Do prior abdominal operations alter the outcome of laparoscopically assisted right hemicolectomy?

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1 Surg Endosc (2000) 14: DOI: /s Springer-Verlag New York Inc Do prior abdominal operations alter the outcome of laparoscopically assisted right hemicolectomy? C. T. Hamel, A. J. Pikarsky, E. Weiss, J. Nogueras, S. D. Wexner Department of Colorectal Surgery, Cleveland Clinic Florida, 3000 West Cypress Creek Road, Fort Lauderdale, FL 33309, USA Received: 31 August 1999/Accepted: 17 March 2000/Online publication: 20 July 2000 Abstract. Background: Adhesions can increase the difficulty of both laparoscopic surgery and laparotomy. The aim of this study was to compare the results of laparoscopically assisted right hemicolectomy in patients after prior abdominal operations (PAOs) with the results in patients without prior abdominal operations (NPAOs). Methods: Between August 1991 and September 1998, 85 patients underwent laparoscopically assisted right hemicolectomy. The Mann-Whitney test or Fisher s exact test was used for statistical analysis. Results: In this study, 36 patients (21 women and 15 men), with an average age of 57.5 years (range, years) had undergone a mean of 1.25 (range, 1 to 3) PAOs, whereas 49 patients (20 women and 29 men), with an average age of 60.0 years (range, 16 to 87 years) (p 0.44) had undergone NPAOs. Overall in the PAO and NPAO groups, respectively, there were no significant differences in the incidence of intraoperative complications (3 versus 4 ; p 1.0). The mean operative time was 151 min (range, 90 to 260 min) versus 148 min (range, 70 to 270 min) (p 0.66), and the mean length of stay was 6.8 days (range, 3 to 18 days) versus 7.6 days (range, 3 to 19 days) (p 0.13). The procedure was converted to laparotomy (p 0.754) for six patients in the PAO group (5 because of adhesions) and 6 patients in the NPAO-group (1 because of adhesions; p 0.078). In the PAO group 17 patients (47%) had 22 postoperative complications: 11 general medical and 4 woundrelated complications. Seven patients (19%) had prolonged postoperative ileus. In the NPAO-group 18 patients (38%) had a total of 22 complications: 7 general medical problems, 6 wound-related complications, and 8 prolonged postoperative ileus, none of which were statistically significant. One patient in the NPAO group had an anastomotic leak. During a mean follow-up period of 41 months (range, 3 to 89 months), three patients in the PAO group and four in the NPAO group developed incisional hernias. Correspondence to: S. D. Wexner Conclusions: Although there is a trend toward more conversions because of adhesions in patients with a history of prior abdominal operations (p 0.078), no increase in morbidity resulted. Therefore, laparoscopically assisted right hemicolectomy can be offered to patients with PAO, whose rate of adhesions can be expected to equal that of patients with NPAO. Key words: Adhesions Colectomy Colon Complications Laparoscopy Laparotomy The technical feasibility of laparoscopic colorectal surgery has been well demonstrated. Although some authors have suggested that laparoscopic colectomy is advantageous as compared with laparotomy [14, 32], others could not demonstrate any significant advantages [9, 13, 21, 38]. However, instrumentation, technical skills, and consequently results have improved over the past eight years. Two recent studies showed significant declines in the incidences of both iatrogenic injuries and postoperative complications with increasing experience [1, 16]. Adhesions are a source of considerable morbidity during abdominal reoperation. The incidence of intra-abdominal adhesions after laparotomies varies from 70% to 90% [8]. Abdominal adhesions are a major danger of abdominal reoperation, including visceral damage and intestinal perforation. Little attention has been paid to the consequences of adhesions at reoperation. Van Goor [35] retrospectively studied 291 patients who underwent a secondary laparotomy and calculated the incidence of iatrogenic bowel perforations. In 61 patients (21%), one or more bowel perforations occurred. The number of previous laparotomies was significantly higher in patients with bowel perforations. In theory, laparoscopic surgery in patients with adhesions may be even more hazardous because of the limited

2 854 Table 1. Patient demographics Total PAO NPAO p Value No. of patients (%) (42) 49 (58) Age (years) Age range (years) Female/male (%) 41 (48)/44 21 (58)/15 20 (41)/29 Operative indication Neoplasm Benign Malignant Functional disorders Crohn s disease Associated cardiopulmonary illnesses (%) 29 (34) 10 (27) 19 (39) Prior abdominal operations (%) 36 (42) 36 (100) 0 <0.001 Immunosuppressive medications (%) 15 (18) 8 (22) 7 (14) visibility and lack of tactile sensation. However, laparoscopic enterolysis has been performed successfully in many centers, even for bowel obstruction, with alleged safety [2, 10, 12, 18]. On the basis of this data, we hypothesized that laparoscopic colectomy is safe even after prior laparotomy. Therefore, the aims of this study were to compare the results of laparoscopic colorectal surgery, and to gauge the impact of a prior abdominal intervention. Specific attention was directed to conversion rates and reasons, intraoperative and postoperative morbidity, and length of hospital stay. A single type of operation (laparoscopically assisted right hemicolectomy) was selected to ensure homogeneity of data analysis. Materials and methods Patients Between August 1991 and September 1998, 85 consecutive patients underwent laparoscopically assisted right hemicolectomy; these patients were divided into two groups: those with prior abdominal operations (PAO) and those without prior operations (NPAO group). All the patients in both groups underwent a standard mechanical bowel preparation with oral and perioperative intravenous broad-spectrum antibiotics. The dissection included the right iliac fossa, the line of Toldt, and hepatic flexure. The right ureter and duodenum were reflected posteriorly, and the omentum was divided to the left of the middle colic arcade. Vascular ligation, bowel resection, anastomosis, and mesenteric defect repair were performed in an extracorporeal manner. Grading of adhesions was not undertaken. No adhesion-reducing gels or barriers were used. Ileus was defined as any placement of a nasogastric tube during the initial hospitalization, and the criterion was vomiting 200 ml or more, two or more times. Conversion was defined as any incision planned, made sooner than planned or longer than 5 cm. A prospective computerized data registry was maintained (Microsoft Access 97, Microsoft Corp., Seattle, WA, USA). Statistical analysis was performed by use of the Mann-Whitney test and Fisher s exact test (GraphPad InStat, GraphPad Software, Inc., San Diego, CA) Results Patients Of the 85 patients eligible for inclusion, 36 patients (21 women [58%] and 15 men [42%]) with an average age of 57.5 years (range, 15 to 87 years) had undergone a mean of 1.25 (range, 1 to 3) prior abdominal operations (PAO group), whereas 49 patients (20 women [41%] 29 men [59%]) with an average age of 60 years (range, 16 to 87 years) (p 0.44) had no history of abdominal intervention (NPAO group). The operative indications and baseline data are listed in Table 1. The different types of prior operations are listed in Table 2. Whereas 28 patients underwent one prior operation, seven patients had two and one patient three prior operations. Appendectomy was the most frequent operation reported (n 20), followed by cholecystectomy (n 9, both open and laparoscopic), then bowel resection (n 10). Six patients had undergone prior gynecologic surgery. Subgroup analysis was not performed because of the small numbers in each group. Operative time and hospital stay are shown in Table 3, which shows that no significant differences were noted in any category. Moreover, the conversions of 17% in the PAO group and 12% in the NPAO group were not significantly different. Complications Overall, there were seven (8%) intraoperative complications: three (8%) in the PAO group and four (8%) in the NPAO group (p 1.0) as shown in Table 4. Postoperative complications noted in 47% of the PAO patients and 37% of the NPAO patients also are detailed in Table 4. The difference between the two groups is not significantly different. Postoperative morbidity (30 days) In the PAO group 17 patients (47%) experienced 22 complications: 11 (27%) related to abdominal surgery and 11 general medical complications (Table 4). Four of the complications related to the operation were wound related. Seven patients (19%) had prolonged postoperative ileus, none requiring a laparotomy. In the NPAO group, 18 patients (37%) experienced 22 complications: 15 related to abdominal surgery and 7 (14%) general medical complications. Six of the surgery-related complications (12%) were wound related. There were no enterotomies or myotomies. Eight patients (16%) had a prolonged ileus/small bowel obstruction, 1 patient of whom required laparotomy and ad-

3 855 Table 2. Results: types of prior operations Type of prior operation/incision Total Women Men None Appendectomy/right lower quadrant Bowel resection/midline Cholecystectomy/right upper quadrant 3 3 Gynecologic operation/pfannensteil 6 6 Appendectomy and bowel resection/right lower quadrant and midline Appendectomy and cholecystectomy/right lower quadrant and right upper quadrant 2 2 Appendectomy and other/right lower quadrant and midline 3 3 Appendectomy, bowel resection, and gynecologic/right lower quadrant and midline 1 1 Table 3. Results: Operative and postoperative hesiolysis. The single anastomotic leak (3%) was associated with an intra-abdominal abscess, which was successfully treated by percutaneous drainage. There were no statistical differences between the two groups relative to any of the complications. Discussion Total PAO NPAO p Value Mean operative time (min) Operative time range (min) Conversions (%) 12 (14) 6 (17) 6 (12) Adhesions (%) 6 (7) 5 (14) 1 (2) Bleeding Failed identification of ureter 2 2 Specimen size (cm) 1 1 Mean hospital stay (days) Hospital stay range (days) First bowel movements (days) First bowel movements range (days) PAO, prior abdominal operation; NPAO, no prior abdominal operation The feasibility of laparoscopic colectomy has well been documented. The question now is its indications and contraindications. Reports of both recognized and unrecognized injuries to the small bowel, ureters, and epigastric vessels exist. Numerous cases of injuries to the epigastric vessels and ureters have been noted. Some of these problems can occur because of adhesions from prior operations [3, 15]. Epigastric vessel injury may be avoided by deliberate transillumination and port placement lateral to the epigastric vessels. Up to 1% of all adult hospital admissions for general surgery are because of adhesions, and 3.3% of all laparotomies are performed for adhesion-related bowel obstruction [19]. In addition, adhesions prolong and may complicate many laparotomies performed for other disease processes. After laparotomy and colectomy, adhesions develop in 93% of patients [5, 19, 20, 25, 36]. Various theories on the etiopathogenesis of adhesions exist including trauma, ischemia, foreign bodies, hemorrhage, and infection. Injury or inflammation in the peritoneal cavity results in a rapid deposition of fibrin, which causes adhesion of the involved surfaces to adjacent structures [17, 28, 31]. Adhesions are responsible for approximately 74% of intestinal obstructions [7, 17, 28, 34]. After either left-side colonic or rectal surgery, adhesions have been reported in up to 25% of patients as compared with 15% after appendectomy and 9% after right colectomy. Raf [29] assessed 1,477 adults with adhesions treated between 1954 and 1965, 86% of whom had undergone prior laparotomy, most commonly either appendectomy or gynecologic procedures. In a postmortem study of 752 individuals, adhesions were found in 67% of those who had undergone prior laparotomy [36]. Intra-abdominal adhesions developed in 91% of patients who had undergone colorectal surgery and 93% of patients who had undergone multiple prior operations, as compared with only 60% after exploratory laparotomy and 47% after appendectomy. In the United States, the annual costs for abdominal adhesiolysis were $1.3 billion [30]. In a recent retrospective cohort study using patient-specific Health Care Financing Administration data, Beck et al. [4] found that within 2 years of laparotomy for different indications, obstruction can occur in 12.4% to 17% of patients dependent on the type of the first operation. In the current study, adhesiolysis for obstruction was performed in 2.3% to 5.1% of the participants. Van Goor [35] retrospectively analyzed the impact of previous laparotomies on bowel perforation at the time of repeat laparotomy. The risk of adhesion-related bowel perforation was found to be 20%, and both the number of previous laparotomies and the age of the patient were identified as independent risk factors. In patients with previous surgery, the division of relevant adhesions requires a mean of 19 additional min (range, min). Laparoscopically assisted right colectomy is the most often performed laparoscopic procedure [37]. In a survey of 635 responding surgeons, 78% said they would perform this procedure. For this reason, the current study concentrated exclusively on this operation. At this writing, reports have varied by indications and procedures, concentrating on length of postoperative ileus, duration of hospital stay, postoperative analgesia requirement, and cost. Conversion rates reported in the literature vary from 14% to 41% [1, 6, 9, 11, 13, 16, 21, 26, 33, 36] and are highest for left-side and lowest for right-side resections. The reason for this difference may be that left-side techniques are intracorporeal whereas assisted operations are preferred for the right side. Accordingly, the technical challenge and ensuring safer procedure may allow a greater number of surgeons to feel confident in a higher number of situations for the right side than for the left side procedures. In this study, 14% of all cases were converted to open procedures. The main reason for a 17% conversion rate in the PAO patients was adhesions, whereas 12% of the NPAO patients had to be converted to laparotomy for other reasons including bleeding. Conversion because of adhesions were not statistically significantly more frequent in the PAO

4 856 Table 4. Complications Total PAO NPAO p Value Intraoperative complications (%) 7 (8) 3 (8) 4 (8) 1 Diathermy injury (skin) 1 1 Pulmonary aspiration 1 1 Bleeding Stapler misfire 1 1 Epigastric vessel laceration 2 2 Postoperative complications (patients (%)/n) 35 (41)/44 17 (47)/22 18 (37)/ Related to abdominal surgery n (%) 26 (31) 11 (31) 15 (31) 1 Wound related 10 (12) 4 (11) 6 (12) 1 Anastomotic leak 1 1 Prolonged ileus/obstruction 15 (18) 7 (19) 8 (16) Other complications n (%) 18 (21) 11 (31) 7 (14) Cardiopulmonary Urologic Other Long-term complications Incisional hernia 3 4 PAO, prior abdominal operation; NPAO, no prior abdominal operation group. In conclusion, laparoscopically assisted right hemicolectomy can be offered to both PAO and NPAO patients with equal expectations of success and acceptable morbidity. Acknowledgments. The first author was supported by the Swiss National Foundation, Lichtenstein Stiftung, Basel, Krebsliga beider Basel. 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