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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.
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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.