Is Laparoscopic Surgery for Most, a Few, or No Patients with Crohnʼs Disease?

The first laparoscopic cholecystectomy was performed in March 1987. Laparoscopic surgery has continued to advance to more sophisticated procedures as new ideas and instrumentation has progressed. In the 12 short years since the concept of therapeutic gastrointestinal laparoscopic surgery, laparoscopic cholecystectomy, fundoplication, Heller myotomy, and splenectomy are considered the procedure of choice for treatment of their corresponding illnesses. However, the acceptance of laparoscopic colectomy, and particularly colectomy for Crohn's disease (CD), has lagged behind. What are the reasons? Are the reasons justifiable? Laparoscopic colectomy requires a certain skill level, which some surgeons have not obtained. Inherent in the ability to perform advanced laparoscopic surgery is the use of angled telescopes, stapling instruments, and twohanded techniques (suturing and knot tying). These skills should be obtained with inanimate and animate training models before attempting procedures in the operating room. Observation of experienced surgeons performing these procedures will go along way in preventing the common mistakes, which have already been learned. Hands-on proctoring in advanced laparoscopic surgery is important. Colorectal surgeons have had to learn this procedure as their first entrée into laparoscopy. Because colectomy is one of the most difficult procedures to perform laparoscopically, colorectal surgeons are at a disadvantage. Many have not been able to use the skills learned with more basic procedures (lap chole) to help in laparoscopic colectomy. Therefore, it was expected that the initial reports on laparoscopic colectomy by colorectal surgeons would not be favorable. General surgeons already experienced in laparoscopic techniques, however, reported much better results. Noninflammatory conditions are easier to operate laparoscopically compared with inflammatory disease. This has been clearly shown in laparoscopic cholecystectomy. Conversion and morbidity rates for laparoscopic cholecystectomy in elective biliary colic are less than in acute cholecystitis. This is also true in inflammatory conditions of the large and small intestine. Surgeons should “learn” laparoscopic bowel surgery on benign, noninflammatory diseases before attempting this on inflammatory conditions. Training issues are important, and they have been one of the major reasons for the slow development of laparoscopic colectomy. Inherent in CD is transmural inflammation. The pathophysiology of this disease can make surgery difficult, and this is magnified by the laparoscopic approach. Steroids, previous surgery, phlegmon, abscess, or fistula formation combine to make the technical aspects of laparoscopic Crohn's surgery hard. Experience with traditional surgery on Crohn's patients is helpful. As in open surgery, the small bowel is visualized from the ligament of Treitz to the distal ileum. Uncommonly, skip areas will be seen that were not appreciated on the preoperative evaluation. The “normal” bowel is dissected before the diseased bowel is approached. In ileocolic resection, this means that the hepatic flexure of the colon is mobilized before the terminal ileum. In left colectomy, the splenic flexure is mobilized before the descending colon. Fistulas are dissected after the bowel has been mobilized. In other words, the laparoscopic approach is the same as in open surgery. At present, I have operated on 138 patients and performed 147 procedures on patients with CD. Table 1 lists the demographics of this group of patients. Previous surgery was present in 50% of the patients, and it was not a contraindication to laparoscopic surgery. Forty percent of the patients were on steroids at the time of surgery. Table 2 documents the procedures performed. Thirty-one percent of the patients had a previous open bowel resection, including 10 patients who had more than two. In 10 patients, a separate small bowel resection was performed at the same time with an ileocolic resection. Six patients underwent gastrojejunostomy for obstructive duodenal disease. Fourteen patients had diagnostic laparoscopy to confirm the presence of CD. In all of these patients, the terminal ileum was spared, and the preoperative evaluation was inconclusive. Table 3 lists the types of fistulas found at the time of surgery. While the preoperative evaluation demonstrated most fistulas, laparoscopy found more. In no patient was fistulization a reason for conversion. The complications of the surgery are detailed in Table 4. Notice the glaring lack of infectious complications, even though 40% of the patients were on steroids at the time of surgery. The main postoperative problem has been intestinal obstruction occurring in 6.5% of the patients. While most obstructions have resolved without operative intervention, the incidence of obstruction seems to be slightly less or on par with open surgery. There has been one conversion to traditional surgery in this group of patients. It occurred in a patient with many years of jejunoileitis and a markedly thickened mesentery without previous surgery. Separation of the mesenteric folds could not be accomplished; therefore, the patient was converted to open. All other patients were completed laparoscopically. Crohn's disease patient demographics Crohn's disease patient demographics Crohn's disease procedures performed Crohn's disease procedures performed Types of fistulas Types of fistulas Complications of surgery Complications of surgery The length of stay of the patients resected was 4.2 days, and 3 days in the patients having gastrojejunostomy. In a matched group of patients (resection) undergoing traditional surgery at our institution, the length of stay was 7.5 days. Even though the operative times were longer in the laparoscopic groups, the total costs were the same as open surgery because of the shortened length of stay. Patients who had previous open surgery subjectively thought that laparoscopic surgery was easier for them. The vast majority of patients were back to normal activities at 14 days. Clearly, in this series of patients, the benefits of minimally invasive surgery were realized. Laparoscopic surgery for CD is safe and feasible in the vast majority of patients. The surgeon must have training and experience in advanced laparoscopic techniques. In my opinion, not all surgeons will be able to perform this complex laparoscopic surgery, but should patients be ex cluded from minimally invasive surgery because of training issues of the surgeon? This is reminescent of the early days of laparoscopic cholecystectomy. While there are no randomized trials proving the advantage of laparoscpic colectomy in CD, there is evidence that for benign disease, laparoscopic colectomy results in shortened length of stay, fewer infections, and quicker return to normal activities. Patients should be offered laparoscopy as a reasonable alternative to traditional open surgery.