Complications Associated With Two Laparoscopic Procedures Used in the Management of Rectal Endometriosis

Background:

To evaluate intra- and postoperative complications associated with laparoscopic management of rectal endometriosis by either colorectal segmental resection or nodule excision.

Methods:

During 39 consecutive months, 46 women underwent laparoscopic management of rectal endometriosis and were included in a retrospective comparative study. The distinguishing feature of the study is that the choice of the surgical procedure is not related to the characteristics of the nodule.

Results:

Colorectal segmental resection with colorectal anastomosis was carried out in 15 patients (37%), while macroscopically complete rectal nodule excision was performed in 31 women (63%). No intraoperative complications were recorded. In the colorectal resection group, 3 women (18%) had a bladder atony (spontaneously regressive in 2 women), 4 women (24%) experienced chronic constipation, one had an anastomosis leakage (6%), while 2 women (13%) had acute compartment syndrome with peripheral sensory disturbance. In the nodule excision group, 1 woman (4%) developed transitory right obturator nerve motor palsy. Based on both postoperative pain and improvement in quality of life, all 29 women in the excision group (100%) and 14 women in the colorectal resection group (82%) would recommend the surgical procedure to a friend suffering from the same disease.

Conclusion:

Our study suggests that carrying out colorectal segmental resection in rectal endometriosis is associated with unfavourable postoperative outcomes, such as bladder and rectal dysfunction. These outcomes are less likely to occur when rectal nodules are managed by excision. Information about complications related to both surgical procedures should be provided to patients managed for rectal endometriosis and should be taken into account when a decision is being made about the most appropriate treatment of rectal endometriosis in each case.     

Deep Infiltrating Colorectal Endometriosis Treated With Robotic-Assisted Rectosigmoidectomy

Background and Objective:

Deep infiltrating pelvic endometriosis with bowel involvement is one of the most aggressive forms of endometriosis. Nowadays, robotic technology and telemanipulation systems represent the latest developments in minimally invasive surgery. The aim of this study is to present our preliminary results and evaluate the feasibility of robotic-assisted laparoscopic colorectal resection for severe endometriosis.

Methods:

Between September 2009 and December 2011, 10 women with colorectal endometriosis underwent surgery with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). We evaluated the following parameters: short-term complications, clinical outcomes and long-term follow-up, pain relief recurrence rate, and fertility outcomes.

Results:

Extensive ureterolysis was required in 8 women (80%). Ovarian cystectomy with removal of the cystic wall was performed in 7 women (70%). Torus resection was performed in all women, with unilateral and bilateral uterosacral ligament resection in 1 woman (10%) and 8 women (80%), respectively. In addition to segmental colorectal resection in all cases, partial vaginal resection was necessary in 2 women (20%). An appendectomy was performed in 2 patients (20%). The mean operative time with the robot was 157 minutes (range, 90–190 minutes). The mean hospital stay was 3 days. Six patients had infertility before surgery, with a mean infertility time of 2 years. After a 12-month follow-up period, 4 women (67%) conceived naturally and 2 (33%) underwent in vitro fertilization.

Conclusion:

We show that robotic-assisted laparoscopic surgery for the treatment of deep infiltrating bowel endometriosis is feasible, effective, and safe.     

Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis.

OBJECTIVE: The purpose of this study was to examine our experience with laparoscopic and laparoscopically assisted management of bowel endometriosis and to recommend treatment approaches, considering patient goals for both pain mitigation or fertility, or both. METHODS: The medical records of 187 women treated laparoscopically for intestinal endometriosis were reviewed retrospectively for presenting symptoms, methods of surgical treatment, complications, and efficacy of treating pain and infertility. The extent of resection was determined by the severity of the endometriotic lesion, tempered by the patient's fertility goals. RESULTS: The most common patient complaint preceding surgery was pelvic pain. In addition, 58 (31%) patients experienced impaired fertility. Of the patients available for long-term follow-up, 152 (85%) reported complete or significant long-term pain relief. Complete pain relief in the immediate postoperative period was significantly more likely with partial bowel resection compared with shaving only, 92% vs 80%, respectively, P<0.04. The least invasive procedure, shaving, was associated with a significantly lower complication rate, 6%, compared with 23% for disc excision (P<0.007) and 38% for segmental resection (P<0.001), and higher pregnancy rates. The incidence of pregnancy in patients with a history of infertility was 34% during the follow-up period.     

Postoperative pain and fatigue after laparoscopic or conventional colorectal resections

Background: Conventional colorectal resections are associated with severe postoperative pain and prolonged fatigue. The laparoscopic approach to colorectal tumors may result in less pain as well as less fatigue, and may improve postoperative recovery after colorectal resections. Methods: Sixty patients were included into a prospective randomized trial to determine the influence of laparoscopic (n= 30) or conventional (n= 30) resection of colorectal tumors on postoperative pain and fatigue. Major endpoints of the study were dose of morphine sulfate during patient-controlled analgesia (PCA), visual analog scale for pain while coughing (VASC), and visual analogue scale for fatigue (VASF). Efficacy of pain medication was assessed by visual analogue score at rest (VASR). Results: Preoperative age, sex, stage, and localization of tumors were comparable in both groups. The PCA dose of morphine given immediately after surgery until postoperative day 4 was higher in the conventional group (median, 1.37 mg/kg; 5–95 percentile 0.71–2.46 mg/kg) than the laparoscopic group (0.78 mg/kg; 0.24–2.38 mg/kg, p < 0.01). Postoperative VASR was comparable between both groups, but VASC was higher from the first to the seventh postoperative day (p < 0.01). Postoperative fatigue was higher after conventional than after laparoscopic surgery from the second to the seventh day (p < 0.05). Conclusions: This study confirms that analgetic requirements are lower and pain is less intense after laparoscopic than after conventional colorectal resection. Patients also experience less fatigue after minimal invasive surgery. Because of these differences, the duration of recovery is shortened, and the postoperative quality of life is improved after laparoscopic colorectal resections. Received: 4 July 1997/Accepted: 16 November 1997     

Laparoscopic versus conventional colorectal resection: a prospective randomised study of postoperative ileus and early postoperative feeding

Background: A shorter duration of postoperative ileus and earlier oral alimentation of patients may be a clinically relevant benefit of laparoscopic compared with conventional colorectal resection. Patients/Methods: A total of 60 patients were randomised to either laparoscopic (n=30) or conventional (n=30) resection of colorectal tumours. Major endpoints were the postoperative time to the first bowel movement and the time until oral feeding without parenteral alimentation was tolerated. Minor endpoints were the postoperative interval to the first peristalsis and first passage of flatus, the distribution of radio-opaque markers in abdominal radiographs on day 3 and day 5 and the incidence of postoperative vomiting. Results: Age, gender, ASA-classification and type of resection were comparable in thetwo groups. Peristalsis was first noticed 26±9 h after laparoscopic and 38±17 h after conventional colorectal resection (P<0.01). First flatus occurred 50±19 h after laparoscopic and 79±21 h after conventional surgery (P<0.01). The incidence of postoperative vomiting was similar in both groups. Three days after surgery radio-opaque markers were found more often in the right colon (P<0.01) and less often in the small intestine (P<0.05) in laparoscopic compared with conventional patients. Five days after laparoscopic surgery, more markers had reached the left colon (P<0.05). The first bowel movement occurred 70±32 h after laparoscopic and 91±22 h after conventional resection (P<0.01). Oral feeding without additional parenteral alimentation was tolerated 3.3±0.7 days after laparoscopic and 5.0±1.5 days after conventional surgery (P<0.01). Conclusion: The shorter duration of postoperative ileus allows earlier restoration of oral feeding after laparoscopic compared with conventional colorectal resection and therefore increases quality of life immediately after resection of colorectal tumours. Received: 17 December 1997     

Bowel endometriosis: Recent insights and unsolved problems

Bowel endometriosis affects between 3.8% and 37% of women with endometriosis.The evaluation of symptoms and clinical examination are inadequate for an accurate diagnosis of intestinal endometriosis.Transvaginal ultrasonography is the first line investigation in patients with suspected bowel endometriosis and allows accurate determination of the presence of the disease.Radiological techniques (such as magnetic resonance imaging and multidetector computerized tomography enteroclysis) are useful for estimating the extent of bowel endometriosis.Hormonal therapies (progestins,gonadotropin releasing hormone analogues and aromatase inhibitors) significantly improve pain and intestinal symptoms in patients with bowel stenosis less than 60% and who do not wish to conceive.However,hormonal therapies may not prevent the progression of bowel endometriosis and,therefore,patients receiving long-term treatment should be periodically monitored.Surgical excision of bowel endometriosis should be offered to symptomatic patients with bowel stenosis greater than 60%.Intestinal endometriotic nodules may be excised by nodulectomy or segmental resection.Both surgical procedures improve pain,intestinal symptoms and fertility.Nodulectomy may be associated with a lower rate of complications.     

Laparoscopic management of colorectal endometriosis

Background: In the past, intestinal endometriosis diagnosed at laparoscopy has generally required conversion to conventional surgery. The purpose of this study was to describe the laparoscopic management of colorectal endometriosis at a tertiary referral center. Methods: From November 1994 to March 1998, 509 consecutive patients with endometriosis requiring laparoscopic intervention were prospectively evaluated. Those with colorectal involvement were analyzed for stage of disease, procedure, operative time, conversion rate, length of hospitalization, and complications. Results: In 30 of the 509 patients (5.9%), colorectal involvement was identified. Twenty-eight of these 30 had stage IV disease. Intestinal involvement was suspected preoperatively in 13 of 30. Twelve required superficial excision of colon or rectal endometriomas. Protectomy/proctosigmoidectomy was done in seven cases, and rectal disc excision was performed in five patients. Four cases required conversion due to the overall severity of the pelvic disease. For those who did (n= 12) and did not (n= 18) require full-thickness excisions/resections, the median operative time was 180 min (range, 90–390) and 110 min (range, 45–355), respectively; the median length of hospitalization was 4 days (range, 3–7) and 1 day (range, 0–4), respectively. A major complication occurred in one patient (colovaginal fistula). At a median follow-up of 10 months (range 1–32), 28 patients were improved, and 24 of these had near or total resolution of preoperative symptoms. Conclusions: Extensive pelvic endometriosis generally requires rectal disc excision or bowel resection. In our experience, laparoscopic treatment of colorectal endometriosis, even in advanced stages, is safe, feasible, and effective in nearly all patients. Received: 1 April 1998/Accepted: 22 March 1999     

Comparison of conventional laparoscopic and hand-assisted oncologic segmental colonic resection

Background Laparoscopically assisted colon resection has evolved to be a viable option for the treatment of colorectal cancer. This study evaluates the efficacy of hand-assisted laparascopic surgery (HALS) as compared with totally laparoscopic surgery (LAP) for segmental oncologic colon resection with regard to lymph node harvest, operative times, intraoperative blood loss, pedicle length, incision length, and length of hospital stay in an attempt to help delineate the role of each in the treatment of colorectal cancer. Methods Patient charts were retrospectively reviewed to acquire data for this evaluation. Between June 2001 and July 2005, 40 patients underwent elective oncologic segmental colon resection (22 HALS and 18 LAP). The main outcome measures included lymph node harvest, operative times, intraoperative blood loss, pedicle length, incision length, and length of hospital stay. Results The two groups were comparable in terms of demographics. The tumor margins were clear in all the patients. The HALS resection resulted in a significantly higher lymph node yield than the LAP resection (HALS: 16 nodes; range, 5–35 nodes vs LAP: 8 nodes; range, 5–22 nodes; p < 0.05) and significantly shorter operative times (HALS: 120 min; range, 78–181 min vs LAP: 156 min; range, 74–300 min; p < 0.05). Both groups were comparable with regard to length of hospital stay, pedicle length, and intraoperative blood loss. However, the LAP group yielded a significantly smaller incision for specimen extraction (LAP: 7 cm; range, 6–8 cm vs HALS: 5.5 cm; range, 5–7 cm; p < 0.05). Conclusion The findings suggest that hand-assisted laparoscopic oncologic segmental colonic resection is associated with shorter operative times, more lymph nodes harvested, and equivalent hospital stays, pedicle lengths, and intraoperative blood losses as compared with the totally laparoscopic approach. The totally laparoscopic technique was completed with a smaller incision. However, this less than 1 cm reduction in incision length has doubtful clinical significance.     

Laparoscopic management of bowel endometriosis: predictors of severe disease and recurrence

Background and Objectives:

The identification of high-stage and recurrent cases of bowel endometriosis is critical, because these cases require careful surgical planning. We aim to describe the clinical characteristics of women with bowel endometriosis, our principles in laparoscopic management of this pathology, and to identify predictors of severe disease and recurrence.

Methods:

This was a retrospective study of 193 patients with pathologically confirmed bowel endometriosis.

Results:

Predictors of higher-stage endometriosis include a history of previous laparoscopic surgery (P=.04) and a presenting complaint of abnormal uterine bleeding (P=.01). The higher the stage of endometriosis, the more likely there would be coexistent urinary tract endometriosis (P=.02), a need for enterolysis (P=.002), ovarian cystectomy (P<.001), and bowel resection (P=.01) performed during laparoscopy. Patients with higher body mass index (BMI) had significantly higher recurrence rates of endometriosis compared to those with lower BMI (P=.002). Within our cohort, 87% of our patients achieved amelioration of symptoms by the end of the first postoperative month.

Conclusions:

Our study confirms that laparoscopic management of bowel endometriosis is safe and effective. We found 2 statistically significant predictors of higher-stage disease that should prompt careful surgical planning. Obesity is associated with a higher rate of recurrence of endometriosis.     

Combined vaginal–laparoscopic–abdominal approach for the surgical treatment of rectovaginal endometriosis with bowel resection: a comparison of this new technique with various established approaches by laparoscopy and laparotomy

Background A new combined vaginal–laparoscopic–abdominal approach for rectovaginal endometriosis allows intraoperative digital bowel palpation to assess bowel infiltration and prevents unnecessary bowel resections. This technique was compared to various established approaches where bowel resection was indicated by clinical symptoms and imaging results only. Methods Patients operated for rectovaginal endometriosis with endometriotic bowel involvement between March 2002 and April 2006 at the gynecological department Charité, Berlin, Germany were included. Bowel involvement was suspected by clinical symptoms, clinical examination, and/or results of imaging techniques. The study group (SG) was operated by the combined vaginal–laparoscopic–abdominal approach (n = 30) and the control group (CG) (n = 18) by laparoscopy (n = 4), laparotomy (n = 3), laparoscopy followed by laparotomy for bowel resection (n = 8) or laparoscopy followed by vaginal bowel resection (n = 3). In all cases histopathology was performed. Results The study group and the control group were comparable regarding age, body mass index, symptoms, American Society for Reproductive Medicine (ASRM) classification, colorectal operative procedures, operating times, length of the resected bowel specimen, and concomitant surgical procedures. However, only in the CG were protective stomas required (p = 0.047). There were significantly less complications in the SG (p = 0.027). No patient experienced leakage of anastomosis. Bowel involvement by endometriosis was confirmed by histopathology in the SG in all cases whereas in the CG only in 16/18 (88.9%) cases. Hospitalization time was significantly shorter in the SG. Rehospitalizations were necessary only in the CG to repair one rectovaginal fistula and to reverse three stomas. Conclusions With the presented technique of a combined vaginal–laparoscopic–abdominal surgical procedure for rectovaginal endometriosis, we showed that the complication rate, rehospitalization rate, and hospitalization time were significantly lower than in the patients of the CG. Furthermore, the combined vaginal–laparoscopic–abdominal technique allowed better evaluation of the invasiveness of the endometriotic lesion and avoided unnecessary bowel surgery.     

Addition of transversus abdominis plane block to patient controlled analgesia for laparoscopic high anterior resection improves analgesia,reduces opioid requirement and expedites recovery of bowel function

IntroductionOpioid sparing in postoperative pain management appears key in colorectal enhanced recovery. Transversus abdominis plane (TAP) blocks offer such an effect. This study aimed to quantify this effect on pain, opioid use and recovery of bowel function after laparoscopic high anterior resection.MethodsThis was a retrospective analysis of prospective data on 68 patients. Patients received an epidural (n=24), intravenous morphine patient controlled analgesia (PCA, n=22) or TAP blocks plus PCA (n=22) determined by anaesthetist preference. Outcome measures were numerical pain scores (0–3), cumulative intravenous morphine dose and time to recovery of bowel function (passage of flatus or stool).ResultsThere were no differences in patient characteristics, complications or extraction site. The TAP block group had lower pain scores (0.7 vs 1.36, p<0.001) and morphine requirements (8mg vs 15mg, p=0.01) than the group receiving PCA alone at 12 hours and 24 hours. Earlier passage of flatus (2.0 vs 2.7 vs 3.4 days, p=0.002), stool (3.1 vs 4.1 vs 5.5 days, p=0.04) and earlier discharge (4 vs 5 vs 6 days, p=0.02) were also seen.ConclusionsUse of TAP blocks was found to reduce pain and morphine use compared with PCA, expedite recovery of bowel function compared with PCA and epidural, and expedite hospital discharge compared with epidural.     

Quality of life and sexual function 1 year after laparoscopic rectosigmoid resection for endometriosis

Aim Endometriosis is relatively common condition in fertile women and may affect the alimentary tract. Laparoscopic rectosigmoid resection for endometriosis has been found to be both feasible and safe. The aim of the present study was to prospectively evaluate the quality of life and sexual function of patients who have undergone rectosigmoid resection for endometriosis. Method All patients undergoing rectal or sigmoid resection for endometriosis in two specialist hospitals were prospectively recruited in the study. Details regarding demography, endometriosis‐related symptoms, procedure and postoperative recovery were collected. One year after the operation patients were sent a postal questionnaire asking about endometriosis‐related symptoms, quality of life and sexual functioning. The 15D Questionnaire and McCoy Female Sexuality Questionnaire were used for this purpose. Results A total of 26 patients responded to the 15D questionnaire. Endometriosis‐related bowel symptoms decreased significantly after the operation. The responses showed improvements in the overall score and scores for five different dimensions (usual activities, P = 0.04; discomfort and symptoms, P < 0.001; distress, P < 0.001; vitality, P < 0.001; sexual activity, P < 0.001). Sexual satisfaction was greater 1 year after the operation (P = 0.01). Sexual problems and partner satisfaction scores had not changed significantly. Conclusion Laparoscopic rectal and sigmoid resection for endometriosis significantly reduce endometriosis‐related symptoms and improve quality of life and sexual well‐being.     

Laparoscopic versus open live donor nephrectomy: outcomes analysis of 266 consecutive patients

Background  Minimally invasive surgical techniques have become the preferred method for live donor nephrectomy (DN) in many centers. We compared our experience with laparoscopic and open DN in a single institution. Methods  Data for 266 consecutive live DNs were collected. Demographic, intraoperative, and postoperative data were compared. Results  A total of 199 hand-assisted laparoscopic (HAL) DNs, 18 totally laparoscopic (TL), and 49 open DNs were performed. Laparoscopic DN was associated with a shorter operative time (p < 0.013), less blood loss (p < 0.0001), and shorter hospital stay (p < 0.0001) than open DN. Warm ischemia time was less for HAL versus TL DN (59.9 vs. 90.0 seconds; p < 0.0001). Compared with open DN, laparoscopic patients had fewer complications (p < 0.03), fewer wound infections (p < 0.004), less wound paresthesias (p < 0.0009), and fewer complaints of chronic incisional pain (p < 0.0001). Delayed graft function during the first 24 h postoperatively was significantly less for the laparoscopic DN versus the open cases (12.9% vs. 30.4%; p = 0.003), but the need for hemodialysis for the recipient was similar between groups (6.9% vs. 5%; p = not significant). Conclusions  Laparoscopic DN resulted in less blood loss, reduced operative time, and shorter hospital stay than open DN. Hand-assisted laparoscopic DN has the potential to decrease warm ischemia time for renal allografts. Donors managed laparoscopically had fewer complications, significantly less wound-related morbidity, and less delayed graft function than patients who underwent open DN.     

Laparoscopic colorectal resection for endometriosis

Background The rectosigmoid colon is affected by deep pelvic endometriosis in 3–37% of cases. In the past, treatment of the affected gastrointestinal tract generally required conversion to conventional surgery. We describe our experience with complete laparoscopic management of deep pelvic endometriosis with bowel involvement.Methods From March 1995 to March 2003, 29 consecutive patients with endometriosis requiring laparoscopic intervention were evaluated. In seven patients (24%) colorectal involvement was identified prior to the operation. A low anterior resection was performed in four patients (57%) and a sigmoid resection in three (43%). In all cases, colonoscopy showed a normal mucosa. In all cases, treatment consisted of resection of the bowel involved together with the excision of all other implants. Data analysis included age, previous abdominal operations, previous history of endometriosis, operative time, conversion rate, complications, length of stay, and pain relief.Results There were seven patients with colorectal involvement whose median age was 32.8 years (range, 28–40), with a history of previous abdominal operation in two (28%). Preoperative symptoms were as follow: dysmenorrea in four patients (57%), dyspareunia in four (57%), pelvic pain in seven (100%), rectal bleeding in one (14%), and tenesmus in five (71%). Mean operative time was 190 min (range, 165–230). Length of stay was 8.3 days (range, 7–11). There were no anastomotic leak and no major postoperative complication. One patient had temporary urinary retention. At a median follow-up of 38.7 months (range, 1–84), complete relief of pelvic symptoms was achieved in five patients (71%), and there was improvement in one patient. In one patient complaining of persistent pain, a new colonic implant was diagnosed two years after the surgery requiring reoperation.Conclusions The results show that provided that the surgeon is highly skilled in laparoscopy, laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement is feasible and effective in nearly all patients.     

Simultaneous Resections of Colorectal Cancer and Synchronous Liver Metastases: A Multi-institutional Analysis

Background The safety of simultaneous resections of colorectal cancer and synchronous liver metastases (SCRLM) is not established. This multi-institutional retrospective study compared postoperative outcomes after simultaneous and staged colorectal and hepatic resections. Methods Clinicopathologic data, treatments, and postoperative outcomes from patients who underwent simultaneous or staged colorectal and hepatic resections at three hepatobiliary centers from 1985–2006 were reviewed. Results 610 patients underwent simultaneous (n = 135) or staged (n = 475) resections of colorectal cancer and SCRLM. Seventy staged patients underwent colorectal and hepatic resections at the same institution. Simultaneous patients had fewer (median 1 versus 2) and smaller (median 2.5 versus 3.5 cm) metastases and less often underwent major (≥ three segments) hepatectomy (26.7% versus 61.3%, p < 0.05). Combined hospital stay was lower after simultaneous resections (median 8.5 versus 14 days, p < 0.0001). Mortality (1.0% versus 0.5%) and severe morbidity (14.1% versus 12.5%) were similar after simultaneous colorectal resection and minor hepatectomy compared with isolated minor hepatectomy (both p > 0.05). For major hepatectomy, simultaneous colorectal resection increased mortality (8.3% versus 1.4%, p < 0.05) and severe morbidity (36.1% versus 15.1%, p < 0.05). Combined severe morbidity after staged resections was lower compared to simultaneous resections (36.1% versus 17.6%, p = 0.05) for major hepatectomy but similar for minor hepatectomy (14.1% versus 10.5%, p > 0.05). Major hepatectomy independently predicted severe morbidity after simultaneous resections [hazard ratio (HR) = 3.4, p = 0.008]. Conclusions Simultaneous colorectal and minor hepatic resections are safe and should be performed for most patients with SCRLM. Due to increased risk of severe morbidity, caution should be exercised before performing simultaneous colorectal and major hepatic resections.     

Laparoscopic excision of rectovaginal endometriosis: report of a prospective study and review of the literature

Aim The surgical management of rectovaginal endometriosis is challenging. We present our experience of the laparoscopic management of these difficult cases, together with a review of the current literature. Method A prospective database was established for all patients undergoing surgery for Deep Infiltrating Endometriosis (DIE) with rectovaginal and/or ureteric and bladder nodules. Outcomes analysed include operation performed, conversion and complication rates, and length of stay. These outcomes were compared with other laparoscopic rectal resections for alternative diagnoses recorded in the database and with outcomes seen in a literature review of studies on the surgical management of endometriosis. Results Between April 2004 and November 2007, 54 patients underwent laparoscopic excision of rectovaginal endometriosis by a combined colorectal and gynaecological surgical team. Out of the 54 patients, 37% of patients underwent a rectal wall shave, 13% had a disc excision of the rectal wall, and 50% underwent segmental resection. There was a conversion rate of 4%, median duration of stay was 3 days, with 2% requiring transfusion. Major complications occurred in 7% of patients, with 4% requiring reoperation. Patients undergoing segmental resection for endometriosis had a higher complication rate than those having surgery for other diagnoses. There was an increased incidence of anastomotic stenosis, with histopathological results suggesting that the disease process might have contributed to this occurrence. Conclusions Laparoscopic resection of rectovaginal endometriosis may be associated with a higher incidence of complications than resections performed for other diagnoses.     

The early outcome of laparoscopic sigmoid and rectal resection for endometriosis

Aim Deeply infiltrating endometriosis (DIE) is the most severe form of endometriosis and may affect the rectum and sigmoid colon. The most effective treatment is segmental resection. We report our results of rectal and sigmoid resection for this. Method The study comprises all patients who have had laparoscopic bowel resection for rectal or sigmoid endometriosis in the Päijät‐Häme Central Hospital between 1 January 2004 and 31 May 2007. Patient demographics, operative details, complications and early postoperative recovery were prospectively collected and analysed. Results A total of 31 patients were treated using a multidisciplinary approach. The mean age was 33.6 years (range 21.7–48.6) and body mass index 24.2 (17–40). The mean operation time was 253.5 min (range 56–484). There were three sigmoid and 28 rectal resections and 80 concomitant gynaecological procedures. Conversion to open surgery was not required. A total of 23 (74.2%) patients recovered without complications. There were two major complications, anastomotic leakage and rectovaginal fistula. Minor complications included transient urinary retention (2), wound infection (1), pneumonia (1) and undefined fever (2). The mean time to full peroral diet was 3.8 days (range 3–7), to first flatus 2.6 days (1–4), to first bowel movement 3.5 days (2–6) and to discharge 5.7 days (4–13). Conclusion Laparoscopic rectal and sigmoid resection for deep intestinal endometriosis is safe with few severe complications and rapid recovery. The long‐term outcome on symptoms requires further study.     

Incidence of small bowel obstruction after laparoscopic and open colon resection

Background

Small bowel obstruction (SBO) is responsible for more than 1 billion dollars in health care costs yearly in the United States. We sought to evaluate whether laparoscopic colorectal surgery resulted in a decreased incidence of SBO within the first year of surgical resection compared with open surgery.

Methods

From January 2003 to December 2008, 339 patients underwent open (open colorectal resection [OPEN]) colorectal resection and 448 patients underwent laparoscopic (laparoscopic colorectal resection [LAP]) colorectal resection. Hospital admissions up to 1 year after the initial resection identified patients admitted for the management of SBO, ileus, or nausea and vomiting.

Results

During the 1st year after surgery, 6 patients in the OPEN group developed SBO, and 5 patients in the LAP group developed SBO. The overall frequency of SBO for the OPEN group was 1.8% and 1.1% for the LAP group (P < .5461).

Conclusions

Although advantages such as quicker postoperative recovery and decreased hospital stay have been attributed to laparoscopic surgery, no difference in the incidence of SBO within the 1st year of surgery was found compared with open colorectal surgery.     

Laparoscopic versus open liver segmentectomy: prospective, case-matched, intention-to-treat analysis of clinical outcomes and cost effectiveness

Introduction  Reduction in hospital stay, blood loss, postoperative pain and complications are common findings after laparoscopic liver resection, suggesting that the laparoscopic approach may be a suitable alternative to open surgery. Some concerns have been raised regarding cost effectiveness of this procedure and potential implications of its large-scale application. Our aim has been to determine cost effectiveness of laparoscopic liver surgery by a case-matched, case–control, intention-to-treat analysis of its costs and short-term clinical outcomes compared with open surgery. Methods  Laparoscopic liver segmentectomies and bisegmentectomies performed at Ninewells Hospital and Medical School between 2005 and 2007 were considered. Resections involving more than two Couinaud segments, or involving any synchronous procedure, were excluded. An operation-magnitude-matched control group was identified amongst open liver resections performed between 2004 and 2007. Hospital costs were obtained from the Scottish Health Service Costs Book (ISD Scotland) and average national costs were calculated. Cost of theatre time, disposable surgical devices, hospital stay, and high-dependency unit (HDU) and intensive care unit (ICU) usage were the main endpoints for comparison. Secondary endpoints were morbidity and mortality. Statistical analysis was performed with Student’s t-test, χ ² and Fisher exact test as most appropriate. Results  Twenty-five laparoscopic liver resections were considered, including atypical resection, segmentectomy and bisegmentectomy, and they were compared to 25 matching open resections. The two groups were homogeneous by age, sex, coexistent morbidity, magnitude of resection, prevalence of liver cirrhosis and indications. Operative time (p < 0.03), blood loss (p < 0.0001), Pringle manoeuvre (p < 0.03), hospital stay (p < 0.003) and postoperative complications (p < 0.002) were significantly reduced in the laparoscopic group. Overall hospital cost was significantly lower in the laparoscopic group by an average of ￡2,571 (p < 0.04). Conclusions  Laparoscopic liver segmentectomy and bisegmentectomy are feasible, safe and cost effective compared to similar open resections. Large-scale application of laparoscopic liver surgery could translate into significant savings to hospitals and health care programmes.     

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