title: What are the consequences of enlarging the extraction site to exteriorize a large specimen during laparoscopic surgery for Crohn's enteritis?
abstract: OBJECTIVE
  The implications of extraction site enlargement for the removal of large specimens during laparoscopic surgery for Crohn's disease have not been clearly described; such a description is the aim of this study.
  
  
  METHODS
  An institutional database was queried to identify patients undergoing laparoscopic resection for Crohn's disease through midline incision between 1995 and 2013. Perioperative outcomes were compared among cases completed through their initial extraction site (L), completed after increasing the length of the initial extraction site (IL) for specimen exteriorization, and cases converted to open surgery (C). Univariate and multivariate statistical analyses were performed.
  
  
  RESULTS
  Out of 309 patients, 52 required IL and 36 required C. Heavier, older, male patients were more likely to require IL or C. There were no differences in disease behaviour (P = 0.260), procedures performed (P = 0.12) or postoperative morbidity (P = 0.33). IL and L groups had a comparable initial length of hospital stay (LOS), which was shorter than in the C group. While there were no significant differences in causes of readmission (P = 0.31), IL had increased readmission rates compared with L [odds ratio (OR) 2.80, P = 0.021] or C (OR 13.89, P = 0.015). When combining initial and readmission LOS, C and IL groups had comparable overall LOS [median ratio (MR) 1.09, P = 0.57], which was significantly longer than in the L group (MR 1.27, P = 0.02).
  
  
  CONCLUSIONS
  Extraction site enlargement during laparoscopic surgery for enteric Crohn's disease had no impact on primary LOS. However, the shorter initial LOS was offset by increased readmission rates when compared with formal conversion. The threshold to convert in case of anticipated difficulty due to a large specimen should be low.
authors.affiliation: Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: L C
authors.initials: LC
authors.lastname: Duraes
authors.affiliation: Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: L
authors.initials: L
authors.lastname: Stocchi
authors.affiliation: Department of Colorectal Surgery, University College of London Hospital, London, UK.
authors.forename: M
authors.initials: M
authors.lastname: Rottoli
authors.affiliation: Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: M M
authors.initials: MM
authors.lastname: Costedio
authors.affiliation: Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: E
authors.initials: E
authors.lastname: Gorgun
authors.affiliation: Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: H
authors.initials: H
authors.lastname: Kessler
mesh_terms: D000328:Adult; D003082:Colectomy / Q000379:methods*; D003106:Colon / Q000601:surgery; D061887:Conversion to Open Surgery / Q000706:statistics & numerical data; D003424:Crohn Disease / Q000601:surgery*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D011183:Postoperative Complications / Q000209:etiology*; D012189:Retrospective Studies; D000072836:Surgical Wound / Q000150:complications*; D016896:Treatment Outcome
keywords: Crohn's disease; colorectal surgery; conversion; incision enlargement; laparoscopy; length of incision