THE USE OF MINIMALLY INVASIVE TECHNIQUES IN A COLON AND RECTAL SURGERY PRACTICE
Rebekah Kim MD, Andrea Ferrara MD, Franciso Itriago MD, Jeremy Cravens MD, Samuel DeJesus MD, Renee
Mueller MD, and Joseph Gallagher MD
Colon and Rectal Clinic of Orlando, Orlando Health, Orlando, Florida
BACKGROUND AND OBJECTIVE: Minimally invasive colon surgery (MIS) has been described since the early
1990s to have short term benefits including decreased length of hospitalization, decreased pulmonary complications,
and fewer wound infections when compared with open surgery. The two main minimally invasive techniques that
have been utilized at our institution are laparoscopic and hand assisted colon surgery. The purpose of this study was
to evaluate the outcomes of patients undergoing surgery with minimally invasive techniques at a colon and rectal
surgery practice.
METHODS: A retrospective review of all patients who underwent an elective minimally invasive surgical technique
was performed from 2008-2009. In the laparoscopic group, five millimeter ports were placed for the mobilization of
the colon and extracorporeal anastomosis was performed via a small midline incision. Only in the case of
laparoscopic low anterior resection, intracorporeal anastomosis was performed under laparoscopy. In the handassisted laparoscopic technique, a 7-8 centimeter Pfannestiel incision was performed to accommodate the GelPort
system (Applied Medical). Colonic devascularization and mobilization was performed with assistance of hand in
the abdomen via the GelPort at the Pfannestiel incision . Extracorporeal anastomosis was performed for all
surgeries undergoing the hand assisted approach. Conversion of either minimally invasive technique was defined as
an unplanned extension of the incision for tissue dissection.
RESULTS: 95 consecutive patients underwent elective minimally invasive colorectal surgery from 2008-2009.
There were 38 patients in the laparoscopic group and 57 patients in the hand assisted group. The following five
diagnosis were the most indications for surgery: colon cancer (25%), diverticulitis(20.5%), colonoscopically
unresectable polyp (19%), rectal cancer (17%), inflammatory bowel disease (7.4%). Conversion to an open
technique occurred in 18% (7/38) the laparoscopic group vs. 2% (1/57) in the hand assisted group. This was
statistically significant (p=0.01). The most common reasons for conversion were adhesions and difficult
mobilization. The rate of complications were similar in both groups(see Table).
Laparoscopic complications 14% (5/38)
Hemorrhage
Small bowel obstruction
Myocardial infarction
Hernia
Pelvic abscess
Hand assisted complications 16% (9/57)
Wound infection (2)
Rectovaginal fistula (2)
Pulmonary complications (2)
Small bowel obstruction
Enterocutaneous fistula
C. difficile infection
DISCUSSION: Laparoscopic colon surgery has been associated with modest but significant improvements in postoperative outcomes compared to conventional open surgery. The use of laparoscopic techniques in colorectal
surgery, however, has been limited to relatively few surgeons due to technical difficulty and its availability of
surgeons trained in minimally invasive techniques. In our study the rate of conversion to an open procedure
occurred less frequency in the hand assisted technique suggesting that more complex procedures may be able to be
completed with hand assisted dissection.
The complication rates were similar in both groups therefore the hand assisted approach may offer a minimally
invasive surgery to patients offering the same benefits of laparoscopic surgery.