Laparoscopic restorative proctocolectomy

Laparoscopic pouch anal anastomosis was first described in 1991 (Wexner et al). The first series in which laparoscopic pouches were compared to open pouches was published sooner thereafter (Schmitt et al) Subsequent data from The Netherlands revealed that laparoscopic pouch surgery conferred significant cosmetic advantages (Bemelman et al), and more recently we identified that the use of energy sources to perform laparoscopic surgery further improves outcomes including allowing smaller incisions (Garfinkle et al). A large national database study revealed that the majority of ileal J-pouches are performed by the laparoscopic approach.  Most recently the group at the Mayo clinic (Baek et al) evaluated 149 patients, 58 of whom underwent a laparoscopic pouch anal anastomosis and 91 of whom underwent an open pouch anal anastomosis in whom a median 8 year follow-up was available. The groups were well matched for standard variables except that stapled anastomoses were more common in the laparoscopic group. Interestingly, stool frequency was lower in the laparoscopic than in the open group both during the day and at night, although there was no difference in the ability to differentiate stool from gas or in rates of continence, use of medication, perianal skin irritation, voiding difficulties, sexual problems, or occupational change. The authors identified the double stapled anastomosis as being advantageous for stool frequency. This study may be more reflective of the fact that the double stapled anastomosis offers superior results to mucosectomy. In my view except in rare extenuating circumstances all colorectal surgery should be performed in a minimally invasive approach, ideally as a true laparoscopic or robotic manner. I have relied upon laparoscopic techniques for performance of J-pouch surgery for the last 27 years.  More recently I have also preferentially employed laparoscopy for reoperative and revisional J pouch surgery