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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

Background:

This study aimed to describe national intermediate-term admission rates for incisional hernia or clinically apparent adhesions following colorectal surgery, and to compare rates following laparoscopic and open approaches.

Methods:

Patients undergoing primary colorectal resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Subsequent inpatient admissions were extracted for up to 3 years after the initial operation or to the end of the study period. Outcomes examined were admissions with a diagnosis of, or operative interventions for, incisional hernia or adhesions.

Results:

A total of 187 148 patients were included between 2002 and 2008, with median follow-up of 31·8 (interquartile range 13·1–35·3) months. Some 8885 (4·7 per cent) of these patients were admitted with a diagnosis of, or underwent a repair of, an incisional hernia. In multiple regression analysis, use of laparoscopy was not a predictor of operative intervention for incisional hernia (odds ratio 1·09, 95 per cent confidence interval (c.i.) 0·99 to 1·21; P = 0·083). Some 15 125 (8·1 per cent) of the patients were admitted with a diagnosis of adhesions or had a procedure for division of adhesions. Overall, 3·5 per cent (6637 of 187 148) of patients underwent adhesiolysis. Patients selected for a laparoscopic procedure had lower rates of admission for adhesions (6·3 per cent (692 of 11 013) for laparoscopic versus 8·2 per cent (14 433 of 176 135) for open surgery; P < 0·001) and reintervention for adhesions (2·8 per cent (305 of 11 013) versus 3·6 per cent (6325 of 176 135) respectively; P < 0·001) than those undergoing an open procedure. In multiple regression analysis, patients selected for a laparoscopic procedure had lower subsequent intervention rates for adhesions (odds ratio 0·80, 95 per cent c.i. 0·71 to 0·90; P < 0·001).

Discussion:

Patients undergoing colorectal resection who are selected for the laparoscopic approach have a lower risk of developing clinically significant adhesions. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

Adhesion and incisional hernias are significant long-term sequelae of colorectal resection. Some 93 per cent of patients who had a previous abdominal procedure are found to have adhesions at laparotomy1. The Surgical and Clinical Adhesions Research (SCAR) group analysed adhesional outcomes of 29 790 patients operated on in Scotland over a 10-year period2. Patients undergoing colorectal procedures appeared to be at particular risk, with around one in 20 colorectal postoperative patients being admitted secondarily to adhesions3. The cost of adhesions was estimated at more than £500 million over the same 10-year period4. Observational studies have suggested that laparoscopic colorectal surgery may result in fewer cases of adhesion than the open approach5–7. Taylor and colleagues8, examining the Medical Research Council's Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC) trial, found that admission rates for intestinal obstruction due to adhesions were comparable between the two approaches.

Incisional hernias are noted to occur in approximately 10–15 per cent of laparotomies9, with morbidity rates of hernia repair approaching 20 per cent10. Case series of laparoscopic colorectal surgery have noted rates of incisional hernia of 0·55–7 per cent6, 7, 11, 12. The relationship between type of approach and the occurrence of incisional hernia remains unclear. The CLASICC cohort and a study meta-analysis by Kuhry and co-workers13 demonstrated comparable outcomes for the open and laparoscopic approaches8. Conversely, Andersen et al.14 noted a significantly reduced risk of incisional hernia in patients undergoing laparoscopic sigmoid colectomy compared with the open approach.

This study aimed to describe national intermediate-term admission rates for incisional hernia and clinically apparent adhesions after colorectal surgery, and to compare the rates of these complications following laparoscopic and open approaches.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

The study was approved under Section 251 (formerly Section 60) by the National Information Governance Board for Health and Social Care (formerly the Patient Information Advisory Group). Approval for using the data for research purposes was granted by the South East Research Ethics Committee.

Hospital Episode Statistics

A description of the Hospital Episode Statistics (HES) database has been published previously15. Briefly, it is an administrative data set that collates information of all National Health Service (NHS) and private patients admitted to NHS hospitals in England. Each admission contains a primary diagnosis and up to 19 secondary diagnoses, categorized according to the International Classification of Diseases, tenth revision (ICD-10), and up to 24 procedure fields coded using the Office of Population Censuses and Surveys (OPCS) Classification of Surgical Operations and Procedures, fourth revision. The Charlson co-morbidity index, derived from the secondary diagnosis codes, is a marker of co-morbidity and was originally formulated to predict mortality16. The Carstairs index of deprivation is derived from the patient postcode17.

Inclusions

All adult patients undergoing primary colorectal resection between 1 April 2002 and 31 March 2008 were included in the study. The first resection that the patient underwent between 2002 and 2008 was considered as the primary resection. Any patient undergoing a colorectal resection between 1996 and 2002 was excluded from this study.

Resections were classified according to the type of resection (OPCS coding), shown in Appendix S1 (supporting information). A laparoscopic procedure was considered to be any procedure associated with OPCS codes Y50·8, Y75 or Y71·4. The code Y71·4 (failed minimal access) was introduced in 2006, and these procedures were included in the laparoscopic group. Procedures coded as Y71·4 were analysed in the laparoscopic group.

Individual diagnoses were recoded into major diagnostic categories according to the ICD-10 code as follows: malignant disease (C18, C19, C20, C21, C26); ulcerative colitis (K51); Crohn's disease (K50); and diverticular disease (K57).

Patients were classified according to how they were admitted to hospital, as an emergency/unplanned admission or as an elective admission. They were grouped into four age cohorts: 17–54, 55–69, 70–79 and 80 years or above, according to age at time of surgery. Charlson score was considered in three categories: 0, 1–4 and 5 or more.

Reoperation was defined as any return to theatre (RTT) for an intra-abdominal procedure or wound complication on the index admission, or on a subsequent admission to hospital within 28 days of the initial resection. This methodology has been described previously18.

Outcome variables

Subsequent admissions were analysed for up to 3 years after the initial resection. Admissions with a diagnosis in any field with an ICD-10 code or a relevant operative code signifying incisional hernia and adhesions were included. Admissions where an operative intervention occurred were considered in the regression analysis. The ICD-10 diagnostic and OPCS procedure codes are shown in Appendix S2 (supporting information).

Statistical analysis

Categorical variables were investigated using the χ2 test. Logistic regression analysis was used to investigate operative reintervention for adhesions and incisional hernias. Factors with a significance level of P⩽0·100 on bivariable analysis were included in the regression analyses. Forward logistic regression models were used to determine significant predictors of operative reintervention for adhesions and incisional hernias. Variables included in the model were age, co-morbid status, level of social deprivation, year of surgery, diagnosis, type of resection, admission status, type of approach, RTT and sex. Statistical analyses were carried out using SPSS® version 18.0 (IBM, Armonk, New York, USA). P < 0·050 was considered statistically significant.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

A total of 187 148 patients underwent primary colorectal resection between 1 April 2002 and 31 March 2008; their characteristics are shown in Table 1. Patients were followed up for a maximum of 3 years, or until the end of the study period if initially operated on during the last 3 years of the study. Median follow-up was 31·8 (interquartile range 13·1–35·3) months. Of these elective and emergency resections, 11 013 patients (5·9 per cent) were selected for the laparoscopic approach. From 2006, 15·6 per cent (1197 of 7650) of laparoscopic procedures were coded as failed minimal access (Y71·4).

Table 1. Descriptive details of patients undergoing resection between 2002 and 2008
 Laparoscopic approach (n = 11 013)Open approach (n = 176 135)P
  • Values in parentheses are percentages.

  • *

    Data missing for 16 and 142 patients in laparoscopic and open groups respectively;

  • data missing for two and 112 patients respectively.

  • χ2 test.

Age (years)  < 0·001
 17–542315 (21·0)33 990 (19·3) 
 55–693567 (32·4)56 696 (32·2) 
 70–793273 (29·7)53 569 (30·4) 
 ≥ 801858 (16·9)31 880 (18·1) 
Sex  < 0·001
 M5344 (48·5)89 648 (50·9) 
 F5669 (51·5)86 487 (49·1) 
Carstairs deprivation index*  < 0·001
 1 (least deprived)2425 (22·1)33 608 (19·1) 
 22666 (24·2)39 549 (22·5) 
 32410 (21·9)38 550 (21·9) 
 41935 (17·6)34 866 (19·8) 
 5 (most deprived)1561 (14·2)29 420 (16·7) 
Admission status  < 0·001
 Elective9871(89·6)111 246 (63·2) 
 Emergency1140 (10·4)64 777 (36·8) 
Diagnosis  < 0·001
 Colorectal cancer6938 (63·0)102 310 (58·1) 
 Inflammatory bowel disease931 (8·5)14 671 (8·3) 
 Diverticular disease1217 (11·1)23 955 (13·6) 
 Other1927 (17·5)35 199 (20·0) 
Type of resection  < 0·001
 Right-sided4137 (37·6)57 888 (32·9) 
 Left-sided2462 (22·4)52 327 (29·7) 
 Rectal3860 (35·0)48 978 (27·8) 
 Subtotal/total554 (5·0)16 942 (9·6) 
Charlson co-morbidity score  < 0·001
 07514 (68·2)110 546 (62·8) 
 1–41271 (11·5)17 688 (10·0) 
 ≥ 52228 (20·2)47 901 (27·2) 

Incisional hernia rates

During the study interval, 4·7 per cent (8885 of 187 148) of patients were admitted with a diagnosis of incisional hernia or underwent a procedure for repair of an incisional hernia. Of these patients, 80·6 per cent (7160 of 8885) had an operative repair of hernia, equating to 3·8 per cent of all patients undergoing colorectal resection. Patients selected for the laparoscopic approach had higher rates of operative intervention for incisional hernia than those selected for the open approach (4·2 per cent (465 of 11 013) versus 3·8 per cent (6688 of 176 135) respectively; P = 0·025, standardized difference 0·02) in unadjusted analysis. Table 2 shows the readmitted patients who required operative intervention for incisional hernia and adhesions in the laparoscopic and open groups. In multiple regression analysis, use of laparoscopy was not a significant predictor of operative repair of incisional hernias (odds ratio (OR) 1·09, 95 per cent confidence interval (c.i.) 0·99 to 1·21; P = 0·083) (Table 3).

Table 2. Crude rates of reintervention for adhesions and incisional hernia repair in laparoscopic and open groups at 1, 2 and 3 years postsurgery
 Laparoscopic approach (n = 11 013)Open approach (n = 176 135)P*
  • *

    χ2 test.

Incisional hernia repair   
 1 year163 (1·5)1655 (0·9)< 0·001
 2 years394 (3·6)5029 (2·9)< 0·001
 3 years465 (4·2)6688 (3·8)0·024
Division of adhesions   
 1 year160 (1·5)3208 (1·8)0·005
 2 years270 (2·5)5351 (3·0)< 0·001
 3 years305 (2·8)6325 (3·6)< 0·001
Table 3. Multiple regression analysis of operative reintervention for incisional hernia and adhesions
 Incisional hernia repairDivision of adhesions
 Odds ratioPOdds ratioP
  • Values in parentheses are 95 per cent confidence intervals.

  • *

    Return to theatre within 28 days of index operation.

Age (years) < 0·001 < 0·001
 17–541·00 1·00 
 55–691·09 (1·03, 1·17)0·0070·75 (0·71, 0·80)< 0·001
 70–790·79 (0·73, 0·84)< 0·0010·49 (0·46, 0·53)< 0·001
 ≥ 800·28 (0·25, 0·32)< 0·0010·26 (0·23, 0·28)< 0·001
Female versus male sex0·78 (0·74, 0·82)< 0·0011·13 (1·07, 1·19)< 0·001
Carstairs deprivation index   0·001
 1 (least deprived)  1·00 
 2  0·98 (0·91, 1·06)0·570
 3  0·97 (0·90, 1·04)0·379
 4  0·93 (0·86, 1·00)0·060
 5 (most deprived)  0·83 (0·76, 0·90)< 0·001
Laparoscopic versus open surgery1·09 (0·99, 1·21)0·0830·80 (0·71, 0·90)< 0·001
Emergency versus elective surgery1·07 (1·01, 1·13)0·0271·49 (1·41, 1·58)< 0·001
Diagnosis < 0·001  
 Cancer1·00 1·00 
 Inflammatory bowel disease1·11 (0·99, 1·23)0·0721·31 (1·19, 1·44)< 0·001
 Diverticular disease2·18 (2·04, 2·34)< 0·0011·08 (1·00, 1·17)0·045
 Other1·21 (1·13, 1·30)< 0·0010·94 (0·88, 1·01)0·088
Type of resection < 0·001 < 0·001
 Right-sided1·00 1·00 
 Left-sided1·45 (1·35, 1·55)< 0·0011·89 (1·76, 2·04)< 0·001
 Rectal1·70 (1·59, 1·83)< 0·0011·95 (1.80, 2·10)< 0·001
 Subtotal/total1·02 (0·92, 1·13)0·6671·92 (1·76, 2·10)< 0·001
Charlson co-morbidity score < 0·001 < 0·001
 01·00 1·00 
 1–40·98 (0·91, 1·06)0·6170·99 (0·91, 1·08)0·817
 ≥ 50·63 (0·59, 0·68)< 0·0010·86 (0·80, 0·91)< 0·001
Surgical complication*1·56 (1·44, 1·69)< 0·0012·16 (2·00, 2·32)< 0·001
Year of surgery < 0·001 0·001
 20021·00 1·00 
 20031·14 (1·04, 1·24)0·0051·07 (0·98, 1·17)0·155
 20041·23 (1·13, 1·34)< 0·0011·15 (1·05, 1·26)0·003
 20051·42 (1·30, 1·54)< 0·0011·27 (1·17, 1·39)< 0·001
 20061·39 (1·28, 1·51)< 0·0011·27 (1·16, 1·38)< 0·001
 20071·12 (1·03, 1·22)0·0121·22 (1·11, 1·33)< 0·001

Adhesion-related admissions

Some 8·1 per cent (15 125 of 187 148) of patients were admitted with a diagnosis of adhesions or underwent a procedure for division of adhesions. Of these, 43·9 per cent (6637 of 15 125) required an operative intervention for division of adhesions. Overall, 3·5 per cent of patients undergoing colorectal resection required division of adhesions within 3 years of the primary procedure. Patients selected for a laparoscopic procedure had lower rates of admission with a diagnosis of adhesions (6·3 per cent (692 of 11 013) for laparoscopic versus 8·2 per cent (14 433 of 176 135) for open surgery; P < 0·001, standardized difference 0·07) and lower rates of reintervention for adhesions than those undergoing an open procedure (2·8 per cent (305 of 11 013) versus 3·6 per cent (6332 of 176 135) respectively; P < 0·001, standardized difference 0·04). In multiple regression analysis, patients selected for a laparoscopic procedure had lower adhesion rates (OR 0·80, 95 per cent c.i. 0·71 to 0·90; P < 0·001) (Table 3).

For patients admitted with adhesions, similar proportions in the laparoscopic and open groups required surgical reintervention: 44·1 per cent (305 of 692) versus 43·9 per cent (6332 of 14 433) respectively (P = 0·916).

Patients who had a complication requiring reoperation in the postoperative period were more likely to have an operative reintervention for adhesions than those who did not need reoperation (13·1 per cent (1639 of 12 481) for RTT versus 7·7 per cent (13 486 of 174 667) for no RTT; P < 0·001).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

The patient-reported benefits of laparoscopic colorectal surgery are well established19–23. This study, the first population-based national epidemiological survey examining incisional hernia and adhesions in laparoscopic and open colorectal resection in England, suggested that the minimally invasive approach results in fewer adhesion-related admissions and reoperations with comparable rates of incisional hernia.

The overall incidence of adhesions and incisional hernia in the present study was similar to findings from other studies8. The overall incisional hernia rate of 4·7 per cent is similar to rates found in a recent Cochrane review13, and the laparoscopic incisional hernia rate of 4·2 per cent falls within the published range of 0·55–7 per cent6, 7, 11, 12. In unadjusted analyses, incisional hernia rates were higher in patients selected for the laparoscopic approach at 1, 2 and 3 years. Although it was not possible to ascertain from the present data set, these may have been port-site hernias. The significance of this increased herniation rate is unclear. In the regression analyses, selection for laparoscopy was not identified as a predictor of increased hernia repair rate. It should be emphasized that this analysis examined only hernia repair rates and not the overall incidence of incisional hernia. It was not possible to quantify the total number of hernias following respective operative approaches.

The high admission rate for adhesions (8·1 per cent) and the adhesiolysis rate (3·5 per cent) confirm the importance of this issue, as recognized by others24–26. Reduced rates of clinically important adhesions following the laparoscopic approach have been suggested in single-centre observational studies5–7. Laparoscopic colorectal surgery may result in fewer adhesions because of reduced tissue handling and/or less environmental exposure of the bowel24, 26. The present study has confirmed the previous findings that patients requiring RTT for complication and those undergoing emergency surgery have an increased risk of adhesions and incisional hernia27–29.

The increasing risk of incisional hernia and adhesions over the study interval merits further investigation. The problem of adhesions following colorectal surgery has been noted increasingly in the surgical literature1, 26. Parker and colleagues26 issued the colorectal community with a ‘call for action’ on adhesions, and advocated adhesion reduction strategies including the use of antiadhesion agents. Although the present study was unable to make an assessment of the antiadhesion strategies used, the evidence surrounding the impact of antiadhesion meshes and solutions requires further elucidation. A systematic review has suggested that some solutions may reduce the development of postoperative adhesions30. Little work has, however, investigated the long-term development of clinically relevant adhesions or the need for admission with adhesional bowel obstruction.

The increased use of the laparoscopic approach in colorectal surgery has important cost implications for the NHS. A recent systematic review and health technology assessment of the cost implications of laparoscopic colorectal surgery demonstrated slightly higher provider costs for the minimally invasive approach compared with open surgery31, 32. Dowson and colleagues5, examining total hospital costs, found that the open and laparoscopic approaches were equivalent, with the higher operating rooms costs of minimally invasive surgery being offset by reduced postoperative costs. A study from Finland demonstrated that the annual direct cost of postoperative small bowel obstruction secondary to adhesions was approximately €3 million, equivalent to the costs of treating both gastric and rectal cancer at the authors' institution33. Reduced risk of adhesions and, in particular, intervention for postoperative adhesions with the laparoscopic approach might further offset the higher initial operating cost.

The limitations of the HES data set have been detailed extensively in previous publications by the authors' group18. There are some aspects of this study that merit further discussion. The data set is not able to code for parastomal hernia, which may be coded with other ventral hernias; this will artificially increase the incidence of incisional hernia. As operation codes are more likely to be accurate than diagnosis codes, the study may not be as specific in identifying incisional hernias or adhesions that did not require admission or operation. Furthermore, the present data set examined only inpatient admissions, so any patient with an incisional hernia treated conservatively on an outpatient basis would not have been included. As discussed above, most clinically significant hernias will have been captured, but the overall incidence of incisional hernia will have been underestimated. The clinical severity of a hernia is not conveyed within this administrative database. The impact of a limited port-site hernia is likely to differ from that of a large midline laparotomy herniation. Moreover, data such as length of incision or previous surgery are not included in the present data set. Thus, the authors cannot be certain that all hernias and adhesions were secondary to the colorectal resection admission included in the study. Although patients who had undergone resection in at least the 6 years before the study interval were excluded, other operations such gynaecological procedures may have been undertaken. Cancer stage and disease severity were not included in the data set, so neither was included in the risk adjustment models. This would be pertinent as patients with a higher cancer stage would have been more likely to have had conversion from laparoscopic to open operation, with the inherent risk of the development of incisional hernia. The coding for failed laparoscopic approach (converted to open surgery) was introduced only in 2006, and before this there was no specific code for conversion. The laparoscopic group will have included some patients who did not have their procedure completed laparoscopically. In addition, patients who underwent a hand-assisted approach were included in the laparoscopic group.

The data set did not contain long-term mortality data, and thus patients in both groups were assumed to be alive at 3 years or at the end of the study period. It was therefore not possible to assess the ‘competing’ risks of death and of adhesions or hernias in each group. This may account in part for the reduced reoperation rates for adhesions and hernia seen in older patients. Long-term survival is likely to be similar following laparoscopic and open colorectal cancer resection13, 34, and thus the impact of excess mortality in the laparoscopic or open group is likely to be limited.

This study analysed incisional hernia and adhesion-related outcomes of open and laparoscopic colorectal surgery in the context of a large population-based cohort study. Acknowledging the limitations of the administrative data on which it was founded, the study demonstrated that patients undergoing a laparoscopic approach for colorectal surgery have an independently lower risk of developing clinically relevant postoperative adhesions than those who have conventional surgery. The reduced adhesion rate associated with laparoscopic surgery may have significant economic implications when the cost of this approach is analysed over the longer term.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

The Dr Foster Unit at Imperial College London is affiliated with the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust, which is funded by the National Institute for Health Research (NIHR). The authors are grateful for support from the NIHR Biomedical Research Centre funding scheme. The Unit is funded largely by a research grant from Dr Foster Intelligence (an independent health service research organization). E.M.B. is supported by a Cancer Research UK clinical lectureship (C42671/A13720). This research was also funded in part by a research grant from Ethicon Endo-Surgery (Europe). OF is funded in part by St Mark's Foundation.

Disclosure: The authors declare no other conflict of interest.

Supporting information

Additional supporting information may be found in the online version of this article:

Appendix S1 Office of Population Censuses and Surveys (OPCS) coding for colorectal resection (Word document)

Appendix S2 International Classification of Diseases, tenth revision (ICD-10), and Office of Populations Censuses and Surveys (OPCS) codes for designation of incisional hernia and adhesions (Word document)

Please note: John Wiley & Sons Ltd is not responsible for the functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information
  • 1
    Menzies D, Ellis H. Intestinal obstruction from adhesions—how big is the problem? Ann R Coll Surg Engl 1990; 72: 6063.
  • 2
    Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS, Menzies D et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet 1999; 353: 14761480.
  • 3
    Parker MC, Wilson MS, Menzies D, Sunderland G, Clark DN, Knight AD et al.; Surgical and Clinical Adhesions Research (SCAR) Group. The SCAR-3 study: 5-year adhesion-related readmission risk following lower abdominal surgical procedures. Colorectal Dis 2005; 7: 551558.
  • 4
    Wilson MS, Menzies D, Knight AD, Crowe AM. Demonstrating the clinical and cost effectiveness of adhesion reduction strategies. Colorectal Dis 2002; 4: 355360.
  • 5
    Dowson HM, Bong JJ, Lovell DP, Worthington TR, Karanjia ND, Rockall TA. Reduced adhesion formation following laparoscopic versus open colorectal surgery. Br J Surg 2008; 95: 909914.
  • 6
    Lumley J, Stitz R, Stevenson A, Fielding G, Luck A. Laparoscopic colorectal surgery for cancer: intermediate to long-term outcomes. Dis Colon Rectum 2002; 45: 867872.
  • 7
    Duepree HJ, Senagore AJ, Delaney CP, Fazio VW. Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? Laparoscopy versus laparotomy. J Am Coll Surg 2003; 197: 177181.
  • 8
    Taylor GW, Jayne DG, Brown SR, Thorpe H, Brown JM, Dewberry SC et al. Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial. Br J Surg 2010; 97: 7078.
  • 9
    Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet 2003; 362: 15611571.
  • 10
    Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004; 240: 578583.
  • 11
    Regadas FS, Rodrigues LV, Nicodemo AM, Siebra JA, Furtado DC, Regadas SM. Complications in laparoscopic colorectal resection: main types and prevention. Surg Laparosc Endosc 1998; 8: 189192.
  • 12
    Skipworth JR, Khan Y, Motson RW, Arulampalam TH, Engledow AH. Incisional hernia rates following laparoscopic colorectal resection. Int J Surg 2010; 8: 470473.
  • 13
    Kuhry E, Schwenk WF, Gaupset R, Romild U, Bonjer HJ. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database Syst Rev 2008; (2)CD003432.
  • 14
    Andersen LP, Klein M, Gögenur I, Rosenberg J. Incisional hernia after open versus laparoscopic sigmoid resection. Surg Endosc 2008; 22: 20262029.
  • 15
    Faiz O, Warusavitarne J, Bottle A, Tekkis PP, Darzi AW, Kennedy RH. Laparoscopically assisted vs. open elective colonic and rectal resection: a comparison of outcomes in English National Health Service Trusts between 1996 and 2006. Dis Colon Rectum 2009; 52: 16951704.
  • 16
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373383.
  • 17
    Carstairs V, Morris R. Deprivation: explaining differences in mortality between Scotland and England and Wales. BMJ 1989; 299: 886889.
  • 18
    Burns EM, Bottle A, Aylin P, Darzi A, Nicholls RJ, Faiz O. Variation in reoperation after colorectal surgery in England as an indicator of surgical performance: retrospective analysis of Hospital Episode Statistics. BMJ 2011; 343: d4836.
  • 19
    Braga M, Vignali A, Gianotti L, Zuliani W, Radaelli G, Gruarin P et al. Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome. Ann Surg 2002; 236: 759766.
  • 20
    Lacy AM, Garcia-Valdecasas JC, Delgado S, Castells A, Taura P, Pique JM et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 2002; 359: 22242229.
  • 21
    Veldkamp R, Kuhry E, Hop WC, Jeekel J, Kazemier G, Bonjer HJ et al.; Colon cancer Laparoscopic or Open Resection Study Group (COLOR). Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 2005; 6: 477484.
  • 22
    Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM et al.; UK MRC CLASICC Trial Group. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 2007; 25: 30613068.
  • 23
    Braga M, Frasson M, Vignali A, Zuliani W, Civelli V, Di Carlo V. Laparoscopic vs. open colectomy in cancer patients: long-term complications, quality of life, and survival. Dis Colon Rectum 2005; 48: 22172223.
  • 24
    Bhardwaj R, Parker MC. Impact of adhesions in colorectal surgery. Colorectal Dis 2007; 9(Suppl 2): 4553.
  • 25
    Parker MC, Wilson MS, Menzies D, Sunderland G, Thompson JN, Clark DN et al.; Surgical and Clinical Adhesions Research (SCAR) Group. Colorectal surgery: the risk and burden of adhesion-related complications. Colorectal Dis 2004; 6: 506511.
  • 26
    Parker MC, Wilson MS, van Goor H, Moran BJ, Jeekel J, Duron JJ et al. Adhesions and colorectal surgery—call for action. Colorectal Dis 2007; 9(Suppl 2): 6672.
  • 27
    Hesselink VJ, Luijendijk RW, de Wilt JH, Heide R, Jeekel J. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993; 176: 228234.
  • 28
    Parker MC, Ellis H, Moran BJ, Thompson JN, Wilson MS, Menzies D et al. Postoperative adhesions: ten-year follow-up of 12 584 patients undergoing lower abdominal surgery. Dis Colon Rectum 2001; 44: 822829.
  • 29
    Rotholtz NA, Laporte M, Zanoni G, Bun ME, Aued L, Lencinas S et al. Predictive factors for conversion in laparoscopic colorectal surgery. Tech Coloproctol 2008; 12: 2731.
  • 30
    Kumar S, Wong PF, Leaper DJ. Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after non-gynaecological abdominal surgery. Cochrane Database Syst Rev 2009; (1)CD005080.
  • 31
    Hernández RA, de Verteuil RM, Fraser CM, Vale LD; Aberdeen Health Technology Assessment Group. Systematic review of economic evaluations of laparoscopic surgery for colorectal cancer. Colorectal Dis 2008; 10: 859868.
  • 32
    Murray A, Lourenco T, de Verteuil R, Hernandez R, Fraser C, McKinley A et al. Clinical effectiveness and cost-effectiveness of laparoscopic surgery for colorectal cancer: systematic reviews and economic evaluation. Health Technol Assess 2006; 10: 1141, iii–iv.
  • 33
    Kossi JA, Salminen PT, Laato MK. Surgical workload and cost of postoperative adhesion-related intestinal obstruction: importance of previous surgery. World J Surg 2004; 28: 666670.
  • 34
    Colon Cancer Laparoscopic or Open Resection Study Group, Buunen M, Veldkamp R, Hop WC, Kuhry E, Jeekel J et al. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol 2009; 10: 4452.

Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information
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bjs_8964_sm_suppinfoa.doc23KSupporting Information
bjs_8964_sm_suppinfob.doc23KSupporting Information

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