Improved Outcomes in Colon and Rectal Surgery part 16 pot

 improved outcomes in colon and rectal surgery 15. Cohen SM, Wexner SD, Binder SR et al. Prospective randomized endoscopic blinded trial comparing precolonoscopy bowel cleansing methods that’s in the Dis Colon Rectum 1994; 37: 689–96. 16. Kolts BE, Lyles, WE, Achem SR et al. A comparison of the effectiveness and patient tolerance of oil sodium phosphate, castor oil, and standard electrolyte lavage for colonoscopy or sigmoidoscopy preparation. Am J Gastroenterol 1993; 88: 1218–23. 17. Markowitz GS, Stokes MB, Radhakrishnan J, D’Agati VD. Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an under recognized cause of chromic renal failure. Am Soc Nephrol 2005; 16: 3389–96. 18. Clark LE, Dipalma JA. Safety issues regarding colonic cleansing for diagnostic and surgical procedures. Durg Saf 2004; 27: 1235–42. 19. Rejchrt S, Burues J, Siroky M et al. A prospective observation study of colonic mucosa abnormalities associated with oral administered sodium phosphate for colon cleansing before colonoscopy. Gastrointest Endosc 2004; 59: 651–4. 20. Zwas FR, Cirillo NW et al. Colonic mucosa abnormalities associated with oral sodium phosphate solution. Gastrointest Endosc 1996; 43: 463–6. 21. Wayne JD. Colonoscopy, CA Cancer J Clin; 42: 350–65, 1992. 22. Rex DK, Lewis BS, Wayne JD. Colonoscopy and endoscopic for delayed post polypectomy hemorrhage. Gastrointest Endosc 1992; 38(2): 127–9. 23. Wayne JD, Lewis BS, Wessayan S. Colonoscopy: prospective report of complications. J Clin Gatroenterology 1992; 15(4): 347–51. 24. Sorbi D, Norton I, Conio et al. Post polypectomy lower GI bleeding descriptive analysis. Gastrointestest Endosc 2000; 51(6): 690–6. 25. Gossum AV, Cozzsoli A, Adler M et al: Colonoscopic snare polypectomy: analysis of 1,485 resection comparing two types occurring. Gastrointest Endosc 1992; 38: 472–5. 26. Gibbs DH, Opelka FG, Beck DE et al. Post polypectomy colonic hemorrhage. Dis Colon Rectum 1996; 39: 806–10. 27. Fatima H., Rex DK. Minimizing endoscopic complications: colonoscopic polypectomy, Gastrointest Endosc N Am 2007; 17: 145–56; 153–4. 28. Wousy M, Gost CJ, Barrone TH et al. Post-polypectomy lower gastro intestinal bleeding, the role of aspirin. Am J Gastrointerol 2004; 99(9): 1785–9. 29. Zuckerman MJ, Hirta WK, Adler DG et al. ASGE Guidelines: the management of low molecular weight epinepherine and non-aspirin antiplatelet agents for endoscopic procedures. Gastrointest Endosc 2005; 61(2): 189–194. 30. Hui AJ, Wong RM, Ching JY et al. Risks of colonoscopic polypectomy with anticoagulants and antiplatelet agents: analysis of 1,657 cases. Gastrointest Endosc 2004; 59(1): 44–8. 31. Timothy SKC, Timmcke AE, Hicks TC, Beck DE, Opelka FG. Colonoscopy in the anticoagulated patient. Dis Colon Rectum 2001; 44: 1845–9. 32. Zuraff-Perryman LA, Renz BW, Beck DE et al. The risk of bleeding and thromboembolic events in patients undergoing colonoscopic evaluation on clopedigrel (Plavix). Dis Colon Rectum; in press. 33. Herman F. Response to the letter entitled Voidance of sedation. Dis Colon Rectum 1990; 33: 540–1. 34. Iber FL, Sutberry M, Gupta R, Kruss D. Evaluation of complications during and after conscious sedation for endoscopy using pulse symmetry Gastrointest Endosc 1993; 39: 620–5. 35. Beck DE, DiPalma JA. Complications of GI procedures. Problems in Critical Care 1989; 3: 261–70. 36. Rex DK, Imperiale T, Portish VL. Patients willing to try colonoscopy without sedation: Associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc 1999; 49: 554–9. 37. Meyer GW. Prophylaxis of infected endocarditis during gastrointestinal procedures: Report of a survey. Gastrointest Endosc 1979; 25: 1–2. 38. Rumfield W, Wallace G, Scott BB. Bacteria endocarditis after endoscopy. Lancet 1980; 1083. 39. Wilson W, Taubert K, Gewitz M, et al. Prevention of infected endocarditis: Guidelines for the American Heart Association. Circulation 2007; 8: 115. 40. Habr-gama A, Wayne JD. Complications and hazards of gastrointestinal endoscopy. World J Surg 1989; 13: 193–201. 41. Kavin H, Sinicrope F, Esker AH. Management of Perforation of Colonoscopy. Am J Gastroenterol 1992; 87: 161–7. 42. Opelka FG. Transanal endoscopy. In: Hicks TC, Beck DE, Opelka FG, Timmcke AE, eds. Complications of colorectal surgery. Baltimore: Williams and Wilkins, 1996: 143–52. 43. Reickert CA, Beck DE. Complications of Colonoscopy. Clin Colon Rectal Surg 2001; 14: 379–86. 44. Lo AY, Beaton HL. Selective management of colonoscopic perforations. J AM Coll Surg 1994; 179: 333–7. 45. Farley DR, Bannon MP, Zietlow SP et al. Management of colonoscopic perforations. May Clin Proc 1997; 72: 729–33. 46. Anderson MI, Pasha TM, Leighton IA. Endoscopic perforation of the colon: lessons from a 10-year study. Am J Gastroenterol 2000; 95: 3418–22. 47. Araghizadeh FY, Timmcke AE, Opelka FG, Hicks TC, Beck DE. Colonoscopic perforations. Dis Colon Rectum 2001; 44: 713–6. 48. Korman LY, Overholt BF, Box T, Winker CK. Perforation during colonoscopy in endoscopic ambulatory surgical centers. Gastrointest Endosc 2003; 58: 554–7. 49. Cobb WS, Heniford BT, Sigmon LB et al. Colonoscopic perforations incidence, management, and outcomes. AM Surg 2004; 70: 750–7. 50. Lqbal CW, Chun YS, Farley DR. Colonoscopic perforations: a retrospective review. J Gastrointest Surg 2005; 9: 1229–35. 51. Levin TR, Zhao W, Connel C et al. Complications of colonoscopy in an integrated heath care delivery system. Ann Intern Med 2006; 145: 880–6. 52. Koltun WA, Collier JA. Incarceration of the colonoscope in an inguinal hernia. “Pulley” Technique of removal. Dis Colon Rectum 1991; 34: 191–3.  transanal endoscopy 53. Amidon PB, Story RK Jr. Cecal Volvulus after colonoscopy. Gastrointestinal endoscopy 1993; 39: 105. 54. Wheeldon MN, Grumdman MJ. Ischemic colitis as a complication of colonoscopy. BMJ 1990; 301: 1080–1. 55. Gruber HE, Weisman MH. Aortic thrombosis during sigmoidoscopy and Bechcet’s syndrome. Arch Intern Med 1983; 143: 343–5. 56. Gores PH, Sisma LA. Splenic injury during colonoscopy. Arch Surg 1989; 124: 1342. 57. Michetti CP. Splenic injury due to colonoscopy: Review and analysis of the World literature, a new case report, and recom- mendations for management. J Am Coll Surg; in press. 58. Conio M, Repici A, Demarquay JF et al. EER of large sessile colorectal polyps in Gastrointest Endosc 2004; 16: 234–41. 59. Wayne JB, Lewis BS, Wessayan S. Colonoscopy: A perspec- tive report of complications. J Clin Gastroenterology 1992; 15(4): 347–51. 60. Nivetongs S. Complications in colonoscopic polypectomy: lesson to learn from an experience with 1,576 polyps. Am Surg 1998; 54(2): 61–3. 61. Christie JP, Marrazzo J III. “Many – perforation” of the colon – not all postpolypectomy perforations require laparotomy. Dis Colon Rectum 1991; 34(2): 132–5. 62. Goligher JC. 4th ed. Injuries of the rectum and colon. In Surgery of the Anus Rectum and Colon. London: Bailliere Tindall, 1980: 916–7. 63. Nelson RL, Abcarian H, Prasad ML. Iatrogenic perforation of the colon and rectum. Dis Colon Rectum 1982; 25: 305. 64. Befeler D. Proctoscopic perforation of the large bowel. Dis Colon Rectum 1967; 10: 376. 65. Andresen AFR. Perforations from proctoscopy. Gastroenter- ology 1947; 9: 32–43. 65. Beck DE, Opelka FG. Pelvic and perineal trauma. Perspectives in Colon and Rectal Surgery 1993; 6: 134–56.  3 Laparoscopic colorectal surgery James W Fleshman and Jonathan S Chun CHALLENGING CASE A 28-year-old male is undergoing an ileocolic resection for Crohn’s disease. During insertion of a right lower quadrant (RLQ) trocar, significant bleeding is observed from the right lower retroperitoneum. MANAGEMENT It appears that the right iliac vein has been injured by the trocar. A Babcock clamp is used to temporarily occlude the bleeding using direct pressure. The anesthesia personnel are informed of the pos- sibility of significant blood loss. While pressure is continued by an assistant, the surgeon rapidly opens the abdomen using a vertical midline incision. With a retractor in place, the Babcock is replaced by the surgeon’s hand. With continued tamponade, proximal and distal control of the vessel is obtained. The venotomy can now be repaired using vascular techniques. It is usually not possible to repair a major vascular injury with laparoscopic techniques. If proximal and distal control can be obtained an experienced laparoscopic surgeon may attempt the repair, but the threshold for opening should be low. INTRODUCTION The rising demand for laparoscopic techniques for colorectal surgery arises from a number of purported benefits, including a reduction in postoperative ileus, decreased pain, earlier recovery, fewer adhesions, and smaller incisional hernias. This enthusiasm, however, has been tempered by, among other things, the long learning curve, increased operative times, and concerns about the oncologic outcomes of laparoscopic resection for curable colon cancer. Concern over cancer implants in trocar sites led to a temporary national moratorium on laparoscopic resection for colon cancer from 1994 to 2004, and multiple national surgical societies called for these procedures to be performed only under the auspices of controlled trials. A number of prospective, randomized trials, including the Colon carcinoma Laparoscopic or Open (COLOR), Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC), and Clinical Outcomes in Surgical Therapy (COST) studies, have helped address some of these concerns and delineate some of these advantages and disadvantages.(1–7) This chapter will address some of these concerns and address how best to optimize outcomes for laparoscopic surgery in various colorectal disease processes. ADVANTAGES Postoperative pain and suppression of pulmonary function are well-known sequelae of abdominal surgery. While physician bias and patient expectations make a truly objective assessment of pain difficult, multiple prospective, randomized trials have found a reduction in narcotic requirements in patients undergoing laparoscopic colectomy.(5, 6, 8) In the COST trial, patients who underwent successful laparoscopic resections had decreased use of both oral and intravenous analgesics.(1) In an attempt to document improved pulmonary function in patients undergoing laparoscopic surgery for colon cancer at the Cleveland Clinic, preoperative and postoperative spirometry was performed every 12 hours postoperatively in 55 patients randomized to the laparoscopic surgery group and 54 patients in the open surgery group.(5) These measurements consisted of an 80% recovery of baseline forced vital capacity and forced expiratory volume in-second from each patient. The median recovery for the laparoscopic group was 3 days vs. 6 days in the conventional group. Schwenk et al. had similar results in a similarly designed trial.(8) These results suggest a reduction in postoperative pain and quicker recovery of pulmonary function in patients undergoing laparoscopic colectomy. Reduction in postoperative ileus is another proposed major advantage of laparoscopic surgery. Time to recovery of bowel function, either flatus or tolerance of food, and time to bowel movement are surrogate markers for the length of the postoperative ileus most patients experience after abdominal operations. Virtually all publications, whether retrospective or prospective, have shown a statistically significant reduction in the time to recovery of bowel function. The advantage appears to be 1–2 days in these studies. The mechanism by which ileus is reduced is unknown, but may relate to decreased bowel manipulation, decreased intestinal exposure to air, exposure to the protective effects of carbon dioxide pneumoperito- neum, or reduced narcotic demands from a smaller incision. The biases of the treating physician and the higher expectations of patients undergoing laparoscopic surgery make it difficult to accurately and reliably determine the true time to ileus resolution. Investigators have, therefore, sought to more formally evaluate the return of bowel function. Canine and porcine mod- els have looked at intestinal myoelectric activity as well as radio- nucleotide techniques in animals that underwent laparoscopic resection.(9–11) These studies confirmed a quicker return of bowel function following laparoscopic vs. open resection. The combination of reduced ileus, decreased pain, and quicker recovery of pulmonary function would logically add up to a reduced length of stay for patients following laparoscopic resection. This benefit appears to be a 1–2 day advantage among patients undergoing laparoscopic resection. The introduction of clinical pathways has been particularly effective and more reliable in patients undergoing minimally invasive approaches.(12, 13) Early ambulation, early feeding protocols, and early switch to nonnarcotic oral analgesics have reduced length of stay for laparoscopic and open procedures. “Fast-tracking” has shown that a 2 day stay after laparoscopic or open colectomy is possible.(14) This may be useful, as patients get used to transferring in-hospital care to home care and become invested in the short hospital stay. Though it is widely accepted that laparoscopic surgery results in fewer adhesions than open surgery, this is difficult to quantify in the context of a clinical trial. A recent observational study by Dowson et al. however, looked at 46 patients (13 laparoscopic and 33 open) who underwent laparoscopy after a previous colectomy. They found a statistically significant difference in adhesions between the two groups, with the laparoscopic group having a lower score.(15)  laparoscopic colorectal surgery While this study was limited due to its small sample size, it does confirm long-held beliefs about decreased adhesions after laparoscopic vs. open surgery, which should help to make later reopera- tions safer. In the past, 3-stage operations for inflammatory bowel disease were felt to be a disadvantage to both the surgeon and the patient. However, laparoscopic total abdominal colectomy and ileostomy to remove the inflamed ulcerative colitis colon, wean steroids, and improve nutrition can be performed without risking increased adhesions at the time of ileal pouch construction and completion proctectomy. The time between these two procedures can also be reduced using laparoscopic approaches. Fertility, especially in females, is an issue after pelvic surgery, particularly restorative proctocolectomy. Multiple studies have suggested that fertility is adversely affected in women undergoing restorative proctocolectomy.(16–18) This is likely related to adhesions in the pelvis causing scarring of the Fallopian tubes. Laparoscopy, with its decreased adhesion formation, may offer benefits in preserving fertility in reproductive-age females. Obesity and a large amount of visceral fat can make laparoscopic colorectal procedures particularly challenging. The associated comorbid illnesses often associated with obesity, however, would seem to make this group of patients the ideal group to benefit from laparoscopy. Delaney et al., in a case-matched comparative study of patients with a body mass index >30, found no difference in median operating time, complications, readmission, or reoperation rates.(19) The median length of stay, however, was significantly shorter (3 vs. 5.5 days) after laparoscopic colectomy. Twenty-eight patients did require conversion, but the lengths of stay, complication, readmission, and reoperative rates were no different than for patients undergoing open colectomy. Senagore et al. studied a series of 260 patients and compared outcomes between patients with a BMI above 30 and those with a BMI below 30 undergoing segmental colectomy.(20) The obese group had a significantly higher rate of conversions (23.7% vs. 10.9%), longer operative times (109 minutes vs. 94 minutes), higher morbidity rate (22% vs. 13%), and a higher anastomotic leak rate (5.1% vs. 1.2%). While this increase in complications paralleled those in obese patients undergoing open colectomy, Senagore et al. concluded that laparoscopic colectomy is feasible and safe, with the main benefit of a shorter hospital stay. While operative times are longer in obese patients, the use of a hand-assist device may offer the surgeon a useful tool to cut down these times, particularly in this challenging group of patients. Marcello et al. found that the use of a hand-assist device allowed for the more efficient completion of technically challenging and complex procedures while preserving the benefits of a laparoscopic approach.(21) The average BMI of patients in their study was only 28.1 in the hand-assist group vs. 26.3 in the straight laparoscopic group. While their results cannot be used to definitively state that a hand-assisted approach is superior in obese patients, they do suggest that it could be a useful tool to overcome the challenge of completing laparoscopic procedures on these patients. DISADVANTAGES A number of challenges have prevented laparoscopic colorectal surgery from becoming more widely accepted and utilized by surgeons. Most general surgeons perform fewer than 50 segmental colon resections per year. Laparoscopic colectomy, unlike laparoscopic cholecystectomy, requires working in multiple quadrants of the abdomen, making depth perception and proprioception more difficult. Several studies have evaluated the learning curve for laparoscopic colectomy and suggested that this curve ranges from 20–50 cases, but may be as high as 150 before the surgeon is able to handle all eventualities during a laparoscopic colectomy. The standardization of technique required for entry into the COST trial resulted in no detriment in oncologic outcomes even though the study was undertaken during early laparoscopic experience and the conversion rate was 20% (25% first half to 19% second half).(22–24) The CLASICC trial, which was a prospective, randomized trial comparing laparoscopic and open resection of both colon and rectal cancer in the United Kingdom, also required that surgeons perform at least 20 laparoscopic resections in order to enter the study.(2) Even with this level of experience, the rate of conversion decreased from 38% to 16% over the course of the study—July 1996 to July 2002. This suggested that 20 cases were likely not enough to reach the plateau of the learning curve. The COLOR trial also highlighted the value of surgeon volume in improving patient outcomes.(3) In this trial out of Europe, the median operative time for high-volume (>10 cases/year) vs. low-volume (<5 cases/year) hospitals was 188 minutes vs. 241 minutes. Conversion rates were 9% with high-volume groups vs. 24% for low-volume groups. High-volume groups resected more lymph nodes, had fewer complications, and shorter hospital stays, but there was no difference in oncologic outcomes. Operative times are generally longer with a laparoscopic approach. This difference is approximately 40–60 minutes longer for the laparoscopic technique depending on the portion of colon removed (left > right). While operating times decrease with surgeon experience, they do not reliably decrease to the level of an open approach. The use of a hand-assist device may be a viable solution to decrease the operative times while still main- taining the benefits of a laparoscopic approach. A multicenter, prospective, randomized trial by Marcello and colleagues, comparing short-term outcomes of left/sigmoid colectomies and total colectomies with a hand-assisted approach vs. a straight laparoscopic approach showed a statistically significant decrease in operating times with a hand-assisted approach (reduced by 33 minutes for sigmoid colectomy, reduced by 57 minutes for total colectomy).(21) They also found no differences in the time to return of bowel function, tolerance of diet, length of stay, postoperative pain scores, or narcotic usage between the two groups. The MITT Study group did not include right colectomy since this procedure is routinely performed via a straight laparoscopic or laparoscopic-assisted approach in the same time as an open operation.(21) TREATABLE CONDITIONS Colon Cancer The treatment of colorectal cancer has been among the most con- troversial topics in the discussion surrounding the application of laparoscopic techniques to colorectal surgery. This controversy centered on early reports of cancer implants at trocar and incision sites and the fear of an inadequate oncologic resection. While  improved outcomes in colon and rectal surgery later studies suggested that the incidence of wound implants was, in fact, no greater than in open surgery when performed by experienced surgeons, the controversy was one of the main factors that resulted in a call for a moratorium on laparoscopic resection for colon cancer outside of the auspices of a randomized, controlled trial.(25, 26) This resulted in a variety of randomized, controlled clinical trials which served to put to rest many of these concerns and help delineate the true advantages and disadvantages of a laparoscopic approach.(1–5, 8, 27) The first large single-center randomized controlled trial was published by Lacy et al. in 2002, with a median follow-up of 39 months.(4) They, in fact, reported a higher cancer-related survival for the laparoscopic group. While there was no difference between the laparoscopic and open groups in Stage II cancers, they reported a significantly improved survival in the laparoscopic group for Stage III cancers. The results of the COST trial, which consisted of nearly 900 patients randomized to open or laparoscopic colon resection, showed no difference in overall or disease-free survival between the two groups.(1, 28) It also did not report the same advantage for Stage III patients that Lacy et al. did. As Fleshman et al. point out, the survival advantage that Lacy and colleagues reported may be the result of an underpowered subset analysis. The theory that the survival advantage was due to some physiologic benefit of laparoscopy is not borne out by the results of the COST trial.(28) Reassuringly, the COST trial reported only two wound recurrences in the laparoscopic group, and one in the open group. The CLASICC trial out of the United Kingdom also showed similarly reassuring results, though the rate of conversions was higher.(2) The meta-analysis of these trials by Bonjer et al. confirms the equivalence of open and laparoscopic treatment of colon cancer.(29) The results of these large, multicenter, randomized trials illus- trate a number of important points in maximizing the outcomes for laparoscopic colon resection. The importance of surgeon experience and judgment cannot be overstated. The consequences of using laparoscopic resection for potentially curable malignan- cies as “learning cases” are potentially devastating to the patient. Strict adherence to oncologic principles, just as in open surgery, is paramount, and the dangers of sacrificing these principles in the name of a minimally invasive approach are obvious. The importance of rigorously testing new techniques under the auspices of a randomized, controlled trial is also highlighted by these results. The controversy and emotion that arose over the initial reports of wound implants following laparoscopic colectomy have been laid to rest by the results of these multiple trials. It is safe to say that laparoscopic colon resection for cancer, when guided by the proper principles, is as safe as open resection, with a number of tangible benefits to the patient. Endoscopically unresectable “benign” polyps, at first glance, would appear to be an ideal case for a laparoscopic resection by a surgeon who is still on their “learning curve.” However, multiple authors have reported that upwards of 18–22% of these “benign” lesions are found to have adenocarcinoma on final pathology. (30–32) Large, flat lesions with high-grade dysplasia are more likely to have cancer present and these criteria should guide the surgeon in their decision making. Thus, a surgeon with little experience with laparoscopic resection should approach these cases with great caution. It is vital that these cases be approached as formal cancer operations, with strict adherence to the usual oncologic principles. INFLAMMATORY BOWEL DISEASE While Crohn’s disease presents its own unique set of challenges for a minimally invasive approach, it can also provide a unique opportunity. In severe Crohn’s disease, severe inflammatory changes in the mesentery, the presence of abscesses or fistulae, and the dif- ficulty in assessing bowel involvement are all challenges that need to be overcome by the surgeon. Isolated terminal ileal disease, however, would seem to be an ideal setting for a minimally invasive approach, especially for the relatively inexperienced laparoscopist. The high incidence of reoperation in Crohn’s patients makes laparoscopy for the initial surgery an appealing option. While randomized, controlled trials are scarce, multiple recent studies support laparoscopy as a viable option in many cases.(33–39) The advantages associated with a laparoscopic approach in Crohn’s disease are the same as those seen in the previously described cancer trials. Resolution of ileus, resumption of diet, postoperative pain, and length of stay were all improved with a laparoscopic approach. In a prospective, randomized trial from Milsom et al. of patients undergoing open or laparoscopic ileocolic resection for refractory Crohn’s disease, the pulmonary function, morbidity, and length of stay were all improved in the short-term with a laparoscopic approach.(40) These studies support the use of laparoscopy in Crohn’s disease, even, in the right setting, for the inexperienced laparoscopist. As always, the surgeon’s judgment is paramount, and there should be a low threshold to switch to an alternate approach in the right situation. There is no difference in recurrence of Crohn’s disease between patients treated by a laparoscopic or open surgical approach.(37) Ulcerative Colitis The slow acceptance of laparoscopic total proctocolectomy revolves around a couple of factors. First, the early reports of laparoscopic total colectomy were unfavorable. The Cleveland Clinic Florida group published several reports of their results with laparoscopic proctocolectomy for ulcerative colitis in the early 1990s.(41, 42) They reported longer operative times and higher blood loss than in the open group without the desired benefits. At that time, the authors discouraged the laparoscopic approach to total colectomy. These initial reports highlight the importance of the aforementioned learning curve. As surgeons have gained experience with segmental resection, and as technology has advanced, the role of laparoscopic total colectomy for inflammatory bowel disease is being reevaluated and is gaining wider acceptance. More recent reports support the use of laparoscopy for total colectomy and proctocolectomy with and without ileoanal pouch construction, with the same advantages for laparoscopy for segmental resections. While some groups have performed laparoscopic total colectomy on an urgent basis for patients with refractory colitis, it is not routinely recommended for those patients with toxic colitis. (43) A recent study from Chung et al. (44) compared their results of a laparoscopic or open approach to total abdominal colectomy for severe colitis and its impact on subsequent restorative proctectomy. They found that patients undergoing a laparoscopic approach had a faster resumption of diet, less narcotic usage, shorter hospital 3 laparoscopic colorectal surgery stays, and a shorter time to subsequent restorative proctectomy and ileostomy takedown. The rate of complications between the laparoscopic and open groups was similar. Stewart et al. showed that accelerating doses of immune suppressants and steroids resulted in higher rates of complications. Thus, utilization of laparoscopoic abdominal colectomy as the initial operation to treat severe ulcerative colitis, with few adhesions and quicker arrival to the final goal of reconstructive surgery, is a good alternative to continued medi- cal therapy in some cases.(45) Laparoscopic total colectomy and proctocolectomy are technically challenging operations with 3 to 5 hour operative times. The use of hand-assisted techniques may be a way to cut down on this time while still realizing the benefits of laparoscopy. Rivadeneira et al. in a comparative study from the Lahey Clinic, compared the hand-assisted approach to conventional laparoscopy in patients undergoing laparoscopic proctocolectomy (10 HAL, 13 standard laparoscopy).(46) The operative times decreased in the HAL group (mean 247 minutes), while remaining constant in the laparoscopic group (mean 300 minutes, p < 0.05) over the course of the study. There was no disadvantage in terms of bowel function, length of stay, or outcome in this study. STOMA CREATION The creation of a stoma can be an ideal scenario in order for a surgeon to gain experience in laparoscopic colorectal surgery. It is an excellent way to achieve the benefits of minimally invasive surgery while not dealing with the same ramifications as discussed with surgery for resectable colon cancer. There are studies that have shown that laparoscopic stoma creation is a viable alternative to an open approach, with benefit shown in several studies in both morbidity and mortality.(47, 48) The key, just as in open surgery, is to ensure that the limbs of the stomas are oriented properly and that the fas- cial opening is adequate in order to preserve the blood supply. Also, adequate mobilization of the bowel in order to eliminate tension on the stoma is critical. In particularly obese patients, the surgeon should give consideration to a divided loop-end stoma. By leaving the stapled closed distal limb within the abdomen and delivering only the proximal functioning end through the fascia, less tissue needs to be brought through the abdominal wall opening. However, when creating an end stoma, it is critical to ensure that the proximal limb is opened. Measures such as marking proximal and distal limbs of bowel with sutures or clips, insuflating air into the distal bowel via the anus, or performing flexible endoscopy of the stoma are rou- tine procedures in many center to minimize this occurence. Potential complications of laparoscopic stoma formation include those related to laparoscopy itself—including insuffla- tion needle or trocar injury, air embolism, arrhythmias, CO2 intolerance, and subcutaneous emphysema—and those related to laparoscopic colorectal surgery in particular. These particular complications mostly relate to unfamiliarity with the anatomy as seen through the laparoscope and include ureter, iliac, and mesenteric vessel injury, as well as improper orientation of the limbs of the stoma. As with all laparoscopic surgery, it is critical not to retract or grasp out of the field of view in order to avoid any collateral injury that is not immediately recognized. If tension is noted on the loop of bowel selected for the stoma site, further mobilization may be of benefit to release the bowel or colon from the retroperitoneal fixation. This should also reduce the incidence of retraction and stricturing at the stoma site. A particular skill needed in the performance of laparoscopic stoma construction is the knowledge of bowel/colon anatomy and rela- tionships of the intestine to adjacent structures as well as vascular anatomy to provide adequate blood supply even to a stoma pulled through a thick abdominal wall. Thus, even though considered a basic laparoscopic case, a certain level of colorectal surgical skill is needed. DIVERTICULITIS Laparoscopy for diverticulitis, while not fraught with the oncologic ramifications of colorectal cancer, presents its own set of challenges, both in the elective and the acute setting. The fibrosis associated with recurrent disease in the elective setting, and the inflammatory changes in the acute setting present their own set of technical issues, and the inexperienced laparoscopist in particular should proceed with caution and retain a low threshold for conversion to an open approach or a hand-assisted approach. As laparoscopy gains more popularity in the management of acute intraabdominal processes like appendicitis or perforated peptic ulcers, the question arises as to whether it may be of benefit in management of diverticulitis in the acute setting. The mainstay of treatment for generalized peritonitis secondary to diverticulitis remains open sigmoid resection with end-colostomy.(49) The subsequent colostomy reversal, however, can be difficult because of the significant adhesions that result. In an effort to ease some of those difficulties, different groups have experimented with various strategies, including a laparoscopic Hartmann’s procedure, and laparoscopic peritoneal lavage with no resection and subsequent elective, one-stage resection.(50, 51) Bretagnol et al. looked at 24 patients who underwent laparoscopic management of perforated sigmoid diverticulitis, of whom 19 were found to have purulent or fecal (Hinchey III or IV) peritonitis. They noted a morbidity of 8%. Laparoscopic sigmoid resection was ultimately performed on these patients electively, with a conversion rate of 16%.(50) Myers et al. in a prospective study of 100 patients, attempted laparoscopic peritoneal lavage on all consenting patients with generalized peritonitis from perforated diverticulitis.(51) Their primary endpoints were operative success and resolution of symptoms. They were successful in 92 patients, with morbidity and mortality rates of 4 and 3%. Two patients developed postoperative pelvic abscesses requiring drainage while two patients represented with diverticulitis at a mean follow-up of 36 months. While they did not look at later reoperation, their results do suggest that laparoscopic peritoneal lavage in expert hands may be a viable option in the acute setting and allow avoidance of a colostomy. The timing of surgery after an acute attack of diverticulitis also remains a question. Zingg et al. in a retrospective study of 178 patients undergoing laparoscopic-assisted sigmoid resection for diverticulitis found that patients undergoing surgery during the same hospitalization had a significantly higher conversion rate, 37.7% vs. 12.9%.(52) In addition, the converted patients had an increased surgical morbidity, though this was not statistically significant (23.8% vs. 19.1%). Hospitalization was significantly longer at 13.5 vs. 10.5 days. Their results suggest that patients who respond  improved outcomes in colon and rectal surgery to initial antibiotic therapy and wish to undergo laparoscopic- assisted sigmoid resection would be better served by delaying colectomy for 6 or more weeks. Similarly, Reissfelder et al. looked prospectively in 2006 at 210 patients who underwent laparoscopic sigmoid resection for acute diverticulitis.(53) They were divided into two groups, one with an elective resection 5–8 days after initial antibiotic treatment, and the other 4–6 weeks after their initial hospitalization. There was a statistically significant increase in conversions and anastomotic leaks in the early group, again supporting the idea of delayed resection after the initial episode. As noted earlier in this chapter, a hand-assisted approach is a potentially attractive way to preserve the benefits of laparoscopy while cutting down on operative times and conversion rates. These benefits may be applied to surgery for diverticulitis, particularly in complicated cases (i.e., abscess or fistula). Lee et al. in 2006 compared operative times and outcomes between patients undergoing hand-assisted laparoscopic sigmoid resections and those undergoing a totally laparoscopic approach.(54) Patients with complicated diverticulitis were found to have significantly shorter operative times and lower conversion rates when compared to those undergoing a totally laparoscopic approach. Ureteral stents should also be considered in patients undergoing laparoscopic surgery for diverticulitis. The indications, however, are the same as in open surgery—reoperation, severe inflamma- tion, or the presence of an abscess. Lighted stents are generally not necessary, as the stents can be felt by the surgeon, even in a totally laparoscopic approach. The surgeon should resist the temptation to utilize stents too liberally, as they carry their own set of risks, including bleeding, ureteral obstruction, and perforation. The existing data suggests that a laparoscopic approach to treatment of sigmoid diverticulitis may offer a number of benefits over an open approach. Case selection and surgeon experience, as with other disease processes, is paramount. Strong consideration should be given to a hand-assisted approach in complicated cases. As a general principle in the treatment of diverticulitis, the use of laparoscopic techniques should not compromise the surgical procedure by reducing the amount of colon removed or failing to resect to the level of soft, normal rectum on the distal resection margin. RECTAL PROLAPSE Abdominal fixation procedures for rectal prolapse may offer an ideal opportunity for a laparoscopic approach. The lack of a specimen or an anastomosis solves two of the most potentially vexing problems in laparoscopic colorectal surgery. Laparoscopically-assisted resection rectopexy, however, also may offer many of the same benefits over the open procedure. Whether a resection is involved or not, abdominal fixation procedures may offer an excellent opportunity to learn how to mobilize the rectum laparoscopically, which can then be applied to more extensive procedures, including proctocolectomy or rectal cancer surgery. Ashari et al. in 2005, looked at ten years’ worth of prospectively collected data of patients undergoing laparoscopically- assisted resection rectopexy for full-thickness rectal prolapse.(55) A total of 117 patients were included in the study. Operative times decreased from a median of 180 minutes in their early experience, down to 110 minutes in the latter part of their experience. At a median follow-up of 62 months, only 2.5% of patients had full-thickness prolapse recurrence. Mucosal prolapse recurred in 18% of patients, while 4% of patients required dilation of an anastomotic stricture. This mucosal prolapse recurrence may be a result of less adhesion formation in the pelvis after a laparoscopic dissection. Solomon et al. in 2002, published the findings of a randomized clinical trial of laparoscopic vs. open abdominal rectopexy for rectal prolapse, with a total of 40 patients with full-thickness rectal prolapse randomized to the laparoscopic and open group.(56) Patients were placed on a clinical pathway, which was designed to result in discharge before postoperative day 5. Not surpris- ingly, mean surgical time was greater in the laparoscopic group (153 vs. 102 minutes, p < 0.01). Nineteen of twenty patients in the laparoscopic group were discharged by day five, while only nine of nineteen in the open group were able to achieve that goal. Total narcotic usage was less in the laparoscopic group as well. While these results are encouraging, the follow-up on these patients is short. In addition, the 18% mucosal prolapse reported by Ashari et al. is concerning. Long-term follow-up is essential in these patients before laparoscopy for rectal prolapse can be considered the gold standard. Other considerations such as anterior deep pelvis mobilization, preservation of the anterior lateral stalks, and combination of sigmoid resection and rectopexy will need to be evaluated to derive the true place of laparoscopic treatment of rectal prolapse. COLONOSCOPIC PERFORATION Iatrogenic perforation of the colon during colonoscopy is a for- tunately rare complication. Treatment has generally consisted of laparotomy and repair vs. resection. Because the colon has usually undergone mechanical bowel preparation, simple oversewing of the defect is generally safe and effective. Just as laparoscopy is being applied more often to the repair of perforated peptic ulcers, it would seem logical that it may offer benefits in the treatment of colonoscopic perforation. Bleier et al. in 2008, looked at a series of 18 patients in a four-year period who underwent surgical treatment of iatrogenic perforation.(57) Eleven patients in the laparoscopic group and seven patients in the open group had similar operative times. The patients in the laparoscopic group, however, had statistically significant shorter lengths of stay, fewer complications, and shorter incision lengths. Laparoscopic repair of colonoscopic perforation may become the next step after con- servative therapy fails and avoid major morbidity and prolonged recovery if accomplished in a timely fashion. TECHNICAL CONSIDERATIONS OF GOOD LAPAROSCOPIC PRACTICE IN COLORECTAL SURGERY A significant part of minimizing morbidity and mortality and maximizing outcomes in laparoscopic colorectal surgery centers around a number of technical considerations, including trocar placement, use of instruments, and techniques for vascular control. TROCAR PLACEMENT The most commonly used trocars are 5 or 10 mm, depending on whether a stapler will be used, and the size of the camera. When selecting the sites, it is important to place them far enough apart to avoid “swordfighting.” They must be placed in a position that  laparoscopic colorectal surgery allows the surgeon to reach the extremes of the opposite quadrants with the instruments. It is important that the trocars and the monitors be placed, and the surgeon and assistant positioned such that the surgeon is working in-line with the camera, the intraabdominal pathology, and the monitors. This maximizes the ability of the surgeon to work efficiently while minimizing the potential awkwardness of working against the camera. The trocars should be placed in such a manner that they are inserted above the level of the bowel. This avoids the potential danger of sticking the bowel or other structures with the instruments each time they are inserted through the trocars. The skin incisions should be large enough to allow the trocars to be placed without undue skin trauma, but should be small enough to avoid unnecessary movement of the trocars, air leaks through the skin site, or falling out of the trocars. When inserting the trocars, the surgeon should take care to insert them at right angles to the tangent of the curve of the abdominal wall to avoid tearing the peritoneum and reduce the risk of an oblique insertion. The abdominal wall should always be illuminated to avoid injury to blood vessels, which can cause nuisance bleeding throughout the operation. The trocars should always be inserted under direct vision and the surgeon should always look at the trocar after placement to ensure that any bleeding from the abdominal wall is dealt with early. In addition, the surgeon should make sure the retainer rings are visible on the peritoneum, so that the trocar is fully fixed in place, and will not move unnecessarily. Nonbladed trocars hold a number of advantages over bladed trocars. They may help to avoid bowel injury, and also limits the size of the peritoneal opening. The healing pattern of nonbladed trocars through the peritoneum is also better than that of bladed trocars. The options for insertion of the initial trocar are an open technique and a closed technique using a Veress needle. While both methods have their proponents, it is the opinion of the authors that an open technique should always be utilized in a patient who has undergone previous abdominal surgery. The risk of injury to bowel or blood vessels is significantly higher with a blind insertion in a patient with adhesions. Options for open insertion include the use of a Hasson trocar, or in the case of a hand-assisted laparoscopic operation, direct guidance through the hand-port. In nearly all cases, the bladder should be decompressed with a Foley catheter. This is particularly important in cases where a suprapubic trocar will be placed, so as to avoid any injury to the bladder upon insertion. An oral gastric tube will also insure gastric decompression. INSTRUMENTS One of the mantras for open surgery has included avoidance of direct handling of the bowel with instruments, especially forceps. The lack of hands inside the abdomen should not change this dictum, if at all possible. The surgeon should try to avoid unnecessary grasping of the bowel. If needed, the instruments should instead be used to push and retract. Rather than grasp the bowel directly, the surgeon should try to grasp the surrounding fat instead. The use of the most atraumatic graspers possible, such as the “wavy” grasper, is essential. When retracting, the surgeon should make every effort to retract in a 3-dimensional manner so as to maximize the effectiveness of the retraction. Wound protectors and specimen bags are two ways in which to avoid contamination of the wound by the specimen. This can have particular implications when dealing with a cancerous specimen, or a contaminated specimen, such as the acutely inflamed or perforated appendix. The skirt of the handport used in a hand- assist case is a very effective wound protector. If the handport is not available, some form of ring drape should be used. Placing a sponge into the abdomen, either through a 10 mm port, or through the handport, can be a very effective technique. It can be used to pack the bowel out of the way, protect the bowel, or reduce free-flowing blood which can impair visualization. It can be a very effective way to protect the bowel during retraction so that the surgeon is pushing on the sponge instead of directly on the bowel. VASCULAR CONTROL Methods for vascular control include monopolar cautery, ultrasonic coagulation, clips, staplers, and bipolar devices. While each method has its advantages and disadvantages, it is important to keep several issues in mind. The monopolar device should never be used on larger vessels (i.e., ileocolic artery, inferior mesenteric artery, inferior mesenteric vein). While the ultrasonic shears are effective for vessels <7 mm in size, they have not been proven to be effective on vessels larger than that. Bipolar devices have been proven to be effective on vessels as large as 7 mm and can be an effective and efficient way to manage vascular pedicles. While staplers are also effective for large vascular pedicles, two caveats should be kept in mind. The stapler requires the use of at least a 10 mm trocar, and the surgeon must beware of bleeding through the staples as well. No matter what the method of control, the surgeon should always make sure to have an alternate means of control available in the operating room. Perhaps the two most common and simplest methods are the Endoloop or surgical clips. CONCLUSION Laparoscopic colorectal surgery offers many potential benefits over traditional open surgery, including quicker return of bowel function, decreased pulmonary morbidity, shorter hospital stays, and improved cosmesis. Its widening use across the spectrum of colorectal diseases, while exciting, is also cause for caution amongst all colorectal surgeons. The key to optimizing outcomes in laparoscopic colorectal surgery lies in following several key principles, including careful patient selection, strict adherence to oncologic principles, meticulous attention to technical details, and a willingness to alter one’s approach when needed. The surgeon should not look upon conversion as a failure, but rather as a switch to an alternative approach. The judicious use of a hand-assisted approach may offer a way for the surgeon to preserve the benefits of laparoscopy while providing a means to complete complex and time-consuming cases in a safer and more efficient manner. Ultimately, randomized, controlled trials with long-term follow-up will be needed to truly determine the role of laparoscopy in managing colorectal diseases. 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Prospective randomized endoscopic blinded trial comparing precolonoscopy bowel cleansing methods. prospective, randomized trials, including the Colon carcinoma Laparoscopic or Open (COLOR), Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC), and Clinical Outcomes in. implants at trocar and incision sites and the fear of an inadequate oncologic resection. While  improved outcomes in colon and rectal surgery later studies suggested that the incidence of wound