorrhage (10), intraabdominal abscess (4), prolonged ileus (6), wound infection (4), intestinal obstruction (2), anastomotic leak (1), aspiration (1), cardiac arrhythmia (1), and upper intestinal bleeding (1); there was no mortality. The overall complication rate in TAC cases was significantly higher (42%) when compared to that of all other procedures (segmental resection 17%, others 9%), P<0.05. The mean length of operating time was 4 (range 2.5–6.5) h for TAC, 2.6 (range 1.5–5.5) h for segmental colonic resections, and 1.7 (range 0.7–4) for all other procedures. The length of ileus was 3.5 (range 2–7) days after TAC, 3 (range 2–7) after the segmental resections and 2 (range 1–4) after the other procedures. The mean length of hospital stay was 6.8 (2–40) days (8.4, 6.5, and 6.3 days for the TAC, segmental resections, and other procedures, respectively). Conclusion: The feasibility of laparoscopic colorectal surgery has been well established. TAC is associated with a higher complication rate compared to other laparoscopic colorectal procedures.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Single‐port laparoscopy in colorectal surgery

Purpose Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single‐port laparoscopic colorectal surgery using a Uni‐X? Single‐Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi‐channel cannula and specially designed curved laparoscopic instrumentation. Method The abdomen was approached through a 3.5 cm incision via the umbilicus and a single‐port access device was utilized to perform a right hemicolectomy on a patient with an unresectable caecal polyp and a body mass index of 35. Ligation of the ileocolic artery was done with a LigaSure Device? (Covidien Ltd, Norwalk, Connecticut, USA), and was followed by colonic mobilization, extraction and extracorporeal ileocolic anastomosis. Results The total operative time was 115 min with minimal blood loss. Hospital stay was 4 days with no undue sequelae. Conclusion Single‐port laparoscopic surgery may allow common colorectal laparoscopic operations to be performed entirely through the patient’s umbilicus and enable an essentially scarless procedure. Additional experience and continued investigation are warranted.     

Laparoscopic surgery for ulcerative colitis – a meta-analysis

OBJECTIVE: To assess the safety and feasibility of laparoscopic surgery for patients with ulcerative colitis. METHODS: A search of published studies in English between January 1992 and September 2005 was obtained, using the MEDLINE and PubMed databases and the Cochrane Central Register of Controlled Trials. Two independent assessors reviewed the studies using a standardized protocol. Where raw data, means and standard deviations were available, meta-analysis was performed using the Forest plot review. Studies where medians and ranges were presented were separately analysed. RESULTS: The duration of surgery for laparoscopic and open procedures were similar (weighted mean difference 62.92 min, P = 0.19). Patients were able to tolerate oral intake significantly earlier, with a weighted mean difference of 1.39 days (P = 0.002), but recovery of bowel function was similar (weighted mean difference 0.73 days, P = 0.36). The length of hospital stay was shorter for patients who had undergone laparoscopic surgery, with a weighted mean difference of 2.64 days (P = 0.003). The complication rate was higher in open colectomy, compared to laparoscopic colectomy (67.6%vs 39.7%, P = 0.005). For restorative proctocolectomy, complication rates were comparable between the laparoscopic and open groups (P = 0.25). CONCLUSIONS: The time taken to perform laparoscopic surgery is similar to open surgery. Patients are able to tolerate oral intake earlier, and have a shorter hospitalization. Laparoscopic colectomy was safer compared to the open procedure, but both were equally safe for patients who had restorative proctocolectomy. Thus, laparoscopic surgery for ulcerative colitis is both safe and feasible.     

Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer

OBJECTIVE: Several large randomized controlled trials on laparoscopic resection for colon and rectosigmoid cancer have recently been published. There is a need to provide an up-to-date systematic review in this subject. METHODS: A literature search of all published randomized trials in English between January 1991 and September 2005 was obtained, from Ovid MEDLINE, EMBASE, CINAHL, and All EBM Reviews (Cochrane Central Register of Controlled Trial, Cochrane Database of Systemic Review, and Database of Abstracts of Reviews of Effects), including e-links to the related articles. Two independent assessors reviewed the trials using a standardized protocol. Where means and standard deviations were available, meta-analysis was performed using the Forest plot review. Studies where medians and ranges were presented were separately analysed. RESULTS: A total of 17 randomized controlled trials with 4013 procedures were reviewed. The conversion rate varied widely between studies and was lowest in single-Centre trials. There were no significant differences in overall and surgical complication rate, anastomotic leak rate, re-operation rate and oncological clearance. However, laparoscopic resection has a significantly lower peri-operative mortality (odds ratio 0.33; P = 0.005), lower wound complications (odds ratio 0.65; P = 0.01), less blood loss (weighted mean difference 0.11 l; P < 0.00001) and reduced postoperative pain scores by 12.6% with reduction of requirements for narcotic analgesia by 30.7%. After laparoscopic surgery, patients passed flatus 38.8% earlier (weighted mean difference 27.6 h; P < 0.00001) and had bowel movement 21.0% earlier (weighted mean difference 23.9 h; P < 0.00001) and resumed oral diet 28.3% sooner than patients in the open group (weighted mean difference 27.3 h; P < 0.00001). Patients were discharged 19.1% earlier after laparoscopic surgery than open surgery (weighted mean difference 1.7 days; P < 0.00001). Laparoscopic resection took 28.7% longer (weighted mean difference 40.1 min; P < 0.00001) to perform. CONCLUSIONS: Laparoscopic resection for colon and rectosigmoid cancer is feasible, safe and has many short-term benefits.     

Single-incision laparoscopic surgery for colorectal cancer

AIM: To determine the effect of single-incision laparoscopic colectomy(SILC) for colorectal cancer on short-term clinical and oncological outcomes by comparison with multiport conventional laparoscopic colectomy(CLC).METHODS: A systematic review was performed using MEDLINE for the time period of 2008 to December 2014 to retrieve all relevant literature. The search terms were "laparoscopy", "single incision", "single port", "single site", "SILS", "LESS" and "colorectal cancer". Publications were included if they were randomized controlled trials, case-matched controlled studies, or comparative studies, in which patients underwent single-incision(SILS or LESS) laparoscopic colorectal surgery. Studies were excluded if they were non-comparative, or not including surgery involving the colon or rectum. A total of 15 studies with 589 patients who underwent SILC for colorectal cancer were selected.RESULTS: No significant differences between the groups were noted in terms of mortality or morbidity. The benefit of the SILC approach included reduction in conversion rate to laparotomy, but there were no significant differences in other short-term clinical outcomes between the groups. Satisfactory oncological surgical quality was also demonstrated for SILC for the treatment of colorectal cancer with a similar average lymph node harvest and proximal and distal resection margin length as multiport CLC.CONCLUSION: SILC can be performed safely with similar short-term clinical and oncological outcomes as multiport CLC.     

Laparoscopic colorectal surgery

Laparoscopic surgery has radically changed the approach for common colorectal operations. These procedures are now well established. However, the path to such acceptance into mainstream practice was not without controversy.     

Laparoscopic and open colorectal surgery: a prospective cost analysis

Aim Cost has been perceived to be a factor limiting the development of laparoscopic colorectal surgery. This study aimed to compare the costs of laparoscopic and open colorectal surgery. Method Patients undergoing laparoscopic or open elective colorectal surgery were recruited into a prospective study to evaluate the healthcare costs of each operative procedure in a district general hospital in England. All healthcare resources used (operation, hospital and community) were recorded and converted to costs in British pounds, 2006–2007. Costs of laparoscopic and open surgery were compared. Results In all, 201 consecutive patients consented and were recruited (131 laparoscopic, 70 open). Operative costs were greater in the laparoscopic group (£2049 vs£1263, P < 0.001) due to the costs of disposable instruments, but the hospital costs were less (£1807 vs£3468, P < 0.001) due to longer lengths of stay in the open group. Community costs were similar in the two groups and had little impact on the overall costs, which were not significantly different (£3875 laparoscopic vs£4383 open, P = 0.308). In the subgroup of patients with a stoma, overall costs in the laparoscopic group are higher (not significant). Conclusion The costs of laparoscopic and open colorectal surgery are broadly equivalent. If there is an associated improvement in patient benefit, then laparoscopic colorectal surgery may be considered to be cost effective compared with open surgery.     

Laparoscopic assisted colectomy: experience from a rural centre

BACKGROUND: This study presents an audit of the first 50 elective laparoscopic assisted colorectal resections carried out at the Launceston General Hospital, Tasmania, particularly in comparison with the 33 elective open resections carried out in the same 18-month period. METHODS: This was a retrospective review and analysis of prospectively recorded data on an intention-to-treat basis using non-parametric methods. RESULTS: With respect to case selection, patients in the laparoscopic group were younger (median = 63 years (range 19-98 years) vs 69 years (33-93 years), P = 0.0392) and more patients had benign pathology (22/50, 44% vs 4/33, 12%, P = 0.002). There was no significant difference in sex or American Society of Anesthesiologists status (P = 0.499 and 0.517, respectively). There were more left-sided than right-sided resections (28/50, 56% vs 14/33, 42%, P = 0.118), along with more total colectomies in the laparoscopic group (7 vs 2). Operation times in the laparoscopic group were longer (197.5 min (87-452 min) vs 144 min (70-260 min), P = 0.0002) and no significant reduction was recorded over the study period (P = 0.50). There were five conversions from laparoscopic to open procedure (a 10% incidence). Compared with the open colectomy group, patients who underwent laparoscopic resections required less parenteral analgesia (2 days (1-5 days) vs 3 days (0-6 days), P < 0.0001). They had earlier first flatus (3 days (1-7 days) vs 4 days (1-6 days), P = 0.0069) and bowel movement (3 days (1-7 days) vs 4 days (2-9 days), P = 0.0021), tolerated solid diet earlier (3 days (1-9 days) vs 4 days (1-30 days), P = 0.0001) and had shorter hospital stay (5 days (3-12 days) vs 7 days (4-37 days), P = 0.0009). Less major perioperative complications were recorded for the laparoscopic group (2/50 vs 4/33, P = 0.162), but very little difference was found with respect to minor complications (17/50 vs 10/33, P = 0.725). For carcinoma resections, there were no positive resection margins. In the laparoscopic group, tumour size was smaller (3.25 cm (1-7 cm) vs 5 cm (2-15 cm), P = 0.0014) and less lymph nodes were harvested (6 (2-16) vs 8 (3-23), P = 0.101). CONCLUSION: Laparoscopic colectomy allowed early postoperative recovery and shorter hospital stay. This was at the expense of a longer operation. It can be taken up by relatively laparoscopically naive surgeons without extra major morbidity/mortality associated with the learning curve. It is technically feasible and safe in small centres.     

Laparoscopic colorectal cancer surgery in obese patients

Aim The aim of this study was to assess the oncological and postoperative outcomes of laparoscopic colorectal cancer surgery in obese patients. Method All obese (BMI > 30) patients who underwent laparoscopic colorectal cancer surgery from January 2005 to January 2008 were compared with nonobese patients undergoing similar surgery. We recorded patient demographics, intra‐operative details and postoperative morbidity and mortality. Results Sixty‐two obese and 172 nonobese patients underwent laparoscopic colorectal cancer resection. Both groups were well matched for demographic parameters. Overall mean operating times were not significantly different. Conversion to open surgery was more likely in obese patients. In particular, for rectal cancers, the conversion rate was 44% in the obese group compared with 17% in the nonobese group (P < 0.05). Postoperative morbidity was also greater in obese patients (P < 0.05). The duration of hospital stay was similar for laparoscopically completed cases (6 days obese vs 7 days nonobese), but in the obese‐converted group it was 14 days (P < 0.05). The resected specimen with respect to length, resection margin and lymph node retrieval was equivalent between obese and nonobese patients. Disease‐free survival and overall survival at a median follow up of 2 years were also similar. Conclusions Laparoscopic colorectal cancer surgery in obese patients is technically feasible and oncologically safe. Despite greater postoperative morbidity, obese patients benefit from shorter length of stay. However, a higher conversion rate, particularly for rectal cancers, should be anticipated in obese male patients.     

老年人结直肠肿瘤的微创手术治疗

目的探讨腹腔镜结直肠手术治疗70岁以上老年人结直肠肿瘤的安全性与有效性. 方法回顾性总结2003年1～10月腹腔镜辅助与开腹结直肠手术治疗70岁以上老年人结直肠肿瘤的经验.同期比较腹腔镜手术(LAP组)30例与传统开腹手术(OPEN组)71例的手术安全性、并发症、术后恢复情况.结果 LAP组无手术相关死亡病例,OPEN组有2例(2.8%)分别因为术后肺部感染与吻合口瘘而死亡.两组病人随年龄增加ASA(american society of anesthesiology score)分级增高.OPEN组有29例(40.8%)发生术后并发症显著多于LAP组6例(20.0%)(P<0.05).LAP组病人术中出血、排气时间与进食半流质时间分别为(91.7±49.9)mL、(2.3±1.2)d与(4.9±1.8)d,与OPEN组(156.3±118.8)mL、(3.4±2.9)d与(5.8±1.2)d相比差异有显著性意义(P<0.05).两组手术时间与住院天数差异无统计学意义(P>0.05).结论腹腔镜结直肠手术治疗70岁以上老年人结直肠肿瘤安全有效,值得进一步推广应用.     

Hand-assisted laparoscopic colorectal surgery using GelPort

Background: An easily usable hand access device will optimize success in hand-assisted laparoscopic surgery (HALS). The authors describe their initial series of HALS colorectal resections using GelPort to evaluate their current technique and results with this new device. Methods: A retrospective study investigated 33 HALS colorectal procedures including total colectomy (n = 16) and low anterior resection (n = 10). All operative data, including intraoperative GelPort performance, were prospectively recorded and retrospectively analyzed. Results: In this study, 3 (9.1%) of 33 HALS procedures were converted to open surgery, and 4 (13.3%) of 30 HALS procedures required minimal enlargement of incisions to facilitate extracorporeal procedures. The operative time was 263 ± 85 min, and the blood loss was 282 ± 148 ml. There were no device malfunctions. Three major complications (9.1%) and 7 minor wound infections (21%) were noted postoperatively. The mean hospital stay was 7.9 ± 3.8 days. Conclusion: When performed with GelPort, HALS is safely and reliably applicable for various colorectal procedures.     

Laparoscopic emergency and elective surgery for ulcerative colitis

Objective To analyse surgical outcomes of fulminate and medically resistant ulcerative colitis (UC) carried out laparoscopically. Method A prospective database identified 69 consecutive patients who underwent surgery for UC under the senior author over a 5‐year period to April 2006. Results Thirty‐two patients (18 male patients), median BMI 26, underwent laparoscopic subtotal colectomy (LSTC): 22 acute emergencies, 10 refractory to medical therapy and unfit for restorative proctocolectomy. All were receiving iv steroids; azathioprine (7), cyclosporin (5). The median operation time was 135 min (65–280). There was one conversion. Twenty‐nine patients have subsequently undergone completion proctectomy and W‐pouch formation [24 patients were performed laparoscopically – laparoscopic completion proctectomy (LCP)]; widespread adhesions precluded in five patients. Twenty‐six patients underwent restorative laparoscopic proctocolectomy (LRP) – one conversion. Twenty patients underwent W‐pouch reconstruction via a Pfannenstiel incision. Six J‐pouches were constructed and returned via the ileostomy site. Three underwent a laparoscopic pan‐proctocolectomy (LPPC); one conversion. Eight patients underwent open STC. The median time to normal diet was 48 h (1–7 days) for LSTC/LCP and 36 h (1–5 days) for LRP. There were two major complications following LRP, two following LSTC, one following LCP, one following LPPC and five following open surgery. Median hospital stay was 8 days (6–72) for LSTC, 7 days (6–9) for LCP and 5 days (3–45) for LRP. There were six 30‐day readmissions following laparoscopic surgery (DVT, reactive depression, ileostomy hold up (2), abdominal pain and high output ileostomy). Conclusion Laparoscopic subtotal and restorative proctocolectomies in fulminate and medically resistant UC are feasible, safe and largely predictable operations that allow for early hospital discharge. Laparoscopic colectomy facilitates subsequent proctectomy and pouch construction.     

Hand‐assisted laparoscopic versus total laparoscopic right colectomy: a randomized controlled trial

Aim Laparoscopic colectomy for colorectal cancer is associated with definite short‐term benefits, and is increasingly practised worldwide. The limitations of a pure laparoscopic approach include a relative lack of tactile feedback and long procedural time. Hand‐assisted laparoscopic surgery was introduced in an attempt to facilitate operation by improving the tactile sensation. To date, there is no consensus as to which approach is better. Herein we conducted a randomized controlled trial comparing hand‐assisted laparoscopic colectomy (HALC) with total laparoscopic colectomy (TLC) in the management of right‐sided colonic cancer. Methods Adult patients with carcinoma of the caecum and ascending colon were recruited and randomized to undergo either HALC or TLC. Measured outcomes included operative time, blood loss, conversion rate, postoperative morbidities, postoperative pain, length of hospital stay, disease recurrence and patient survival. Results Sixty patients (HALC = 30, TLC = 30) were recruited. The two groups were comparable with regard to age, gender distribution, body mass index and final histopathological staging. No difference was observed between the groups in terms of operating time, conversion rate, operative blood loss, pain score and length of hospital stay. With a median follow‐up of 27 to 33 months, no difference was observed in terms of disease recurrence, and the 5‐year survival rates remained similar (83%vs 80%, P = 0.923). Conclusion HALC is safe and feasible, but it does not show any significant benefits over TLC in terms of operating time and conversion rate. Routine use of the hand‐assisted laparoscopic technique in right hemicolectomy is therefore not recommended.     

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.     

Laparoscopic colorectal anastomosis using the novel Chex® circular stapler: a case–control study

Aim The purpose of this study was to assess the safety and effectiveness of a new cost‐effective circular stapler for colorectal anastomosis, the Chex^® CS. Method From 2007 to 2009, a case–control study was conducted of 54 patients who underwent left colectomy with stapled anastomosis using the Chex stapler. The patients were matched to 64 patients in whom the anastomoses were performed using the CDH^® stapler or the EEA^® stapler. The following criteria were matched: sex, age, body mass index, American Society of Anesthesiology grade, diagnosis, formation of a temporary stoma and surgical approach. Primary end‐points were postoperative mortality and morbidity. The surgeon was asked to fill out a questionnaire to assess the ergonomics of the device using an analogue visual scale. A cost analysis was performed to compare the cost of the different devices. Results There were no postoperative deaths. Morbidity, including anastomotic leakage (9%vs 8%, P = 1.000), was similar in the two groups. The surgeon’s overall appreciation was scored at 8.1/10 (3–9.5), including the best score for stapler removal (9.5). No major device failure was observed during the study. Mean surgical costs were significantly lower in the Chex group: € 903 ± 73 (885–1192) vs the control group € 971 ± 61 (956–1263) (P < 0.0001). Conclusion This study suggests that colorectal anastomosis using the Chex circular stapler is safe and does not increase overall morbidity. In particular, this device did not have a higher rate of anastomotic leakage in our patients than more expensive models currently used in our hospital.     

Single-Port Laparoscopic Right Hemicolectomy: Intermediate Results

Background:

Single-port laparoscopic colectomy was first described in 2008 as a new technique for colorectal surgery.¹ No available reports have stated the intermediate- or long-term outcome. We report our intermediate results for the first 20 single-port laparoscopic right hemicolectomies performed by a single laparoscopically trained surgeon at our institution.

Design:

Between February 2009 and September 2010, 20 consecutive patients with an indication for right hemicolectomy who were candidates for laparoscopic surgery underwent a single-port laparoscopic approach. The only exclusion was a previous midline laparotomy. The patients were followed for outcomes after a median of 27 months (range: 15 to 35).

Results:

The mean age was 65 years (range: 59 to 88). The mean body mass index was 28 (range: 20 to 35). Seventy-five percent of patients had significant comorbidities, with an American Society of Anesthesiologists class of III or IV. The median estimated blood loss was 25 mL (range: 25 to 250). The mean number of lymph nodes was 13 (range: 0 to 29). There was one conversion to hand-assisted laparoscopic colectomy and one to open colectomy secondary to bleeding. The mean hospital stay was 5 days (range: 3 to 7). Thirty-day postoperative complications included 1 wound infection, 1 patient with alcohol withdrawal, and 1 incidence of colitis caused by Clostridium difficile infection.At a median follow-up of 27 months, there were no local recurrences or distant metastases. One death occurred at 17 months from myocardial infarction. Two patients developed incisional hernias, with one requiring a laparoscopic hernia repair. One patient required a completion proctocolectomy for a pathological diagnosis of hyperplastic polyposis syndrome.

Conclusions:

Single-port laparoscopic right hemicolectomy has been safely performed in patients who are candidates for conventional laparoscopic hemicolectomy. This small series indicates that intermediate-term results are similar to conventional laparoscopic surgery in efficacy, safety, and oncological outcomes. Larger datasets are necessary to determine cost-effectiveness, differences in postoperative outcomes, and patient satisfaction.