Garfinkle Richard, Boutros Marylise, Hippalgaonkar Neha, Maimon Geva, da Silva Giovanna, Potenti Fabio, Wexner Steven D
Section of Colorectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada.
Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
Surg Endosc. 2016 Jul;30(7):2840-7. doi: 10.1007/s00464-015-4565-3. Epub 2015 Oct 28.
Laparoscopic total proctocolectomy (TPC) with or without ileoanal pouch is a major operation for which the traditional benefits of laparoscopy were not immediately apparent, in part due to the longer operating times. The use of energy devices has been shown to improve operative outcomes for patients who undergo laparoscopic segmental colectomies, but there are limited data for laparoscopic TPC (LTPC).
All patients who underwent LTPC between January 2002 and July 2011 were identified from a prospectively maintained institutional-review-board-approved database. Univariate and multiple linear regression analyses were performed to assess the impact of electrothermal bipolar vessel sealers (EBVS) for vessel ligation on operative time. Secondary outcomes included vessel ligation failures, estimated blood loss, and other intra- and postoperative outcomes.
One hundred and forty-five patients underwent LTPC, including 126 restorative ileoanal pouch and diverting ileostomy operations and 19 TPC and end ileostomy procedures. Fifteen percent of LTPCs were totally laparoscopic, 45 % were laparoscopic-assisted, 32 % were hand-assisted, and 8 % were laparoscopic-converted cases. Laparoscopic vessel ligation was performed using EBVS (76 %), endoscopic staplers (12 %), or hybrid techniques (12 %). Vessel ligation groups were similar in demographics, body mass index, surgical indication, immunosuppression, and prior surgery. EBVS were associated with shorter median operative times (247 vs. 290 vs. 300 min, p = 0.018) and fewer vessel ligation failures (1 vs. 11 vs. 12 %, p = 0.027) compared with endoscopic staplers and hybrid techniques, respectively. There were no differences in estimated blood loss and intra-operative complications among the three groups. Length of stay, 30-day morbidity, and 30-day re-operation rates were also similar. On multiple linear regression analysis, EBVS were a significant predictor of operative time (p = 0.019).
Routine use of electrothermal bipolar vessel ligation for LTPC is associated with shorter operative time and fewer vessel ligation failures without higher risk of complications than other vessel control methods.
腹腔镜全直肠系膜切除术（TPC）无论是否行回肠肛管吻合术都是一项大型手术，腹腔镜传统的优势在此手术中并不立即显现，部分原因是手术时间较长。能量设备的使用已被证明可改善接受腹腔镜节段性结肠切除术患者的手术结局，但关于腹腔镜全直肠系膜切除术（LTPC）的数据有限。
从一个前瞻性维护的、经机构审查委员会批准的数据库中识别出2002年1月至2011年7月期间接受LTPC的所有患者。进行单因素和多线性回归分析，以评估用于血管结扎的电热双极血管闭合器（EBVS）对手术时间的影响。次要结局包括血管结扎失败、估计失血量以及其他术中及术后结局。
145例患者接受了LTPC，包括126例保留性回肠肛管吻合术和转流性回肠造口术以及19例TPC和末端回肠造口术。15%的LTPC为完全腹腔镜手术，45%为腹腔镜辅助手术，32%为手辅助手术，8%为腹腔镜中转手术。腹腔镜血管结扎使用EBVS（76%）、内镜吻合器（12%）或混合技术（12%）。血管结扎组在人口统计学、体重指数、手术指征、免疫抑制和既往手术方面相似。与内镜吻合器和混合技术相比，EBVS分别与较短的中位手术时间（247 vs. 290 vs. 300分钟，p = 0.018）和较少的血管结扎失败（1% vs. 11% vs. 12%，p = 0.027）相关。三组间估计失血量和术中并发症无差异。住院时间、30天发病率和30天再次手术率也相似。在多线性回归分析中，EBVS是手术时间的显著预测因素（p = 0.019）。
LTPC常规使用电热双极血管结扎与较短的手术时间和较少的血管结扎失败相关，且与其他血管控制方法相比并发症风险不高。
