Impact of previous abdominal surgery on the outcome of laparoscopic colectomy: a case-matched control study

The impact of previous abdominal surgery on colorectal cancer patients undergoing laparoscopic surgery

The current study aimed to investigate whether previous abdominal surgery (PAS) could affect the outcomes of colorectal cancer (CRC) surgery. We conducted the search strategy in three databases (PubMed, Embase, and the Cochrane Library) from inception to May 26, 2022. The short-term and long-term outcomes were compared between the PAS group and the non-PAS group. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled up. Stata (V.16.0) software was used for data analysis. We included 34,827 patients from 14 studies in the current study. After pooling up all the data, we found that there were higher proportions of overall complications (OR = 1.12, I2 = 4.65%, 95% CI 1.03 to 1.23, P = 0.01), ileus (OR = 1.96, I2 = 59.74%, 95% CI 1.12 to 3.44, P = 0.02) and mortality (OR = 1.26, I2 = 0.00%, 95% CI 1.11 to 1.42, P = 0.00) in the PAS group than the non-PAS group. Patients with a history of PAS had higher risks of overall complications and death following CRC surgery. However, it did not appear to significantly affect the short-term outcomes apart from ileus. Surgeons should raise awareness of patients with a history of PAS, and take steps to reduce postoperative complications and mortality.

Impact of prior abdominal surgery on short-term outcomes following laparoscopic colorectal cancer surgery: a propensity score-matched analysis

BACKGROUND

Whether laparoscopic surgery after prior abdominal surgery (PAS) is safe and feasible for colorectal cancer (CRC) remains controversial. The present study aimed to evaluate the impact of PAS on short-term outcomes following laparoscopic CRC surgery.

METHODS

We performed retrospective analysis used propensity score-matched analysis to reduce the possibility of selection bias. Participants comprised 1284 consecutive patients who underwent elective laparoscopic CRC surgery between 2010 and 2020. Patients were divided into two groups according to PAS. Patients with PAS were then matched to patients without these conditions. Short-term outcomes were evaluated between groups in the overall cohort and matched cohort, and risk factors for conversion to laparotomy and severe postoperative complications were analyzed.

RESULTS

After propensity score matching, we enrolled 762 patients (n = 381 in each group). Before matching, significant group-dependent differences were observed in sex, age, primary tumor site, pathological (p) T stage, and type of procedure. No significant difference was found between groups in terms of rate of conversion to laparotomy, estimated blood loss, rate of extended resection, length of postoperative stay, and postoperative complications. After matching, estimated operative time was significantly longer in the PAS group (p = 0.01). Significant differences were found between groups in terms of reason for conversion to laparotomy. Multivariate analyses identified significant risk factors for conversion to laparotomy as pT stage ≥ 3 (odds ratio [OR] 2.36; 95% confidence interval [CI] 1.05-5.26) and body mass index ≥ 25 kg/m² (OR 3.56; 95% CI 1.07-11.7). Multivariate analyses identified rectum in the primary tumor site as the only significant risk factor for severe postoperative complications (OR 2.37; 95% CI 1.08-5.20).

CONCLUSIONS

Laparoscopic CRC surgery after PAS showed acceptable short-term outcomes compared to Non-PAS. The laparoscopic approach appears safe and feasible for CRC regardless of whether the patient has a history of PAS.

Impact of previous abdominal surgery on the outcome of laparoscopy-assisted open appendicovesicostomy (Mitrofanoff) creation in children: a comparative study

INTRODUCTION AND OBJECTIVE

For patients who require self-intermittent catheterization, a continent catheterizable stoma is a viable option. This patient population often has had previous abdominal surgery (PAS), a risk factor for complicated laparoscopic procedures. Therefore, the authors aim to determine whether PAS has an impact on the peri-operative outcomes of the laparoscopic-assisted Mitrofanoff procedure in children.

MATERIALS AND METHODS

A research ethics board-approved retrospective review was performed to assess peri-operative outcomes among pediatric patients who underwent laparoscopic-assisted Mitrofanoff procedures in the authors institution from May 2000 to March 2016. Patients with no PAS were compared with those with intraperitoneal PAS. Demographic/baseline characteristics and peri-operative outcomes such as operative time, estimated blood loss, hospital stay, unanticipated additional operations, stomal stenosis, and urinary continence were compared. To ensure there is no confounding based on PAS characteristics, subgroups were created to compare the recency (PAS <1 year ago) and extent (ventriculoperitoneal (VP) shunt vs non-VP shunt PAS) to assess their peri-operative outcomes. Fisher's exact test and Mann-Whitney U test were used to determine statistical significance.

RESULTS

Thirty-four patients (15 no PAS and 19 PAS) were included in the analysis. No significant difference in demographics and baseline characteristics was noted between the patient groups. The median age was 6.5 years (interquartile range [IQR] 4.8-14.0) and 9.9 years (4.2-14.3), respectively (NS). Peri-operative outcomes of operative time, estimated blood loss, and hospital stay were similar between the PAS and no PAS groups. There was no statistical difference in complications requiring surgical intervention (n = 3, 20.0%; n = 9, 47.4%). The median follow-up period was 25.9 (IQR 7.7-47.2) months and 28.0 (IQR 13.0-53.0) months, respectively (NS). Patients with VP shunts as their only PAS had higher estimated blood loss compared with no PAS group (50 [IQR 25-150], 25 [IQR 25-50], respectively) but without other differences in peri-operative outcomes.

DISCUSSION

Findings support the use of a minimally invasive approach in this patient population as it is feasible, comparable, and safe but with careful consideration for risk factors that may predispose PAS patients to postsurgical complications requiring intervention. Although limited by small sample size, this study provides valuable insight into performing laparoscopic operations in children who have undergone prior surgeries and invites future studies to compare the outcomes between patients undergoing open, pure laparoscopic, and robotic-assisted laparoscopic Mitrofanoff procedures for children with PAS.

CONCLUSION

Laparoscopic-assisted Mitrofanoff creation may be safely performed in children with PAS.

Effect of Previous Abdominal Surgery on Laparoscopic Roux-en-Y Gastric Bypass Surgery

BACKGROUND

Previous abdominal surgery (PAS) is a relative contraindication of laparoscopic surgery. In this study, we aimed to investigate the effect of PAS on the feasibility and safety of laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) in patients with obesity and type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

A retrospective analysis was conducted for a total of 235 consecutive patients with obesity and T2DM from Shanghai Tongren Hospital from February 2011 to December 2015. The patients were classified into two groups: no previous abdominal surgery group (NPAS group, n = 179) and previous abdominal surgery group (PAS group, n = 56). The patients underwent LRYGB, and the data of basic information, presence of adhesions, adhesiolysis requirement, operative time, blood loss, hospital stay, and perioperative and postoperative complications were collected and compared between the groups.

RESULTS

Adhesion was found in 14 patients in the NPAS group and in 43 patients in the PAS group, with adhesiolysis requirement in 4 (2.23%) and 37 (66.07%) patients, respectively (P < 0.05). There were no complications directly associated with adhesiolysis. No patients were converted to open surgery. There were no significant differences in gender (P = 0.30), T2DM duration (P = 0.58), body mass index (P = 0.06), blood loss (P = 0.36), or perioperative or postoperative complications (P = 0.41) between the groups. Significant differences were observed in the mean age, ASA score, operative time, and hospital stay between the groups (P < 0.001).

CONCLUSIONS

PAS is relatively safe and feasible for LRYGB in Chinese patients with obesity and T2DM.

Colorectal surgery in patients with prior pancreaticoduodenectomy

Objectives: Colorectal cancer (CRC) surgery after pancreaticoduodenectomy (PD) is difficult to perform, because PD involves dissection and complex reconstruction of the digestive tract. We evaluated the clinical outcomes of CRC surgery in patients with prior PD. Methods: Between January 2008 and March 2018, a total of 1727 patients received CRC surgery at our institution. Of these, 10 had previously undergone PD (PD group). As a control group, 280 patients were collected who had undergone resection without any history of previous abdominal surgery. The PD and control groups were further subdivided into four groups by right or left side. Outcomes of colorectal surgery were investigated in the PD and control groups. Results: The number of harvested lymph nodes was significantly lower in the PD group. In the right colectomy group, distance from the surgical margin was significantly shorter in the PD group. The rate of postoperative complications was higher in the PD group. Peritoneal dissemination originating from pancreatic cancer was found during CRC surgery for one patient, and one patient developed refractory ascites. Three patients died of pancreatic cancer, rectal cancer, and other disease. Seven patients were alive without recurrence. Conclusions: CRC surgery for patients with prior PD can involve difficulty in dissecting lymph nodes and higher postoperative morbidity rates but can provide sufficiently curative resection for CRC.

Usefulness of the endoscopic surgical skill qualification system in laparoscopic colorectal surgery: short-term outcomes: a single-center and retrospective analysis

Background

The use of laparoscopic surgery has become widespread, and many surgeons are striving to acquire the necessary techniques for it. The Endoscopic Surgical Skill Qualification System (ESSQS), established by the Japan Society for Endoscopic Surgery, serves to maintain and improve the quality of laparoscopic surgery in Japan. In this study, we aimed to determine whether ESSQS certification is useful in maintaining and improving the quality of surgical techniques and in standardization of laparoscopic surgery in Japan.

Methods

This retrospective study used data from the Institute for Integrated Medical Sciences, Tokyo Women’s Medical University, Japan. From January 2016 to October 2017, 241 patients with colorectal cancer underwent laparoscopic surgery. Of them, 220 patients were selected and divided into two groups on the basis of surgery performed by an ESSQS-qualified surgeon (QS group) (n = 170) and a non-ESSQS-QS (NQS) (n = 50). We compared the short-term results in the two groups and examined those before and after propensity score matching (PSM).

Results

Mean operation time was longer in the NQS group than in the QS group. Furthermore, mean blood loss was significantly less in the QS group. These were similar before and after PSM. The rate of conversion to open surgery was significantly higher in the NQS group before PSM. However, the rate of postoperative complications was not different between the two groups.

Conclusions

A laparoscopic procedure performed by ESSQS-QS often leads to good short-term outcomes. Thus, the ESSQS system works and is potentially useful in maintaining and improving the quality of surgical techniques and in standardization of laparoscopic surgery in Japan.

Laparoscopic Colorectal Surgery in Patients With Previous Abdominal Surgery: A Single-center Experience and Literature Review

To present the outcomes of laparoscopic colorectal surgery in colorectal cancer patients with a previous history of abdominal surgery. Data of a total of 121 patients with primary colorectal cancer who underwent laparoscopic surgery were retrospectively analyzed. The patients were divided into 2 groups as those with previous abdominal surgery (PAS, n=34) and those without (non-PAS, n=87). Gastric and colonic surgeries were the most common procedures in the major PAS group, whereas gynecologic and obstetric surgeries and appendectomy were the most common procedures in the minor PAS group. However, there were statistically significant differences in the overall complication rates, wound complications, and anastomotic leaks, although there were no significant differences in the rates of postoperative ileus, pneumonia, port site herniation, and postoperative bleeding between the groups. Our study results suggest that laparoscopic colorectal surgery can be safely performed in patients with colorectal cancer who underwent abdominal surgery previously.

One-Anastomosis Gastric Bypass: First 407 Patients in 1 year

BACKGROUND

One-anastomosis gastric bypass (OAGB) is a promising laparoscopic procedure with various benefits including shorter operating times and less operative complications. That said, it is yet to gain widespread acceptance. Here, we describe our first-year experience with OAGB in our department, in particular the safety and efficacy of this procedure.

METHODS

This study is a retrospective analysis of all patients who underwent OAGB between March 2015 and March 2016 by our bariatric surgery unit. Patient demographics, comorbidities, operative and postoperative data were collected and analyzed as well as outcomes during the first year.

RESULTS

Four hundred and seven patients underwent OAGB (254 females, average age 41.8 ± 12.05, BMI = 41.7 ± 5.77 kg/m²). Ninety-eight patients (24%) had prior bariatric surgery. Ninety-four patients (23%) had diabetes, 93 patients (22.8%) had hypertension, 123 (28.8%) had hyperlipidemia, and 35 patients (8.6%) suffered from obstructive sleep apnea. Eight patients (1.96%) had early minor complications (Clavien-Dindo 1-3a), and 10 patients (2.45%) suffered early major complications (Clavien-Dindo ≥3b). The average length of hospital stay was 2.2 ± 0.84 days (range 2-10 days). Twenty patients (4.8%) were readmitted, and 10 patients underwent reoperation. Patients who had had previous bariatric surgery had higher rates of complications, a prolonged hospital admission, higher rates of readmission, and early reoperations. The average excess weight loss (%EWL) 1 year following surgery was 88.9 ± 27.3 and 72.8 ± 43.5% in patients that underwent primary and revision OAGB, respectively.

CONCLUSIONS

OAGB is both safe and effective as a primary as well as a revision bariatric surgery.

Robotic surgeries for patients with colorectal cancer who have undergone abdominal procedures: Protocol for meta-analysis

BACKGROUND

Although the safety and the advantages of laparoscopic and robotic colorectal surgeries have been confirmed, the use of both modalities in patients with previous abdominal surgeries (PAS) history remains uncertain. Herein, we perform a meta-analysis to investigate the impact of PAS on perioperative recovery outcomes from laparoscopic and robotic colorectal surgeries.

METHODS

We will search PUBMED, the Cochrane Library, the Chinese Biomedical database (CBM), WanFang data, China National Knowledge Infrastructure (CNKI) up to January 2018. Studies will be screened by title, abstract, and full text independently and in duplicate. Studies that report the impact of PAS on perioperative recovery outcomes from laparoscopic and robotic colorectal surgeries will be eligible for inclusion. Outcome variables will be assessed included combined resection, conversion, operation time, blood loss, number of retrieved lymph nodes, days to soft diet intake, length of hospital stay, and postoperative complications. Assessment of risk of bias and data synthesis will be performed using STATA SE 12.0. Heterogeneity among studies will be assessed using the I statistic.

RESULTS

Randomized controlled trials, prospective cohort studies, and propensity-matched comparative studies will be used for the quantitative synthesis of the meta-analysis to evaluate the impact of PAS on perioperative recovery outcomes from laparoscopic and robotic colorectal surgeries.

CONCLUSIONS

We aim to draw an objective conclusion of the comparisons in aspects of perioperative outcomes and provide physicians level I evidences for clinical decision makings.

Attempting a Laparoscopic Approach in Patients Undergoing Left-Sided Colorectal Surgery Who Have Had a Previous Laparotomy: Is it Feasible?

BACKGROUND

The feasibility of a laparoscopic approach in patients who have had a prior laparotomy (PL) remains controversial. We hypothesized that laparoscopic colorectal resection was safe and feasible in patients with previous open abdominal surgery.

METHODS

A retrospective review (2007-2015) of all patients undergoing laparoscopic resection for sigmoid and rectal adenocarcinoma with or without prior midline laparotomy (NPL) was performed. Primary endpoints included conversion and perioperative morbidity. Secondary endpoints included length of stay and perioperative outcomes. Demographics, surgical history, oncologic staging, and short-term outcomes were reviewed.

RESULTS

We identified 211 patients, of whom 33 (15.6%) had a prior laparotomy. Significantly more patients in the PL group were female (76.2 vs. 52.8%, p = 0.004). Patients with PL were of similar age to NPL patients (69.3 vs. 62.5, p = 0.09), and comorbidities, tumor staging, and neoadjuvant therapy were comparable between groups (all p > 0.05). Additional trocar placement was significantly higher in PL group (33.3 vs. 17.4%, p = 0.03), while conversion rate did not reach statistical significance (24.2 vs. 12.9%, p = 0.08). The postoperative complication rate was comparable between PL and NPL patients (33.3 vs. 25.3%, respectively, p = 0.2).

CONCLUSIONS

Prior laparotomy should not be a contraindication to patients undergoing laparoscopic colorectal surgery, though surgeons should anticipate a higher likelihood of conversion to open.

Comparison of the Short-Term Outcomes of Laparoscopic and Open Resections for Colorectal Cancer in Patients with a History of Prior Median Laparotomy

This study aimed to investigate the short-term outcomes of laparoscopic resection in comparison with those of open resection for colorectal cancer in patients with a history of prior median laparotomy (PML). Eighty-seven consecutive patients (87/1121, 7.8 %) with a history of PML who underwent major colorectal cancer resection were enrolled (laparoscopy, n = 40; open, n = 47). The conversion rate to open surgery was 25 % (n = 10). The laparoscopy group had a higher proportion of female patients (57.5 vs. 36.2 %), a lower rate of American Society of Anesthesiologists (ASA) score for physical status of ≥3 (7.5 vs. 25.5 %), and a lower pT4 tumor rate (15 vs. 38.3 %) than the open resection group. Regarding the reasons for PML, radical hysterectomy with extended lymphadenectomy for gynecologic cancer was more common (32.5 vs. 4.3 %), but gastrointestinal surgeries, such as gastrectomy and colectomy, were less frequent in the laparoscopy group. Regarding intraoperative outcomes, the laparoscopy group showed a similar operative time (197 vs. 204 min), intraoperative enterotomy rate (2.5 vs. 2.1 %), and bowel resection rate (2.5 vs. 2.1 %) with the open resection group. Regarding postoperative outcomes, the laparoscopy group showed a lower complication rate (20 vs. 40.4 %), significantly reduced time to soft diet (5 vs. 7 days), and shorter hospital stay (12 vs. 18 days). Despite the high rate of open conversion, favorable short-term outcomes were observed in the laparoscopic group. Laparoscopy may be chosen as the primary approach in selected patients with a history of non-gastrointestinal PML (prior abdominal surgery for gynecological cancer).

Laparoscopic and Robotic Surgeries for Patients With Colorectal Cancer Who Have Had a Previous Abdominal Surgery

PURPOSE

The impact of previous abdominal surgery (PAS) on surgical outcomes from laparoscopic and robot surgeries is inconclusive. This study aimed to investigate the impact of PAS on perioperative outcomes from laparoscopic and robotic colorectal surgeries.

METHODS

From March 2007 to February 2014, a total of 612 and 238 patients underwent laparoscopic and robotic surgeries, respectively. Patients were divided into 3 groups: those who did not have a PAS (NPAS), those who had a major PAS, and those who had a minor PAS. We further divided the patients so that our final groups for analysis were: patients with NPAS (n = 478), major PAS (n = 19), and minor PAS (n = 115) in the laparoscopy group, and patients with NPAS (n = 202) and minor PAS (n = 36) in the robotic surgery group.

RESULTS

In the laparoscopy group, no differences in the conversion rates between the 3 groups were noted (NPAS = 1.0% vs. major PAS = 0% vs. minor PAS = 1.7%, P = 0.701). In the robotic surgery group, the conversion rate did not differ between the NPAS group and the minor PAS group (1.0% vs. 2.8%, P = 0.390). Among the groups, neither the operation time, blood loss, days to soft diet, length of hospital stay, nor complication rate were affected by PAS.

CONCLUSION

PAS did not jeopardize the perioperative outcomes for either laparoscopic or robotic colorectal surgeries. Therefore, PAS should not be regarded as an absolute contraindication for minimally invasive colorectal surgeries.

Advances in Laparoscopic Colorectal Surgery

Laparoscopic colorectal surgery has now become widely adopted for the treatment of colorectal neoplasia, with steady increases in utilization over the past 15 years. Common minimally invasive techniques include multiport laparoscopy, single-incision laparoscopy, and hand-assisted laparoscopy, with the choice of technique depending on several patient and surgeon factors. Laparoscopic colorectal surgery involves a robust learning curve, and fellowship training often lays the foundation for a high-volume laparoscopic practice. This article provides a summary of the various techniques for laparoscopic colorectal surgery, including operative steps, the approach to difficult patients, and the learning curve for proficiency.

Influence of previous abdominal surgery on surgical outcomes between laparoscopic and open surgery in elderly patients with colorectal cancer: subanalysis of a large multicenter study in Japan

BACKGROUND

The aim of the present study was to examine the technical and oncological feasibility of laparoscopic surgery (LAP) in elderly patients with a history of abdominal surgery.

METHODS

We conducted a propensity score-matched case-control study of colorectal cancer (CRC) patients aged ≥80 years that were treated at 41 hospitals between 2003 and 2007. We included 601 patients who had a history of abdominal surgery and underwent curative and elective surgery for stage 0 to III CRC. After the matching procedure, 153 patients were included in each cohort. The surgical outcomes of LAP and open surgery (OS) were compared. P-values of <0.05 were considered statistically significant.

RESULTS

LAP resulted in a significantly longer surgical time (220 vs. 170 min, p < 0.001), but significantly less intraoperative blood loss (39 vs. 100 ml, p < 0.001). A number of postoperative recovery-related parameters, including the length of the hospitalization period (12 vs. 14 days, p = 0.002), and the days to the resumption of fluid (2 vs. 3 days, p < 0.001) and solid food intake (4 vs. 5 days, p < 0.001), were significantly better in the LAP group. Moreover, the overall morbidity rate (43 vs. 66 %, p = 0.009) and the frequency of postoperative ileus (7 vs. 19 %, p = 0.023) were significantly lower in the LAP group, while the frequencies of other morbidities did not differ significantly between the groups. In the survival analyses, overall survival and disease-free survival did not differ between the two groups.

CONCLUSIONS

In this population, LAP can be performed safely in elderly CRC patients with a history of abdominal surgery, and LAP resulted in a lower postoperative morbidity rate than OS.

Abdominal fat ratio - a novel parameter for predicting conversion in laparoscopic colorectal surgery

INTRODUCTION Laparoscopic surgery has become the standard for colorectal cancer resection in the UK but it can be technically challenging in patients who are obese. Patients whose body fat is mainly inside the abdominal cavity are more challenging than those whose fat is mainly outside the abdominal cavity. Abdominal fat ratio (AFR) is a simple parameter proposed by the authors to aid identification of this subgroup. MATERIALS AND METHODS All 195 patients who underwent elective, laparoscopic colorectal cancer resections from March 2010 to November 2013 were included in the study. For patients who were obese (body mass index greater than 30), preoperative staging computed tomography was used to determine AFR. This was assessed by two different, blinded observers and compared with conversion rate. RESULTS Of the 195 patients, 58 (29.7%) fell into the obese group and 137 (70.3%) into the non-obese group. The median AFR of the obese group that were converted to open surgery was significantly higher at 5.9 compared with those completed laparoscopically (3.3, P = 0.0001, Mann-Whitney). There was no significant difference in conversion rate when looking at body mass index, tumour site or size. DISCUSSION Previous studies have found body mass index, age, gender, previous abdominal surgery, site and locally advanced tumours to be associated with an increased risk of conversion. This study adds AFR to the list of risk factors. CONCLUSION AFR is a simple, reproducible parameter which can help to predict conversion risk in obese patients undergoing colorectal cancer resection.

Short-term outcomes after laparoscopic colorectal surgery in patients with previous abdominal surgery: A systematic review

AIM: To perform a systematic review focusing on short-term outcomes after colorectal surgery in patients with previous abdominal open surgery (PAOS).

METHODS: A broad literature search was performed with the terms “colorectal”, “colectomy”, “PAOS”, “previous surgery” and “PAOS”. Studies were included if their topic was laparoscopic colorectal surgery in patients with PAOS, whether descriptive or comparative. Endpoints of interest were conversion rates, inadvertent enterotomy and morbidity. Analysis of articles was made according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS: From a total of 394 citations, 13 full-texts achieved selection criteria to be included in the study. Twelve of them compared patients with and without PAOS. All studies were retrospective and comparative and two were case-matched. The selected studies comprised a total of 5005 patients, 1865 with PAOS. Among the later, only 294 (16%) had history of a midline incision for previous gastrointestinal surgery. Conversion rates were significantly higher in 3 of 12 studies and inadvertent enterotomy during laparoscopy was more prevalent in 3 of 5 studies that disclosed this event. Morbidity was similar in the majority of studies. A quantitative analysis (meta-analysis) could not be performed due to heterogeneity of the studies.

CONCLUSION: Conversion rates were slightly higher in PAOS groups, although not statistical significant in most studies. History of PAOS did not implicate in higher morbidity rates.

Role of Minimally Invasive Surgery in the Reoperative Abdomen or Pelvis

Laparoscopy has become widely accepted as the preferred surgical approach in the management of benign and malignant colorectal diseases. Once considered a relative contraindication in patients with prior abdominal surgery (PAS), as surgeons have continued to gain expertise in advanced laparoscopy, minimally invasive approaches have been increasingly incorporated in the reoperative abdomen and pelvis. Although earlier studies have described conversion rates, most contemporary series evaluating the impact of PAS in laparoscopic colorectal resection have reported equivalent conversion and morbidity rates between reoperative and non-reoperative cases, and series evaluating the impact of laparoscopy in reoperative cases have demonstrated improved short-term outcomes with laparoscopy. The data overall highlight the importance of case selection, careful preoperative preparation and planning, and the critical role of surgeons' expertise in advanced laparoscopic techniques. Challenges to the widespread adoption of minimally invasive techniques in reoperative colorectal cases include the longer learning curve and longer operative time. However, with the steady increase in adoption of minimally invasive techniques worldwide, minimally invasive surgery (MIS) is likely to continue to be applied in the management of increasingly complex reoperative colorectal cases in an effort to improve patient outcomes. In the hands of experienced MIS surgeons and in carefully selected cases, laparoscopy is both safe and efficacious for reoperative procedures in the abdomen and pelvis, with measurable short-term benefits.

Laparoscopic surgery for colorectal cancer patients who underwent previous abdominal surgery

BACKGROUND

Laparoscopic colorectal surgery may be impeded by intraperitoneal adhesions caused by previous abdominal surgery. The aim of this study was to determine the effect of previous abdominal surgery on short- and long-term outcomes of laparoscopic colorectal surgery.

METHODS

We retrospectively reviewed 3188 patients with primary colorectal cancer who underwent laparoscopic colorectal surgery between January 2004 and December 2013. Patients with a history of abdominal surgery (n = 593, 18.6 %) were compared to those without such history (n = 2595, 81.4 %).

RESULTS

Patients who had undergone previous abdominal surgery exhibited acceptable intraoperative outcomes, including conversion to open surgery, operative time, estimated blood loss, and the number of harvested lymph nodes. Overall, postoperative complication rates were similar between the groups (10.8 vs. 10.6 %, p = 0.885). Subgroup analysis revealed that patients with history of major abdominal surgery (n = 165) had higher rates of conversion to open surgery (4.2 vs. 1.7 %, p = 0.033), prolonged postoperative ileus (5.5 vs. 2.0 %, p = 0.008), and wound complications (4.2 vs. 1.2 %, p = 0.006), when compared to those without prior abdominal surgery. Previous major abdominal surgery was an independent risk factor for conversion to open surgery [adjusted odds ratio = 2.740; 95 % confidence interval (CI) 1.197-6.269]. Disease-free survival [adjusted hazard ratio (HR) = 0.847; 95 % CI 0.532-1.346] and overall survival (adjusted HR = 0.846; 95 % CI 0.432-1.657) were not observed to differ between the previous major abdominal surgery group and those without previous abdominal surgery.

CONCLUSION

Laparoscopic colorectal surgery in patients with a history of abdominal surgery exhibited acceptable short- and long-term outcomes. Patients with a history of previous abdominal surgery had relatively higher rate of conversion to open surgery as well as higher incidences of prolonged postoperative ileus and wound complications compared to patients without such history.

Impact of Prior Abdominal Surgery on Rates of Conversion to Open Surgery and Short-Term Outcomes after Laparoscopic Surgery for Colorectal Cancer

Purpose

To evaluate the impact of prior abdominal surgery (PAS) on rates of conversion to open surgery and short-term outcomes after laparoscopic surgery for colon and rectal cancers.

Methods

We compared three groups as follows: colon cancer patients with no PAS (n = 272), major PAS (n = 24), and minor PAS (n = 33), and rectal cancer patients with no PAS (n = 282), major PAS (n=16), and minor PAS (n = 26).

Results

In patients with colon and rectal cancers, the rate of conversion to open surgery was significantly higher in the major PAS group (25% and 25%) compared with the no PAS group (8.1% and 8.9%), while the conversion rate was similar between the no PAS and minor PAS groups (15.2% and 15.4%). The 30-day complication rate did not differ among the three groups (28.7% and 29.1% in the no PAS group, 29.2% and 25% in the major PAS group, and 27.3% and 26.9% in the minor PAS group). The mean operative time did not differ among the three groups (188 min and 227 min in the no PAS group, 191 min and 210 min in the major PAS group, and 192 min and 248 min in the minor PAS group). The rate of conversion to open surgery was significantly higher in patients with prior gastrectomy or colectomy compared with the no PAS group, while the conversion rate was similar between the no PAS group and patients with prior radical hysterectomy in patients with colon and rectal cancers.

Conclusions

Our results suggest that colorectal cancer patients with minor PAS or patients with prior radical hysterectomy can be effectively managed with a laparoscopic approach. In addition, laparoscopy can be selected as the primary surgical approach even in patients with major PAS (prior gastrectomy or colectomy) given the assumption of a higher conversion rate.

Mesh herniorrhaphy with simultaneous colorectal surgery: a case-matched study from the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

The aim of this study is to evaluate the impact of concurrent mesh herniorrhaphy on short-term outcomes of colorectal surgery by using a large, nationwide database.

METHODS

Patients who underwent simultaneous ventral hernia repair (VHR) and colorectal surgery between 2005 and 2010 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent VHR with mesh repair were case matched with patients who underwent VHR without mesh based on the type of colorectal procedure, diagnosis, and American Society of Anesthesiologists score.

RESULTS

Two hundred sixty-two patients who underwent VHR with mesh were case matched with 524 patients who underwent VHR without mesh. Mean operating time was significantly longer in patients who underwent VHR with mesh (195.8 ± 98.7 vs 164.3 ± 84.4 minutes, P < .001). Postoperative morbidity (P = .58), mortality (P = .27), superficial surgical site infection (SSI) (P = .14), deep SSI (P = .38), organ space SSI (P = .17), wound disruption (P > .99), reoperation (P = .48), and length of hospital stay (P = .71) were comparable between the groups.

CONCLUSION

The American College of Surgeons National Surgical Quality Improvement Program data suggest that VHR with mesh does not increase 30-day mortality, medical or surgical morbidity in colorectal surgery setting.

Feasibility and safety of laparoscopic surgery for metachronous colorectal cancer

PURPOSE

This study assessed the feasibility and safety of laparoscopic surgery for metachronous colorectal cancer in patients who had previously undergone surgery for primary colorectal cancer.

METHODS

Of the 52 patients who underwent curative resection for metachronous colorectal cancer from August 2004 to April 2013, 26 each underwent laparoscopic and open surgery. Their clinical characteristics and surgical and postoperative outcomes were compared.

RESULTS

The percentage of patients who underwent previous open surgery was significantly higher in the open group than in the laparoscopic group (92.3 vs. 65.4 %). The body mass index was higher in the laparoscopic group than in the open group (23.8 vs. 21.1 kg/m(2)), and the amount of blood loss was significantly smaller in the laparoscopic than in the open group (30 vs. 195 ml); however, the mean operative time did not differ significantly. The time to first flatus (1 vs. 3 days) and first stool (2 vs. 3.5 days), as well as the length of postoperative hospital stay (10 vs. 16 days), was significantly shorter in the laparoscopic group than in the open group, although the rates of postoperative complications did not differ (15.4 vs. 23.1 %).

CONCLUSIONS

Laparoscopic surgery for metachronous colorectal cancer shows short-term benefits compared with open surgery and should be considered as a treatment option in these patients.

Factors affecting morbidity after conversion of laparoscopic colorectal resections

BACKGROUND

The impact of conversion on postoperative outcomes of laparoscopic colorectal surgery remains controversial. The purpose of this study was to assess whether a conversion results in increased postoperative morbidity and mortality, and to evaluate whether any specific factors affect the outcomes of converted procedures.

METHODS

Outcomes of procedures requiring conversion among patients undergoing elective laparoscopic colorectal resection between 1992 and 2011 were compared with those for operations completed laparoscopically. Subset analyses were also performed to evaluate the selective impact of patient-, disease- and treatment-related factors and the timing of conversion during surgery on outcomes. Primary endpoints were postoperative mortality and morbidity.

RESULTS

Of 2483 patients undergoing laparoscopic colorectal resection, 270 (10.9 per cent) required conversion to open surgery. The 30-day postoperative mortality rate was comparable after laparoscopically completed and converted procedures (0.4 versus 0 per cent respectively; P = 0.610). Factors significantly associated with morbidity after conversion were smoking, cardiovascular co-morbidity, previous abdominal operations (particularly colectomy or hysterectomy) and adhesions. Overall morbidity was not affected by conversion (27.0 per cent at 30 days in both groups; P > 0.999). However, patients experiencing morbidity tended to have had earlier conversions: median (range) 40 (15-90) min into surgery versus 50 (15-240) min for those who did not develop morbidity (P = 0.006). The risk of reoperation for postoperative morbidity was higher following conversion because of complications (13 versus 2.9 per cent; P = 0.024).

CONCLUSION

Conversions of laparoscopic colorectal resection are not associated with increased overall morbidity, regardless of the timing of conversion.

Effect of previous abdominal surgery on outcomes following laparoscopic colorectal surgery

OBJECTIVE

The impact of previous abdominal surgeries on the need for conversion to open surgery and on short-term outcomes during/after laparoscopic colectomy was retrospectively investigated.

DESIGN

This retrospective cohort study was conducted from December 1996 through December 2009.

SETTING

This study was conducted at Osaka Medical College Hospital.

PATIENTS

A total of 1701 consecutive patients who had undergone laparoscopic resection of the colon and rectum were classified as not having previous abdominal surgery (n = 1121) or as having previous abdominal surgery (n = 580).

MAIN OUTCOME MEASURES

Short-term outcomes were recorded, and risk factors for conversion to open surgery were analyzed.

RESULTS

There were no significant differences in operative time, blood loss, number of lymph nodes removed, or conversion rate between the groups. The rate of inadvertent enterotomy was significantly higher in the previous abdominal surgery group than in the not having previous abdominal surgery group (0.9% versus 0.1%; p = 0.03), and the postoperative recovery time was significantly longer in the previous abdominal surgery group than in the not having previous abdominal surgery group. Ileus was more frequent in the previous abdominal surgery group than in the not having previous abdominal surgery group (3.8% versus 2.1%; p = 0.04). Significant risk factors for conversion to open surgery were T stage ≥3 (OR, 2.81; 95% CI, 1.89-3.75), median incision (OR, 4.34; 95% CI, 1.23-9.41), upper median incision (OR, 2.78; 95% CI, 1.29-5.42), lower median incision (OR, 1.82; 95% CI, 1.09-3.12), and transverse colectomy (OR, 1.76; 95% CI, 1.29-2.41).

CONCLUSION

The incidence of successfully completed laparoscopic colectomy after previous abdominal surgery remains high, and the short-term outcomes are acceptable.

Prior abdominal open surgery does not impair outcomes of laparoscopic colorectal surgery: a case-control study in 367 patients

AIM

This prospective case-matched study was conducted to compare the outcome of laparoscopic colorectal surgery in patients with and without prior abdominal open surgery (PAOS).

METHOD

From June 1997 to December 2010, 167 patients with PAOS (including midline, Pfannenstiel, subcostal, right upper quadrant or transverse incision) were manually matched to all identical patients without PAOS from our prospective laparoscopic colorectal surgery database. Matching criteria included age, gender, American Society of Anesthesiology (ASA) score, body mass index, diagnosis and surgical procedure performed. Primary end-points were postoperative 30-day mortality and morbidity. Secondary end-points included operating time, conversion rate and length of stay.

RESULTS

A total of 367 patients (167 with PAOS and 200 without PAOS) were included in this study. PAOS was associated with a significantly increased mean operating time (229±66 min vs 216±71 min, P=0.044). The conversion rate was significantly higher in patients with PAOS, compared with patients without PAOS (22%vs 13%, P=0.017). There was one (0.3%) postoperative death. The overall postoperative morbidity rate was similar in both groups (22%vs 19%, P=0.658), including Grade 3 or Grade 4 morbidity, according to Dindo's classification (5%vs 5%, P=0.694). Mean hospital stay showed no difference between both groups (10±7 days vs 9±5 days, P=0.849).

CONCLUSION

This large case-control study suggests that PAOS does not affect postoperative outcomes. For this reason, a systematic laparoscopic approach in patients with PAOS, even with midline incision, should be considered in colorectal surgery.

Is laparoscopic surgery for recurrent Crohn's disease beneficial in patients with previous primary resection through midline laparotomy? A case-matched study

BACKGROUND

Patients undergoing abdominal surgery for Crohn's disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn's through midline laparotomy is controversial.

METHODS

Patients with previous open resection for intestinal Crohn's disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (±5 years), gender, body mass index (±2 kg/m(2)), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (±3 years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data.

RESULTS

26 patients undergoing laparoscopic ileocolectomy (n = 14), proctocolectomy (n = 5), small bowel resection (n = 4), abdominoperineal resection (n = 1), extended right colectomy (n = 1), and strictureplasty (n = 1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158 min, p = 0.94), estimated blood loss (222 versus 427 ml, p = 0.32), overall morbidity (39 versus 69%, p = 0.051), reoperation rates (8 versus 0%, p = 0.5), postoperative return of bowel function (3.5 ± 1.4 versus 3.9 ± 1.7 days, p = 0.3), mean length of hospital stay (6.4 ± 6.2 versus 6.9 ± 3.5 days, p = 0.12), and readmission rates (8 versus 12%, p = 0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27%, p = 0.01).

CONCLUSIONS

Surgery for recurrent Crohn's disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated.

Conversion risk factors in laparoscopic colorectal surgery

Introduction

This study is aimed at identifying important risk factors associated with conversion of laparoscopic colorectal surgery. Laparoscopic surgery is usually associated with less operative trauma, more favourable post-operative course and lower morbidity than open surgery. However, conversion is connected with some risks according to some authors.

Aim

To identify the risk factors associated with conversion and to create a model to predict possible conversion for a patient before surgery.

Material and methods

The source data file contained information about 649 patients who underwent laparoscopic colorectal surgery between 2001 and 2009 at the University Hospital Ostrava, Czech Republic. Conversion to open surgery was necessary in 54 cases. The variables gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, stage of disease, number of previous operations and operation severity were included in the analysis as the potential risk factors of conversion. Discriminant analysis was used for the data evaluation; statistical software SPSS 17 and NCSS 2004 were used for the calculations.

Results

The created model had only low discriminating ability. The variable ASA classification was identified as the most important risk factor of conversion, followed by the variables operation severity, gender and BMI.

Conclusions

Discriminant analysis did not find the chosen input variables satisfactory enough to make a reasonable model for the prediction of conversion. The expected fact was confirmed that large bowel surgery and greater BMI mean greater risk of conversion, whereas there is no reason to refuse laparoscopy for a patient with higher ASA classification.

Short-term outcomes of laparoscopic colorectal resection in patients with previous abdominal operations

BACKGROUND

Laparoscopic colorectal procedures (LCPs) are technically demanding; previous abdominal surgery may add to their complexity. The aim of our study was to assess the effect of previous abdominal surgery (PAS) on laparoscopic colorectal surgery.

SUBJECTS AND METHODS

A prospective database was used to record LCPs between 2001 and 2011. Patients were divided into two groups: Group A consisted of patients with no PAS, and Group B of patients with PAS. Data collected included prior abdominal operations, type of LCP, operative time, and conversions. Operative mortality, morbidity, and ward stay in both groups were compared. Statistical analysis was performed using Fisher's exact test and Student's t test.

RESULTS

One hundred eighty-one patients underwent LCPs: 113 in Group A and 68 in Group B. Mean operative time in Group A and Group B was 216.5 (range, 60-520) minutes and 233.2 (range, 114-544) minutes, respectively (P = .17). In the first 90 cases, the mean operative time was significantly lower for Group A (203 minutes) than in Group B (236.5 minute) (P = .02). The rate of conversion was 10.6% (12/113) in Group A and 13.2% (9/68) in Group B (P = .6). Two patients in Group B had small bowel enterotomies (1 missed on the operating table) compared with none in Group A. Morbidities were comparable in both groups. Median hospital stay was 4.5 and 4 days in Groups A and B, respectively (P=.9). There were 3 deaths in Group A (2 due to medical causes and 1 surgical-related). One surgical-related death (missed enterotomy) occurred in Group B.

CONCLUSIONS

Short-term outcomes of laparoscopic colorectal surgery in patients with PAS are acceptable. There is no significant difference in conversion rate, hospital stay, morbidity, or mortality. The difference in the operative time is significant only in the early part of the learning curve. Meticulous adhesiolysis to avoid and recognize enterotomy is of paramount importance.

Impact of prior abdominal surgery on curative resection of colon cancer via minilaparotomy

PURPOSE

To evaluate the impact of prior abdominal surgery on curative resection of colon cancer via a minilaparotomy approach.

METHODS

Feasibility, safety, and oncological outcomes were evaluated retrospectively in 263 patients scheduled to undergo curative resection of colon cancer via a minilaparotomy approach, defined as a skin incision of ≤ 7 cm, between September 2000 and March 2009.

RESULTS

Abdominal adhesions were found in 59 (77.6%) of 76 patients who had undergone prior abdominal surgery (PAS group) and in 4 (2.1%) of 187 patients who had not (control group). The success rate of the minilaparotomy approach was 92.1% in the PAS group and 97.3% in the control group (P = 0.08). The incidence of extending the minilaparotomy wound for adhesiolysis was significantly higher in the PAS group than in the control group (6.6% vs 0.5%; P < 0.01). The two groups did not differ significantly in terms of the types of surgery, pathological stage, body mass index, operative time, blood loss, incidence of postoperative complications, length of postoperative hospital stay, and disease-free survival.

CONCLUSIONS

These results suggest that prior abdominal surgery might require an extension of the minilaparotomy incision but that it does not seem to contraindicate a minilaparotomy approach for curative colectomy.

Curative colectomy via minilaparotomy approach without utilizing specific instruments

BACKGROUND

This study evaluated the need for specific instruments when performing a curative resection of colon cancer via a minilaparotomy approach, which has been reported to be a minimally invasive alternative to a laparoscopic approach.

METHODS

The feasibility, safety, and early oncological outcome were compared among 73 patients (first group), in whom a curative resection of colon cancer was performed via a minilaparotomy (skin incision < or =7 cm) utilizing specific instruments (North-bridge retractor system) between September 2002 and March 2005, and 94 patients (second group), in whom a similar procedure was performed without utilizing specific instruments between April 2005 and October 2007.

RESULTS

The two groups did not differ significantly in terms of age, sex, body mass index, site of tumor, level of lymph node dissection, blood loss, UICC stage, number of harvested lymph nodes, incidence of postoperative complications, length of postoperative hospital days, or overall survival, although the frequency of prior abdominal surgery was higher (38.3 vs. 21.9%; P = 0.03) and the median operating time required for a standard lymph node dissection was shorter (120 vs. 135 min; P = 0.03) in the second group.

CONCLUSION

With improved techniques and experience, specific instruments are not necessary for the performance of a curative colectomy via a minilaparotomy approach.

Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs

BACKGROUND

Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4.

METHODS

Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant.

RESULTS

In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted.

CONCLUSION

The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.

Is laparoscopic colon surgery appropriate in patients who have had previous abdominal surgery?

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.

Is Operative Conversion Necessary for Patients Diagnosed With Dense Adhesions During an Elective Laparoscopic Colectomy?

Laparoscopic colectomy is often complicated by adhesions. Studies examining the morbidity of laparoscopic lysis of adhesions (LOA) combined with colectomy are sparse. Objectives. The goal of this study was to prospectively evaluate the results of using the harmonic scalpel to lyse adhesions in patients undergoing laparoscopic colectomy. Methods. Laparoscopic colectomy was performed in 83 patients between November 2003 and April 2007. A total of 20 patients underwent laparoscopic colectomy with LOA and 53 patients underwent laparoscopic colectomy alone. Patients were prospectively followed to determine operative time (OT), blood loss, operative conversion, length of stay (LOS), and 30-day morbidity. Results. Operative conversion was 2%, mean estimated blood loss (EBL) was 95 ± 84 mL, and mean OT was 220 ± 64 minutes. There were no anastomotic leaks or perioperative mortalities. There were 9 major complications (11%). Patients undergoing laparoscopic colectomy with LOA (n = 20) compared with patients undergoing laparoscopic colectomy alone (n = 63) had similar conversion rates (5% vs 2%), EBL (115 ± 108 vs 88 ± 74 mL), and major complications (15% vs 10%), but prolonged minor complications (25% vs 6%) and LOS (6.0 ± 3.0 vs 4.6 ± 1.5 days). Conclusions. Laparoscopic LOA combined with colectomy leads to similar conversion rates and major morbidity compared to laparoscopic colectomy alone.