laparoscopic colon resection is superior to open surgery in regards to postoperative pain , recovery , and hospital stay . however , there are no standardized techniques , and data on technique - specific outcomes are lacking .
various terms are used for laparoscopic colon surgery in the literature , for example , laparoscopic - assisted colectomy ( lac , usually with extracorporeal anastomosis ) , hand - assisted colectomy ( hac or hals ) , and laparoscopic colectomy with intracorporeal anastomosis ( lcia ) .
additionally , there are various techniques for mobilization of the mesentery ( medial - to - lateral vs. lateral - to - medial ) and ligation of the vasculature ( extra- vs. intracorporeally ) .
laparoscopic - assisted colectomy ( lac ) with creation of an extracorporeal ileocolonic anastomosis ( ea ) for right - or extended right colectomies remains the preferred approach in most centers .
however , this technique limits the ability to choose an extraction site , which is usually a small midline incision .
in addition , problems with intestinal alignment after extraction are known to occur . a completely intracorporeal anastomosis ( ia )
may reduce the likelihood or intestinal twists and offers the possibility of using any abdominal location for specimen extraction .
the question of whether there is any advantage or disadvantage between these 2 techniques remains unanswered .
the goal of this retrospective study was to evaluate the safety and feasibility of an intracorporeal anastomotic technique for laparoscopic right hemicolectomies .
all patients requiring a right hemicolectomy for neoplasm who presented to city of hope from september 2004 to april 2008 were analyzed .
data such as sex , age , body mass index ( bmi ) , pathology , operative technique , blood loss , operative times , intra- and postoperative complications , and length of stay were entered into a prospective database approved by the institutional review board . during the study period , 80 laparoscopic right hemicolectomies with either an intracorporeal ( ia , n=23 ) or extracorporeal ( ea , n=57 ) anastomosis were performed . a retrospective analysis of all data collected in regards to these 80 laparoscopic right hemicolectomies was performed . to ensure accuracy of the collected data ,
the 3 right hemicolectomies that were converted from a laparoscopic to an open approach were not included , as conversion rate was not an outcome parameter in this study . due to the retrospective nature of this study , an intention to treat analysis could not be performed .
all cases with ia were performed by a single surgeon ( a. pigazzi ) starting in january 2006 with all his cases performed with an ia by june 2006 .
all patients had preoperative colonoscopies with biopsy and tattooing of lesions located in areas other than the cecum .
postoperative ileus was defined as abdominal distension requiring either conversion to an npo - status after a diet was started , placement of a nasogastric tube for decompression , or radiological imaging .
pneumoperitoneum was created either via the percutaneous insertion of a veress needle or with the open hassan technique as per surgeon 's preference .
four to 5 ports were used : a 10-mm to 12-mm umbilical camera port for a 30-degree laparoscope , one 10-mm working port for stapling devices in the left lower abdomen , and 2 to 3 five - mm working ports located in the left upper abdomen and suprapubic region .
the mobilization of the right colon and mesentery was carried out in a medial - to - lateral fashion in most cases as previously described . in the ea group , the ileocolic pedicle and the right branch of the middle colic artery
were divided close to their origin intracorporeally with a vascular endo - gia stapler or hemoclips in 26 patients . in 15 cases ,
the ileocolic pedicle was divided intracorporeally , whereas branches of the middle colic artery and the remaining mesentery were ligated after the colon was exteriorized . in the remaining 16 cases ,
the exteriorization of the colon and creation of the external anastomosis was carried out in most cases through extension of the umbilical port to a 4-cm to 8 cm midline incision after sufficient mobilization of the right colon and hepatic flexure .
a side - to - side , stapled ileocolonic anastomosis was created in all cases with a stapled closure of the enterotomy in 91% of cases and a double - layer , hand - sewn closure in the remaining 9% .
the anastomosis was re - evaluated in situ after closure of the incision and reinsertion of the laparo - scope in all cases . in the ia group , the ileocolic pedicle and
after completion of the medial - to - lateral mobilization , the terminal ileum and transverse colon were divided intracorporeally with a 60-mm endo - gia stapler , blue load . in 21 patients , we used a pfannenstiel incision covered with a wound protector to retrieve the specimen .
the specimen was always opened on the side table to ensure that the tumor or inked lesion was included in the resection .
after closure of the incision and re - insufflation of the pneumoperitoneum , the intracorporeal ileocolonic anastomosis was created in a side - to - side , isoperistaltic fashion by using the 60-mm endo - gia .
the enterotomy was then closed laparoscopically with a 2-layer , running suture with 3.0 vicryl .
wound protectors were used in all 80 cases ; bags for specimen extraction were not used in the ia group .
quantitative and categorical variables were analyzed with a 2-tailed , unpaired student t test and the chi - square or fisher exact probability test , respectively .
all patients requiring a right hemicolectomy for neoplasm who presented to city of hope from september 2004 to april 2008 were analyzed .
data such as sex , age , body mass index ( bmi ) , pathology , operative technique , blood loss , operative times , intra- and postoperative complications , and length of stay were entered into a prospective database approved by the institutional review board . during the study period , 80 laparoscopic right hemicolectomies with either an intracorporeal ( ia , n=23 ) or extracorporeal ( ea , n=57 ) anastomosis were performed . a retrospective analysis of all data collected in regards to these 80 laparoscopic right hemicolectomies was performed . to ensure accuracy of the collected data ,
the 3 right hemicolectomies that were converted from a laparoscopic to an open approach were not included , as conversion rate was not an outcome parameter in this study . due to the retrospective nature of this study , an intention to treat analysis could not be performed .
all cases with ia were performed by a single surgeon ( a. pigazzi ) starting in january 2006 with all his cases performed with an ia by june 2006 .
all patients had preoperative colonoscopies with biopsy and tattooing of lesions located in areas other than the cecum .
postoperative ileus was defined as abdominal distension requiring either conversion to an npo - status after a diet was started , placement of a nasogastric tube for decompression , or radiological imaging .
pneumoperitoneum was created either via the percutaneous insertion of a veress needle or with the open hassan technique as per surgeon 's preference .
four to 5 ports were used : a 10-mm to 12-mm umbilical camera port for a 30-degree laparoscope , one 10-mm working port for stapling devices in the left lower abdomen , and 2 to 3 five - mm working ports located in the left upper abdomen and suprapubic region .
the mobilization of the right colon and mesentery was carried out in a medial - to - lateral fashion in most cases as previously described . in the ea group , the ileocolic pedicle and the right branch of the middle colic artery
were divided close to their origin intracorporeally with a vascular endo - gia stapler or hemoclips in 26 patients . in 15 cases ,
the ileocolic pedicle was divided intracorporeally , whereas branches of the middle colic artery and the remaining mesentery were ligated after the colon was exteriorized . in the remaining 16 cases ,
the exteriorization of the colon and creation of the external anastomosis was carried out in most cases through extension of the umbilical port to a 4-cm to 8 cm midline incision after sufficient mobilization of the right colon and hepatic flexure .
a side - to - side , stapled ileocolonic anastomosis was created in all cases with a stapled closure of the enterotomy in 91% of cases and a double - layer , hand - sewn closure in the remaining 9% .
the anastomosis was re - evaluated in situ after closure of the incision and reinsertion of the laparo - scope in all cases . in the ia group , the ileocolic pedicle and
after completion of the medial - to - lateral mobilization , the terminal ileum and transverse colon were divided intracorporeally with a 60-mm endo - gia stapler , blue load . in 21 patients , we used a pfannenstiel incision covered with a wound protector to retrieve the specimen .
the specimen was always opened on the side table to ensure that the tumor or inked lesion was included in the resection .
after closure of the incision and re - insufflation of the pneumoperitoneum , the intracorporeal ileocolonic anastomosis was created in a side - to - side , isoperistaltic fashion by using the 60-mm endo - gia .
the enterotomy was then closed laparoscopically with a 2-layer , running suture with 3.0 vicryl .
wound protectors were used in all 80 cases ; bags for specimen extraction were not used in the ia group .
quantitative and categorical variables were analyzed with a 2-tailed , unpaired student t test and the chi - square or fisher exact probability test , respectively .
demographic and pathologic data for the study cohort are listed in table 1 . in 57 patients ,
there was no statistically significant difference in operative time , estimated blood loss , number of nodes harvested , or length of hospital stay between the 2 groups .
the length of the incision was significantly shorter in the ia group ( 4 cm vs. 5 cm , p=0.004 ) .
overall , 17.5% ( 14/80 ) of patients had postoperative ileus ( table 3 ) . however , there was no difference in the incidence of ileus between the 2 groups ( 22% ia vs. 16% ea , p=0.75 ) .
patient demographic data ia : intracorporeal anastomosis ; ea : extracorporeal anastomosis ; asa : american society of anesthesiology score .
ia = intracorporeal anastomosis ; ea = extracorporeal anastomosis ; ns = not significant . in the ea group , 3 ( 5.3% )
patients had intraoperative complications that included 2 cases of twisted mesentery requiring intraoperative revision of the anastomosis , and one case of bleeding from the extracorporeally divided mesentery .
one volvulus of the anastomosis caused a complete bowel obstruction requiring reoperation on postoperative day # 8 .
one patient in the ea group experienced an anastomotic leak , which was treated with an end - ileostomy .
overall , 4 ( 7% ) complications were directly related to the anastomosis in the ea group compared with one ( 4.3% ) in the ia group ( p=1.0 ) .
the one anastomotic - related complication in the ia group included a leak from the anastomosis in a patient with a bmi ( body mass index ) of 37kg / m .
overall , the major complication rate for all patients ( 2 anastomotic leaks , 1 reoperation for volvulus , and 1 death ) was 6.25% ( 5/80 ) with no statistically significant difference between groups ( table 3 ) .
the only death in our series occurred in a patient from the ea group ( overall 30-day mortality 1.3% ) .
this patient was initially discharged on postoperative day # 7 , but readmitted on postoperative day # 12 for acute abdomen .
a significant amount of ischemic small bowel proximal to the anastomosis due to vascular compromise was found , and the patient developed multisystem organ failure .
injury to the sma / smv during the dissection or forceful stretching of the mesentery may have caused this fatal bowel ischemia ; however , we can not conclude whether this was related to the anastomotic technique .
one patient in the ia group was converted from an extracorporeal approach due to a short mesentery and a high bmi of 32 kg / m , but was counted in the ia group .
late complications consisted of 4 ( 7% ) incisional hernias in the ea group , 2 ( 8.7% ) in the ia group , and 1 internal hernia requiring reoperation 6 months after surgery in the ea group .
the 2 incisional hernias in the ia group occurred in the only 2 patients in whom the specimen was not removed through a pfannenstiel incision .
the literature is limited comparing outcomes between the different surgical techniques in laparoscopic colon resections .
bernstein at al compared laparoscopic - assisted versus completely laparoscopic colectomies and found no difference in the length of hospital stay or the duration of postoperative ileus .
the series by franklin et al is the largest series comparing intracorporeal anastomosis for right colon resections ( n=82 ) with 10 cases with extracorporeal anastomosis .
their intracorporeal approach was found to be safe and feasible with similar operative times and complication rates .
these findings are confirmed by bergamaschi et al who recently described the short - term outcomes of 111 intracorporeal right colectomies .
however , the most commonly applied technique for creation of an anastomosis after laparoscopic right colectomy remains an extracorporeal , stapled ileocolonic anastomosis . in this laparoscopic - assisted technique ,
some authors argue that , once mobilized , the right colon is a midline structure and can be easily exteriorized through a 4-cm to 6-cm midline incision that directly overlies the base of the ileocolic pedicle , allowing for easy proximal ligation .
the limitations of this approach include poor exposure of the ileocolic pedicle in obese patients through a small incision as well as limitations in regards to the location of the incision .
difficult exposure of the base of the mesentery could lead to compromise of a high mesenteric ligation necessary for optimal oncologic outcome .
therefore , many series describe the technique of intracorporeal high - vessel ligation combined with an extracorporeal anastomosis .
we did not see a difference in the number of lymph nodes in either group ; however , our numbers may be too low to detect any significant difference .
the creation of the anastomosis in an obese patient may be facilitated by an internal approach , because this technique eliminates the need to exteriorize heavy mesentery and large specimens through a small incision in a thick abdominal wall .
raftopoulos et al compared laparoscopic right hemicolectomies with intracorporeal anastomosis in the obese and nonobese patients and reported the same incision length , conversion rate , morbidity , and length of stay for thin and obese patients .
this compares very favorably with other reports in the literature with conversion rates up to 39% and morbidity rates up to 52% for laparoscopic - assisted colectomies with extracorporeal anastomosis in obese patients . in our series
, one patient with a bmi of 32 kg / m scheduled for an ea was found to have shortened , thick small bowel mesentery so that the terminal ileum could not be exteriorized adequately .
he was therefore converted to an ia , thus avoiding conversion to an open procedure .
this may suggest an advantage of the intracorporeal anastomosis in patients with short or very heavy mesentery .
an additional benefit of the intracorporeal technique is the ability to remove the specimen through any type of incision .
incisional hernia rate in laparoscopic colon surgery is described as high as 17% to 24% with a higher rate for midline versus off - midline incisions . in comparison
, the pfannenstiel incision is known for excellent cosmetic results and rare incisional hernia rates of 0% to 2% .
interestingly , the 2 incisional hernias in the ia group occurred in the only 2 patients in which the specimen was removed though a small midline incision .
overall , 6 hernias occurred in 59 patients with midline incisions , which equals a hernia rate of 10.2% with the midline incision compared with 0% ( 0/21 ) with the pfannenstiel incision .
therefore , our practice has been modified to only perform pfannenstiel incisions for specimen extraction after intracorporeal anastomosis . in the ea group ,
it appears that alignment of the mesentery or volvulus of the anastomosis itself can be a problem when an extracorporeal anastomosis is performed . in 2 patients in the ea group ,
the anastomosis had to be redone due to twisting of the mesentery , and in one patient a volvulus of the anastomosis was missed leading to reoperation for bowel obstruction .
references in the literature in regards to this problem are scarce . senagore et al reported a 1.6% incidence of operative small bowel obstruction in their series of 70 laparoscopic - assisted right hemicolectomies .
some opponents of laparoscopic colectomy with ia argue that the operative time is longer , especially because the ia approach requires laparoscopic suturing skills . in our series ,
the median operative time of 190 minutes for the ia group was not significantly different from the operative time of 180 minutes for the ea group .
the 4 studies on intracorporeal anastomosis with right colectomies reported operative times from 120 minutes to 218 minutes comparing favorably to operative times of 85 minutes to 190 minutes recorded for laparoscopic - assisted colectomies with extracorporeal anastomosis .
these early results show that an intracorporeal anastomosis with transabdominal extraction has similar outcomes compared with extracorporeal anastomosis for laparoscopic right colectomies
. however , there appears to be a trend towards smaller incision length in the ia group compared with a trend of more anastomosis - related complications in the ea group .
because our study is a retrospective analysis of a small number of cases , a larger prospective trial will be necessary to confirm these findings .
 background : during laparoscopic right hemicolectomy , the anastomosis can be created intra- or extracorporeally . this study aimed to determine whether a difference exists in short - term outcomes between these techniques.methods:prospectively collected 
 data of 80 consecutive patients who underwent laparoscopic right hemicolectomies since 2004 were reviewed retrospectively . 
 an intracorporeal anastomosis was performed in 23 patients , an extracorporeal anastomosis in 57.results:there were no significant differences in median length of stay ( 4 days ) , number of removed lymph nodes , estimated blood loss , operative time ( 190 minutes intracorporeal vs. 180 minutes ) and postoperative ileus ( 22% intracorporeal vs. 16% ) . 
 the incision length was significantly shorter in the intracorporeal group ( 4 cm vs. 5 cm ; p=0.004 ) . 
 complications related to the anastomosis including twisting of the mesentery ( n=2 ) , anastomotic volvulus ( n=1 ) , or leak ( n=1 ) occurred in 4 patients in the extracorporeal group compared with one minor anastomotic leak in the intracorporeal group . 
 major complication rates were similar between the 2 groups ( 4.3% intracorporeal vs. 5.3% extracorporeal).conclusion : the type of anastomosis does not influence short - term outcomes after laparoscopic right hemicolectomy . 
 an intracorporeal anastomosis results in shorter incision length and may decrease wound - related complications . 
INTRODUCTION
MATERIALS AND METHODS
Patients
Surgical Technique
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSION