Hand-assisted laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis.

INTRODUCTION: In this study, we aimed to evaluate the feasibility and safety of undergoing restorative proctocolectomy through ileal pouch-anal anastomosis (RPC-IPAA) with hand-assisted laparoscopic (HALS) in patients with ulcerative colitis (UC). PATIENTS AND METHODS: We reviewed 40 consecutive patients who underwent RPC-IPAA with HALS or open technique for treatment of UC between 2010 and 2013. Moreover, the intra-/post-operative outcomes were compared.
RESULTS: We found the median operative time was significantly longer in the HALS group while the blood loss was significantly less in patients with HALS than with open surgery. In the HALS group, the median duration of bed rest and the length of hospital stay were significantly shorter. Moreover, the rate of early post-operative complications in the HALS group was significantly less than that in the open surgery group, among which one patient died in the 30th day after surgery for the extensive use of steroids before the operation.
CONCLUSION: These findings clearly show that HALS RPC is safe and less invasiveness. HALS can become a more comfortable and standardised procedure for UC with the adoption of evolving technologies.

INTRODUCTION

In the recent decade, there is a significant increase in the incidence of ulcerative colitis (UC) in China. Colectomy has been thought necessary when intensive medical therapy does not improve the condition in the patients. In general, surgical treatment for UC includes segmental colectomy, and subtotal or total colectomy with or without end ileostomy or total proctocolectomy, depending on the severity and distribution of the disease. In practice, extensive colonic resection tends to be considered when the disease is diffuse, and recent studies have shown its safety and reasonableness.[1]

Conventionally, restorative proctocolectomy (RPC) has been performed through a full-scale laparotomy. With the improvement of laparoscopic surgery, several previous studies have already reported the feasibility and safety of laparoscopic RPC for UC in the elective setting.[23] The majority of reports have shown the advantages of laparoscopic RPC such as reduced post-operative pain, earlier return of intestinal function, decreased length of hospital stay and improved cosmesis.[4] So far, it has not gained the universal acceptance accorded other laparoscopic procedures. The reluctant use of laparoscopy may be attributed to the following limitations specific to this pathology. First, the lack of tactile feedback complicates adequate judgment concerning the extent of resection intra-operatively; second, the absence of optimal retracting devices further leads to poor surgical exposure in multiple quadrants of the abdomen, resulting in a longer operative time.[56] Therefore, there is a necessity for an effective operation method.

Recently, hand-assisted laparoscopic surgery (HALS) has increasingly gained clinical acceptance as a practical and useful alternative to laparoscopic and open surgery.[7891011] Using HALS, surgeons are enabled to obtain tactile sensation, manual retraction, and digital vascular control, by which complex laparoscopic operations are able to be performed more effectively. Several studies have shown the applicability of this technique in complicated and extensive colorectal diseases,[89101112] and their initial results are generally promising.

In this study, we compared HALS to open operation RPC with ileal pouch-anal anastomosis (IPAA) for UC in terms of operative and early post-operative outcomes to evaluate the feasibility, safety and potential benefits of HALS in the surgical treatment of UC.

PATIENTS AND METHODS

Patients

Between January 2010 and December 2013, a total of 42 consecutive patients who diagnosed with UC were performed with RPC-IPAA at the Second Hospital Affiliated to Soochow University. The surgery was indicated when the patients were unresponsive to medical therapy. Of these, two patients with colorectal cancer were excluded from the present study. The records of the remaining 40 patients were then reviewed, among whom 20 received HALS and 20 received open surgery, respectively. All operations were performed by the same surgical team.

All data were collected in a prospectively compiled computer database, which included patients’ age, gender, history, duration of disease, indication for surgery, body mass index (BMI), pre-operative medical treatment, operative time, operative bleeding, intra- and post-operative complications, duration of bed rest, time to resume solid diet and length of hospital stay. Statistical analyses were performed using SPSS 14.0 software (IBM, 2013). Independent-samples t-test was performed and P < 0.05 was considered statistically significant.

Surgical technique

Hand-assisted laparoscopic

Under general anaesthesia, the patients were placed in the modified lithotomy position with the legs positioned in padded stirrups. A 7-cm minilaparotomy was made, and a hand access device was assembled [Figure 1]. We prefer a lower transverse incision. Since when the incision healed, it can hardly be seen [Figure 2].

Figure 1

Port and incision placement for hand-assisted laparoscopic subtotal colectomy. We use one 12-mm port and one or two 5- to 10-mm ports in addition to the 7-cm lower transverse incision

Figure 2

Scar shown at 8 weeks after surgery

Two trocars were placed under a regular carbon dioxide pneumoperitoneum, one in the supraumbilical region for optics and the other in the left mid abdomen for instruments. The ‘lateral-to-medial’ bowel mobilisation and division of the colonic mesentery were performed intracorporeally with HALS technique. The remainder procedure including pelvic dissection, distal rectal stapling, ileal pouch construction and double-stapled ileoanal anastomosis, was then accomplished under direct vision through the opened hand access device. The creation of a diverting ileostomy was performed at the discretion of the surgeon on a case-by-case basis.

Our current favourite hand access device was Gelexis (Applied Medical, Rancho Santa Margarita, CA, USA), which enables unlimited hand exchanges into every quadrant of the abdomen without any gas leakage.[1314]

In recent cases, we have exclusively used a 10-mm bipolar vessel sealing system (LigaSure Atlas; Valleylab, Boulder, CO, USA) for ligature of vascular pedicles, division of the mesentery and takedown of the omentum.

Open surgery

Under general anaesthesia, the patients were placed in the supine position. Upper and lower midline incisions were placed and the abdomen was entered. Mobilisation of the colon, vascular division, dissection of the greater omentum and construction of a mucous fistula, and Brooke ileostomy were done with a technique similar to that described above.

RESULTS

There was no significant difference between the two groups in terms of gender, BMI, prior laparotomy, duration of disease, interval from the deterioration to operation, location of disease and indication for surgery [Table 1].

Table 1

Patients’ characteristics

The results in terms of intra-operative parameters are shown in Table 2. No case in the HALS groups was converted to open procedure in our series during the surgery. The median operative time was significantly longer in the HALS group (261 min; range, 190–450 min) than in the open group (203 min; range, 150–450 min). In addition, the blood loss was significantly less in the HALS group (175 ml; range, 96–423 ml) than in the open group (338 ml; range, 121–1055 ml).

Table 2

Intra-operative parameters

The results of the post-operative periods are shown in Table 3.

Table 3

Post-operative recovery and complications

After surgery, we found that patients in HALS group recovered faster than in the open surgery group. In particular, the median duration of bed rest (3.4 days vs. 4.4 days; P = 0.029) and the post-operative hospital stay (21.0 days vs. 25.9 days; P = 0.007) in the HALS group were significantly shorter than that in the open surgery group. In addition, the number of post-operative complications during the hospital stay in the HALS group was significantly less than in open surgery group (20% vs. 55%; P = 0.022).

Infection was the most frequently registered complication for patients post-surgery. In the open surgery group, 3 of 20 patients (15%) had surgical site infection, and one patient among them developed wound dehiscence and needed resuture of the wound. Whereas in the HALS group, 2 of 20 patients (10%) had surgical site infection, but no patient had developed wound dehiscence. Regarding other complications, the peritoneal abscess was observed in one patient from the HALS group and two patients from the open surgery group. There is one patient of open surgery group who had pneumonia after operation received antibiotic therapy. Bleeding that required blood transfusion occurred in 1 patient in the HALS group and two patients in the open surgery group. Ileus that required ileus tube occurred in 3 patients in the open surgery group and none in HALS group. Overall, 3 patients in the open surgery group were required relaparotomy because of peritoneal abscess (1 patient) or strangulation ileus (2 patients), but no patient needed relaparotomy in the HALS group (P = 0.075). In the open surgery group, one patient died in the 30th day after surgery due to the extensive use of steroids before the operation.

DISCUSSION

UC are typically benign, and the patients are usually young, active and highly motivated individuals who desire a cosmetically appealing and functional result.[15] Patients who require RPC-IPAA for UC could be good candidates for minimally invasive surgery.[315] The avoidance of a full-scale laparotomy in favour of a HALS technique could have a physiological benefit; it may also be advantageous to reduce wound complications in steroid-dependant patients and future formation of intra-abdominal adhesions in younger patients.[3]

Besides the obvious cosmetic advantage resulting from a reduced number and size of scars, limiting the incisions may result in less post-operative pain and a reduced need for analgesics and bed rest, and consequently, a faster recovery and earlier discharge, together with a lower rate of wound-related complications.[16] The initial data from the literature seem to be confirmed here in our series, where an improvement in bowel function, resumption of oral feeding and shorter hospital stay were observed in our study in comparison with those reported in the literature.[17]

The HALS procedure has been increasingly accepted as a practical and useful alternative to open operation for complex and extensive colorectal operations because it permits direct tactile feedback, gentle retraction of large masses of tissue and digital blunt dissection.[789101112] The recovery of tactile sense further contributes to better exposure, easier identification of anatomic structures and more rapid control of bleeding.[714]

The LigaSure was used during HALS and we found it is an ideal vascular control device for HALS since the device provided consistent coagulation and rapid/precise division even on the friable UC mesentery. The heat production at the tip of LigaSure was minimal in comparison to other surgical energy devices such as the laparosonic coagulating shears, enabling its safer and closer use adjacent to surgeon's fingers during HALS RPC. It is believed that this feature also partially contributed to the shorter surgical time and reduced blood loss.

A major drawback of HALS, from our experience, is the discrepancy in feedback from surgical team members. The operating surgeon can enjoy regained tactile feedback while the other members should assist him or her only through conventional laparoscopic visual cues. From this standpoint, HALS is virtually solo surgery and thus requires a different system of assistance. One partial solution is using a positive verbal communication. The surgeon can deliver his or her sense of palpation verbally to the surgical crew using a hand gesture, making timely orientation and understanding possible. We believe that HALS is not a bridge technology for the novice, but it should be performed by experienced laparoscopic surgeons because abundant experience and profound understanding of both open and laparoscopic surgery are necessary for adequate feedback to coordinate the performance of the surgical team members during the procedure.

Our preliminary results are encouraging when considering the HALS as a promising technique to improve the short-term outcomes for this procedure. However, we do not think that this approach should be offered to everyone; patients should be selected carefully base on their body habitus (particularly the BMI), associated medical conditions, and surgical history. Rather, we believe that in the hands of experienced laparoscopic surgeons this procedure can be a valuable surgical option for a subset of UC patients. Further studies in a larger series and longer follow-up will be urged to demonstrate the full advantages of this technique over the standard laparoscopic techniques before its acceptance as a new standard for care.

Finally, we should mention the limitation of the present study. Since the present study was not a randomised trial, some bias in favour of the HALS group is possible. However, pre-operative data were well matched in both groups, and intra-operative safety and post-operative recovery period were satisfactory in the HALS group. We, therefore, believe in the effectiveness of HALS RPC-IPAA for patients with UC, further studies in a larger series and longer follow-up will be required.

CONCLUSION

The HALS RPC with IPAA seems to be a safe and feasible approach to the treatment of refractory UC. We used HALS device that allows the surgeon to perform the procedure with multiple conventional laparoscopic instruments, thus avoiding the need for modifying the standard laparoscopic technique. We found that when performed by surgeons with experience in laparoscopic surgery, this procedure can offer better short-term outcomes in patients without lengthening the operating time. Further studies will be required to address questions such as the other benefits of HALS over the standard laparoscopic techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.