The pneumoperitoneum for the reoperative surgery was performed by opening the port sites used in the first approach. The bowel was carefully managed to avoid any visceral injury. The conversion rate of the reoperative laparoscopic surgery group was 13.8 % (4 of 29). One patient required laparotomy because of ischemia in the descending colon, and another two patients were converted because of significant intestinal distention secondary to generalized peritonitis that did not permit adequate abdominal pneumoperitoneum. In 20 patients (69 %) AL was found during the reoperative laparoscopic surgery (Tables 13.2 and 13.3). Most of these cases (n = 18) were able to be managed by a rigorous abdominal lavage with the placement of an abdominal drain near the anastomotic dehiscence. This confirms that AL from the left side or after anterior resection can be readily managed by laparoscopic reoperative surgery. In three patients in whom the defect was found easily, a laparoscopic suture of the leaking anastomosis was performed. In all patients a proximal defunctioning ileostomy was fashioned where the right lower quadrant trocar was primarily placed (Fig. 13.1). One patient required a second exploration because of fecal peritonitis, resulting in a Hartmann’s operation. Between the second and third postoperative months, a contrast enema confirmed anastomotic integrity and the stoma closure was scheduled.

In three patients the persistence of severe postoperative pain at a trocar incision (umbilical, epigastric, or suprapubic) associated with significant abdominal distension motivated the second laparoscopic surgery. The finding in these patients was an acute herniation that could be easily reduced using the laparoscopic approach with fascial defect closure. Two patients required reoperative surgery because of intestinal injury, probably resulting from the lysis of adhesions from previous multiple surgeries. Although previous abdominal surgeries are not a formal contraindication for a minimally invasive approach, the adhesiolysis has to be performed carefully to avoid bowel injury. In our experience we were able to find the bowel perforation and suture it laparoscopically.