Laparoscopic Colorectal Resection in Patients With Previous Abdominal and Colonic Surgery

AUTHORS

Najaf N. Siddiqi 1 , * , Qmar Zaman 1 , Keval M. Patel 1 , Manfred Odermatt 1 , Jim Khan 1 , Amjad Parvaiz 1

1 Minimally Invasive Colorectal Unit, Queen Alexandra Hospital, National Centre for Training in Laparoscopic Colorectal Surgery, Cosham, U.K.

How to Cite: Siddiqi N N, Zaman Q, Patel K M, Odermatt M, Khan J, et al. Laparoscopic Colorectal Resection in Patients With Previous Abdominal and Colonic Surgery, J Minim Invasive Surg Sci. 2015 ; 4(3):e31968. doi: 10.17795/minsurgery-31968.

ARTICLE INFORMATION

Journal of Minimally Invasive Surgical Sciences: 4 (3); e31968
Published Online: August 29, 2015
Article Type: Research Article
Received: July 1, 2015
Revised: July 15, 2015
Accepted: July 15, 2015
Crossmark

Crossmark

CHEKING

READ FULL TEXT
Abstract

Background: Previous abdominal surgery and its related adhesions are usually a relative contraindication for laparoscopic surgery or reason for conversion.

Objectives: This study aim to identify patients with previous abdominal surgery and compare the clinical outcomes in patients with and without previous abdominal surgery.

Patients and Methods: Data was collected prospectively from September 2006 to Dec 2010 of all laparoscopic colorectal resections done for both benign and malignant diseases.

Results: Out of 718 patients 476 had no previous abdominal surgery (Group A), whilst 190 patients had previous abdominal surgery not involving colonic surgery (Group B), and 52 had previous bowel surgery (Group C). The conversion rate was 4% for all groups, the re-admission rate was 11.8% for Group A, 12.6% for Group B and 9.6% for Group C, the median length of stay was 4 days for Groups A and B and 5 days for Group C. There was no statistically significant difference between groups for any of the above measures. However, there was a statistically significant difference in the length of operative time between groups. Patients in Group A and Group B requiring a median of 180 minutes, whilst Group C required a median of 210 minutes of operative time. (P = 0.026 and 0.002, respectively).

Conclusions: Previous abdominal surgery, including previous colonic surgery, confers no added risk of conversion to an open operation, morbidity or mortality for patients undergoing laparoscopic colorectal surgery. The operative time however is longer (30 minutes) for patients with previous colonic surgery.

Keywords

Laparoscopic Surgery Conversion Rates Previous Abdominal Surgery Previous Colonic Surgery

Copyright © 2015, Minimally Invasive Surgery Research Center and Mediterranean & Middle Eastern Endoscopic Surgery Association. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Since Jacobs et al. (1) described the first laparoscopic colectomy in 1991, the use of laparoscopic approaches to benign and malignant colorectal disease has increased dramatically. Despite initial concern over surgical learning curves and port site recurrence, several large multi-centre trials have shown that laparoscopic surgery is safe and has comparable surgical outcomes and complication rates when compared with open surgery (2) and in particular can improve return to function of GI tract, reduce length of hospital stay and shorten time off work.

However, concern remains over laparoscopic conversion rates, which vary wildly in the published literature (3, 4). Indeed, patients who have conversion to open surgery are more likely to have increased length of stay (2), decreased survival (5) and increased complication rates (6). Therefore attention has turned to identifying subgroups of patients who are thought to be particularly high risk for conversion to open surgery (7-10). Patients with previous abdominal surgery and therefore are predisposed to having intra-abdominal adhesions, are one such group (11).

Adhesions are a common consequence of previous surgery. Indeed, reports suggest that 90% of patients with previous abdominal surgery will have adhesions on post-mortem (12) or on subsequent laparotomy (13). Morbidity from adhesions range from periodic abdominal pain, infertility to intestinal obstruction requiring adhesiolysis or bowel resection (14-16) and are a significant cause of readmission to the surgical acute take. In addition, adhesions may cause concern for the laparoscopic colorectal surgeon. Curet (11) describes how adhesions can cause increased risk of bowel injury, inadequate operative field exposure and a restricted view of the operative field and subsequent operative series found an increased conversion rate (17), re-operation and higher complication rates (10). This led many surgeons to avoid laparoscopic approaches in patients with previous abdominal surgery or, opt for early conversion upon demonstrating intra-abdominal adhesions.

2. Objectives

Our study aim is to examine the effects of previous abdominal surgery on clinical outcomes. In addition, patients previously undergone open colonic resections were also included.

3. Patients and Methods

We describe a prospective series of 718 unselected patients. From 2006 to 2010, patients undergoing elective and emergency laparoscopic colonic surgery for benign and malignant disease at Queen Alexandra hospital, Portsmouth, U.K., were enrolled in our study.

Data collected includes, Patient’s demographic details, previous abdominal procedures, indication for surgery, type of surgery, conversion to open surgery, length of operation, length of hospital stay, readmissions within 30 days following surgery, postoperative major complications and 30 days mortality.

3.1. Operative Technique

Laparoscopic colorectal surgery was performed under general anaesthetic, with the patients positioned in modified Lloyd Davies position. Pneumoperitoneum was established using Hassan’s open technique or blunt port insertion. Surgeon stands on the opposite side of the colon to be resected. The standard 4 - 5 ports techniques was used with extraction of the specimen carried out using either transverse or paraumblical incision of approximately 3 - 5 cm. Mobilisation of the colon and ligation of supplying vessels were performed intra-corporeally and specimens were extracted according to onco-surgical principles using wound protector. Right-sided resections were followed with extracorporeal anastomosis, while all left sided resections were completed using intra corporeal anastomosis techniques (18).

All patients had DVT prophylaxis with subcutaneously administered clexane. All patients with rectal cancer underwent bowel preparation while all other patients including the emergency resection were not given bowel preparation. Post operatively, all elective resection patients were managed with enhance recovery protocol as described by Kehlet and Wilmore (19) with an exception of selective use of epidural catheter and avoidance of pre-operative glucose loading.

3.2. Statistical Analysis

Microsoft access Database was used to collect and store data. Continuous data was expressed as median (range). To compare treatment groups, the Mann-Whitney U test was applied to the continuous data and the Chi square test to categorical data. P < 0.05 was considered as statistically significant. All analyses were performed using Graphpad prism 5. (Graphpad software Inc., San Diego, CA).

4. Results

For the comparison of outcomes, patients were divided into three groups based on their previous surgical history. Patients in Group A (n = 476) did not have previous abdominal surgery. Patients included in Group B had previous abdominal surgery, but not colonic surgery (n = 190) and Group C patients had previously undergone colonic surgery (n = 52). Details of the laparoscopic procedures performed during are listed in Table 1 details of previous operative abdominal procedures for Groups B and C are listed in Table 2.

Table 1. Patient Demographics of the Different Patient Groups, Including Indication of Surgery and Laparoscopic Procedure at the Time of Studya
Patient DemographicsNo Previous SurgeryPrevious Abdominal SurgeryPrevious Colonic Surgery
Elective laparoscopic lower GI surgery476 (66)190 (26)52 (7)
Male280 (59)74 (39)32 (62)
Age (median, range)68 (18 - 92)69 (24 - 89)58 (22 - 90)
Current Procedure
Anterior resection223 (46.8)89 (46.8)9 (17.3)
Right Hemicolectomy131 (27.5)54 (28.4)8 (15.4)
Other7 (1.5)1 (0.5)21 (40.4)
Sigmoid colectomy28 (5.9)22 (11.6)0 (0.0)
Proctectomy0 (0.0)0 (0.0)7 (13.5)
Panproctocolectomy9 (1.9)3 (1.6)4 (7.7)
Extended right Hemicolectomy20 (4.2)6 (3.2)0 (0.0)
Hartmann’s procedure7 (1.5)4 (2.1)1 (1.9)
APER27 (5.7)4 (2.1)1 (1.9)
Subtotal colectomy13 (2.7)4 (2.1)1 (1.9)
Left Hemicolectomy11 (2.3)3 (1.6)0 (0.0)
Other current procedure
Reversal Hartmann’s0 (0)0 (0.0)11 (21.2)
Ileo-colic resection0 (0)0 (0.0)8 (15.4)
Ileo-rectal resection0 (0)0 (0)1 (1.9)
Rectal resection0 (0)0 (0)1 (1.9)
Excision rectovaginal septum3 (0.6)0 (0)0 (0.0)
Small bowel resection4 (0.8)1 (1)0 (0.0)
Anastomosis430 (90)179 (94)46 (88)
Diagnosis
Colorectal cancer368 (77.3)155 (81.6)19 (36.5)
Diverticular disease25 (5.3)14 (7.4)6 (11.5)
Colitis13 (2.7)4 (2.1)12 (23.1)
Other13 (2.7)5 (2.6)6 (11.5)
Crohn’s disease32 (6.7)4 (2.1)7 (13.5)
Adenoma16 (3.4)2 (1.1)2 (3.8)
Volvulus6 (1.3)3 (1.6)0 (0.0)
Carcinoid3 (0.6)3 (1.6)0 (0.0)

aData are presented as No. (%) except age (median, range).

Table 2. The Previous Abdominal Surgeries for Patients in Groups B and Ca
Previous Abdominal SurgeryPrevious Colonic Surgery
Previous Abdominal Procedure
Unrecorded 27 (14)0 (0)
Hysterectomy 59 (31)0 (0)
Appendicectomy 52 (27)0 (0)
Laparotomy 14 (7)0 (0)
Hartmann’s 0 (0)12 (23)
Other 15 (8)5 (10)
Subtotal colectomy 0 (0)10 (19)
Right Hemicolectomy 0 (0)10 (19)
Cholecystectomy 10 (5)0 (0)
Anterior resection 0 (0)7 (13)
Bowel resection (unknown detail) 0 (0)6 (12)
Caesarian 9 (5)0 (0)
AAA repair 4 (2)0 (0)
Sigmoid colectomy 0 (0)2 (4)
Total 19052
Other previous abdominal procedure
Sterilisation 30
Pyeloplasty 20
Liver resection 40
Nephrectomy 10
Stoma 03
Splenectomy 10
Umbilical hernia repair 2
Twisted bowel 01
Adhesiolysis 10
Perforated colon after polyp removal 01
Perforated diverticulum 10
Total 155

aData are presented as No. (%) or No.

During our series, overall conversion rate was 4.0% (29/718) and 30 days mortality rate of 0.6% (5) was seen. Post-operative morbidity was 12.5% (90/718), of which 30 patients (4.2%) required re-operation < 30 days following surgery. Overall, median length of stay in hospital was 4 days (range 1 - 74).

There were no significant differences detected between groups for conversion rates (P = 0.954), post-operative re-admission rate (P = 0.852), re-operation (P = 0.701) rate or mortality (P = 0.281). This is shown below in Table 1. Indications for conversion are given in Table 3. Clinical outcomes, readmission rate and reoperation rate with reasons for reoperations are displayed in Table 4.

Table 3. The Conversion Rate and Indication of Conversiona
Conversion or CompleteNo Previous SurgeryPrevious Abdominal SurgeryPrevious Colonic Surgery
Laparoscopic complete456 (96)183 (96)50 (96)
Conversion to open surgery20 (4)7 (4)2 (4)
Adhesions0 (0)3 (2)2 (4)
Oncological9 (2)3 (2)0 (0)
Obese1 (0)1 (1)0 (0)
Technical2 (0)0 (0)0 (0)
Difficult operation5 (1)0 (0)0 (0)
Bleed1 (0)0 (0)0 (0)
Other2 (0)0 (0)0 (0)

aData are presented as No. (%).

Table 4. Outcomes and Complication Rates for the Three Patient Groupsa
OutcomesNo previous surgeryPrevious Abdominal SurgeryPrevious colonic surgery
Length of hospital stay: median, range4 (1 - 74)4 (2 - 50)5 (2 - 43)
Readmission < 30 days surgery56 (11.8)24 (12.6)5 (9.6)
Postoperative mortality5 (1.1)0 (0)0 (0)
Reoperation < 30 days surgery22 (5)6 (3)2 (4)
Reoperation for anastomotic leak14 (3)2 (1)1 (2)
Reoperation for abscess0 (0)0 (0)1 (2)
Reoperation for bleed0 (0)1 (1)0 (0)
Reoperation for obstruction0 (0)1 (1)0 (0)
Reoperation for revision of stoma2 (0)2 (1)0 (0)
Reoperation for small bowel injury1 (0)0 (0)0 (0)
Reoperation for wound dehiscence1 (0)0 0 ()0 (0)
Reoperation for exploration port site2 (0)0 (0)0 (0)
Reoperation for exploratory investigation2 (0)0 (0)0 (0)

aData are presented as No. (%) except median, range.

In addition, length of hospital stay was not significantly different between groups A and B (P = 0.07) and groups A and C (P = 0.22). However, median length of operating time did differ between groups. Surgery for patients in Group A took 180 minutes (SD = 79.2 minutes), Group B took 180 minutes (SD = 69.2 minutes) and Group C took 210 minutes (SD = 86.4 minutes) on average to complete. The difference between Groups A and C was statistically significant (P = 0.026), as was the difference between groups B and C, (P = 0.002)

5. Discussion

Experience in minimally invasive surgery has rapidly increased and adhesions due to previous abdominal surgery are not considered to be contra-indication for laparoscopy (20).

In our series of 718 unselected patients, the overall conversion rate was 4%. This is lower than previously published conversion rates in laparoscopic colorectal surgery, which ranged from 5% in selected patient groups to in excess of 20% in unselected groups (3, 4, 21).

Postoperative mortality and morbidity was low and hospital length of stay was only 4 days, further corroborating the findings of randomised control trials of laparoscopic surgery (2, 22, 23). Therefore, we too conclude that laparoscopic surgery is a safe approach for colorectal surgery with few postoperative complications.

There were more women in the previous abdominal surgery group and this is likely to be due to previous abdominal hysterectomies. However, there was no statistical difference in the number of males with no previous surgery and those with previous colonic surgery (P = 0.809).

In patients with no previous abdominal surgery, the commonest cause for conversion was oncological clearance. However, the reason for conversion in groups with previous abdominal and colonic surgery was abdominal adhesions. Our study revealed no statistically significant difference in conversion rates between all three groups of patients with no previous abdominal surgery (4 %), those with previous abdominal surgery (3.8%) and even between patients with previous colonic surgery (4%). These results show that having previous abdominal or colonic surgery confers no added risks for conversion to open surgery or worse clinical outcomes.

Previous studies have also shown that conversion rates are unaffected by previous surgery (24). However, Gonzalez (17) described a 20% increase (P = 0.02) and Vignali (25) an 8% increase (P = 0.001) in conversion rates for patients with previous abdominal surgery compared with patients with a “virgin abdomen”. However, the numbers involved in these studies were smaller (n = 86 and n = 182, respectively) and additionally, having found no difference in complication rates, both Gonzalez (17) and Vignali (25) concluded that laparoscopic surgery was safe in patients with previous colonic surgery.

Complications encountered are included in Table 4. Of note, no statistically significant difference in complication rates was detected between patients with and without prior surgery, even those who have had prior colonic surgery (P = 0.852). These findings are consistent with previously published studies (17, 26).

Concerning operative time, previous studies have shown little consensus over whether patients with previous abdominal surgery require more operative time. Indeed, Vignali (25), found that approximately 26 minutes extra were needed for laparoscopic resections in patients with previous abdominal surgery, whilst Gonzalez (17) found no significant difference in operating times, between these groups. Our results show that laparoscopic colectomies on patients with previous abdominal but not colonic, surgery does not take longer. However, laparoscopic resections on patients with previous colonic surgery take approximately 30 minutes longer than for patients with virgin abdomens or with other previous abdominal surgeries. In addition, patients with protective ileostomies in Group C resulted in increase length of stay by one day due to stoma competencies. We therefore suggest that previously contradicting studies’ findings in patients with previous abdominal surgery may have been due to not taking account of whether patients had previous colonic surgery or not.

A surgeon experience in laparoscopy plays an important role in patients with previous abdominal surgery. Low conversion rate in our study is due to the fact they are heavily experienced in laparoscopic surgery. In literature authors have used different sites for port insertion but in our experience the best approach is to either use umblical port, but if this is not possible we have used right upper quadrant or left upper quadrant 5mm port with an off centre 5mm camera which enable us to create pneumoperitoneum and division of adhesions.

Our study found no difference in conversion rate and short term clinical outcomes including major morbidity, re operation rate, readmission rates, length of hospital stay and 30 days mortality for patients undergoing laparoscopic colorectal surgery with or without previous abdominal surgery. Previous colonic surgery does require additional operating time but other previous abdominal surgeries confers no added risk for this too. We conclude that previous abdominal surgery and previous colonic surgery confer no added risk to laparoscopic colonic surgery and therefore, should not be considered contra-indication for a laparoscopic approach. However extensive experience with laparoscopic technique makes the surgery safe and possible with very low rate of conversions. Additionally, with recent publications showing a reduced rate of adhesion formation in laparoscopic surgery (27), it is likely that future surgeons will be able to operate on patients with previous abdominal and previous colonic surgery with even greater confidence.

Acknowledgements

References

  • 1.

    Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc. 1991; 1(3) : 144 -50 [PubMed]

  • 2.

    Hewett PJ, Allardyce RA, Bagshaw PF, Frampton CM, Frizelle FA, Rieger NA, et al. Short-term outcomes of the Australasian randomized clinical study comparing laparoscopic and conventional open surgical treatments for colon cancer: the ALCCaS trial. Ann Surg. 2008; 248(5) : 728 -38 [DOI][PubMed]

  • 3.

    Ortega AE, Beart RJ, Steele GJ, Winchester DP, Greene FL. Laparoscopic Bowel Surgery Registry. Preliminary results. Dis Colon Rectum. 1995; 38(7) : 681 -5 [PubMed]

  • 4.

    Schiedeck TH, Schwandner O, Baca I, Baehrlehner E, Konradt J, Kockerling F, et al. Laparoscopic surgery for the cure of colorectal cancer: results of a German five-center study. Dis Colon Rectum. 2000; 43(1) : 1 -8 [PubMed]

  • 5.

    Moloo H, Mamazza J, Poulin EC, Burpee SE, Bendavid Y, Klein L, et al. Laparoscopic resections for colorectal cancer: does conversion survival? Surg Endosc. 2004; 18(5) : 732 -5 [DOI][PubMed]

  • 6.

    Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, 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(9472) : 1718 -26 [DOI]

  • 7.

    Schlachta CM, Mamazza J, Gregoire R, Burpee SE, Pace KT, Poulin EC. Predicting conversion in laparoscopic colorectal surgery. Fellowship training may be an advantage. Surg Endosc. 2003; 17(8) : 1288 -91 [DOI][PubMed]

  • 8.

    Schwandner O, Schiedeck TH, Bruch H. The role of conversion in laparoscopic colorectal surgery: Do predictive factors exist? Surg Endosc. 1999; 13(2) : 151 -6 [PubMed]

  • 9.

    Schrenk P, Woisetschlager R, Rieger R, Wayand WU. A diagnostic score to predict the difficulty of a laparoscopic cholecystectomy from preoperative variables. Surg Endosc. 1998; 12(2) : 148 -50 [PubMed]

  • 10.

    Tekkis PP, Senagore AJ, Delaney CP. Conversion rates in laparoscopic colorectal surgery: a predictive model with, 1253 patients. Surg Endosc. 2005; 19(1) : 47 -54 [DOI][PubMed]

  • 11.

    Curet MJ. Special Problems in Laparoscopic Surgery. Surg Clinics North America. 2000; 80(4) : 1093 -110 [DOI]

  • 12.

    Weibel MA, Majno G. Peritoneal adhesions and their relation to abdominal surgery. Am J Surg. 1973; 126(3) : 345 -53 [DOI]

  • 13.

    Menzies D, Ellis H. Intestinal obstruction from adhesions--how big is the problem? Ann R Coll Surg Engl. 1990; 72(1) : 60 -3 [PubMed]

  • 14.

    Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS, Menzies D, et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet. 1999; 353(9163) : 1476 -80 [DOI]

  • 15.

    Vrijland WW, Jeekel J, van Geldorp HJ, Swank DJ, Bonjer HJ. Abdominal adhesions: intestinal obstruction, pain, and infertility. Surg Endosc. 2003; 17(7) : 1017 -22 [DOI][PubMed]

  • 16.

    Hackethal A, Sick C, Brueggmann D, Tchartchian G, Wallwiener M, Muenstedt K, et al. Awareness and perception of intra-abdominal adhesions and related consequences: survey of gynaecologists in German hospitals. Eur J Obstet Gynecol Reprod Biol. 2010; 150(2) : 180 -9 [DOI][PubMed]

  • 17.

    Arteaga Gonzalez I, Martin Malagon A, Lopez-Tomassetti Fernandez EM, Arranz Duran J, Diaz Luis H, Carrillo Pallares A. Impact of previous abdominal surgery on colorectal laparoscopy results: a comparative clinical study. Surg Laparosc Endosc Percutan Tech. 2006; 16(1) : 8 -11 [DOI][PubMed]

  • 18.

    Hemandas AK, Abdelrahman T, Flashman KG, Skull AJ, Senapati A, O'Leary DP, et al. Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery. Ann Surg. 2010; 252(1) : 84 -9 [DOI][PubMed]

  • 19.

    Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002; 183(6) : 630 -41 [DOI]

  • 20.

    Kim RS, Itriago FP, Rosser JJ, Redan JA. Don't Fear Adhesions: Safe Approaches for Reoperative Minimally Invasive Surgery. Surg Technol Int. 2011; 21 : 147 -55 [PubMed]

  • 21.

    Scala A, Huang A, Dowson HM, Rockall TA. Laparoscopic colorectal surgery - results from 200 patients. Colorectal Dis. 2007; 9(8) : 701 -5 [DOI][PubMed]

  • 22.

    Clinical Outcomes of Surgical Therapy Study G. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004; 350(20) : 2050 -9 [DOI][PubMed]

  • 23.

    Lujan J, Valero G, Hernandez Q, Sanchez A, Frutos MD, Parrilla P. Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br J Surg. 2009; 96(9) : 982 -9 [DOI][PubMed]

  • 24.

    Barleben A, Gandhi D, Nguyen XM, Che F, Nguyen NT, Mills S, et al. Is laparoscopic colon surgery appropriate in patients who have had previous abdominal surgery? Am Surg. 2009; 75(10) : 1015 -9 [PubMed]

  • 25.

    Vignali A, Braga M, Zuliani W, Frasson M, Radaelli G, Di Carlo V. Laparoscopic colorectal surgery modifies risk factors for postoperative morbidity. Dis Colon Rectum. 2004; 47(10) : 1686 -93 [PubMed]

  • 26.

    Law WL, Lee YM, Chu KW. Previous abdominal operations do not affect the outcomes of laparoscopic colorectal surgery. Surg Endosc. 2005; 19(3) : 326 -30 [DOI][PubMed]

  • 27.

    Gutt CN, Oniu T, Schemmer P, Mehrabi A, Buchler MW. Fewer adhesions induced by laparoscopic surgery? Surg Endosc. 2004; 18(6) : 898 -906 [DOI][PubMed]

  • COMMENTS

    LEAVE A COMMENT HERE: