Retroperitoneal fibrosis

For some patients, minimally invasive procedures (MIPs) are acceptable and desirable alternatives to traditional open surgeries. Without compromising efficacy, MIPs generally have shown advantages regarding pain, recovery, and other studied outcomes. As surgical expertise increases, these procedures can be made available to greater numbers of patients for an increasing variety of conditions. Family physicians can help ensure successful outcomes for their patients through familiarity with the MIPs for common surgeries, such as hemorrhoidectomy, hysterectomy, ventral hernia repair, and colectomy. The following is a review of the surgical techniques used in these procedures, a discussion of patient selection for the minimally invasive approach, and a look at the evidence.

Treatment of Hemorrhoids

Hemorrhoids are vascular cushions within the anal canal consisting of both direct arteriovenous communications and the surrounding connective tissue. As one of the most common problems that family physicians encounter, hem orrhoidal disease may be the result of several factors: abnormal dilatation of veins of the internal hemorrhoidal venous plexus, abnormal distention of the arteriovenous anastomosis, prolapse of the cushions, and destruction of the surrounding connective tissue. All or some may coexist, and understanding the pathology of the disease is essential in order to comprehend the different treatment modalities. (1)

Lifestyle factors may also contribute to hemorrhoidal disease. Inadequate dietary fiber, straining, prolonged lavatory sitting, constipation, diarrhea, conditions in which the intra-abdominal pressure is raised (pregnancy, ascites, pelvic space-occupying lesions) and family history of hemorrhoidal disease have been proposed as contributors to the development of this condition. (2-3)

Hemorrhoids are categorized according to their origin (internal, external, or mixed). Internal hemorrhoids are further classified into 4 grades according to the extent of prolapse (TABLE 1). This classification is very important, as the grade determines the therapeutic options. Grades I and II can be treated with a variety of nonsurgical measures.

Surgical Intervention

According to the revised practice parameters for the management of hemorrhoids, surgical treatment should be offered to patients who fail to respond to office-based procedures, patients who are not capable of tolerating office procedures, patients with large external hemorrhoidal disease, or patients with grades III-IV mixed (internal-external) hemorrhoidal disease. (4) Traditional surgery for hemorrhoidal disease treats both the internal and external components of the hemorrhoids. Excision can be accomplished by different techniques (eg, Ferguson's [closed] or Milligan-Morgan [open]) with or without closure of the anorectal mucosa or the anoderm (5)

Ferguson's Hemorrhoidectomy

The excision of the hemorrhoidal tissue can be achieved with a scalpel, scissors, electrocautery, or laser. The numerous publications regarding these techniques and their results are inconsistent regarding which method causes fewer complications and less pain. The simplest techniques of excising hemorrhoids include the use of scissors or a scalpel. When performed in the correct plane between the hemorrhoidal tissue and the anal sphincters, the bleeding is usually minimal.

The use of an ultrasonically activated scalpel allows cutting and coagulation of hemorrhoidal tissue at lower temperatures at a specific point, thus causing less lateral thermal damage and less smoke compared with lasers or electrosurgical instruments. (6) With electrocautery, coagulation is achieved by burning at temperatures higher than 150 [degrees] C, resulting in the formation of eschar that covers and seals the bleeding area. The use of laser requires special skills, since the light is invisible and may cause damage to the operator and the assistant if not handled correctly. The only significant differences when the laser is used are increased cost and prolonged wound healing. (7,8) Vessel sealing technology for sutureless hemorrhoidectomy is a relatively new technique, using a bipolar electrothermal device. The procedure offers surgical treatment with shorter operative time and, supposedly, less postoperative pain. (5,9) After the hemorrhoidal pedicle has been mobilized, a suture is placed at the pedicle site and the defect in the mucosa, anoderm, and skin is closed.

Milligan-Morgan Hemorrhoidectomy

In this procedure, the hemorrhoidal tissue and vessels involved are excised in the same manner as in the closed hemorrhoidectomy, including the placement of a suture in the hemorrhoid pedicle, but the wounds are left open. Often, due to location, technical difficulties, or profound disease with gangrenous hemorrhoidal tissue, an open approach is preferred. To achieve hemostasis, the use of electrocautery is often required. Frequently, the procedure will be a combination of open and closed techniques, in which some of the sites will be left open while others will be primarily closed. Publications comparing the closed and open techniques are numerous and present conflicting results. (10,11)

Stapled Hemorrhoidopexy,

Procedure for Prolapse and Hemorrhoids In 1995, Longo described a new operative technique for hemorrhoidal disease. (12) This novel procedure is not a hemorrhoidectomy; neither the anal mucosa nor the hemorrhoidal tissue is excised. The procedure is performed in the distal rectal mucosa and submucosa, proximally to the dentate line. It includes excision of a band of excessive or loose mucosa and submucosa within the rectum, proximally to the hemorrhoidal tissue and fixation of the mucosa by stapled anastomosis. This maneuver supposedly interrupts the blood supply of the superior hemorrhoidal artery above the hemorrhoidal tissue.

The terms mechanical hemorrhoidectomy with a circular stapler, stapled hemorrhoidectomy, circular stapler hemorrhoidopexy, stapled circumferential mucosectomy, stapled anopexy, stapled hemorrhoidopexy, and procedure for prolapse and hemorrhoids (PPH) are all synonyms. Shortly after Longo introduced this technique, numerous publications, mainly from Asia and Europe, confirmed its benefits. (12)

Patient Selection and Contraindications

Indications for PPH include patients with grade III hemorrhoids, with uncomplicated grade IV hemorrhoids that are reducible at surgery or after manipulation in the operating room (the hemorrhoidal tissue is not excised during the procedure), and in those who failed other treatment modalities. (13) Contraindications for PPH include active sepsis, anal stenosis, and full-thickness rectal prolapse because these conditions are not adequately treated by PPH.

Performing all of these surgical procedures requires special training. Although PPH is usually considered relatively safe and simple, complications still may occur and sometimes may be devastating, resulting in hemorrhage, incontinence, anal stenosis, fistula, and septic complications. (14-16)

Surgical Complications

Possible complications of both open and closed hemorrhoidectomy include anal stenosis, postoperative pain, urinary retention, secondary hemorrhage, anal fissure, abscess or fistula, formation of skin tags, pseudopolyps, and incontinence. Postoperative pain is a main concern after hemorrhoidectomy; none of the techniques offers the patient a pain-free recovery. Urinary retention can be a result of pain, narcotics and anticholinergic drugs, fluid overload, high ligation of the hemorrhoidal pedicle and operative trauma. Limiting the perioperative fluid intake is the best preventive measure. Secondary hemorrhage after hemorrhoidectomy typically occurs 7-10 days after surgery. (17) Incontinence is one of the most dreadful complications of hemorrhoidectomy. Anal leakage is common in the early postoperative course, and the patient regains full control within a few weeks after the procedure. Anal stenosis results from anal narrowing because of fibrosis. This complication can be minimized by retaining large mucosal bridges during closed hemorrhoidectomy.

Rare, serious complications have been reported with PPH, including rectal perforation, retroperitoneal sepsis, retropneumoperitoneum, rectal stricture, rectal obstruction, and rectovaginal fistula. (15,18) However, a recently published meta-analysis by Lan et al, which included 10 randomized controlled studies that compared the safety and efficacy of PPH with open hemorrhoidectomy, suggested that PPH may be at least as safe as open hemorrhoidectomy. (19)

Body of Evidence

The meta-analysis by Lan et al included 799 patients with grades III and IV hemorrhoidal disease. (19) There was evidence in favor of PPH for operating time, length of hospital stay, postoperative pain, anal discharge, and patient satisfaction. These benefits may appear only after surgeons have gained sufficient experience with the procedure. However, skin tags and recurrent prolapse occurred at higher rates after PPH. The metaanalysis did not find significant difference in the rates of postoperative bleeding, urinary retention, anal fissure, stenosis, or difficulties in evacuation between the 2 techniques.

Another prospective multicenter study compared PPH with closed hemorrhoidectomy. (20) Patients with grade III hemorrhoidal disease were included. There was no significant difference in the complications between the 2 groups. The authors concluded that PPH offers the benefits of less postoperative pain (FIGURE), less need for analgesics, and less pain at the first bowel movement.

Hysterectomy

Given the frequency with which hysterectomy is performed in the United States, primary care physicians likely will discuss this surgery with patients. During such conversations, patients want to understand their options and receive effective counseling. Physicians need to be familiar with the paradigm for hysterectomy and the issues that complicated the choice of procedures.

According to the American College of Obstetricians and Gynecologists, the route of hysterectomy should depend upon the patient's anatomy and the surgeon's experience. (21) Contributing judgment factors include the possible presence of malignancy, the size of the uterus, the presence and extent of pelvic and abdominal adhesions, the presence of adnexal pathology, and ultimately the patient's desire to proceed with surgery after balanced, informed consent.

Conditions for Treatment

The majority of hysterectomies are electively performed for a variety of benign conditions including uterine fibroids, abnormal uterine bleeding, endometriosis, and uterine prolapse. (22) Hysterectomy can be justified as the treatment of choice for certain conditions. It can provide a permanent solution for menorrhagia and pressure symptoms from symptomatic fibroids, treatment for severe symptoms from endometriosis when other treatments have failed and fertility is not desired, treatment for symptomatic uterine prolapse, and as a solution for women suffering from recalcitrant and disabling dysmenorrhea who have failed with or refused other treatment.

Review of Techniques

Ideally, the chosen technique should be the least invasive method. There are 3 fundamental technical approaches to hysterectomy: abdominal, vaginal, and laparoscopic. Laparoscopic hysterectomy, a substitute for abdominal hysterectomy, may be divided into laparoscopicassisted vaginal hysterectomy (LAVH) when the procedure is done partly laparoscopically and partly vaginally, and total laparoscopic hysterectomy (TLH) when the entire procedure is performed laparoscopically. The latter is more technically demanding and only performed by advanced laparoscopic surgeons. Laparoscopic hysterectomy is contraindicated only when ovarian neoplasms of concern cannot be excised without the risk of spillage and whenever underlying intraabdominal anatomy precludes peritoneal access.

Vaginal Hysterectomy

Whenever possible, the vaginal route should be considered as a first choice for all benign conditions. (23) Vaginal hysterectomy has been associated with decreased costs, shorter lengths of stay, and lower complication rates relative to abdominal hysterectomy and LAVH. (24) Nevertheless, 60% to 75% of hysterectomies continue to be performed by the traditional abdominal route. (26,26) Fueled by the lack of sufficient numbers of cases and the paucity of surgical mentoring in residency training, the art of vaginal surgery is disappearing. Understandably, the perceived risk for intraoperative conversion to an abdominal approach most often drives the decision to perform abdominal hysterectomy. Furthermore, unsubstantiated traditional contraindications such as prior cesarean section, nulliparity, or poor uterine descent are all barriers to offering this option to women.

For the very experienced vaginal surgeon, LAVH is only restrictively used to ensure removal of the adnexae when access may be limited and removal is mandatory (eg, positivity for BRCA1 and BRCA2 mutations), for the extremely large uterus, and to assist in the midst of severe adhesive or endometriotic disease. (27)

Laparoscopic Hysterectomy

During the past decade there has been a 30-fold growth in the proportion of laparoscopic hysterectomies performed (0.3 to 9.9%) in the United States. (22) Without question, the laparoscopic approach causes less postoperative pain, lower stress levels, and substantially better cosmetic results than does abdominal hysterectomy. (28) Also without question, laparoscopic hysterectomy is more difficult to perform than is abdominal or vaginal hysterectomy and has a substantial learning curve. (29) Consequently, the results of any study examining the comparative value of laparoscopic hysterectomy with other methods are very dependent upon the intrinsic visual-motor skill and level of experience of each surgeon.

The relative merits of the laparoscopic approach continue to be a matter of debate. Depending upon the skill and experience of the surgeon, the rate of complications may be higher for laparoscopic than abdominal hysterectomy. A large, multicenter, parallel trial evaluated the effectiveness of laparoscopic vs abdominal hysterectomy and laparoscopic vs vaginal hysterectomy in more than 1300 women without uterine prolapse or significant uterine enlargement. Compared with abdominal hysterectomy, the laparoscopic approach was associated with a 2-fold risk of complications (11.1% vs 6.2%) and significantly longer operating times, despite decreased pain and improved quality of life postoperatively. (30) There were no significant differences when the laparoscopic was compared with the vaginal approach.

Body of Evidence

The Cochrane Collaborative recently conducted a meta-analysis of 27 randomized controlled trials to compare vaginal, laparoscopic, and abdominal hysterectomy for benign uterine disease in 3643 participants. (24) They found a significant advantage for vaginal and laparoscopic hysterectomy over abdominal hysterectomy. Women returned to normal activity sooner after vaginal and laparoscopic hysterectomy than abdominal hysterectomy. At the cost of a longer operating time and more lower urinary tract injuries (ureter and bladder), laparoscopic hysterectomy had fewer wound or abdominal wall infections, less pain, less pyrexia, smaller drop in hemoglobin, shorter hospitalization, and faster return to work than abdominal hysterectomy [TABLE 2).

In the meta-analysis, laparoscopic hysterectomy had a number of disadvantages when compared with vaginal hysterectomy, including more postoperative analgesia and greater hospital cost. Vaginal hysterectomy had significantly shorter operating time than laparoscopic or abdominal hysterectomy. Due to insufficient data, no conclusions could be reached as to whether there is equivalence between vaginal hysterectomy and TLH. The authors concluded that, as it had no disadvantage when compared with the other 2 approaches, vaginal hysterectomy should be performed whenever possible because of the combined benefit of fewer complications, shorter operating room time, and lower costs.

However, when vaginal hysterectomy is not possible, laparoscopic hysterectomy can facilitate oophorectomy if it is needed, and offers advantages over abdominal hysterectomy. The laparoscopic route should be considered when it reduces the necessity of laparotomy to perform hysterectomy.

Supracervical Hysterectomy

Total abdominal hysterectomy involves the removal of both the fundus of the uterus and the cervix, whereas supracervical hysterectomy conserves the cervix and supportive tissues. Supracervical abdominal hysterectomy is faster, requires less mobilization of the bladder, minimizes risk to the ureters, and is easier to perform in obese women with a deep cul-de-sac. (31) Supracervical hysterectomy is contraindicated in women who participate in high-risk behavior, have been diagnosed with cervical neoplasia, suffer from uterine prolapse, or are unwilling to undergo periodic cervical screening.

Preservation of the cervix during hysterectomy has been primarily advocated for the putative advantages of decreased surgical complications, reduced pelvic floor defects and incontinence after hysterectomy, and comparatively improved sexual function. It is theorized that cervical preservation prevents disruption of autonomic nerves in the supportive and nutritive uterosacral and cardinal ligament tissues that serve the cervix. (32) Recent preliminary data indicate that in the short term there is no significant difference in sexual function, pelvic floor support, or recovery between abdominal total and supracervical hysterectomy. (31,33)

Two recently published randomized studies did not detect any significant differences in sexual function including frequency of intercourse, orgasm, and rating of relationship to partner. (34,35) Less adequately addressed by the relatively small numbers in these same studies, bladder injury and transfusion were no greater with removal of the cervix. Of some concern, preservation of the cervix after abdominal supracervical hysterectomy may obligate some women to reoperation due to cyclical bleeding or spotting from the cervical stump and symptomatic cervical prolapse. In one study, nearly 7% had cyclical bleeding and nearly 2% cervical prolapse, potentially leading to reoperation in approximately 10% of those women randomized to abdominal supracervical hysterectomy. (31)

Benefits of a kaparoscopic Approach

Among the various laparoscopic approaches to hysterectomy, laparoscopic supracervical hysterectomy (LSH) is the least invasive and continues to grow in popularity among laparoscopic gynecologic surgeons. Depending upon the ability to access the peritoneal cavity and the experience of the surgeon, LSH can be performed even for a very large uterus. (36) Although reasons for its ascent have not been clearly established, its attractiveness remains in part due to the recent availability of efficient instrumentation to incrementally remove the fundus and myomas directly from port incisions using electromechanical morcellation similar to that used for removal of cartilage during arthroscopy. Added to this are the truncated technical demands, the perception of reduced risk for bleeding and lower urinary tract damage, and the abridged operating time when compared to LAVH or TLH, especially for the large uterus.

Furthermore, the combination of cervical and adnexal preservation via a laparoscopic approach is an ideal antidote for women in search of less invasive options that are perceived to preserve as much of their bodies as possible. For some patients, LSH can be emotionally viewed as a hysterectomy alternative.

LSH has been established as a reasonable option for women suffering from abnormal uterine bleeding. In one well-designed, prospective study, LSH was compared with hysteroscopic endometrial ablation for the treatment of menorrhagia that was unresponsive to medical treatment. (37) Over 24 months, patients' recoveries were similar after 3 postoperative days, and the overall quality of life was higher in the LSH group.

Ventral Hernia Repair

Ventral hernia is a broad term that typically is used to describe hernias located in the abdominal wall, such as epigastric and umbilical hernias. It is estimated that more than 90,000 ventral hernia repairs are performed annually in the United States. (38,39) A subset of this group, the incisional hernias, arise at the site of previous abdominal surgery and may occur at a rate of 3% to 20%. (38) Risk factors for developing a ventral/incisional hernia include suboptimal closure of an abdominal incision; development of a wound infection; presence of obesity, immunosuppression, or prostatism; re-use of an abdominal incision; previous aortic aneurysm surgery; and presence of a previous incisional hernia. (40,41)

Review of Techniques

Current treatment options for ventral/incisional hernias include both open and laparoscopic procedures. Numerous hernia repair methods have been described in the medical literature. Generally speaking, a traditional, primary open repair entails a laparotomy with suturing of strong fascial tissue on each side of the defect. Recurrence rates after this procedure range from 41% to 52% during long-term follow-up. (42-44)

Open tension-free hernia repairs, which implant large prosthetic meshes, appear to have lower failure rates (12% to 24%) than traditional primary open repair procedures. Open tension-free hernia repairs require a surgeon to dissect wide areas of soft tissue, increasing the incidence of wound and mesh-related complications to 12% or higher. (44-46)

Interest in less morbid hernia repairs and the appeal of minimally invasive surgical techniques encouraged the development of laparoscopic methods for repairing ventral hernias. (39) Since the first report of laparoscopic ventral hernia repair in the early 1990s, the popularity of the procedure has grown. Many surgeons initially believed that laparoscopic compared with open ventral hernia repair would result in decreased hospital stays and complication rates and improved patient outcomes. Results from several comparative studies are now available to support these beliefs. (47-51)

Laparoscopic ventral hernia repair is an intra-abdominal, intraperitoneal repair that uses a mesh prosthesis to close and cover the hernial defect. In most cases, the mesh is anchored with tacks and transabdominal permanent sutures. Typically, the hernial defect itself is not closed. An important principle of mesh repair is to choose or tailor the mesh to be at least 4 to 5 cm wider than the hernial defect on all 4 sides, thus permitting the mesh to be anchored to the solid musculofascial layer. The mesh should initially be placed taut with the abdomen insufflated; however, when the abdomen deflates, there should be no tension.

When a mesh repair is contraindicated, open non-mesh repairs, such as the component separation technique, are utilized.

Patient Selection and Contraindications

Generally, patients who have a fascial defect of 3 cm or more and meet the criteria for a traditional open hernia repair are considered candidates for laparoscopic repair. Small hernial defects less than 3 cm in diameter can be readily repaired by standard primary repair techniques; however, recent data suggest that patients with small hernial defects may also benefit from mesh repair. (42) Patients with multiple small defects, sometimes referred to as Swiss cheese hernias, are also good candidates for laparoscopic hernia repair.

There are very few absolute contraindications to laparoscopic repair of ventral hernias. As with most laparoscopic procedures, contraindications are dependent on each surgeon's expertise and skill level. One absolute contraindication is the inability to tolerate general anesthesia. Relative contraindications include loss of abdominal domain, history of frozen abdomen, acute strangulation or incarceration, and high-grade or complete bowel obstruction.

In some cases, obesity may be considered a contraindication to laparoscopic ventral hernia repair. However, the difficulty of a ventral hernia repair using either a laparoscopic or open approach is increased in obese compared with nonobese patients. Since obese patients are also at increased risk of developing complications during and following an open ventral hernia repair, many surgeons prefer to treat obese patients with ventral hernias laparoscopically.

A history of multiple abdominal operations may be a contraindication to laparoscopic surgery. However, in most cases, these patients can be treated laparoscopically, although surgery length and difficulty may be increased, just as they would be with an open approach.

Case Study Reports

Long-term results from case series support the use of laparoscopic repair of ventral hernias. Heniford et al described their experience with 850 consecutive laparoscopic ventral hernia repairs performed over a period of 9 years. (39) In this series there was a low conversion rate to open repair (3.6%), short hospital stay (2.3 days), moderate complication rate (13.2%), and low recurrence rate (4.7%) after an average follow-up time of approximately 20 months (range 1-96 months). Franklin et al reported similar results from their 11-year experience. (52) In this series, 4% of laparoscopic procedures were converted to an open procedure, the mean hospital stay was 2.9 days, the overall complication rate was 10.1%, and the recurrence rate was 2.9% after an average follow-up time of approximately 47.1 months (range 1-141 months).

Outcomes Measured in Clinical Trials

Results from a number of mostly small (N<100) comparative studies suggest that laparoscopic ventral hernia repair compared with open repair is advantageous for several reasons, including decreased hospital stay, fewer complications, and decreased chance of recurrence {TABLE 3). (47-49,53-61) Operating time may be shorter when performing a laparoscopic ventral hernia repair, although this is not consistently seen in studies.

A meta-analysis including data from 8 comparative studies reported similar results as those from the comparative studies mentioned above. Goodney et al reported a lower complication rate (14% vs 27%) and shorter hospital stay (2 vs 4 days) in patients who underwent laparoscopic compared with open ventral hernia repair. (62) Currently, data from large, randomized, controlled studies confirming these results are lacking and long-term results from comparative studies are needed.

Despite the lack of prospective randomized data comparing laparoscopic and open ventral hernia repair, it is clear that the primary advantage of the laparoscopic approach is the ability to perform a tension-free mesh repair with a low wound and mesh complication rate.

Colectomy

Since colectomy is performed for a variety of colon diseases and can be approached in several ways, family physicians should familiarize themselves with the procedure, even though a surgeon usually already has been involved with the patient when the decision to perform a colectomy is made.

Conditions for Treatment

As of mid-2005, numerous case series and several randomized, clinical trials have compared laparoscopic with open colon resection in patients with a variety of colon conditions, such as Crohn's disease, diverticulitis, rectal prolapse, ulcerative colitis (UC), and cancer of the colon (TABLE 4). (63-83)

All types of abdominal colorectal procedures can be performed laparoscopically including colon and rectal resections, pouch operations, ostomy construction, and combination surgeries involving pelvic procedures such as hysterectomy. Each procedure varies in complexity and difficulty, but the experienced laparoscopic surgeon usually can perform any of them.

In 2 meta-analyses, outcomes have been compared in these trials with varying results. (63,64) Laparoscopic procedures appear to offer several short-term advantages including decreased blood loss, less pain, shorter duration of postoperative ileus, reduced stress response, less scarring, shorter recovery time as measured by length of hospital stay and return to normal activity, and improved pulmonary function.

Operating time is always shorter for open surgical procedures. However, operating times for laparoscopic procedures appear to decrease with increased surgeon and surgery-center experience. Operative times for laparoscopic right colectomy now approach that of open right colectomy. Hand-assisted laparoscopy is one method of reducing operative times without compromising recovery. (84)

Crohn's Disease

Most patients with Crohn's disease will need colorectal surgery at some point during their lifetimes. Initial results from uncontrolled, nonrandomized trials that compared laparoscopic with open colon-resection procedures suggested no benefit from laparoscopic surgery in patients with Crohn's disease. However, several comparative publications and a randomized controlled trial suggest that laparoscopic surgery can be beneficial for some of these patients. (67,75)

Milsom et al conducted a randomized trial comparing laparoscopic (n=31) with conventional open (n=29) surgery in patients with refractory ileocolic Crohn's disease. (67) Pulmonary function, as measured by recovery of 80% of forced expiratory volume and forced vital capacity, returned significantly sooner in patients who underwent laparoscopy compared with conventional surgery. Patients in the laparoscopic group experienced significantly fewer minor complications and left the hospital sooner (5 vs 6 days). Differences in analgesic use, flatus, and time to first bowel movement were not significant. Laparoscopy has been shown to be feasible and safe even in patients with Crohn's disease manifested as recurrent Crohn's disease, abscess drained percutaneously, and fistula disease, (75) Complex Crohn's disease is therefore not a contraindication to laparoscopic management.

Diverticular Disease

Under current recommendations, patients less than 50 years of age who have had 1 episode of diverticulitis should consider elective colonic resection because of the increased morbidity and mortality associated with a second episode. To date, results from randomized clinical trials comparing laparoscopic with open sigmoid colectomy for the treatment of diverticular disease have not been published. However, results from a substantial number of studies suggest that elective laparoscopic colectomy is effective for diverticulitis. (76-78) Two early feasibility studies showed low morbidities and complication rates with laparoscopic colectomy. A comparison of results of 18 laparoscopic colectomies and 18 standard laparotomies showed that laparoscopic resection of diverticulitis can be performed without additional morbidity, especially as the surgeon's experience increases. (77) A review of 271 sigmoid colectomies for diverticulitis (56 conducted laparoscopically and 215 performed with the standard open technique) showed favorable results for the laparoscopic procedure regarding complications and mortality. (78)

Rectal Prolapse

Laparoscopic procedures also appear beneficial in the treatment of rectal prolapse based on results from comparative studies and 1 randomized, controlled trial. (69,65) Solomon et al randomized 20 patients to laparoscopy and 19 to open rectopexy for the treatment of rectal prolapse. (69) Mean operating time was longer for the laparoscopy compared with the open-laparotomy group. In contrast, hospital stays were shorter, a solid diet was tolerated sooner, and morphine requirements and morbidity were decreased in the laparoscopic compared with the open group.

Results from a meta-analysis were consistent with these findings. Recurrence rates and morbidity were similar between laparoscopic and open abdominal rectopexy groups but length of stay was shorter and operative times longer in the laparoscopic group. (65)

Ulcerative Colitis

Unlike other benign colorectal conditions, the use of laparoscopic techniques for the treatment of UC is not widely accepted because the surgical procedures tend to be more technically challenging. Results from studies comparing laparoscopy with open surgery in patients with UC have been mixed. (79-80) Interestingly, some results from comparative studies that have included patients with either Crohn's disease or ulcerative colitis show beneficial effects with laparoscopy compared with open proctocolectomy for patients with Crohn's disease but not for those with UC. (82,83) Prospective, randomized, clinical trials are needed to help determine the role of laparoscopic procedures in the treatment of patients with UC.

Malignant Colon Tumors

The use of laparoscopic techniques for the treatment of colorectal cancer was not initially embraced by many physicians. Some were concerned that the strict oncologic principles that guide open surgical procedures for colorectal cancer could not be followed when a laparoscopic procedure was performed. In addition, there were reports suggesting an increased risk of port-site recurrence in patients who underwent a laparoscopic compared with an open procedure for colon cancer. As of 2005, results from large randomized controlled clinical trials supporting the safety and efficacy of laparoscopic colectomy for colon cancer have tempered many of these original concerns.

The first long-term trial to report results was conducted by the Clinical Outcomes of Surgical Therapy (COST) study group. (70) This noninferiority trial, designed to assess whether laparoscopically assisted colectomy for cancers of the right and left colon causes additional risk of cancer recurrence, was conducted at 48 institutions in North America and randomized 428 patients to open and 435 to laparoscopic colectomy. A total of 90 patients (21%) in the laparoscopic group were converted to an open procedure.

At 3-year follow-up, cancer recurrence rates (combined distant, distant and local, local only) were similar between the 2 groups. A recurrence occurred in 16% of patients randomized to laparoscopy and 18% randomized to open colectomy. Thus, the cancer operation as performed by laparoscopic approaches is essentially equivalent to an open operation. Surgical wound recurrence was evident in less than 1% of patients in both groups. Eighty-six percent of patients randomized to laparoscopy and 85% to open laparotomy were alive at 3 years. Recovery after surgery was faster in patients randomized to the laparoscopic arm compared with the open group. Similarly, length of hospital stay was shorter in the laparoscopic (5 days) compared with the open surgery group (6 days). Patients treated with laparoscopy also used parenteral and oral narcotics for a shorter time period. Not surprisingly, operative time was longer when the laparoscopic approach was taken.

Results were similar from the multicenter COlon Cancer Laparoscopic or Open Resection (COLOR) trial. (72) In this trial, conducted with 1248 patients in 29 European institutions, a total of 91 (14.5%) patients randomized to laparoscopy were converted to an open procedure. As in the COST study, operative time was longer for the laparoscopic (145 minutes) compared with the open (115 minutes) group. However, analgesic use and length of hospital stay (8.2 vs 9.3 days) were decreased, and bowel function returned earlier in the laparoscopic group. Short-term morbidity and mortality were similar between the 2 treatment groups. Long-term results are not yet available.

Finally, the UK Medical Research Council Trial of Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (MRC-CLASICC) trial showed results similar to those of the COST and COLOR trials. (73) In this study, 526 patients were randomized to laparoscopic and 268 patients to open surgery for the treatment of colorectal cancer; analysis was by intention to treat and 484 patients actually received laparoscopic surgery. A total of 143 (29%) patients were converted from a laparoscopic to an open procedure, a conversion rate that is comparable to that of the COST trial; that it is slightly higher is probably due to the inclusion of patients with advanced cancer, high body mass indices, and rectal cancer in the trial. In this trial as well, operating time was longer (180 vs 135 minutes) but hospital stay was shorter (9 vs 11 days) in patients who underwent a laparoscopic compared with an open procedure. There were no differences in complications or in-hospital mortality between the 2 treatment groups. The CLASICC trial showed a slightly increased number of patients in the laparoscopic group with positive surgical margins. This may indicate that laparoscopic techniques need to be critically evaluated in the treatment of rectal cancer.

Patient Selection and Contraindications

Currently, there are very few absolute contraindications to laparoscopic colectomy, although appropriate patient selection is important. Laparoscopic colectomy may be contraindicated in patients with increased bleeding risks because the surgeon has only limited access to bleeding sites. The inability to visualize organs due to tumor bulk, is considered a contraindication; however, the size of the tumor may not matter. Nassiopoulos et al reported that laparoscopic colectomy is possible in patients with large, sessile colorectal polyps. (85) Laparoscopic colectomy for benign polyps is an effective way to reduce morbidity in a radical treatment of a benign process. Since about 20% of polyps that cannot be removed by colonoscopy will contain invasive cancer, care must be taken to perform an adequate cancer operation. Invasion of the tumor into adjacent organs or tissue should be considered a relative contraindication to laparoscopic colectomy since a wide en bloc resection may actually be possible laparoscopically.

Laparoscopy appears to be possible after laparotomy, although the presence of severe adhesions or dense scar tissue are contraindications. However, the potential need to convert a laparoscopic procedure to an open procedure in this group of patients is increased.

Laparoscopically assisted colectomy in obese patients can present several technical challenges such as abdominal access and port insertion, but results from several studies suggest that it can be accomplished safely for many colorectal diseases. (86,87)

Advanced age by itself does not preclude laparoscopy; 2 studies reported significantly less morbidity after laparoscopic colectomy than open colectomy in older patients (88,89) and complication and conversion rates are similar in older and younger patients. (83)

Other Outcomes Measured in Clinical Trials

Several studies have compared quality-of-life outcomes in patients randomized to either laparoscopic or open colectomy. Basse et al compared functional recovery in 60 patients with a benign or malignant colorectal condition, randomized to undergo either a laparoscopic or open procedure. (90) Both treatment groups were also prescribed multimodal rehabilitation. In this study, there were no significant differences in functional recovery between the 2 groups. In contrast, Weeks et al and Dunker et al reported small quality-of-life improvements with laparoscopic procedures. (80,91) Dunker and colleagues reported that in the long term, improved cosmesis was probably the most important benefit associated with laparoscopic surgery. (67)

Finally, for patients with a malignant colon disease, the most important comparisons relate to recurrence and long-term outcomes. Although some early studies suggested an increased risk of port-site recurrence with laparoscopic compared with open procedures, data from more recent trials found port-side recurrence to be similar between these groups. (66,68,70,71)

Several studies have reported longer-term outcomes; most studies however, are still ongoing. As mentioned previously, recurrence rate, overall survival, and disease free survival were similar between the laparoscopic and open colectomy groups in the COST trial. (79) Results were similar in several other studies. To date, no studies reported significantly decreased survival or increased recurrence rates with laparoscopic compared with open procedures. (66,68,70,71)

Summary

Options are available to patients and referring physicians when surgery is necessary for many common conditions. The choice of treatment should be tailored to a patient's condition and concerns. The outcomes of numerous studies and large trials suggest that MIPs may be a safe alternative to traditional open surgery with benefits to many patients. No MIP is without complications, however, and surgeons who have extensive experience in a particular procedure should be selected for referral. Nevertheless, MIPs appear to result in faster recovery, fewer complications and better cosmesis in general, and offer additional procedure-specific benefits with efficacy and safety that are similar to traditional approaches. More data are needed to determine whether laparoscopic hysterectomy is equivalent to vaginal hysterectomy, and large, randomized, controlled trials are necessary to confirm the benefits of laparoscopic ventral hernia repair compared with open repair.

References

(1.) Sardinha TC, Corman ML. Hemorrhoids. Surg Clin North Am. 2002;82:1153-1167.

(2.) Loder PB, Kamm MA, Nicbolls RJ, Phillips RK. Haemorrhoids: pathology, pathophysiology and aetiology. Br J Surg. 1994;81:946-954.

(3.) Johannsson HO, Graf W, Pahlman L. Bowel habits in hemorrhoid patients and normal subjects. Am J Gastroenterol. 2005;100:401-406.

(4.) Cataldo P, Ellis CN, Gregorcyk S, et al, for The Standards Practice Task Force, The American Society of Colon and Rectal Surgeons, USA. Practice parameters for the management of hemorrhoids (revised). Dis Colon Rectum. 2005;48:189-194.

(5.) Fleshman J. Advanced technology in the management of hemorrhoids: stapling, laser, harmonic scalpel, and ligasure. J Gastrointest Surg. 2002;6:299-301.

(6.) Armstrong DN, Ambroze WL, Schertzer ME, Orangio GR. Harmonic scalpel vs. electrocautery hemorrhoidectomy: a prospective evaluation. Dis Colon Rectum. 2001;44:558-564.

(7.) Plapler H, de Faria Netto AJ, da Silva Pedro MS. 350 ambulatory hemorrhoidectomies using a scanner coupled to a CO2 laser. J Clin Laser Med Surg. 2000;18:259-262.

(8.) Hodgson WJ, Morgan J. Ambulatory hemorrhoidectomy with CO2 laser. Dis Colon Rectum. 1995;38:1265-1269.

(9.) Chung YC, Wu HJ. Clinical experience of sutureless closed hemorrhoidectomy with LigaSure. Dis Colon Rectum. 2003;46:87-92.

(10.) You SY, Kim SH, Chung CS, Lee DK. Open vs. closed hemorrhoidectomy. Dis Colon Rectum. 2005;48:108-113.

(11.) Ho YH, Seow-Choen F, Tan M, Leong AE Randomized controlled trial of open and closed haemorrhoidectomy. Br J Surg. 1997;84:1729-1730.

(12.) Longo A. Mechanical hemorrhoidectomy using a circular stapler. Refresher course on hemorrhoidal disease therapy. Paper presented at: 24th International Congress of Latin Mediterranean; 1995; Palermo: Renna s.p.a graphic.

(13.) Corman ML, Gravie JF, Hager T, et al. Stapled haemorrhoidopexy: a consensus position paper by an international working party--indications, contra-indications and technique. Colorectal Dis. 2003;5:304-310.

(14.) Person B, Wexner SD. Novel technology and innovations in colorectal surgery: the circular stapler for treatment of hemorrhoids and fibrin glue for treatment of perianal fistulae. Surg Innov. 2004;11:241-252.

(15.) Pescatori M. PPH stapled hemorrhoidectomy-a cautionary note. Dis Colon Rectum. 2003;46:131.

(16.) Holzheimer RG. Hemorrhoidectomy: indications and risks. Eur J Med Res. 2004;9:18-36.

(17.) Chen HH, Wang JY, Changchien CR, et al. Risk factors associated with posthemorrhoidectomy secondary hemorrhage: a single-institution prospective study of 4,880 consecutive closed hemorrhoidectomies. Dis Colon Rectum. 2002;45:1096-1099.

(18.) Ripetti V, Caricato M, Arullani A. Rectal perforation, retropneumoperitoneum, and pneumomediastinum after stapling procedure for prolapsed hemorrhoids: report of a case and subsequent considerations. Dis Colon Rectum. 2002;45:268-270.

(19.) Lan P, Wu X, Zhou X, Wang J, Zhang L. The safety and efficacy of stapled hemorrhoidectomy in the treatment of hemorrhoids: a systematic review and meta-analysis of ten randomized control trials. Int J Colorectal Dis. 2005 Jun 22; [Epub ahead of print].

(20.) Senagore AJ, Singer M, Abcarian H, et al and the Procedure for Prolapse and Hemorrhoids (PPH) Multicenter Study Group. A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results. Dis Colon Rectum. 2004;47:1824-1836.

(21.) ACOG Committee Opinion. Appropriate use of laparoscopically assisted vaginal hysterectomy. Obstet GynecoL 2005;105:929-930.

(22.) Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol. 2002;99:229-234.

(23.) Bran DF, Spellman JR, Summitt RL Jr. Outpatient vaginal hysterectomy as a new trend in gynecology. AORNJ. 1995;62:810-814.

(24.) Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2005. Issue 3.

(25.) Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB. Hysterectomy in the United States, 1988-90. Obstet Gynecol. 1994;83:549-555.

(26.) ECRI. Laparoscopy in hysterectomy for benign conditions. Plymouth Meeting, Pa: Health Technology Assessment Information Service. 1995.

(27.) Larai E, Soriano D, Kimata P, LaPlace C, Lecuru E Vaginal hysterectomy for enlarged uteri, with or without laparoscopic assistance: randomized study. Obstet Gynecol. 2001;97:712-716.

(28.) Olsson JH, Ellstrom M, Hahlin. A randomised prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynaecol. 1996; 103:345-350.

(29.) Harkki-Siren P, Sjoberg J. Evaluation and the learning curve of the first one hundred laparoscopic hysterectomies. Acta Obstet Gynecol Scand. 1995;74:638-641.

(30.) Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004;328:129-133.

(31.) Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med. 2002;347:1318-1325.

(32.) Kilkku P, Gronroos M, Hirvonen T, Rauramo L. Supravaginal uterine amputation vs. hysterectomy--effects on libido and orgasm. Acta Obstet Gynecol Stand. 1983;62:147-152.

(33.) Learman LA, Summitt RL, Varner RE, et al, for the Total or Supracervical Hysterectomy (TOSH) Research Group. A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Obstet Gynecol. 2003;102:453-462.

(34.) Kuppermann M, Summitt RL, Varner RE et al, for the the Total or Supracervical Hysterectomy (TOSH) Research Group. Sexual functioning after total compared with supracervical hysterectomy: a randomized trial. Obstet Gynecol. 2005;105:1309-1318.

(35.) Roovers JP, van der Born JG, van der Vaart CH, Heintz AP. Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. BMJ. 2003;327:774-778.

(36.) Lyons TL. Laparoscopic supracervical hysterectomy: A comparison of morbidity and mortality results with laparoscopically assisted vaginal hysterectomy. J Reprod Med. 1993;38:763-767.

(37.) Zupi E, Zullo F, Marconi D, et al. Hysteroscopic endometrial resection versus laparoscopic supracervical hysterectomy for menorrhagia: a prospective randomized trial. Am J Obstet GynecoL 2003;188:7-12.

(38.) Read RC, Yoder G. Recent trends in the management of incisional herniation. Arch Surg. 1989;124:485-488.

(39.) Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years' experience with 850 consecutive hernias. Ann Surg. 2003;238:391-399

(40.) Cobb WS, Kercher KW, Heniford BT. Laparoscopic repair of incisional hernias. Surg Clin North Am. 2005;85:91-103.

(41.) Park A, McKinlay R. Laparoscopic ventral hernia repair. Dis Mon. 2004;50:591-593.

(42.) Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392-398.

(43.) Hesselink VJ, Luijendijk RW, de Wilt JH, Heide R, Jeekel j. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet. 1993;176:228-234.

(44.) Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg. 1989;13:545-554.

(45.) Leber GE, Garb JL, Alexander AI, Reed WP. Long term complications associated with prosthetic repair of incisional hernias. Arch Surg. 1998;133:378-382.

(46.) White TJ, Santos MC, Thompson JS. Factors affecting wound complications in repair of ventral hernias. Am Surg. 1998;64:276-280.

(47.) Holzman MD, Purut CM, Reintgen K, Eubanks S, Pappas TN. Laparoscopic ventral and incisional hernioplasty. Surg Endosc. 1997;11:32-35.

(48.) Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg. 1999;65:827-831.

(49.) Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc. 1999;13:250-252.

(50.) DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Prospective comparison to open prefascial polypropylene mesh repair. Surg Endosc. 2000;14:326-329.

(51.) Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery. 1998;124:816-821.

(52.) Franklin ME Jr, Gonzalez JJ Jr, Glass JL, Manjarrez A. Laparoscopic ventral and incisional hernia repair: an 11 year experience. Hernia. 2004;8:23-27.

(53.) Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of laparoscopic incisional hernia repair. Surg Endosc. 2000; 14:117-119.

(54.) Olmi S, Magnone S, Erba L, Bertolini A, Croce E. Results of laparoscopic versus open abdominal and incisional hernia repair. JSLS. 2005;9:189-195.

(55.) McGreevy JM, Goodney PP, Birkmeyer CM, Finlayson SR, Laycock WS, Birkmeyer JD. A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs. Surg Endosc. 2003;17:1778-1780.

(56.) Raftopoulos I, Vanuno D, Khorsand J, Kouraklis G, Lasky P. Comparison of open and laparoscopic prosthetic repair of large ventral hernias. JSLS. 2003;7:227-232.

(57.) Robbins SB, Pofahl WE, Gonzalez RP. Laparoscopic ventral hernia repair reduces wound complications. Am Surg. 2001;67:896-900.

(58.) van't RM, Vrijland WW, Lange JF, Hop WC, Jeekel J, Bonier HJ. Mesh repair of incisional hernia: comparison of laparoscopic and open repair. Eur J Surg. 2002;168:684-689.

(59.) Wright BE, Niskanen BD, Peterson DJ, et al. Laparoscopic ventral hernia repair: are there comparative advantages over traditional methods of repair? Am Surg. 2002;68:291-295.

(60.) Zanghi A, Di Vita M, Lomenzo E, De Luca A, Cappellani A. Laparoscopic repair vs open surgery for incisional hernias: a comparison study. Ann Ital Chir. 2000;71:663-667.

(61.) Lal P, Kajla RK, Chander J, Saha R, Ramteke VK. Randomized controlled study of laparoscopic total extraperitoneal versus open Lichtenstein inguinal hernia repair. Surg Endosc. 2003;17:850-856.

(62.) Goodney PP, Birkmeyer CM, Birkmeyer JD. Short-term outcomes of laparoscopic and open ventral hernia repair: a meta-analysis. Arch Surg. 2002;137:1161-1165.

(63.) Schwenk W, Haase O, Neudecker J, et al. Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev. 2005. Issue 2.

(64.) Abraham NS, Young JM, Solomon MJ. Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer. Br J Surg. 2004;91:1111-1124.

(65.) Purkayastha S, Tekkis P, Athanasiou T, et al. A comparison of open vs. Laparoscopic abdominal rectopexy for full-thickness rectal prolapse: a meta-analysis. Dis Colon Rectum. 2005 Jun 20; [Epub ahead of print].

(66.) Milsom JW, Bohm B, Hammerhofer KA, et al. A prospective, randomized trial comparing laparoscopic versus conventional techniques in colorectal cancer surgery: a preliminary report. J Am Coil Surg. 1998;187:46-54.

(67.) Milsom JW, Hammerhofer KA, Bohm B, et al. Prospective, randomized trial comparing laparoscopic vs. conventional surgery for refractory ileocolic Crohn's disease. Dis Colon Rectum. 2001 ;44:1-8.

(68.) Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet. 2002;359:2224-2229.

(69.) Solomon MJ, Young CJ, Eyers AA, et al. Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. Br J Surg. 2002;89:35-39.

(70.) Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004;350:2050-2059.

(71.) Leung KL, Kwok SP, Lain SC, et al. Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. Lancet. 2004;363:1187-1192.

(72.) Veldkamp R, Kuhry E, Hop WC, et al, for the COlon Cancer Laparoscopic or Open Resection Study Group (COLOR). Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 2005;6:477-484.

(73.) Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): Multicentre, randomised controlled trial. Lancet. 2005;365:1718-1726.

(74.) Fleshman JW, Nelson H, Peters WR, et al. Early results of laparoscopic surgery for colorectal cancer. Retrospective analysis of 372 patients treated by Clinical Outcomes of Surgical Therapy (COST) Study Group. Dis Colon Rectum. 1996;39(suppl 10): S53-S58.

(75.) Wu JS, Birnbaum EH, Kodner IJ, et al. Laparoscopic-assisted ileocolic resections in patients with Crohn's disease: are abscesses, phlegmons, or recurrent disease contraindications? Surgery. 1997;122:688-689.

(76.) Faynsod M, Stamos MJ, Arnell T, et al. A case-control study of laparoscopic versus open sigmoid colectomy for diverticulitis. Am Surg. 2000;66:841-843.

(77.) Sher ME, Agachan F, Bortul M, et al. Laparoscopic surgery for diverticulitis. Surg Endosc. 1997;11:264-267.

(78.) Lawrence DM, Pasquale MD, Wasser TE. Laparoscopic versus open sigmoid colectomy for diverticulitis. Am Surg. 2003;69:499-503.

(79.) Wexner SD, Cera SM. Laparoscopic surgery for ulcerative colitis. Surg Clin North Am. 2005;85:35-47.

(80.) Dunker MS, Bemelman WA, Slors JF, et al. Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study. Dis Colon Rectum. 2001;44:1800-1807.

(81.) Marcello PW, Milsom JW, Wong SK, et al. Laparoscopic restorative proctocolectomy: case-matched comparative study with open restorative proctocolectomy. Dis Colon Rectum. 2000;43:604-608.

(82.) Sardinha TC, Wexner SD. Laparoscopy for inflammatory bowel disease: pros and cons. World J Surg. 1998;22:370-374.

(83.) Reissman P, Salky BA, Pfeifer J, et al. Laparoscopic surgery in the management of inflammatory bowel disease. Am J Surg. 1996;171:47-50.

(84.) Litwin DE, Darzi A, Jakimowicz J, et al. Hand-assisted laparoscopic surgery (HALS) with the HandPort system: initial experience with 68 patients. Ann Surg. 2000;231:715-723.

(85.) Nassiopoulos K, Pavlidis TE, Menenakos E, et al. Laparoscopic colectomy in the management of large, sessile, transformed colorectal polyps. JSLS. 2005;9:58-62.

(86.) Delaney CP, Pokala N, Senagore AJ, et al. Is laparoscopic colectomy applicable to patients with body mass index >30? A case-matched comparative study with open colectomy. Dis Colon Rectum. 2005;48:975-981.

(87.) Senagore AJ, Delaney CP, Madboulay K, et al. Laparoscopic colectomy in obese and nonobese patients. J Gastrointest Surg. 2003;7:558-561.

(88.) Delgado S, Lacy AM, Garcia Valdecasas JC, et al. Could age be an indication for laparoscopic colectomy in colorectal cancer? Surg Endosc. 2000;14:22-26.

(89.) Vignali A, Di Palo S, Tamburini A, et al. Laparoscopic vs. open colectomies in octogenarians: a case-matched control study. Dis Colon Rectum. 2005 Aug 3; [Epub ahead of print].

(90.) Basse L, Jakobsen DH, Bardram L, et al. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg. 2005;241:416-423.

(91.) Weeks JC, Nelson H, Gelber S, et al. Short-term quality-of-life outcomes following laparoscopic-assisted colectomy vs open colectomy for colon cancer: a randomized trial. JAMA. 2002;287:321-328.

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