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Objective: To carry out a review of the literature for the short- and long-term effects of various laparoscopic operations in the inflammatory bowel diseases ulcerative colitis and Crohn's disease and to compare these operations with open surgical procedures., Design: Review of the literature., Method: PubMed (Medline), Embase and Cochrane databases were searched for randomised clinical trials and meta-analyses on this topic, published between January 1991 and August 2008. If no level A1, A2 or A2B studies were found, we searched for the best available evidence., Results: For Crohn's disease, there was level A2 evidence that, in comparison with open surgery, in experienced hands laparoscopic ileocaecal resection enhanced recovery and led to a shorter hospital stay and lower costs. Following laparoscopic surgery, subjective body image and cosmetic appearance scores were higher, when compared in the long term. In patients with ulcerative colitis, the expected benefits of laparoscopic proctocolectomy have not yet been demonstrated in a randomised study. Although there was a trend towards a reduced hospital stay (1.6 days) when laparoscopy proctocolectomy was performed, the operating time was 1.5 h longer than in conventional surgery. Body image and cosmetic appearance scores were also higher here when compared in the long term., Conclusion: Laparoscopic ileocaecal resection is preferable in Crohn's disease, provided that it is performed in a centre with sufficient expertise in laparoscopic surgery. In patients with ulcerative colitis, laparoscopic proctocolectomy with construction of an ileoanal pouch is indicated in young active patients who are concerned for their appearance. Given its complexity, this operation should be performed only in specialist centres.

The aim of surgical treatment of perianal fistulas is to treat the patient's symptoms, with low recurrence rates and risk of incontinence. In recent years there have been developments regarding the classification and diagnosis ofperianal fistulas. MRI is the most appropriate diagnostic tool. In the hands of an experienced operator anal endosonography is a suitable, less expensive and readily-available alternative. As a result of developments in fistula surgery it is now more practical to classify perianal fistulas as low or high fistulas, as this has implications for the further treatment. Low perianal fistulas are defined as fistulas of which the fistula tract is located in the lower third of the external anal sphincter. High fistulas are fistulas in which the fistula tract runs through the upper two-thirds of the external sphincter muscle. Low perianal fistulas can be treated safely by fistulotomy. At present, rectal advancement is the gold standard for the surgical treatment of high transsphincteric perianal fistulas. The anal fistula plug might be an alternative for the treatment of high transsphincteric perianal fistulas.

Over the past few decades gastrointestinal endoscopy has developed from a purely diagnostic technique to one having numerous therapeutic gastrointestinal applications. Simultaneously, minimal invasive surgery is increasingly replacing traditional open abdominal procedures. These trends have led to a new and innovative way of accessing the peritoneal cavity through the orifices of the body (mouth, anus and vagina) by means ofendoscopic surgery: natural orifice translumenal endoscopic surgery (NOTES). Thanks to excellentcollaboration between surgeons and gastroenterologists and experimental animal research, NOTES has developed extremely rapidly over the past few years. Although many limitations need to be surmounted before NOTES can reach the human clinical trial stage, the prospect of safe, minimal invasive and scar-less surgery appears very promising. The near future will tell whether current barriers will be broken down and NOTES will acquire a fixed place in the diagnostic and therapeutic work-up of certain gastrointestinal afflictions.

Conventionally, patients with acute left-sided malignant colonic obstruction are treated with emergency surgery to restore luminal patency. These emergency operations have a mortality rate of 15-34% and a morbidity rate of 32-64% despite advances in perioperative care. Since the early 1990s, colonic stenting has been introduced, mainly in the left-sided colon, to restore luminal patency. In uncontrolled studies, stent placement before elective surgery has been suggested to improve the patient's clinical condition, thus decreasing mortality, morbidity, and the number of colostomies. To date, only one randomised controlled trial has been published: this study had several limitations, due to which there is still insufficient evidence. Therefore, a large-scale comparison between these two treatment algorithms has been initiated in a prospective multicentre randomised setting with respect to quality of life, morbidity, mortality, and healthcare costs.

Objective: To evaluate the results of the first 100 hand-assisted donor nephrectomies in our hospital., Design: Prospective, descriptive., Method: In the period January 2000-July 2004, 100 consecutive donors underwent laparoscopic nephrectomy as part of a living-related kidney transplantation at the Academic Medical Center in Amsterdam, the Netherlands. The operation was performed laparoscopically using a hand port (hand-assisted nephrectomy). The incision made for the hand port was also used for the removal of the kidney., Results: Mean operating time was 168 min (range: 88-285). Median warm ischaemia time was 3 min (1.0-4.5) and median blood loss was 50 ml (20-1500). None of the operations required conversion to an open procedure and there were no deaths among donors or recipients. Postoperatively, 12 complications occurred in 10 donors. Median hospital stay for the donors was 5 days. In 3 recipients, the transplanted kidney had to be removed within 14 days. 1n 3 other recipients, surgical re-intervention was necessary due to urological complications. One-year graft survival was 94%., Conclusion: Hand-assisted laparoscopic donor nephrectomy was a safe and minimally invasive procedure for renal transplantation in this patient series.

In fast-track surgical programmes, a variety ofperioperative elements are combined in an intensive multidisciplinary approach for the purpose of preserving the preoperative body composition and organ functions and actively stimulating functional recovery. Such programmes have already been introduced in several surgical procedures. The essence of fast-track colon surgery consists of extensive preoperative counselling, adequate preoperative nutrition with the avoidance of prolonged fasting, a minimum of invasive procedures and anaesthesia, no routine use of drains and nasogastric tubes, adequate perioperative analgesia encompassing high thoracic epidural anaesthesia, rapid mobilisation, rapid resumption of postoperative feeding, and medicinal support with prokinetics and laxatives. A systematic review shows that this programme accelerates recovery and hence shortens the primary and total hospital stay.

Two randomised controlled studies comparing laparoscopic-assisted and open surgery for colorectal cancer (the CLASICC and COLOR trials) have been published recently. There is now sufficient evidence that laparoscopic-assisted surgery is as effective as open surgery for cancer of the colon. There is no difference in short-term results (hospital mortality and complications) or 3-year survival rates. The substantial learning curve is a potential drawback for rapid implementation in daily practice and the procedure is associated with extra costs. The impact of the introduction of fast-track surgery has to be considered as another important way to reduce hospital stay. Wide application of laparoscopic-assisted resection of rectal cancer is not justified yet due to impaired short-term outcomes, such as increased circumferential resection margins and urogenital complications.

Although the laparoscopic treatment of colon cancer was introduced more than a decade ago, its application is still under debate. The minimally invasive approach slightly shortens postoperative recovery and hospital-stay as compared to open resection of colon cancer. The disease-free and overall survival following the laparoscopic resection of colon cancer are similar to those of the open procedure, but the data are still limited. Over the next few years, more solid data will become available concerning the effects on long-term survival, quality of life and cost-effectiveness. At present, wide application outside of clinical trials should not be favoured. The laparoscopic technique has a long learning curve and can only be offered as a safe procedure if sufficient expertise is available.

Zenker's diverticulum; diverticula of the small intestine; Meckel's diverticulum.

Objective: To evaluate the results of proctocolectomy with creation of an ileac pouch anal anastomosis (IPAA)., Design: Retrospective., Method: Of the 100 patients in whom an IPAA procedure was performed in the period 1994/'99 in the Department of Surgery of the Academic Medical Centre, Amsterdam, the Netherlands, data were collected on the complications: in the patients with a follow-up of over 12 months the functional results were studied., Results: The group comprised 48 males and 52 females with a mean age of 36.3 years (range: 15-62). Preoperative diagnoses were ulcerative colitis (n = 84), familial polyposis coli (12), slow transit obstipation (2), Hirschsprung's disease (1) and Muir-Torre syndrome (1). Median operating time was 2.3 h, peroperative blood and fluid loss 500 ml and median hospital stay 15 days. There was no mortality. Ten patients had a loop ileostomy formation, in 6 because of postoperative complications. A total of 30 patients developed postoperative complications, peroperatively or during follow-up 10 of those patients needed a relaparotomy. After 12 months 1 pouch had to be excised and 2 patients still had a loop ileostomy due to postoperative complications. In 56 patients with at least 12 months follow-up, median 24-hour stool frequency was 6. Eighty-nine per cent of these patients were satisfied or highly satisfied with the overall outcome., Conclusion: A proctocolectomy with IPAA formation is a safe procedure with good functional results.

Rebound tenderness is generally practiced in the diagnosis of acute abdominal pain. It is a test that inflicts much discomfort to the patient. Literature data derived from reports assessing the reliability of the diagnosis of acute appendicitis indicate a sensitivity of 0.78-0.91 (pooled: 0.91) and a specificity of 0.48-0.60 (pooled: 0.60) of rebound tenderness. It would appear that rebound tenderness is a test of little specificity (leading to many false positive results) and that it has very little additional value, particularly in the presence of local tenderness and/or rigidity in patients with acute abdominal pain.