**4. Conclusions**

In the last few years a large number of studies was performed to understand if intracorporeal anastomosis were safe and associated with less morbidity and mortality. As we exposed above, IA is now considered safe from surgical and oncological point of view as long as colorectal surgeon had trained on it. Regarding morbidity and mortality, **Table 1** summarizes differences in IA and EA group published by Ricci et al. [16].

Regarding duration of surgery, some studies report that IA is associated with longer operating time but others found no differences between IA and EA group.

**111**

**Author details**

ence in duration of surgery.

*Differences in IA and EA group.*

**Table 1.**

(DISCOG), Italy

Andrea Kazemi Nava and Giacomo Zanus

provided the original work is properly cited.

analysis and clinical trial [7, 16, 17, 21, 22].

*Laparoscopic Right Colectomy. Intracorporeal Anastomosis Is Associated with Better Outcome*

**Outcome of interest Intracorporeal Extracorporeal P value** Anastomotic leakage (%) 29 (3.4) 39 (4.6) 0.120 Operative time (min) 129 ± 32 121 ± 38 0.460 SSI (%) 39 (4.9) 71 (8.9) 0.030 Internal hernia (%) 0 (0) 3 (2.3) 0.440 First flatus (days) 2 ± 1 2 ± 1 0.110 First defecation (days) 3 ± 1 4 ± 1 0.110 Hospital stay (days) 5 ± 5 5 ± 4 0.004 Overall morbidity 176 231 0.009 Overall mortality 0 5 0.320

This variance could be explained with different level in laparoscopic surgery training in addition to various number of patient treated per year: when anastomosis is performed by trained colorectal surgeon, there is no significant differ-

IA showed better outcome in anastomotic leakage rate, surgical site infection rate, development of incisional hernia, postoperative pain and recovery of gastrointestinal function. All these aspects can explain the difference in length of hospital stay, that is reported shorter in IA as compared to EA by all most recent meta-

Unfortunately, all currently available data are too uneven to be compared; further randomized controlled trial with homogeneity in surgeons training and large number

Giulio Aniello Santoro\*, Simone Novello, Ugo Grossi, Martino Zucchella,

of patient should be performed to understand the real advantage of IA.

\*Address all correspondence to: giulioasantoro@yahoo.com

IV Division of General Surgery, Regional Hospital of Treviso – Padua University

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*DOI: http://dx.doi.org/10.5772/intechopen.93996*

**Outcome of interest Intracorporeal Extracorporeal P value** Anastomotic leakage (%) 29 (3.4) 39 (4.6) 0.120 Operative time (min) 129 ± 32 121 ± 38 0.460 SSI (%) 39 (4.9) 71 (8.9) 0.030 Internal hernia (%) 0 (0) 3 (2.3) 0.440 First flatus (days) 2 ± 1 2 ± 1 0.110 First defecation (days) 3 ± 1 4 ± 1 0.110 Hospital stay (days) 5 ± 5 5 ± 4 0.004 Overall morbidity 176 231 0.009 Overall mortality 0 5 0.320

*Laparoscopic Right Colectomy. Intracorporeal Anastomosis Is Associated with Better Outcome DOI: http://dx.doi.org/10.5772/intechopen.93996*

### **Table 1.**

*Colorectal Cancer*

studies [14, 15] showed that the stapled technique is an independent risk factor for ileocolic anastomotic leak. Future large, randomized controlled trials are needed to identify the best anastomotic technique. To the authors' knowledge in 2018 has been proposed a study protocol for a randomized controlled trial IA versus EA in which primary endpoint is to compare hospital stay and secondary endpoints are intraoperative and postoperative events included AL. The results os this study will

Surgical site infection (SSI) is reported in several case series; a meta-analysis by Ricc et al. reported a reduced risk of wound infection in favor of IA. The higher incidence of infection at the extraction site incision in EA anastomosis may be due to wound contamination during exteriorization of the bowel ends and performing

The length of incision is another factor that influence morbidity after laparoscopic surgery: patients who had an EA were more likely to develop incisional hernia due to the longer incision required for specimen extraction and anastomosis: in EA group the extraction site is about 2.2 cm longer than IA group. Beside its length, the location of the extraction site incision may favor the development of incisional hernia. This was most frequently observed in cases of midline incision in the EC group, as compared to the IC group, where a Pfannenstiel incision was preferred [17]. Moreover, shorter incision is associated to less postoperative pain

Gastrointestinal function, demonstrated by time to first flatus and time to bowel

The technical challenges of EA may explain the earlier recover observed in the IA group. Indeed, delayed recovery of GI function may arise from traction on the bowel ends and mesentery needed to allow complete mobilization of the transverse colon during EA [17]. A recent RCT supports this hypothesis [19] by showing a significantly less surgical stress response after IA. Interleukin-6 and C-reactive

Another aspect of intracorporeal ileocolic anastomosis which deserve to be studied is the configuration between ileum and colon. The anastomosis can be carried out in isoperistaltic or antiperistaltic configuration. ISOVANTI randomized clinical trial, performed in 2017 and published in 2018, has compared iso- and antiperistaltic configuration in order to understand if there is any difference in postoperative outcome. The results show that no differences were found in conversion rate, total operative time, and global complication rates after applying Clavien-Dindo's classification. Regarding functional results, the antiperistaltic group showed better results than the isoperistaltic group with less time to first flatus, less time to first stool and shorter time to satisfactory oral intake with statistically significant differences in all cases. However, this fact did not reduce hospital

In the last few years a large number of studies was performed to understand if intracorporeal anastomosis were safe and associated with less morbidity and mortality. As we exposed above, IA is now considered safe from surgical and oncological point of view as long as colorectal surgeon had trained on it. Regarding morbidity and mortality, **Table 1** summarizes differences in IA and EA group

Regarding duration of surgery, some studies report that IA is associated with longer operating time but others found no differences between IA and EA group.

be available in 2021, depending on the volume of patients.

the anastomosis through the incision [16].

which result in early recovery after surgery [18].

movement, resume sooner in IA group than EA.

protein levels were indeed markedly lower in this group.

stay and there was no difference between both groups [20].

**110**

**4. Conclusions**

published by Ricci et al. [16].

*Differences in IA and EA group.*

This variance could be explained with different level in laparoscopic surgery training in addition to various number of patient treated per year: when anastomosis is performed by trained colorectal surgeon, there is no significant difference in duration of surgery.

IA showed better outcome in anastomotic leakage rate, surgical site infection rate, development of incisional hernia, postoperative pain and recovery of gastrointestinal function. All these aspects can explain the difference in length of hospital stay, that is reported shorter in IA as compared to EA by all most recent metaanalysis and clinical trial [7, 16, 17, 21, 22].

Unfortunately, all currently available data are too uneven to be compared; further randomized controlled trial with homogeneity in surgeons training and large number of patient should be performed to understand the real advantage of IA.
