Laparoscopic restorative proctocolectomy ileal pouch anal anastomosis: How I do it?

A critical appraisal of the cost effectiveness of laparoscopic colorectal surgery for oncological and non-oncological resections

The aim of this study was to critically appraise the cost effectiveness of the laparoscopic colorectal (LCRS) surgery using published randomised, control trials (RCTs). Published RCTs comparing the cost effectiveness of LCRS with conventional open surgery were selected from the search of standard electronic databases and the extracted data were analysed using the statistical software RevMan 5.3. Seven RCTs on 2197 patients reported the cost effectiveness of the LCRS. There was significant heterogeneity (τ ² = 161,772.25, χ ² = 166.69, df = 6, p = 0.00001, I ² = 96%) among included randomised, controlled trials. In the random effects model analysis (MD 320.37, 95% CI -38.21, 678.95, z = 1.75, p < 0.08), the LCRS was costing £320.37 more than open colorectal resection but it failed to reach the statistical significance indicating that LCRS is as much cost effective as the open approach. LCRS is a cost effective intervention and should be offered routinely to all patients requiring colorectal resections provided the resources and expertise are available.

Vascular High Ligation and Embryological Dissection in Laparoscopic Restorative Proctocolectomy for Ulcerative Colitis

INTRODUCTION

After its description in 1980, restorative proctocolectomy has become the procedure of choice for ulcerative colitis (UC). The supposed advantages of the laparoscopy have proven beneficial for colorectal operations but a standard technique in laparoscopic restorative proctocolectomy (LRP) is still lacking. In this study, we present our technique of LRP with vascular high ligation (VHL) and embryological dissection (ED).

MATERIALS AND METHODS

This retrospective study reviewed patients who underwent LRP with VHL for UC from January 2009 to June 2015. Of these, only two-stage LRP patients were included to the study. The LRP technique was performed by five ports through a medial-to-lateral approach. The dissection was carried out between the embryological planes and all the vessel roots were highly divided. A diverting ileostomy was performed in all of the patients.

RESULTS

Forty-six patients were operated for UC with the laparoscopic approach. Among these patients, there were 19 (8 females) patients who were performed LRP with VHL. The median age was 42 (range 25-62) years. No intraoperative complications occurred. There was no conversion to open procedure. Early postoperative complications were observed in 3 (15.8%) patients, including postoperative mechanical bowel obstruction (n = 1), wound infection (n = 1), and ileal pouch bleeding (n = 1).

DISCUSSION

High ligation of the vessels is not routinely performed except in the presence of malignancy. In our study, we focus on the importance of high ligation and ED for better observation and preservation of the important anatomical structures. According to our opinion, this approach aids in the preservation of the ureters, nerves, and the duodenum providing better observation of dissection planes.