No randomized controlled trial has compared laparoscopic sigmoid resection (LSR) to open sigmoid resection (OSR) for symptomatic diverticulitis of the sigmoid colon. This study tested the hypothesis that LSR is associated with decreased postoperative complication rates as compared with OSR. This was a prospective, multicenter, double-blind, parallel-arm, randomized controlled trial. Eligible patients were randomized to either LSR or OSR. Endpoints included postoperative mortality, and complications were classified as major and minor. The generator of the allocation sequence was separated from the executor. Blinding was ensured using an opaque wound dressing to cover the abdomen. Symptomatic diverticulitis of the sigmoid colon was defined as recurrent disease Hinchey I, IIa, IIb, symptomatic stricture, or severe rectal bleeding. The decision to discharge patients was made by independent physicians blind to the allocation sequence. Data were analyzed according to the intention to treat principle. From 2002 to 2006, 104 patients were randomized in 5 centers. All patients underwent the allocated intervention. Fifty-two LSR patients were comparable to 52 OSR patients for gender, age, BMI, ASA grade, comorbid conditions, previous abdominal surgery, and indication for surgery. LSR took longer (P = 0.0001) but caused less blood loss (P = 0.033). Conversion rate was 19.2%. Mortality rate was 1%. There were significantly more major complications in OSR patients (9.6% vs. 25.0%; P = 0.038). Minor complication rates were similar (LSR 36.5% vs. OSR 38.5%; P = 0.839). LSR patients had less pain (Visual Analog Scale 1.6; P = 0.0003), systemic analgesia requirement (P = 0.029), and returned home earlier (P = 0.046). The short form-36 questionnaire showed significantly better quality of life for LSR. LSR was associated with a 15.4% reduction in major complication rates, less pain, improved quality of life, and shorter hospitalization at the cost of a longer operating time.

Despite the significant benefits of laparoscopic surgery, limitations still exist. One of these limitations is the loss of several degrees of freedom. Robotic surgery has allowed surgeons to regain the two lost degrees of freedom by introducing wristed laparoscopic instruments. At the first Pelvic Surgery Meeting held in Brescia in June 2007, the participants focused on the role of robotic surgery in pelvic operations surgery for malignancy including prostate, rectal, uterine, and cervical carcinoma. All members of the interdisciplinary panel were asked to define the role of robotic surgery in prostate, rectal, and uterine carcinoma. All key statements were reformulated until a consensus within the group was achieved (Murphy et al., Health Technol Assess 2(i–v):1–88, 1998). For the systematic review, a comprehensive literature search was performed in Medline and the Cochrane Library from January 1997 to June 2007. The keywords used were Da Vinci^®, telemonitoring, laparoscopy, neoplasms for urology, colorectal, gynecology, visceral surgery, and minimally invasive surgery. The pelvic surgery meeting was supported by Olympus Medical Systems Europa. As of December 31, 2007, there were 795 unit shipments worldwide of the Da Vinci^®: 595 in North America, 136 in Europe, and 64 in the rest of the world (http://investor.intuitivesurgical.com/phoenix.zhtml?c=122359&p=irol-faq#22324). It was estimated that, during 2007, approximately 50,000 radical prostatectomies were performed with the Da Vinci^® robot system in the USA, reflecting market penetration of 60% of radical prostatectomies in the USA. This utilization represents 50% growth as in 2006 only 42% of all radical prostatectomies performed in the USA employed robotics. While robotic prostatectomy has become the most widely accepted method of prostatectomy, robotic hysterectomy and proctectomy remain far less widely accepted. The theoretical benefits of the increased degrees of freedom and three-dimensional visualization may be outweighed in these areas by the loss of haptic feedback, increased operative times, and increased cost.

This study aimed to evaluate the impact of surgery-associated variables on recurrence rates after sigmoid resection for diverticulitis. Patients who underwent elective sigmoid resection for uncomplicated diverticulitis between 1992 and 2000 at two tertiary referral centers were followed up for recurrent disease as the primary end point. Recurrence after surgery was defined as left lower quadrant pain, fever, and leukocytosis, with consistent CT and/or contrast enema findings on admission and after six weeks. A logistic regression of the following variables was undertaken: patient demographics, duration of preoperative symptoms, previous admissions and abdominal surgery, surgical access (laparoscopic or open), postoperative complications, splenic flexure mobilization, anastomotic technique (handsewn or stapled), specimen length, inflammation at proximal resection margin, and anastomotic level (colosigmoid or colorectal). The last three variables were defined by the pathologist. Anastomosis level was based on muscle layer configuration (taeniae coli) at the distal resection margin. Two hundred thirty-six patients (105 females) with a mean age of 60.4 (standard deviation, ± 10) years were available for follow-up at 67 ± 30 (range, 11-130) months. The median duration of preoperative symptoms was 18 (range, 12-120) months. All but one (99 percent) patient had at least one admission before surgery. One hundred forty (59 percent) and 96 (41 percent) patients underwent laparoscopic or open resection, respectively. The conversion rate was 13 percent (18 patients) in the former group and the 30-day complication rate was 23 percent, with 0.4 percent 30-day mortality and a 2.1 percent reoperation rate. The splenic flexure was mobilized in 109 patients (47 percent). Anastomoses were fashioned by stapler in 171 patients (73 percent) and were to the rectum in 143 patients (72 percent). Specimen length was 17.9 ± 5.9 (range, 9-47) cm with inflammation at the proximal margin in 30 patients (14 percent). Twelve (5 percent) patients developed a recurrence at a mean of 78 ± 25 (range, 34-109) months with reoperation in one (0.4 percent). The level of anastomosis was the only predictor of recurrence in regression analysis (P= 0.033). Patients with colosigmoid anastomosis had a four times higher risk of having a recurrence compared with patients with colorectal anastomosis (odds ratio, 95 percent confidence interval = 1.12, 14.96). Colorectal (rather than colosigmoid) anastomosis was the single predictor of lower recurrence rates after elective sigmoid resection for uncomplicated diverticulitis.

The purpose of this study was to compare open with laparoscopic ileocolic resection in selected patients with refractory Crohn's disease confined to terminal ileum and cecum in terms of small-bowel obstruction and recurrence rates at a follow-up of five years. Thirty-nine patients who underwent laparoscopic ileocolic resection during a four-year period were compared with 53 patients who had previously undergone open ileocolic resection by the same surgeons at the same institution. Small-bowel obstruction was any clinical evidence of obstruction requiring hospital admission, regardless of recurrent disease or the need for surgery. Recurrence was defined as histologically proven Crohn's disease requiring reoperation and assessed by the actuarial method. Data were presented as medians and ranges and analyzed with Fisher's exact test, Student's t-test, Wilcoxon's rank-sum test, and log-rank test. Open ileocolic resection and laparoscopic ileocolic resection patients were well matched for age, gender, body mass index, American Society of Anesthesiologists grade, smoking, length of time from diagnosis to index operation, site of disease, preoperative medical treatment, previous abdominal surgery, indications for surgery, anastomosis configuration, microscopical involvement of resection margins, and postoperative complications (9.4 vs. 10.2 percent). Operating time was longer for laparoscopic ileocolic resection patients (105 (60-120) vs. 185 (130-210) min, P < 0.001). Hospital stay was shorter for laparoscopic ileocolic resection patients (11.2 (5-20) vs. 5.6 (3-11) days, P <0.001). At five-year follow-up, 90.5 percent of open ileocolic resection patients and 92.3 percent of laparoscopic ileocolic resection patients were available. Five-year small-bowel obstruction rates were 35.4 and 11.1 percent, respectively, in open ileocolic resection and laparoscopic ileocolic resection patients (17 vs. 4 patients, P = 0.02). Five-year-recurrence rates were 29.1 (14/48) and 27.7 percent (10/36). Median time to recurrence was 48 and 56 months, respectively, following open ileocolic resection and laparoscopic ileocolic resection (P = 0.9104). When compared with open ileocolic resection, laparoscopic ileocolic resection led to lower five-year small-bowel obstruction rates in selected patients with ileocecal Crohn's disease. Five-year recurrence rates did not differ.