Mark H Hanna, MD1, Grace S Hwang, MD2, Michael J Phelan, PhD3, Thanh-Lan Bui, BS1, Joseph C Carmichael, MD1, Steven D Mills, MD1, Michael J Stamos, MD1, Alessio Pigazzi, MD, PhD1. 1University Of California – Irvine, Dept of Surgery, 2University of Southern California, Dept of Surgery, 3University Of California – Irvine, Dept of Statistics
Introduction: The use of laparoscopy in right hemicolectomy has gained popularity, which allows for the option of a totally intracoporeal anastomosis (IA) for the construction of an ileocolic anastomosis. This may alleviate some of the technical limitations that a surgeon faces with a laparoscopic-assisted extracorporeal anastomosis (EA). Experience with IA in the literature has been limited and thus we present a large consecutive case series comparing the postoperative and oncologic outcomes of IA versus EA for laparoscopic right hemicolectomy.
Materials and Methods: A retrospective chart review of 195 consecutive patients that underwent laparoscopic right hemicolectomy by 4 colorectal surgeons from March 2005 to June 2014 was preformed. Patient demographics were reported and multivariate regression analysis was used to compare postoperative outcomes. Patients who underwent laparoscopic hemicolectomy for colon cancer also had their oncologic outcomes analyzed and survival assessed with Kaplan-Meier survival curves.
Results: A total of 195 patients underwent laparoscopic right hemicolectomy over the study period, with 86 (44%) patients receiving IA and 109 (56%) patients receiving an EA. Both groups were demographically similar with the majority of patients having an ASA Class of II and III. The IA group had a higher median Charlson comorbidity index of 3 compared to the EA group score of 2. The most common indication for surgery in both groups was cancer: 56 (65%) of IA cases and 57 (52%) of EA cases, followed by adenoma: 15 (17%) of IA cases and 12 (11%) of EA cases. Over the study period there was a steady improvement in operative time, from an average of 240 minutes in 2005 to an average of 170 minutes by 2014. Using multivariate analysis to compare IA cases against EA cases, there was no significant difference in length of stay, return of bowel function, risk of anastomotic leak, risk of intra-abdominal abscess or risk of wound complications. A subset analysis of patients who underwent laparoscopic right hemiclectomy for cancer showed no significant difference in the median number of lymph nodes harvested (18 LNs in IA group vs. 19 LNs in EA group, P>0.05). There was also no difference in overall survival and disease-free survival at 5.7 years between the two groups.
Conclusions: Our large experience reveals that intracoporeal anastomosis in laparoscopic right hemicolectomy is associated with similar postoperative and oncologic outcomes compared to extracorporeal anastomosis. This suggests that IA represents a valid technical advantage in the arsenal of the experienced colorectal surgeon without compromising outcomes. Large prospective randomized trials are needed to validate these findings.
