Chapter 3

Laparoscopic approach of inflammatory bowel disease

Chapter 3.1

Laparoscopically assisted bowel surgery for inflammatory bowel disease: the combined experiences of two academic centers

W.J.H.J. Meijerink^l, Q.A.J. Eijsbouts², M.A. Cuesta², R.A. van Hogezand¹, J. Ringers, S.G.M. Meuwissen², G. Griffioen¹, W.A. Bemelman¹

¹ Department of Surgery, Leiden University Medical Center, Leiden,

² Department of Surgery, the Vrije Universiteit, Amsterdam,

The Netherlands

Surg Endosc 1999; 13:882-6

Abstract

Background: laparoscopic bowel surgery was evaluated in 44 consecutive patients who underwent surgery for inflammatory bowel disease (IBD). We studied feasibility, results, and final outcome.

Methods: At two academic institutes, 44 laparoscopically assisted colectomies and laparoscopic ileostomies or colostomies were attempted. All patients had histologically proven IBD and no prior surgery for IBD. Loop ileostomy (n=4), end colostomy (n=1), ileocaecal resection (n=26) and (procto)colectomy (n=13) were performed. All resections were laparoscopically assisted with extracorporal resection and anastomosis.

Results: Only in two patients (ileocaecal resections in both) was conversion to open surgery necessary. Two patients with laparoscopic ileocolic resection had intra-abdominal abscesses, which were drained percutaneously in both. One patient in the laparoscopically assisted colectomy group had a subphrenic abscess that was drained percutaneously, and one patient had a generalized candidiasis.

Conclusion: Laparoscopically assisted colectomies can be performed safely in treating IBD. The laparoscopic method with use of a small vertical umbilical or Pfannenstiel incision seems acceptable with regard to operating time and overall costs, also allowing superior cosmesis to be maintained.

Introduction

Since introduction in 1991 [12, 37], there has been an increasing documentation on laparoscopically assisted colectomy. The procedure has been proved safe in large series [8, 9, 21, 28, 32, 43, 45], and randomized trials [40]. Potential benefits such as a decreased peroperative blood loss, less postoperative pain and narcotic requirements, reduced pulmonary complications, earlier postoperative recovery [2, 7, 16, 29, 32, 47], and shortened hospital stay have been suggested, with no increase in postoperative morbidity and mortality [5, 7, 8, 15, 16, 19, 25, 32, 39]. The most obvious benefits of laparoscopy to the patient are the preservation of the abdominal wall and the cosmetic aspect [29]. Disadvantages include a more elaborate procedure with prolonged operative time, more surgical expenses for stapling devices, and a difficult learning curve [32, 33, 36, 38, 46].

Laparoscopic colectomy for malignancy technically is a feasible procedure and seems to be gaining more support. The absence of inflammatory changes makes it possible to standardize the surgical technique. Extent of resection, tumor-free margins, and the number of nodes harvested have been shown to compare closely with those in conventional surgery [6, 14, 21]. The high percentage of port-site metastases reported initially have resulted in prospective randomized studies to analyze the possible advantages of laparoscopic colectomy in colorectal cancer.

No such controversy exists in laparoscopic surgery for benign diseases. Laparoscopic colectomy for benign noninflammatory disease seems both feasible and safe. On the contrary, laparoscopic bowel surgery for inflammatory bowel disease (IBD) presents the surgeon with important additional pitfalls: an inflammatory mass, thickened mesentery and bowel, unexpected enteric fistulae and abscesses that hamper laparoscopic dissection and challenge the surgeon with small removal incisions. Few reports in the literature, with limited numbers, have been published on this subject [3, 11, 17, 19, 23, 24, 30, 31, 34, 41].

The objective of this study was to evaluate the combined experience with laparoscopically assisted bowel surgery for IBD at the surgical departments of two academic hospitals (Leiden University Medical Center and the Vrije Universiteit in Amsterdam). Patient characteristics, indications for surgery, the lapararoscopic approach used, and the results and final outcome of the patients are reported in this article.

Patients and methods

Patient population

A prospective study of all consecutive laparoscopic bowel resections for IBD performed between January 1995 and June 1997 in the two surgical departments was performed. Forty-four laparoscopic “dissection-facilitated” bowel procedures were performed in patients with either histologically proven Crohn’s disease (n=33) or ulcerative colitis (n=11). In all, 26 ileocolic resections, 1 left hemicolectomy, 12 total colectomies with four one-stage ileal pouch anal anastomosis and one ileorectal anastomosis, 4 loop ileostomies and 1 colostomy were performed.

All surgery performed was primary surgical intervention because of IBD. Laparoscopic approaches in treating IBD recurrences were not included in this series. Prior median laparotomy was considered to be a relative contraindication, because no improved cosmesis was to be expected from using a laparoscopic approach. All patients were informed of the relative risks with laparoscopic surgery and the possibility of conversion to the open technique. Informed consent was obtained in all patients.

Laparoscopic technique

Preoperative preparation was the same as that used in open bowel surgery. On the day before the operation, patients are allowed liquid diet and underwent colonic cleansing using 4 L of Clean Prep^®. At 30 min before surgery, patients receive antibiotic prophylaxis (Cefuroxime 750 mg, metronidazole 500 mg).

All operations were performed with the patient under general anaesthesia. A nasogastric tube and a Foley catheter were inserted after intubation. For stoma procedures patients, were placed in supine position. For ileocaecal resections and right-sided colectomies, patients were placed in the French position with the arms tucked at their sides. For left-sided and rectal procedures patients were placed in stirrups in modified lithotomy position.

For all the patients, pneumoperitoneum reaching 15 mm Hg at the inferior umbilical rim was induced by the Veress needle. An initial 10- to 12-mm port replaced the Veress needle. After abdominal inspection with a 10-mm 0⁰ laparoscope, other cannulas were placed under direct vision.

Stoma creation

The stoma sites were preoperatively marked with ink by the stoma nurse. After the laparoscope was introduced at the umbilical site, the stoma skin was excised, and under direct vision the second 10-mm cannula was inserted through this aperture.

For a loop ileostomy, the patient was placed in the Trendelenburg position with left side down, and the most distal segment of the ileum that can be exteriorized without tension was used. After it was verified by laparoscopic inspection which of the two ends was to be the oral end, the ports were closed and the ileostomy matured.

For the end sigmoid colostomy, a third 5-mm cannula was introduced into the left upper quadrant to dissect the lateral peritoneal reflection. A laparoscopic Babcock clamp was used to facilitate bowel traction. There was no intracorporeal dissection of mesentery. The bowel segment was exteriorized through the stoma aperture using the Babcock clamp. The sigmoid was diverted extracorporeally by a conventional linear stapling device. The aboral part was sutured to the abdominal fascia to facilitate future reanastomosis before the stoma was matured.

Ileocaecal resection

The surgeon stood between the patient’s legs, with the assistant on the patient’s left side and the monitor to the right of the patient. After placement of first trocar below the umbilicus, the patient was placed in steep Trendelenburg position with the left side down. Two additional 10-mm trocars were placed at the lower lateral right and left sides (halfway between the umbilicus and the anterior spine), avoiding the epigastric vessels. The small bowel was completely examined from terminal ileum to the ligament of Treitz by hand-over-hand technique to exclude other lesions. A laparoscopic retractor was used to facilitate bowel retraction. The peritoneal reflection was dissected up to and sometimes beyond the hepatic flexure. Right ureter and duodenum were identified. The majority of the dissection was performed by scissors and diathermia. The ileocaecal segment then was exteriorized by a muscle-splitting Mc Burney or a vertical transumbilical incision. Mesentery dissection, resection of the affected bowel, and hand-sewn anastomosis were performed extracorporeally. After approximation of the mesentery, the bowel was returned to the abdominal cavity. After closure of the abdominal fascia, laparoscopic inspection of the anastomosis was performed, and the anastomosis covered by omentum.

Colectomy

The surgeon stood between the patient’s legs with the assistant to the patient’s left side. The monitor was placed at patient’s left shoulder. An optional second monitor could be placed at patient’s left foot. After first trocar placement at the lower umbilical rim and inspection of the abdominal cavity, two 10-12 mm trocars were placed, one in the right and the other in left lower quadrant within the range of the future Pfannenstiel incision in the second half of the procedure. A fourth 5-mm trocar was placed in the left upper quadrant. The peritoneal reflection was mobilized starting on left or right side, including the hepatic and splenic flexures. The omentum was dissected free from the transverse colon and mobilization of the flexures was completed. One or two Babcock retractors were used for bowel retraction, and dissection was performed mainly by scissors and curved grasper. Both ureters were identified, as was the duodenum. After complete mobilization of the colon up to the promontory, including the presacral spaces of the rectum, a Pfannenstiel incision (10 cm) was made for open rectal dissection, dissection and ligation of the colonic mesentery with the help of abdominal retractors and. if appropriate, the creation of J-ileal pouch and ileoanal anastomosis. Creation of a stoma dependened on patient characteristics.

All patients were studied for the following parameters: surgical procedure, duration of procedure, peroperative blood loss, conversion rate, length of removal incisions and some postoperative parameters such as complications (both minor and major) and hospital stay. Minor complications included prolonged ileus with delay of oral intake, urinary tract infection or pulmonary infection with the need for antibiotics, or wound infection. Major complications include intra-abdominal abscesses, leakage of anastomosis or other complications requiring (surgical) intervention.

Results

Laparoscopic creation of stomas

Five women underwent laparoscopic creation of fecal diversion because of extensive Crohn’s fistula disease (four loop ileostomies and one colostomy in the sigmoid). Mean age was 28,2 years (range, 23-39 years). Procedure length varied, because in the majority of cases additional procedures including perianal fistula exploration, drainage of abscesses, colonoscopy, and adhesiolysis, were performed (range, 30 - 145 min). There were no postoperative complications. All patients resumed oral intake within the first 48 hours. Length of hospitalization was 8.3 days (range, 7-9 days) beacuase of stoma care training.

Ileocaecal resection

Twenty-six patients (20 women, 6 man) underwent an ileocaecal resection because of active Crohn’s ileocaecal disease in 25 patients and a caecal polyp as a result of ulcerative colitis in the other patient. Mean age was 31.3 years (range, 17-56 years). Mean length of procedure was 138 minutes (range, 100-210 min). In five cases additional procedures were performed: 2 take-downs of internal fistulae (135 min and 200 min, respectively), closure of split colostomy (210 min), stricturoplasty (210 min), and extended adhesiolysis (155 min). There were two conversions to open procedures: in one patient with a colojejunal fistula with mesenteric infiltration and in other patient who had extremely dense intra-abdominal adhesions.

The mean length of bowel resection was 30.5 cm (range, 15 - 70 cm) and the length of the minilaparotomy was 4.6 cm (range, 3 - 7 cm), determined by the size of the inflammatory mass. Peroperative blood loss was less than 100 ml in 14 patients and less than 250 ml in another 8 patients. One patient showed a major complication with a retrocaecal abscess and a recurrent Douglas abscess. Both were percutaneously drained and did not need further surgical intervention.

Total hospitalization averaged 5.6 days (range, 3-9 days), this being 8 and 12 days, respectively, in the two converted patients. All patients had resumed normal oral diet and were ambulant at time of discharge.

Colectomy

Thirteen laparoscopic dissection-facilitated (procto) colectomies were performed (on 1 man and 12 women) because of severe therapy-resistant colitis (3 Crohn’s disease patients and 10 patients with ulcerative colitis). The mean age of the patients was 32 years (range, 21 - 45 years). All patients were receiving corticosteroids and immunosuppressive therapy at the moment of surgery. Seven of 10 colectomies for ulcerative colitis were acute surgical interventions because of a (potential) toxic megacolon. Operating time averaged 300 min (range, 225 -360 min) and there were no conversions. Peroperative blood loss was low (mean, 160 ml; range, 100 - 500ml).

Two patients experienced minor complications one a urinary tract and wound infection, and a wound infection and the other a wound infection. Two patients had major complications: The first had a wound infection and a subphrenic abscess treated with percutaneous drainage, and the other had a general candidiasis with sepsis, a urinary tract infection, and a wound infection which needed surgical drainage).

Postoperative hospitalization averaged 13.2 days (range, 7-36 days) with a mean of 10.8 days in patients with minor or no complications.

Discussion

The objectives of the laparoscopic approach are reduced postoperative pain, early mobilization, virtual absence of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital, return to normal activity [36], and an improved cosmesis.

With the increasing abilities and skills being developed in laparoscopic surgery, laparoscopic bowel surgery for benign disease is a logical extension of this approach. The already demanding procedure of laparoscopic bowel surgery is even more challenging in IBD patients.

Reports of laparoscopic surgery to tread IBD are scarce, with small patient populations [1, 3, 4, 11, 13, 17, 19, 24, 34, 42]. Active inflammation and induration of the mesentery, fragile intestinal tissue, abscesses between intestinal loops, and dens adhesions can significantly complicate this procedure and might be responsible for the increased likelihood of conversion. High doses of immunosuppressive medication and the high incidence of malnutrition increase the likelihood of postoperative complications in these patients and may be the reason why many surgeons avoid laparoscopic surgery in IBD. Laparoscopically “dissection-facilitated” bowel surgery can, by adequate inspection of disease extent, mobilization of the affected bowel segment, and exteriorization through a limited incision, be used in inflammatory bowel surgery. In IBD patients, it combines the advantages of the minimally invasive approach with the safety and costeffectiveness of open surgery. The laparoscopic approach permits the safe division of the thickened mesentery and conventional vascular ligation. A hand-sewn anastomosis avoids the use of expensive intra-abdominal stapling devices. Additionally, the final cosmetic result is superior.

Stoma

The length of the surgical procedure depended on the additional procedures. In a series of 14 patients with a procedure of fecal diversion for reasons other than inflammatory bowel disease, laparoscopic stoma creation did not take longer than 45 minutes in our hospital [3]. No postoperative complications were seen in this group. The avoidance of a laparotomy was of great advantage in this group of frequently malnourished and immunocompromized patients. In the early postoperative period, when spilling and leakage are frequently encountered problems, the absence of a laparotomy wound in the proximity of the stoma reduced wound complications to almost zero and facilitates stoma care. Although patients quickly resumed oral intake and ambulating, hospital stay (mean, 8.3 days) was the same as in open surgery. This was mainly because of patients’ need for getting accustomed to stoma care and handling. The same results are found in the literature [10, 20, 27].

Laparoscopic stoma creation allows an excellent inspection of the intestines for localization of Crohn’s disease as evidenced by active inflammation, fatty overgrowth, and adhesion formation. It may also reduce adhesion formation as compared with open surgery in the event of future surgery, which can be expected in this group of patients. Maturation of the stoma can easily be performed through the stoma aperture. The aboral loop is sutured to the abdominal fascia to facilitate future localization.

Laparoscopic creation of stomas is easy and effective. Postoperative complications are limited because a laparotomy is avoided and the cosmetic results obtained are good.

Ileocaecal resections

The time required for laparoscopic ileocaecal resections was 138 min, which is virtually the same as the time reported in a historical control group given conventional surgical treadment (127 min). Laparoscopy permitted a complete small bowel inspection for other inflammatory lesions. Blood loss was minimal during the procedure, even in severely inflamed bowel conditions. The conversion rate was 8% (2 of 26). In the literature, the conversion rate of general bowel surgery varies between 7% and 35% [6, 15, 21, 32, 33, 39]. In a large survey of 1056 patients surgically treated by 118 surgeons, Ortega et al. found a conversion rate of 24% [28]. Nearly all articles on laparoscopically assisted colectomy claim reduced postoperative ileus. Studies on open bowel surgery show patients’ inability to tolerate liquids or pass flatus for 4 to 5 days postoperatively [18, 22, 44]. Hospitalization of 5.7 days in ileocaecal resection is in accordance with the literature, in which hospital stay of 6.0 to 6.5 days is mentioned [1, 13, 19, 24, 34]. This is short compared with conventional surgery. The postoperative morbidity was minimal, with only one major complication, and comparable with the figures for open surgery.

[Procto]colectomy

Despite the learning curve and combination with open pelvic dissection of the rectum, mesentery ligation, and anastomosis, this procedure remains elaborate and timeconsuming. In a recent review, Sardinha and Wexner state [35] that only in selected cases should laparoscopic surgery in mucosal ulcerative colititis be considered. Although a laparoscopic dissection facilitated approach, it is an extensive surgical procedure. Of potential benefit is the limited Pfannenstiel incision. Its location away from the stoma site lowers the chance of infection. Also, this procedure can be performed safely with a minimum of blood loss. The six patients with toxic megacolon caused by ulcerative colitis underwent their laparoscopically assisted procedures without any procedure-related complication. Hospital stay was similar to that of conventional procedures. It is not expected that this will be reduced significantly because of patient characteristics. Contributing factors are stoma training; resumption of oral intake, sometimes after weeks or months of parenteral or drip feeding by jejunal catheters; and withdrawal of parenteral medication.

Conclusion

This preliminary study shows that laparoscopic bowel surgery in patients with inflammatory bowel disease is feasible, well tolerated, and characterized by very low morbidity. We believe that laparoscopic stoma creation and ileocaecal resections in IBD can be performed safely, and that this should be the approach of choice in the first surgical intervention in IBD.

Sufficient experience in medical treatment of IBD and advanced laparoscopic assisted bowel surgery are prerequisites. Especially in these young patients, probably facing multiple future surgery, reduction of operation trauma and adhesion formation is important. Also, maintenance of of body image integrity can be of psychological benefit in helping the patient to accept the disease and its surgical therapy.

Laparoscopically assisted proctocolectomies may also be of benefit. Combined laparoscopic mobilization of the entire colon, especially both flexures, and open dissection of the rectum and anastomosis can reduce costs by avoiding expensive endostaplers and enable safe ligation of thickened mesentery. Future trials must prove the differences between laparoscopic and conventional approaches and justify elaborate and prolonged surgical intervention. The cosmesis, however, is superior (48).

References

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16.    Liberman MA, Phillips EH, Carroll BJ, Fallas M, Rosenthal R. (1996) Laparoscopic colectomy vs traditional colectomy for diverticulitis. Outcome and costs (see comments). Surg Endosc. 10:15-18.

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21.     Lumley JW, Fielding GA, Rhodes M, Nathanson LK, Siu S, Stitz RW. (1996) Laparoscopic-assisted colorectal surgery. Lessons learned from 240 consecutive patients. Dis Colon Rectum. 39:155-159.

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48    Dunker MS, Stiggelbout, AM, van Hogezand R A, Ringers J, Griffioen G, Bemelman W A. (1998) Cosmesis and body image after laparoscopic-assisted and open ileo-colic resection for Crohn’s disease. Surg Endosc 12:1334-40.

Chapter 3.2

A feasibility study of laparoscopic assisted subtotal colectomy and proctocolectomy for benign diseases

Q.A.J. Eijsbouts, C. Sietses, S.G.M. Meuwissen, M.A. Cuesta

Submitted

Abstract

Background: Subtotal colectomy implies resection of the whole colon with the exception of the rectum. After a subtotal colectomy, several possibilities exist, such as preserving the rectum but creating either an ileostomy or an ileo-rectal anastomosis; or extirpating the rectum and creating either a conventional ileostomy, a continent ileostomy or an ileo-anal pouch anastomosis. The usual indications are ulcerative colitis, Crohn’s disease or familial polyposis coli. Currently the intervention is performed via a long median incision. Laparoscopic mobilization of the colon with division of the mesentery may have important advantages with better recovery and cosmetic outcome in a commonly young group of patients for whom surgery signifies an important obstacle.

Methods: Twenty-two patients with either ulcerative colitis, Crohn’s disease or familial polyposis coli underwent a laparoscopic assisted subtotal colectomy followed by retrieval of the specimen via a Pfannenstiel incision. The procedure could be completed using this approach.

Results: There was one conversion to laparotomy, and two major complications. Operative time up to the retrieval of the specimen via Pfannenstiel incision was average 2 hours 30 minutes, the hospital stay being 13 days.

Conclusions: Subtotal colectomy performed as a laparoscopic assisted operation is feasible, having a limited number of complications and improved recovery and cosmetic outcome. This last advantage is important in a group of patients in whom surgery usually is considered as a serious obstacle.

Introduction

Subtotal colectomy implies the resection of the whole colon with the exception of the rectum. Indications for this type of resection include ulcerative colitis, Crohn’s disease, familial colonic polyposis, morbid obstipation and multiple colon carcinomas. Following subtotal colectomy, several possibilities exist, such as to leave the rectal stump closed and to create an ileostomy; to perform an ileo-rectal anastomosis; to resect the rectum (proctocolectomy) and to create an ileostomy or a continent ileostomy; or to perform a restorative procedure by means of an ileo-anal pouch anastomosis [1]. During the subtotal colectomy, mobilization of the hepatic and splenic flexures are an important part of the procedure necessitating a near-total midline incision from xiphoid down to pubis.

Laparoscopic mobilization of the whole colon with division of its mesentery is feasible and may have important advantages such as a smoother recovery but especially a better cosmetic result, an important consideration for a young group of patients in whom conventional surgery signifies an important obstacle [2-4].

As a feasibility study, this paper deals with the experience of a consecutive group of twenty-two patients who underwent a laparoscopic assisted subtotal colectomy (or proctocolectomy) for benign colonic diseases. Surgical technique, complications and results are described.

Patients and methods

From January 1996 up to January 1999, twenty-two patients underwent a laparoscopic assisted subtotal colectomy (or proctocolectomy) for different benign colonic and rectum diseases. There were eighteen inflammatory bowel disease (IBD) patients (of these four patients with Crohn’s colitis) and four young patients with familial colonic polyposis.

They include five male and seventeen female patients with an average age of 37 years, with varying distribution according to the disease: for ulcerative colitis, 22 to 68 years; for Crohn’s disease, 26 to 37 years; and for familial colonic polyposis, 18 to 45 years. In the ulcerative colitis (UC) group (fourteen patients), there were:

A)    Seven patients with an acute attack of ulcerative colitis with no response to conservative treatment including high doses of corticosteroids and immunosuppressives (azathioprine or cyclosporine) and elemental nutrition. Four of them were treated with subtotal colectomy with closure of the rectum and conventional ileostomy (as first step, restorative procedure will follow) and the other three by proctocolectomy and restorative ileo-anal J pouch (and protective loop-ileostomy).

B)    Seven patients with long-term ulcerative colitis (mean 7 years). Of these seven: five were treated by proctocolectomy with a conventional ileostomy, two patients having sphincter defects and fistulas, another two due to advanced age, and one patient because of obesity and extensive adhesions of the small bowel, resulting in insufficient length to reach the anus; one by proctocolectomy with restorative ileo-anal J-pouch; and one by proctocolectomy with continent ileostomy (Kock pouch) because of a sphincter defect after an episiotomy and perineal fistula.

Those with an indication for colectomy included four patients with Crohn’s diseases: three undergoing a subtotal colectomy with ileorectal anastomosis; and another receiving a proctocolectomy with a conventional ileostomy.

Besides these IBD patients, another four patients with familial colonic polyposis (FCP) were treated by laparoscopic assisted proctocolectomy with a restorative ileo-anal J-pouch procedure.

Operative technique

After bladder catherization, the patient is placed with the legs on leg rests. Two monitors are placed, one to the left of the patient’s feet and the other to the right side. The surgeon starts by standing at the patient’s right with the second assitant (camera) on the surgeon’s left. The first assistant stands to the left of the patient and the nurse between the legs. A five-cannulae approach (S-shape placement) is used, taking care to place one of the cannulae in the site marked for the stoma (Fig. 1). Cannula number 1 is for the laparoscope, numbers 2 and 3 are inserted in the right lower abdomen for instruments to dissect, mobilize and devascularize the colon, number 4 at the left lower abdomen for instruments to hold and tilt the sigmoid, and number 5 between the subcostal margin and umbilicus for the purpose of mobilizing the splenic flexure.

The patient is placed in the Trendelenburg position slightly tilted to the right. After mobilization of the sigmoid, the left ureter is identified and the most distal part of the descending colon and proximal rectum are then mobilized. For mobilization of the splenic flexure, the patient is then placed in the reverse Trendelenburg position slightly tilted to the right side. The monitor is shifted to the level of the patient’s left shoulder and the optic is changed to port no. 4 in the left lower abdomen. The surgeon dissects the splenic flexure free using the umbilical and right abdominal ports (no. 1 and 2) while the first assistant helps to hold the laparoscope (left hand) and the instruments through the upper left abdominal trocar (no. 5). In this way the splenic flexure and transverse colon are dissected free from the greater omentum (Fig. 2). Without changing the position, the surgeon continues with dissection of the transverse colon up to the hepatic flexure.

For mobilization of the hepatic flexure and right colon the surgeon and the first assistant stand on the left side of the patient looking to the monitor placed on the right side of the patient. The patient is tilted to the left side. Using trocars no. 1 for the camera and 3, 4 and 5 for instruments, the hepatic flexure is mobilized. Further dissection continues to the caecum with the patient in the Trendelenburg position.

The surgeon returns to the right of the patient and starts with the division of the mesentery by means of endostaplers, clips or the ultracision device. The mesentery is sequentially divided, halfway between the arcade and its root, from the sigmoid vessels up to the right colic artery.

If the chosen procedure is a subtotal colectomy with temporary ileostomy, as first step in acute colitis, after division of the mesentery, the rectum is divided with the endostaplers. Through the ileostomy wound can the specimen, starting by the sigmoid, be retrieved and the ileostomy created without the need for any other incision.

For the rest of procedures, a Pfannenstiel incision of about 10-15 cm in length is made. Through this incision, the intervention will continue with retrieval of the specimen, and further dissection of the rectum, construction of a pouch or creation of an anastomosis.

Results

Operation times (range) of the different types of colonic resection are depicted in Table 1.

Blood loss

An average of 150 cc (range 100 to 300 cc) blood was lost during the laparoscopic part of the procedure.

Conversions

There was one conversion to laparotomy in one patient due to a fatty and very inflammated mesentery.which left the dissection very difficult.

Complications

Postoperative: four complications were observed (14%). Two of them were patients with ulcerative colitis not responding to conservative measures. One of them had a bleeding from the mesentery of the transverse colon with shock immediately after the laparoscopic intervention, being solved through a median laparotomy and in the second patient an intra-abdominal abscess was diagnosed two weeks after operation once she left the hospital. The abscess was percutaneously drained. Another patient had an intestinal obstruction caused by a bridge after a J-pouch reconstruction because of FCP. Through a infraumbilical laparotomy the bridge was divided and the protective ileostomy closed. In the fourth patient a partial paralysis of the right femoral nerve reversed after a period of three months.

Middle-term complications (up to 1 year): In one patient an intestinal obstruction was treated by taking down the bride through a laparotomy. Long-term complications (longer than 1 year): A parastomal hernia is diagnosed in one patient with a definitive conventional ileostomy, being treated conservatively so far.

Pathological anatomy

In all cases with ulcerative colitis the histological diagnosis was confirmed. In two patients with long-term colitis (longer than ten years) an significant grade of dysplasia was found, but no malignancy. The diagnosis of Crohn’s colitis was also confirmed. In the patients with familial colonic polyposis, adenomatous polyps were found, but no cancer.

Hospital stay

The overall average hospital stay was thirteen days with a range of 8 to 40 days. The high number of patients in this series with a stoma implicated a longer hospital stay to ensure proper stoma care and instruction.

Second procedures

After subtotal colectomy, three of the four patients with ulcerative colitis underwent a protectomy through a Pfannenstiel approach followed by a restorative ileo-anal J-pouch procedure and a protective ileostomy (between three and five months after the first operation). In all of them, the ileostomy was already taken down. After proctocolectomy and J-pouch anastomosis (8 patients), the protective ileostomy has been taken down in all of them with acceptable outcome.

Discussion

Subtotal colectomy (and proctocolectomy) in combination with any form of surgical solution such as ileo-anal J-pouch anastomosis or definitive ileostomy (conventional or continent) or ileorectal anastomosis is the technique of choice in cases of IBD that no longer respond to conservative treatment or in patients with familial colonic polyposis.

Conventional surgery implies an approach through a long median laparotomy from the xyphoid down to the pubis in order to mobilize the entire colon, especially the hepatic and splenic flexures [1].

Laparoscopic mobilization of the flexures, and rest of the colon and rectum is possible along with division of its mesentery [3]. This division can be performed by means of endostaplers, clips or the use of ultrasound surgery. Once this is accomplished the rest of the operation can be performed through a limited assisted Pfannenstiel incision. Through this approach, if necessary, the rectum can be resected with nerve preservation followed by an anastomosis with the anus or any kind of ileostomy [5-7]. This last part of operation, performed through the incision may reduce operating time and make this lengthy operation acceptable. Only in the case of acute colitis and as a first step of treatment, the subtotal colectomy can be performed totally laparoscopically with retrieval of the specimen through the ileostomy wound. The Pfannenstiel incision should be reserved for the second operation in which the rectum extirpation and the ileo-anal procedure will be performed. Peters performed the first successful total proctocolectomy with an ileostomy in two patients with severe ulcerative colitis [6].

In a prospective study, Schmitt et al, have compared the duration of the postoperative ileus and hospitalization between conventional and laparoscopic assisted proctocolectomy and ileal pouch anastomosis. Neither the length of time for ileus resolution nor the hospital stay were reduced after the laparoscopic procedure. In their experience the laparoscopic assisted approach conferred none of the theoretical advantages associated with other laparoscopic procedures [8].

In 1996 Reissman et al published the compound experience of two surgical departments about laparoscopic surgery for IBD patients. A total of thirty abdominal colectomies were included in this series. They found an average operating time of 4.5 hours, an average hospital stay of 8.7 days and an overall morbidity of 30%. Even with laparoscopic dissection of the rectum, the creation of the pouch and anastomosis was done through the Pfannenstiel incision [7]. The results confirmed the previous results obtained by Wexner et al in 1992, with two small groups of patients [9].

Araki et al, found the operating time comparable with the conventional approach, but the nasogastric tube removal and the passage of stools were earlier than in the conventional group [10].

Ho et al compared this laparoscopic with the open technique in a group of patients with slow transit constipation and found that even if the operating time was longer in the laparoscopic group, the cosmetic advantage was remarkable [11]. The same results have been found by others [4, 5, 12-15]. In this study the operative time is longer than in some other series, but acceptable and the hospital stay longer due to the stoma care which in Europe is usually taking place in the hospital. Our morbidity, in five patients of 22, is in line with their results. On the other hand in this group of usually young patients, most of whom have difficulty in accepting a major operation such as in the case of IBD or familial colonic polyposis, the possibility to perform it with maximal cosmetic outcome will help to break the psychological barrier. Body image and preservation of the integrity of the abdominal wall seem important in patients with IBD or FCP facing an operation, as has been demonstrated by Dunker et al in patients with ileocaecal Crohn’s diseases [2].

Our goal in the beginning was to perform a practical standardized procedure, obtaining clear advantages for the patient (smoother recovery and good cosmesis) at an acceptable duration of the operation. In an initial pilot study, the Pfannenstiel incision was done after mobilization of the entire colon without division of the mesentery [4]. The division of the mesentery and the rest of the procedure were completed through the incision. The division of the mesentery at the flexures in particular was not possible through a limited incision of less than 10 cm. The incision had to be enlarged to 15 cm and the abdominal wall forcibly elevated by the assistant. Also, the ligatures of the frequently thick mesentery were risky at the least. In the current series we have proceded not only to mobilize but also to divide the mesentery by means by clips and endostaplers, and since 1997 by means of the Ultracision device (Ethicon Endo-Surgery) and endostaplers. Endostaplers will be used there where a very thick and fibrotic mesentery is found especially in IBD patients. In this way it is possible to complete the exteriorization of the colon in less than three hours. The average time for restorative ileo-anal J-pouch anastomosis is less than five hours.

In conclusion, laparoscopic assisted total colectomy followed by a Pfannenstiel incision to complete the operative procedure is a feasible intervention for young patients with IBD and familial colonic polyposis.

Even if operation time and hospital stay are quite long, protection of the abdominal wall integrity and subsequent cosmetic outcome are considered very important in this patient’s group with problems to accept this major surgical intervention.

References

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