Laparoscopic-assisted restorative proctocolectomy (LA-RP) is a hybrid colorectal procedure. It is doubtful that when Sir Alan Parks conceived the operation he originally described in 1978 (1), he saw it being performed through a small Pfannenstiel incision together with several 5–10 mm scars. This is now a viable alternative to his open technique. The first LA-RP case report was published in 1992 (2) and the first series in 1992 (3).

There is no consensus defining “a laparoscopic-assisted restorative proctocolectomy.” Descriptions include procedures involving either partial or complete laparoscopic mobilization, with or without the aid of a hand-assisted port. Totally laparoscopic restorative proctocolectomy (total L-RP) combines complete laparoscopic mobilization with intracorporeal division of the rectum before conventional extracorporeal J-pouch formation (4,5). For the purposes of this article, we define a LA-RP as one in which the entire colon is laparoscopically mobilized, followed by the creation of a small Pfannenstiel incision that is used for rectal dissection. The rectum is then transected with a conventional open stapling device. Hand port techniques are associated with significantly more inflammatory response compared to laparoscopic-assisted procedures, but may be useful to reduce the need for conversion in patients with a hostile abdomen (6).

The main advantage of performing LA-RP over a totally laparoscopic procedure, particularly in males, is the ability to transect sufficiently low, just above the anorectal junction with a single staple line. The difficulties of a narrow pelvis and low rectal dissection are associated with conversion (4). Laparoscopic stapling devices are often unable to produce a satisfactory staple line in the depths of the pelvis, which may prevent construction of a safe stapled J-pouch. At present the maximum angulation obtainable by any laparoscopic stapling device is 45 degrees and multiple firings are often required. Irregular staple lines are associated with higher risks of anastomotic breakdown (7). Subsequent pelvis sepsis has devastating consequences on pouch function and can ultimately lead to pouch failure.

To date most surgeons favor the pragmatic approach of LA-RP over totally laparoscopic or hand-assisted procedures (Table 27.1) (8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24).

Studies examining other laparoscopic colorectal procedures have demonstrated shorter postoperative recovery, with lower analgesia requirements, fewer perioperative complications, and shorter durations in hospitals when compared with similar open procedures (25).

These short-term benefits have not been confirmed in studies comparing LA-RP with conventional open surgery. A recently published Cochrane meta-analysis compared 354 patients who underwent open RP with 253 patients who had LA-RP (including hand-assisted laparoscopic-RP) (26). There was no difference in mortality or complications. Within this analysis, no randomized controlled trial (RCT) comparing
LA-RP with open surgery was identified. There was only one RCT examining patients having either hand-assisted laparoscopic procedure or open surgery (18). In this specific study, each arm consisted of 30 patients only and there was no significant difference in complication rate, hospital stay, length of time to bowel activity, or blood loss between either group. The only significant short-term difference confirmed that laparoscopic surgery was associated with longer operative times. There are several reasons to explain the lack of overall benefit of one approach compared to another. Patient numbers in these case series examined were relatively small. The type of surgeries performed and outcomes measured demonstrated wide heterogeneity. Further, L-RP is a complex procedure composed of several distinct elements involving a total colectomy, proctectomy, followed by pouch formation and ileal anal anastomosis. Each individual procedure requires significant surgical expertise. The learning curve for segmental colonic resections is estimated at 40–50 cases to reach competency (27). Additional surgical experience is necessary to competently perform laparoscopic total colectomies (28

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