Erman Aytac, Luca Stocchi, Julie DeLong, Meagan M Costedio, Emre Gorgun, Hermann Kessler, Feza H Remzi. Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio.
INTRODUCTION: The effectiveness of laparoscopic intestinal resection in patients with previous midline laparotomy (PML) is controversial. The aim of this study was to assess the feasibility of laparoscopic surgery and identify possible factors associated with postoperative outcomes in patients with PML.
METHODS AND PROCEDURES: Patients with PML (at least an infraumbilical incision or longer) undergoing elective laparoscopic intestinal resection between 1997-2011 were case-matched with patients without PML undergoing laparoscopic surgery based on age, gender, body mass index, ASA score, surgical procedure and diagnosis. Comparisons of the groups were performed by using χ2 or Fisher exact tests with respect to categorical data and by using the Wilcoxon rank-sum test with respect to quantitative data.. Parametric data were reported as means and nonparametric data as numbers.
RESULTS: Fifty patients with PML undergoing laparoscopic intestinal resection were well matched to 50 counterparts (table). Conversion to open surgery (n=8 vs. n=4, p=0.22), operating time (211 vs. 192 minutes, p=0.22) and estimated blood loss (158 vs. 184 ml, p=0.95) were similar between the groups. Intrabdominal adhesions (either disease-related or from previous operations) were significantly more common in patients with PML (n=24 vs. n=11, p=0.01). Intraoperative complications included inadvertent enterotomy and hemorrhage and were comparable between the groups (1 vs. 0, p=1 and 1 vs. 2, p=1 for PML vs. no PML, respectively). One patient without PML died postoperatively from aspiration pneumonia. Overall morbidity (n=26 vs. n=10, p=0.001), and particularly postoperative ileus (n=10 vs. n=3, p=0.04) were significantly increased in the PML group when compared to laparoscopy without PML, unlike the respective differences in postoperative return of bowel function (4 vs. 3 days, p=0.15), reoperations (n=5 vs. n=3, p=0.72), length of hospital stay (9 vs. 6 days, p=0.09) and readmissions (n=5 vs. n=4, p=0.73).
CONCLUSIONS: Intestinal resections in patients with PML can be frequently completed laparoscopically but are associated with worse postoperative outcomes when compared to laparoscopy on a virgin abdomen. Future studies should compare laparoscopic and open surgery in individuals with PML to further assess the benefits of laparoscopy in this patient subgroup.
| Previous midline laparotomy (n=50) | No prior abdominal operation (n=50) | P value | |
| Age (years) | 58 ± 17 | 57 ± 18 | 0.93 |
| Gender (F/M) | 28/22 | 28/22 | 1 |
| ASA score | 2 (2-3) | 2 (2-3) | 1 |
| Body mass index (kg/m2) | 26 ± 5 | 26 ± 5 | 0.99 |
| Operations performed, n | 0.91 | ||
| Partial colectomy (Right/left sided) | 41 | 41 | |
| Total colectomy/proctocolectomy | 4 | 4 | |
| Proctosigmoidectomy | 3 | 3 | |
| Small bowel resection | 2 | 2 | |
| Diagnosis, n | 1 | ||
| Benign | 38 | 38 | |
| Malignant | 12 | 12 | |
| Causes of conversion, n | 0.46 | ||
| Adhesion | 5 | 2 | |
| Unclear anatomy | 1 | 2 | |
| Obesity | 1 | 0 | |
| Bleeding | 1 | 0 | |
| Specific postoperative complications, n | |||
| Atelectasis | 3 | 1 | 0.62 |
| Venous thromboembolism | 2 | 1 | 1 |
| Urinary complications | 2 | 3 | 1 |
| Anastomotic leak | 3 | 1 | 0.62 |
| Abdomino-pelvic abscess | 4 | 1 | 0.36 |
| Wound infection | 7 | 3 | 0.32 |
| Fistula | 2 | 0 | 0.50 |
ASA: American Society of Anesthesiologists, IRA: Ileorectal anastomosis, IPAA: ileal pouch-anal anastomosis