Combination of hand-assisted and laparoscopic proctocolectomy (HALP): Technical aspects, learning curve and early postoperative results

Abstract

Background Various techniques for laparoscopic proctocolectomy have been reported worldwide. We evaluated the technical aspects and early postoperative results of hand-assisted laparoscopic proctocolectomy (HALP) with construction of an ileal pouch-anal anastomosis through a Pfannenstiel incision. Patients and methods Between June 2004 and May 2006, 20 patients (median age 28 years) underwent combined HALP at our institution. Preoperative diagnosis included ulcerative colitis (n = 16), indeterminate colitis (n = 1), familial adenomatous polyposis (n = 2), and carcinoma of the rectum associated with ulcerative colitis (n = 1). All patients were under immunosuppressive therapy. Laparoscopic mobilisation of rectum, sigmoid and descending colon was performed first. Subsequently, hand-assisted laparoscopic mobilization of the transverse and ascending colon as well as creation of an ileal J-pouch were performed through a Pfannenstiel incision. Ileal pouch-anal anastomosis was completed by transrectal stapling device and protected by a loop ileostomy. Results The ileal pouch-anal anastomosis could be achieved in 19 cases (95%). There was one conversion (5%) to open surgery with construction of an end-ileostomy. No intraoperative blood transfusions were necessary. The median operating time was 210 minutes (range 180 min to 330 min). It was longer for the first five procedures but then remained constant. Two patients (10%) developed anastomotic leakage, which could be treated conservatively. Mean length of hospital stay was 11 days (range 7-32 days). Conclusions Combined HALP with construction of an ileal J-pouch-anal anastomosis can be performed safely and effectively. The Pfannenstiel incision proved to be advantageous for hand-assisted mobilisation of the transverse colon. Additionally, it was useful for the specimen removal and the J-pouch construction. Our new technique not only proved to be safe, but also resulted in a shortened total operation-time after a learning curve of about five procedures.

Laparoscopic colectomy and restorative proctocolectomy for familial adenomatous polyposis

“…The median surgical time was 300 min and postoperative hospital stay was 7 days, consistent with other reports in the literature (Table 5) [4,19,21,23,[27][28][29][30][31][32][33][34][35].…”

Early postoperative and long-term oncological outcomes of laparoscopic treatment for patients with familial adenomatous polyposis

“…These results might be related to improved laparoscopic technique and accumulation of surgical experience [14]. In addition, after the plateau in the learning curve (22 cases), the operative time, which was 238 minutes (range, 135 to 385 minutes), was also comparable to the open approach for FAP in previous reports [8,15]. In addition, hospital stays and postoperative morbidity showed a decreasing trend after the surgeons gained sufficient experience in phase 3 (Table 4).…”

Laparoscopic Restorative Proctocolectomy with Ileal S-Pouch

“…Though a number of slightly different techniques for laparoscopic restorative proctocolectomy exist, thus far, all reported series but one (W-pouch), 3 have used a stapled ileal J-pouch configuration [4][5][6][7][8][9][10][11][12][13][14][15] (Table 3). Interestingly, there have been no reports of laparoscopicassisted restorative proctocolectomy with ileal S-pouch construction.…”

“…Though several methods are used, all reports but one 3 describe a laparoscopicassisted approach for total proctocolectomy with ileal Jpouch reconstruction. [4][5][6][7][8][9][10][11][12][13][14][15] While a double limb, J-pouch construction is by far the most common configuration, alternative pouch designs may be employed using a 3-limb S-pouch design for its reach advantage and compliance properties. 16,17 At our institution, we continue to use this S-pouch design and have now added the potential benefits of a minimally-invasive approach.…”