Total abdominal colectomy for refractory ulcerative colitis. Surgical treatment in evolution

Minimally Invasive Rectal Surgery: Current Status and Future Perspectives in the Era of Digital Surgery

Over the past two decades, minimally invasive approaches in rectal surgery have changed the landscape of surgical interventions, impacting both malignant and benign pathologies. The dynamic nature of rectal cancer treatment owes much to innovations in surgical techniques, reflected in the expanding literature on available treatment modalities. Local excision, facilitated by minimally invasive surgery, offers curative potential for patients with early T1 rectal cancers and favorable pathologic features. For more complex cases, laparoscopic and robotic surgery have demonstrated significant efficacy and provided precise, durable outcomes while reducing perioperative morbidity and enhancing postoperative recovery. Additionally, advancements in imaging, surgical instrumentation, and enhanced recovery protocols have further optimized patient care. The integration of multidisciplinary care has also emerged as a cornerstone of treatment, emphasizing collaboration among surgeons, oncologists, and radiologists to deliver personalized, evidence-based care. This narrative review aims to elucidate current minimally invasive surgical techniques and approaches for rectal pathologies, spanning benign and malignant conditions, while also exploring future directions in the field, including the potential role of artificial intelligence and next-generation robotic platforms.

The Role of Minimally Invasive Surgery in the Management of Inflammatory Bowel Disease: Current Trends and Future Directions

Minimally invasive surgery (MIS) provides superior results in the surgical treatment of inflammatory bowel disease (IBD). There exist various minimally invasive procedures, each possessing its own set of benefits and drawbacks. This literature review outlines these methodologies and underscores their importance in enhancing the outcomes of patients with IBD. A grand total of 192 studies were carefully chosen and succinctly summarized. Conventional multiport laparoscopy is the most widely used MIS for IBD, with single-incision laparoscopy showing even better results. Robotic surgery offers comparable results but at higher costs and longer operation times. In the future, there will be widespread acceptance of single-incision laparoscopy and robotic surgery due to improved training and reduced expenses. Further research into the technology's utility in different IBD presentations could increase its usage.

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.

Single access laparoscopic total colectomy for severe refractory ulcerative colitis

BACKGROUND

Single port laparoscopic surgery allows total colectomy and end ileostomy for medically uncontrolled ulcerative colitis solely via the stoma site incision. While intuitively appealing, there is sparse evidence for its use beyond feasibility.

AIM

To examine the usefulness of single access laparoscopy (SAL) in a general series experience of patients sick with ulcerative colitis.

METHODS

All patients presenting electively, urgently or emergently over a three-year period under a colorectal specialist team were studied. SAL was performed via the stoma site on a near-consecutive basis by one surgical team using a “surgical glove port” allowing group-comparative and case-control analysis with a contemporary cohort undergoing conventional multiport surgery. Standard, straight rigid laparoscopic instrumentation were used without additional resource.

RESULTS

Of 46 consecutive patients requiring surgery, 39 (85%) had their procedure begun laparoscopically. 27 (69%) of these were commenced by single port access with an 89% completion rate thereafter (three were concluded by multi-trocar laparoscopy). SAL proved effective in comparison to multiport access regardless of disease severity providing significantly reduced operative access costs (> 100€case) and postoperative hospital stay (median 5 d vs 7.5 d, P = 0.045) without increasing operative time. It proved especially efficient in those with preoperative albumin > 30 g/dL (n = 20). Its comparative advantages were further confirmed in ten pairs case-matched for gender, body mass index and preoperative albumin. SAL outcomes proved durable in the intermediate term (median follow-up = 20 mo).

CONCLUSION

Single port total colectomy proved useful in planned and acute settings for patients with medically refractory colitis. Assumptions regarding duration and cost should not be barriers to its implementation.

Acute histologic inflammatory activity and postoperative outcomes in pediatric patients with ulcerative colitis

BACKGROUND

The aim of this study was to determine whether acute histologic inflammatory activity at the rectal margin predicts postoperative complications in children with ulcerative colitis following ileal pouch-anal anastomoses (IPAA).

METHODS

Patients who underwent IPAA following previous total abdominal colectomy for ulcerative colitis between 2006 and 2014 were included. Data collected included demographics, operative and postoperative data, histologic grading of the rectal margin at time of IPAA, and stooling outcomes at one, six and 12 months following ileostomy closure.

RESULTS

Twenty-seven patients were included. Acute inflammation scores ranged between 2 and 13. Unadjusted and adjusted models showed no statistically significant relationship between inflammation and presence of any postoperative complications, number of daily stools, nighttime stooling, soiling, or stool-altering medication usage.

CONCLUSION

Acute histologic inflammatory activity at the rectal margin is not associated with increased rates of postoperative complications following IPAA creation in children, nor with poorer continence outcomes following ileostomy closure.

Impact of single-incision laparoscopic surgery on postoperative analgesia requirements after total colectomy for ulcerative colitis: a propensity-matched comparison with multiport laparoscopy

AIM

To compare the requirements for postoperative analgesia in patients with ulcerative colitis after single-incision versus multiport laparoscopic total colectomy.

METHOD

All patients undergoing single-incision or multiport laparoscopic total colectomy as a first stage in the surgical treatment of ulcerative colitis between 2010 and 2016 at the University Hospital of Leuven were included. The cumulative dose of postoperative patient-controlled analgesia was used as the primary end-point. A Z-transformation was performed combining values for patient-controlled epidural analgesia and patient-controlled intravenous analgesia, resulting in one hybrid outcome variable. The two groups were matched using propensity scores. Subgroup analysis was performed to analyse the impact of extraction site on postoperative pain.

RESULTS

A total of 81 patients underwent total colectomy for ulcerative colitis (median age 35 years). Thirty patients underwent single-incision laparoscopy, while 51 patients had a multiport approach. The mean normalized patient-controlled analgesia dose was significantly lower in patients undergoing single-incision laparoscopy (-0.33 vs 0.46, P < 0.001). This difference was no longer significant in subgroup analysis for patients with stoma site specimen extraction (P = 0.131). The odds of receiving tramadol postoperatively was 3.66 times lower after single-incision laparoscopy (P = 0.008). The overall morbidity rate was 32.1% (26/81). The mean Comprehensive Complication Index in single-incision and multiport laparoscopy group was 18.33 and 21.39, respectively (P = 0.506). Hospital stay was significantly shorter after single-incision laparoscopic surgery (6.3 days vs 7.6 days, P = 0.032).

CONCLUSION

Single-incision total colectomy was associated with lower postoperative analgesia requirements and shorter hospital stay, with comparable morbidity. However, the specimen extraction site played a significant role in postoperative pain control.

Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis

AIM

The aim was to study the feasibility of the laparoscopic approach in the management of ulcerative colitis, to assess the functional results at 1-year and to review of literature on the topic.

MATERIALS AND METHODS

All patients presenting for surgical management of histopathologically proven ulcerative colitis during the study period were included in the study. All patients presenting in a non-emergency setting were offered a two-stage procedure (Group A). The first-stage consisted of laparoscopic total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) with a diverting split end ileostomy. Ileostomy was closed in the second stage. For patients presenting in acute setting (Group B), the first-stage consisted of laparoscopic TPC with end ileostomy followed by IPAA with diverting split end ileostomy in the second-stage and finally ileostomy closure in the third-stage. The technique is described.

RESULTS

A total of 31 cases underwent laparoscopic TPC-IPAA, of which 28 belonged to Group A and 3 were included in Group B. All surgeries were successfully completed laparoscopically without need for conversion. The average operating time was 375 min in Group A (range: 270-500 min) and 390 min in Group B (range: 250-480 min). Oral diet was resumed at a mean of 3.4 days (range: 1.5-6 days) and the mean hospital stay was 8.2 days (range: 4-26 days). Overall morbidity rate was 16.2%; re-operation rate was 9.7% while mortality was nil.

CONCLUSIONS

Laparoscopic TPC-IPAA is feasible in acute as well as non-acute setting in patients needing surgical management of ulcerative colitis.

Minimally invasive surgery for inflammatory bowel disease

Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohn's disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic "incisionless," single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

Systematic review of single-incision laparoscopic colonic surgery

BACKGROUND

Randomized clinical trials (RCTs) have shown multiport laparoscopic surgery to be safe compared with open surgery in elective colonic disease. Single-incision laparoscopic surgery (SILS) represents the latest advance in laparoscopic surgery. The aim of this systematic review was to establish the safety and complication profile of colonic SILS.

METHODS

The search was performed in October 2011 using PubMed, MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. Search terms were 'colorectal', 'colon', 'colectomy', 'rectal' and single incision/port/trocar/site/scar. Only pure single-incision laparoscopic colonic surgery for benign and malignant colonic disease was included. Primary outcomes were the early postoperative complication profiles of colonic SILS. Secondary outcomes were duration of operation, lymph node yields, conversion rate and duration of hospital stay.

RESULTS

Colonic SILS data were compared with data from a Cochrane review on the short-term outcomes of laparoscopic colonic surgery and four main RCTs on laparoscopic colonic surgery. Median operating times and time to first bowel motion for colonic SILS were comparable with those for laparoscopic colonic surgery. The median lymph node retrieval for malignant disease achieved with SILS was acceptable. Evidence for a reduction in postoperative pain with SILS was conflicting. There was no significant reduction in length of hospital stay with SILS. Most patients selected for colonic SILS had a low body mass index, non-bulky tumours and were operated on by experienced laparoscopic surgeons. There was significant heterogeneity in study group characteristics, indications for surgery, research methodology, operative techniques and follow-up time.

CONCLUSION

Colonic SILS should be restricted to highly selected patients; operations should be performed by experienced laparoscopic surgeons, with critical appraisal of clinical outcomes.

Laparoscopy impacts outcomes favorably following colectomy for ulcerative colitis: a critical analysis of the ACS-NSQIP database

INTRODUCTION

The surgical management of ulcerative colitis (UC) often involves complex operations. We investigated the outcome of patients who underwent surgery for UC by analyzing a nationwide database.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP, 2005-2008) for all UC patients who underwent colectomy. To analyze by operation, groupings included: partial colectomy (PC; n = 265), total abdominal colectomy (TAC; n = 232), total proctocolectomy with ileostomy (TPC-I; n = 134), and total proctocolectomy with ileal pouch-anal anastomosis (IPAA; n = 446) to analyze 30-day outcomes.

RESULTS

From 1,077 patients (mean age, 44 years; 45 % female; 7 % emergent), a laparoscopic approach was used in 29.2 %, with rates increasing 8.5 % each year (18.5 % in 2005 to 41.3 % in 2008, P < 0.001). Complications occurred in 29 %, and laparoscopy was associated with a lower complication rate (21 vs. 32 % open, P < 0.001). On multivariate regression, postoperative complications increased when patients were not functionally independent [odds ratio (OR) = 3.2], had preoperative sepsis (OR = 2.0), or prior percutaneous coronary intervention (OR = 2.8). A laparoscopic approach was associated with a lower complication rate (OR = 0.63). When stratified by specific complications, laparoscopy was associated with lower complications, including superficial surgical site infections (11.4 vs. 6.7 %, P = 0.0011), pneumonia (2.9 vs. 0.6 %, P = 0.023), prolonged mechanical ventilation (3.9 vs. 1.3 %, P = 0.023), need for transfusions postoperatively (1.6 vs. 0 %, P = 0.016), and severe sepsis (2.9 vs. 1.0 %, P = 0.039). Laparoscopy was also was associated with a lower complication rate in TACs (41.7 vs. 18.8 %, P < 0.0001) and IPAA (29.9 vs. 18.2 %, P = 0.005) and had an overall lower mortality rate (0.2 vs. 1.7 %, P = 0.046).

CONCLUSIONS

Results from a large nationwide database demonstrate that a laparoscopic approach was utilized in an increasing number of UC patients undergoing colectomy and was associated with lower morbidity and mortality, even in more complex procedures, such as TAC and IPAA.

Single-port laparoscopic surgery for inflammatory bowel disease

Background. Single Port Laparoscopic Surgery (SPLS) is being increasingly employed in colorectal surgery for benign and malignant diseases. The particular role for SPLS in inflammatory bowel disease (IBD) has not been determined yet. In this review article we summarize technical aspects and short term results of SPLS resections in patients with Crohn's disease or ulcerative colitis. Methods. A systematic review of the literature until January 2012 was performed. Publications were assessed for operative techniques, equipment, surgical results, hospital stay, and readmissions. Results. 34 articles, published between 2010 and 2012, were identified reporting on 301 patients with IBD that underwent surgical treatment in SPLS technique. Surgical procedures included ileocolic resections, sigmoid resections, colectomies with end ileostomy or ileorectal anastomosis, and restorative proctocolectomies with ileum-pouch reconstruction. There was a wide variety in the surgical technique and the employed equipment. The overall complication profile was similar to reports on standard laparoscopic surgery in IBD. Conclusions. In experienced hands, single port laparoscopic surgery appears to be feasible and safe for the surgical treatment of selected patients with IBD. However, evidence from prospective randomized trials is required in order to clarify whether there is a further benefit apart from the avoidance of additional trocar incisions.