The role of laparoscopic surgery has been shown to be safe, feasible, and equivalent to open surgery for moderate diverticulitis, but its role in severe disease is still being elucidated. The aim of this study was to compare short-term outcomes in patients who underwent laparoscopic sigmoidectomy for moderate and severe diverticulitis.

All patients who had elective laparoscopic sigmoidectomy for diverticulitis between April 2003 and September 2011 at the University Hospital of Luxembourg were selected from a retrospective database. The patients were divided in two groups: moderate acute diverticulitis (MAD) included patients with an episode of left-lower-quadrant pain, elevated inflammatory markers, and radiologic evidence of diverticulitis, and severe acute diverticulitis (SAD) included patients with diverticula associated with abscess, phlegmon, perforation, fistula, obstruction, bleeding, or stricture.

A total of 121 patients (81 MAD and 40 SAD) underwent elective laparoscopic sigmoidectomy with primary anastomosis. There were no significant differences between the two groups with respect to demographic characteristics, except for sex ratio. In this series the overall morbidity rate at 30 postoperative days (POD) was 12.4 %, with no significant differences between MAD and SAD (16.0 vs. 5 %, respectively; P = 0.083). No significant differences were found with respect to mean length of hospital stay (6.7 vs. 7.7 days; P = 0.399) as well. The overall conversion rate to open surgery was 2.5 % (3 patients), with no difference between the two groups. Conversion to laparotomy was associated with an increased morbidity rate (11.0 % for full laparoscopy vs. 66.6 % for conversion; P = 0.040) and a longer length of stay (6.8 vs. 16.7 days; P = 0.008). There were no deaths within 30 POD.

Elective laparoscopic sigmoidectomy is safe and feasible for patients with moderate and severe acute diverticulitis and the outcomes are equivalent.

Obesity is becoming increasingly more common among patients with inflammatory bowel disease. In this review, we will explore the epidemiological trends of inflammatory bowel disease, the complex interplay between the proinflammatory state of obesity and inflammatory bowel disease, outcomes of surgery for inflammatory bowel disease in obese as compared with non-obese patients, and technical concerns pertaining to restorative proctocolectomy and ileoanal pouch reservoir, stoma creation and laparoscopic surgery for inflammatory bowel disease in obese patients.

Laparoscopic techniques in colon surgery reduce postoperative pain, length of hospital stay, and 30-day morbidity when compared with open surgery. The objective of this study was to determine the feasibility of a laparoscopic colectomy in patients who have previously undergone abdominal surgery. We performed a retrospective, single-institution review of laparoscopic colorectal procedures for benign or malignant pathology between October 2002 and September 2008. Our analysis included 55 patients who previously had laparoscopic, open, or a combination of procedures and subsequently underwent laparoscopic colorectal surgery. We observed a 14.5 per cent conversion rate (n = 8). Of the patients who had previous open procedures (n = 48 [87.3%]), the conversion rate was 16.7 per cent. Only one patient (12.5%) who had a history of only laparoscopic surgery required conversion. The highest conversion rate in our study was from patients who underwent a left colectomy (60%, n = 3/5), which was the only statistically significant factor found for conversion. Since the emergence of laparoscopy, use in colon and rectal surgery nationwide has been poor as a result of multiple factors, including a frequent history of abdominal surgery. Our experience shows that laparoscopic colorectal surgery in patients with prior intra-abdominal surgery can be completed with an acceptable conversion rate.

During the past 15 years, there has been increasing enthusiasm for the use of laparoscopic techniques in the operative treatment of patients suffering from colorectal disease. Laparoscopic colectomy has been demonstrated to be safe for patients suffering from adenocarcinoma of the intraperitoneal colon. Attention is now being focused on the treatment of patients with rectal adenocarcinoma using laparoscopic methods. Prospective data analysis will be crucial in determining whether laparoscopic proctectomy provides equivalent results to open procedures.

The purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure.

Between 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed.

Catheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn's disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group.

Ureteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.

We discuss a rare complication in a patient who underwent laparoscopic colectomy. A 69-year-old woman underwent laparoscopy-assisted right colectomy for cancer of the ascending colon. Two months after the operation, bowel obstruction developed. Decompression with a long intestinal tube failed to resolve the obstruction. Thus, surgery was performed. Abdominal exploration revealed a strangulated ileal loop caused by herniation through the mesenteric opening at the anastomotic site. The mesenterium had not been sutured during the previous operation. The anastomotic segment had twisted semicircularly and adhered to the retroperitoneum, so the mesenteric opening had narrowed.

The purpose of this study was to present our experience of laparoscopic total mesorectal resection, including ultralow resection and coloanal anastomosis.

Between 1993 and 2005, patients fit for general anesthesia, with resectable cancers, and with lower edge of tumor beyond 5 cm of the anal verge were subjected to laparoscopic anterior resection with sphincter preservation. Double stapling technique is used to establish bowel continuity.

A total of 170 patients, 88 males and 82 females, were subjected to successful laparoscopic anterior resection, which included high anterior resection (n=90), low anterior resection (n=52), ultralow anterior resection (n=20), and coloanal anastomosis (n=8). The average age of patients was 58.4 years (12-90 years). Mean operating time was 130 min and mean hospital stay was 7 days. The morbidity was 13.5% with nil mortality. With an average follow-up of 49 months (range 9 years to 3 months), 9 patients developed local recurrence and 45 patients developed distant metastasis.

In selected cases, laparoscopic anterior resection is possible for all levels of rectal tumors, allowing sphincter preservation and maintaining oncological safety.

With the increasing popularity of minimally invasive approaches to surgery, laparoscopic techniques are being applied increasingly to more complex procedures. Surgeons who are interested in gaining skill and confidence with the techniques of rectal mobilization and resection initially should consider attempting procedures for benign disease. Patients who have rectal prolapse, who often have wide, accommodating pelvic anatomy, are the logical choice with whom to begin the laparoscopic rectal experience. Laparoscopic restorative proctocolectomy is more technically challenging. Laparoscopic proctectomy for rectal cancer probably should remain in the hands of well-trained, high-volume, experienced surgeons who have built a dedicated team for treatment of these patients, and who track their outcomes prospectively.

Perioperative care of clinically severely obese patients presents numerous unique challenges. These patients have distinctive issues with regard to cardiovascular, pulmonary, and thromboembolic complications. In addition, hospital equipment must be able to accommodate the body habitus of this population.

A Medline search using the terms "morbid obesity," "colon resection," "obesity comorbidities," "laparoscopic colectomy," "perioperative challenges," and "risk factors" was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each publication.

The authors discussed the most relevant challenges surgeons encounter in the perioperative setting when treating obese patients.

The management of the morbidly obese patient requires meticulous preoperative, intraoperative, and postoperative care. Colorectal surgeons should be familiar with obesity-related problems when treating colorectal disease processes in this patient population. The associated comorbid illnesses in this population, as well as the technical difficulties regularly posed by them, make laparoscopic colectomy a more challenging procedure than normally encountered in the nonobese patient population.

The adoption of laparoscopic proctectomy for rectal cancer has been relatively slow, primarily because of the technical difficulty of the procedure. The wide surgeon-to-surgeon variability in disease-free survival and local pelvic recurrence noted after open proctectomy is probably due to differences in surgical technique, and these differences are likely to be magnified when the additional challenge of laparoscopy is added to the procedure. At present, oncologic and functional outcomes data are limited. Although the adoption of laparoscopic techniques to perform curative proctectomy is likely to expand as technical challenges are overcome and experience and training improve, the results of prospective multicenter trials are necessary to ensure that the procedures provide an oncologic and functional outcome equivalent to that of conventional surgery.

We report a case of a rare complication in laparoscopic colectomy. A 55-year-old woman underwent a laparoscopy-assisted transverse colectomy for transverse colon cancer. On the 5th postoperative day, she developed bowel obstruction. Decompression by a long intestinal tube failed to resolve the bowel obstruction. She underwent operative intervention. Abdominal exploration showed jejunal loop caused by a strangulation forming on an internal hernia through the mesenteric opening at the anastomotic colonic stumps, which had not been sutured during the previous operation. Our experience might indicate the need for closure of small mesenteric opening after laparoscopic colectomy.

The advantages of laparoscopy in the treatment of benign diseases have been well demonstrated. Compared with laparotomy, the laparoscopic approach is associated with a shorter hospitalization period, shorter duration of ileus, decreased postoperative pain, earlier return to work, and improved cosmesis. The role of laparoscopy for the treatment of gastrointestinal malignancy has had a slower evolution and been the subject of considerable debate over the past decade. Since 1991, several concerns have limited the widespread use of laparoscopy for attempted cure of colorectal carcinoma. This review aims to analyze the results of several studies published to date on short and long term outcome of laparoscopy for colorectal carcinoma, based on levels of evidence. From the least to the most convincing data, the hierarchy of study designs progresses through a spectrum ranging from retrospective reviews to prospective series, to case-controlled, cohort, and ultimately randomized controlled trials.

Laparoscopic-assisted colon resection (LACR) for benign disease has gained acceptance and has a lower morbidity than open surgery. Reports in Western literature have outlined the use of LACR for diverticulosis, ulcerative colitis, and Crohn's disease. We evaluated the use of LACR in patients with ileo-cecal tuberculosis (IC-TB) and describe our technique and results.

Twenty-six patients (20 F) between 16 and 45 years of age underwent a LACR for IC-TB over a 4-year period. Three access ports were used in 22 patients, four patients needed four ports. The cecum, ascending colon, proximal transverse colon, and terminal ileum were mobilized completely. The right colic vessels were divided intracorporeally. The specimen was delivered using a 5- to 6-cm incision. The ileo-colic pedicle and bowel were divided outside and an ileocolic anastomosis performed. After placing the bowel within the abdomen the pneumoperitoneum was recreated, saline irrigation done, and hemostasis achieved.

No patient needed a formal laparotomy. Peristalsis returned within 48 h in 19 patients and after 72 h in the remaining seven. Oral liquids were started on all patients by the 3rd postoperative day (POD) and a soft diet by the 5th POD. Twenty patients had a bowel movement by the 4th POD and the rest by the 5th POD. Eighteen patients were discharged by the 5th day and the remaining by the 7th day. Three patients developed wound sepsis. Twenty-one patients could resume normal activity within 2 weeks, the rest within a month.

Laparoscopic-assisted colon resection seems to be an ideal operation for patients with ileo-cecal tuberculosis. It has minimal morbidity and allows a quick return to normal activity.

Nowadays laparoscopic colorectal surgery has demonstrated its advantages, including reduced postoperative pain, decreased duration of ileus, and shorter hospital stay. Few studies report results of laparoscopic surgery in complicated diverticulitis. This study was designed to analyze the results of laparoscopic sigmoidectomy in patients with fistulized sigmoiditis.

The authors retrospectively reviewed 16 patients who had laparoscopic sigmoidectomy for fistulized diverticulitis between 1992 and 2003 in a series of 247 laparoscopic colectomies. Eleven patients presented with colovesical, four with colovaginal, and one with colocutaneous fistulas; all were caused by sigmoiditis. The procedure always consisted of celioscopic sigmoidectomy with stapled transanal suture and, when indicated, closure of the cystic or vaginal fistula orifice.

Mean age was 60 (range, 39-78) years. Mean number of episodes of diverticulitis before operation was three (range, 1-5). Mean time between the last episode and operation was 46 (range, 2-250) weeks. In our first three years of experience, three cases (18.7 percent) were converted to laparotomy. Reasons for conversion were the necessity for intestinal resection, splenectomy, and a wound of the anterior rectum. The mean operative time was 172 (range, 100-280) minutes. Mean hospital stay was 5.7 (range, 3-12) days. There was no mortality. Postoperative morbidity (2 patients, 12.5 percent) consisted of one pulmonary infection and one splenectomy. Long-term follow-up revealed no recurrence of diverticulitis and one incisional hernia.

In experienced hands, laparoscopic sigmoidectomy may be a safe and effective procedure for fistulized sigmoiditis.

To define the current role of laparoscopic resection for colorectal cancer.

Perhaps in no other field has so much controversy been generated by laparoscopy as in its application to curative resection of cancer of the colon and rectum. The main controversy centers around the oncologic outcomes of laparoscopic resections. The 3 major issues are: the adequacy of oncologic resection, recurrence rates and patterns, and the long-term survival.

A review of published data by search of Medline database with focus on clinical studies.

Laparoscopic colectomy is feasible and safe. Modest benefits in the quality of life are observed. Same oncologic resection can be performed laparoscopically with no adverse influence on the recurrence rates. In particular, wound recurrences are not a specific complication of laparoscopic technique. At least equivalent survival is obtained by laparoscopic colectomy.

Laparoscopy does not seem to adversely affect chance of cure of colorectal cancer.

Laparoscopic techniques have expanded since their introduction 15 years ago. The laparoscopic approach for colorectal surgery has been slower to develop than other fields of surgery. However, this approach does provide significant benefits for colorectal resection, although concerns regarding the ability to satisfy oncological criteria have restricted its use in the past. This review studies the published data on the use of laparoscopic surgery for colorectal cancer including the short- and long-term outcomes. New long-term outcome data is now available which is likely to encourage the use of this technique for colon cancer resection. Laparoscopic rectal cancer resection is also discussed including the more limited outcome data that is available.

The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002.

A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer.

Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery.

Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.

Laparoscopic colon resection for cancer is as yet an unproven operation. This review article summarizes current data on the topic.

A Medline review identified articles published since 1990 summarizing patients with potentially curable colon cancer who underwent a laparoscopic-assisted colon resection. Only articles that were randomized or had a control group with historical or matched open cases were used.

Very few prospective randomized controls exist. Several clinical trials are under way with one completed. Data thus far support some patient benefits with a laparoscopic approach. No differences in morbidity, oncologic data, or survival appear to exist.

The results of ongoing clinical trials are still needed to further evaluate the role of laparoscopic assisted colon resection in patients with potentially curable colon cancer.

The purpose of this study was to compare the actual and predicted risk-adjusted morbidity and mortality after laparoscopic colectomy (LAC) calculated using both the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) scoring systems.

All patients who underwent LAC performed by a single surgeon between March 1999 and December 2000 were analysed. The observed morbidity and mortality rates were compared with those predicted by the POSSUM scoring system, and the observed mortality rate with that predicted by P-POSSUM. The operative severity component of the operative score was sequentially decreased from 4 (standard score for open colectomy) to 2, then 1, in an attempt to correct overprediction.

Two hundred and fifty-one consecutive patients underwent LAC, with a conversion rate of 8.0 per cent. The morbidity rate (6.8 per cent) was significantly lower than the predicted rates calculated with an operative score of 4 or 2 (12.4 per cent, P < 0.001; 9.6 per cent, P = 0.001), but was fully corrected with an operative score of 1 (7.0 per cent, P = 0.325). The observed mortality rate (0.8 per cent) was significantly different from the expected mortality rates calculated using either uncorrected POSSUM (9.6 per cent, P = 0.001) or P-POSSUM (3.5 per cent, P = 0.001). POSSUM (2.6 per cent, P = 0.007) continued to overpredict mortality but P-POSSUM (1.0 per cent, P = 0.001) accurately predicted mortality with an operative score of 1.

LAC appeared to be associated with lower morbidity and mortality rates than those predicted by the POSSUM scoring system, and with a lower mortality rate than that predicted using the P-POSSUM system.

Laparoscopic colectomy for colorectal cancer (CRC) has been criticized because of the potential for inadequate nodal dissection and incomplete staging. Lymphatic mapping (LM) and sentinel lymph node (SLN) analysis can improve the accuracy of staging in open colectomy, but its utility during laparoscopic colectomy is unknown.

Between 1996 and 2002, 30 patients with clinically localized colorectal neoplasms or premalignant polyps underwent subserosal or submucosal injection of isosulfan blue dye via a colonoscope, via a percutaneously inserted spinal needle, or through a hand port. Blue-stained lymphatics were visualized through the laparoscope and followed to the SLN, which was tagged. The colectomy was completed in standard fashion. All lymph nodes were stained by hematoxylin and eosin, and multiple sections of each SLN were examined by immunohistochemical (IHC) staining using cytokeratin antibody.

An SLN was identified laparoscopically in all patients. The SLN accurately predicted the tumor status of the nodal basin in 93% of cases. In 8 cases (29%), an unexpected lymphatic drainage pattern altered the extent of mesenteric resection, and in 4 cases (14%), tumor deposits were identified only by IHC and limited to the SLN.

This study, which updates a preliminary report (Am Surg. 2002;68:561-565) confirms that SLN mapping during laparoscopic colon resection can alter the margins of resection and may improve staging by allowing a focused pathologic examination of the SLN, although direct comparison with the "gold standard" of open CRC with adequate lymphadenectomy will be required. Better ultrastaging of CRC lymph nodes may more accurately assign patients to prospective protocols to assess the significance of nodal micrometastases or isolated tumor cells.

Obese patients carry a higher risk of wound complications and cardiopulmonary complications along with a higher incidence of comorbidity, all of which have the potential to affect outcome after a variety of surgical procedures. The data regarding outcomes after laparoscopic colectomy in obese and nonobese patients are limited. The purpose of this report was to compare the outcome of laparoscopic bowel resection in obese and nonobese patients. All patients prospectively entered into a laparoscopic bowel resection database from March 1999 to December 2001, who underwent a segmental colectomy for any pathologic condition, were analyzed. Patients with a body mass index above 30 were defined as obese, and patients with a body mass index below 30 were defined as nonobese. Data collected included age, sex, duration of operation, body mass index, American Society of Anesthesiologists score, operative procedure, diagnosis, complications relating to length of hospital stay, mortality, and readmission within 30 days of discharge. Statistical analysis consisted of Student's t test and chi-square analysis where appropriate, with significance set at P < 0.05. A total of 260 patients were evaluated (201 [77.3%] in the nonobese group and 59 [22.7%] in the obese group). There were no significant differences between the two groups with respect to age, sex, operative procedure, length of hospital stay, or readmission rates. The obese group had significantly more conversions to an open procedure (23.7% vs. 10.9%), a longer operative duration (109 minutes vs. 94 minutes), a higher morbidity rate (22% vs. 13%) and a higher anastomotic leakage rate (5.1% vs. 1.2%). This large experience with laparoscopic colectomy for a variety of conditions demonstrates that despite higher conversion rates, an increased risk of pulmonary complications, and anastomotic leakage rates in obese laparoscopic patients that parallel those of open surgery, laparoscopic colectomy can be performed safely in both obese and nonobese patients with the similar benefit of a shorter hospital stay in both groups.

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.

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.

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.

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.

The purpose of the present study was to evaluate prospectively the abdominal wall recurrence rate after laparoscopic resection for colorectal cancer, to analyze the impact of the learning curve on abdominal wall recurrence, and to assess the outcome of those patients.

The Italian Registry of Laparoscopic Colorectal Surgery database was analyzed to obtain data on cancer patients with abdominal wall recurrence, concomitant local or distant metastases, and interval between initial surgery and diagnosis of trocar site or minilaparotomy recurrences. The records of the initial procedures and the technique of specimen removal were reviewed.

From January 1992 to July 2000, 2,583 patients (1,753 cases of carcinomas and 830 cases of benign diseases) were recorded. The malignant lesions were located on the right colon in 19 percent, the left colon in 48.8 percent, and rectum in 32.2 percent. Sixteen patients with histologic evidence of colorectal adenocarcinoma recurrences at the abdominal wall were observed (0.9 percent). Ten patients presented an advanced stage (III for 7 patients and IV for 3 patients). Eleven cases occurred during the learning curve period (the first 50 consecutive cases). The median survival time after abdominal wall recurrence diagnosis was 16 (range, 12-60) months. By July 2000 only two patients were alive.

The results of the Italian prospective Registry of Laparoscopic Colorectal Surgery confirm that the incidence of abdominal wall recurrences is similar to that reported in open studies (<1 percent). Most abdominal wall recurrences occurred in the learning curve period, suggesting that surgical experience may play a role in the development of this outcome. The prognosis of these patients is very poor.

The feasibility and safety of a minilaparotomy approach to terminal ileal Crohn's disease have not been fully elucidated. The purpose of this study was to compare early outcomes utilizing this technique as an alternative to conventional approaches. Nine patients with terminal ileal Crohn's disease (but no complicating enteric fistulas) who underwent minilaparotomy between January 1998 and September 2000 were studied prospectively. The minilaparotomy approach entails a complete surgical procedure performed through a skin incision of less than 7 cm. Ten similar patients who underwent conventional laparotomy between January 1995 and December 1997 served as the control group. Age, gender, body weight, height, body mass index, number of prior laparotomies, operating times, operative blood loss, and types of operative procedure were similar for cases and controls. The length of the laparotomy incision in the minilaparotomy approach group was significantly shorter than that in the conventional approach group (median length 6.0 vs. 16.5 cm; p <0.05). Postoperative intervals until initial standing and walking were significantly shorter for minilaparotomy patients than conventional surgery patients (p <0.05 and p <0.05, respectively), whereas postoperative intervals until passing flatus, urinary catheter removal, and tolerance of liquids and solids did not differ for the two groups, nor did the analgesic requirement or postoperative hospital stay. Postoperative complications developed in two conventional-group patients; none was noted with the minilaparotomy approach. Our data suggest that the minilaparotomy approach to terminal ileal Crohn's disease without an enteric fistula is feasible, safe, and less invasive than the conventional approach.

The aim of this prospective study was to assess the outcome of laparoscopic colectomy for sigmoid diverticulitis in normal weighted, overweighted and obese patients.

From January 1995 to December 2000, all patients (n = 77) undergoing an elective colectomy for sigmoid diverticulitis were included in the study. The patients were divided into three groups: group 1 (n = 29): normal weighted patients (BMI: 18-24.9); group 2 (n = 27): overweighted patients (BMI: 25.0-29.9); group 3 (n = 21): obese patients (BMI: 30.0-39.9). Comparison between these three groups was only made during the per and postoperative period.

There were no differences in the three groups with regard to age, sex and ASA classification. Duration of operation did not differ between group 1 and 2 (187 vs 210 min, P = 0.6) but was shorter in group 1 than in group 3 (187 vs 247 min, P = 0.003). Conversion rate did not differ and was respectively in group 1, 2 and 3: 13.8, 14.8 and 14.3%. The postoperative period during which parenteral analgesics were required was not different for group 1 and 2 but was longer in group 3 than in group 1 (8.5 vs 5.7 days, p = 0.03). Morbidity rate was similar in group 1, 2 and 3: 15, 14 and 17%. There was no perioperative mortality. Duration of hospital stay was similar in the three groups.

Data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely to overweighted and obese patients.

Conversion rates following laparoscopic colorectal surgery vary widely between studies, and the outcome of converted patients remains controversial.

A comprehensive search of the English-language literature was updated until May 1999.

Twenty-eight studies on 3232 patients were considered for analysis. The overall conversion rate was 15.38%. Seventy nine percent of the studies did not include a definition for conversion; in these studies, the conversion rate was significantly lower than in the series where a specific definition was considered (13.7% vs 18.9%, chi-square test, p < 0.001). Converted patients had a prolonged hospital stay (11.38 vs 7.41 days) and operative time (209 vs 189 min) in comparison with laparoscopically completed patients (95% confidence interval (CI), 1.70-4.00 and 35.90-37.10, respectively). The factors associated with an increased rate for conversion were left colectomy (Odds Ratio [OR] = 1.061), anterior resection of the rectum (OR = 1.088), diverticulitis (OR = 1.302), and cancer (OR = 2.944) (for each parameter, Wald chi-square value, p < 0.001).

In nonrandomized studies, the rate of laparoscopically completed colorectal resections is close to 85%. Because converted patients have a distinct outcome, a clear definition of conversion is required to compare the results of randomized trials. Such trials should also consider a 20% rate of conversion when estimating the sample size for the desired power level. It is likely that converted patients will have a significant impact on the results of future clinical research in laparoscopic colorectal surgery.

The feasibility and safety of a minilaparotomy approach for curative resection of colonic cancer have not been fully elucidated. The purpose of this study was to compare outcomes utilizing this alternative technique with those of conventional laparotomy.

Eighty-four patients scheduled to undergo resection for colonic cancer via minilaparotomy between 1997 and 1999 were studied prospectively. The minilaparotomy involved complete resection performed through a skin incision less than 7 cm in length. Sixty-nine patients who underwent a similar resection via a conventional laparotomy between 1994 and 1996 served as the control group.

The minilaparotomy approach was successful in 72 of 84 patients. Colectomy type, operating time and histopathological features of tumours were similar between cases and controls, whereas operative blood loss in the control group was significantly greater (P = 0.002). Postoperative times to standing, walking, passage of flatus and urinary catheter removal were significantly shorter in the minilaparotomy group (P = 0.007, P = 0.003, P = 0.03 and P = 0.006 respectively), and analgesic requirements were significantly lower (P = 0.001). At a median follow-up of 24.8 months there have been no tumour recurrences at the minilaparotomy incision sites.

A minilaparotomy approach to the curative resection of colonic cancer is an attractive alternative to conventional laparotomy in selected patients.

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.

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.

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).

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.

The conventional and accepted treatment for curative resection of colon cancer is laparotomy with hemicolectomy for right or left sided lesions. The technique of colon resection through an open laparotomy incision is well known. Over the past several years, laparoscopically assisted colectomy has been developed and studied, following the explosion of laparoscopic technology from the cholecystectomy experience and with acquisition of advanced general laparoscopic techniques. The right, left or sigmoid colon can be mobilized and regional lymphadenectomy performed using laparoscopic instruments and video-imaging equipment. The advantage of laparoscopic colectomy is the use of small abdominal port site and wound incisions which translate to reduced postoperative pain and analgesic requirement, earlier return of bowel function and normal physical activities, and shorter hospital stay without increasing health care costs. Laparoscopic colectomy compares favorably with open colectomy in terms of surgical morbidity and mortality. The laparoscopic approach has been shown to be technically and oncologically feasible with equivalent lymph node harvest from mesenteric lymphadenectomy and achieves adequate proximal and distal margins of colonic resection. Despite initial early anecdotal reports of port site cancer recurrence in laparoscopically assisted colectomy, port site recurrence is rare and its incidence is similar to incisional recurrences in conventional open colectomy. Recent prospective comparative studies have demonstrated equivalent patient survival and equivalent local or distant colon cancer recurrences for open versus laparoscopic curative resection of colon cancer.

The unique challenges of a laparoscopic approach to colorectal surgery have delayed its widespread adoption into clinical practice. Advances in instrumentation, modifications of technique, and an unequivocal demonstration of its safety undoubtedly will increase its popularity in the future.

Laparoscopy is still controversial when applied for the attempted cure of colorectal cancer. Although some advantages may be possible, some disadvantages also have been postulated. Laparoscopic treatment of benign disease is far less controversial. Three of the best procedures and indications, respectively, are laparoscopic sigmoid colectomy for diverticulitis, laparoscopic-assisted ileocolic resection for terminal ileal Crohn's disease, and laparoscopic stoma creation for perianal Crohn's disease. Other potentially advantageous surgeries and indications include laparoscopic-assisted total abdominal colectomy for colonic Crohn's disease, laparoscopic total proctocolectomy for colonic and anorectal Crohn's disease, and laparoscopic secondary ileoproctostomy or coloproctostomy as Hartmann reversal procedures. Significant benefits can be expected with these procedures relative to decreased pain; ileus; length of hospital stay; disability, and, possibly, adhesion formation and subsequent bowel obstruction, and improved cosmesis.

The use of laparoscopic surgery to treat colon cancer has been well studied; however, the specific use of laparoscopic colectomy for Dukes A colon cancer has not been evaluated. The data of laparoscopic colectomy were compared with those of conventional open colectomy, and the surgical results of patients who underwent surgery for Dukes A colon cancer were evaluated. Between November 1993 and October 1997, 20 patients underwent laparoscopic colectomy for Dukes A colon cancer. Operation time, blood loss, first passage of flatus, day of resumption of oral intake, length of hospital stay after surgery, and number of dissected lymph nodes were compared between 20 patients who underwent laparoscopic colectomy and 23 patients who underwent conventional open colectomy for Dukes A colon cancer. In patients with laparoscopic colectomy, when compared with those with conventional open colectomy, mean blood loss was less (103 g vs. 318 g), flatus returned more quickly (3.5 days vs. 4.2 days), oral intake resumed earlier (3.7 days vs. 4.7 days), and postoperative hospital stay was shorter (16.4 days vs. 24.6 days). The mean number of dissected lymph nodes was not different between the two groups (9.2 vs. 9.2 for D2 dissection). No patient had port-site metastasis or recurrence during a follow-up period from 13 to 60 months (median, 38 months). Review of the literature and the authors' findings indicated that none of the 142 reported patients had port-site metastasis after laparoscopic colectomy for Dukes A colon cancer. The results indicate that laparoscopic colectomy is safe and useful when applied to patients with Dukes A colon cancer and performed carefully by trained surgeons.

The incidence of most cancers increases with age. Although the risk for surgery increases in elderly patients who have comorbidities, evaluations of risk can allow interventions that may decrease morbidity and mortality. Appropriate treatments should be offered to the elderly until studies demonstrate the elderly can safely be managed differently from younger patients. The elderly should not be denied adequate treatment simply because of age.