Laparoscopic Colectomy

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Ask whether your case is suitable for a keyhole approach

Send the colonoscopy report, the scan reports of abdomen and pelvis, your height and weight, a list of every previous abdominal or pelvic operation with approximate dates, and any biopsy result. A colorectal surgeon reads the file and tells you whether the operation is planned as laparoscopic, what would prompt a conversion to open surgery in your case, and how many of these that surgeon does in a year. No fee, no obligation, and a coordinator replies in your own language, usually within the same working day.

What keyhole means here

Four things about the approach are worth understanding before anything else, because most of the misunderstandings on this subject come from one of them.

Who is a candidate

Two patient factors come up in every discussion of suitability, and both of them are more nuanced than the usual advice suggests.

Body weight, and where the fat sits

Pooling 43 comparative studies, a higher body mass index was associated with a longer operation, more blood loss, more conversions to open surgery, more complications overall, more wound infection, more leaks at the join and fewer lymph nodes retrieved. That analysis reported probability values without effect sizes, so it establishes the direction and not the magnitude. A more specific question is where the fat sits, because fat inside the abdomen obstructs the view in a way that fat under the skin does not, and four studies measuring visceral fat on a scan found the operation took about 24 minutes longer, the odds of conversion were 2.24 times higher with a confidence interval of 1.05 to 4.78, the odds of a complication were 2.33 times higher, and about six fewer lymph nodes were retrieved. None of that makes a heavier patient unsuitable, and it is precisely why an experienced surgeon matters more in those cases than in easy ones. Ask the question directly and expect an honest answer about difficulty rather than a refusal.

Previous abdominal operations

Previous surgery is the factor patients most often assume rules them out, and the evidence says otherwise. A matched study of 756 patients compared 378 with previous abdominal surgery against 378 without, and conversion ran at 16.67 percent against 9.55 percent, with adhesions responsible for 55.56 percent of the conversions in the first group against 27.78 percent in the second. The operation took twenty minutes longer. Everything else was the same, including recovery time, length of stay, complications, deaths, lymph node yield and survival at three years. A second series of 181 patients found no significant difference in conversion at all, and found that the extra operating time appeared only in the surgeon's first 90 cases, which points at experience rather than at the adhesions. Two patients in that series had a small bowel injury during the freeing of adhesions and one of them was not noticed at the time, which is the specific risk worth naming.

Genuinely harder cases

Some situations are difficult in a way that no amount of patient optimism changes, and being told so plainly is more useful than being reassured. Repeat surgery for Crohn's disease is the clearest example. Among 65 patients having a second ileocolic resection, 28.1 percent of the laparoscopic attempts were converted to an open operation and 43.1 percent had a complication in the first month, most of them minor. A previous open operation in the same area was the strongest thing pushing toward conversion. Against that, a series of 27 patients having laparoscopic surgery for recurrent Crohn's disease reported conversion in only 2 of them, a median operating time of 110 minutes, a median stay of 4 days and a return to work at three and a half weeks, so the approach is far from futile in the right hands.

Complicated diverticular disease is the other one. Where the inflamed colon has stuck itself to the bladder and formed a fistula, a review of 202 patients across 25 studies reported operating times ranging from 150 to 321 minutes, a single leak and no deaths, though its authors were explicit that they could not work out the conversion rate at all from the published data. In an emergency, four non-randomized studies covering 436 patients found fewer complications after a laparoscopic approach, with a relative risk of 0.62 and a confidence interval of 0.49 to 0.80, and no difference in operating time, reoperation or 30-day mortality. Those authors put their own warning in unusually blunt language, saying the patients who had open surgery were sicker and that the results must be treated with extreme caution, which is a fair way of saying that laparoscopy is feasible in some emergencies and that the published numbers flatter it. The decision in a genuine emergency turns on how stable you are rather than on anybody's preference, and it is made by the surgeon who is looking at you at the time.

Conversion

How often it happens, and why

Across 4,796 elective colorectal operations in an American state-wide quality collaborative, 18.2 percent of laparoscopic cases were converted to open surgery against 7.7 percent of robotic ones, and the factors pushing toward conversion in the laparoscopic group were moderate or severe adhesions, obesity, cancer as the diagnosis, high blood pressure, operations on the rectum, unplanned scheduling and smoking. Notice what is missing from that list, which is age, and notice that most of the items are things about you rather than things about the surgeon. That study also found that a higher surgeon caseload protected against conversion in both groups, which is the same finding that runs through everything else on this page. A single-center series of 183 right colectomies reported conversion in 12 percent, with advanced disease, a tumor longer than five centimeters and having the operation in the earlier years all making it more likely, and the year effect is the learning curve showing up again.

What it means if it happens to you

The honest answer is that converted operations do worse than completed ones, and the honest interpretation is that this reflects who gets converted more than what conversion does. In that series of right colectomies, patients whose operation was converted had wound infection in 27.3 percent against 5 percent, 30-day mortality of 9.1 percent against 0.62 percent, and five year survival after curative surgery of 53.8 percent against 72.6 percent. The same pattern shows up in a much larger American database of 25,253 operations, where the 6.0 percent of robotic cases that were converted had higher mortality, more complications, longer stays and more infections than the ones that were completed. What none of that tells you is whether starting open in the first place would have been better, because nobody randomizes patients to that. The practical conclusion is the opposite of what many patients take from it, which is that you want a surgeon who converts when the operation demands it and who tells you beforehand what would make them do so.

How much the surgeon matters

The learning curve, measured

Statistical methods exist that track a surgeon's results case by case and identify the point at which they stop improving, and they have been applied to this operation repeatedly. The largest analysis pooled 4,852 cases from 19 surgeons and found the curve flattened at 152 cases for conversions, 143 for complications, 103 for length of stay, 96 for operating time and 87 for blood loss, which its authors summarized as a learning curve of 88 to 152 cases. A study of two experienced surgeons doing hand-assisted resections found the change point at 105 and 108 cases, with mean operating time falling from 263 minutes to 185 and with fewer complications, fewer infections and fewer readmissions in the later period. Single incision surgery has its own separate curve, and one surgeon's 113 cases put it at 61 to 65. A different number appears for supervised trainees, where 13 residents doing proctored sigmoid resections were performing them consistently without failure after about 11 cases, and that figure means something quite different because it describes one narrowly defined procedure with an expert standing beside them.

What a national training program changed

England ran a formal training and mentoring program for consultant surgeons who wanted to convert their practice to laparoscopic colorectal surgery, and the results were measured against every other surgeon in the country. Across 108 delegates, comparing 4,586 operations before with 5,115 afterwards and against 72,930 matched operations by surgeons who did not take part, the proportion of operations done laparoscopically rose by 20.9 percentage points more than the national trend, with a confidence interval of 18.5 to 23.3. Thirty day mortality fell by a relative 1.6 percent with a confidence interval of 0.2 to 3.4, and ninety day mortality by 2.3 percent with a confidence interval of 0.4 to 4.3. That is a rare thing to be able to show, which is that structured training of already qualified surgeons measurably changed how many patients survived. It is also the reason asking about training and caseload is a reasonable question rather than an impolite one.

Hospital volume

What it affects

A Dutch national study of 61,394 patients compared hospitals by how many colorectal resections they did each year. Hospitals doing fewer than 50 colon resections a year converted laparoscopic operations to open more often than those doing 100 or more, with an odds ratio of 1.25 and a confidence interval of 1.06 to 1.46. Thirty day mortality after colon surgery was also higher in the lower volume group, with an odds ratio of 1.17 and a confidence interval of 1.02 to 1.35. Both of those are modest effects and both are real, and together they describe a hospital where the difficult case is a little more likely to become an open operation and the sick patient is a little less likely to be rescued. Neither figure is a reason to travel past a competent hospital, and both are a reason to ask how many colorectal resections a year the unit does, which is a number every hospital knows and most will give you if you ask directly.

What it does not affect

In that same study of 61,394 patients, leak rates at the join did not differ between high and low volume hospitals, and neither did survival at five years. That is a genuinely reassuring result and it deserves to be stated as clearly as the other one. Volume is a proxy for something, and the something it appears to be a proxy for is the ability to complete a difficult operation laparoscopically and to recognize and rescue a patient who is deteriorating, rather than the quality of the cancer operation itself. The study's authors noted that they had no data on the individual surgeon's caseload, which is probably the variable that matters most and the one nobody publishes. Since you cannot look it up, ask it.

Single incision surgery

Instead of four or five separate ports, everything goes through one opening, usually at the navel. It is offered in some centers as an upgrade and the evidence for it is more mixed than the marketing suggests.

• Complications are the same. Pooling 11 randomized trials covering 1,370 patients, overall complications gave an odds ratio of 0.99 with a confidence interval of 0.75 to 1.30, and operating time was no different either.
• Wounds are genuinely shorter, and the pain is genuinely less. Across 16 studies and 2,425 patients, total incision length was 3.31 centimeters shorter and pain scores were lower on the first and second days after surgery, both by a clear margin.
• Conversion may be more likely. In the same 11 trials, converting to conventional keyhole or to open surgery gave an odds ratio of 3.10 with a confidence interval of 0.95 to 10.14, which the authors described as just missing statistical significance. That is a wide interval and it means the question is unresolved rather than answered.
• One careful review disagreed with the enthusiasm. A group that assessed six earlier meta-analyses found all of them methodologically weak, and when they restricted their own analysis to properly randomized evidence they were left with 2 trials and 82 patients. Their conclusion was that single incision colectomy should still be considered experimental.
• It has a longer learning curve of its own. One surgeon's series put the curve at 61 to 65 cases for a procedure they were already doing conventionally, so the question to ask is how many of these specifically the surgeon has done.

No abdominal wound at all

If the specimen leaves through the rectum or the vagina, the larger incision disappears entirely and only the port holes remain. This has better randomized evidence behind it than single incision surgery does, and it is offered far less often.

• Wound infection falls sharply. Across 21 randomized trials and 2,112 patients, infection overall gave a relative risk of 0.34 and infection of the incision a relative risk of 0.24. There is very little in surgery that halves a complication rate, let alone quarters it.
• Recovery is faster. Hospital stay was 2.21 days shorter with a confidence interval of 1.06 to 3.36, gas returned about half a day sooner, pain scores were lower and cosmetic scores were higher.
• Total complications fall too. The relative risk was 0.81 with a confidence interval of 0.71 to 0.93, and a separate analysis of 1,437 patients found an odds ratio of 0.48 for complications and 0.13 for wound infection.
• Operating time rises a little. About 8 minutes in the randomized data and about 14 in the wider analysis, which is the price and it is a small one.
• It only suits certain specimens. A bulky tumor or a thickened inflamed colon will not pass through the rectum, so this is a decision made on the size of what is coming out. Ask whether it is possible in your case and, if the answer is no, ask what the limiting factor is.

Hand-assisted and fewer ports

Two more variants exist at either end of the spectrum, and they answer different questions.

1. Hand-assisted surgery puts one of the surgeon's hands inside the abdomen. A sealed sleeve in a small incision, made where the extraction wound was going to be anyway, lets the surgeon feel the tissue and retract with a hand while operating with instruments through the ports.
2. Its main measured benefit is fewer conversions. A Cochrane review of three randomized trials covering 189 patients found conversion significantly reduced, with operating time and complication rates no different. That review reported no pooled effect size, and its authors said the trials had methodological limitations and that better ones were needed.
3. It is a reasonable middle position rather than a compromise. For a large or inflamed colon, for a heavier patient, or for a surgeon partway through the learning curve, keeping a hand inside is a sensible way of finishing an operation laparoscopically that would otherwise have been opened.
4. At the other end, some surgeons use three ports instead of five. A retrospective comparison of 163 right colectomies reported the three-port operation was faster, at 140.9 minutes against 178.2, retrieved more lymph nodes and had faster return of gas, with no difference in complications or conversion.
5. Treat that last one carefully. A single retrospective series where the same team chose which patients got which approach cannot separate the technique from the selection, and no randomized trial of reduced-port colectomy exists to check it against.

The operation, port by port

Knowing the sequence explains why some of the aftermath feels the way it does.

What differs in recovery

Some of the advantages people expect from keyhole surgery are real and some are not, and it is worth separating them.

Port site problems

Small wounds are the part nobody discusses beforehand, and one number about them is quoted misleadingly often.

Questions to ask

Six questions, in the order that gets the most useful answers. None of them is rude and all of them have short answers.

Robotic or laparoscopic

The robot is a laparoscopic instrument with a different interface, and the comparison is often presented with more confidence than the evidence supports. Almost all of it is observational.

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What can go wrong

Some problems belong to the keyhole approach specifically. The complications of the colectomy itself, principally the leak at the join, are the same whichever way the abdomen was entered.

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Reading a quote

No figure appears on this page. The table below is what has to be in writing before any figure means anything, and the first row is the one people forget.

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Does age change it

Older patients are offered keyhole surgery less often, on the reasoning that a longer operation under a longer anesthetic is riskier in someone with less reserve. The pooled evidence points the other way and it is worth knowing before anybody decides on your behalf.

Across seven studies covering 528 patients aged over 80 who had keyhole surgery and 484 who had open surgery, death carried an odds ratio of 0.48, complications overall 0.54 and prolonged ileus 0.56, all in favor of the keyhole approach, with a shorter hospital stay and faster return of bowel function. Leak rates at the join and reoperation rates were no different. Every one of those studies was observational.

A large American database looking at 79,581 elective colectomies found that laparoscopy reduced 30-day readmission and reduced the chance of being discharged to a nursing facility rather than home, in both older and younger patients, though the size of that second benefit was larger in the younger group. A Spanish cost-effectiveness study of 1,591 patients found laparoscopy produced slightly more quality-adjusted life years overall and cost less, and its authors noted a subgroup in which open surgery appeared to do better in older patients with early or very advanced disease. That last observation comes from a subgroup of an observational cohort and it should be read as a question rather than as an answer. Taken together, being older is a reason to ask for a keyhole approach and to ask about the surgeon's experience rather than a reason to accept an open operation without discussion. The practical version of all this is that age on its own is a weak basis for being offered an open operation, and that fitness, heart and lung reserve and the surgeon's own experience are the things actually doing the work in that decision.

Cancer at a port site

When keyhole colon cancer surgery began, cases were reported of tumor growing in the small port wounds, and the fear that gas and instruments were spreading cancer cells nearly stopped the technique before the trials had run. It is the single reason those trials were done, and the answer that came back is unambiguous.

A review pooling the long-term results of randomized trials, covering 3,346 patients, found no difference between keyhole and open surgery in recurrence at the wound or port sites. Recurrence at the site of the original tumor in the colon was 5.2 percent against 5.6 percent, and the hazard ratio for any recurrence after keyhole surgery in colon cancer was 0.86 with a confidence interval of 0.70 to 1.08.

One historical figure puts the size of the original worry in perspective. A German five-center registry of 399 curative laparoscopic resections performed between 1991 and 1997, in the earliest years of the technique, recorded a single port site recurrence in the whole series at an average follow-up of thirty months. The precautions that came out of that period are still standard practice, which is that the specimen is brought out inside a protective sleeve and the abdomen is handled to avoid seeding, and they are done on every case without anybody discussing them. If somebody raises port site spread with you as a current reason to avoid keyhole surgery, they are describing a problem that was solved before most of today's surgeons started training. Nothing in that history is a reason to worry now, and it stands as a good illustration of what happens when a surgical fear is taken seriously rather than dismissed, tested properly in randomized trials, and then settled by the answer that comes back.

Coming to Istanbul

Twelve to sixteen days covers assessment, the operation and a safe departure for a planned laparoscopic segmental colectomy in somebody arriving with the workup already done.

After you get home

Flying is generally cleared at around ten to fourteen days, and later if the operation was converted to open, because a leak at the join declares itself between the third and seventh day and is far easier to manage in the hospital that made the join. Ask for the operation note in particular, because it is the document that records how many ports were used, where the extraction incision was placed, whether the fascia was closed and whether anything unexpected was found. None of that can be reconstructed later and all of it matters if you develop a problem at home.

Two things then belong in your own diary. The six week restriction on heavy lifting applies exactly as it would after an open operation, because the extraction wound is where the hernia risk lives and the small scars are misleading about how much healing is going on underneath. And a wound review at around two weeks with your own doctor, who should be given the operation note, the pathology report and the discharge summary together rather than one at a time. Your coordinator stays reachable on the same WhatsApp number, so a question about a port wound or a line in the report reaches somebody with your notes in front of them.

Laparoscopic colectomy FAQ