Laparoscopic colon resection

Hand-Assisted Laparoscopic Approach in Colon Surgery

BACKGROUND

This study sought to compare outcomes of patients who underwent hand-assisted laparoscopic (HAL) colectomy with open and laparoscopic colectomy (LP).

STUDY DESIGN

The NSQIP databases were used to examine the clinical data of patients who underwent elective colectomy during 2012-2013. Multivariate regression analysis was performed to compare the three surgical approaches.

RESULTS

We sampled a total of 21,090 patients who underwent colectomy. Of these, 7480 (35.5 %) had open colectomy (OC), 8751 (41.5 %) had a laparoscopic colectomy, 2860 (13.6 %) had a HAL colectomy, and 1999 (9.5 %) had an open procedure converted from LC or HAL. Multivariate regression analysis revealed HAL colectomy had a similar mortality (AOR 0.53, P = 0.07) and a lower morbidity (AOR 0.37, P < 0.01) compared to OC. LC had lower mortality (AOR 0.58, P = 0.02) and morbidity (AOR 0.43, P < 0.01) compared to OC. Mortality of patients who underwent HAL was not significantly different from LC (AOR 0.90, P = 0.79); however, morbidity of such patients was significantly higher than for patients who underwent LC (AOR 1.29, P < 0.01).

CONCLUSIONS

HAL colectomy is a safe approach with significant advantages compared to open colectomy. Although the morbidity of patients who underwent HAL is higher than patients who underwent LC, the morbidity rate is still lower than OC.

Hand-Assisted Laparoscopic Approach in Colon Surgery

BACKGROUND

This study sought to compare outcomes of patients who underwent hand-assisted laparoscopic (HAL) colectomy with open and laparoscopic colectomy (LP).

STUDY DESIGN

The NSQIP databases were used to examine the clinical data of patients who underwent elective colectomy during 2012-2013. Multivariate regression analysis was performed to compare the three surgical approaches.

RESULTS

We sampled a total of 21,090 patients who underwent colectomy. Of these, 7480 (35.5 %) had open colectomy (OC), 8751 (41.5 %) had a laparoscopic colectomy, 2860 (13.6 %) had a HAL colectomy, and 1999 (9.5 %) had an open procedure converted from LC or HAL. Multivariate regression analysis revealed HAL colectomy had a similar mortality (AOR 0.53, P = 0.07) and a lower morbidity (AOR 0.37, P < 0.01) compared to OC. LC had lower mortality (AOR 0.58, P = 0.02) and morbidity (AOR 0.43, P < 0.01) compared to OC. Mortality of patients who underwent HAL was not significantly different from LC (AOR 0.90, P = 0.79); however, morbidity of such patients was significantly higher than for patients who underwent LC (AOR 1.29, P < 0.01).

CONCLUSIONS

HAL colectomy is a safe approach with significant advantages compared to open colectomy. Although the morbidity of patients who underwent HAL is higher than patients who underwent LC, the morbidity rate is still lower than OC.

Comparison of hand-assisted laparoscopic surgery using tissue fusion devices and open resection for treatment of rectosigmoid carcinoma

Modern tissue fusion devices used in hand-assisted laparoscopic surgery (HALS), a method of combining endoscopic surgery with tactile sensation, can minimize surgical trauma and hospitalization times beyond both conventional laparoscopy and open surgery. The outcomes of HALS using tissue fusion devices and conventional open surgery for curative resection of rectosigmoid carcinoma were compared. A total of 78 (45 males, 33 females; mean age, 57.2±11.7 y) rectosigmoid carcinoma patients underwent HALS surgery (HALS group) and 78 age-matched, sex-matched, and tumor status-matched rectosigmoid carcinoma patients (control group) underwent open resection between June 2008 and June 2010. In the HALS and control groups, abdominal incision length, intraoperative blood loss, procedure time, postoperative abdominal drainage, time to first flatus (bowel function return), length of hospital stay, morbidity, mortality, and pathology were assessed. Procedure times were similar in both groups (142.37±42.09 vs. 137.56±36.24 min). However, length of abdominal incision (5.14±0.47 vs. 13.17±2.41 cm), intraoperative blood loss (125.96±75.58 vs. 142.56±65.37 mL), need for postoperative analgesia, bowel function return (68.01±22.64 vs. 79.77±19.94 h), and postoperative hospital stay (6.47±1.73 vs. 7.73±1.71 d) were all significantly improved in the HALS group. At a median follow-up of 26 months, no significant differences in anastomotic recurrence were observed between groups (1 case/each group). Thus, the HALS approach for curative resection of rectosigmoid carcinoma was found to be similarly safe and effective compared with open resection. Furthermore, HALS may improve postoperative recovery and reduce hospitalization times.

Clinical outcomes of 103 hand-assisted laparoscopic surgeries for left-sided colon and rectal cancer: single institutional review

Purpose

The laparoscopic colectomy is avoided principally because of its technical difficulty, steep learning curve, and increased operative time. Hand-assisted laparoscopic surgery (HALS) is an alternative technique that addresses these problems while preserving the short-term benefits of a laparoscopic colectomy. Our study was aimed to describe the characteristics of patients admitted due to left-sided colon and rectal cancer for HALS.

Methods

A prospectively maintained database was used to identify patients who underwent HALS at the Institute of Oncology, Vilnius University, from July 1, 2009, to October 1, 2012.

Results

One hundred-three HALS colorectal resections were performed. The patients' mean age was 64 ± 13.4 years. There were 46 male and 57 female patients. The body mass index was 27.3 ± 5.8 kg/m². Forty-three patients (41.8%) had experienced prior abdominal surgery. The mean HALS time was 105 minutes (range, 55-85 minutes). The conversion rate was 2.7% (3/103). The median of return of gastrointestinal function was 2.5 days (range, 2.2-4.5 days). The median length of hospital stay was 9 days. The postoperative complication and mortality rates were 10.7% and 0.97%, respectively. Four incisional hernias (3.9%) were seen at a mean follow-up of 7.0 ± 3.4 months. None of the patients had a trocar or a hand-port site recurrence.

Conclusion

A HALS colorectal resection is a safe and effective technique, and it provides all the benefits of minimally invasive surgery.

Toward the rational use of standardized infection ratios to benchmark surgical site infections

BACKGROUND

The National Healthcare Safety Network transitioned from surgical site infection (SSI) rates to the standardized infection ratio (SIR) calculated by statistical models that included perioperative factors (surgical approach and surgery duration). Rationally, however, only patient-related variables should be included in the SIR model.

METHODS

Logistic regression was performed to predict expected SSI rate in 2 models that included or excluded perioperative factors. Observed and expected SSI rates were used to calculate the SIR for each participating hospital. The difference of SIR in each model was then evaluated.

RESULTS

Surveillance data were collected from a total of 1,530 colon surgery patients and 185 SSIs. C-index in the model with perioperative factors was statistically greater than that in the model including patient-related factors only (0.701 vs 0.621, respectively, P < .001). At one particular hospital, for which the percentage of open surgery was lowest (33.2%), SIR estimates changed considerably from 0.92 (95% confidence interval: 0.84-1.00) for the model with perioperative variables to 0.79 (0.75-0.85) for the model without perioperative variables. In another hospital with a high percentage of open surgery (88.6%), the estimate of SIR was decreased by 12.1% in the model without perioperative variables.

CONCLUSION

Because surgical approach and duration of surgery each serve as a partial proxy of the operative process or the competence of surgical teams, these factors should not be considered predictive variables.

Elective open versus laparoscopic sigmoid colectomy for diverticular disease: a meta-analysis with the Sigma trial

BACKGROUND

A meta-analysis of published literature comparing open versus laparoscopic elective sigmoid resections for diverticular disease was conducted.

METHODS

Electronic databases were searched for data from January 1991 to March 2009. A systematic review was performed to obtain a summative outcome.

RESULTS

Twenty-two comparative studies involving 10,898 patients were analyzed; 1538 patients were in the laparoscopic group and 9360 were in the open group. The operative time for laparoscopic sigmoid resection (LSR) is longer than open resections (OSR) [random-effects model: SMD = 1.94, 95% CI = (1.14, 2.74), z = 4.74, p < 0.001]. However, patients who undergo LSR have earlier return to passage of feces [random-effects model: SMD = -1.01, 95% CI (-1.80, -0.22), z = -2.50, p = 0.013] and shorter hospital stay [random-effects model: SMD = -7.65, 95% CI (-10.96, -4.32), z = -4.52, p < 0.001]. Overall morbidity was higher in the OSR group [random-effects model: RR = 0.56, 95% CI (0.40, 0.80), z = -3.24, p < 0.001] and no difference in mortality rates was observed (p = 0.81).

CONCLUSIONS

Laparoscopic sigmoid resection takes longer to perform than open procedures; however, it is safe and has lower overall morbidity, earlier return of bowel function, and shorter hospital stays. This approach should be considered for elective cases but more randomized controlled trials are required to strengthen the evidence.

Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis

BACKGROUND

We performed a meta-analysis of published literature comparing the complications after open and laparoscopic elective sigmoidectomy for diverticular disease.

METHODS

Electronic databases were searched from January 1991 to March 2009. A systematic review was performed to obtain a summative outcome.

RESULTS

Nineteen comparative studies involving 2,383 patients were analyzed. There were 1,014 patients in the laparoscopic group and 1,369 patients in the open group. There was no significant heterogeneity among any of the complications analyzed. Patients in the laparoscopic sigmoid resection group had fewer wound infections (fixed effects model: risk ratio [RR], .54; 95% confidence interval [CI], .36-.80; z, -3.05; P < .01; random effects model: RR, .59; 95% CI, .39-.89; z, -2.54; P < .05), blood transfusions (fixed effects model: RR, .25; 95% CI, .10-.60; z, -3.10; P < .01; random effects model: RR, .28; 95% CI, .11-.68; z, -2.81; P < .01), and ileus rates (fixed effects model: RR, .37; 95% CI, .20-.66; z, -3.34; P = .001; random effects model: RR, .37; 95% CI, .20-.68; z, -3.21; P = .001) compared with open sigmoid resections. No difference was seen for medical complications, need for rehospitalization, and reoperation.

CONCLUSIONS

Laparoscopic sigmoid resection is safe and has fewer postoperative surgical complications. This approach should be considered for elective cases, however, more randomized controlled trials are required to strengthen the evidence.

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 laparoscopic 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.

Management of complications in surgery of the colon

BACKGROUND

General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly.

METHODS

We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads).

RESULTS

Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision®, Ligasure®) as well as a well coordinated team help to reduce complications and duration of surgery.

CONCLUSIONS

To avoid is better than to repair. If complications do occur, appropriate surgical and intensive - care measures should be taken immediately.

Hand-assisted laparoscopic colectomy: rational evolution for diverticulitis

Laparoscopic technique has proved to be a revolutionary advance in the surgical treatment of disease. However, limits exist regarding its application to colorectal resection as evidenced by the higher conversion rate and longer learning curve seen with colectomy. Conversion remains a complex issue related to multiple factors. One of the factors, inflammatory disease such as diverticulitis, exposes limitations of laparoscopic technique, specifically the absence of tactile sensation and use of one's hand as a surgical instrument. Nonetheless, the clinical benefits of smaller incisions, decreased pain, decreased ileus, and reduced hospitalization and disability make laparoscopic colectomy a compelling surgical option for the treatment of diverticulitis. Hand-assisted technique offers surgeons a practical and rational innovation for conventional laparoscopic colectomy and offers promise for improved feasibility and efficacy for the treatment of diverticulitis.

Laparoscopic "radical appendectomy" is an effective alternative to endoscopic removal of cecal polyps

BACKGROUND

The endoscopic removal of cecal polyps can be complicated by hemorrhage, perforation, or incomplete resection. Laparoscopic radical appendectomy represents a safe alternative for the definitive resection and accurate pathologic evaluation of selected cecal polyps.

METHODS

Patients with cecal cap polyps not involving the ileocecal valve were candidates for laparoscopic radical appendectomy. Intraoperative colonoscopy and resection of the appendix and cecum to the level of the ileocecal valve were accomplished via three midline ports. For each patient, histologic evaluation by frozen section ruled out malignancy and ensured complete resection.

RESULTS

Five patients, four of whom had significant medical comorbidities, presented with large adenomatous polyps contained within the cecum. Each polyp was determined to be unresectable endoscopically; therefore, a laparoscopic radical appendectomy was performed. One patient with cirrhosis also underwent intraoperative liver ultrasonography and biopsies, which contributed to the longest operative time and hospital stay. The histologic diagnosis by frozen section was benign for each patient. The mean operative time was 95 minutes, and the mean length of hospital stay was 1.8 days. No postoperative complications were observed during a mean follow-up of 6 months.

CONCLUSION

Laparoscopic "radical appendectomy" is an effective treatment for selected cecal adenomatous polyps. Our ability to resect the polyps completely and avoid a standard right hemicolectomy supports this approach.

Laparoscopic colectomy vs. open colectomy for sigmoid diverticular disease

PURPOSE

The feasibility of laparoscopic colectomy for colon surgery has now been well established. Most of the studies on laparoscopic colectomies include all types of colonic pathologies without discrimination. Our goal was to compare laparoscopic sigmoid colectomy open sigmoid colectomy for simple sigmoid diverticular disease, to assess whether it can be done safely and whether the proposed advantages could be realized.

METHODS

We evaluated the differences in outcomes of 66 laparoscopic sigmoid colectomy patients and 88 open sigmoid colectomy patients. We report a five-year outcomes analysis of 154 patients undergoing sigmoid colectomy for diverticular disease. We compared age, gender, history of prior abdominal surgery, estimated blood loss, operative time, total conversions with reason for conversion, time until a liquid diet was started, postoperative complications, hospital length of stay, operation costs, and total hospital charges incurred for both laparoscopic sigmoid colectomy and open sigmoid colectomy.

RESULTS

Mean age and gender were similar in the two groups. However, the mean estimated blood loss (143 ml 314 ml), time until a liquid diet was started (2.9 4.9 days), and hospital length of stay (4.8 8.8 days) were all significantly less in laparoscopic sigmoid colectomy patients. The mean operative time for laparoscopic sigmoid colectomy was 212 minutes as compared with 143 minutes for open sigmoid colectomy ( < 0.05). Conversion rate of laparoscopic sigmoid colectomy to open procedure was 19.7 percent. All laparoscopic sigmoid colectomy patients received a lighted ureteral stent preoperatively, which was removed at the end of surgery. Relevant complications for laparoscopic sigmoid colectomy open sigmoid colectomy were as follows: anastomotic leak in 1 3 (1.5 3.4 percent) patients, hematuria in 64 6 (97 6.8 percent) patients, with an average duration for 2.93 3 days, urinary tract infection in 5 4 (7.6 4.5 percent) patients, and ureteral injury in 1 2 (1.5 2.2 percent) patients. Although the mean operating room charges were greater in the laparoscopic sigmoid colectomy patients ($9,566 $7,306) the mean hospital charges ($13,953 $14,863) were less.

CONCLUSIONS

We recommend laparoscopic sigmoid colectomy as the modality of treatment for diverticular disease. Laparoscopic sigmoid colectomy seems to be a reliable, safe and efficacious treatment modality with better outcomes for diverticular disease of the sigmoid colon. The operative time for laparoscopic sigmoid colectomy is decreasing as surgeons gain more experience.

Experience as a factor influencing the indications for laparoscopic colorectal surgery and the results

BACKGROUND

The influence of experience on the results of treatment with laparoscopic surgery is indisputable. The establishment of indications and contraindications is relative, and varies depending on the experience of the surgeon. Learning curves have been described for a number of laparoscopic interventions, in particular laparoscopic cholecystectomy. The current prospective multicenter study investigates, among other things, the interrelation between experience and the results of treatment using laparoscopic colorectal surgery. The study makes no pronouncements on the long-term results achieved in patients with colorectal carcinoma who underwent an operation with curative intent, although relevant data were indeed collected.

RESULTS

Between August 1, 1995 and February 1, 1999, a total of 1,658 patients were recruited to the prospective multicenter study initiated by the Laparoscopic Colorectal Surgery Study Group. To investigate the influence of surgical experience, two groups were formed. Group A comprised all the institutions and surgeons with experience of more than 100 laparoscopic colorectal operations. Group B contained institutions and surgeons with experience of fewer than 100 such interventions. The results of this study clearly show that in Group A, significantly more procedures involving the rectum were performed (26.7% vs 9.5%), and significantly more carcinomas were surgically managed (37.3% vs 17.3%). Despite this significantly higher level of technically difficult procedures in the patient population of group A, which was comparable in terms of age, gender, height, and weight with the patient in group B, the postoperative mortality and morbidity was, with the exception of urinary tract infections, identical between the two groups. Conversion to open surgery was significantly less frequent in group A (4.3% vs 6.9%), and, finally, the duration of the procedures performed by the more experienced surgeons of group A was appreciably shorter than in institutions with a smaller frequency of such operations.

CONCLUSIONS

Laparoscopic colorectal surgery is very demanding, and can be performed with low morbidity and mortality rates only by a surgeon with above-average experience with this type of surgery and a large caseload of laparoscopic colorectal procedures. The learning curve for such procedures is appreciably longer than for other laparoscopic operations. With increasing experience, technically more demanding operations, including radical oncologic rectal laparoscopic procedures, can be performed with appreciably reduced operating times and conversion rates, but with no increase in morbidity or mortality.

Defining a learning curve for laparoscopic colorectal resections

PURPOSE

The purpose of this review was to define the learning curve for laparoscopic colorectal resections.

METHODS

A prospectively accumulated, computerized database of all laparoscopic colorectal resections performed by three surgeons between April 1991 and March 1999 was reviewed.

RESULTS

A total of 461 consecutive resections were evenly distributed among three surgeons (141, 155, and 165). Median operating time was 180 minutes for Cases 1 to 30 in each surgeon's experience and declined to a steady state (150-167.5 minutes) for Cases 31 and higher. Subsequently, Cases 1 to 30 were considered "early experience," whereas Cases 31 and higher were combined as "late experience" for statistical analysis. There were no significant differences between patients undergoing resections in the early experience and those undergoing resections in the late experience with respect to age, weight, or proportion of patients with malignancy, diverticulitis, or inflammatory bowel disease. There were greater proportions of males (42 vs. 54 percent, P = 0.046) and rectal resections performed (14 vs. 32 percent, P = 0.002) in the late experience. Trends toward declining rates of intraoperative complications (9 vs. 7 percent, P = 0.70) and conversion to open surgery (13.5 vs. 9.7 percent, P = 0.39) were observed with experience. Median operating time (180 vs. 160 minutes, P < 0.001) and overall length of postoperative hospital stay (6.5 vs. 5 days, P < 0.001) declined significantly with experience. There was no difference in the rate of postoperative complications between early and late experience (30 vs. 32 percent, P = 0.827).

CONCLUSIONS

The learning curve for performing colorectal resections was approximately 30 procedures in this study, based on a decline in operating time, intraoperative complications, and conversion rate. Learning was also extended to clinical care because it was appreciated that patients could be discharged to their homes more quickly.

Importance of conversion for results obtained with laparoscopic colorectal surgery

PURPOSE

The need for a conversion is a problem inherent in laparoscopic surgery. The present study points up the significance of conversion for the results obtained with laparoscopic colorectal surgery and identifies the risk factors that establish the need for conversion.

METHOD

The study took the form of a multicentric, prospective, observational study within the Laparoscopic Colorectal Surgery Study Group. A total of 33 institutions in Germany, Austria, and Switzerland participated. The study period was 3.5 years. Cases were documented with the aid of a standardized questionnaire.

RESULTS

Within the framework of the Laparoscopic Colorectal Surgery Study Group, a total of 1,658 patients were recruited to a multicenter study over a period of three and one-half years (from August 1, 1995 to February 1, 1999). The observed conversion rate was 5.2 percent (n = 86). The patients requiring a conversion were significantly heavier (body mass index, 26.5 vs. 24.9) than those undergoing pure laparoscopy. Resections of the rectum were associated with a higher risk for conversion (20.9 vs. 13 percent). Intraoperative complications occurred significantly more frequently in the conversion group (27.9 vs. 3.8 percent). The duration of the operation was significantly increased after conversion in a considerable proportion of the procedures performed. Postoperative morbidity (47.7 vs. 26.1 percent), mortality (3.5 vs. 1.5 percent), recovery time, and postoperative hospital stay were all negatively influenced by conversion, in part significantly. Institutions with experience of more than 100 laparoscopic colorectal procedures proved to have a significantly lower conversion rate than those with experience of fewer than 100 such interventions (4.3 vs. 6.9 percent).

CONCLUSION

Although, of itself, conversion is not considered to be a complication of laparoscopic surgery, it is true that the postoperative course after conversion is associated with appreciably poorer results in terms of morbidity, mortality, convalescence, blood transfusion requirement, and postoperative hospital stay. The importance of experience in laparoscopic surgery can be demonstrated on the basis of the conversion rates. Careful patient selection oriented to the experience of the surgeon is required if we are to keep the conversion, morbidity, and mortality rates of laparoscopic colorectal procedures as low as possible.

Re-establish pneumoperitoneum in laparoscopic-assisted sigmoid resection? Randomized trial

PURPOSE

Operating room time and anastomosis-related morbidity of laparoscopic-assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision or laparoscopically after re-establishing pneumoperitoneum were compared.

METHODS

A randomized trial was performed on patients with recurrent uncomplicated diverticulitis of the sigmoid colon during a 14-month period. Inclusion criteria were persistence of symptoms despite medical treatment and two previous admissions. Exclusion criteria included complicated diverticulitis, suspected cancer, and previous extensive abdominal surgery. Because skin incisions were similar and patients were randomly assigned in the operating room, the trial was performed as double blind.

RESULTS

There were no deaths. Two patients were excluded before randomization. Three patients were not treated as allocated because of conversion to open surgery. Aside from previous abdominal-surgery rates, 16 patients with laparoscopic-assisted sigmoid resections after re-establishing pneumoperitoneum and 15 patients with laparoscopic-assisted sigmoid resections with anastomosis performed in an open fashion through a horizontal suprapubic incision were well-matched for age, gender, weight, American Society of Anesthesiology class, previous admissions, skin-incision length, size of circular stapler, and mobilization of splenic flexure. There were no significant differences in morbidity rates (3/16 vs. 3/15), complete doughnuts (16/16 vs. 15/15), blood loss (300 vs. 200 ml), flatus (4 vs. 4 days), solid-food resumption (5 vs. 6 days), stay (8.5 vs. 9 days) in laparoscopic-assisted sigmoid resection after re-establishing pneumoperitoneum and laparoscopic-assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision groups, respectively. Patients with laparoscopic-assisted sigmoid resection after re-establishing pneumoperitoneum had statistically longer operating room time (295 vs. 190 minutes; P < 0.01). Median follow-up was 12 and 10 months in 10 patients with laparoscopic-assisted sigmoid resection after re-establishing pneumoperitoneum and 11 patients with laparoscopic-assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision, respectively. One patient with laparoscopic-assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision had an anastomotic stenosis endoscopically dilated.

CONCLUSIONS

Nonrestoration of pneumoperitoneum after laparoscopic-assisted sigmoid resection allows a decrease in operating room time and a similar outcome.

Laparoscopic Colon Resections: A Five-Year Retrospective Review

In recent years, laparoscopic surgery has become a matter of growing interest. It has been shown that laparoscopic colectomy is well tolerated and safe for benign disease. However, there is some uncertainty about using this method for malignant disease when curative resection is the aim. These uncertainties mainly consist of spread of cancer to port site, long-term survival, and adequacy of resection. The majority of laparoscopic colectomies are technically assisted procedures in which anastomosis is performed outside the abdomen. However, some surgeons are now performing this surgery totally laparoscopically with the anastomosis performed inside the abdomen. Laparoscopic colectomy is currently practiced with great frequency by general surgeons. Its performance requires a steep learning curve and a large number of cases to obtain proficiency. The indications for laparoscopic colectomy are different from one institution to another. In some institutions all patients with colorectal disease are candidates for laparoscopic colectomy and in others it may be limited to benign disease only. The purpose of this review is to analyze all laparoscopic colectomies performed at our medical center since 1992. We conducted a retrospective chart review of both hospital and clinic charts of patients who underwent colectomies at our hospital. A total of 338 patient charts were reviewed. In a comparison of both laparoscopic (n = 285) and converted (n = 53) methods, the age and operative time were about the same. Age average and operating room time average were similar for both groups. With laparoscopy, there was a 3-day drop in length of hospital stay as well as a 1-day-earlier regaining of bowel function. Hospital cost dropped $5000 average for the laparoscopic colectomy. The conversion rate at our center was 15 per cent. Complication rates were lower in the laparoscopic group. Recurrence of cancer at the port site (0.7%) was no higher than in the converted group (incisional recurrence, 1.8%). We conclude that laparoscopic colectomy does show an improvement in return of bowel function, hospital cost, and shorter hospital stay. Long-term follow-up will be necessary to determine the effectiveness of laparoscopic colon resection for colorectal cancer.

Laparoscopic surgery for colorectal cancer

Despite the widespread use of laparoscopic techniques in many fields, in the realm of malignant diseases, a great concern has been raised regarding safety, efficacy, and long-term results. The authors report their experience of 163 patients operated on for colorectal malignancies by minimally invasive access. The conversion rate (20.4%), morbidity (15.1%), and null mortality compare well with other studies published worldwide. The postoperative outcome was characterized by a prompt return to activity (1.3 days) and of bowel movements (2.9 days), while length of stay and an adequate oral resumption were comparable to those of open surgery. Peritoneal lavage did not show tumor cells disseminated during the operative maneuvers. The distance of tumor from resection margins and the number of lymph nodes harvested with the operative specimen did not vary from those obtained in open surgery. Two patients (1.2%) recurred at the mini-laparotomy and port sites, but, in both cases, the traumatic manipulation of the cancer specimen was probably responsible for the event. After a mean follow-up of over 3 years, 34 patients died of neoplastic recurrence, and 17 are alive with disease relapse. The laparoscopic approach to colectomy has not yet gained an unquestioned place in the experience of the colorectal surgeon. However, if sound surgical method and judgement are used to minimize local recurrences, and if a better preservation of postoperative immune function proves to be of clinical significance in the long term, laparoscopic colectomy may prove to be a safe and less stressful approach to colon resection.

A three-trocar midline approach to laparoscopic-assisted colectomy

Several techniques have been described for the trocar placement in laparoscopic-assisted colectomy (LAC). They share the placement of four or five trocars in different areas of the abdomen. A specimen extraction incision in these techniques generally incorporates only one or two trocar sites, and combined length of these incisions approximates the length of a limited laparotomy incision for open colectomy. In addition, intracorporeal communication between the surgeon and the first assistant, who usually works "against" the camera, is challenging and may actually prolong the procedure. We describe here a three-trocar midline approach to laparoscopic-assisted colectomy that allows incorporation of these trocar sites into a midline laparotomy approximately 3 inches long for "open" bowel resection and anastomosis. As a result, the total length of the abdominal wall incision is smaller and cosmesis is superior, while the relative simplicity of the technique, in comparison to complete laparoscopic colectomy, is emphasized. In this technique, the surgeon is much less dependent on the assistant's laparoscopic skills, allowing the laparoscopic part of the procedure to be performed by one surgeon assisted only by a camera operator.

Hand-assisted laparoscopic surgery (HALS): a useful technique for complex laparoscopic abdominal procedures

Advanced laparoscopic abdominal surgery is now being performed routinely. However, it can be extremely challenging and time-consuming, and it may be associated with increased intraoperative and postoperative complications, mainly due to the loss of tactile sensation with totally laparoscopic techniques. This article describes a technique of hand-assisted laparoscopic surgery for complex abdominal procedures that allows the surgeon to insert a nondominant hand into the abdominal cavity while preserving the pneumoperitoneum. Use of the hand allows for rapid exploration, methodical dissection, identification of crucial structures, and expeditious performance of a procedure because of the maintenance of the tactile sensation. Our experience with this approach has been favorable.

Hand-assisted laparoscopic sigmoidectomy for diverticulitis

BACKGROUND

Sigmoid colectomy for diverticular disease, a routine procedure when performed using standard open methods, can prove much more challenging using minimum access techniques. Hand-assisted laparoscopic colectomy is a new technique that reportedly has a minimum learning curve, yet retains the benefits of a laparoscopic procedure. The purpose of this study was to perform and then prospectively to evaluate the outcome of this procedure on patients needing elective sigmoidectomy for diverticular disease.

METHODS

Hand-assisted laparoscopic sigmoidectomy was performed on all patients undergoing elective sigmoidectomy for diverticular disease between January 18, 1996, and November 21, 1996.

RESULTS

The study group consisted of six men and three women. Age averaged 50.8 (range, 39-66) years, weight averaged 183 (range, 150-224) pounds, and operation time averaged 3 hours and 42 minutes (range, 3-5 hours). No cases were converted to open methods. There were two minor postoperative complications (bleeding from the staple line, 1 patient; urinary retention, 1 patient; 22 percent). Resumption of flatus (which was the indication to start the patient on an oral diet) occurred between one and three (average, 1.44) days postoperatively. Patients were discharged from the hospital between one and three (average, 2.1) days postoperatively. Primary surgeon responsibility was distributed among four different surgeons, of which only the lead author previously had performed laparoscopic colectomy at this institution.

CONCLUSIONS

Hand-assisted laparoscopic sigmoidectomy is a procedure that has a minimum learning curve, yet retains the benefits of a laparoscopic procedure.

Standardized perioperative care protocols and reduced length of stay after colon surgery

BACKGROUND

Recent studies have suggested that critical pathways and standard order sets decrease hospital length of stay and improve quality of care. A recently conducted prospective, randomized study at our institution found that patients undergoing elective colon resections had earlier return of bowel function if perioperative epidural anesthesia and analgesia were provided. All patients in the study were also placed on a standardized perioperative regimen. We hypothesized that the standardized perioperative protocol used in this study contributed to early return of bowel function and hospital discharge compared with similar patients managed off protocol.

STUDY DESIGN

To test this hypothesis, we performed a case-controlled study comparing the hospital courses of 36 study patients to 36 control patients undergoing colorectal surgery by the same surgeons during the same calendar year. The distribution of types of operations and anesthetic techniques was similar in both groups.

RESULTS

As dictated by the protocol, all study patients had their nasogastric tubes removed, were started on a low fat liquid diet, and ambulated in the first postoperative day. Nasogastric tubes were removed in control patients and study patients 2.2 +/- 0.9 (mean value +/- SD) and 1.0 +/- 0.0 days postoperatively, respectively. Control patients were started on an oral diet, usually clear liquids, an average of 2.9 +/- 1.1 days postoperatively, a specific liquid diet was started 1.0 day postoperatively in study patients (p < 0.001). Return of bowel function, as determined by bowel tones, flatus, and bowel movements, occurred approximately 1 day earlier in study patients. Study patients were discharged 1 day sooner than control patients.

CONCLUSIONS

Our results suggest that the return of bowel function and the length of stay of patients undergoing colon surgery are improved if patients are entered into a standardized protocol that eliminates variation in intraoperative and postoperative anesthesia and postoperative surgical care. We believe these results can be reproduced in routine clinical surgery by having a clearly outlined protocol for perioperative care similar to that used in this study.