Surg Clin N Am 86 (2006) 867–897

Laparoscopic Colon Surgery:

Past, Present and Future
Guillaume Martel, MD, CM,
Robin P. Boushey, BSc, MD, PhD, CIP, FRCSC*
Division of General Surgery, Minimally Invasive Surgery Research Group,
University of Ottawa, The Ottawa HospitaldGeneral Campus, 501 Smyth Road,
Ottawa, ON K1H 8L6, Canada

In September 1985, Eric Mühe performed the first human laparoscopic

cholecystectomy [1]. As is often the case, this revolutionary technique was
not readily embraced by the surgical community; however, by 1989, Reddick
and Olsen [2] had reported their own experience with the procedure, which
would soon become the standard of care for patients with cholelithiasis. By
1992, the early success of minimally invasive surgery of the gallbladder had
spread to include a number of first publications on laparoscopic splenectomy,
Nissen fundoplication, adrenalectomy, nephrectomy, and appendectomy.
Similarly, reports of laparoscopic colon surgery were published in 1991
[3,4], introducing a promising technique for the management of some of the
most common abdominal pathologies. Nevertheless, minimally invasive sur-
gical techniques for the colon have not enjoyed as rapid a rise in popularity as
many other laparoscopic procedures have throughout the 1990s. Several fac-
tors account for this difference, including a steep learning curve for the sur-
geon, the need for laparoscopic intra-abdominal vascular control, the time
required to perform the procedure, the need for larger incisions to retrieve
specimens, and concerns over the oncologic safety of the procedure in malig-
nant disease [5]. In this article, we review the current state of laparoscopic
colon surgery, focusing on the evidence surrounding its use in malignant
and benign disease, and addressing advantages, disadvantages, and common
controversies. Finally, we explore several recent technological advances
facilitating laparoscopic colon surgery, including hand-assist technologies,
hemostatic devices, and new laparoscopic imaging systems.

* Corresponding author.
E-mail address: rboushey@ottawahospital.on.ca (R.P. Boushey).

0039-6109/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.suc.2006.05.006 surgical.theclinics.com
868 MARTEL & BOUSHEY

Laparoscopic surgery for malignant disease

Port site metastases
In 1993, Alexander and colleagues [6] reported a case of wound recurrence
at 3 months following a laparoscopically-assisted right hemicolectomy in a 67-
year-old woman who had Dukes’ C adenocarcinoma. In a similar fashion,
O’Rourke and coworkers [7] described port site recurrences merely 10 weeks
following resection of a Dukes’ B adenocarcinoma with intent to cure. Over-
all, greater than 35 cases of port site metastases associated with laparoscopic
colon cancer resection were published within a 2-year span of this initial
report, including both limited and advanced primary lesions [8]. The true
incidence of port site recurrences was unknown at the time, leading Wexner
and Cohen [9] to report a series incidence of 6.3% (range 1.5%–21%) among
all published cases up to 1995. These data stand in sharp contrast with rates of
wound recurrences in colon resections performed via traditional laparotomy.
Indeed, a retrospective series by Hughes and colleagues [10] found a rate of
0.81% (CI 0.43%–1.38%) among 1603 patients undergoing traditional
open resection between 1950 and 1980, whereas Reilly and coworkers [11]
found only 11 cases among 1711 reviewed patients (0.64%, CI 0.32%–1.15%)
from 1986 to 1989. Thus, when compared with rates of wound metastases in
open resections, early data did seem to indicate that laparoscopic manage-
ment of colon malignancies compromised oncologic safety, despite the poor
quality of the evidence available at the time.
In response to these concerns, the American Society of Colon and Rectal
Surgeons recommended that laparoscopic colon resections for malignant dis-
ease be limited to formal prospective data collection [12]. The data obtained
from these studies were most helpful in determining the true incidence of
port site recurrences in minimally invasive colon surgery. In a critical review
of the literature from 2001, Zmora and colleagues [8] analyzed a total of 16
series of laparoscopic colorectal resections for carcinoma published between
1993 and 2000, each comprising greater than 50 patients, and found an inci-
dence of port site metastases of less than 1% among 1737 patients. Using
a similar methodology, Allardyce [13] found an incidence of 0.85% (CI
0.14%–1.18%) among 1769 patients. More recently, data from well-designed,
randomized controlled trials have provided definitive evidence against
a higher incidence of port site metastases in laparoscopic colon surgery com-
pared with traditional resection (Table 1). The Clinical Outcomes of Surgical
Therapy (COST) study [14], in which 872 patients were randomized to lapa-
roscopically assisted or open colectomy for cancer, reported only two such
patients (0.5%) who had wound recurrences within the laparoscopic arm,
compared with one for the open arm (0.2%, P ¼ 0.50) after a median
follow-up of 4.4 years. Similarly, Lacy and colleagues [15] found a single
case of port site recurrence within their laparoscopic surgery group (n ¼ 106)
and none within their open group (n ¼ 102) after a median follow-up of
Table 1
Major randomized controlled trials comparing laparoscopic and open surgery for colon cancer
No. patients No. Conversion Port site
Authors/studies Year (lap/open) centers Disease site rate metastases Outcomes Follow-up

LAPAROSCOPIC COLON SURGERY

COLOR [22,38] 2005 627/621 Multi (29) C 19% - Short-term, costs -
Guillou et al [23] 2005 526/268 Multi (27) C, R 29% - Short-term, QoL -
COST [14,33,55] 2004 435/437 Multi (48) C 21% 0.5% Short-term, long-term, QoL, costs 4.4 years
Leung et al [50] 2004 203/200 Single R, S 23% 0% Short-term, long-term, costs 4.4 years
Kaiser et al [18] 2004 29/20 Single C 45% 0% Short-term, long-term 2.9 years
Hasegawa et al [32] 2003 29/30 Single C, R 17% 0% Short-term, immunology 1.7 year
Lacy et al [15] 2002 111/108 Single C 11% 0.94% Short-term, long-term 3.6 years
Braga et al [122] 2002 136/133 Single C, R 5% 0% Short-term, costs, immunology 1.0 year
Tang et al [123] 2001 118/118 Single C, R 13% - Immunology -
Curet et al [17] 2000 25/18 Single C, R 28% 0% Short-term, long-term 4.9 years
Milsom et al [16] 1998 55/54 Single C, R - 0% Short-term 1.5 years
Schwenk et al [27,31] 1998 30/30 Single C, R - - Short-term -
Stage et al [29] 1997 18/16 Single C 17% 0% Short-term, immunology 1.2 years
Abbreviations: C, colon, excluding transverse; Multi, multi-center trial; QoL, quality of life; R, rectum; S, sigmoid colon; Single, single-center trial.

869
870 MARTEL & BOUSHEY

43 months. Three additional smaller prospective trials comprising a total of 201

patients randomized between laparoscopic-assisted and open resection for co-
lon cancer found no additional case of port site or wound tumor recurrence
[16–18]. As such, the evidence to date indicates that patients undergoing lap-
aroscopic resection of colon malignancies are at no increased risk of port site
metastases compared with those undergoing open surgery. It appears that early
reports of high rates of port site recurrences were in fact related to surgeon
inexperience, and inappropriate handling of the tumor laparoscopically [19].

Adequacy of oncologic resection

The goals of laparoscopic colectomy performed in the setting of colon can-
cer are the same as for open surgery. Those involve appropriate vessel ligation,
adequate resection with 5 cm proximal and distal resection margins, and rad-
ical mesenteric lymphadenectomy. In addition, a thorough inspection of the
abdominal cavity and liver surface is expected, together with the creation of
a reliable anastomosis. Many of these elements have been evaluated in the
context of clinical trials. Perhaps the most extensively studied factors have
been the number of recovered lymph nodes within surgical specimens and
the adequacy of resection margins. A recent meta-analysis [20] reviewed five
randomized controlled trials reporting specifically on these issues, and found
no significant difference between laparoscopic and open resection groups.
Similarly, a Cochrane Collaboration review of 7 trials comprising 688 patients
[21] found no difference in the total number of retrieved lymph nodes between
the two groups (P ¼ 0.86). Recent pathological data from large-scale, ran-
domized controlled clinical studies further support these conclusions. Indeed,
the European Colon Cancer Laparoscopic or Open Resection (COLOR)
Study Group found identical rates of positive resection margins of 2% be-
tween their two groups (P ¼ 1.0) [22], whereas the UK Medical Research
Council trial of Conventional versus Laparoscopic-Assisted Surgery in Colo-
rectal Cancer (MRC CLASICC) reported nonsignificant positive circumfer-
ential resection margins of 7% and 5% (P ¼ 0.45) in laparoscopic-assisted
and open resections, respectively [23]. In the COST study [14], the median
number of recovered lymph nodes was 12 in both study arms, whereas longi-
tudinal resection margins of less than 5 cm were present in only 5% and 6% of
laparoscopic and open colectomies, respectively (P ¼ 0.52). Despite the lack
of good data on other elements of adequate oncologic surgery mentioned ear-
lier, there appears to be no appreciable difference in the oncologic outcomes
between laparoscopic and open colectomies for cancer.

Short-term outcomes
Much like other minimally invasive surgical procedures, laparoscopic co-
lon surgery offers numerous short-term benefits, including reduced postop-
erative pain, potentially improved quality of life, shorter length of stay in
 LAPAROSCOPIC COLON SURGERY 871

hospital, quicker recovery of bowel function, and potentially, costs savings

(see Table 1). These factors can be extremely advantageous for the patient,
but must nonetheless be balanced against increased operating time required
to perform these procedures. Although the mean increase in operating time
seems to approach 1 hour in the literature [24], this value does appear to de-
crease significantly with surgeon experience [25].
Faster recovery of bowel function is one of the important potential ben-
efits of laparoscopic colon surgery, because this often impacts on the dura-
tion of the postoperative hospital stay. Schwenk and colleagues [21] found
that first passage of flatus was typically 1.0 day earlier in the laparoscopic
colectomy group (P!0.0001), whereas passage of first bowel movement
was 0.9 days earlier (P!0.0001). More recent randomized controlled trials
also demonstrated a shorter recovery in bowel function, namely a report by
Kaiser and coworkers [18], as well as the recent COLOR trial [22], both of
which showed a significant decrease in time to first stool after laparoscopic
colectomy. The major criticism associated with these studies is that exam-
iners were not blinded with respect to the procedure performed, thus poten-
tially allowing a positive discriminating bias in favor of patients treated
laparoscopically. In addition, several studies failed to standardize the post-
operative diet regimen, although Lacy and colleagues [15] used a strict pro-
tocol and demonstrated faster initiation of peristalsis and oral intake in
patients undergoing laparoscopic colectomy. Despite these limitations in-
herent to nonblinded trials, objective evidence of improved peristalsis favor-
ing laparoscopic colectomy has been published in the form of animal
experiments [26], as well as clinical motility studies involving radio-opaque
markers [27] and manometric recordings at the splenic flexure [28]. Thus,
high-level evidence indicates that laparoscopic colectomy offers faster bowel
function recovery than open surgery.
Numerous randomized controlled trials have demonstrated a significant
reduction in pain or analgesic requirements in the immediate postoperative
period [14,16,18,22,29–32]. In fact, data from the Cochrane Collaboration
meta-analysis by Schwenk and colleagues [21] supports a difference in
pain perception limited to the first (P!0.0001) and third (P ¼ 0.0002) post-
operative days, with no statistically significant difference found on post-
operative day 2 (P ¼ 0.16). In another meta-analysis, Abraham and
coworkers [20] found significant advantages for the laparoscopic colectomy
group in pain levels at rest and during coughing, from 6 to 8 hours until 3
days postoperatively. More recently, data from the COST study [14] showed
that patients treated with laparoscopic colectomy required on average fewer
days of both parenteral narcotics (3 versus 4 days, P!0.001) and oral anal-
gesics (1 versus 2 days, P ¼ 0.02), when compared with open resection. Sim-
ilarly, short-term outcomes from the COLOR trial [22] showed a lower need
for opioid analgesia on postoperative days 2 and 3, as well as a lower need
for nonopioid analgesia on postoperative day 1 within the laparoscopy
group. When compared with postoperative pain indices, results from quality
872 MARTEL & BOUSHEY

of life surveys have been less impressive in demonstrating a difference be-

tween patients treated by laparoscopic versus open colon resection. In an in-
terim analysis of the COST trial, Weeks and colleagues [33] administered
three different quality of life assessment scales to patients randomized to ei-
ther laparoscopic-assisted (n ¼ 228) or open colectomy (n ¼ 221). Although
the authors did show a significant difference in the number of days of oral
and parenteral analgesia requirements, they did not find any significant dif-
ferences in quality of life indices at 2 days, 2 weeks, and 2 months postop-
eratively, except for the global rating scale at 2 weeks in favor of the
laparoscopic group. Similarly, the authors of the MRC CLASICC trial
[23] administered the QLQ-C30 and QLQ-CR38 quality of life question-
naires to patients randomized to laparoscopic-assisted (n ¼ 526) or open
surgery (n ¼ 268) for colon cancer. They found very little difference between
the two treatment arms at 2 weeks and 3 months follow-up, with most in-
struments showing equally worse quality of life at 2 weeks, with a return
to baseline at 3 months. Despite these disappointing results, it should
be noted that the quality of life instruments used in the COST and MRC
CLASICC trials were not designed to assess acute to subacute postoperative
patients who have potentially curable cancers. Although convenient because
of their established validity, all but one of the questionnaires used were
taken from the oncology literature, focusing heavily on chronic pain issues.
Thus it is possible that meaningful quality of life differences between the two
groups may have been missed because of the lack of a more sensitive and
appropriate instrument. Therefore, based on the literature available thus
far, the superiority of laparoscopic surgery in reducing immediate postoper-
ative pain following colon resection seems evident. On the other hand,
short- to medium-term quality of life indices assessed in two randomized
controlled trials do not appear to improve with laparoscopic surgery, war-
ranting further investigation using quality of life instruments dedicated for
colon cancer surgery.
Length of hospital stay following colorectal surgery is often dependent
upon bowel function recovery and the severity of postoperative pain.
With the exception of one study [16], all reported randomized studies thus
far have shown a shorter length of stay in hospital with laparoscopic colon
resection compared with open surgery, with a wide variability in total length
of stay between centers [14,15,17,18,22,23,29,31–33]. Although none of these
studies were blinded to the treating surgical team, it is unlikely that this
overwhelming trend in the literature is the result of an early discharge selec-
tion bias in favor of patients treated laparoscopically. A more recent meta-
analysis [21] found that the length of stay in hospital was indeed 1.5 days
shorter in the laparoscopic group (CI -1.94 to -1.12, P!0.0001). It should
be noted that patients whose laparoscopic procedure was converted to
open had in fact a longer length of stay than those who had conventional
open resections, highlighting the importance of identifying this subgroup
of patients preoperatively [23]. Nevertheless, there is high-level evidence
 LAPAROSCOPIC COLON SURGERY 873

indicating that laparoscopy for colon cancer is associated with a shorter stay
in hospital compared with laparotomy.

Costs
Direct costs following laparoscopic surgery for colon cancer are generally
assumed to be higher than those incurred with equivalent open procedures;
however, certain authors have argued that total costs to society may actually
be lower for patients receiving laparoscopic surgery, given the improved
short-term and potential long-term outcomes associated with the minimally
invasive approach. A number of early publications limited to malignant dis-
ease have found conflicting data, with all papers reporting higher or similar
costs associated with laparoscopic colon resection [34–36]. One of these
studies by Philipson and colleagues [35] retrospectively assessed 61 consec-
utive patients who had undergone either laparoscopic-assisted (n ¼ 28) or
open (n ¼ 33) right hemicolectomy for adenocarcinoma. By breaking
down total incurred expenditures into direct (operating room, recovery,
ward, intensive care unit) and indirect (hospital overhead) costs, but exclud-
ing any preoperative or postdischarge expenses, the authors reported a total
of $9064 for laparoscopic-assisted procedures versus $7881 for open hemi-
colectomy (P!0.001). It is important to note that this study has significant
limitations, including its retrospective nature and the lack of data regarding
postdischarge societal costs, which one would predict to be lower in the lap-
aroscopic surgery group. In addition, this report is one of only a handful
that failed to show a shorter length of stay in hospital with a laparoscopic
approach, a fact which could have substantially increased the hospital costs
associated with this group. On the other hand, another retrospective study
by Khalili and colleagues [36] reported no significant difference in total costs
between the procedures (P ¼ 0.48), despite higher operating room costs in
the laparoscopic group. More recently, data from a case-controlled series
of 150 laparoscopic and 150 open colorectal procedures [37] demonstrated
higher operating room expenses associated with laparoscopy. The total di-
rect costs were significantly lower in this same group, however, owing to
shorter stay in hospital and lower pharmacy, laboratory, and nursing expen-
ditures. The only costs data available from high-quality, randomized con-
trolled trials have recently been reported in two separate studies. The first
one [38], an interim analysis of the European COLOR study, compared
98 cases of laparoscopic colectomy for cancer compared with 112 open
cases. In the context of a significantly longer operating room time in the lap-
aroscopic group and a similar length of stay in hospital, Janson and co-
workers found significantly higher total primary operation costs (V3493
versus V2322, P!0.001) and total cost of first admission (V6931 versus
V5375, P ¼ 0.015) in the laparoscopic colectomy group compared with
the open group; however, productivity loss was greater in the open group
(V2579 versus V2181), yielding no statistically significant difference in total
874 MARTEL & BOUSHEY

costs between the two groups (V11,660 versus V9814, P ¼ 0.104) [38]. On
the other hand, the second major trial [39] assessed 512 patients randomized
to laparoscopic versus open colectomy for colorectal cancer. The authors re-
ported net extra costs per patient of V125 within the laparoscopic group, re-
lated to V1171 in additional operating costs, and savings of V1046 in
postoperative complications [39]. Therefore, the data available in the litera-
ture do not provide adequate evidence on whether total costs significantly
differ between laparoscopy and conventional open surgery in the treatment
of colonic malignancy. It appears that costs may differ significantly, depend-
ing on health care systems and local practices.

Long-term outcomes
Long-term outcomes following laparoscopic resection for colon cancerd
namely tumor recurrence, disease-free survival, and overall survivaldare
much more challenging to assess than short-term outcomes. Since the incep-
tion of minimally invasive techniques for resecting colon cancer, a number
of prospective and retrospective case series [40–46], cohort studies [47–49],
and randomized controlled trials [18,50] have provided low- to moderate-
quality evidence regarding the equivalency of laparoscopic and open colonic
resections. The vast majority of comparative studies published thus far have
found no significant difference in long-term outcomes between laparoscopic
and open resections, and case series have found recurrence and survival data
that measure up favorably with accepted rates for traditional colon
resections.
In 2002, Lacy and colleagues [15] published one of the first landmark ran-
domized controlled trials comparing laparoscopic-assisted (n ¼ 105) and
open resection (n ¼ 101) for colon cancer. The study authors reported tu-
mor recurrence rates of 17% and 27% respectively, with a nonsignificant
trend favoring laparoscopic resection (P ¼ 0.07). Similarly, based on an in-
tention-to-treat analysis, the overall mortality rates were not significantly
different between the laparoscopic and open resection groups (18% versus
26%, P ¼ 0.14), but the rates of cancer-related mortality favored the lapa-
roscopic group (9% versus 21%, P ¼ 0.03). When analyzed by procedure
actually performed, the differences in rates of tumor recurrence, overall
mortality, and cancer-related mortality, all became strongly statistically sig-
nificant in favor of the laparoscopic approach. Interestingly, by analyzing
patients based on cancer staging, the Lacy group demonstrated that the
overall advantages found with the laparoscopic approach were attributable
to a subgroup of patients who had locally-advanced Stage III disease [15].
Indeed, these data by Lacy and coworkers seem to suggest that laparoscopic
resections may provide a potential survival advantage for Stage III colon
cancer. The mechanism behind these data is speculative at best, but may
be related to alterations in immune function with laparoscopy. At least
one other large case series has described a similar survival advantage in
 LAPAROSCOPIC COLON SURGERY 875

locally-advanced disease [51]. Although very interesting and provocative,

these results have yet to be replicated in other large-scale randomized
studies.
Despite Lacy’s report, laparoscopic surgery for malignant disease of the
colon has only recently become an acceptable routine procedure, following
the publication of long-term outcomes data from the COST study [14]. As
stated earlier, this multicenter trial randomized 435 patients to laparo-
scopic-assisted colectomy and 428 patients to undergo traditional open co-
lectomy. The surgeons participating in this study were required to meet
strict adherence criteria, providing video evidence of proficiency in laparo-
scopic colon surgery. Despite this safeguard mechanism, the conversion
rate in this study was 21%. After a median follow-up of 4.4 years, the study
authors reported tumor recurrence in 76 and 84 patients (P ¼ 0.32) within
the laparoscopic and open groups, respectively, with no significant differ-
ence noted for time to recurrence and at different stages of disease. Simi-
larly, the 3-year survival rate was 86% for the laparoscopic-assisted group
and 85% for the open group (P ¼ 0.51), with comparable disease-free sur-
vival rates (P ¼ 0.70). It is fair to say that the COST study group demon-
strated that laparoscopic colectomy for curable cancer is safe and at least
equivalent to open resection in experienced hands [14]. The implications
of the COST trial results have been far-reaching, including endorsement
by American Society of Colon & Rectal Surgeons in a recent position state-
ment [52]. It should be noted that long-term outcomes data from the Euro-
pean COLOR and MRC CLASICC trials had yet to be published at the
time of manuscript preparation.
Finally, the issue of conversion to open surgery after attempting laparo-
scopic resection for colon cancer should be discussed briefly. Indeed, data
exist in the literature indicating that patients undergoing attempted laparo-
scopic resection who are subsequently converted to traditional laparotomy
fare substantially worse than either open procedures or laparoscopic resec-
tions, both with respect to short- and long-term outcomes. A recent report
by Moloo and colleagues [53] reviewing 377 consecutive cases of laparo-
scopic resections for colorectal cancer described a significantly lower overall
2-year survival rate among converted patients who had curable Stage I
through III malignancies, compared with those who had their colectomy
completed laparoscopically (75.7% versus 87.2%, P ¼ 0.0201). Similarly, re-
cently published short-term data from the multicenter MRC CLASICC trial
[23] revealed that converted patients had significantly higher postoperative
complication rates, in-hospital mortality, transfusion requirements, and
proportion of Dukes’ C2 cancers than did completed patients. It is unclear
whether these surprising outcomes were the result of an active learning curve
documented by the authors throughout this study, or whether this repre-
sents a true unexpected outcome. Adverse outcomes associated with conver-
sion have been examined by several additional groups, including a recent
report by Casillas and coworkers [54], who used a case-control strategy to
876 MARTEL & BOUSHEY

evaluate 51 such converted cases. The authors of this report found no signif-
icant short-term outcome differences between their groups of converted and
open control patients. Similarly, a recent post-hoc analysis by the COST
trial study group [55] reported no significant difference in oncologic out-
come after conversion to open surgery, both in terms of overall survival
and disease-free survival at 3 years. Thus, although there appear to be con-
flicting results regarding short-term outcomes, long-term data from one
important multicenter randomized trial do not appear to demonstrate any
adverse oncologic outcome with conversion to open surgery [55]. Short-
and long-term follow-up results from the COLOR and MRC CLASICC
trials will have to be released before one can make any further conclusions.

Laparoscopic surgery for benign disease

Inflammatory bowel disease
It is known that patients suffering from inflammatory bowel diseases
(IBD) have a high lifetime likelihood of requiring surgery. Specifically, pa-
tients who have Crohn’s disease (CD) have an 80% overall chance, whereas
patients suffering from ulcerative colitis (UC) have a 30% to 40% probabil-
ity of requiring a colectomy [56]. Given their proportionally younger age
and the risk of requiring multiple procedures, patients are increasingly seek-
ing care from specialized colorectal centers offering laparoscopic treatment
of IBD. Several short-term benefits similar to those described in colon can-
cer have been associated with laparoscopic surgery for IBD. In addition,
theoretical long-term advantages include fewer adhesions formation, de-
creased rates of bowel obstruction, decreased likelihood of chronic pain,
and decreased incidence of infertility or wound hernias [56,57].
In Crohn’s disease involving the colon, the presence of inflammatory
changes, thickened mesentery, skip lesions, and fistulas and abscesses makes
the laparoscopic approach to surgery particularly challenging. Nevertheless,
the indications for surgery remain the same as with open techniques. Ac-
cording to one review [57], up to three different minimally invasive proce-
dures can be performed, including diagnostic laparoscopy, diversion
procedures, and bowel resections, which can be approached using pure lap-
aroscopic methods or hand-assisted techniques. Two randomized controlled
trials have been published to date [58,59], with numerous small comparative
case series [60–66], making it very difficult to assess the superiority of lapa-
roscopic techniques when compared with conventional open outcomes
(Table 2). In the first study, Milsom and colleagues [58] randomized 60 pa-
tients to elective laparoscopic-assisted (n ¼ 31) or open (n ¼ 29) ileocolic
resection for CD. They reported a decreased incidence of minor complica-
tions favoring the laparoscopic group (four versus eight, P!0.05), with
a significantly faster return to preoperative pulmonary function within
this same group (2.5 versus 3.5 days, P ¼ 0.03). Interestingly, total morphine
 LAPAROSCOPIC COLON SURGERY 877

requirements and recovery of bowel function were not significantly different

between the two groups, whereas operative time was significantly shorter
within the open group (140
45 versus 85
21 minutes, P!0.0001). As
expected, incision length was substantially shorter within the laparoscopic
group (5.3
1.6 versus 12.7
5.5 cm, P!0.0001). Recently, a second trial
by Maartense and coworkers [59] used a similar comparative strategy with
60 patients who had CD. They reported shorter hospital stays (5 versus 7
days, P ¼ 0.008), lower 30-day postoperative morbidity rates (10% versus
30%, P ¼ 0.028), and lower total costs over 3 months (V6412 versus
V8196, P ¼ 0.042) within the laparoscopic resection group. Interestingly,
no significant quality of life difference was found between the two groups
using the SF-36 Health Survey and the Gastro-Intestinal Quality of Life In-
dex. Based on the data obtained from these two randomized controlled tri-
als, it appears that laparoscopic ileocolic resection for CD is advantageous
over open approaches, in addition to providing an apparent cosmetic benefit
[67]. It should be noted that the short-term benefits of laparoscopic surgery
for CD have also been supported by a recent meta-analysis on the topic [68].
Finally, long-term outcomes following laparoscopic ileocolic resection for
CD have simply not been addressed in prospective trials. As such, proposed
long-term benefits associated with the laparoscopic approach remain hypo-
thetical, and should not form the basis for choosing this method over a tra-
ditional open approach.
The surgical management of UC by minimally invasive methods is com-
plex, and has thus far been limited to highly experienced laparoscopic sur-
geons working in specialized centers. The three procedures currently
performed are laparoscopic subtotal colectomy, total proctocolectomy,
and restorative proctocolectomy [69]. As is the case in open surgery, these
procedures require the mobilization of the entire colon, as well as the taking
of several important vascular pedicles. This area of laparoscopic colon sur-
gery has paralleled the development of operative experience within special-
ized colorectal centers, and has been facilitated by the evolution of
laparoscopic technologies. Many early publications on the topic described
significantly worse postoperative outcomes among UC patients treated lap-
aroscopically compared with those receiving traditional open procedures
[70], in addition to longer operative times of up to 8 hours [71]. More re-
cently, however, data from case-controlled studies have demonstrated that
patients undergoing laparoscopic surgery for UC had no worse outcomes
than those receiving open procedures [72], despite operative times that
have remained significantly longer in most series (see Table 2). In fact,
many groups have documented shorter postoperative stays in hospital by
approximately 1 day within their laparoscopic groups [72–74], in addition
to superior body image data, and equivalent functional outcomes [74,75].
Larson and colleagues [75] have recently reported comparable functional
outcomes at a median follow-up of 13 months, among patients who had un-
dergone laparoscopic (n ¼ 33) and open (n ¼ 33) ileal pouch-anal
 878
Table 2
Major studies of laparoscopic colon resection for benign disease
Authors Year Study type No. patients (lap/open) Disease site Conversion rate Comparative outcomes*
Crohn’s disease
Maartense et al [59] 2006 RCT 30/30 IC 10% [ OR time, Y hospital stay,
Y morbidity, Y costs
Huilgol et al [66] 2004 CC 21/19 IC 5% Y time PO intake, Y bowel
time, Y hospital stay

MARTEL & BOUSHEY

Msika et al [61] 2001 PNS 20/26 SB, IC, C 0% [ OR time, Y bowel time,
Y hospital stay,
Y complications, Y costs
Milsom et al [58] 2001 RCT 31/29 IC 6% [ OR time, Y pulmonary
recovery time,
Y complications
Ulcerative colitis
Larson et al [75] 2005 CC 33/33 C - No difference in morbidity
or functional outcomes
Dunker et al [74] 2001 CC 16/19 C 0% [ OR time, Y hospital stay,
Y bowel time, [ body
image
Hashimoto et al [73] 2001 RCS 11/13 C 0% [ OR time, Y blood loss,
Y pain, Y hospital stay,
[ cosmesis
Araki et al [124] 2001 RCS 21/11 C - Y time PO intake, Y bowel
time, [ cosmesis
Marcello et al [72] 2000 CC 20/20 C 0% [ OR time, Y bowel time,
Y hospital stay
Diverticular disease
Alves et al [80] 2005 PNS 163/169 S 15% [ OR time, Y blood loss,
Y hospital say,
Y morbidity
Lawrence et al [79] 2003 RCS 56/215 S 7% [ OR time, Y hospital stay,
Y complications, Y costs
Dwivedi et al [78] 2002 RCS 66/88 S 20% [ OR time, Y blood loss, Y
hospital stay, Y time PO
intake, Y costs
Senagore et al [77] 2002 PNS 61/71 S 7% Y hospital stay,
Y complications, Y costs

LAPAROSCOPIC COLON SURGERY

Abbreviations: CC, case controlled study; IC, ileocolic; OR, operating room; PNS, prospective non-randomized study; RCS; retrospective case series; RCT,
randomized controlled trial; SB, small bowel; [, increased; Y, decreased.
* Outcome results are pertaining to the laparoscopic group, relative to the comparison group; non-statistically significant results are omitted.

879
880 MARTEL & BOUSHEY

anastomosis for UC or familial adenomatous polyposis. Despite numerous

reports highlighting the safety and feasibility of laparoscopic surgery for UC
among expert hands, no comparative randomized trial with open surgery
has yet been completed. The current level of evidence in the literature is
thus insufficient to conclude the superiority of one approach over another.
Nevertheless, it is likely that the minimally invasive approach will continue
to gain in popularity among expert laparoscopists, given its clear cosmetic
advantages and potentially improved short-term outcomes.

Diverticular disease
In recent years, laparoscopic resection methods have been successfully
applied to diverticulitis of the sigmoid colon [76]. Good data exist from
a number of nonrandomized studies highlighting the advantages of laparo-
scopic sigmoid resection in uncomplicated diverticular disease (see Table 2).
These benefits include most of the advantageous short-term outcomes asso-
ciated with laparoscopic colon surgery, and also include decreased postop-
erative wound and pulmonary complications, as well as lower direct costs
[77–79]. Recently, Alves and coworkers [80] published the results of a pro-
spective national study involving 332 consecutive patients undergoing lapa-
roscopic (n ¼ 163) or open (n ¼ 169) elective sigmoid resection for
diverticular disease. They reported significantly higher overall morbidity
rates within the open group (16.0% versus 31.4%, P!0.001), including
higher wound complications, abscesses, and fistulas, as well as significantly
longer lengths of stay in hospital within this same group. Although this
study suffered from a significant patient selection bias associated with its
lack of randomization, the study authors did determine that open colectomy
was an independent risk factor for morbidity, using a multiple logistic re-
gression analysis model. Therefore, despite the lack of large randomized tri-
als comparing open and laparoscopic sigmoid colectomy for diverticulitis,
good evidence exists supporting the use of laparoscopy for elective resec-
tions, based on improved short-term outcomes [76]. One should keep in
mind, however, that this conclusion does not necessarily hold true for com-
plicated diverticular disease. Some groups have shown significant increases
in morbidity and conversion rates associated with laparoscopic resection of
complicated diverticulitis [81]. It is recommended that such resections be
performed by experienced laparoscopists.

Emerging techniques and technologies

Since the early days of laparoscopic colon surgery, techniques and tech-
nologies have evolved to render this procedure more amenable to routine
use by general surgeons. Putting aside issues of oncologic safety and out-
come equivalency between laparoscopic and open colorectal procedures, it
remains that laparoscopic-assisted colectomy is a difficult technique to
 LAPAROSCOPIC COLON SURGERY 881

adopt for surgeons without advanced minimally invasive surgical training.

Conversion rates as high as 29% have been described [23], highlighting
the steep learning curve associated with this procedure. Many new tech-
niques and technologies have emerged in an attempt to flatten this learning
curve, in part by relying upon skills surgeons have acquired in open surgery.

Hand-assist devices
Simply stated, hand-assisted laparoscopic surgery (HALS) involves the
insertion of a hand inside the abdomen during a laparoscopic procedure,
while maintaining pneumoperitoneum, to facilitate the procedure. The po-
tential clinical benefits of hand-assist technology in laparoscopic colon sur-
gery are significant. They include the restoration of tactile sensation and
proprioception, the ability to perform blunt dissection, the ability to retract
organs atraumatically, the ability to apply immediate hemostatic pressure,
and a potential reduction in the total number of ports required during sur-
gery. In cases of resection for malignancy, hand-assist devices restore the
surgeon’s ability to palpate the tumor. In short, hand-assist devices have
the potential to provide the operating surgeon with many of the technical
advantages of open surgery, while maintaining the short-term benefits of
minimally invasive surgery.
Since the early days of laparoscopic colon resections, attempts have been
made at inserting a hand inside the abdomen to help with the procedure.
The evolution of hand-assisted laparoscopic surgery has paralleled the evolu-
tion of technologies to maintain pneumoperitoneum, while allowing for con-
venient access to the abdomen by a hand or laparoscopic instruments [82]. In
1995, Ou [83] first reported his experience with the hand-assisted technique,
whereby he inserted his hand in the peritoneal cavity using a 5 to 6 cm incision
and maintained pneumoperitoneum with two stay stitches to tighten the fascia
around his hand. Comparing two cohorts of 12 patients each undergoing
hand-assisted laparoscopic or open colectomy, Ou reported shorter lengths
of stay in hospital for the hand-assisted group (5.6 versus 8.3 days), despite
slightly longer total operating time (135 versus 100 minutes). Other groups
have also reported their own uncontrolled case series, emphasizing short stays
in hospital and the lack of conversion to open resection [84,85].
Based on these early results, a number of hand-access devices have been
marketed to facilitate hand-assistance in minimally invasive surgery. So-
called ‘‘first generation devices’’ were all built in a similar fashion, including
a type of sleeve secured between the abdominal wall and the surgeon’s fore-
arm to prevent leakage of carbon dioxide, as well as a circular base designed
to adapt to the contour of the abdominal wound [82]. These devices include
the Dexterity Pneumo Sleeve (Dexterity Surgical, San Antonio, Texas), In-
tromit (Applied Medical, Rancho Santa Margarita, California), Handport
(Smith & Nephew Endoscopy, Andover, Massachusetts), and Omniport
(Advanced Surgical Concepts, Bray, Ireland). These initial designs all
882 MARTEL & BOUSHEY

suffered from similar problems, including hand fatigue for the operating sur-
geon and regular leakage of pneumoperitoneum in as many as 41% to 48%
of cases [86,87]. The latter problem specifically resulted in conversion to
open surgery in 14% of reported cases in one series [86]. More recently,
sleeveless hand-port technology has been introduced on the market, includ-
ing the Gelport (Applied Medical, Rancho Santa Margarita, California) and
LapDisc (Ethicon Endosurgery, Cincinnati, Ohio) devices. These second-
generation designs include a wound-contouring system that maintains the
system in place, in addition to a reliable lock-on gel or disclike cover top
that seals the device shut [82]. Effectively, the self-sealing nature of these
new constructs provides a functional ‘‘port’’ into the abdomen, allowing
the surgeon to insert or withdraw a hand at will. In addition, this property
permits the use of laparoscopy trocars, cameras, or instruments, thus max-
imizing the utility of this port and minimizing the need for additional port
sites on the abdominal wall.
Data regarding the validity of HALS in colon surgery now exists in the
form of several case series, as well as an increasing number of randomized
controlled trials (Table 3). In 1999, the Southern Surgeons’ Club Study
Group [86] published results of their multicenter prospective study involving
58 patients who underwent HALS, of whom 22 had mixed colon proce-
dures. The average operating time for this subgroup was 157 minutes (94–
240 minutes), with a mean length of stay in hospital of 6.4 days. Both figures
compare favorably with previously published data from large trials of lapa-
roscopic colectomy [14,22]. In another randomized controlled trial compar-
ing hand-assisted (n ¼ 22) versus standard laparoscopic (n ¼ 18) colorectal
resections for a variety of benign conditions and incurable malignancy, the
HALS Study Group reported slightly shorter, albeit nonsignificant, opera-
tive time for the laparoscopic surgery group (152
66 versus 141
54 min-
utes, P ¼ 0.58) [87]. After removing seven cases of conversion to open
surgery from the analysis, operative time became somewhat more favorable
for the hand-assisted group (144 versus 152 minutes, P ¼ 0.70). Lengths of
incision, number of cases converted to open, and stay in hospital were all
similar between the two study groups. In another study, Targarona and col-
leagues [88] randomized 54 patients who had diagnoses of cancer, polyps, or
volvulus to hand-assisted or laparoscopic colectomy. Although this group
reported similar total anesthetic times, it did find higher conversion rates
among laparoscopic patients (7% versus 22%), leading surgeons to find
a clear subjective advantage for the hand-assisted procedure in 13 of 54
cases. The authors of this study found no significant difference in length
of stay in hospital, requirements for analgesia, overall morbidity rate, onco-
logical features, or costs of the procedures. Although not performed on an
intention-to-treat basis, an analysis of interleukin-6 and C-reactive protein
inflammatory markers revealed a significantly higher postoperative increase
in the hand-assisted colectomy group, highlighting the greater tissue trauma
generated by this procedure compared with simple laparoscopy [88].
Table 3
Major studies of hand-assisted laparoscopic surgery in colonic resections
Authors/studies Year Study type Comparison groups No. patients Diseases Comparative outcomes*
Segmental resections
Chang et al [89] 2005 PNS HALS versus LAP 66/85 B, M, P Y OR time (P ¼ 0.07),
[ incision, Y conversion

LAPAROSCOPIC COLON SURGERY

Kang et al [90] 2004 RCT HALS versus OPS 30/30 B, M, P Y incision, Y analgesia,
Y blood loss, Y bowel time
Targarona et al [88] 2002 RCT HALS versus LAP 27/27 B, M, P Y conversion,
[ inflammation
HALS Study Group [87] 2000 RCT HALS versus LAP 22/18 B, I, P Comparable results
Southern Surgeons’ Club 1999 PNS HALS 24 B, M, P N/A
[86]
Total abdominal colectomy/total proctocolectomy
Maartense et al [94] 2004 RCT HALS versus OPS 30/30 B [ OR time
Rivadeneira et al [92] 2004 RCT HALS versus LAP 10/13 B Y OR time, Y bowel time
Nakajima et al [93] 2004 RCS HALS versus LAP 12/11 B Y OR time, Y number of
trocars
Abbreviations: B, benign; HALS, hand-assisted laparoscopic surgery; I, incurable malignant; LAP, laparoscopic surgery; M, malignant; OPS, open sur-
gery; P, polyps; PNS, prospective non-randomized study.
* Outcome results are pertaining to HALS, relative to the comparison group; non-statistically significant results are omitted.

883
884 MARTEL & BOUSHEY

Though interesting, these data did not appear to influence the immediate
postoperative clinical outcome.
More recently, Chang and coworkers [89] reported the results of a larger
cohort study in which they compared 66 patients undergoing hand-assisted
segmental resections with 85 undergoing standard laparoscopic colectomy.
Both groups were well-matched in terms of demographics and diagnosis.
The authors found a trend toward shorter average operative time in the
hand-assisted group (189 versus 205 minutes, P ¼ 0.07), with a significantly
decreased need for conversion to open surgery in this same group (0% ver-
sus 13%, P!0.01). No differences were noted in any of the standard post-
operative variables. Interestingly, the authors noted that despite the
advantageous conversion data and equivalent postoperative results, propor-
tionally more hand-assisted resections were performed by surgeons with lim-
ited minimally invasive surgery experience compared with the laparoscopic
colectomy group (27% versus 16%, P!0.05), highlighting the potential
value of this technology in training laparoscopic surgeons. In another recent
study, Kang and colleagues [90] randomized 60 patients to undergo either
hand-assisted laparoscopic colectomies or traditional open resections. To
the authors’ knowledge, this report is the only randomized-controlled trial
to date comparing HALS and open surgery for segmental colon resections.
Whereas reported operating times were similar between the two groups, the
study authors reported significantly less blood loss (193
85 cc versus 343

143 cc, P!0.001), and shorter incision length (7.17
0.38 cm versus 13.73

1.87 cm, P!0.001) with the HALS procedure compared with open resec-
tions. They commented that the favorable operative time obtained in the
hand-assisted group may have been related to the use of new dissection tech-
nologies. Similarly, time to oral intake, time to passage of flatus and stool,
use of analgesia, and length of hospital stay were all significantly better in
the hand-assisted group compared with the laparotomy group. Finally,
pain scores were significantly lower on postoperative days 1, 3, and 14,
but were equivalent on day 30 [90]. Overall, the data presented by Chang
and colleagues and by Kang and coworkers indicate that hand-assisted
laparoscopic techniques may be equivalent to standard laparoscopy for seg-
mental resections of the colon in terms of short-term outcomes. Data from
larger randomized-controlled trials will be necessary to confirm this state-
ment. Given that most general surgeons perform only a few colon resections
each year [91], it is likely that modern sleeveless handport devices will be
helpful in flattening the learning curve associated with laparoscopic colon
surgery, and will help in bridging the transition between the purely open
and minimally invasive approaches.
Hand-assisted technologies were also recently studied in the context of
highly complex colorectal procedures, such as total proctocolectomy with il-
eal pouch-anal anastomosis or total abdominal colectomy. Given the extent
of the colonic and rectal dissections involved in these cases, it is logical to
consider these procedures separately from simple segmental resections of
 LAPAROSCOPIC COLON SURGERY 885

the colon. Rivadeneira and colleagues [92] compared two series of patients
who had undergone hand-assisted (n ¼ 10) or standard laparoscopic
(n ¼ 13) restorative proctocolectomy for UC or familiar adenomatous
polyposis using a prospective database. Interestingly, the study authors
found no difference in incision size or length of stay in hospital between
the two approaches, but did appreciate a small difference in operative
time favoring the hand-assisted group (247 [210–390] versus 300 [240–400]
minutes, P!0.01). In another retrospective study, Nakajima and coworkers
[93] reported similar results, including shorter operative time in hand-assis-
ted total colectomy, but otherwise equivalent intra- and postoperative
courses. Although these two studies seem to indicate that total colectomy
is easier to perform using hand-assist devices than standard laparoscopy,
both suffer from very small sample sizes and retrospective methodologies.
As such, a recent randomized controlled trial performed by Maartense and
colleagues [94] is particularly interesting. In this study, the authors compared
patients undergoing hand-assisted laparoscopic (n ¼ 30) versus open (n ¼ 30)
total proctocolectomy with ileal pouch anal anastomosis. They found no
difference in postoperative pain, morphine requirements, time to recovery
of bowel function, length of stay in hospital, or quality of life between the
two groups. The only significant results were related to increased operative
time and costs associated with the hand-assisted laparoscopic procedure. It
should be noted that the authors used relatively rigid postoperative care
protocols, which may have skewed the results in favor of the open approach.

New dissection technologies

Obtaining reliable hemostatic control in mesocolic or mesorectal dissec-
tion is not always straightforward, particularly when inflammatory pro-
cesses such as diverticulitis, or inflammatory bowel disease are present
[95]. As such, a number of different methods have been used for hemostatic
control, including monopolar and bipolar coagulation, clips, staples, su-
tures, and ultrasonic dissection. In this section, we review the use and role
of two such relatively novel technologies: the high-frequency ultrasonic
scalpel and the electrothermal bipolar vessel sealer.
The ultrasonic scalpel was first introduced for laparoscopic use by Ama-
ral in 1994 [96]. Today, three different models of ultrasonically-activated
scalpels exist on the market: Harmonic Scalpel/UltraCision (Ethicon Endo-
surgery, Cincinnati, Ohio), AutoSonix (United States Surgical, Norwalk,
Connecticut), and SonoSurg (Olympus Surgical, Orangeburg, New York).
These instruments consist of laparoscopic shears that are induced to vibrate
at a frequency of 23.5 to 55.5 kHz using a piezoelectric transducer over a 80
to 200 mm arc at the functional tip. This high-frequency vibration is said to
achieve hemostasis at low temperatures (50 C–100 C) by denaturing pro-
teins, thus producing a sticky coagulum that effectively seals blood vessels
up to 5 mm in diameter [97]. It should be noted that this proposed
886 MARTEL & BOUSHEY

mechanism of action was challenged in a recent experimental study by Fo-

schi and colleagues [98]. In contrast to ultrasonic dissection, traditional elec-
trosurgery uses much higher temperatures (150 C–400 C) to rapidly
desiccate and char tissues, resulting in eschar formation that seals the bleed-
ing area. Based on these differences, several advantages favoring ultrasonic
technology have been proposed, including the ability to coagulate in close
proximity to other structures, given the theoretical lack of thermal damage
to adjacent tissues, the absence of charring, the absence of smoke, and the
ability to use the ultrasonic scalpel for dissection, cutting, grasping, and tis-
sue coagulation, thus saving valuable operative time [97]. Potential limita-
tions of this technology include high costs, the limited availability of
reusable shears (both Harmonic Scalpel and AutoSonix are disposable),
possible coagulation failure caused by inadequate power application or
grip strength, and the creation of a vapor mist that has the potential to con-
tain viable cells [97].
Despite the theoretical benefits of ultrasonic dissection, care must be
taken given the data obtained by Emam and Cuschieri in a porcine model
[99]. Indeed, they demonstrated histologically that despite the lack of mac-
roscopic damage, ultrasonic dissection of the colon at power level 5 for
more than 10 seconds caused partial- to full-thickness injury to the adjacent
ureters, in the context of a large zone of significant hyperthermia surround-
ing the instrument. Nevertheless, the study authors found nonsignificant
changes surrounding the dissection when they limited their use of the ultra-
sonic scalpel to 5 second bursts at a power level of 3. Emam and Cuschieri
thus recommend the use of level 4 power in short bursts of 5 seconds or less
for routine dissection, and level 3 power in the presence of important sur-
rounding structures [99]. The cost of this technology is another important
issue. It has been addressed in two studies of laparoscopic hysterectomy
and Nissen fundoplication, comparing the use of ultrasonic shears with
endoscopic staplers and clip applicators, respectively [100,101]. In both
instances, the study authors reported lower costs associated with ultrasonic
dissection, given the need for additional stapler cartridges or clip applica-
tors. Finally, the issue of potentially viable cellular debris within the vapor
mist created by ultrasonic dissection should be addressed, because it is
directly relevant to the routine use of this technology in colon cancer. In
an experimental rat tumor model, Nduka and colleagues [102] demon-
strated that despite the release of airborne cellular debris from ultrasonic
dissection, no viable cells were present and no subsequent growth occurred
in vitro.
Only limited clinical data exists regarding the safety and efficacy of ultra-
sonic dissection in laparoscopic colon resection. In one such study, Heili and
coworkers [103] reviewed 85 patients undergoing laparoscopic-assisted right
hemicolectomy or sigmoid resection using either traditional instruments or
ultrasonic shears. They reported favorable operative times (P ¼ 0.1989)
and lengths of stay in hospital (P ¼ 0.0018) for the ultrasonic dissection
 LAPAROSCOPIC COLON SURGERY 887

group. Similarly, a recent prospective series of 34 colorectal resections by

Msika and colleagues [104] demonstrated the short-term safety of this in-
strument, with no reported bleeding complications. Moreover, they also ar-
gued in favor of a cost advantage for ultrasonic dissection in this setting,
when compared with the use of an average 2.5 clip applicators in laparo-
scopic colorectal resections. The only randomized controlled trial available
to date was published recently, comparing ultrasonic versus monopolar elec-
tric dissection in laparoscopic colorectal surgery [105]. In this study, 146 pa-
tients were randomized to ultrasonic dissection (n ¼ 74) or monopolar
electrosurgery (n ¼ 72), with bipolar cautery used in both groups at the dis-
cretion of the operating surgeon. The study authors reported equivalent op-
erative times, except for low anterior resections, for which ultrasonic
dissection was significantly shorter (95.4 versus 115.6 minutes, P ¼ 0.01),
and reported significantly reduced overall intraoperative blood loss
(140.79 versus 182.58 mL, P ¼ 0.032). All other studied parameters were
found to be equivalent between the two study groups, including operative
complications, conversion rates, time to recovery of bowel function, stay
in hospital, and postoperative complications. Nevertheless, the authors
did report a very significant rate of conversion to ultrasonic dissection
(20.8% or 15/72 patients) within the standard electrosurgery group. This
conversion was based on the operating surgeon’s judgment that ultrasonic
dissection was essential to the safe completion of the procedure laparoscopi-
cally, and was more frequent during right hemicolectomy (26%) and low an-
terior resection (26%) [105]. Despite concerns raised by the authors of that
report regarding the high costs of the technology, ultrasonic dissection ap-
pears to be valuable in complex laparoscopic colorectal resections, perhaps
more so when issues of learning curves are taken into consideration. Further
studies will be required to ascertain the true effectiveness of the ultrasonic
scalpel over other hemostatic devices.
The electrothermal bipolar vessel sealer (LigaSure, Valleylab, Boulder,
Colorado) is another relatively new hemostatic device in laparoscopic sur-
gery. Its mechanism of action is entirely different from that of the ultrasonic
scalpel, relying on high current (4 amps) and low voltage (!200 volts) to
denature the collagen and elastin within vessel walls [106]. This reaction,
combined with the high compression pressure of the instrument, effectively
seals vessels up to 7 mm in diameter by rearranging the collagen and elastin
across the collapsed vessel wall. Clinically, this process yields a translucent
band of tissue that can then be cut using a second instrument, or using the
internal blade of the laparoscopic LigaSure Atlas variant. In theory, this
technology is thus particularly well-suited for laparoscopic colon resections,
because it allows the operating surgeon to obtain hemostatic control over
most if not all large arteries encountered during this procedure. This fact
was confirmed in ex vivo experimental protocols using isolated abattoir por-
cine veins and arteries ranging in diameter from 1.0 to 7.0 mm [107]. In this
study, the authors recorded acute burst pressures of 761
221 mmHg for
888 MARTEL & BOUSHEY

arteries 3.1 to 5.0 mm in diameter, and of 654
227 mmHg for arteries of
5.1 to 7.0 mm in diameter. Despite three of eight failed seals within the 5.1 to
7.0 mm category, the overall probability of burst strengths being less than
400 mmHg for the electrothermal sealer was only 0.04 (0.00–0.13), com-
pared with 0.95 (0.82–1.00) for the ultrasonic coagulator. In another exper-
imental study by Harold and colleagues [108], the superiority of the
electrothermal bipolar vessel sealer over the ultrasonic shears was specifi-
cally addressed using small-, medium-, and large-sized arteries harvested
from freshly euthanized pigs. Although the recorded burst pressures were
statistically comparable for vessels of 2 to 3 mm, the electrothermal bipolar
sealer had significantly higher burst pressures for both vessels of 4 to 5 mm
(601 versus 205 mmHg, P!0.0001) and 6 to 7 mm diameter (442 versus 174
mmHg, P!0.0001). Finally, the study authors reported no significant differ-
ence in histological thermal injury between the two dissection technologies,
although the mean reported spread using the ultrasonic shears (2.18 mm) is
almost one order of magnitude smaller than that published recently by
Emam and Cuschieri [99]. This discrepancy is difficult to explain at this
time, but it may be related to differences in methodology between these
two studies.
To our knowledge, only five clinical studies have assessed the electrother-
mal bipolar vessel sealer in laparoscopic colon surgery [106,109–112]. An
initial study by Heniford and colleagues comprising 18 cases of laparoscopic
colon and small bowel resections among 98 major operations yielded a he-
mostatic failure rate of only 0.3% for vessels of 2 to 7 mm diameter, dem-
onstrating the safety and effectiveness of this new technology for vascular
pedicles of large sizes [106]. Three of the five studies mentioned above
were retrospective in nature, and compared small series of restorative proc-
tocolectomies [109], hand-assisted total colectomies [110], and sigmoid and
transverse colectomies [111] done using either the electrothermal bipolar
sealer or the ultrasonic dissector. In all three series, the electrothermal bipo-
lar sealer was found to be slightly superior to the ultrasonic dissector in
terms of decreased mean total operating time [109,110], decreased intraoper-
ative blood loss [110], decreased costs [109], fewer episodes of rebleeding
[111], and decreased time to dissect the mesocolon [111]. Finally, Marcello
and colleagues [112] reported recently published data from the only prospec-
tive randomized clinical trial comparing the electrothermal bipolar sealer
(n ¼ 52) to conventional staplers and clips (n ¼ 48) during elective laparo-
scopic right, left, and total colectomies. In their study, the authors reported
a non-statistically significant reduction in mean operative time of 11 minutes
in the electrothermal bipolar sealer group (P ¼ 0.44), in addition to a differ-
ence in vascular pedicle ligation failure rate that was significantly higher in
the clips and staples group (3% versus 9.2%, P ¼ 0.02). Blood loss associ-
ated with device failure was somewhat lower within the clips and staples
group, because a single case of major hemorrhage associated with inade-
quate sealing of the inferior mesenteric vein occurred within the
 LAPAROSCOPIC COLON SURGERY 889

electrothermal bipolar sealing group. Interestingly, the study authors also

reported significantly lower operative costs associated with the use of the Li-
gaSure Atlas device over laparoscopic clips and staples ($317
0 versus
$400
$112, P!0.001) [112]. As expected, this difference was more pro-
nounced for total colectomies, for which six to nine major vascular pedicles
must be divided using multiple stapler reloads and clip applicators. It should
be kept in mind that purchase prices for such proprietary devices vary enor-
mously across the United States, Canada, and Europe, thus altering the val-
idity of cost-benefit calculations presented above based on practice location.
In addition, the calculation would have easily favored the traditional ap-
proach had the authors decided to compare the device to laparoscopic clips,
instead of clips and staples. That being said, the electrothermal bipolar
vessel sealer represents an exciting new tool in laparoscopic colon surgery.

Advances in camera technologies

Improvements in laparoscopic cameras and video imaging systems have
paralleled the development of minimally invasive surgery. Recently, im-
portant advances in laparoscopic camera technologies have dramatically
improved the ease with which surgeons can perform advanced laparo-
scopic surgery, including colonic resections. One such innovation has
been the introduction of charged coupled device (CCD) chip cameras
[113], which have essentially replaced traditional tube laparoscopes. Sim-
ply put, CCD chips work by acquiring optical or analog images, and con-
verting them into electronic or digital information, which can then be
displayed on a monitor for the surgeon to see. The image resolution pro-
vided by CCD chips is directly related to a vertical and horizontal grid of
sensor elements known as pixels situated on the chip, which provide res-
olutions of 450 to 600 horizontal lines [114]. Three-chip cameras have
also been developed, which function by separating the image signal into
red, blue, and green components, thus providing an improved resolution
of 700 horizontal lines. These cameras tend to be slightly heavier and to
lose their alignment over time due to repeated handling and sterilization,
however; hence the potential for deterioration in resolution [114]. More
recently, new ‘‘chip-on-a-stick’’ video laparoscopes have been introduced
[113,114]. These new designs of laparoscopic cameras involve the place-
ment of a single CCD chip at the tip (patient’s side) of the laparoscope,
immediately behind the lens. This system allows the immediate processing
of the image by the chip, and in doing so, eliminates the bulky fiber-optic
apparatus traditionally located within the shaft of the laparoscope. By
transmitting the image via cables from the CCD chip at the tip of the lap-
aroscope to a camera now located on the endoscopic cart, this system has
several advantages, including improved image quality and resolution, re-
duced possibility of inadvertent camera damage, less cumbersome video
cables, and potentially smaller laparoscope shaft diameter.
890 MARTEL & BOUSHEY

The traditional rigid surgical laparoscope is based upon the Hopkins rod-
lens system. It is currently available in 0 forward-viewing and 30 forward-
oblique-viewing designs [115]. Although the 0 scope provides greater direct
illumination on the field of vision, the 30 scope is particularly well-suited
for advanced laparoscopic surgery, because it allows the operator to visual-
ize an object from all directions by rotating the shaft of the laparoscope. It
should be noted though, that the 30 scope requires somewhat more user ex-
perience than its 0 counterpart, but this additional requirement is easily off-
set by the improved field of vision provided by this laparoscope. Given its
clear advantages and similar costs, the 30 scope is used routinely at the au-
thors’ center for laparoscopic colon surgery, because it is most valuable for
difficult pelvic dissections requiring different points of view. Nevertheless,
the need for even greater control and improved visualization over the surgi-
cal field has also led to the introduction of flexible-tip laparoscopes [116].
These novel devices provide an observation range of 14 to 120 mm, a vertical
motion ability of 100 , and a horizontal motion ability of 60 to 90 , de-
pending on the manufacturer. As such, these laparoscopes allow for a field
of view of 80 to 90 , compared with 75 for the 30 scope. In a recent study
by Perrone and coworkers [117], two models of flexible-tip laparoscopes
(Fujinon EL2-R310 and Olympus LTF-V3) were compared with 30 and
0 models in performing three experimental tasks. Although the study au-
thors did show a significant difference in procedure time, accuracy, and sub-
jective difficulty between the 0 and all three other types of laparoscopes,
they did not find a significant improvement when comparing the 30 scope
and flexible-tip laparoscopes. Although surprising, these data may be attrib-
utable to the simplicity of the in-vitro model used in this study. Indeed, it is
likely that the flexible laparoscope would perform much better in the setting
of complex colorectal dissections. Based on the current data, however, it ap-
pears that the 30 laparoscope provides excellent surgical field visualization
at a lesser cost than the novel flexible-tip laparoscopes. Further head-to-
head clinical studies will be required to ascertain the true value of these
new technologies in colorectal surgery.
Another recent advancement in camera technology is the development of
three-dimensional (3D) video imaging systems for minimally invasive sur-
gery [118]. It is well known that the lack of depth perception in laparoscopic
surgery has a direct influence on the steep learning curve associated with
learning new laparoscopic skills, whether basic ones for the novice surgeon,
or advanced ones for the more experienced laparoscopist. Indeed, experi-
mental data have demonstrated that specific tasks such as laparoscopic su-
turing or knot tying can be performed faster and more accurately using a 3D
video imaging system [119]. This system relies upon a stereoendoscope,
which acquires the surgical image from two separate side-by-side lenses,
yielding two offset images that can be visualized into a single 3D image using
simple shutter glasses. Experimental data obtained using early 3D laparo-
scopes was not very promising, revealing that 3D imaging was both tiring
 LAPAROSCOPIC COLON SURGERY 891

and awkward to use for the surgeon, and provided no benefit over standard
2D laparoscopy [120]. Nevertheless, more recent data obtained from new
second-generation 3D laparoscopes are much more encouraging. Taffinder
and colleagues [121] showed that 3D imaging reduced the handicap associ-
ated with traditional 2D laparoscopy by as much as 41% to 53% for a vari-
ety of experimental tasks, both for novice and experienced laparoscopists.
Although not currently widely used, this system may have the potential to
reintroduce 3D vision and depth perception to minimally invasive surgery,
which would be most useful in colonic resections. Further clinical data
will be required before this experimental system can become more widely
used in surgical practice.

Summary
Since its first described case in 1991, laparoscopic colon surgery has
lagged behind minimally invasive surgical methods for solid intra-abdomi-
nal organs in terms of acceptability, dissemination, and ease of learning.
In colon cancer, initial concerns over port site metastases and adequacy
of oncologic resection have considerably dampened early enthusiasm for
this procedure. Only recently, with the publication of several large, random-
ized controlled trials [14,15,22,23], has the incidence of port site metastases
been shown to be equivalent to that of open resection. Laparoscopic surgery
for colon cancer has also been demonstrated to be at least equivalent to tra-
ditional laparotomy in terms of adequacy of oncologic resection, disease re-
currence, and long-term survival. In addition, numerous reports have
validated short-term benefits following laparoscopic resection for cancer, in-
cluding shorter hospital stay, shorter time to recovery of bowel function,
and decreased analgesic requirements, as well as other postoperative vari-
ables. In benign colonic disease, much less high-quality literature exists sup-
porting the use of laparoscopic methods. Two recent randomized controlled
trials have demonstrated some short-term benefits to laparoscopic ileocolic
resection for CD [58,59], in addition to evident cosmetic advantages. On the
other hand, the current evidence on laparoscopic surgery for UC does not
support its routine use among nonexpert surgeons outside of specialized
centers. Laparoscopic colonic resection for diverticular disease appears to
provide several short-term benefits, although these advantages may not
translate to cases of complicated diverticulitis.
Despite the increasing acceptability of minimally invasive methods for
the management of benign and malignant colonic pathologies, laparoscopic
colon resection remains a prohibitively difficult technique to master. Numer-
ous technological innovations have been introduced onto the market in an
effort to decrease the steep learning curve associated with laparoscopic co-
lon surgery. Good evidence exists supporting the use of second-generation,
sleeveless, hand-assist devices in this context. Similarly, new hemostatic
devices such as the ultrasonic scalpel and the electrothermal bipolar vessel
892 MARTEL & BOUSHEY

sealer may be particularly helpful for extensive colonic mobilizations, in

which several vascular pedicles must be taken. The precise role of these he-
mostatic technologies has yet to be established, particularly in comparison
with stapling devices and significantly cheaper laparoscopic clips. Finally,
recent advances in camera systems are promising to improve the ease with
which difficult colonic dissections can be performed.

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