Original article

Laparoscopic reintervention for anastomotic leakage after

primary laparoscopic colorectal surgery
J. Wind, A. G. Koopman, M. I. van Berge Henegouwen, J. F. M. Slors, D. J. Gouma and
W. A. Bemelman
Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands
Correspondence to: Prof. Dr W. A. Bemelman (e-mail: w.a.bemelman@amc.uva.nl)

Background: Anastomotic leakage is associated with high morbidity and mortality rates. The aim of this
study was to assess the potential benefits of a laparoscopic reintervention for anastomotic leakage after
primary laparoscopic surgery.
Methods: Between January 2003 and January 2006, ten patients who had laparoscopic colorectal resection
and later developed anastomotic leakage had a laparoscopic reintervention. A second group included 15
patients who had relaparotomy after primary open surgery.
Results: Patient characteristics were comparable in the two groups. The median time from first operation
to reintervention was 6 days in both groups. There were no conversions. The intensive care stay was
shorter in the laparoscopic group (1 versus 3 days; P = 0·002). Resumption of a normal diet (median
3 versus 6 days; P = 0·031) and first stoma output (2 versus 3 days; P = 0·041) occurred earlier in the
laparoscopic group. The postoperative 30-day morbidity rate was lower (four of ten patients versus 12
of 15; P = 0·087) and hospital stay was shorter (median 9 versus 13 days; P = 0·058) in the laparoscopic
group. No patient developed incisional hernia in the laparoscopic group compared with five of 15 in the
open group (P = 0·061).
Conclusion: These data suggest that laparoscopic reintervention for anastomotic leakage after primary
laparoscopic surgery is associated with less morbidity, faster recovery and fewer abdominal wall
complications than relaparotomy.

Presented to meetings of the European Association for Endoscopic Surgery, Berlin, Germany, September 2006, and the
European Society of Coloproctology, Lisbon, Portugal, September 2006, and published in abstract Form in Colorectal
Disease 2006; 8 (Suppl 4): 3–13
Paper accepted 19 July 2007
Published online 14 August 2007 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.5892

Introduction colorectal surgery compared with open surgery. Laparo-

Anastomotic leakage is the most important surgical
complication following colorectal resection with intestinal
anastomosis. The reported clinical leakage rate after
colorectal resection depends on the site of anastomosis
and ranges from 2 to 21 per cent1 – 6 . Anastomotic leakage
after colorectal surgery is associated with a high morbidity
rate and even death. Morbidity may result in a long stay
in intensive care, sepsis, and abdominal wall complications
due to reinterventions and wound infections. Furthermore,
the risk of permanent stoma ranges from 10 to 100 per cent.
Elective laparoscopic colectomy was introduced in the
early 1990s7 . Since then, several randomized controlled
trials have reported favourable results of laparoscopic
scopic surgery offers several advantages, including faster
postoperative recovery and a shorter hospital stay8 – 10 .
The rate of anastomotic leak after laparoscopic colorectal
surgery is similar to that after open surgery8 .
Massive anastomotic leakage and peritonitis generally
requires prompt reintervention by relaparotomy. Despite
the short-term benefits of laparoscopic colorectal resection
and the high implementation rate, reintervention for
suspected anastomotic leakage generally takes an open
approach. Most authors consider peritonitis to be a
contraindication to the laparoscopic approach because of
the risk of enhancing bacteraemia by pneumoperitoneum,
the risk of a bowel injury from distended bowel, and the

Copyright  2007 British Journal of Surgery Society Ltd British Journal of Surgery 2007; 94: 1562–1566
Published by John Wiley & Sons Ltd
Anastomotic leakage after laparoscopic colorectal surgery
presumed better visualization and irrigation afforded by
open surgery10 – 13 . In theory, laparoscopic reintervention
for anastomotic leakage after primary laparoscopic surgery
might be beneficial when considering abdominal wall
complications and postoperative recovery. However,
laparoscopic reintervention in patients with anastomotic
leakage is not yet current practice, and there are no
comparative data.
The aim of this study was to assess the feasibility
and safety of laparoscopic reintervention for anastomotic
leakage after primary laparoscopic surgery compared with
relaparotomy, focusing on postoperative morbidity and
recovery.
Methods
This retrospective study assessed a consecutive series of
patients with anastomotic leakage after open or laparo-
scopic colorectal resection who had surgery between
January 2003 and January 2006. One group included
patients who had laparoscopic colorectal resection fol-
lowed by anastomotic leakage and a repeat laparoscopy
(laparoscopic group). The other group included patients
who had relaparotomy after initially having open surgery
(open group). The study excluded one patient who had a
laparotomy after primary laparoscopic surgery as well as all
patients who received conservative treatment for anasto-
motic leakage. The choice between laparoscopy and open
surgery for the initial operation was based on the capability
of the surgeon, and on patients’ and surgeons’ preferences.
Referral patterns for all surgeons were similar throughout
the study period.
Patients’ charts were reviewed and data were extracted
on patient characteristics, primary and secondary surgery,
co-morbidity, abdominal cavity cultures, postoperative
recovery, morbidity and mortality. The outcome and
complications were noted during clinical and outpatient
clinic follow-up.
Operative procedures
The diagnosis of anastomotic leakage was established
clinically or by computed tomography in all patients.
The operative procedure consisted of inspection and
exploration, then culturing and lavaging of the abdominal
cavity. The diagnosis required findings to include a
collection of pus or faecal material related to an insufficient
anastomosis and signs of peritonitis, with a positive culture
indicating intestinal bacteria. Morbidity was defined as any
complication within 30 days of the reintervention.
Ileoanal, coloanal and low colorectal anastomoses were
diverted by creating a loop ileostomy and irrigation of the
Copyright  2007 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
1563
rest of the colon. In patients with major breakdown, the
afferent loop was exteriorized as an end stoma. In patients
with anastomotic leakage after intra-abdominal resections,
the anastomosis was dismantled. An end colostomy was
created in those with anastomotic leakage after left-sided
resections and an end ileostomy was created after right-
sided resections.
During laparoscopic reintervention, the previous trocar
wounds were used for insertion of a blunt TrocDoc
trocar (Storz; Tubingen, Germany), establishing the
pneumoperitoneum14,15 . The whole reintervention was
performed laparoscopically, and the minilaparotomy used
for specimen retrieval at the first operation was opened
only when necessary. Wound closure and postoperative
wound care were left to the discretion of the surgeon.
All open procedures were performed or supervised by one
of two colorectal surgeons. All laparoscopic procedures
were performed by a single colorectal surgeon trained in
laparoscopic surgery.
Incisional herniation was assessed at long-term follow-
up during a survey in September 2006. Intensive care and
hospital stay are given as the total number of days patients
stayed in each after the reintervention.
Statistical analysis
Continuous data are presented as median (range) unless
otherwise specified. Differences between groups were
assessed using Mann–Whitney U test for continuous data
and Fisher’s exact test for categorical data. P < 0·050 was
considered significant. Statistical analysis was performed
using SPSS software version 12.0 (SPSS, Chicago,
Illinois, USA).
Results
Between January 2003 and January 2006, 398 consec-
utive patients had a colorectal resection with intestinal
anastomosis and without a diverting stoma. Of these,
251 (63·1 per cent) had an open resection and 147
(36·9 per cent) had a laparoscopic resection. Subsequently,
26 patients (6·5 per cent) had repeat surgery for anasto-
motic leakage: 15 (6·0 per cent) of those who had primary
open surgery, all of whom had relaparotomy, and 11
(7·5 per cent) of those who originally had laparoscopic col-
orectal resection, ten of whom had repeat laparoscopy. The
other patient had an open reintervention on day 6 after an
initial laparoscopic left colectomy, and was excluded from
the study. In this patient, the anastomosis was dismantled
and a colostomy was constructed; an episode of dyspnoea
due to cardiac decompensation occurred after surgery, and
www.bjs.co.uk British Journal of Surgery 2007; 94: 1562–1566
1564 J. Wind, A. G. Koopman, M. I. van Berge Henegouwen, J. F. M. Slors, D. J. Gouma and W. A. Bemelman

the patient was discharged on day 14 with no apparent Table 2 Operative data for the reintervention and postoperative
wound or abdominal wall complications. course of 25 patients
Primary operations in the 25 included patients con-
Laparoscopic Open
sisted of 16 segmental colonic resections, five restorative group group
proctocolectomies and four other procedures (Table 1). (n = 10) (n = 15) P†
The number of open and laparoscopic procedures was
Duration of operation (min)* 116 (59–181) 105 (59–328) 0·523
comparable between the first and second study period (Jan- Procedure 0·337‡
uary 2003–June 2004 and July 2004–January 2006). Five End ileostomy 3 9
patients participated in different trials in which patients Diverting ileostomy 6 5
End colostomy 1 1
were randomized between open and laparoscopic surgery. Diverting colostomy 0 0
Patients in the two groups were comparable in terms Postoperative APACHE II 14 (8–20) 13 (11–19) 0·695
of age, sex, American Association of Anesthesiologists score*
ICU stay (days)* 1 (0–1) 3 (0–15) 0·002
grade, surgical indication, type of initial procedure
Postoperative 30-day 4 12 0·087‡
and preoperative Acute Physiology and Chronic Health morbidity
Evaluation (APACHE) II scores16 (Table 1). The median Resumption of normal diet 3 (1–6) 6 (1–11) 0·031
time from the primary operation to reintervention was (days)*
First stoma output (days)* 2 (1–4) 3 (1–8) 0·041
6 days in both groups. There was a non-significant trend Hospital stay (days)* 9 (6–28) 13 (7–38) 0·058
for a higher proportion of patients with a history of midline Readmission within 30 days 1 (10) 2 (13) 1·000‡
laparotomy in the open group (P = 0·088). Incisional hernia 0 5 0·061‡
Stoma closure rate 8 9 0·402‡

Table 1 Characteristics of the 25 patients *Values are median (range). APACHE II, Acute Physiology and Chronic
Health Evaluation II; ICU, intensive care unit. †Mann–Whitney U test
Laparoscopic Open
unless indicated otherwise; ‡Fisher’s exact test.
group group
(n = 10) (n = 15) P†
Reintervention
Age (years)* 45 (17–71) 45 (20–79) 0·781
Sex ratio (M : F) 3:7 7:8 0·678‡ There were no conversions in the laparoscopic group. The
BMI (kg/m2 )* 22·4 (16·6–28·1) 22·2 (16·8–32·0) 0·956
minilaparotomy needed to be opened in two of the ten
ASA grade 0·665‡
I 5 6 patients, both after a right-sided resection, in order to exte-
II 5 8 riorize the afferent loop as an ileostomy and to exteriorize
III 0 1 the efferent loop for closure or mucus fistula creation.
Previous midline 1 7 0·088‡
laparotomy
No intraoperative morbidity was reported in the
Indication for surgery 0·402‡ laparoscopic group. In the open group there was one
Inflammatory bowel 6 8 iatrogenic bowel perforation requiring an additional bowel
disease resection. Median operating times were not significantly
Malignancy 3 2
Diverticulitis 1 2
different between the groups (116 min in the laparoscopic
Other 0 3 group compared with 105 min in the open group; P =
Initial procedure 0·834‡ 0·523) (Table 2).
Right-sided colonic 3 6
Four of 15 patients in the open group had a second
resection
Left-sided colonic 3 2 reoperation compared with none in the laparoscopic
resection group (P = 0·125). In two patients, the reoperation was
Low anterior resection 1 1 a planned second-look operation as part of a randomized
Restorative 2 3
proctocolectomy
trial comparing relaparotomy on demand with planned
Other 1 3 laparotomy; in one it was for a blow-out of the ascending
Time to reintervention 6 (3–9) 6 (2–11) 0·736 colon and in the other it was for dehiscence.
(days)*
APACHE II score before 10 (7–15) 10 (5–17) 0·889
reintervention* Short-term outcome
The median length of intensive care stay was shorter in
*Values are median (range). BMI, body mass index; ASA, American
Society of Anesthesiologists; APACHE II, Acute Physiology and Chronic
the laparoscopic group than in the open group. There
Health Evaluation II. †Mann–Whitney U test unless indicated otherwise; was less postoperative morbidity within the first 30 days
‡Fisher’s exact test. of reintervention in the laparoscopic group, although

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Anastomotic leakage after laparoscopic colorectal surgery
this difference was not significant (P = 0·087) (Table 2).
Four of ten patients in the laparoscopic group had one
or more complications, which included abscesses (three
patients), wound healing disorders (one), cardiovascular
complications (one), psychiatric complications (one) and
prolonged postoperative ileus (one). In the open group,
12 of 15 patients had one or more complications,
which included abscesses (five patients), wound healing
disorders (three), ongoing sepsis (three), cardiovascular
complications (two), and respiratory complications (one).
The first stoma output and return to a normal diet occurred
significantly earlier in the laparoscopic group. The median
hospital stay in the laparoscopic group was 9 (range 6–28)
days compared with 13 (range 7–38) days in the open
group (P = 0·058). One patient in the laparoscopic group
and two in the open group were readmitted within 30 days
(P = 1·000) (Table 2). One patient was readmitted after
30 days in each group, for abdominal abscesses in the
laparoscopic group and dehydration in the open group.
Long-term outcome
There were fewer patients with incisional hernias in
the laparoscopic group (none versus five), although this
difference was not significant (P = 0·061). In eight patients
in the laparoscopic group, the stoma was closed after a
median of 5 (range 2–12) months. In comparison, nine of
15 patients in the open group had the stoma closed at a
median of 6 (range 3–16) months (P = 0·402) (Table 2).
Two patients in the open group had an extensive abdominal
wall reconstruction at the same time. In the laparoscopic
group, one patient had a surgical correction of a post-stoma
scar. There were no other abdominal wall reconstructions
in either group during the study period. The median
follow-up was 22 (range 12–28) months in the laparoscopic
group and 22 (range 10–48) months in the open group
(P = 0·720). No patient was lost to follow-up.
Discussion
The present study has shown that laparoscopic reinter-
vention after primary laparoscopic surgery for anastomotic
leakage is feasible, and may be safe in terms of conver-
sions, intraoperative morbidity, necessity for opening the
minilaparotomy and operating time. In addition, it may
be associated with less postoperative morbidity, a faster
recovery and fewer abdominal wall complications than
open reintervention after primary open surgery.
Laparoscopy has gained widespread acceptance in sur-
gical practice as a diagnostic and therapeutic tool. Abdom-
inal emergencies have been managed increasingly by
Copyright  2007 British Journal of Surgery Society Ltd
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1565
laparoscopy, including peritonitis13,17 – 21 . Reintervention
for anastomotic leakage generally uses an open approach,
mainly because of the fear of causing bowel injury to a
distended bowel and the lack of exposure. After primary
laparoscopic surgery, the earlier trocar incisions can easily
be reused. In the present series of patients, the pneu-
moperitoneum was established through an earlier trocar
wound by an open entry technique using a blunt trocar22 .
This technique minimizes the risk of bowel injury, even in
patients with a distended bowel. Laparoscopic reinterven-
tion after open surgery might appeal on the grounds that it
could avoid wound problems and incisional hernia. How-
ever, creation of the pneumoperitoneum is more difficult,
because the trocars need to be inserted in an open manner
or blindly after using a Veress needle.
The morbidity observed here was comparable with that
reported in other studies5,6 . However, there were no deaths
in either group. This can be explained in part by the fact that
the patients were relatively young, as most had surgery for
inflammatory bowel disease. In any case, this observation
is limited because of the small sample size.
Laparoscopic reintervention after primary laparoscopic
surgery can be initiated as an early diagnostic tool to
confirm the anastomotic leakage or to explore other
causative pathology if patients do not improve as expected.
Recovery after laparoscopic surgery is generally fast9,10 .
Anastomotic leakage must be suspected if a patient cannot
tolerate a normal diet within a couple of days and has
signs of infection. For this reason, reintervention might
be expected to be possible earlier after laparoscopic
surgery than after open surgery. This earlier reintervention
might prevent severe generalized peritonitis and systemic
sepsis. On the other hand, longstanding peritonitis with
pus pockets and inflammatory adhesions is probably not
amenable to laparoscopic treatment.
The systemic immunological function is depressed after
open surgery, with adverse alterations in cytokine levels
and changes in the function of cellular components of
the systemic immune response. Furthermore, peritoneal
macrophage function is better preserved when laparo-
tomy is avoided. Other authors have suggested that a
laparoscopic approach might be beneficial in the surgi-
cal management of intra-abdominal sepsis and result in
fewer postoperative septic complications23,24 . However,
further research is warranted on the effect of laparoscopy
and pneumoperitoneum on the intra-abdominal immune
system in the presence of peritonitis.
Another important advantage of laparoscopic reinter-
vention appears to be a reduction in wound complications
such as early dehiscence and incisional hernia. However,
the present study has several limitations and the results
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1566 J. Wind, A. G. Koopman, M. I. van Berge Henegouwen, J. F. M. Slors, D. J. Gouma and W. A. Bemelman
must be interpreted carefully. First of all, it is a small,
single-centre, retrospective study. In addition, the surgical
indications and primary procedure were varied. Although
patient characteristics were comparable between the two
groups and the indication for the initial laparoscopic pro-
cedure was mainly based on referral, selection bias could
not be ruled out. Furthermore, the patients were not typ-
ical of those having laparoscopic surgery. Most patients in
the present study had laparoscopic surgery for inflamma-
tory bowel disease, whereas most laparoscopic resections
are performed for diverticular disease, adenoma and early-
stage cancer.
Nonetheless, these preliminary data suggest that a
laparoscopic reintervention for anastomotic leakage after
primarily laparoscopic surgery is feasible and might be
safe, with no conversions or intraoperative complica-
tions observed. Furthermore, a laparoscopic reintervention
tends to be associated with less postoperative morbidity,
a faster recovery and fewer abdominal wall complications.
Ideally, these data should be confirmed in a prospective
trial. To evaluate the effect of laparoscopic reinterven-
tion after primary laparoscopic surgery, it would have to
be a large study randomizing patients to laparoscopic or
open surgery.
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