A review of minimally invasive surgery in ulcerative colitis: more than one way to skin a cat

: Minimally invasive surgery (MIS) in ulcerative colitis (UC) remains an important part of the surgical arsenal despite advances in biologic treatments for UC. There remains a need for operative intervention in approximately 30% of patients, even with advanced medical therapies. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgery for UC patients with medically refractory disease, refractory bleeding, or dysplasia/cancer. As in most surgical procedures, the move toward MIS has improved overall patient outcomes and UC is no exception. Historically patients have undergone laparotomy for total abdominal colectomy (TAC) and IPAA with the frequent need for multistage surgery as well as multiquadrant abdominopelvic surgery presenting a challenge in the adoption of MIS surgery for UC. However, advances in minimally invasive techniques over the last two decades from hand-assist laparoscopy, to totally laparoscopic surgery, robotic surgery, and transanal approaches have facilitated the gradual move toward MIS. With clear advantages in short-term surgical outcomes including reduced pain, shorter hospital stay, faster return of bowel function, improved cosmesis as well as some potential long-term benefits in bowel function, female fertility, and male sexual function it is clear that MIS for UC is here to stay. Even in an urgent setting with fulminant colitis, laparoscopy is safe and should be preferred over midline laparotomy except in unstable patient. Here, we will discuss the various approaches for MIS surgery in UC including potential advantages and pitfalls of each approach.