TY - JOUR
AU1 - Gurland, Brooke H.
AU2 - Wexner, Steven D.
AB - Summary Laparoscopic colectomy is one of the most difficult laparoscopic procedures. Surgeons attempting to perform laparoscopic surgery for inflammatory bowel disease (IBD) must have significant experience with IBD and advanced laparoscopic skills. Surgical management for IBD may be treated with a range of laparoscopic procedures that vary in complexity. After 10 years of experience, studies comparing laparoscopy versus laparotomy are favoring laparoscopy when evaluating reduction in postoperative ileus, pain, and length of hospitalization, disability, and cosmesis. The indications and contraindications for laparoscopic surgery for IBD are evolving as surgical expertise and equipment improve. Laparoscopy, Colon surgery, Inflammatory bowel disease Introduction Surgeons attempting to perform laparoscopic surgery for inflammatory bowel disease (IBD) must have both significant experience working with IBD and advanced laparoscopic skills. Patients with IBD are often young, malnourished, anemic, and have received long-term immunosuppressive agents. The wide spectrum of challenging operative procedures for IBD are frequently pursued only after standard medical therapy has failed. The indication for surgery, and the preoperative evaluation and technique should be the same regardless of operative approach. The potential advantages of laparoscopic surgery as compared with laparotomy, such as reductions in postoperative ileus, pain, length of hospitalization, and disability along with superior cosmetic results, are very appealing. History of Laparoscopic Intestinal Surgery Laparoscopic colectomy is one of the most difficult advanced laparoscopic procedures. It requires a steep learning curve (1) demanding the ability to dissect all four quadrants using angled telescopes, intracorporeal stapling devices, and two-handed techniques. Since the first laparoscopic cholecystectomy in 1987, laparoscopic colonic surgery has lagged behind other advanced laparoscopic procedures (Heller myotomy, fundoplication, paraesophageal hernia repair, splenectomy, and bariatric surgery). There are several factors that have contributed to the delayed acceptance of laparoscopic colon surgery. First, after the reports of port site tumor recurrence (2), many surgeons were reluctant to perform laparoscopic colectomy for cancer. Second, laparoscopic surgery requires longer operative time, and increased operating room expense. The timing of rising cost with decreasing medical reimbursement was inopportune and undoubtedly thwarted acceptance of laparoscopic techniques. During the early 1990s, the advantages of laparoscopic colon surgery were speculative. For example, advocates of laparoscopy reported earlier oral intake and return of bowel function, claiming that reduced manipulation of the intestine resulted in a shorter postoperative ileus. However, these surgeons instituted a diet earlier after laparoscopy than if the patient had undergone a standard laparotomy (3). In two large, prospective, randomized studies, Binderow et al. (4) and Reissman et al. (5) refuted this claim by showing that early oral intake is also possible after laparotomy and colonic resection and is not a unique attribute of laparoscopy. However, 10 years after its initiation, the evidence is favoring laparoscopic colon surgery. Studies comparing laparoscopic assisted versus conventional surgery have demonstrated significant reductions in postoperative ileus (6), pain, hospitalization, quicker return to daily activities (7), and better cosmetic results (8). Other advantages of laparoscopy include better preservation of the immune response (9) and decreased adhesion formation (10,11) as compared with laparotomy. The clinical significance of these latter findings has not as yet been determined. Several papers deal specifically with laparoscopic surgery for IBD, but as Bemelman et al. (12) astutely noted in a review on the topic, these papers originate from a few centers in the world (UCLA Medical Center (13), Mount Sinai (14,15), University Hospital Saarland, Hamberg (16), Cleveland Clinic Foundation, Ohio (17), Cleveland Clinic Florida (18,19), Leiden University Medical Center (20), and Free University Hospital, Amsterdam (21). Laparoscopy for IBD Patients with IBD are frequently young (15–35 years) and image conscious. They are often resistant to surgery because of the anticipated discomfort and disfigurement, time lost from work or school activities, and the fear of compromise to bowel function or possible stoma (22). Overall, an estimated 70% of patients with Crohn's disease (CD) will require at least one operation for their disease (23), whereas 45% of patients will require repeated surgery over their lifetime (24). Laparoscopic surgery is especially appealing to these patients with a benign disease who will have the potential to benefit from decreased disability and a better body image from a more cosmetic incision. Only long-term data will reveal the clinical significance of decreased adhesion formation and the impact on small bowel obstruction. Indications The indications for laparoscopic surgery in CD include primary and recurrent ileocolic disease, isolated strictures of the small or large bowel, and anorectal sepsis. Less common indications include: complex fistulas, abscess, obstruction from stricture or adhesions, pancolonic inflammation, diagnostic laparoscopy for abdominal pain, and reestablishment of intestinal continuity (reversal of Hartmann's procedure). The indications for laparoscopy in mucosal ulcerative colitis (MUC) are not as well defined as are those for CD. At Cleveland Clinic Florida, we have abandoned restorative proctocolectomy because of early inferior results when compared with laparotomy. Relative contraindications to laparoscopy in IBD include critical illness, dense adhesions, inability to identify normal anatomy, free perforation with extensive intraabdominal soiling, peritonitis, large abscess or phlegmon, and multiple complex fistulas. However, the indications for laparoscopic surgery for IBD are evolving as surgical expertise and equipment improve. Technical Considerations Transmural inflammation, the hallmark of CD, results in thickened friable mesentery, inflammatory adhesions and masses, fistulae, or abscesses. Enteric fistula and large inflammatory masses obscure normal anatomy and increase the risk of injury to vital structures, making surgery challenging, even for experienced surgeons. The complexity of IBD surgery is magnified during laparoscopy. The thickened, foreshortened mesentery is difficult to manipulate and is at an increased risk of bleeding. Stapling devices and the ultrasonic scalpel are not always hemostatic on inflamed tissue, and bleeding is difficult to control. Hemorrhage can obscure the view by making it impossible to identify tissue planes and deflecting the light, creating a darker image on the monitor. Furthermore, it is not always feasible to bring a large inflammatory mass through a “cosmetic” incision; conversely, there is a risk of tearing inflamed tissue and causing mesenteric bleeding, hematomas, and venous stasis by forcing a large mass through a small skin and fascial incision. When the mesentery is thickened, laparoscopic mobilization and extracorporeal vascular ligation may be safer, quicker, and less expensive than the intracorporeal approach. However, Canin-Endres et al. (15) described intracorporeal mesenteric ligation with the exception of patients with severely inflamed mesentery, where they agree that extracorporeal vascular ligation is the safest approach. Aleali et al. (25) reported intracorporeal mesenteric ligation with the Ligasure (Valleylab, Boulder, CO, U.S.A.), a vessel-sealing device that uses bipolar thermal energy, in 60 patients with CD and thickened, friable mesentery. They failed to report any significant intraoperative or postoperative bleeding. However, the degree of “friability” and “thickening” are obviously highly subjective. Conversion rates depend on surgeon experience, and several patient-related and disease-related factors such as obesity, prior abdominal surgery, inflammation (abscess and fistula formation), and disease location (26). Conversion rates vary in the literature from 2% to 77% (27). Conversion is not a complication of laparoscopic surgery but a necessary measure for procedures that cannot be done safely through the laparoscope. Inflammatory conditions may result in a higher conversion rate to laparotomy than noninflammatory conditions. However, a prospective multiple regression analysis of 416 laparoscopic resections with a conversion rate of 11% revealed that conversion was influenced by the patient's weight, malignancy, and early experience of the surgeon. The most common reasons for conversion were tumor fixation or inability to perform adequate oncologic resection (4.6%) and adhesions and inflammation (2.2%). IBD was not an independent predictor of conversion, whereas the factors that contributed significantly to operative time were patient weight, CD, and the type of resection (28). Procedures for CD Problems from CD may be treated by a range of laparoscopic procedures that vary in complexity (diagnostic laparoscopy, adhesiolysis, fecal diversion for perineal sepsis or complex fistulas, closure of stoma, segmental small bowel resection, ileocolectomy, strictureplasty, segmental or total abdominal colectomy with or without anastomosis). Several recent reviews have described these techniques (29,30). Procedures for MUC The main objectives of the surgical treatment of MUC are to extirpate the disease and to preserve continence, if possible. The surgical options available for the elective treatment of MUC are total proctocolectomy with end ileostomy, colectomy with ileorectal anastomosis, proctocolectomy with continent (Kock) ileostomy, and restorative proctocolectomy with ileal pouch anal anastomosis. Restorative proctocolectomy with ileal pouch anal anastomosis is the procedure of choice to restore continence. Total abdominal colectomy with end ileostomy is reserved for patients with poor sphincter function, fulminant colitis, severe malnutrition, or indeterminate colitis. These complex laparoscopic surgical procedures are currently under investigation and should be attempted only by very experienced colorectal surgeons. Results CD: Less Challenging Procedures Diagnostic laparoscopy and fecal diversion for perianal CD are good introductory procedures that require minimal equipment and may be performed by the novice laparoscopist. Diagnostic laparoscopy is helpful when the diagnosis is unclear despite extensive endoscopic and radiographic presurgical evaluation. It can also be performed as an initial assessment of the abdomen to determine the feasibility of laparoscopic resection. Laparoscopic fecal diversion is used for patients with severe perineal sepsis and complex fistulas. These patients derive the benefits from laparoscopy as compared with laparotomy such as better cosmetic results, early return of bowel function, decreased length of hospitalization, and intraoperative time that is comparable to that for open procedures. Oliveira et al. (31) reviewed laparoscopic stoma creation in 32 patients, including 6 patients with CD, and reported a mean operating room time of 55 min for patients who had no prior abdominal surgery and 117 min for patients who had prior abdominal surgery. Hollyoak (32) compared laparoscopic (n = 40) to open (n = 15) stoma formation. Return of bowel function was significantly shorter (1.6 versus 2.2 days, p < 0.0007) in the laparoscopy group, and hospital stay and operative time were also decreased (7.4 versus 12.6 days, p < 0.0189; and 54.3 versus 72.7 min, p < 0.0366, respectively); there was a 5% conversion rate. Iroatulum et al. (33) compared laparoscopic (n = 41; n = 9 with CD) to open stoma creation (n = 11; n = 2 with CD) confirming prior results. In the laparoscopic group, intestinal function returned earlier (2.3 versus 4.5 days p < 0.05) and hospitalization was shorter (5.3 versus 7.6 days p < 0.05), unlike earlier series. There was no significant difference in the operating room time. A comparison of early versus late experience with laparoscopic stoma formation found that parameters such as operative time and length of stay did not improve with experience, whereas conversion rates decreased with increasing experience (34). Thus, we conclude that laparoscopic stoma formation does not have as steep a learning curve as do other laparoscopic colon procedures. CD: More Challenging Procedures Other procedures that are technically more complex include reversal of stomas, small bowel resections, laparoscopic assisted small bowel strictureplasty, and colon resections. Diagnostic laparoscopy is helpful to assess intraoperative adhesions and to determine the feasibility of laparoscopic colon resection. Laparoscopic assisted small bowel resection and strictureplasty follow the same guidelines as for laparotomy. The entire small bowel is inspected with a two-handed technique assessing radiographically unidentified proximal diseased segments (skip lesions). In experienced hands, tactile sensation is preserved with laparoscopic graspers, and the entire small bowel is evaluated in a sequential manner. Diseased segments are marked and exteriorized for resection or strictureplasty. A summary of the published data on laparoscopy for CD is presented in Table 1. Ileocolic resection has been the most commonly described laparoscopic procedure for CD. Milsom et al. (35) reported the first series in 1993 on 9 patients with terminal ileitis who underwent laparoscopic-assisted ileocolic resection with extracorporeal anastomosis. There were no complications, 3 conversions, and 170 min of operative time. Liu et al. (13) described five successfully managed laparoscopic ileocolic resections for CD. Table 1. Results of laparoscopic surgery for Crohn's disease     Nτ, total number; LICR, laparoscopic ileocolic resection; LSBR, laparoscopic small bowel resection; LSTC, laparoscopic subtotal colectomy; RPC, restorative proctocolectomy; MUC, mucosal ulcerative colitis; Rsx, resection; TAC, total abdominal colectomy; IRA, ileorectal anastomosis; NR, not recorded; NA, not applicable; UTI, urinary tract infection; PE, pulmonary embolus. View Large Table 1. Results of laparoscopic surgery for Crohn's disease     Nτ, total number; LICR, laparoscopic ileocolic resection; LSBR, laparoscopic small bowel resection; LSTC, laparoscopic subtotal colectomy; RPC, restorative proctocolectomy; MUC, mucosal ulcerative colitis; Rsx, resection; TAC, total abdominal colectomy; IRA, ileorectal anastomosis; NR, not recorded; NA, not applicable; UTI, urinary tract infection; PE, pulmonary embolus. View Large Between 1992 and 1994, Bauer et al. (14) successfully performed laparoscopic-assisted ileocolic resection in 14 of 18 patients with CD; 4 procedures were converted to laparotomy (22%). Three of the failures in this group had fixed masses associated with fistulas, and one patient had recurrent disease. They compared the laparoscopic cases to 14 patients who underwent laparotomy and noted earlier resolution of postoperative ileus, earlier discontinuation of pain medication, and earlier discharge after laparoscopy. Reissman et al. (36) reported the first large series: 72 consecutive patients with IBD (CD, n = 49, and mucosal UC, n = 23). Laparoscopic ileocolic resection was performed in 30 patients with a morbidity of 10%, a procedure time of 150 min, and a length of stay of 5.2 days. When they compared laparoscopic ileocolic resection to laparoscopic total abdominal colectomy, a significantly longer operative time, longer hospitalization, and higher morbidity (p < 0.05) was noted after total abdominal colectomy. This feature is reflected in the overall morbidity of 18% and conversion rate of 14%. Ludwig et al. (17) reported 31 selected patients with CD who underwent 25 successful laparoscopic procedures (12 stoma creations, 10 laparoscopic ileocolic resection, 2 partial colectomy, and 1 total abdominal colectomy with ileorectal anastomosis.). Operative time, oral intake, and length of stay were comparable to other series. Hildebrandt et al. (16) reported an experience of 222 elective laparoscopic resections for CD. Thirty cases (13%) were converted to laparotomy. The average operating time was 152 min and length of stay was 6.5 days. In a prospective analysis of two centers (Department of Colorectal Surgery, Cleveland Clinic Florida, and Abteilung fur Allgemeine Chirurgie, Abdominal und Gefasschirurigie, Universitatskliniken des Saarlandes, Germany), Hamel et al. (37) collected the largest series to date describing laparoscopic resection for CD. They compared laparoscopic ileocolic resection versus laparoscopic subtotal colectomy in 130 patients with CD. The total operative time was shorter after laparoscopic ileocolic resection compared with laparoscopic subtotal colectomy (167 versus 231 min; p < 0.001). The length of stay was 8.8 days in both groups. The intraoperative complication rate was 11%, which was significantly less after laparoscopic ileocolic resection compared with laparoscopic subtotal colectomy (7% versus 29%; p = 0.01) but the 30-day postoperative morbidity was the same in both groups. As laparoscopic surgical skills have technically evolved, reports of more complicated procedures emerge in the literature. Prior abdominal surgery, inflammatory mass, and fistula, although once considered a contraindication to resection, have been shown to be technically feasible by laparoscopy. Canin-Endres et al. (15) reported on 88 consecutive patients who underwent 94 elective laparoscopic assisted intestinal resections for CD. Forty-two percent had prior abdominal surgery, a third of patients with prior resection for CD. Intraoperative findings included inflammatory mass (n = 17), abscess (n = 11), and fistula (n = 16). One patient who underwent primary ileocolic resection required a conversion to laparotomy for a large inflammatory mass, adherent intestinal loops, and thickened mesentery. In this series, the operative time was 183 min and blood loss was 168 ml. Return of bowel function occurred at an average of 3 days and length of stay averaged 4.2 days. Three of the seven patients who developed early postoperative small bowel obstruction required reoperation. Wu et al. (38) illustrated that abscess, phlegmon, and recurrent CD were not contraindications to laparoscopic surgery. Forty-six patients were divided into three groups. Group I included 14 patients with abscess or phlegmon. Group II included 10 patients with prior ileocolic resection and Group III consisted of 22 patients without prior surgery, abscess, or phlegmon. Group IV was composed of 70 consecutive open ileocolic resections for CD. Conversion to open procedures occurred in only five patients (Group I 7%, Group II 20%, Group III 9%). Morbidity, hospitalization, and blood loss were highest in the open procedures. Bemelman et al. (20) compared 30 patients after laparoscopic assisted ileocolic resection to 48 patients after laparotomy. They revealed similar morbidity, shorter hospital stay (5.7 versus 10.2 days; p < 0.0007), and improved cosmetic results. The conversion rate was 6.6%. Laparoscopic operating times were significantly longer than were those in the laparotomy groups (138 versus 104 min). Alabaz et al. (19) compared laparoscopic assisted ileocolic resection (n = 26) to conventional laparotomy (n = 48) for CD. In the laparoscopic group, the mean operating time was longer (150 versus 90 min; p < 0.0001), and the length of stay was shorter (7 versus 9.6 days; p < 0.0001). Patients after laparoscopic surgery returned to work earlier than after conventional surgery (3.7 versus 8.2 weeks; p = 0.01). There were no differences between the groups regarding early complications. At mean follow-up of 30 months, significantly more patients in the laparotomy group developed bowel obstruction (15/48 versus 2/26; p = 0.02). Chen et al. (7) demonstrated that there is less disability after laparoscopic colectomy compared with laparotomy. Seventy-one patients with benign colorectal diseases who underwent laparoscopic colectomy were compared with 71 patients who underwent open colectomy. These patients were case matched for age, gender, procedure, and disease. A standardized questionnaire was mailed to patients to assess disability that included the number of days until return to partial activity, full activity, and work on the basis of their subjective response. The mean times until return to partial activity were shorter in the laparoscopy group (2.1 ± 1.2 versus 4.4 ± 2.8 weeks; p < 0.0001). Return to full activity was also shorter in the laparoscopy group (4.2 ± 2.3 versus 10.5 ± 6.4 weeks; p < 0.0001) as well as return to work (3.7 ± 2.1 versus 7.5 ± 7.5 weeks; p = 0.01). The major criticisms to these studies that compare laparoscopy to laparotomy are the lack of randomization. Milsom et al. (39) published a small randomized trial comparing elective laparoscopic versus conventional ileocolic resections in 60 selected patients with CD. There was some bias toward “easier” cases as each patient was subject to diagnostic laparoscopy to determine that laparoscopic resection was possible before randomization. Objective short-term endpoints were measured such as pulmonary function, return of bowel function, analgesia use, and length of stay. Presumably because of the preliminary diagnostic laparotomy, only two laparoscopic surgeries were converted to laparotomy secondary to adhesions and inflammation. Despite this optimal case selection, the duration of surgery was significantly longer in the laparoscopic group (140 versus 85 min). However, because large masses were presumably excluded incisional length was significantly smaller in the laparoscopic group (5.3 versus 12.7 cm). All patients underwent preoperative spirometry to assess forced expiratory volume in one second and forced vital capacity. There was faster return to preoperative values in the laparoscopic compared with the laparotomy group (2.5 versus 3.5 days; p = 0.03). Despite the optimization of the laparoscopic group, there were no differences relative to resolution of postoperative ileus, analgesia use or length of stay between the two groups. Again, perhaps because of exclusion of patients with significant sepsis from the laparoscopic group, there were fewer complications in the laparoscopic group (two cases of prolonged ileus and two wound infections) versus the laparotomy group (three cases of ileus, one small bowel obstruction, two wound infections, one incisional hernia, and one postoperative pneumonia). There were no major complications or clinical recurrences at 12 or 45 months. It is unfortunate that despite the interest of these authors in laparoscopy and the potential selection bias toward the laparoscopic group, so few benefits were noted. A somewhat overlooked benefit of laparoscopy is a smaller incision. In general, surgeons disregard the effects of surgery on body image. Dunker et al. (40) demonstrated the cosmetic impact and body image in 34 patients with terminal ileal CD. Eleven patients underwent ileocolic resection by laparotomy, 11 patients by laparoscopy, and 12 patients did not undergo resection. Retrospectively, these patients were asked to fill out questionnaires pertaining to body image, hospital experience, and quality of life. There were no differences among the three groups relative to disease activity, age, and gender, incidence of colonic involvement, perianal disease, or hospital experience. The laparoscopy group had significantly better results on the cosmetic score and body image, which correlated strongly with cosmesis and quality of life. The cosmetic scale correlated with self-confidence after surgery and having fewer additional abdominal scars. Furthermore, if patients were given the opportunity to choose, 75% (7/11 in the laparotomy, 7/11 in laparoscopy, 10/12 in the no-resection group) preferred the laparoscopic approach even if there were risks of damaging the ureter or if additional fees were incurred. The importance of cosmetic results was also retrospectively analyzed by Alabaz et al. (19). A detailed questionnaire was sent to both groups to assess subjective recovery including postoperative pain, use of pain medication, cosmetic results, bowel function, sexual and social activity, and postoperative return to full activity. Forty-seven patients (64%) returned the questionnaires: 31 of 48 (65%) in the laparotomy group and 16 of 26 (62%) in the laparoscopy group. Laparoscopic-assisted ileocolic resection had better cosmetic results (14/16 versus 13/31) and was more likely associated with improved social and sexual lives (8/16 compared with 5/31). Laparoscopic Surgery in MUC A summary of the published data of laparoscopic procedures for MUC is presented in Table 2 (44,–46). Peters et al. (41) first published the results of laparoscopic total proctocolectomy in two patients with UC. In 1992 with laparoscopic colorectal procedures in its infancy, Wexner et al. (42) published a prospective study comparing laparotomy and laparoscopic restorative proctocolectomy (n = 4) and laparoscopic total abdominal colectomy and ileoproctostomy (n = 1). The colon was laparoscopically mobilized and delivered through a Pfannensteil incision before extracorporeal mesenteric vessel ligation. In the laparoscopic group, operative time, oral intake, and length of stay were longer than conventional surgery (230 min versus 150 min; 5.3 versus 4.7 days; 9.2 versus 8 days). Table 2. Review of series evaluating laparoscopic surgery for mucosal ulcerative colitis     TPC, total proctocolectomy; IP, ileoproctostomy; RPC, restorative proctocolectomy; NR, not recorded; UTI, urinary tract infection. View Large Table 2. Review of series evaluating laparoscopic surgery for mucosal ulcerative colitis     TPC, total proctocolectomy; IP, ileoproctostomy; RPC, restorative proctocolectomy; NR, not recorded; UTI, urinary tract infection. View Large Subsequent data from the same institution (43) compared laparoscopic restorative proctocolectomy to laparotomy and restorative proctocolectomy in 22 patients with mucosal UC (n = 16) or familial adenomatous polyposis (n = 5) or juvenile polyposis (n = 1). Neither resolution of the postoperative ileus nor reduction in the length of hospitalization was reduced in the laparoscopic group. Although the patients were not stratified for steroid dose or hemoglobin levels before or after surgery, transfusions were required in twice as many patients in the laparoscopic group (73% versus 35%; p < 0.05). Morbidity was noted in 68% of the laparoscopic patients versus 35% of the laparotomy patients (p < 0.05). In this series, laparoscopic restorative proctocolectomy conferred none of the theoretical advantages of laparoscopic procedures and could not be advocated. Since that time there have been numerous advances in both instrumentation and surgical technique. Santoro et al. (47) reported on five patients after restorative proctocolectomy using a completely laparoscopic approach with intracorporeal vessel ligation. For each colonic segment, the first step is laparoscopic clip closure and division of the vascular pedicle at their origin before dissecting the mesocolon and its ligaments. None of the procedures was converted, and the average operating time was 364 min. Operative time diminished with increasing experience. There were no intraoperative complications, and the average blood loss was 500 ml. A single postoperative hemorrhage occurred but spontaneously subsided. Oral intake was tolerated on postoperative day 4, and the average length of stay was 12.6 days. Marcello et al. (48) performed a case-matched comparative study of laparoscopic restorative proctocolectomy (n = 20) and restorative proctocolectomy by laparotomy (n = 20). Patients with MUC were matched for severity of disease using hemoglobin and albumin levels, whole blood count, and steroid dependency; there were no intraoperative complications or conversions. The operative time was significantly longer in the laparoscopic cases (330 min) versus the laparotomy cases (230 min); p < 0.001. However, bowel function returned earlier (2 versus 8 days; p < 0.03), and length of stay was shorter in the laparoscopic group (7 versus 8 days; p < 0.02). For diverted patients, the median length of stay was reduced by 2 days in the laparoscopic group (6 versus 8 days; p < 0.01). Complications occurred in 4 of 20 laparoscopic patients (3 obstruction/ileus and 1 pelvic abscess) and 5 of 20 open patients (2 obstruction and ileus, 1 anastomotic leak, 1 abscess, and 1 episode of dehydration). Conclusions During the past decade, laparoscopy has evolved from a feasible procedure to being the preferred procedure for some patients with IBD. Specifically, patients with primary or recurrent terminal ileal CD or perianal conditions in need of fecal diversion should be considered for laparoscopy. The rare individual with Crohn's colitis who is a candidate for segmental colectomy may also be suited to the laparoscopic approach. Patients who require reestablishment of intestinal continuity as an ileoproctostomy after a Hartmann's procedure or extirpation of the remaining rectum after a Hartmann's procedure may also benefit from laparoscopy. Clear advantages compared with laparotomy have included lower rates of postoperative complications, a shorter period of ileus, a shorter hospitalization, less disability, better pulmonary function, superior immune preservation, improved cosmesis, and fewer adhesions. Subtotal and total colectomy for CD and MUC and restorative proctocolectomy for MUC can be performed. However, clear advantages have not yet been demonstrated with the exception of cosmesis. 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TI - Laparoscopic Surgery for Inflammatory Bowel Disease: Results of the Past Decade
JF - Inflammatory Bowel Diseases
DO - 10.1097/00054725-200201000-00007
DA - 2002-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/laparoscopic-surgery-for-inflammatory-bowel-disease-results-of-the-6aVBc6OhwD
SP - 46
EP - 54
VL - 8
IS - 1
DP - DeepDyve
ER -