Laparoscopic-assisted ileocolic resection is an acceptable alternative to traditional open resection in the adult population (1–4). Despite operating on patients with abscesses, fistulae, and inflammatory masses that were initially considered to be contraindications for laparoscopic-assisted surgery, the procedure has been associated with minimal differences in morbidity (3). The laparoscopic approach is associated with a shorter hospital stay, and patients are able to resume normal activities sooner than with the open procedure. Adult patients report higher scores on measures of postoperative cosmesis (5) and seem to be better at adapting socially and sexually following the procedure (2). The laparoscopic-assisted approach also has been associated with lower elevations in biochemical inflammatory markers after surgery (6,7). No studies have examined laparoscopic-assisted ileocolic resection in the adolescent population with Crohn disease. To address this issue, we did a retrospective review of 23 consecutive adolescents at a children's hospital, of whom 12 underwent laparoscopic-assisted resection and 11 had open resection.
The Ethics Review Board for Human Studies at the Hospital for Sick Children approved the study. The charts of all patients undergoing ileocolic resection for Crohn disease at our institution between February 1, 1998, and January 31, 2001, were retrospectively reviewed. Patients were grouped according to whether they underwent laparoscopic-assisted or open resection. The following data were collected for patients undergoing each procedure: 1) baseline characteristics (sex, age, weight, time from diagnosis of Crohn disease to surgery, length of preoperative hospital stay, and preoperative parenteral nutrition); 2) indications for surgery; 3) operative course (operative time, length of specimen resected, and intraoperative complications); and 4) early postoperative course (postoperative complications, number of days of and dosage of parenteral narcotic analgesia, and time to ambulation, initial diet, diet as tolerated, first bowel movement, and discharge). Data were analyzed using the Student t test for independent samples and χ 2 analysis where appropriate. A P value of <0.05 was considered statistically significant.
A staff pediatric surgeon and a pediatric surgery fellow performed all procedures. In all cases, the gross appearance of the bowel determined the extent of resection.
Open resections were performed through a single midline or right lower quadrant incision. After the abdomen was entered, the right colon was mobilized in the usual fashion and, following vascular and bowel division, a primary ileocolic anastomosis was performed using a functional end-to-end stapling technique. The entire small bowel was examined before closure.
In the laparoscopic-assisted procedure a 3-trocar approach was used (12-mm umbilical, 3- to 5-mm right lower quadrant, 3- to 5-mm left lower quadrant). The surgeons stood on either side of the patient for the duration of the procedure. Using the laparoscope, the bowel was examined and the right colon mobilized to the extent that the cecum could be brought up to the umbilical port site. The umbilical incision was then extended in the midline to a total length of 3 cm to 5 cm, and the cecum and distal ileum were exteriorized. The mesenteric vessels were divided, the bowel was resected, and a primary ileocolic anastomosis was performed using a functional end-to-end stapling technique. The entire small bowel was examined. The bowel was then returned to the abdomen, and the umbilical incision closed. The abdomen was then inspected with the laparoscope through the remaining two ports and irrigated before closure of the two lower abdominal port sites.
Postoperatively patients received morphine for analgesia either through patient-controlled analgesia or by continuous infusion. The individual attending surgeon made decisions regarding postoperative nasogastric drainage, feeding, ambulation, and discharge.
Patient Characteristics and Preoperative Factors
Twelve patients underwent laparoscopic-assisted ileocolic resection, and 11 patients underwent open resection. The patients in the laparoscopic-assisted group did not differ from those in the open group with respect to sex, age, weight, indications for surgery, time from diagnosis of Crohn disease to surgery, length of preoperative hospital stay, or preoperative parenteral nutrition (Table 1). Of the patients being operated on for an abscess or fistula, one patient in the laparoscopic-assisted group and one patient in the open group underwent a percutaneous drainage procedure before surgery. One patient in the laparoscopic-assisted group had previously undergone an open appendectomy; no other patient in the study had previously undergone any abdominal operations.
The mean operative time for the laparoscopic-assisted group was 146 minutes, compared with 137 minutes for the open group (P = 0.580). Mean length of bowel resected was 34.1 cm in the laparoscopic-assisted group and 22.8 cm in the open group (P = 0.142). One patient in the laparoscopic-assisted group who had a known enterocutaneous fistula to the right flank required conversion to an open procedure, due to extensive adhesions of the cecum and an associated inflammatory mass to the posterior abdominal wall. This patient was included in the laparoscopic-assisted group for purposes of analysis. There were no other intraoperative complications in either group.
Nine patients in the laparoscopic-assisted group received morphine by patient-controlled analgesia and three by constant infusion. Nine patients in the open group received patient-controlled analgesia and one received constant infusion. One patient in the open group received epidural analgesia postoperatively. The groups did not differ with respect to the total dose of morphine received by the parenteral route (laparoscopic-assisted, 2.27 mg/kg, vs. open, 2.46 mg/kg;P = 0.688) or by the mean dose of parenteral morphine per day (laparoscopic-assisted, 0.74 mg/kg, vs. open, 0.74 mg/kg;P = 0.997).
Figure 1 contrasts the postoperative course of patients in the laparoscopic-assisted and open groups. Patients did not differ statistically with respect to the postoperative day of ambulation, clear fluids, diet as tolerated, first bowel movement, or number of days of parenteral narcotics. However patients in the laparoscopic-assisted group were discharged home 2.2 days earlier than those in the open group (P = 0.021). Cosmetic appearance of the incisions was superior in the patients undergoing the laparoscopic-assisted procedure, although this was not quantified (Fig. 2).
One patient in the laparoscopic-assisted group developed an unexplained fever during postoperative days 2 through 5. This same patient presented to the emergency room 1 week after discharge with a wound infection. One patient in the open group developed a wound infection on postoperative day 2, and another patient in the open group had an intraabdominal abscess on postoperative day 8. All complications were managed without further surgical intervention.
Laparoscopic-assisted ileocolic resection is an acceptable alternative to open resection in adults with Crohn disease (1–4). Our data support a similar conclusion for the adolescent population. Patients undergoing laparoscopic-assisted and open resections did not differ with respect to intraoperative course, postoperative course, or complications. However, patients undergoing laparoscopic-assisted resection were discharged home on average 2.2 days earlier than those who underwent open resection. This is likely because of the smaller incision and shorter length of time that the abdominal wall is retracted during the laparoscopic-assisted approach.
One patient in the laparoscopic-assisted group required conversion to an open procedure as a result of an inflammatory mass with fistula that was fixed to the posterior abdominal wall. This rate of conversion is comparable to the 2.5% to 22.2% cited in the literature (1). A palpable, inflammatory mass is known to be a risk factor for conversion (8). Although the procedure was completed as an open resection, the incision required was likely smaller than it would have been for a primary open resection, because much of the dissection had already been completed. This patient's operative time of 120 minutes was still below the mean for both laparoscopic-assisted and open resections in this series. Despite one patient requiring conversion because of a fistula, we successfully completed the laparoscopic-assisted procedure in four other patients who were undergoing surgery for either a fistula or intraabdominal abscess, which supports the previous literature suggesting that these problems are not a contraindication for the laparoscopic-assisted approach (3). As often as possible, we attempt to wait a minimum of 3 months from the time of intraabdominal sepsis to the time of surgery, using home nasogastric elemental tube feeding or total parenteral nutrition in most cases to provide simultaneous nutrition and bowel rest (9).
We elected to use a laparoscopic-assisted approach, with an extracorporeal anastomosis, rather than an entirely laparoscopic approach with an intracorporeal anastomosis. The latter procedure has been successfully used in both adults and children with ileocolic Crohn disease (10) (S. Rothenberg, personal communication, May 2001). However, we believe that our approach provides the benefits of laparoscopic surgery while maintaining the advantages of open vascular division and anastomosis, i.e., speed, low risk of intraabdominal stool spillage, and no need for advanced laparoscopic skills such as suturing, which many pediatric surgeons do not possess. Furthermore, a small incision is still necessary when using the entirely laparoscopic approach to remove the specimen.
Because this was not a randomized study, patient selection bias may have existed in determining which patients received each procedure. However, we do not believe that this was the case, because 9 of the 11 open resections were performed before the first laparoscopic-assisted resection, and 12 of the 14 procedures thereafter were performed using the laparoscopic-assisted approach. In addition, neither of the two surgeons who performed the laparoscopic-assisted procedures performed an open-resection during the same period. It therefore appears that the type of procedure performed was determined more by which surgeon performed the operation than by inherent patient characteristics.
The decrease in time to discharge in the laparoscopic-assisted group may have been due to differences in individual surgeons' practices rather than to the type of procedure performed. Although the potential of such a bias calls into question the magnitude of any advantage that the laparoscopic-assisted method may have, it does not change the overall conclusion that the laparoscopic-assisted procedure is a safe alternative to the open approach.
Previous authors have shown that laparoscopic-assisted ileocolic resection has an advantage over open resection in terms of patients' perception of postoperative cosmesis and return to social function (2,5). We did not explore these issues in our study, although it is clear from the feedback received from our adolescent patients that improved cosmetic result is import to them. Formal quality-of-life evaluation would be of interest in this population, and we plan to address these issues in a prospective long-term study of laparoscopic-assisted surgery for Crohn disease.
Few studies have examined long-term outcome of patients undergoing laparoscopic-assisted resection. It would be of interest to determine whether the decreased incidence of adhesion formation that has recently been documented following laparoscopic surgery (11,12) is also true of the laparoscopic-assisted approach. In one recent study, with a 30-month follow-up, the incidence of symptomatic bowel obstruction was significantly lower in patients undergoing laparoscopic-assisted surgery than in patients undergoing open resection (2).
This study suggests that the laparoscopic-assisted approach to ileocolic resection is a safe alternative to open surgery in adolescents with Crohn Disease. This approach can even be used in children whose disease is complicated by intraabdominal abscess or fistula formation. Long-term studies with larger numbers of patients are needed to further document the relative merits of this approach.
The authors thank Karen Diefenbach and Robin Vaughan for their assistance with this project.
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