Laparoscopic-assisted Colon and Rectal Surgery—DCS Koh et al 223

Original Article

Laparoscopic-assisted Colon and Rectal Surgery – Lessons Learnt from Early

Experience
DCS Koh,1MBBS, FRCS (Edin) (Gen Surg), FAMS, KS Wong,2MBBS, FRCS (Edin), FAMS, R Sim,1MBBS, FRCS (Edin), FAMS, YP Ng,1MBBS,
ZQ Hu,1BSc (UK), Dip Nurs, DMO Cheong,1MBBS, FRCS (Glas), A Foo,1BSc, Dip Nurs

Abstract
Introduction: Current evidence shows that laparoscopic bowel surgery is associated with a
lower incidence of postoperative ileus, lower postoperative pulmonary and wound complication
rates, shorter hospital stays and a quicker return to activity than open surgery. This paper aims
to report our early experience with laparoscopic-assisted colorectal procedures in our Centre for
Advanced Laparoscopic Surgery and the important lessons we have learnt from this. Materials
and Methods: All laparoscopic-assisted colon and rectal surgical (LAC) procedures performed
between January 2000 and December 2003 were reviewed. Clinical and operative records of
these patients were reviewed. Data retrieved included patient demographics, selected intra-
operative parameters, and postoperative outcomes. In order to provide a comparable reference,
an equal number of matched open procedures over the same period were accrued and similarly
analysed. All patients were managed on a standard carepath. All data were entered into a
database and analysed using a statistical software package. Results: Forty-two laparoscopic-
assisted colorectal procedures were performed from June 2000 to December 2003. A similar
number of diagnosis-matched patients with open colorectal procedures were used as comparison.
The diagnoses included cancer (68.5% versus 73.8%), diverticulosis (5.7% versus 9.5%) and
polyps (14.3% versus 9.5%). Seven were converted to open surgery because of bleeding,
adhesions and locally advanced disease. Laparoscopic-assisted procedures performed included
1 right hemicolectomy, 5 left hemicolectomies, 9 anterior resections, 1 abdominal-perineal
resection, 3 sigmoid colectomies, 11 colostomies and 1 Hartmann’s procedure. Mean perioperative
time (146 min versus 125 min, P = 0.173) was comparatively longer. Mean duration for analgesic
requirement (2.25 days versus 2.64 days, P = 0.05), mean length of stay (5.31 days versus 9.07
days, P <0.05), mean time to commencement of diet (2.91 days versus 4.05 days, P <0.001) and
mean time to first bowel movement (2.57 days versus 4.10 days, P <0.001) were all comparatively
shorter. General morbidity rates (17.1% versus 21.4%, P = 0.35) were lower. No local wound
complications were found in our laparoscopic-assisted group. Patients who had undergone open
surgery instead of the planned laparoscopic-assisted procedures fared more poorly. Conclusions:
Laparoscopic-assisted colorectal procedures performed in well-selected patients are associated
with shorter hospital stays, quicker return of bowel function and lower morbidity when
compared to the matched open procedures. Early experience should be acquired from perform-
ing technically simple procedures in patients with benign conditions before progressing to
definitive resections in those with cancer.
Ann Acad Med Singapore 2005;34:223-8

Key words: Colorectal cancer, Diverticulosis, Laparoscopic colorectal surgery, Laparoscopy,

Perioperative outcomes, Polyps

Introduction laparoscopically today than when the first laparoscopic

Great strides in laparoscopic surgical techniques have cholecystectomy came to light in 1982.
been progressively made throughout the various surgical The impact of these techniques on colon and rectal
subspecialties. More procedures can be performed surgery has been significant. Emerging evidence in the

1
Colorectal Unit, Department of General Surgery
Tan Tock Seng Hospital, Singapore
2
Division of Colorectal Surgery, Department of Surgery,
National University Hospital, Singapore
Address for Reprints: Dr Dean Chi-Siong Koh, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433.
Email: [email protected]

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224 Laparoscopic-assisted Colon and Rectal Surgery—DCS Koh et al

literature has shown that laparoscopic bowel surgery is mm trocars were performed under direct laparoscopic
associated with less ileus, lower rates of pulmonary vision. A straight-viewing 0° laparoscope was used.
and wound complications, shorter hospital stays and Dissection was faciliated by the use of the harmonic shears
quicker return to activities of daily living.1-5 Initial concerns (Harmonic Scalpel, Ethicon Endo-Surgery, Inc, Cincinnati,
over port site recurrences in oncologic resections, OH, USA) or the Ligasure (Valleylab, Tyco Healthcare,
adequacy of surgical resections, oncologic clearance Boulder, CO, USA). Delivery of resected specimens took
and immunomodulation have been addressed by several place via a small minilaparotomy in the midline, a
studies.6-8 Pfannenstiel incision or a skin-crease lower abdominal
Our unit began performing colon and rectal surgical incision, depending on the preference of the surgeon.
procedures laparoscopically in 2000. The aim of this study Postoperative analgesics were administered either with
was to review our early experience and results by comparing patient-controlled analgesia (PCA) pumps or intramuscular
them with a group of matched procedures performed using opioids. These were converted to oral analgesics once the
the conventional open method. These results would enable patient was able to tolerate oral feeding. All patients,
us to identify key lessons learnt from this early experience, regardless of the surgical approach, were managed with a
which may be beneficial to a unit embarking on laparoscopic standard colorectal carepath that had been in place since
colon and rectal surgery. 1999 in this department.
Materials and Methods To provide a comparable reference, an equal number of
diagnosis-matched open procedures over the same period
All laparoscopic-assisted colon and rectal surgical (LAC) were accrued and similarly analysed.
procedures performed between January 2000 and December
2003 were included in this study. The clinical and operative All data were obtained from the patients’ case notes,
records of these patients were reviewed with the intention operative notes, outpatient clinic notes and clinical charts.
of obtaining the relevant clinical data, recording selected These were entered into an Excel database and analysed
intraoperative parameters, and postoperative outcomes of using SPSS software. The Student’s t-test and the Mann-
these patients. Whitney U test were used to determine the significance of
the differences in mean values for continuous variables. A
All procedures were performed by at least 1 of the 3
P value of <0.05 was deemed significant.
trained consultant colorectal surgeons in the department
(DMOC, RS, KSW), assisted by the colorectal residents. Results
These 3 surgeons had completed exit certification in general
surgery and spent some time training in laparoscopic A total of 42 laparoscopic-assisted colon and rectum
colorectal surgery at overseas centres of excellence. The (LAC) procedures were performed over the 4-year period.
selection of patients was based on individual surgeon There was an equal gender distribution, with 20 male and
preference. Initial patient selection was confined to patients 22 female patients. Their mean age was 60 years (range, 23
who had benign conditions. However, with improved to 83). Thirty-nine were Chinese whilst the other 3 patients
experience over time, the technique was also offered to comprised 1 Malay, 1 Indian and 1 Eurasian (Table 1).
patients with malignancies. The diagnoses of these 42 patients are shown in Table 2.
All patients had their procedures performed under general Thirty patients had procedures performed for cancer. The
anaesthesia. They were placed in Lloyd Davies stirrups other 12 had benign conditions, including 3 with diverticular
together with pneumatic calf compression stockings. disease, 5 with colorectal polyps and 1 with full thickness
Beanbags were used as shoulder blocks to prevent the rectal prolapse. The comparison group comprised a
patient from slipping off the operating table if a steep matching group of patients, with the diagnoses shown in
Trendelenberg position was indicated. The patient’s arms the same table.
were tucked in by the side with soft sponge cushions and Of these 42 procedures attempted laparoscopically, 7
the thighs were placed almost parallel to the floor. Standard (16.7%) required conversion to an open technique for the
thromboembolic prophylaxis in the form of subcutaneous following reasons: 5 were converted due to the extensive
low molecular weight heparin was administered before and adhesions encountered, 1 for excessive bleeding
after surgery until the patients were ambulant. encountered during dissection and 1 for locally advanced
The open technique of the initial 10-mm trocar insertion disease which made dissection technically difficult. The
was adopted for all cases. Carbon dioxide insufflation was remaining 35 LAC procedures completed successfully are
used to create the pneumoperitoneum and an intra- shown in Table 3. Eleven patients had a diverting loop
abdominal pressure of 12 mm Hg to 15 mm Hg was colostomy created laparoscopically.
maintained. Subsequent placement of 5-mm, 10-mm or 12- Of the 30 cancer patients who had LAC procedures

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 Laparoscopic-assisted Colon and Rectal Surgery—DCS Koh et al 225

Table 1. Demographic Data Table 2. Indications for Surgery

Laparoscopic-assisted Open LAC Converted Open

Number 42 42 Cancer 24 68.5% 6 85.7% 31 73.8%
Gender Male Female Male Female Diverticular disease 2 5.7% 1 14.3% 4 9.5%
20 22 18 24 Polyps 5 14.3% - - 4 9.5%
Mean age (years) 60 64 Rectal prolapse 1 2.9% - - - -
Range 23-83 27-93 Other benign 3 8.6% - - 3 7.1%
conditions
Race Chinese 39 Chinese 36 • Sigmoid volvulus
Indian 1 Indian 2 • SRUS
Malay 1 Malay 2 • Rectovaginal fistula
Others 1 Others 2
LAC: laparoscopic-assisted colorectal procedures; SRUS: solitary rectal
ulcer syndrome

Table 3. Types of Operation

LAC Converted Open

Right hemicolectomy 1 3 11 Table 4. Operations for Cancer
Left hemicolectomy 5 1 2
LAC Open
Anterior resection 9 - 13
Suture rectopexy 2 - - Right hemicolectomy 2 7
Abdominoperineal resection 1 - 3 Left hemicolectomy 5 1
Others 17 3 13 Anterior resection 6 11
Colostomy 11 1 2 APR 1 3
Sigmoid colectomy 3 1 5 Loop colostomies/ileostomies 12 2
Hartmann’s 1 - 4 Hartmann’s procedure 2 4
Total colectomy 2 1 2 Sigmoid colectomy 2 3

Total 35 7 42 Total 30 31

LAC: laparoscopic-assisted colorectal procedure APR: abdominoperineal resection; LAC: laparoscopic-assisted colorectal
procedures

performed, 12 were diverting loop stomas (Table 4). The The mean operative time for the LAC group was 146
rest included 2 right hemicolectomies, 5 left minutes (range, 15 to 315) (Table 5). This compared with
hemicolectomies, 6 anterior resections, 1 abdominoperineal 125 minutes (range, 40 to 245) in the open group. This
resection, 2 sigmoid colectomies and 2 Hartmann’s difference was not significant (P = 0.173). Analgesia was
procedure. The mean tumour size for the 18 who had required for an average of 2.25 days for those in the LAC
definitive resection performed was 4.7 cm (range, 2 to 10). group. This compared with 3.43 days in the converted
Following adequate mobilisation of the indicated segment group and 2.64 days in the open group (P = 0.05). When the
of colon, intracorporeal bowel transection was performed groups were compared for time to commencement of oral
in all but 1 patient. Fifteen patients had restoration of bowel feeding, the LAC group took a significantly shorter time at
continuity performed. In 10 of them, the anastomosis was 2.91 days as compared to 4.29 days (P = 0.07) for the
created intracorporeally after re-establishment of converted group and 4.05 days for the open group (P
pneumoperito-neum following complete bowel resection <0.001). The time taken to the first bowel movement was
and delivery. For the remaining 5, the transected ends were similarly shorter in the LAC group, when compared to
brought out through the delivery incision and a hand-sewn those who had the procedure converted (mean of 2.57 days;
anastomosis fashioned using absorbable sutures. range, 1 to 6 versus mean of 3.71 days; range, 2 to 11; P =
Analysis of the histological reports showed that the mean 0.45). When compared to the open group, which had a
number of lymph nodes harvested for the LAC group was mean of 4.1 days (range, 1 to 10), the difference was
11.8 (range, 4 to 21). This was comparable to the statistically significant (P <0.001).
corresponding harvest in the open group, which was 12.2 There were 6 (17.1%) patients who had general
(range, 3 to 28). complications (Table 6). This compared with 4 (57.1%) in
In the converted group, 3 underwent right the converted group and 9 (21.4%) in the open group.
hemicolectomies, 1 a left hemicolectomy, 1 a loop These differences were, however, not statistically
colostomy, 1 a Hartmann’s procedure and 1 a total significant.
colectomy. It was notable that there were no respiratory complications

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226 Laparoscopic-assisted Colon and Rectal Surgery—DCS Koh et al

Table 5. Perioperative Outcomes Table 6. Morbidity

LAC Open Sig Converted LAC Open Sig Converted

(n = 35) (n = 42) (n = 7)
General complications 6 9 P = 0.35 4
Mean operative time 146 125 P = 0.17 154 Respiratory - 3 1
(minutes) Cardiac 1 1 -
Range 15-315 40-245 105-200 Ileus 3 2 2
Mean duration of 2.25 2.64 P = 0.05 3.43 Pulmonary embolism - - 1
analgesic requirements Deep vein thrombosis - 2 -
(days) Others 2 1 -
Range 1-7 1-4 2-7
Local complications - 4 P <0.001 2
Mean time to 2.91 4.05 P <0.001 4.29 Wound infection - 4 1
commencement on Wound dehiscence - - 1
oral diet (days)
Range 1-9 1-11 2-6 Total 6 8 6

Mean length of stay 5.31 9.07 P <0.05 12.71 LAC: laparoscopic-assisted colorectal procedures; Sig: statistical
significance
(days)
Range 2-15 2-62 4-27
Mean time to first 2.57 4.10 P <0.001 3.71
bowel movement Our institution’s Centre for Advanced Laparoscopic
(days) Surgery (CALS) conducts laparoscopic courses accredited
Range 1-6 1-10 2-11 by the Society of American Gastrointestinal Endoscopic
LAC: laparoscopic-assisted colorectal procedures; Sig: statistical Surgeons (SAGES) Framework for Post-Residency Surgical
significance Education and Training. In line with this effort, we
commenced performing laparoscopic bowel surgery in
in the LAC group. Similarly, there were no complications 2000. The results of this analysis of our early experience
related to the wound in this group of patients. This was not serve as an audit as well as a reference for our practice.
the case for the converted group (2 out of 7) and the open The demographic distribution of our patients was
group (4 out of 42). consistent with the spectrum of patients in the capture zone
of our institution. The 2 groups were comparable in this
Discussion aspect. The indications for surgery for both groups were
Laparoscopic or minimally invasive surgery has become similar, although not identical in number. The larger
an integral component of the modern day surgeon’s proportion of patients with cancer was again reflective of
armamentarium. Today’s patient demands that the option the distribution of the workload of the colorectal unit. Our
of this form of surgery be made available when confronted early cases were mainly confined to patients with benign
with a condition that is acceptably treated using conditions, namely diverticulosis, large polyps, and rectal
this modality. prolapse, all of which have been proven to benefit from
There is sufficient evidence at present to demonstrate the treatments using laparoscopic techniques.12
benefits of laparoscopic bowel surgery in benign colon and The procedures performed in patients with cancer were
rectal conditions. These include lower frequencies of ileus, initially confined to those who required a loop diversion
lower rates of postoperative complications including less colostomy either prior to initiation of neoadjuvant
pulmonary complications and wound infections, shorter chemoradiation or those who had advanced, irresectable
hospital stays, earlier return of gastrointestinal function disease. Laparoscopic stoma creation is an ideal prelude to
and earlier return to work.1-4,9-11 Initial technical difficulties the more complex laparoscopic colorectal resections. It is
with advanced laparoscopic skills required for bowel not as technically demanding, associated with much less
mobilisation and manipulation have been overcome as an morbidity, familiarises the surgical team with the operating
increasing number of surgeons spend more time perfecting room set-up and various technical manoeuvres such as
their techniques. Early experience with inflammatory bowel bowel handling and mobilisation, and affords some form of
disease and diverticulosis has led to the tentative use of staging of the malignancy. With familiarisation with, and
laparoscopic techniques in managing colon and rectal improvements in, the techniques acquired over the course
cancers. This issue remains contentious and until long- of time, laparoscopic-assisted resections were used for
term results of several trials conducted in the United States selected cancer patients. The decision for using this approach
and Europe are published, concerns of port site recurrences, was made by the individual surgeon. Nevertheless, large,
adequacy of oncologic resection and long-term survival bulky and locally advanced tumours were excluded. The
will remain. number of lymph nodes harvested for both the LAC and the

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 Laparoscopic-assisted Colon and Rectal Surgery—DCS Koh et al 227

open group with cancers were essentially identical, in LAC in well-selected patients. Although the matched
suggesting that the adequacy of oncological clearance in groups were not completely identical, we felt that obtaining
these patients is comparable, a point that has been proven a cross-section of cases performed by the same group of
in several well-conducted studies.6-8 surgeons over the same period of time would be the ideal
The LAC group did not have a significantly longer mean means of comparison.
operative time compared to the open group. However, this In a unit that is embarking on laparoscopic bowel surgery,
could have been due to the larger number of diverting we believe that surgeons should hone their experience with
colostomies in the former group. Nevertheless, as is the benign procedures such as diversion colostomies and
case for all laparoscopic surgeons, operative time was rectopexies before proceeding to resections for benign
progressively reduced with increased experience. Our conditions such as huge sessile polyps not amenable to
conversion rate of 16.7% fell within the ranges that have colonoscopic removal and diverticular disease. These
been reported in the literature.13-15 It is our hope that this operations are associated with lower morbidity than the
will improve as the CALS develops, with more LAC corresponding open procedures. However, the decision to
procedures being routinely performed. convert to open surgery should be made early in the
Despite the smaller length of incisions, the mean duration surgery. A rule of thumb would be failure of progress of the
of analgesic requirements for both groups of patients operation after an hour of laparoscopic dissection or when
did not differ significantly (2.25 days versus 2.64 days, there is excessive blood loss obscuring the visual field.
P = 0.40). Resections for malignant conditions should only be
embarked on when the surgeon has acquired sufficient
The significant benefits seen in our LAC group
experience and expertise in laparoscopic bowel surgery.
of patients were in their ability to tolerate diet quicker
Bulky tumours requiring an incision length greater than 10
(2.91 versus 4.05 days, P <0.001) and the earlier
cm for delivery are perhaps best resected by laparotomy or
return of bowel movements as manifested by the time taken
a skin-crease mini-laparotomy, depending on the surgeon’s
to move their bowels (2.57 versus 4.10 days, P <0.001). In
preference.
terms of the length of stay in hospital, our LAC
group required much shorter stays (mean of 5.31 Conclusion
days versus 9.07 days, P <0.02). The perioperative
Laparoscopic-assisted colon and rectal procedures in
management of the patients in both groups was identical,
selected patients can be performed safely and effectively.
adhering to the standard carepath the unit employs for all
There are significant advantages of shorter periods of
colorectal resections. These results essentially corroborate
bowel ileus, earlier toleration of oral diet and shorter
those of the large randomised series published in the
hospital stays. Minimal local wound complications and
literature.2,3,16
pulmonary complications are additional benefits.
When we looked at the results for the small group of Experience should be acquired by performing procedures
patients who had their procedures converted from in benign conditions (where there are no issues of long-
laparoscopic to the open method, it is worth noting that term survival, oncological clearance and port-site
these compared unfavourably with even those of the open recurrences) before progressing to definite resections in
group, a finding that has been described in the literature.12,17,18 malignant conditions. The decision to convert to an open
We attribute this to the added duration of the operation, procedure should be made early in order to improve
given that the time taken before the decision to make the outcomes.
conversion might have adversely affected the operative
outcome. We therefore believe that in cases where Acknowledgements
laparoscopic surgery is judged to be difficult, the decision The authors wish to thank Ms Ee Keng Kee for her
to convert should be made early. invaluable service rendered in managing the database and
Although there was an absolute difference in the general performing the statistical analysis.
complication rates between the LAC and the open group,
this was not significant. Not unexpectedly, there were no
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Annals Academy of Medicine