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Background: After one decade of laparoscopic resections of the colon and rectum the parameters morbidity, conversion and complications were analyzed. The analysis of the literature comprises the results of operations performed for benign and malignant indications., Methods: The analysis is based on the medline research of the past ten years. Publications in German language not listed were added. Results of multicenter studies were included if differentiation by indication and dignity could be achieved. Surveys of different operations of the colon and rectum not differentiated by the parameters to be analyzed were excluded. Publications of the early beginning of laparoscopic surgery were included even if not more than 10 cases were presented but the parameters described in detail., Results: ADENOMAS OF THE COLON: The morbidity ranges from 0-17.4%, the conversion rate is 17.4 and 18.4% in 23 respectively 38 patients. SIGMOID DIVERTICULITIS: Mortality 0-1.8%. The morbidity was 16% in the early series and was later below 10% (8.7 and 7.3%). In the beginning the conversion rate was over 10% (12.0-38.9%) with one exception (0%). It dropped below 10% (4.6-9.2%) and was 0% in a recent study of 64 patients. The reasons for conversion are: inflammatory mass, fistula; perforation and obesity. Intraoperative complications are rare. The rate of postoperative complications did not change within 10 years (9.7 to 25.0% against 7.3 to 17.0%). CROHN'S DISEASE: The morbidity is around 10% (10.6-14.0%) and is lower in series with exclusively ileocoecal resections. The conversion rate is low or zero in ileocoecal resections and raises with the degree of inflammation and the spectrum of procedures. COLON CANCER: Mortality: 0-1.9%. The morbidity ranges from 6.8 to 30% and is especially high after conversions (up to 50%). The conversion rate reflects with the range of 4.2 to 21.0% in the beginning and 1.6 to 23.5% later the experience of the individual surgeon. RECTAL CANCER: Even in large series (n = 157) the mortality of laparoscopic rectal resections is zero. The conversion rate is 0-7.6%; the morbidity 11.5 to 26.4%. REVERSAL OF HARTMANN PROCEDURE: The number of cases is low, the conversion rate is around 20%. The morbidity ranges from 14.3-41.1% with one exception (0%). RECTOPEXY: Four different techniques are applied laparoscopically. The morbidity ranges from 0 to 16%. The conversion rate is 0-2.6%, except one (16.0%)., Conclusion: After one decade of laparoscopic colorectal surgery there are advantages for benign indications (adenomas, Crohn's disease, rectopexy) when compared with open surgery. Disadvantages arise from conversions. Experience of the surgeon is a strong parameter for a successful outcome. Results of ongoing studies are awaited for malignant indications.

Purpose: The aim of this study was to assess whether systemic proinflammatory cytokines (IL-6), anti-inflammatory cytokines (IL-4, IL-10), acute phase proteins (C-reactive protein), or granulocyte elastase are valuable indicators for determining the degree of surgical trauma after open vs. laparoscopic-assisted resections in Crohn's disease., Method: Eleven patients in each group (open and laparoscopic-assisted surgery) were matched for indication, surgical procedure, and Crohn's disease activity index. Serum IL-4, IL-6, and IL-10 were measured using enzyme-linked immunosorbent assay. Serum C-reactive protein was determined by immunoturbidimetric assay. Plasma granulocyte elastase was determined by immunoactivation immunoassay. Blood was sampled preoperatively, six hours after the operation, and at postoperative Days 1 to 5., Results: IL-4 was not detectable in any sample analyzed. Serum IL-6 and IL-10 levels peaked postoperatively in both groups without significant differences between laparoscopic-assisted (185.6 +/-54.1 pg/ml and 112.1 +/- 19.4 pg/ml, respectively; mean +/-standard error of the mean) and open surgery (431.1 +/-240.4 pg/ml and 196.7 +/- 56.5 pg/ml, respectively). Serum C-reactive protein levels also rose postoperatively, with a peak on the second day, but showed similar values after laparoscopic-assisted (107.1 +/- 12.1 mg/l) and open (128.3 +/- 17.5 mg/l) surgery. Plasma granulocyte elastase levels peaked on the first and second postoperative day and were found elevated almost throughout the five-day observation period. Comparison between the groups revealed significantly (P < 0.02) lower values after laparoscopic-assisted (Day 1, 46.5 +/- 8.9 microg/l; Day 2, 41.9 +/- 5.9 microg/l) when compared with open surgery (Day 1, 89.7 +/- 13.8 microg/l; Day 2, 91.4 +/- 14)., Conclusions: Serum IL-6 and IL-10 may not be ideal measures for evaluation of the degree of tissue trauma in laparoscopic-assisted and open resections in Crohn's disease, probably because of interference with disease-specific cytokine interactions. In contrast, granulocyte elastase has to be considered a strong marker discriminating the different severity of surgical trauma induced by laparoscopic-assisted vs. open resection in Crohn's disease.

Background: Although it is widely proposed that surgeons, before introducing a novel laparoscopic technique in man, should practice in an appropriate animal model for acquisition of the necessary technical skills, the effectiveness of those hands-on training courses are rarely documented., Methods: In 1995 we have organized eight hands-on training courses for laparoscopic anterior interbody spine fusion in an in vivo porcine model. A total of 72 colleagues from 50 different centers of 12 countries participated, including orthopedic, trauma, visceral, neuro-, and vascular surgeons. Quality and effectiveness of the course were evaluated by a questionnaire after a 1.5- to 2.5-year period., Results: During this time, 42.2% of the participating centers had applied the new technique successfully in man. Centers which participated in the course with a team that included a skilled laparoscopic surgeon and an orthopedic or trauma surgeon introduced the technique more frequently to clinical practice (57.9%) than those represented by only one participant (30. 8%). Moreover, there was a tendency toward a more frequent introduction of the technique to clinical practice in centers associated with university hospitals (57.1% vs. 29.2%), indicating the requirement of a particular infrastructure for this complex interdisciplinary procedure. Almost all participants (98.3%) agreed that for novel surgical techniques requiring advanced technical skills, there should first be training in a large animal model before the technique is applied in man., Conclusions: Complex laparoscopic procedures (i.e., laparoscopic spine surgery) can be successfully learned by in vivo hands-on training courses. We propose that for refinements and modifications of the technique (e.g. , the lumboscopic approach), there should also first be training in a large animal model before these are applied in man.

Since 1992 laparoscopic-assisted resections have been performed in 43 patients with tumors of the right or left colon. Excluding one patient with anastomotic leak there were no harvest complications. After a mean follow-up of 25 months 26/39 patients are living without tumor progress or recurrence, none of the 39 patients have abdominal wall metastases as yet; nine patients died due to tumor progress.