Ian M Paquette, MD, Bobby Johnson, MD, Bradley R Davis, MD. University of Cincinnati College of Medicine.
Introduction: Laparoscopic colectomy has become a standard approach due to improved patient recovery and decreased hospital stay. There is large variability in the surgical techniques used in laparoscopic colectomy. Surgeons may use a straight laparoscopic approach, hand-assisted approach, or a laparoscopic assisted approach. We hypothesized that the benefit of a short length of stay would be most pronounced in patients who underwent a straight laparoscopic approach.
Methods and Procedures: We performed a retrospective review of all patients who underwent a laparoscopic sigmoid colectomy by one of four colorectal surgeons at an academic institution from 2012 to 2013. Operative notes were reviewed by an attending surgeon to determine which operative approach was utilized. The laparoscopic approach involved intra-corporeal colon mobilization and transection of vessels. Only specimen extraction and anastomosis were accomplished through the extraction site. The hand-assisted approach involved intra-corporeal transection of vessels and colon mobilization using a hand assisted approach. The laparoscopic assisted approach included laparoscopic mobilization of the colon and extracorporeal completion of the procedure. No enhanced recovery pathway was used in any patient. The means of normally distributed variables were compared using the ANOVA test, while the Kruskal-Wallis test was used to compare median values of continuous variables without normal distribution. Logistic regression was performed to determine factors associated with the outcome of interest, early hospital discharge (hospital discharge on postoperative day 2 or 3).
Results: A total of 48 patients underwent a laparoscopic sigmoid colectomy. Nineteen patients underwent a straight laparoscopic approach vs. 20 laparoscopic assisted and 9 hand assisted. The patient groups were identical with respect to age, gender, medical comorbidities, ASA score, and diagnosis. The only difference between the groups was a difference in the choice of procedure type by different attending surgeons. Median length of stay was significantly shorter in the laparoscopic group (4 days, IQR 4-5) vs. the laparoscopic assisted (5, 4-7) and hand- assisted (5, 5-6) groups (p = 0.0084). GI function returned faster in the laparoscopic group (2.3 days to flatus) vs. the laparoscopic assisted (3.3d) and hand assisted groups (2.9d) (p = 0.001). Early discharge was observed in 63.2% of laparoscopic patients vs. 30% of laparoscopic assisted patients and 22.2% of hand-assisted patients (p = 0.006). When controlling for patient comorbidities, operative time, blood loss, and postoperative complications, patients who had a straight laparoscopic approach were 6 times more likely to have an early hospital discharge (OR 6.1, p = 0.013). There were no differences in postoperative complications, or hospital readmissions between the groups.
Conclusions: Patients who undergo a straight laparoscopic approach to sigmoid colectomy experience a faster return of gastrointestinal function and significantly earlier hospital discharge compared to patients who undergo a hand-assisted, or laparoscopic assisted approach. When technically feasible, the straight laparoscopic approach should be preferred.
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