There are only two randomized controlled trials (RCT) in the literature: Milsom’s study [4] from the Cleveland Clinic and Maartense’s study [5] from three centers in the Netherlands. In both studies, 60 patients were recruited: 31 laparoscopic vs. 29 open, and 30 laparoscopic vs. 30 open, respectively. Patients undergoing elective surgery with disease confined to the terminal ileum and cecum were included. Exclusion criteria were emergency or urgent surgery, multiple disease sites, a history of prior surgery, and obesity (BMI > 32 kg/m²). Both studies showed fewer complications and shorter hospital stays in the laparoscopic group. Also, Milsom et al. [4] found faster recovery of pulmonary function, and Maartense et al. [5] showed an earlier return to diet and lower cost in the laparoscopic group. However, there was no significant difference in the use of morphine or the Quality of Life Scale score.

The long-term outcomes of these two RCTs were reported by Stocchi et al. [6] and Eshuis et al. [7] with a median follow-up of 10.5 and 6.7 years, respectively. They concluded that open surgery was more likely to lead to incision hernia and small bowel obstruction. The recurrence rate was comparable between the groups. Eshuis et al. noted better body-image ratings and cosmesis in the laparoscopic group.

Recently, Dasari et al. [8] in their Cochrane review analyzed these RCTs exclusively and found no difference in the perioperative outcomes and reoperation rate for recurrence. They argued that no reliable conclusions could be drawn regarding the benefits of laparoscopic surgery probably because of the limited data available from these two small RCTs.

Other meta-analyses, however, reported faster recovery of bowel function and oral intake, shorter hospital stay, and lower complication rates, with one meta-analysis noting a lower surgical recurrence in laparoscopic patients (Table 30.2). Excluding Dasari’s Cochrane review, which had limited inclusion criteria, the other meta-analyses showed a general consensus that there were short-term benefits associated with laparoscopic ileocecal resection for CD [8–12].

Lesperance et al. [13] analyzed Nationwide Inpatient Sample (NIS) data between 2000 and 2004. Among 49,609 resections in patients with CD, only 6 % were performed laparoscopically. They found that an age of less than 35 years old (OR 2.4), female gender (OR 1.4), ileocecal location (OR 1.5), and undergoing the procedure in a teaching hospital (OR 1.2) were predictors of undergoing laparoscopic surgery for CD. Open surgery was an independent predictor of inpatient complications (OR 3.4).

Lee et al. [14] analyzed the National Surgical Quality Improvement Program (NSQIP) database (2005–2009). They identified 1,917 cases of ileocolic resections for CD, of which 644 (33.6 %) were performed laparoscopically. They found that laparoscopy was associated with a significantly lower rate of 30-day major and minor complications and a shorter hospital stay.

Evidence in support of laparoscopic surgery for Crohn’s colitis is lacking, and there are no RCTs for this condition. Instead, there are only a few limited retrospective case-control studies.

The largest series was conducted by Umanskiy and colleagues [15]. They analyzed the data of 125 prospectively collected cases, including 55 (44 %) laparoscopic procedures. The most common procedures were total colectomy and total proctocolectomy with ileostomy. Surprisingly, they reported a shorter mean operative time (212 vs. 286 min, P = 0.032) in the laparoscopy group, which is a unique result. The authors suggested that this may be due to the high level of experience of the laparoscopic surgeons. Other short-term benefits of laparoscopy included less blood loss, early return of bowel function, and shorter hospital stay.

A case-matched study from the Cleveland Clinic [16] with 27 laparoscopic and 27 open colectomies showed that laparoscopy was associated with a longer operative time (240 vs. 150 min, P = 0.01), but no other short-term benefits were demonstrated.

Nakajima et al. [17] evaluated 38 patients with Crohn’s colitis who underwent subtotal or total colectomies divided into three groups (14 open, 18 hand assisted, and 6 laparoscopic). The operation time for the hand-assisted laparoscopic surgery (HALS) group was shorter than that for the laparoscopic group, but there was no difference in complication rates or blood loss.

The role of HALS in other diseases remains controversial. Orenstein et al. [18] reported favorable outcomes in a HALS group, while Cochrane review by Moloo et al. [19] showed only a decreased conversion rate in HALS groups.

There is no definitive evidence supporting the superiority of laparoscopic surgery or HALS in patients with Crohn’s colitis. This may be due to the diversity of disease extent, complexity of surgical technique, and lack of surgical cases in a particular center to enable an RCT to be performed.

Inflammatory conditions, such as abscess, phlegmon, or enteric fistulas, are frequently associated with CD and make laparoscopic surgery more challenging. Some surgeons have regarded these conditions as relative contraindications for laparoscopic surgery, due to the high conversion rate and postoperative morbidity.

Goyer et al. [20] reviewed 54 cases of laparoscopic Ileocolic resections for complex CD in which 43 % had fistula, 30 % abscess, and 27 % recurrent disease. They reported that the presence of complex CD was significantly associated with increased operation time (214 vs. 191 min, P < 0.05), increased conversion rate (37 % vs. 14 %, P < 0.01), and increased use of temporary stoma (39 % vs. 9 %, P < 0.001). Postoperative morbidity and hospital stay were comparable.

Okabayashi et al. [21] investigated the association of Vienna classification with outcomes following 107 cases of laparoscopic surgery for CD. They found a significant association between conversions and more complicated types of CD (B3, L3/4). However, there was no difference in the rate of complications.

Recently, a case-match study was published by Beyer-Berjot et al. [22]. They compared 11 laparoscopic ileocecal resections for fistulizing CD with 22 matched controls. They found no significant difference in operation time (120 vs. 120 min), conversion rate (9 % vs. 0 %), postoperative morbidity (18 % vs. 32 %), and hospital stay (8 vs. 9 days).