title: Hybrid laparoscopic flexure takedown and open procedure for rectal resection is associated with significantly shorter length of stay than equivalent open resection.
abstract: OBJECTIVE
  Laparoscopic-assisted, sphincter-saving resection (largest incision < 7 cm) of the middle and distal rectum is technically very difficult and, with regard to cancers, has not been demonstrated to be oncologically safe. The hypothesis of this retrospective study is that a hybrid operation that combines laparoscopic and open methods would be associated with short-term outcome benefits compared with open surgery results for patients undergoing sphincter-saving proctectomy.
  
  
  METHODS
  A total of 31 hybrid and 25 fully open rectal resection patients were compared in this retrospective review. All patients had splenic flexure takedown and rectal anastomosis. The hybrid approach consisted of laparoscopic splenic flexure takedown (with or without partial rectal mobilization and devascularization) followed by completion of the procedure via infraumbilical midline laparotomy. The indication was neoplasm in 87 percent of hybrid patients and in 68 percent of open patients. The majority of tumors were located between 4 and 10 cm from the dentate line.
  
  
  RESULTS
  Fifty-eight percent of hybrid and 68 percent of open patients had low anterior or coloanal resections, and 48 percent of hybrid and 64 percent of open patients underwent temporary diversion via ileostomy. The mean hybrid midline incision length was 11 cm compared with 24 cm for open patients (P < 0.0001). The neoplastic specimens were similar with regard to margins and lymph node harvest. Similar complication rates were noted in both groups. Nonsignificant benefits for hybrid patients (0.9-1.2 days) were seen with regard to length of time until toleration of liquid or solid diet and first flatus. Hybrid patients experienced their first bowel movements 4.1 days vs. 5.7 days for the open group (P = 0.03). Mean length of stay was significantly shorter for hybrid patients (6.1. days) than for open patients (11.1 days; P = 0.0006).
  
  
  CONCLUSIONS
  This preliminary retrospective study suggests that a combined hybrid laparoscopic and open approach to sphincter-saving proctectomy permits a similar resection as open methods and may be associated with a length-of-stay benefit and more rapid return of bowel function. Prospective studies will be needed before any firm conclusions can be drawn.
authors.affiliation: Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY 10032.
authors.forename: S
authors.initials: S
authors.lastname: Vithiananthan
authors.forename: Z
authors.initials: Z
authors.lastname: Cooper
authors.forename: K
authors.initials: K
authors.lastname: Betten
authors.forename: G S
authors.initials: GS
authors.lastname: Stapleton
authors.forename: J
authors.initials: J
authors.lastname: Carter
authors.forename: E H
authors.initials: EH
authors.lastname: Huang
authors.forename: R L
authors.initials: RL
authors.lastname: Whelan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000502:physiology / Q000601:surgery*; D000714:Anastomosis, Surgical; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007813:Laparotomy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012004:Rectal Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome