Laparoscopic surgery for Crohn's disease?-a conditional yes

Beginning with the introduction of laparoscopic cholecystectomy a little more than a decade ago, minimally invasive techniques have revolutionized abdominal surgery. Since that time, it has been established that virtually any abdominal operation can be performed through the laparoscope. For the most part, the introduction of these procedures has been driven by technologic innovation and patient demand in the absence of randomized trials demonstrating their benefits. For some procedures, such as laparoscopic cholecystectomy and Nissen fundoplication, the advantages are obvious. In the case of others, such as splenectomy and probably herniorrhaphy, the benefits are less marked but still demonstrable. Finally, it appears that some complex operations, such as laparoscopic pancreatectomy and esophagectomy, while representing interesting technical exercises, are probably of no real benefit and may even be associated with increased morbidity and/or cost. In the case of laparoscopic surgery for Crohn's disease (CD), the verdict is not yet in, although an increasing amount of evidence would suggest that such an approach may be appropriate in selected patients with specific indications for operation. Numerous recent studies have demonstrated the feasibility of minimally invasive intestinal surgery (1). In the case of colorectal cancer, controversies regarding the extent of lymphadenectomy and the incidence of port site recurrence have limited application and prompted randomized trials. In contrast, a range of benign intestinal conditions, including appendicitis, colonic polyps, and diverticular disease, are increasingly being approached with the laparoscope. Presumed benefits include better cosmesis and reductions in pain, and in the extent of physiologic disturbance, leading to an earlier return of gastrointestinal function, discharge, and recovery. However, at a time when earlier feeding, mobilization, and discharge have also become more common after open intestinal operation, laparoscopic advocates have found it difficult to prove an advantage and have faced some skepticism based on both the higher cost and longer times of operation and on safety and efficacy (2). Many recent reports have suggested that laparoscopic surgery for CD is likewise feasible (3). Minimally invasive approaches have been described for virtually every surgical indication, including resection and stricturoplasty for small bowel and colonic obstruction, defunctioning ileostomy or colostomy, gastrojejunostomy, and even subtotal or total colectomy. Although many surgeons have considered phlegmon, abscess, or fistula contraindictions to laparoscopic operation, successful series have been reported under even these conditions. It has been suggested that, in this frequently young population likely to require more than a single procedure, the cosmetic benefits and reduction in the intensity of postoperative adhesions represent strong arguments in favor of a minimally invasive approach. Although many series have reported a reduction in pain and more rapid recovery, most have employed either historical or nonrandomized controls. One recent prospective randomized trial in 60 patients undergoing elective ileocolic resection demonstrated a modest improvement in postoperative pulmonary function and a reduction in the length of postoperative hospitalization from 6 to 5 days (4). There was no significant difference in the amount of pain medication or the time until flatus in the two groups. It seems unlikely that larger series will improve on these somewhat modest benefits. Despite this, based on both patient and physician enthusiasm, these procedures are here to stay. We have had some published (5) and unreported experience with these minimally invasive approaches and believe that they can indeed be useful under selected circumstances. For the patient undergoing elective ileocecal resection for stricture with minimal phlegmon, laparoscopic and open operations seem equally reasonable. We have found that, for at least some young patients for whom operation is clearly indicated but cosmesis is a major concern, the availability of laparoscopic techniques has strengthened the argument for surgery. We are convinced that, using the laparoscope in this setting, there is minimal risk of missing some significant lesion that was not appreciated preoperatively. All patients undergoing such an operation should have both an upper gastrointestinal series with small bowel follow-through and a barium enema preoperatively. We prefer barium enema to colonoscopy because, although it may not be as sensitive for mucosal disease, it does seem to provide more information about stricturing that may need to be dealt with at the time of operation. In addition, the entire small bowel should be examined intraoperatively. Most surgeons are using the laparoscopic technique to mobilize the right colon and terminal ileum and then making a 6-8 cm incision through which the intestine is delivered, and the resection and anastomosis performed. Under most circumstances, this entire procedure might be done through an only slightly larger incision using open techniques alone, with we suspect very similar outcomes. It is our feeling that the major impediments to resumption of postoperative gastrointestinal function are the anastomosis and the immediately adjacent intestinal segments; it seems likely that these are manipulated to similar extents with open and laparoscopic methods. Some surgeons employ an extended right lower quadrant port site for resection and anastomosis. The resulting scar can interfere substantially with the future use of this site for an ostomy. Using either technique, we would favor a midline or even Pfannensteil (bikini) incision, leaving the lower quadrants untouched. In more complicated patients, we have more concern about a laparoscopic approach. The patient with a large inflammatory mass has a mesentery that can be treacherous under even the best conditions; an inadequately controlled mesenteric vessel can produce a significant hematoma that may require sacrifice of even nondiseased intestine. In such a patient, although laparoscopic techniques are feasible in many, the occasional patient with a unpredictable problem argues against such an approach. Likewise, in the patient with multiple foci of disease, it may be very difficult to determine which areas need to be addressed and when to perform a resection versus stricturoplasty without the capacity to visualize and palpate the entire small bowel in continuity provided by laparotomy. It is not uncommon for areas of visible disease to prove to be insignificant when palpated, while other segments that appear mild are found to harbor significant strictures. Similarly, although a simple fistula between adjoining loops of intestine or even to the bladder may be adequately managed with the laparoscope, the more complex fistulae, often in combination with undrained areas and particularly those that connect to the skin, seem more appropriately managed using open techniques. Finally, the patient who has undergone multiple previous procedures generally has relatively dense adhesions that would make a laparoscopic approach tedious if not impossible for even the most experienced minimally invasive surgeon. Clearly, there are some patients in whom a judgment regarding the appropriateness of laparoscopic techniques cannot be made preoperatively; the possibility of conversion to an open procedure when problems are encountered should always be included in preoperative discussions and should never be considered a failure. In the colon, we have found that, in the patient with an isolated stricture for whom segmental resection seems appropriate, laparoscopic mobilization followed by resection through an extended port site can significantly enhance cosmesis and possibly postoperative recovery. In contrast, subtotal or total colectomy is often prohibitively time consuming, with little obvious benefit. If cosmesis is a significant concern, most such colectomies can be performed through a Pfannensteil incision with comparable results. There are several other indications for which a minimally invasive approach seems particularly appropriate. First, in the patient undergoing simple diversion, colostomy, or ileostomy for complicated perianal disease, virtually the entire procedure can be performed through the laparoscope and the stoma matured through an only slightly extended port site; the reduction in pain and disability is usually quite dramatic. Gastrojejunostomy for stricture of the duodenum can likewise be performed completely through the laparoscope, without the need for any extracorporeal manipulation. Finally, for the patient in whom the diagnosis remains in question despite contrast studies and endoscopy, the identification of creeping fat through the laparoscope can provide a basis for medical therapy without the need for laparotomy. In summary, despite its marginal benefits in some situations, laparoscopic surgery for CD is more than just a passing fad. In fact, it is increasingly common for these sophisticated patients to present requesting a laparoscopic approach. It is incumbent on the surgeon to identify those individuals in whom this is appropriate and to proceed cautiously, with a liberal policy toward conversion to laparotomy should the procedure prove difficult. In contrast to such procedures as laparoscopic cholecystectomy and Nissen fundoplication, which have made operation for cholelithiasis or reflux more common because the benefits are so obvious, we do not believe that the availability of laparoscopic surgery for CD should in any way alter the traditional indications for operation.