Results of a standardized technique and postoperative care plan for laparoscopic sigmoid colectomy - A 30-month experience

Introduction: Laparoscopic sigmoid colectomy has been accepted slowly despite potential advantages because of the perceptions of a steep learning curve and increased operative times and costs. The purpose of this article is to review the outcome of a standardization of all the intraoperative and postoperative processes used in our department for the performance of laparoscopic sigmoid colectomy. Methods: A consecutive series of patients requiring laparoscopic sigmoid colectomy from March 1999 through December 2001 at the Cleveland Clinic Foundation, Cleveland, Ohio, was analyzed. Patients requiring sigmoid or rectosigmoid resection for all colonic pathologies were included. Criteria for exclusion from an attempted laparoscopic sigmoid colectomy were body mass index >35 and prior major abdominal surgeries (exclusive of hysterectomy, cholecystectomy, or appendectomy). Data collected included age, gender, indication for surgery, American Society of Anesthesiology class, body mass index, operative duration, length of hospital stay, complications, mortality, and 30-day readmission. The operative steps for laparoscopic sigmoid colectomy were as follows: 1) open insertion of the umbilical port; 2) placement of three operating ports; 3) dissection/division of the vascular pedicle after identification of the left ureter; 4) mobilization of the sigmoid and descending colon; 5) rectal mobilization/division; 6) exteriorization of the specimen; and 7) circular stapled anastomosis. Instrumentation for the procedure was standardized. Conversion was performed when a sequential step could not be completed in a reasonable time frame. A standard perioperative care plan was used. Results: From March 1999 through December 2001, the primary surgeon performed 207 sigmoid colectomies, including 181 (87.4 percent) attempted laparoscopic sigmoid colectomies and 22 (12.1 percent) conversions. Indications for the laparoscopic sigmoid colectomies were diverticular disease (115), colonic neoplasia (32), prolapse (14), endometriosis (10), and other (10). The male/female ratio was 85:96, and the mean body mass index was 27.3+/-5.6. Mean operative time was 119+/-35 minutes. Mean length of stay was 2.9+/-1.2 days for completed cases and 6.4+/-1.4 days for converted cases. Anastomotic leaks occurred in two patients (1.1 percent), one of whom died of multisystem organ failure, yielding an operative mortality of 0.6 percent. The overall complication rate was 6.6 percent, and the 30-day readmission rate was 8 percent. Conclusion: The results indicate that a structured approach to laparoscopic sigmoid colectomy provides the surgeon with objective measures of operative progress that limit unduly long operations without increasing conversion rates and that control resource utilization. This approach provides a potential guideline for teaching and mastering laparoscopic sigmoid colectomy, reducing the learning curve, and optimizing results.