|MAIN MENU||INTRODUCTION TO LAPAROSCOPIC COLECTOMY||HISTORY OF LAPAROSCOPIC COLECTOMY||
CARDIOVASCULAR CHANGES DURING
LAPAROSCOPIC COLECTOMY FOR
LAPAROSCOPIC COLECTOMY AT A
|REVIEW OF 752 LAPAROSCOPIC COLECTOMIES||
|Dr BALLANTYNE||CENTER (CALS)||GERD (REFLUX)||Rx OF GERD||NISSEN FUNDO|
|LAPAROSCOPY||COLECTOMY||HERNIA REPAIR||GALLBLADDER||ALT MEDICINE|
This review summarizes the early results of 652 laparoscopic assisted colorectal operations published in 16 series and 100 operations done by the author. Operations for colorectal neoplasms accounted for two thirds of the procedures. The average age of patients was 63 years old. Operations were performed in men and women with equal frequency. Right hemicolectomies and sigmoid colectomies were the most common operations (65.3%). On average, 77 percent of attempted procedures were converted to open operations. After his first 20 operations, however, the author maintained about a 90 percent success rate. The average length of operation for 542 successful laparoscopic assisted operations was 170 minutes (range 45 - 540). The average number of lymph nodes harvested from 226 laparoscopic specimens was 10.5 (range 0 - 35). In 3 institutions the yield of nodes in 80 laparoscopic specimens was 8.8 and in 88 open specimens was 7.5. The need for postoperative parenteral injections was decreased for patients after laparoscopic assisted colorectal operations compared to open operations. The rate of major complications was 16.7 percent for 647 attempted laparoscopic assisted operations and the rate of mortality 0.8%. The average length of postoperative stay after 543 successful laparoscopic assisted colorectal operations was 5.9 days. Among 329 patients treated in private hospitals, the average postoperative length of stay was 4.7 days. The cost of laparoscopic assisted operations was greater than that of open operations. The total cost of hospitalization for patients undergoing laparoscopic assisted colorectal operations, however, was less than or about equal to that for open colorectal operations. The shortened stay offset the increased cost of operation. These results suggest that following laparoscopic assisted colorectal operations, patients suffer fewer complications, decreased mortality, less pain and shortened length of stay than patients after traditional open operations. These data, however, have been compiled from selected patients and demonstration of these preliminary conclusions will require testing by randomized trials.
In 1987, Mouret performed the first laparoscopic cholecystectomy in France . McKernam and Saye performed the first laparoscopic cholecystectomy in the United States in 1988 . Reddick and Olsen first published a report of a laparoscopic cholecystectomy in 1989 and also developed the technique of laparoscopic cholangiography  . Within two years, laparoscopic cholecystectomy became the standard of care in the United States   . This rapid acceptance of a radically new technique was forced by the conspicuous improvement in the postoperative course of patients. Replacement of the traditional large abdominal wound by four or five 5 - 10 mm incisions decreased postoperative pain, length of hospital stay and period of disability   . Moreover, the use of video technology produced a magnified view of the operative field. This combination of improved outcome and improved visualization caused laparoscopic cholecystectomy to be embraced by patients, surgeons and hospitals
The shortened period of postoperative disability achieved by laparoscopic cholecystectomy caught surgeons by surprise. It suggested that the principle determinant of postoperative disability was the abdominal wall wound and not the intra-abdominal procedure. As a result, some surgeons reasoned that a laparoscopic approach to other gastrointestinal operations might also garner similar benefits for patients in terms of postoperative recovery. Towards this end, Jacobs accomplished the first laparoscopic assisted right hemicolectomy in April, 1990 and Fowler the first laparoscopic assisted sigmoid colectomy in October, 1990 . Indeed, early experience with laparoscopic assisted colectomy suggested that patients experienced less pain and required a shorter hospital stay than after traditional techniques using large abdominal incisions    .
More than four years have passed since the first laparoscopic assisted colectomy was accomplished. Unlike laparoscopic cholecystectomy, however, laparoscopic assisted colectomy has not become the standard of care in the United States and remains an operation performed by only a few highly skilled laparoscopic surgeons. In 1992, Pappas warned of a difficult and prolonged learning curve for this procedure and urged that rates of complications should be carefully monitored . Since that time sixteen series of laparoscopic assisted colorectal procedures with more than 10 patients in each report have been published                . These papers characterized this learning curve and detailed the postoperative course of patients after laparoscopic assisted colorectal operations.
The purpose of this review is to examine the early results of laparoscopic assisted colorectal operations. Initially, the terminology is defined and the technique described. The results of 16 published series totaling 651 patients are compiled and compared with the first 100 patients in the Yale series. The potential role of laparoscopic-assisted procedures in the treatment of colorectal cancer is discussed.
LAPAROSCOPIC ASSISTED COLECTOMY: A procedure in which the surgeon observes the operative field with a videolaparoscope. The operation is performed with laparoscopic instruments inserted into the abdomen through trocars but requires a small incision for recovery of the resected section of the colon.
LAPAROSCOPIC COLECTOMY. A procedure in which the surgeon performs the operation with videolaparoscopic visualization and laparoscopic instruments but does not use an abdominal incision other than the trocar sites. The resected section of bowel is recovered through the anus.
This review is based on the compiled data from 16 international series published from 1991 to 1994. The series were selected based on two major criteria: 1) Inclusion of 10 or more patients, and 2) presentation of a similar range of data. Thus, individual case reports have not been compiled. Also, four series with an adequate number of patients were not included since their results were presented in a manner that could not be readily tabulated    . None of the reports represent randomized trials. Most of the series performed laparoscopic assisted procedures in selected patients and consequently the results are somewhat biased. The series from St. Mary's Hospital in London represents a noteable exception19: Monson and colleagues attempted laparoscopic assisted procedures in 40 consecutive patients. Data from the 16 series were compiled for each category if the respective item was included in the publication. In a number of areas such items as the sex of the patients or even the type of operations performed were not listed and as a result the number of series and total number of patients vary for different data items. Statistical analysis was not attempted since patient recruitment was heavily selected and comparison groups were selected by various criteria. Nonetheless the compiled data offers a reasonable snapshot of the early results of laparoscopic assisted colorectal procedures and may prove helpful in the design of more rigorous studies in the future.
THE YALE SERIES. This series represents the first 100 consecutive laparoscopic assisted colorectal procedures performed by the author. It includes patients recruited by different methods and at various institutions. It includes 50 patients treated at the West Haven VA Medical Center in an unselected and consecutive manner. Comparisons for this group are made with a consecutive group of patients treated with open operations in the same hospital during roughly the same time period by other surgeons. The other 50 patients represent private patients treated at Yale-New Haven Hospital by the author and also patients treated in a preceptor program at private hospitals by the author. These patients tended to be heavily preselected for laparoscopic assisted procedures. Because of differences in patient recruitment and the type of institution in which the patients were treated, the data for the two groups is segregated for some data categories.
Laparoscopic assisted colorectal procedures have been performed for virtually all indications. Table 1 list the diagnoses for 585 patients who underwent attempted laparoscopic procedures17-23, 25-32. The most common diagnosis was colorectal cancer and the second colorectal polyps. Together these represented 65.9 percent of operations. Similarly, among 100 patients treated in the Yale series, two thirds of patients underwent laparoscopic assisted operations for either colorectal cancers or polyps. Complications of diverticular disease represented the third most common diagnosis. This included recurrent episodes of diverticulitis, diverticular strictures, colovesicle fistulas, and closure of colostomies following Hartman procedures for acute diverticulitis. Thus, colorectal neoplasms and complications of diverticular disease account for the vast majority of operations performed both in the compiled series of patients and the Yale experience.
Functional bowel disorders including volvulus, rectal prolapse and constipation accounted for 3 percent of the compiled series and 6 percent of the Yale series. The redundant lengths of bowel in these patients make the performance of laparoscopic assisted procedures easier. In addition, these represent non-malignant conditions. Consequently, these patients often make excellent candidates for laparoscopic assisted procedures even early in the experience of the surgeon.
The report from the Cleveland Clinic accounted for the majority of patients with inflammatory bowel disease in the compiled series. These patients are often afflicted with a chronic disease and are consequently thin. This facilitates the procedure since the mesentery is more easily dissected. However, some patients develop thickened mesenteries because of the chronic inflammatory process. Transection of the mesentery by laparoscopic techniques in these patients may prove difficult. Nonetheless, the avoidance of a large wound in these patients who are prone to wound complications offers the possibility of significantly decreasing the morbidity of the operation.
CONTRA-INDICATIONS. Very few contra-indications for laparoscopic assisted bowel surgery have been identified. There are occasional patients who have such severe restrictive pulmonary disease that they can not tolerate the acidosis generated by the carbon dioxide pneumoperitoneum. The restrictive pulmonary disease in these patients limit the rate of ventilation by the anesthesiologist. In patients with large bulky lesions that will require large incisions for delivery of the specimen, it makes little sense to attempt a laparoscopic assisted procedure.
Several patient characteristics make it more difficult to accomplish a laparoscopic assisted procedure. Men tend to be more difficult than women since men deposit more fat in their mesenteries. This impedes dissection and division of the mesentery. For the same reason, fat patients are more difficult than thin patients. At the Scotsdale Mayo Clinic, for example, the rate of conversion to open operations was significantly greater for patients weighing more than 90 kg31. People who have undergone previous abdominal operations may have intra-abdominal adhesions that can impede the performance of the operation. Bleeding disorders may hamper efforts at hemostasis and the accumulation of blood may obscure the video image. An enlarged uterus from pregnancy tends to fill the abdomen obstructing the image obtained through the videolaparoscope. All of these factors make performance of a laparoscopic operation more difficult but they also make open operations more difficult.
EFFECT OF THE CARBON DIOXIDE PNEUMOPERITONEUM ON CARDIAC FUNCTION. Many patients who require bowel operations are afflicted with cardiac disease. Consequently, we studied the effect of position changes and different pressures of pneumoperitoneum on cardiac function in 16 patients undergoing laparoscopic assisted bowel operations at the West Haven VA Medical Center . Cardiovascular function was monitored with Swan-Ganz catheters as well as trans-esophageal cardiac ultrasonography. The average age of the patients was 66+12 years and all were ASA III or IV. The results are listed in Table 2. Following insufflation, the mean arterial pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure and systemic vascular resistance significantly increased. Pulmonary vascular resistance and cardiac output remained unchanged. During the pneumoperitoneum (Insufflation, Trendelenberg and Trendelenberg II), the mean arterial pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure and peak airway pressures all significantly increased compared to values in the supine position. Also, the cardiac output significantly increased when the patient was dropped into Trendelenberg position. At the end of the laparoscopy after the pneumoperitoneum was deflated, the mean arterial pressure, mean pulmonary artery pressure, central venous pressure, pulmonary capillary wedge pressure and peak airway pressures did not differ significantly from the baseline values. In contrast, the systemic vascular resistance remained depressed and the cardiac output remained significantly elevated. Finally, temperature was significantly dropped throughout the operation. This study indicates that carbon dioxide pneumoperitoneum was associated with increased filling pressures while the patient was in Trendelenberg position. This resulted in improved cardiac function.AGE AND SEX.
AGE. An older population of patients require bowel surgery than that which undergoes cholecystectomy. The average age of 651 patients compiled from 16 series was 63 years old with a range of 15 through 9517-32. Among the 100 Yale patients the average age was 65 with a standard deviation of + 16 and a range of 21 through 91. The older patients tended to have colorectal neoplasms, complications of diverticular disease, rectal prolapse or sigmoid volvulus. The younger patients often presented with complications of Crohn's disease or Chronic Ulcerative Colitis.
SEX. Colorectal operations are performed in relatively equal frequency for both men and women. Among 567 patients who underwent laparoscopic assisted bowel procedures listed in 13 series, 48 percent were women and 52 percent men17, 19-20, 22, 26-32. Among the 100 Yale patients, 70 were men and 30 women. The preponderance of men reflects the 98% male population of the West Haven VA Medical Center. Although laparoscopic procedures can be accomplished somewhat more easily in women because of their having less mesenteric fat, this has not proven to be an important factor in selection of patients.
Laparoscopic techniques have been applied to virtually all types of colorectal operations. Table 3 lists the types of operations performed on 609 patients from 15 series as well as the 100 Yale patients17-23, 25-32. Right hemicolectomy accounted for about a third of the operations in both groups of patients. Similarly, sigmoid colectomy represented another third among the 15 series and a quarter of the Yale series. The next most common group was the Miscellaneous operations. This included construction of colotomies, closure of Hartmann procedures, and polypectomies. Other operations were performed much less frequently. In general, low anterior resection, abdominal perineal resection and total colectomy are more difficult to accomplish than sigmoid colectomies and right hemicolectomies. As a result, these procedures show up infrequently in the series reporting experience with selected patient populations. The least commonly performed operation was a transverse colectomy. This represents the rarity of this type of operation in general rather than any inherent difficulty of this procedure.
In addition to the operations listed in Table 3, other types of operations have been reported in small numbers. Several techniques for laparoscopic rectopexy have been described    . This operation represents a laparoscopic approach and not a laparoscopic assisted technique since no incision is required other than the trocar sites. Gynecologists and general surgeons have developed combined approaches to the treatment of endometriosis infiltrating the colorectal wall in which the involved segment is excised . Other operations include laparoscopic assisted resection of a colonic lipoma , laparoscopic local excision of a proximal rectal carcinoid , laparoscopic assisted construction of various of stomas , laparoscopic assisted placement of a feeding jejunostomy  and laparoscopic cecostomy for colonic pseudo-obstruction .
An exciting group of new procedures utilize the benefits of both colonoscopy and laparoscopy   . In some patients the base of a polyp can not be visualized since it is obscured by an angulation of the bowel wall. After insufflation of the pneumoperitoneum, the laparoscopic surgeon divides the retroperitoneal attachments of the segment of bowel that contains the lesion and straightens it out (FIGURE 1). The endoscopist inserts the colonoscope. Often the stalk of the polyp is now easily visualized and the snare polypectomy readily accomplished.
PATIENT POSITION. The patient is placed on the operating room table with legs spread on stirrups (modified Lloyd-Davies position). The thighs are straight since flexion will limit the excursion arcs of the videolaparoscope and laparoscopic instruments. The stomach is drained with a nasogastric tube and the bladder with an urinary catheter. This decreases the likelihood of damage of these organs during insertion of the trocars. The legs are wrapped with pneumatic compression stockings. During the operation, the operating room table is shifted between various positions so that gravity assists in obtaining exposure. In deep Trendelenburg position, the small intestines roll out of the pelvis up towards the stomach. In reverse Trendelenberg position, the transverse colon slides away from the liver, stomach and spleen. Rotation of the right shoulder up causes the right colon to move away fron the abdominal wall.
LAPAROSCOPIC ASSISTED RIGHT HEMICOLECTOMY . The abdomen is insufflated with carbon dioxide to a pressure of 12 to 15 mmHg. Four or five trocars are inserted into the abdomen. The videolaparoscope is inserted through the trocar near the umbilicus. The assistant surgeon retracts the right colon towards the midline with grasping instruments (FIGURE 2). The surgeon opens the retroperitoneum with scissors and identifies the right ureter. The retroperitoneal attachments of the right colon and its mesentery are divided. The mesentery of the hepatic flexure and transverse colon are elevated off of the duodenum. The ileocolic vessels, the right colic vessels and the right branch of the middle colic artery are divided near their origins. This can be accomplished with sutures or stapling devices. The terminal ileum is divided with a laparoscopic stapling device. A two to three inch incision is made near the umbilicus and the two ends of the divided small bowel are withdrawn. The right colon and proximal transverse colon are delivered through this incision. A point of distal transection is selected in the transverse colon and divided with a stapling device or clamps. The specimen is handed off of the field. The two ends of the bowel are sutured or stapled together forming an ileocolic anastomosis. The bowel is returned within the abdomen. The incision and trocar sites are closed.
LAPAROSCOPIC ASSISTED SIGMOID COLECTOMY  . The carbon dioxide pneumoperitoneum is established. Four or five trocars are inserted. The videolaproscope is introduced through the umbilical trocar. The assistant provides traction with grasping instruments. The surgeon incises the posterior peritoneum over the iliac vessels. The left ureter is identified (FIGURE 3). The remainder of the retroperitoneal attachments of the sigmoid colon and sigmoid mesocolon are freed. The inferior mesenteric vessels are divided with sutures or a stapling device. If the operation is being performed for a benign condition, the inferior mesenteric vessels are preserved and only the sigmoid branches are divided. The proximal rectum is divided with a laparoscopic linear stapling device just distal to the rectosigmoid sphincter. A two to three inch incision is made in the left lower quadrant or just above the pubis. The sigmoid colon is withdrawn through the incision. The proximal limit of resection is selected and divided outside the abdomen. The anvil of a circular stapling device is inserted into the proximal lumen and secured in place with a pursestring suture. The bowel is returned within the abdomen. The incision is closed and the pneumoperitneum is re-established. The circular stapling device is introduced through the anus and advanced to the stapled closure of the rectum. A spike is screwed out from the stapling device and used to penetrate the previous staple line. The anvil in the proximal colon is inserted into the head of the circular stapling device in the rectum. The two parts of the stapling device are screwed together. The stapling device is fired and an end to end anastomosis is constructed.
Laparoscopic assisted colorectal operations are more difficult to perform than laparoscopic cholecystectomy. The gallbladder lies in a small two dimensional plane. As a result, the two dimensional limitations of conventional video technology hampers the surgeon very little. The surgeon can operate with one instrument, a hook cautery, and complete the operation in a brief period. In contrast, the colon traverses a complex three dimensional zone that encompasses the entire abdomen. As a result, the two dimensional image on the video monitor hampers the surgeon's understanding of the three dimensional relationships of the complex anatomy. Also, the surgeon must operate with two instruments and must perform difficult dissections with these instruments without causing past pointing injuries. Moreover, most operations require the active participation of the assistant and, thus, require two experienced team members. These features have contributed to a longer learning curve for laparoscopic assisted colorectal operations than was experienced by surgeons with laparoscopic cholecystectomy. The average rate of completion of the 652 attempted laparoscopic assisted colorectal operations listed in Table 4 was 77 percent with a range from 59 to 100 percent17-32. The author converted 21 percent of his first 100 procedures into open operations. These results indicate that completion of a laparoscopic assisted colorectal operation was substantially more difficult than for laparoscopic cholecystectomy.
The learning curve for laparoscopic bowel operations is longer than that for laparoscopic cholecystectomy. FIGURE 4 shows the rate of completion of attempted laparoscopic assisted colorectal operations for the Yale series as a function of experience. The author converted the majority of attempted procedures for the first 20 operations to open operations. After the first twenty operations, however, a completion rate over 90 percent has been maintained. This poor early rate of success was partially attributable to an "all comers" approach to patient selection. Nevertheless, surgeons should anticipate a high rate of conversion to open operations even with selected patients during their first twenty operations.
LENGTH OF OPERATION.
The length of an operation contributes to the total cost of the procedure. Many hospitals bill the patient for use of the operating room based on a fixed rate per minute or other time unit. Table 5 lists the average and range of operating times for 542 procedures compiled from 15 series17-23, 25-32. The average length of these operations was just under three hours with a range of 45 minutes to over 9 hours. The average and range for the Yale experience was similar.
The intent of laparoscopic assisted colorectal resections has been to excise exactly the same portion of bowel and mesentery as would have been resected with an open technique. The number of lymph nodes harvested from specimens resected for colorectal cancers can provide some objective data on the success of this intent. Nine of the reviewed series indicated the yield of lymph nodes for the patients treated for colorectal cancers (Table 6)17, 19, 23-24, 26-30, 32. The average number of lymph nodes found in 226 specimens was 9.6 with a range of 0 to 32. The yield in the Yale series was an average of 10.5 lymph nodes from 45 specimens.
The yield of lymph nodes from colorectal surgical specimens has been studied for generations. The yield depends as much on the method of preparation of the specimen and the diligence of the pathologist as on the surgical technique of the resection. Slanetz and Herter at Columbia Presbyterian Medical Center found in fat cleared specimens an an average of 29 nodes along the ileocolic vessels, 11.1 along the right colic vessels, 22.4 along the middle colic vessels and 25.2 along the left colic vessels . Similarly, Morikawa and colleagues from Osaka, Japan identified an average of 74.3 lymph nodes from 311 fat cleared colorectal specimens  In contrast, Hernanz and colleagues from Santander, Spain, calculated an average of 11 lymph nodes (range 1 - 36) from 193 specimens examined by routine methods . Thus, a large variation in the yield of lymph nodes will exist between institutions and even individual pathologists based on the techniques used for the identification of lymph nodes. Consequently, the adequacy of the laparoscopic specimen can only be judged based on comparisons of lymph nodes from open specimens processed in the same institution.
The yield of lymph nodes from laparoscopic assisted and open operations was compared directly in three studies (Table 7)23, 27, 29. In these studies, the comparison groups were concurrently performed operations in the same institution usually performed by other surgeons. The yield was remarkably similar from both types of operations. We observed similar results at the West Haven VA Medical Center. These data indicate that surgeons resect similar specimens for the treatment of colorectal cancer regardless of whether these were obtained by minimally invasive or traditional open techniques.
Patients experienced decreased levels of pain after laparoscopic cholecystectomy. Pain levels appear to be decreased after laparoscopic assisted colorectal operations as well. At the West Haven VA Medical Center, 33 patients required a median of 4 doses of narcotic pain injections after laparoscopic assisted colorectal operations while 34 patients required a median of 16 doses after open operations. At the Scotsdale Mayo Clinic, the laparoscopic patients required significantly fewer days of parenteral analagesia than patients after open operations: 2.85 days versus 4.8 days31. Similarly, patients in Norfolk, Virginia required only two days of parenteral narcotics after laparoscopic assisted operations and 4.5 days after open operations29. The use of small trocar sites and a 2 to 3 inch extraction site causes less postoperative pain than traditional laparotomy incisions.
MORBIDITY AND MORTALITY.
Colorectal operations carry a high rate of complications because of the advanced age of the patients, the infectious potential of the colonic contents, and the difficulty of the surgery. The average rate of complications for the 647 patients listed in Table 8 was 17 percent17-32. The rate in the Yale series was similar. This rate compares favorably with previous reports for open operations . Ondrula and colleagues, for example, reported the rate of complications after 972 colorectal resections at Lutheran General Hospital in Park Ridge, Illinois . Among these patients, 16% of the 448 male patients suffered major complications and 13.7 percent of the 524 female patients. In a group of 150 patients with an average age of 60 (range 10 - 87) treated at the Mayo Clinic for rectal prolapse with anterior resection, 28 percent sustained major complications . The types of complications reported in these 16 series were similar to those associated with open operations. This includes intraoperative complications such as enterotomies, ureteral injuries or hemorrhage. The post-operative complications included pulmonary embolous, pneumonia, myocardial infarction, pelvic sepsis, anastomotic dehiscence, urinary tract infections and phlebitis.
Two differences in the pattern of complications following laparoscopic assisted operations, however, should be emphasized. Both were related to the trocar sites. Wound infections were unusual. In the Yale series, for example, only one patient developed a wound infection. This complication did not prolong hospitalization and was treated with oral antibiotics in an outpatient setting. This emphasizes the principle advantage of laparoscopic assisted operations: the avoidance of large abdominal wall wounds. The other difference was an increased rate of Richter's hernias, entrapment of a knuckle of bowel usually in a trocar site. One patient suffered this complication in the Yale series. This complication has been unusual after laparoscopic cholecystectomy and probably stems from the use of trocars of larger calibre for the bowel operations than used for removal of the gallbladder   .
The rate of mortality of 0.8 percent for the 647 patients listed in Table 8 was less than or equal to rates reported after open operations17-32. Ondrula and colleagues reported a mortality rate of 4.9% after 448 colon resections in men and 5.3% after 524 in women58. Ballantyne and Beart calculated a mortality rate of 3.6 percent after 2683 left colon resections reported in 7 published series . Wolf and Dietzen listed a 0.7 percent mortality after anterior resection for rectal prolapse in 150 patients. The low rate of complications among the laparoscopic patients may reflect the preselection of healthier patients. The one death in the Yale series was a patient who required excision of a recurrent rectal carcinoma. The patient had previously undergone a low anterior resection at another institution. The operation was initiated as a laparoscopic operation but was converted to an open operation and underwent an abdominal perineal resection. Unfortunately, the patient developed pelvic sepsis and died on the 33 postoperative day. The data in Table 8 indicates that laparoscopic assisted colorectal operations can be accomplished with a low rate of morbidity and mortality.
AVERAGE LENGTH OF STAY
The use of laparoscopic techniques in the performance of colorectal operations shortened the average length of stay for patients. Table 9 lists the average length of postoperative stay for 543 patients that underwent successful laparoscopic assisted colorectal operations17-32. Patients who were converted to open operations were not included. The average length of stay for these patients was 5.9 days with a range of 1 to 60 days. The Yale series was divided into patients treated at the West Haven VA Medical Center and private hospitals. The average postoperative stay for the patients in the private hospital group was 5 days and that for the VA patients over 8 days. Similarly, if the patients in Table 9 treated in private hospitals or private clinics within the United States were examined separately, the average length of stay for these 329 patients was 4.7 days.
Length of stay after colorectal operations was not an important concern in the past. Consequently, information about this for traditional operations has been scant. Hoffman and colleagues found that the average length of stay of 5.2 days for the laparoscopic assisted colon operations compared favorably to the 7.8 days for the last 53 open operations that they had performed before the laparoscopic operations29. Similarly, Musser and colleagues reported an average length of stay of 5.6 days after laparoscopic assisted operations and 9.9 days after 24 open colorectal operations27. Three trials on the usefulness of nasogastric tube decompression after colorectal resections also provide some useful historical data. Wolf and colleagues of the Mayo Clinic reported an average postoperative stay of 11 days after 535 elective colon and rectal operations . In a similar study, Meltvedt and colleagues calculated an average postoperative stay of 8 days for 118 patients . Also, Colvin and colleagues found an average postoperative stay of 11.6 days after 138 colorectal operations . In a study comparing methods of bowel preparation in Cologne, Germany, the three groups totalling 163 patients had median postoperative hospital stays of 22, 22 and 24 days . Although these results for laparoscopic assisted operations have been compiled from selected patients, the data suggests that patients require a shorter length of stay than has been generally observed after open operations.
TOTAL COSTS OF HOSPITALIZATION.
Videolaparoscopic techniques of minimally invasive surgery have been introduced into clinical practice at a time when hospitals, insurance companies, government and society have focused attention on the increasing cost of medical care . Consequently, the impact of laparoscopic surgery on medical costs has come under close scrutiny. The dramatic decrease in length of stay for laparoscopic cholecystectomy, clearly established the beneficial impact of this procedure on the total cost of hospitalization. Some data has been published on the effect of laparoscopic assisted bowel procedures on the cost of treatment of colorectal diseases.
Table 10 compares the total cost of hospitalization for patients treated by traditional open or laparoscopic assisted colorectal operations in five private hospitals21, 24, 27-29. The costs proved remarkably similar. In addition, the cost in three institutions for patients in which the operation was commenced as a laparoscopic procedure and then converted to an open operation is listed. Clearly, the cost of hospitalization for this group was significantly increased.
Falk and colleagues and Musser and colleagues (Table 10) stratified the various costs of the hospitalizations24, 27. Table 10 also lists the cost comparison from their institutions for the operation itself. These data indicate that laparoscopic techniques increased the cost of colorectal operations. The picture generated by all the data in Table 10 suggests that laparoscopic assisted operations can be accomplished at about the same total cost of hospitalization as traditional open techniques. The increased cost of the operation was compensated for by the shortened length of stay. Further, the best cost strategy for an institution will require the minimization of the group of patients in whom a laparoscopic attempted procedure was converted to an open operation. It is this group that might adversely impact the total cost of an institution for the treatment of colorectal diseases with minimally invasive technqiues.
RETURN TO NORMAL ACTIVITY.
Patients return to work sooner after a laparoscopic cholecystectomy than after open operations. This parameter has not been studied after laparoscopic assisted colorectal operations since many of these elderly patients do not work. Senagore and colleagues21, however, have studied return to normal activity using the Karnofsky performance score . The patients who underwent laparoscopic assisted operations demonstrated a significantly superior performance score as compared to the open patients. These results were promising but more data will be required to establish that patients return to normal activity sooner after laparoscopic assisted colorectal operations.
TREATMENT OF COLORECTAL CANCER.
The first laparoscopic assisted colorectal resection for the treatment of colorectal cancer was accomplished in 1990. Consequently, longterm data on follow up for patients treated by minimally invasive techniques are not available. Thus, the use of laparoscopic assisted procedures in the treatment of these patients will remain controversial for some time  . Nonetheless, in the series summarized in this review, colorectal cancer was the most common diagnosis among the patients who had undergone laparoscopic assisted colorectal operations (Table 1). Surgeons at the Cleveland Clinic have carefully evaluated the feasibility of the performance of laparoscopic oncologic operations in animal models and fresh cadavers  . They concluded in the case of abdominoperineal resections, for example, that "a laparoscopic technique of abdominoperineal resection can be performed according to oncologic principles with proximal vascular ligation of the inferior mesenteric artery, wide clearance of pelvic side walls, and complete removal of mesorectum". Moreover, quantitative measurements of the specimens resected in these operations have been indistinguishable from specimens removed during traditional open operations . The average number of lymph nodes, for example, in 80 laparoscopic specimens was 8.8 and for 88 open specimens was 7.5 (Table 7). Similarly, at the Ferguson Clinic there was no difference in the lengths of proximal and distal margins of specimens obtained by either laparoscopic or open techniques21. Also, preliminary data on follow-up of patients treated for colorectal cancer suggested that patterns of recurrence were similar for both groups of patients. Thus, the limited data available suggests that laparoscopic assisted techniques will achieve results similar to those obtained during the last 50 years with open techniques. This, of course, is not surprising since surgeons perform the same resections with both techniques but simply use different incisions. Fortunately, randomized controlled trials have been initiated that will test this preliminary conclusion.
A number of case reports have suggested that laparoscopic assisted techniques for the resection of colorectal cancer may increase the probability of tumour implantation in the site of specimen extraction or other trocar sites     . Data from the Laparoscopy Registry of the American Society of Colon and Rectal Surgeons has better quantified the rate of this unusual occurance. Three wound implantations have been observed following 498 laparoscopic resections for colorectal cancer entered into the registry: a rate of 0.6 percent . This rate approximated that observed after open operations. Sir Edward Hughes, one of the pre-eminent Colon & Rectal Surgeons of the 20th Century, reported 16 wound recurrances of colorectal cancer in 1603 patients who had undergone curative resections: a rate of 1 percent . In eleven patients, the implantations occurred within the abdominal wall wound. In three patient, it was found at a distant site: one in the umbilicus, one in a colostomy scar and one within an ileostomy scar. Thus, tumor implantation in the abdominal wall wound is a rare but well documented occurence after curative resections for colorectal accomplished either by a laparoscopic assisted or traditional open technique.
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