as surgeons gain more experience and instrumentation technology advances , more challenging procedures are attempted .
acute and chronic inflammation , fistulization , and abscesses make dissection and mobilization difficult . in 1995
, we published our experience with 25 patients and demonstrated that laparoscopic - assisted ileocolic resection was feasible in patients with cd . in that early report , resections in patients with a large mass or fistulae often
minimally invasive techniques have become applicable in a greater number of patients with complex cd - related pathology , such as secondary surgery and the presence of fistulizing disease or abscesses . as a result , criteria for selecting which patients might be candidates for laparoscopic - assisted ileocolic resection ( laicr ) have become more liberal .
the aim of this study was to review our experience with laicr in patients with cd during the past 13 years .
specific attention was paid to assessing the adequacy and safety of this procedure , the incidence of intra- and postoperative complications , and an assessment of the adequacy of the resection as defined by disease - free margins . in an attempt to assess changes in patient selection and our performance during this 13-year experience
from a prospectively maintained practice database , all patients undergoing attempted laicr for cd between 1992 and 2005 were reviewed .
gross and microscopic evaluation of all specimens was performed by pathologists without specific knowledge of the conduct of the surgical procedure .
surgical technique was generally uniform , and the senior authors were all familiar with laparoscopic intestinal techniques .
the specimen was extracted through the incision , and the mesenteric divisions as well as the anastomosis were preformed extracorporeally . based on
previously reported data , conversion to an open technique ( laparotomy ) was defined as a fascial incision > 6 cm in length . to evaluate any change in our experience or outcomes during this 13-year period , we divided the entire group arbitrarily into 3 time intervals ( 1992 to 1997 , 1998 to 2001 , 2002 to 2005 ) .
data were complete in 158 including 95 women ( 60% ) and 63 men ( 40% ) .
one hundred twenty - four patients ( 78.4% ) underwent primary icr , 31 patients ( 18.9% ) underwent secondary re - section , and 3 ( 1.8% ) patients underwent tertiary resection .
thirty - eight patients ( 24% ) had fascial incision > 6 cm and were considered to have been converted to laparotomy ( cl ) .
however , the conversion rate to laparotomy in patients for whom this was not a primary resection was 61% .
this was not statistically different from the conversion rate in patients undergoing primary icr , which was 24% .
average laicr operating time was 144 minutes compared with 172 minutes in the cl group .
these usually occurred during the laparoscopic portion of the case and were , in most cases , the reason for conversion .
postoperative complications consisted mostly of prolonged ileus ( 5 patients ) , anastomotic leaks ( 2 patients ) , one portal and mesenteric vein thrombosis , and one bleeding episode requiring reoperation .
postoperative hospital stay was 5.9 days in the laicr group versus 7.4 days in the cl group ( p<0.05 ) .
the average ileal length resected was 20.9 cm in the laicr group versus 24.9 cm in the cl group .
the average colon length resected was 6.5 cm in the laparoscopic group versus 10.6 cm in the converted group ( p<0.01 ) .
in the laicr group , 20 patients ( 16.6% ) had microscopic margins consistent with cd .
no differences in the ot , intra- and postoperative complications , length of stay , or conversion rate to laparotomy were noted when data divided into 3 time intervals ( 1992 to 1997 , 1998 to 2001 , 2002 to 2005 ) was analyzed .
our early experience with 25 patients who underwent laicr for crohns ' disease ileitis demonstrated the feasibility and safety of the technique in a highly select group of patients .
the presence of a large mass combined with complex intraabdominal fistulae proved to be a predictor of failure to complete the procedure laparoscopically . in all cases , an attempt at laparoscopy
, a significant difference appears between the laicr and the cl groups . with increased experience and improved technology , such as tissue - sealing devices and minimally invasive stapling instruments ,
laicr is achievable in patients with complex cd ( fistulae , abscesses , and previous surgery ) .
when evaluating our experience in each time interval , it is obvious that during the later intervals we were attempting and completing more cases with more complex cd pathology and more patients who had previous icr . in this series
, 78.5% of patients had a primary icr , and 21.5% had either secondary or tertiary icr .
secondary and tertiary resections constituted 18% of the patients from 1992 to 1997and 28% of the patients in the interval from 2001 to 2005 ( figure 1 ) .
the conversion rate to laparotomy in patients for whom this was not a primary resection was 61% .
however , this was not statistically significant from the conversion rate in patients undergoing primary resection , which was 24% .
laicr obviously requires an  extraction incision .  in our initial results from 1995 , the average length of fascial incision was 5.5 cm .
we therefore made an arbitrary decision to define any extraction incision > 6 cm as a conversion to laparotomy .
numerous authors have reported that the use of minimally invasive techniques shortens postoperative length of hospital stay , and the current study confirms this .
the most common reason for conversion was the presence of adhesions ( 47% ) ( figure 2 ) .
unlike our first report from 1995 , the presence of a mass and fistulae accounted for only 15% of the reasons for conversion to laparotomy .
it is possible that in the later time interval , experience was gained , and cases with more complex pathology , such as fistula or abscess , could be completed laparoscopically .
although more intraoperative complications occurred in the cl , most of the complications occurred during the laparoscopic portion of the procedure ( enterotomies , bleeding ) .
2 parameters were compared : the length of small and large bowel resected and the involvement of the surgical margins .
the data suggest that when a laparoscopic procedure was performed , shorter lengths of bowel were resected .
this difference was significant when comparing the length of the right colon resected in the laicr group and the cl group .
the length of the crohns ' involvement of the ileum varies , and it is therefore impossible to evaluate 
it is possible that mobilization of the ascending colon near the hepatic flexure during the laparoscopic portion was suboptimal , thus limiting the extent of the colon resection .
evaluation of the different time intervals reveals no statistically significant differences when comparing operating time , length of stay , conversion to laparotomy , intra- or postoperative complications , length of large and small bowel resected , or positive resection margins . of the entire group of 158 patients ,
the relevance of microscopically positive margins has been evaluated previously . while these reports demonstrated no increase in anastomotic complications or higher recurrence rates when resection margins are microscopically positive , the difference in margin positivity between the laicr and cl groups is striking ( figure 3 ) .
laicr is a safe and feasible procedure for patients with cd . compared with our earlier reports
, secondary and tertiary icr were performed more commonly . advanced minimally invasive techniques and surgical devices enable surgeons to perform resections in patients with more complex crohns ' pathology than previously .
 background : this study reviews our experience with laparoscopic - assisted ileocolic resection in patients with crohn 's disease . the adequacy and safety of this procedure as measured by intraoperative and postoperative complications were evaluated . 
 special attention was paid to the group in which laparoscopy was not feasible and conversion to laparotomy was necessary.methods:between 1992 and 2005 , 168 laparoscopic - assisted ileocolic resections were performed on 167 patients with crohn 's ileal or ileocolic disease . 
 follow - up data were complete in 158 patients.results:in 38 patients ( 24% ) , conversion to laparotomy was necessary . 
 previous resection was not a predictor of conversion to laparotomy . 
 average ileal and colonic length of resected specimens was 20.9 cm and 6.5 cm , respectively , in the laparoscopic group , versus 24.9 cm and 10.6 cm in the converted group . 
 twenty of 120 specimens ( 16.6% ) in the laparoscopic group were found to have margins microscopically positive for active crohn 's disease . 
 none of the 38 specimens in the converted group had positive ileal margins.conclusions:laparoscopic-assisted ileocolic resection can be safely performed in patients with crohn 's disease ileitis . 
 the finding of positive surgical margins following laparoscopic resections compared with none among conventional resections has to be thoroughly evaluated . 
INTRODUCTION
METHODS
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSION