Safety and advantages of laparoscopic-assisted colectomy 

Varnost in prednosti laparoskopsko asistirane 
kolektomije 

Elizabet Glavan, Dujo Kovačević, August Mijić, Dinko Vidović, Darko 
Jurišić, Kristijan Matković, Dario Franjić, Miroslav Bekavac-Bešlin 

Department of Surgery, University Hospital Sestre milosrdnice, Zagreb, Croatia 

Avtor za dopisovanje (correspondence to): 
Elizabet Glavan, MD, Department of Surgery, University Hospital Sestre milosrdnice, Vinogradska 
29, 10 000 Zagreb, Croatia; phone: +385 13787 111, fax: +385 1 3769067, e-naslov: eglavan@mef.hr 

Prispelo/Received: 3.9.2005 

Abstract 
Aim. Laparoscopic surgery for colorectal cancer, especially laparoscopic rectal surgery, has been 
introduced recently. Laparoscopic colectomy has developed rather slowly because of the relatively 
complicated anatomy and demanding surgical techniques. This study was designed to report our 
early experience with laparoscopic-assisted colorectal procedures done at this Department, and 
presents important lessons we have learned therefrom. 
Materials and Methods. The first laparoscopic colon resection was performed at this Department on 
16 January 1996. Clinical and operation records of 38 operations for benign and malignant diseases 
done by 2005 were reviewed. The data retrieved included patient demographics, selected intra-
operative parameters, and postoperative outcomes. Similar data were collected for 1,207 case-
matched open surgical procedures performed during the same period. All data were entered into a 
database and analysed using a statistical software package. 
Results. The diagnoses included: cancer (92.1% vs. 95%), polyps (5.3% vs. 3.1%) and rectovaginal 
fistula (2.6% vs. 1.9%). In four (10.5%) cases, laparoscopy was converted to open surgery because of 
bleeding and locally advanced disease. The laparoscopic-assisted procedures performed included: 
six right hemicolectomies, nine left hemicolectomies, seven anterior resections and 16 abdominoperi-
neal resections. The mean operative time was longer for laparoscopic-assisted colectomy than for 
open surgery (208 minutes vs.150 minutes, P<0.05), but the mean duration of analgesic requirements 
(2.5 days vs. 4.5 days, P=0.008), mean time to resumption of oral diet (2.42 days vs. 3.95 days, 
P=0.005) and mean length of hospital stay (7 days vs. 11 days, P=0.007) were shorter, and the mor-
biddity rates (13.1% vs. 40.1%, P<0.05) were lower. No respiratory and local wound complications 
were found in our laparoscopic-assisted group. 
Conclusions. Laparoscopic-assisted colorectal surgery has proved a safe and effective treatment 
modality with statistically significant clinical benefits for strictly selected patients 
Key words. Laparoscopy, colorectal cancer, operative time, morbidity, hospital stay. 
Endoscopic Rev, Vol. 11, No. 25, April 2006 


Izvleček 
Cilj. Laparoskopska kirurgija kolorektalnega raka, zlasti še laparoskopska rektalna kirurgija, je bila 
uvedena v klinično prakso šele pred kratkim. Metoda laparoskopske kolektomije se je razvijala dokaj 
počasi zaradi sorazmerno zapletene anatomije in zahtevne kirurške operativne tehnike. V študiji 
prikazujemo naše zgodnje rezultate z laparoskopsko asistirano kolorektalno kirurgijo na našem 
oddelku in predstavljamo pomembne izkušnje, ki smo si jih pri tem pridobili. 
Bolniki in metode. Prvo laparoskopsko resekcijo širokega črevesa smo naredili na tukajšnjem 
oddelku 16. januarja 1996. Predstavljamo klinične in operativne značilnosti 38 operacij benignih in 
malignih bolezni širokega črevesa v letu 2005. Prikazujemo demografske podatke bolnikov, nekatere 
medoperativne kazalce in pooperativne izide zdravljenja. Enaki kazalci so bili zbrani pri 1207 bolni-
kih z različnimi klasičnimi operativnimi postopki, narejenimi v istem obdobju. Podatki so bili vnešeni 
v bazo podatkov in analizirani s statističnimi programi. 
Rezultati. Vključeni so bili bolniki z naslednjimi diagnozami: rak, polipi in rektovaginalna fistula. V 
štirih primerih se je kirurg odločil za preklop v odprt klasični poseg zaradi krvavitve in/ali lokalno 
napredovane bolezni. Laparoskopsko asistirani postopki, ki smo jih izvajali, vključujejo: šest desnih 
hemikolektomij, devet levih hemikolektomij, sedem sprednjih nizkih resekcij in 16 abdominalnoperi-
nealnih resekcij. Povprečni operativni čas je bil daljši pri laparoskopsko asistirani kolektomiji kot pri 
klasični kirurgiji, toda povprečni čas trajanja analgezije in čas, potreben za pričetek oralne prehrane in 
srednja ležalna doba so bili krajši, prav tako pa je bila tudi stopnja obolevnosti nižja pri laparoskop-
skih posegih. V laparoskopsko asistirani skupini ni bilo zapletov v dihalih ali na mestu kirurških ran. 
Zaključek. Laparoskopsko asistirana kolorektalna kirurgija se je izkazala kot varna in učinkovita 
metoda zdravljenja s statistično značilnimi kliničnimi prednostmi za izbrane bolnike. 
Ključne besede. Laparoskopija, kolorektalni rak, trajanje operacij, obolevnost, ležalna doba. 
Cilj. Laparoskopska kirurgija kolorektalnega raka, zlasti še laparoskopska rektalna kirurgija, je bila 
uvedena v klinično prakso šele pred kratkim. Metoda laparoskopske kolektomije se je razvijala dokaj 
počasi zaradi sorazmerno zapletene anatomije in zahtevne kirurške operativne tehnike. V študiji 
prikazujemo naše zgodnje rezultate z laparoskopsko asistirano kolorektalno kirurgijo na našem 
oddelku in predstavljamo pomembne izkušnje, ki smo si jih pri tem pridobili. 
Bolniki in metode. Prvo laparoskopsko resekcijo širokega črevesa smo naredili na tukajšnjem 
oddelku 16. januarja 1996. Predstavljamo klinične in operativne značilnosti 38 operacij benignih in 
malignih bolezni širokega črevesa v letu 2005. Prikazujemo demografske podatke bolnikov, nekatere 
medoperativne kazalce in pooperativne izide zdravljenja. Enaki kazalci so bili zbrani pri 1207 bolni-
kih z različnimi klasičnimi operativnimi postopki, narejenimi v istem obdobju. Podatki so bili vnešeni 
v bazo podatkov in analizirani s statističnimi programi. 
Rezultati. Vključeni so bili bolniki z naslednjimi diagnozami: rak, polipi in rektovaginalna fistula. V 
štirih primerih se je kirurg odločil za preklop v odprt klasični poseg zaradi krvavitve in/ali lokalno 
napredovane bolezni. Laparoskopsko asistirani postopki, ki smo jih izvajali, vključujejo: šest desnih 
hemikolektomij, devet levih hemikolektomij, sedem sprednjih nizkih resekcij in 16 abdominalnoperi-
nealnih resekcij. Povprečni operativni čas je bil daljši pri laparoskopsko asistirani kolektomiji kot pri 
klasični kirurgiji, toda povprečni čas trajanja analgezije in čas, potreben za pričetek oralne prehrane in 
srednja ležalna doba so bili krajši, prav tako pa je bila tudi stopnja obolevnosti nižja pri laparoskop-
skih posegih. V laparoskopsko asistirani skupini ni bilo zapletov v dihalih ali na mestu kirurških ran. 
Zaključek. Laparoskopsko asistirana kolorektalna kirurgija se je izkazala kot varna in učinkovita 
metoda zdravljenja s statistično značilnimi kliničnimi prednostmi za izbrane bolnike. 
Ključne besede. Laparoskopija, kolorektalni rak, trajanje operacij, obolevnost, ležalna doba. 
Introduction 

Since the successful introduction of laparoscopic 
colectomy by Jacobs et al. (1), laparoscopic 
surgery, especially laparoscopic rectal surgery 
used for the treatment of colorectal cancer, has 
developed considerably (2-20). The evolution of 
laparoscopic colorectal surgery in the past decade 
has brought immediate short-term benefits to patients, 
including earlier postoperative pain relief 
and return of bowel function, shorter hospital 
stay, and better cosmesis (21-23). As compared 
to the open technique, the new surgical approach 
allows the same oncological radicality in the 
term of length of specimen, extent of regional 
lymphadenectomy, and recurrence rate (2,6,19, 
24-31). 
Colon and rectal surgical procedures by laparoscopic 
approach were introduced at this 
Department in 1996 (32). The aim of this study 
was to review our early results by comparing 
them with those obtained in a series of matched 
conventional open operations, and to identify key 

lessons learned from this early experience that 
may be beneficial to any department embarking 
on laparoscopic colon and rectal surgery. 

Materials and methods 

Clinical and operative records of all patients 
undergoing laparoscopic-assisted colon and 
rectal surgical procedures between January 1996 
and December 2004 were reviewed with the aim 
of obtaining clinical data, and recording selected 
intraoperative parameters and postoperative outcomes 
of these patients. All procedures were 
performed by at least one of the two consultant 
colorectal surgeons at the Department (MBB, 
DK), assisted by colorectal residents. These two 
surgeons had completed exit certification in 
general surgery and had attended training courses 
on laparoscopic colorectal surgery at overseas 
centres of excellence. The selection of patients 
was based on the preference of the operating 
surgeon. The initial series included only patients 
with benign conditions, but with improved 

Endoscopic Rev, Vol. 11, No. 25, April 2006 


experience the technique began to be used in 
patients with malignant lesions. 
All patients were given a mechanical bowel preparation 
a day before surgery. A combination of 
two antibiotics, cefuroxime (Ketocef) and metronidazole 
(Medazol), was infused intravenously 
on induction of anaesthesia. A urinary catheter 
and a nasogastric tube were inserted in all cases. 
Patients were placed in the supine or gynaecological 
position for the right or left hemicolectomy, 
respectively. 
All laparoscopic colonic resections were performed 
after the creation of a pneumoperitoneum 
with carbon dioxide, either via the percutaneous 
insertion of a Veress needle or, if the patient had 
previous abdominal surgery, using the open 
Hasson technique. For both right and left hemicolectomy, 
four 10-12-mm laparoscopic trocars 
(Ethicon Endo-Surgery) were used. The location 
of the port sites depended on the site of the 
lesion. 
For right hemicolectomy, the entire cecum, the 
ascending colon, and the hepatic flexure as far as 
the proximal third of the transverse colon were 
mobilized. After the right ureter, the iliac vessels, 
and the duodenum had been identified, the right 
colic and ileocolic arteries to their origin, the 
right branch of the middle colic artery and the 
distal ileum were divided intracorporeally using a 
laparoscopic linear stapling device (Endo-GIA, 
Ethicon Endo-Surgery),. The distal margins of 
the specimen were divided extracorporeally at 
the level of the transverse colon through a 5-6cm 
mini-laparotomy placed supraumbilically. 
The affected area was draped with a plastic 
sleeve to prevent the implantation of neoplastic 
cells. An extracorporeal ileocolic anastomosis 
was made in an end-to-end or end-to-side fashion 
using a hand-sewn technique. A silastic intraperitoneal 
drain was left in situ for as long as flatus 
passed. 
For left hemicolectomy, the superior and mid 
extraperitoneal rectum, the sigmoid, the descending 
colon, and the splenic flexure as far as the 
distal third of the transverse colon were mobilized. 
The left ureter and the iliac vessels were 
identified, along with the inferior mesenteric 
pedicle. The inferior mesenteric artery at its 
origin (or after the origin of the left colic artery), 
the inferior mesenteric vein at the level of the 

ligament of Treitz, and the superior rectum were 
divided intracorporeally with the endo-GIA stapler. 
The left colon was divided and the stapler 
head was placed extracorporeally through a 5-6cm 
protected suprapubic mini-laparotomy 
(Pfannenstiel incision). Using a circular stapler a 
T-T stapled colorectal anastomosis was performed 
intracorporeally and checked with a hydro-
pneumatic test. Additional intracorporeal stitches 
were placed to reinforce the suture and prevent 
gas leakage. In all patients the inferior margin of 
resection was below the peritoneal space after the 
pelvic peritoneum had been sutured. A silastic 
intracorporeal drain was left in place for 48 
hours, and a perianastomotic extraperitoneal 
drain for as long as the faeces passed. All the 
removed specimens were measured after fixation 
in 10% formalin for 24 hours. The lymph nodes 
were dissected and counted using standard 
methods. 
The following parameters were evaluated: 
conversion rate (for the laparoscopic group), 
operative time, resumption of gastrointestinal 
functions, length of hospital stay, morbidity rates 
within 30 days of operation, length of surgical 
specimen, number of harvested lymph nodes and 
pathological Dukes’stage. 
The Student’s t-test and the Mann-Whitney U 
test were used to determine the significance of 
the differences in mean values for continuous 
variables. A P value of <0.05 was deemed 
significant. 

Results 

A total of 1,245 patients were enrolled in the 
study: 38 treated by laparoscopy and 1,207 by 
open surgery. The groups were matched for 
gender and consisted of 20 male and 18 female 
patients. Their mean age was 67.5 years (range; 
51 – 74 yrs) (Table 1). 
Table 2 shows the diagnoses for the laparoscopy 
group of 38 patients. Thirty-five patients were 
operated on for carcinoma, two had colorectal 
polyps and one a rectovaginal fistula. The diagnoses 
established in the control group are 
indicated in the same table. 

Endoscopic Rev, Vol. 11, No. 25, April 2006 


Table 1 

Patient characteristics. 

Laparoscopic-assisted Open 
Number 38 1207 
Male Female Male Female 
Gender 20 18 668 539 
Mean age (years) 
Range 
67.5 
51-74 
65.6 
33-90 

Table 2 

Indications for surgery. 

Laparoscopic-assisted Converted Open 
Cancer 35 (92.1%) 4 (11.4%) 1146 (95%) 
Polyps 2 (5.3%) -37 (3.1%) 
Rectovaginal fistula 1 (2.6%) -24 (1.9%) 

Table 3 

Types of operation. 

Laparoscopic-assisted Converted Open 
Right hemicolectomy 6 -252 
Left hemicolectomy 9 3 398 
Anterior resection 7 1 503 
Abdominoperineal resection 16 -54 
Total 38 4 1207 

Table 4 

Mean specimen length, mean number of harvested lymph nodes, and pathological stage. 

Laparoscopic-assisted Open 
Mean length of specimen (cm) 21.3 (16-29) 22.1 (15-32) 
Mean number of lymph nodes 10.4 (5-17) 10.8 (4-31) 
Pathological stage 
Dukes A (%) 6 (17.1) 229 (20) 
Dukes B (%) 7 (20) 309 (27) 
Dukes C (%) 13 (37.2) 412 (36) 
Dukes D (%) 9 (25.7) 195 (17) 

Endoscopic Rev, Vol. 11, No. 25, April 2006 


Laparoscopicassisted 
Open Sig. 
Mean operative times (minutes) 208 150 <0.001 
Range 80-305 90-260 
Mean duration of analgesic requirements (days) 2.5 4.5 0.008 
Range 1-4 1-8 
Mean time to commencement of oral diet (days) 2.42 3.95 0.005 
Range 2-8 2-11 
Mean length of stay (days) 7 11 0.007 
Range 5-13 5-19 

Table 5 

Factors in postoperative recovery. 

Table 6 

The incidence of postoperative complications. 

Laparoscopicassisted 
Open Sig. 
General complications 5 192 n.s. p>0.05 
Respiratory -29 
Cardiac 1 16 
Urinary 2 24 
Intraabdominal haematoma 1 -
Anastomotic dehiscence 1 120 
Local complications -301 s. p<0.05 
Wound infection -279 
Wound dehiscence -22 
Total 5 493 s. p<0.05 

Four (10.5%) of the 38 procedures attempted 
laparoscopically required conversion to open 
surgery: two because of excessive bleeding 
occurring during dissection, and two because of 
locally advanced disease which made the dissection 
technically difficult. Table 3 shows the 
remaining 34 laparoscopic-assisted procedures 
which were completed successfully. 
The mean tumor size in the 35 cancer patients 
undergoing laparoscopic-assisted procedures was 

4.5 cm (range; 2.2-10.5 cm). The mean specimen 
length in the laparoscopic-assisted and open 
surgery groups was 21.3 cm and 22.1 cm, respectively 
(P>0.05). The mean number of lymph 
nodes identified in the specimens resected 
laparoscopically was 10.4 vs. 10.8 in the open 
group specimens (P>0.05). The distribution of 
patients by the Dukes’ stage was similar (Table 
4). 
The laparoscopic approach required significantly 
longer times in the operating room. The mean 
operative time was 150 minutes (90-260) for the 
open procedure, and 208 minutes (80-305) for 
the laparoscopic-assisted operation, averaging an 
additional 58 minutes in this series (Table 5). 
The number of days patients required parenteral 
opiates was significantly less in the laparoscopic 
cohort, i.e. a mean of 2.5 days compared to 4.5 

Endoscopic Rev, Vol. 11, No. 25, April 2006 


days in the open group (P=0.008). As concerns 
the commencement of oral feeding, the 
laparoscopic-assisted group took a significantly 
shorter time than the open surgery group, i.e. 

2.42 days versus 3.95 days (P=0.005). Similarly, 
laparoscopic-assisted group was discharged from 
the hospital significantly earlier than the open 
group (mean; 7 vs. 11 days) (Table 5). General 
complications were established in five (13.1%) 
patients in the laparoscopic-assisted group, as 
compared to 192 (15.9%) in the open group 
(Table 6). The laparoscopic groups had no 
respiratory or wound complications, which was 
not the case in the open-resection group (301 of 
1,207). 
Discussion 

Minimally invasive surgical procedures are 
associated with well-described patient benefits, 
which include: less postoperative pain, shorter 
period of ileus, reduced hospital stay, and 
improved cosmesis (21-23).The benefits of 
laparoscopic-assisted colorectal procedures, 
however, have not been consistently demonstrated 
(33,34). 
Laparoscopic bowel surgery was introduced at 
this Department in 1996. The results of this 
analysis of our early experience serve as the audit 
database, as well as the reference for our 
practice. 
Both groups were comparable concerning the 
demographic distribution of patients. The indications 
for surgery were similar in both groups, yet 
not identical in number. The decision for using 
the minimally invasive approach was invariably 
made by the operating surgeon. Large, bulky and 
advanced tumors were excluded. The initial 
series included mainly patients who required a 
loop diversion colostomy for advanced cancer in 
the lower third of rectum. Laparoscopic stoma 
creation is an ideal prelude to the more complex 
laparoscopic colorectal resections: it is less 
technically demanding and carries much lower 
morbidity rates, and, in addition, it familiarizes 
the surgical team with the operating room setup 
and with various technical maneuvres, such as 
bowel handling and mobilisaton. 
The identical number of lymph nodes harvested 
in both the laparoscopic-assisted and open surgery 
group with cancers (10.4 vs. 10.8) suggested 

a comparable adequacy of oncological clearance 
in these patients, a point that has been proven in 
several studies (35,36). The laparoscopic-assisted 
group did have a significantly longer mean operative 
time than the open group, yet it was progresssively 
reduced with increased experience, as 
is generally the case in laparoscopic surgeons. 
Our conversion rate of 10.5% fell within the 
range reported in the literature. Hopefully, it will 
further improve with a larger number of laparoscopic 
procedures being performed routinely. 
A significant advantage conferred by the laparoscopic-
assisted technique was reduced duration 
of analgesic requirements (2.5 vs.4.5 days; 
P=0.008), which was probably due to a smaller 
incision length. Similarly, the laparoscopic group 
tolerated oral diet sooner than the open surgery 
patients (2.42 vs. 3.95 days; P=0.005), and had a 
significantly shorter hospital stay than the open 
group (mean 7 vs. 11 days; P=0.007). 
Despite the established absolute difference in the 
overall complication rate, no significant differrentces 
were found between the two groups as 
concerns the general complication rate. On the 
other hand, the laparoscopic-assisted group 
showed no pulmonary complications and no local 
wound complication, while the wound-related 
complication rate in the open group was 24.9 %. 
Our experience to date indicates that laparoscopic-
assisted colon and rectal procedures used in 
selected patients are safe. They confer significant 
advantages in terms of decreased morbidity, faster 
postoperative recovery and preservation of 
functional status. Early experience should be 
acquired from performing technically simple 
procedures, such as abdominoperinal resection, 
before progressing to definitive resections, i.e. 
right and left hemicolectomy or anterior rectal 
resections for cancer. 

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