Does a laparoscopic approach to total abdominal colectomy and proctocolectomy offer advantages?

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Abstract
Controversy exists regarding the feasibility, safety, and outcomes of laparoscopic total abdominal colectomy (LTAC) and laparoscopic total proctocolectomy (LTPC). The object of this study was to assess the outcomes of LTAC and LTPC and compare them with those of institutional open procedure used as controls. Perioperative data and surgical outcomes of patients who underwent TAC or TPC were analyzed and compared retrospectively at a single institution between 1991 and 1999. A total of 73 TACs performed during a 9-year period were evenly distributed between laparoscopic (n=37) and open (n=36) approaches. There were no significant differences between patient groups with respect to genders, age, weight, proportion of patients with inflammatory bowel disease, and the number of patients undergoing ileorectal anastomosis. The median operative time was longer with the laparoscopic method (270 vs 178 min; p=0.001), but the median length of hospital stay was significantly shorter (6 vs 9 days; p=0.001). The short-term postoperative complication rate up to 30 days from surgery was not statistically different (25% vs 44%; p=0.137), although there was a clear trend toward a reduced number of overall complications in the laparoscopic group (9 vs 24). Wound complications were significantly fewer (0% vs 19%; p=0.015) and postoperative pneumonia was nonexistent in laparoscopic patients. Long-term complications also were less common in the laparoscopic group (20% vs 64%; p=0.002), largely because of reduced incidence of impotence, incisional hernia, and ileostomy complications. Total proctocolectomy was performed laparoscopically in 15 patients and with an open procedure in 13 patients over the same period. There were no statistically significant differences between the two groups with respect to gender, age, weight, and diagnosis. Median operating time was longer for the laparoscopic patients (400 vs 235 min; p=0.001), whereas the length of hospital stay, morbidity, and mortality were not significantly different. The results indicate that LTAC can be performed safely with a statistically significant reduction in wound and long-term postoperative complications, as compared with its open counterpart. Operating time is increased, but there is a marked reduction in length of hospital stay. Preliminary results demonstrate that LTPC also is technically feasible and safe, with equal morbidity, mortality, and hospital stay, as compared with open procedures. Studies with larger numbers of patients and a randomized controlled trial giving special attention to patient quality-of-life issues are needed to elucidate the real advantages of this minimally invasive technique.