Laparoscopic Versus Open Loop Ileostomy Reversal: Is there an Advantage to a Minimally Invasive Approach?

BACKGROUND: Ileostomy reversals are commonly performed procedures after colon and rectal operations. Laparoscopic ileostomy reversal (LIR) with lysis of adhesions has potential benefits over conventional open surgery. The aim of this study was to compare outcomes of laparoscopic and open ileostomy reversal. METHODS: 133 consecutive patients undergoing ileostomy reversal at our institution between June 2009 and August 2013 were analyzed using a retrospective database. The group comprised 53 laparoscopic cases and 80 open cases, performed by four surgeons at a single center. The data were analyzed for patient demographics, operative characteristics, postoperative outcomes, and 30-day morbidity and mortality. RESULTS: The two groups had comparable mean age, gender distribution, ASA scores, and BMI. The laparoscopic group had a significantly longer duration of surgery compared to the open reversal group (109 versus 93 min, p < 0.05). However, this group underwent more lysis of adhesions (60.4 % versus 26.3 %, p < 0.01) as well as concurrent stoma site mesh reinforcement (32.1 % versus 6.3 %, p < 0.01). In the laparoscopy group, 20.7 % of patients underwent intra-corporeal ileo-ileal anastomosis. There were no significant differences between the laparoscopic and open groups with regard to estimated blood loss (31 versus 40 ml, respectively) or mean length of stay (5.3 vs. 5.7 days, respectively). The rates of overall 30-day morbidity (16.9 % for laparoscopic vs. 21.3 % for open) as well as rates of specific complications were equivalent between groups. 30-day mortalities were not noted in either group. CONCLUSION: LIR is safe and effective with low perioperative morbidity and mortality. The use of laparoscopy as an option in terms of concomitant hernia repair and lysis of adhesions may be considered in selected patients.

Incisional reinforcement in high-risk patients.

Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions.

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.

Laparoscopic versus robotic-assisted rectal surgery: a comparison of postoperative outcomes.

Rectal surgery continues to be an area of advancement for minimally invasive techniques. However, there is controversy regarding whether a robotic approach imparts any advantages over established laparoscopic procedures. The aim of this study was to analyze and compare outcomes of laparoscopic and robotic rectal resection operations. A single-institution retrospective review was performed identifying 83 consecutive patients undergoing low rectal resection requiring proximal diversion between 2009 and 2013. The cohort was comprised of 38 laparoscopic and 45 robotic cases. Data were analyzed for postoperative outcomes as well as 30-day morbidity and mortality. Male gender frequency, body mass index, and American Society of Anesthesiologists class were higher in the robotic group (71%, 28.6 kg/m(2), and 2.6, respectively) compared with the laparoscopic group (42%, 23.7 kg/m(2), and 2.2, respectively; P < 0.01). Length of stay was significantly longer for patients undergoing laparoscopic (7.5 days) compared with robotic procedures (5.7 days, P < 0.01). This difference was even greater when comparing patients who underwent a hybrid laparoscopic-assisted open total mesorectal excision (TME) with robotic TME (8.2 vs 5.7 days, respectively, P < 0.01). Conversion rate was 7.9 per cent for the laparoscopic group and zero per cent for the robotic (P = 0.09). There were no mortalities in either group. A pure laparoscopic or robotic rectal surgery may be associated with a shorter hospital stay compared with a laparoscopic-assisted approach.