Our findings indicate that the two treatment strategies are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favour of the SBTS procedure when performed in expert hands.

Local anatomy and pathologic features directly affect surgical outcome in the laparoscopic approach to the rectum. Sex, BMI, lower pelvis diameter, and tumor size are independent predictors for conversion, operative time, and morbidity. These data should be taken into account when planning this kind of procedure.

The development of operative laparoscopic surgery is linked to advances in ancillary surgical instrumentation. Ultrasonic energy devices avoid the use of electricity and provide effective control of small- to medium-sized vessels. Bipolar computer-controlled electrosurgical technology eliminates the disadvantages of electrical energy, and a mechanical blade adds a cutting action. This instrument can provide effective hemostasis of large vessels up to 7 mm. Such devices significantly increase the cost of laparoscopic procedures, however, and the amount of evidence-based information on this topic is surprisingly scarce. This study compared the effectiveness of three different energy sources on the laparoscopic performance of a left colectomy. The trial included 38 nonselected patients with a disease of the colon requiring an elective segmental left-sided colon resection. Patients were preoperatively randomized into three groups. Group I had electrosurgery; vascular dissection was performed entirely with an electrosurgery generator, and vessels were controlled with clips. Group II underwent computer-controlled bipolar electrosurgery; vascular and mesocolon section was completed by using the 10-mm Ligasure device alone. In group III, 5-mm ultrasonic shears (Harmonic Scalpel) were used for bowel dissection, vascular pedicle dissection, and mesocolon transection. The mesenteric vessel pedicle was controlled with an endostapler. Demographics (age, sex, body mass index, comorbidity, previous surgery and diagnoses requiring surgery) were recorded, as were surgical details (operative time, conversion, blood loss), additional disposable instruments (number of trocars, EndoGIA charges, and clip appliers), and clinical outcome. Intraoperative economic costs were also evaluated. End points of the trial were operative time and intraoperative blood loss, and an intention-to-treat principle was followed. The three groups were well matched for demographic and pathologic features. Surgical time was significantly longer in patients operated on with conventional electrosurgery vs the Harmonic Scalpel or computed-based bipolar energy devices. This finding correlated with a significant reduction in intraoperative blood loss. Conversion to other endoscopic techniques was more frequent in Group I; however, conversion to open surgery was similar in all three groups. No intraoperative accident related to the use of the specific device was observed in any group. Immediate outcome was similar in the three groups, without differences in morbidity, mortality, or hospital stay. Analysis of operative costs showed no significant differences between the three groups. High-energy power sources specifically adapted for endoscopic surgery reduce operative time and blood loss and may be considered cost-effective when left colectomy is used as a model.

ObjectiveTo analyze the impact of spleen size on operative and immediate clinical outcome in a series of 74 laparoscopic splenectomies (LS). Summary Background DataLS is gaining acceptance as an altemative to open splenectomy. However, splenomegaly hinders LS, and massive splenomegaly has been considered a contraindication. MethodsBetween February 1993 and September 1997, 74 patients with a wide range of splenic disorders were treated by laparoscopy and prospectively recorded. They were classified into three groups according to spleen weight: group 1, <400 g (n = 52); group 11, 400 to 1000 g (n = 9); and group 111, >1000 g (n = 13). Age, operative time, number of trocars required, need for perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia requirements, length of hospital stay, and morbidity rates were recorded. ResultsLS was completed in 69 patients, and the conversion rate was thus 6.7%. Operative time was significantly longer in patients with larger spleens, and an accessory incision was more frequently required. However, there were no significant differences in transfusion rate, length of stay, severe morbidity, or conversion rate. ConclusionsPreliminary evaluation of LS for patients with large spleens suggests that it requires a longer operative time, but it is feasible and may potentially offer the same advantages (shorter stay and faster recovery) as it does to those with smaller spleens.Laparoscopic surgery is gaining in interest as an approach to splenectomy. The main indications for laparoscopic splenectomy (LS) are hematologic diseases that are not associated with splenomegaly, such as idiopathic thrombocytopenic purpura.1 Intraabdominal manipulation of bulky organs during laparoscopic surgery increases the technical difficulty of the procedure and the retrieval of the specimen from the abdomen. Splenomegaly was initially considered a contraindication to LS, but improvement and refinement of the techniques of LS have shown that an enlarged spleen can be managed successfully by laparoscopy.24 Many hematologic diseases associated with an enlarged spleen are malignant conditions, and the open approach has been clas-

These results suggest that laparoscopically assisted colectomy may be particularly indicated in elderly patients.

Laparoscopic surgery is associated with better preservation of the immune system than open surgery. This results in a decreased incidence of infectious complications. Although carbon dioxide pneumoperitoneum affects the peritoneal response to injury, it seems to have no harmful effect in terms of intra-abdominal infection. Nevertheless, at laparoscopic operation the virulence of intestinal micro-organisms should be recognized and, while knowing the advantages of minimally invasive surgery, the surgeon should consider the complexity of this technique. Furthermore, maintenance of laparoscopic instruments should be governed by the same norms as those used in open surgery; recommendations offered by the manufacturers should be respected.

The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to establish technical alternatives that would ensure the durability of the repair.

SILS access can be safely used for operative visualization, hilum transection, and spleen removal, further reducing parietal wall trauma. The definitive clinical, esthetic, and functional advantages require further analysis.