The role of hand-assisted laparoscopic surgery in subtotal and total colectomy for Crohn's colitis

Minimally invasive surgery in Crohn's disease: state-of-the-art review

Surgery for Crohn's disease (CD) has undergone significant advancements over the last two decades, especially minimally invasive surgery. In addition to its feasibility and safety, minimally invasive surgery provides manifold advantages, including a decreased hospitalization duration, improved aesthetic results, and fewer occurrences of intra-abdominal adhesions. Due to the special intraoperative characteristics of CD, such as chronic inflammation, a thickened mesentery, fistulas, abscesses and large masses, a minimally invasive approach seems to be challenging. Complete implementation of this technique for complex disease has yet to be studied. In this review, we provide a review on the applicability of minimally invasive surgery in CD and future perspectives for the technical advances in the field.

Hand-assisted versus straight laparoscopy for colorectal surgery - a systematic review and meta-analysis

PURPOSE

Hand-assisted laparoscopic surgery (HALS) is an alternative to straight laparoscopy (LAP) in colorectal surgery. Many studies have compared the two in terms of efficacy, complications, and outcomes. This meta-analysis aims to uncover if there are any significant differences in conversion rates, operative times, body mass index (BMI), incision lengths, intraoperative and postoperative complications, and length of stay.

METHODS

Comprehensive searches were performed on databases from their respective inceptions to 16 December 2021, with a manual search performed through Scopus. Randomized controlled trials (RCTs), cohort studies, and case series involving more than 10 patients were included.

RESULTS

A total of 47 studies were found fitting the inclusion criteria, with 5 RCTs, 41 cohort studies, and 1 case series. Hand-assisted laparoscopic surgery was associated with lower conversion rates (odds ratio [OR] 0.41, 95%CI 0.28-0.60, p < 0.00001), shorter operative times (Mean Difference [MD] - 8.32 min, 95%CI - 14.05- - 2.59, p = 0.004), and higher BMI (MD 0.79, 95%CI 0.46-1.13, p < 0.00001), but it was also associated with longer incision lengths (MD 2.19 cm, 95%CI 1.66-2.73 cm, p < 0.00001), and higher postoperative complication rates (OR 1.15, 95%CI 1.06-1.24, p = 0.0004). Length of stay was not different in HALS as compared to Lap (MD 0.16 days, 95%CI - 0.06-0.38 days, p = 0.16, and intraoperative complications were the same between both techniques.

CONCLUSIONS

Hand-assisted laparoscopy is a suitable alternative to straight laparoscopy with benefits and risks. While there are many cohort studies comparing HALS and LAP, more RCTs would be needed for a better quality of evidence.

Outcomes of laparoscopic subtotal colectomy with cecorectal anastomosis for slow-transit constipation: a single center retrospective study

PURPOSE

To study the safety and efficacy of laparoscopic subtotal colectomy (LASC) with cecorectal anastomosis for slow-transit constipation (STC).

METHODS

This study was a retrospective review of all patients undergoing LASC with cecorectal anastomosis for STC between March 2010 and May 2017. The main variables included the operative time, blood loss, length of postoperative hospital stay, complications, and long-term outcomes.

RESULTS

In this analysis, 56 patients were included. There were 17 males and 39 females aged between 34 and 80 years old. The mean operative time was 208 ± 21 min, and the mean perioperative blood loss was 116 ± 48 mL. The mean postoperative hospital stay was 7.7 ± 3.5 days, and the incidence of perioperative complications was 19.6%, with no mortality. One patient required reoperation because of intra-abdominal bleeding. During the follow-up period, 26.8% of patients suffered from chronic pain and bloating, with no recurrence of STC. The causes of these symptoms included small bowel obstruction (7.1%), slow transit (10.7%), anastomotic stenosis (5.4%) and gastroptosis (3.6%). Postoperatively, after 12 months, the frequency of defecation was 2-4 times per day. Patients with follow-up of at least 60 months, the mean frequency of defecation was 0.9 ± 0.5 times per day. The percentage of satisfaction was 82.1%.

CONCLUSION

LASC with cecorectal anastomosis is a safe and effective surgical approach for STC, with the majority of patients being satisfied with the outcome of surgery.

Hand-Assisted Laparoscopic Versus Standard Laparoscopic Colectomy: Are Outcomes and Operative Time Different?

BACKGROUND

HAL colectomy is a technique perceived to provide the benefits of laparoscopic surgery while improving tactile feedback and operative time. Published data are largely limited to small, single-institution studies.

METHODS

The 2012-2013 National Surgical Quality Improvement Program Participant Data Use File was queried for patients undergoing elective SL or HAL colectomy. Patients underwent 1:1 propensity matching and had outcomes compared. An additional subgroup analysis was performed for patients undergoing segmental resections only.

RESULTS

13,949 patients were identified, of whom 6084 (43.6 %) underwent HAL colectomy. Patients undergoing HAL versus SL colectomy had higher rates of postoperative ileus (8.7 vs. 6.3 %, p < 0.001), wound complication (8.8 vs. 6.8 %, p = 0.006), and 30-day readmission (7.5 vs. 6.0 %, p = 0.002), without any differences in operative time (156 vs. 157 min, p = 0.713). Amongst segmental colectomies, HAL remained associated with higher rates of wound complications (8.6 vs. 6.5 %, p = 0.016), postoperative ileus (8.9 vs. 6.3 %, p < 0.001), and 30-day readmission (7.1 vs. 5.9 %, p = 0.041) with no difference in operative time between HAL and SL (145 vs. 145 min, p = 0.334).

CONCLUSIONS

Use of HAL colectomy is associated with increased risk of wound complications, postoperative ileus, and readmissions. Importantly, this technique is not associated with any decrease in operative time.

Comparison of hand-assisted laparoscopy with open total colectomy for slow transit constipation: a retrospective study

OBJECTIVE

To compare the efficacy and safety of hand-assisted laparoscopic colectomy (HALC) and open colectomy (OC) for patients with slow transit constipation (STC).

METHODS

Data of patients with STC who underwent total colectomy from January 2008 to December 2012 were retrospectively reviewed after clinical evaluation and an exclusion of secondary causes. These patients were further divided into the HALC and OC groups. Patients' outcomes, including intraoperative and postoperative data on their recovery and complications were compared between the two groups.

RESULTS

A total of 68 patients with STC were finally enrolled in the study, including 32 in the HALC group and 36 in the OC group. The baseline characteristics did not significantly differ between the two groups. Compared with the OC group, patients in the HALC group had a shorter length of incision, a longer operative time and less blood loss volume. There was no conversion to OC for patients undergoing HALC and no intraoperative complications in both groups. Furthermore, after operation, patients in HALC group experienced less pain (3.4 ± 0.7 vs 4.8 ± 1.0), earlier first passage of flatus (58.3 ± 6.3 h vs 73.4 ± 13.0 h), shorter length of postoperative hospital stay (8.8 ± 1.2 days vs 11.3 ± 1.7 days) but higher medical cost (RMB 33 979 ± 3 135 vs RMB 29 828 ± 3 216). The overall postoperative complications and the satisfaction in defecation were comparable in the two groups.

CONCLUSION

HALC is a safe, minimally invasive and effective surgical alternative for treating STC, which is comparable to OC.

Laparoscopic surgery for crohn disease: a brief review of the literature

Crohn disease remains a challenging clinical entity, both medically and surgically. It frequently presents in early adulthood and imposes a lifetime exposure to chronic inflammation that can affect the entire gastrointestinal tract. Although the mainstay of therapy is treatment with immunomodulating drugs, ∼70 to 90% of patients with Crohn disease will ultimately require surgery. Furthermore, there are high rates of symptomatic recurrences that may also require surgical intervention over time. There is no definitive cure for Crohn disease and surgery is reserved for failed medical therapy or the complications of the disease, namely, obstruction, septic complications (abscess, perforation), and fistulas. However, the robust inflammatory environment during these periods is not always conducive to a minimally invasive surgical approach. Despite the inherent technical challenges, the literature has increasingly shown that laparoscopy for Crohn disease, in the appropriate setting, is feasible and safe. In fact, it offers many advantages, which are particularly beneficial to this subset of patients, such as fewer wound complications, a shortened hospital course, less tissue trauma and subsequent adhesion formation, and earlier resumption of oral intake and bowel function.

The role of hand-assisted laparoscopic surgery in a right hemicolectomy for right-sided colon cancer

PURPOSE

The purpose of this study is to evaluate the perioperative and long-term oncologic outcomes of hand-assisted laparoscopic surgery (HALS) and standard laparoscopic surgery (SLS) and assess the role of HALS in the management of right-sided colon cancer.

METHODS

The study group included 53 patients who underwent HALS and 45 patients who underwent SLS for right-sided colon cancer between April 2002 and December 2008.

RESULTS

The patients in each group were similar in age, American Society of Anesthesiologist (ASA) score, body mass index, and history of previous abdominal surgeries. Eight patients in the HALS group and no patient in the SLS group exhibited signs of tumor invasion into adjacent structures. No differences were noted in the time to return of normal bowel function, time to toleration of diet, lengths of hospital stay and narcotic usage, and rate of postoperative complications. The median incision length was longer in the HALS group (HALS: 7.0 cm vs. SLS: 4.8 cm, P < 0.001). The HALS group had a significantly higher pathologic TNM stage and significantly larger tumor size (HALS: 6.0 cm vs. SLS: 3.3 cm, P < 0.001). The 5-year overall, disease-free, and cancer-specific survival rates of the HALS and the SLS groups were 87.3%, 75.2%, and 93.9% and 86.4%, 78.0%, and 90.7%, respectively (P = 0.826, P = 0.574, and P = 0.826).

CONCLUSION

Although patients in the HALS group had more advanced disease and underwent more complex procedures than those in the SLS group, the short-term benefits and the oncologic outcomes between the two groups were comparable. HALS can, therefore, be considered an alternative to SLS for bulky and fixed right-sided colon cancer.

The role of hand-assisted laparoscopic surgery in total colectomy for colonic inertia: a retrospective study

Purpose

To compare and assess the efficacy, safety and utility of hand-assisted laparoscopic surgery (HALS) with open surgery (OS) in total colectomy with ileorectal for colonic inertia.

Methods

From January 2001 to February 2012, 56 patients diagnosed with colonic inertia who failed to respond to medical treatments underwent hand-assisted laparoscopic total colectomy with ileorectal anastomosis. Another 68 patients underwent laparotomy. Main parameters such as clinical manifestations, conversion to open procedure, operative time, incision length, pain score, intraoperative blood loss, time to first flatus and hospitalization, early postoperative complications and hospitalization cost were retrospectively analyzed. Postoperative defecating frequencies were followed up in both groups.

Results

All patients received successful operation, no surgical mortality happened and none of the patients required conversion to an exploratory laparotomy in HALS group. The clinical features, the estimated blood loss, incision length, pain score, first passing flatus time, and postoperative hospitalization time were superior in HALS group (P < 0.05). The early postoperative complications and frequency of defecation were similar. However, the mean operative time was longer and hospitalization cost was higher in HALS group than those in OS group (P < 0.05).

Conclusion

HALS total colectomy can be a safe and efficient technique in the treatment of colonic inertia. HALS can result in a better cosmetic result and a quicker postoperative recovery, but requires higher direct cost.

Laparoscopic surgery for Crohn's disease: a meta-analysis of perioperative complications and long term outcomes compared with open surgery

Background

Previous meta-analyses have had conflicting conclusions regarding the differences between laparoscopic and open techniques in patients with Crohn’s Disease. The objective of this meta-analysis was to compare outcomes in patients with Crohn’s disease undergoing laparoscopic or open surgical resection.

Methods

A literature search of EMBASE, MEDLINE, The Cochrane Central Register of Controlled Trials and the US National Institute of Health’s Clinical Trials Registry was completed. Randomized clinical trials and non-randomized comparative studies were included if laparoscopic and open surgical resections were compared. Primary outcomes assessed included perioperative complications, recurrence requiring surgery, small bowel obstruction and incisional hernia.

Results

34 studies were included in the analysis, and represented 2,519 patients. Pooled analysis showed reduced perioperative complications in patients undergoing laparoscopic resection vs. open resection (Risk Ratio 0.71, 95% CI 0.58 – 0.86, P = 0.001). There was no evidence of a difference in the rate of surgical recurrence (Rate Ratio 0.78, 95% CI 0.54 – 1.11, P = 0.17) or small bowel obstruction (Rate Ratio 0.63, 95% CI 0.28 – 1.45, P = 0.28) between techniques. There was evidence of a decrease in incisional hernia following laparoscopic surgery (Rate Ratio 0.24, 95% CI 0.07 – 0.82, P = 0.02).

Conclusions

This is the largest review in this topic. The results of this analysis are based primarily on non-randomized studies and thus have significant limitations in regards to selection bias, confounding, lack of blinding and potential publication bias. Although we found evidence of decreased perioperative complications and incisional hernia in the laparoscopic group, further randomized controlled trials, with adequate follow up, are needed before strong recommendations can be made.

Current status of laparoscopic surgery for patients with Crohn's disease

PURPOSE

Minimally invasive surgery is increasingly utilized in treatment for refractory or complicated Crohn's disease, and new developments aim at further reducing the abdominal trauma and improving the outcome. This review evaluates current literature about minimally invasive surgery for patients with Crohn's disease, latest advances in single-incision surgery, and methods of specimen extraction.

METHODS

Literature was reviewed with focus on the following topics: indications, surgical procedures, conversions, complications, and short- as well as long-term outcomes of laparoscopic compared to open surgery for refractory, complicated, and recurrent Crohn's disease.

RESULTS

Short-term benefits such as shorter hospital stay and faster postoperative recovery are accompanied by long-term benefits such as better cosmetic results and lower treatment-associated morbidity. Single-incision surgery and minimally invasive methods of specimen extraction help to further reduce the surgical trauma and are gradually implemented in the treatment.

CONCLUSION

In experienced centers, laparoscopic surgery for Crohn's disease is safe and as feasible as open operations, even for selected cases with operations for complicated or recurrent disease. However, accurate analysis of the data is complicated by the heterogeneity of clinical presentations as well as the variety of performed procedures. Additional long-term data are needed for evaluation of true benefits of the new techniques.

Surgical management of Crohn's disease

INTRODUCTION

Crohn's disease is an inflammatory bowel disease that can affect the entire gastrointestinal tract. It is chronic and incurable, and the mainstay of therapy is medical management with surgical intervention as complications arise. Surgery is required in approximately 70% of patients with Crohn's disease. Because repeat interventions are often needed, these patients may benefit from bowel-sparing techniques and minimally invasive approaches. Various bowel-sparing techniques, including strictureplasty, can be applied to reduce the risk of short-bowel syndrome.

METHODS

A review of the available literature using the PubMed search engine was undertaken to compile data on the surgical treatment of Crohn's disease.

RESULTS AND CONCLUSION

Data support the use of laparoscopy in treating Crohn's disease, although the potential technical challenges in these settings mandate appropriate prerequisite surgical expertise.

Recent results of laparoscopic surgery in inflammatory bowel disease

Inflammatory bowel diseases are an ideal indication for the laparoscopic surgical approach as they are basically benign diseases not requiring lymphadenectomy and extended mesenteric excision; well-established surgical procedures are available for the conventional approach. Inflammatory alterations and fragility of the bowel and mesentery, however, may demand a high level of laparoscopic experience. A broad spectrum of operations from the rather easy enterostomy formation for anal Crohn’s disease (CD) to restorative proctocolectomies for ulcerative colitis (UC) may be managed laparoscopically. The current evidence base for the use of laparoscopic techniques in the surgical therapy of inflammatory bowel diseases is presented. CD limited to the terminal ileum has become a common indication for laparoscopic surgical therapy. In severe anal CD, laparoscopic stoma formation is a standard procedure with low morbidity and short operative time. Studies comparing conventional and laparoscopic bowel resections, have found shorter times to first postoperative bowel movements and shorter hospital stays as well as lower complication rates in favour of the laparoscopic approach. Even complicated cases with previous surgery, abscess formation and enteric fistulas may be operated on laparoscopically with a low morbidity. In UC, restorative proctocolectomy is the standard procedure in elective surgery. The demanding laparoscopic approach is increasingly used, however, mainly in major centers; its feasibility has been proven in various studies. An increased body mass index and acute inflammation of the bowel may be relative contraindications. Short and long-term outcomes like quality of life seem to be equivalent for open and laparoscopic surgery. Multiple studies have proven that the laparoscopic approach to CD and UC is a safe and successful alternative for selected patients. The appropriate selection criteria are still under investigation. Technical considerations are playing an important role for the complexity of both diseases.