The best surgical approach for left colectomy: a comparative study between transverse laparotomy, midline laparotomy and laparoscopy.

Aim: To compare the early and late complications after left colectomy (LC) by left transverse laparotomy (LTL), midline laparotomy (ML) and laparoscopy (La).

Methods: From 1998 to 2003, 328 patients underwent an LC by LTL, ML or La. After matching patients for age, ASA score and indication, 159 patients were divided into three groups of 53 patients each according to the surgical approach performed. The median follow-up was 8 years. Early and late complications were compared by univariate and multivariate analysis.

Results: Early morbidity rates after LTL, ML and La were 52%, 45% and 21%, respectively (p = 0.002). Extra digestive complication rates after LTL, ML and La were 36%, 34% and 13.2%, respectively (p = 0.02). Respiratory complication rates were 15%, 21% and 2% (p = 0.01). The rate of wound infection was higher after LTL (15% vs. 6% and 6%, p = 0.06). Length of stay was significantly shorter after La (median: LTL, 10 days; ML, 9 days; La, 6 days; p < 0.0001). At a median follow-up of 8 years, the obstruction rate was 6.3%, regardless of the surgical approach. The rates of incisional hernia after LTL, ML and La were 8%, 23% and 3% (p = 0.004), respectively, with odds ratio (OR) = 4.47 (1.2 to 16).

Conclusion: Our study shows that although La has a significant lower rate of complications, LTL, with fewer respiratory complications and hernia than ML, should be considered as the reference incision in case of conversion or contra-indication for laparoscopy.