Laparoscopy is increasingly becoming the standard of care for patients undergoing colorectal surgery for both benign and malignant diseases [1]. Many complications such as respiratory and wound infections and deep vein thrombosis have decreased with the use of laparoscopy in these patients [2, 3]. However, other complications such as anastomotic leakage and bleeding persist regardless of the minimally invasive approach used and are associated with significant morbidity and mortality if they are not promptly recognized and treated [4,5,6,7,8]. Many groups have gained great experience in minimally invasive colorectal surgery, allowing them to expand the use of laparoscopy. One of the most challenging indications that possibly require the greatest experience to treat postoperative complications is laparoscopic reintervention (“relaparoscopy”) (RL) [9,10,11,12,13]. Although there are some publications on this subject [14,15,16,17,18,19,20], its application is neither widespread nor standardized.

Previous studies, including one of our groups, have demonstrated the feasibility of RL in this setting [14,15,16,17,18,19,20]. However, most of them have been limited by the low number of cases evaluated.

The aim of this study was to analyze the results obtained with the use of RL to treat early complications following laparoscopic colorectal surgery in a larger series of patients.

Methods

Study design and population

A retrospective study based on a prospectively collected database was performed. Patients who underwent laparoscopic colorectal surgery and required a reoperation between June 2000 and December 2019 were included. Patients in whom the laparoscopy was converted during the primary resection were excluded.

The cohort of patients subject to reoperation was divided into two groups according to the approach: laparoscopy (RL) and laparotomy (LPM). Early complication was considered when the reoperation was performed in the period of 30 days after primary surgery. The use of laparoscopy at the reoperation was determined according to the surgeon's preference. All reoperations were performed by senior national board-certified colorectal surgeons. Patients who underwent RL but converted to open procedure were placed in the RL group based on intention-to-treat analysis.

Variables and outcomes

Demographics, intraoperative complications, and conversion rate at the second surgery were analyzed. Recovery parameters such as length of hospital stay (LOS) before and after reoperation, intensive care unit (ICU) admission, morbidity scored as Clavien–Dindo classification, and mortality rate were also considered for analysis. Severe complications were considered for those included in Clavien–Dindo ≥ 3b. The RL technique was performed as described previously [14].

Statistical analyses

The Student’s t-test was used to compare continuous variables, whereas the χ2 and Fisher test were used for categorical variables. A multivariate logistic regression model was used to identify potential variables associated with the use of laparoscopy for reoperation.

A p value < 0.05 was considered statistically significant for all tests.

The institutional review board (IRB) of our institution approved this study. Written informed consent was waived by the IRB owing to the study’s retrospective nature.

Results

Relaparoscopy was possible in 78% (n = 124) of the overall cohort of 159 of 1843 who required reoperation after laparoscopic colorectal surgery. Figure 1 shows the progression of the use of the RL during the analyzed period of time.

Fig. 1
figure 1

Progression of the use of the RL during the period of time analyzed. In orange LPM (laparotomy), in blue RL (laparoscopy)

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Demographics were similar in both groups. (Table 1).

Table 1 Demographic characteristics
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Patients in whom the primary procedure was longer were more likely to be included in the LPM group. Conversely, patients who underwent left colectomy/sigmoidectomy were more frequently included in the RL group (Table 2).

Table 2 Type of surgery at the first operation
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If the reoperation was done within the first 5 days, the chances of performing a RL were significantly higher (RL: 40.3% vs. LPM: 62.8%, p: 0.017). Length of stay after reoperative surgery (RL: 10.2 days vs. 12 days, p: 0.29) and total length of stay (11.3 days vs. 14.2 days, p: 0.10) were similar in both groups.

The most common finding at reoperation was anastomotic leak, which was diagnosed in 93 (58.5%) patients (Table 3). This complication was mostly treated by RL (RL: 67.7% vs. LPM: 25.7%, p: 0.0001). Treatment of this complication was mainly by peritoneal lavage, drain placement near the anastomosis, and performance of a protective loop ileostomy (RL: 65.8% vs. LPM: 17.6%, p: 0.00001). Although RL was useful to treat other complications, the majority of these complications were treated by LPM (Table 4). Conversion was necessary in 12 (9.6%) patients owing to absence of surgical field (58.3%), generalized fecal peritonitis (33.3%), and massive colonic ischemia (8.3%). Eight percent of patients had negative RL. The operative time was shorter in the RL group (Table 4). After reoperation, there were no differences in the use of ICU and LOS.

Table 3 Complications identified at re-operative surgery
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Table 4 Type of surgery at reoperation
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However, overall morbidity was similar in both groups (RL: 46.8% vs. LPM: 72.6%, p: 0.8). Severe complications were less frequent after RL (RL: 14.2% vs. LPM: 33.4%, p: 0.01). Mortality occurred in 11 (6.9%) patients (RL: 5.6%, vs. LPM: 11.4%, p: 0.23) due to septic shock, cardiovascular, and pulmonary complications (Table 5).

Table 5 Reoperative surgery outcome
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Multivariate analysis showed that patients undergoing resection with redo anastomosis were significantly less likely to be reoperated by laparoscopy (OR 0.09, 95% CI 0.01–0.88, p = 0.04) (Table 6).

Table 6 Multivariate analysis evaluating variables associated with the use of laparoscopy in the reoperation
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Discussion

The aim of this study was to evaluate the safety and feasibility of relaparoscopy to manage postoperative complications after laparoscopic colorectal surgery. We found that (a) the success rate of RL is high; (b) anastomotic leak after left colectomy was the complication more suitable to be treated by this approach; and (c) severe complications after the use of RL were significantly lower compared with the LPM outcome.

RL has been demonstrated to be a successful approach for the treatment of early complications after laparoscopic colorectal procedures when it is adequately indicated and performed by experienced surgeons [21]. In our study, a large proportion of patients with postoperative complications were managed safely with RL approach. Although demographics and comorbidities were similar in patients undergoing laparoscopy and laparotomy, there was a trend toward younger and healthier patients in the relaparoscopy group. Surgeons’ confidence and training in minimally surgery might have also contributed to an unconscious selection bias in our study. Overall, we still believe that patients’ characteristics, severity of the complication, and experience of the surgeon should all be considered before deciding the approach of the reoperation.

The most frequent severe complication in colorectal surgery is anastomotic leakage, with a prevalence that can vary between 1 and 30 percent with optimum values between 2% and 5% [4, 6]. In the present series, anastomotic dehiscence was the most frequent postoperative complication requiring reoperation. If a minor defect with vital anastomotic ends is found during reoperation, the standard procedure is to perform a peritoneal lavage, drain placement near the anastomosis, and a protective loop ileostomy. All of these steps can be performed laparoscopically using the same port sites of the initial operation. RL was more useful for some complications after certain surgeries. For instance, left colectomies with dehiscence were more likely to be resolved by this approach, as well as was demonstrated in other studies [9]. In the present series, patients with previous abdominal operations had a higher likelihood of undergoing a reoperation with an open approach (LPM). However, since all these patients had the initial operation done by laparoscopy, we believe that this difference at reoperation was a fact of chance with no clinical significance.

Although patient’s clinical presentation determines the timing of reoperation, an early laparoscopic procedure is more likely to be technically feasible before ileus develops, the contamination is limited, and the adhesions are soft. In fact, in the present series, the time elapsed before performing the reoperation was shorter in the RL group.

Unlike in previous studies [16], we found no differences in postoperative outcome in terms of recovery and length of stay. However, severe complications (Clavien 3b) were significantly lower in the RL group. This is possibly the most relevant finding of our study. A recent meta-analysis tried to determine the feasibility of laparoscopic reoperation for early postoperative complications following colorectal surgery and concluded that the number of studies available is still low [21]. In addition, all the publications included were retrospective cohort studies with an overall low quality and internal validity [21].

Limitations of this study include its retrospective design, which is the main limiting factor. In addition, selection bias might have affected the chosen surgical approach, which was at the surgeon's discretion at the time of the reoperation. However, the main strength of this study is that, to our knowledge, it is one of the largest institutional series regarding this topic to date.

Conclusion

Relaparoscopy used to treat early complications after colorectal surgery is feasible and safe in experienced centers. Anastomotic leak seems to be the complication with the highest chance to be resolved by this approach. A decreased rate of severe postoperative complications could be one of its main benefits. Prospective studies are needed to confirm our findings and determine which patients will benefit the most from relaparoscopy.