Conventional and Videolaparoscopic Treatment

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When IPAA is performed for UC some technical questions are still debated, especially about the type of ileoanal anastomosis (hand-sewn after mucosectomy or stapled without mucosectomy) and the number of surgical stages: one, two or three (total colectomy, restorative proctectomy with IPAA, removal of protection ileostomy). In patients affected with FAP, total colectomy and IRA are performed in a single operation without any protection ileostomy, whereas IPAA is usually a two-stage technique (with a loop ileostomy, to be removed about 2 months later); a single operation (avoiding the loop ileostomy) can be performed only with a stapled ileoanal anastomosis [28-30], but this could be regarded as a non-radical therapy because of the risk of adenomatous growth in the spared transitional mucosa. Both operations, IPAA and IRA, can be approached in a traditional or videolaparoscopic way.

The conventional approach involves a large central laparotomy through which total colectomy and total proctocolectomy are easily performed with a traditional technique familiar to all colorectal surgeons, even if details may differ according to the surgical school and points of view on the radicality of IPAA. Laparoscopic surgery has spread widely in the last 10 years thanks also to the continuous improvement of the instruments involved and to the enthusiasm of various surgical schools.

As regards colorectal surgery, the laparoscopic approach was initially used to treat benign diseases or in palliative operations because of the fear of neoplasm implantation on the scars of trocar accesses; however, despite its progressive diffusion and satisfactory employment in the oncology field, its use is still not completely accepted. The need to remove large and voluminous specimen from the abdomen has led to the use of videolaparoscopic-assisted techniques (VDLA), meaning short "service" incisions to carry out this part of the operation. Some problems still remain: a major technical complexity (difficult manoeuvres to be performed on delicate organs such as the colon, ileum and relative mesentery without the help of stereoscopic vision and tactile sensibility) and a long learning curve [31,32], so that at present most major colorectal surgery is still performed using the traditional approach, whereas the laparoscopic technique is employed at specialised centres.

However, videolaparoscopy offers significant advantages for patients mainly of a young age who can appreciate the better cosmetic effect due to small scars or scars located in easily hidden sites (Pfannenstiel incision). In addition, postoperative pain is reduced, offering advantages in terms of hospitalisation, with an earlier recovery capacity and return to normal activity, which are in line with the literature [33, 34]. A more favourable immune response [35] and reduction or absence of visceral adhesions represents another reason for using the laparoscopic approach, thereby increasing its indications.

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