ORIGINAL ARTICLES

A Multivariate Analysis of Potential Risk Factors for

Intra- and Postoperative Complications in 1316 Elective
Laparoscopic Colorectal Procedures
Philipp Kirchhoff, MD, Selim Dincler, MD, and Peter Buchmann, MD

Objective: To identify predictive risk factors for intra- and postoperative complications in patients undergoing laparoscopic colorectal surgery.
Background Data: In emergency situations or in elective open and
laparoscopic colorectal surgery, there are many risk factors that
should be recognized by the surgeon to reduce complications and
initiate adequate treatment. Most available data, thus far, refer to
open colorectal surgery and literature that focuses mainly on a
laparoscopic approach is still rare.
Methods: Univariate and multivariate analyses of a prospectively
gathered database (19932006) were performed on a consecutive
series of patients (1316) undergoing laparoscopic colorectal surgery who were operated at a single institution (first referral
center). Patients were assessed for demographic data, operative
indications, type of resection, and intra- and postoperative complications. Altogether, we analyzed 20 potential risk factors to
identify significant influence on the intra- and postoperative
outcome.
Results: Significant risk factors that led to intraoperative complications consisted of age 75 years and malignant neoplasia.
Increased postoperative rate of surgical complications was significantly influenced by male gender, age 75 years, American
Society of Anesthesiology class III, malignant neoplasia, and
the experience of the surgeon. The analysis of specific medical
postoperative complications revealed even more significant predictive risk factors. In addition, our analysis showed that specific
risk factors predict specific complications such as postoperative
bleeding, anastomotic leakage, and surgical site infections. The
type of surgical procedure performed also influenced patient
outcome.
Conclusion: This large single center study provides the first evidence of the significance of predictive risk factors for intra- and
postoperative complications in laparoscopic colorectal surgery.
(Ann Surg 2008;248: 259 265)

From the Department of Surgery, City Hospital Waid, Zurich, Switzerland.

First two authors contributed equally to this work.
Reprints: Peter Buchmann, MD, Department of Surgery, City Hospital
Waid, Tie`chestrasse 99, 8037 Zurich, Switzerland. E-mail: peter.
buchmann@waid.stzh.ch.
Copyright 2008 by Lippincott Williams & Wilkins
ISSN: 0003-4932/08/24802-0259
DOI: 10.1097/SLA.0b013e31817bbe3a

Annals of Surgery Volume 248, Number 2, August 2008

o date, most studies of laparoscopic colorectal procedures

have been descriptive reports that do not account for the
potentially complex interaction of outcome predictors. Many
recent studies have shown that the laparoscopic approach in
colorectal surgery is well established and more feasible in
comparison with the open access techniques. Numerous studies show the advantages of laparoscopic colorectal surgery
such as reduced need for analgesics, faster onset of postoperative activity, less wound infections, and shorter length of
hospital stay.1,2 The decision to perform a laparoscopic intervention remains challenging and the risk of complications
must be weighed against the advantages of reduced invasiveness. Although there is no difference in mortality between
laparoscopic and open colorectal surgery, the conversion rate
in the laparoscopic approach is up to 30% and leads to an
increased operating time but similar treatment costs.35 Although it is well proven that laparoscopic surgery can be
performed efficiently for a broad spectrum of diseases affecting the gastrointestinal tract, it is still necessary to evaluate
the best surgical treatment in every individual case. Surgeons
use many factors to determine whether a patient will tolerate
a particular surgical procedure. The decision until now has
mostly been based on intuition and knowledge of the relative
risk of the operation itself. Therefore, there is a strong need to
provide the surgeon with more objective means of assessment
for individual patients to choose the best surgical procedure.
Intra- and postoperative complications might occur in patients at risk. Many criteria determining this risk have been
proposed, but to date, there is no large and well-designed
study to confirm these predictive risk factors especially in
laparoscopic colorectal surgery.
Scoring systems to predict morbidity and mortality
from surgery are important tools used to give information to
the surgeon and patient. The existing scoring systems in
colorectal surgery are CR-POSSUM (colorectal physiologic
and operative severity score for enumeration of mortality and
morbidity), AFC (4-item predictive score of mortality after
colorectal surgery), and the Cleveland Clinic Foundation
colorectal cancer model. Most of these scoring systems are
lacking in feasibility, accuracy, and predict only mortality,
not morbidity.6
To date, there is no scoring system predicting complications in laparoscopic colorectal procedures. Even studies
evaluating predictive risk factors for complications in open
colorectal surgery are rare and mainly small in sample size.

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Annals of Surgery Volume 248, Number 2, August 2008

Kirchhoff et al

In this study, we analyzed 20 parameters from a prospective data collection (19932006) of 1316 patients undergoing laparoscopic colorectal surgery and their influence on
the intra- and postoperative complications.

PATIENTS AND METHODS

A consecutive series of patients undergoing laparoscopic colorectal surgery from 1993 through 2006 was prospectively entered into a database in the Department of
Surgery at the City Hospital Waid, Zurich, Switzerland. City
Hospital Waid is a teaching hospital and provides training in
general surgery and laparoscopic techniques. A total of 1316
colorectal procedures were performed during this 13-year
period. The different diagnoses and performed surgical procedures are listed in Tables 2 and 3. The population of this
study consisted of patients with an age range from 13 to 94
(mean, 64.2 years), undergoing laparoscopic colorectal surgery. The operations were performed by 13 different surgeons. Two of them did 889 surgical interventions of the
1316. In addition to the listed procedures, we also performed
surgeries such as cholecystectomy, adnexectomy, appendectomy when indicated intraoperatively. Data recorded for each
patient included age, sex, body mass index, indication for
surgery, performed surgical procedure, surgeons experience,
conversion to laparotomy, length of operation, intra- and
postoperative complications, American Society of Anesthesiology (ASA) score, preoperative hemoglobin, length of
hospital stay, tumor classification, mortality, neoadjuvant
radio/chemotherapy, reoperation, and multiple comorbidities
according to the Charlson Index such as diabetes mellitus,
history of heart failure or myocardial infarction, chronic
obstructive pulmonary disease, cirrhosis, renal insufficiency,
dementia, AIDS, leucemia, and vascular disease. The demographic and clinical data are given in Table 1.
We recorded intraoperative complications such as bowel
injury, urethral injury, bleeding, anastomotic problems, and
anesthesiologic complications. Anastomotic problems, bowel,
and urethral injury were defined as problems in which further
surgical procedures were needed. Bleeding as a complication
was recorded when additional treatment such as blood transfusion, vascular surgery, or conversion to open surgery was applied. Anesthesiologic complications were included, when any
additional treatment of the anesthesiologist or conversion due to
anesthesiologic complications was necessary.
TABLE 1. Demographics and Clinical Characteristics of
Patients
Age (yrs)
Men/woman (n)
BMI
Obesity BMI 30
Malnutrition BMI 17
Cancer/benign disease
Operating time (min)
Hemoglobin (g/L)
Length of stay (d)
BMI indicates body mass index.

260

64.2 14.65
526/790
25.14 4.38
167 (12.7%)
18 (1.4%)
463 (35.1%)/853 (64.9%)
205.51 73.09
133.5 16.1
10.5 7.7

Postoperative complications were differentiated into surgical complications such as bleeding, abscess, anastomotic insufficiency, surgical site infection or wound dehiscence, and
medical complications such as pneumonia, pulmonary embolus,
thrombosis, cardiac failure or infarction, and renal failure. Postoperative bleeding was recorded if reoperation was necessary or
a blood transfusion was given. Abscess was defined by detection
through ultrasound or CT scan followed by reoperation, antibiotic therapy, or CT-guided drainage. Anastomotic insufficiency
diagnosed by CT scan and treated either with antibiotics or
reoperation was included. Surgical site infection was defined by
clinical signs and open-wound treatment with or without antibiotic usage. Deep wound dehiscence was recorded if surgical
reintervention was necessary. Medical complications were included if diagnosed clinically and verified by objective diagnostics and/or additional medical treatment.
To identify potential predictive risk factors for intraand postoperative complications, we used univariate and
multivariate analysis. We separately analyzed medical and
surgical complications and their influence by the preoperative-recorded parameters. Here, we also looked in detail if the
parameters could predict specific surgical complications. In
addition, we calculated the complication rate for each performed surgical procedure.

Statistics
Statistical analysis was performed using the SPSS statistical software package (SPSS Inc.; Chicago, IL). The
univariate relation between each independent variable and
intra- and postoperative complications was evaluated using a
logistic model for continuous variables and Pearson 2 test
for categorical variables. Independent variables with a P
value 0.05 in the univariate analysis were entered into the
multivariate logistic regression model. P values 0.05 were
considered to be statistically significant.

RESULTS
Between 1993 and 2006, 1316 laparoscopic colorectal
procedures were performed at our department. The mean
patient age was 64.2 14.65 years (range, 1394). There
were 790 women (60%) and 526 men (40%); the mean BMI
was 25.1 4.38. The mean duration of hospitalization was
10.5 7.7 days. Patient demographic data are shown in
Table 1 and the indications for surgery are shown in Table 2.

TABLE 2. Indications of Laparoscopic Colorectal Procedures

Diagnosis

N (%)

Carcinoma
Diverticulosis
Acute diverticulitis
Prolapse
Polyps
IBD
Outlet obstruction
Other

463 (35.1)
361 (27.4)
189 (14.4)
121 (9.2)
71 (5.5)
44 (3.3)
23 (1.7)
44 (3.3)

IBD indicates inflammatory bowel disease.

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Complications in Laparoscopic Colorectal Procedures

TABLE 3. Performed Surgical Procedures and Specific Complication Rates

Surgical Procedures
Sigma resection
Low anterior resection
Right hemicolectomy
Sigma resection plus rectopexy
Rectosigmoid resection
Rectum resection
Rectum amputation
Coecum resection
Retrofixation vaginae
Proctocolectomy
Left hemicolectomy
Other
Overall

N (%)

Intraoperative
Complications, N (%)

Postoperative Complications,
(Surgical; Medical), N (%)

562 (42.7)
180 (13.7)
116 (8.8)
102 (7.8)
94 (7.1)
68 (5.2)
49 (3.7)
32 (2.4)
26 (2.0)
21 (1.6)
18 (1.4)
48 (3.6)
1316 (100)

28 (5.0)
31 (17.2)
1 (0.9)
5 (4.9)
11 (11.7)
4 (5.9)
7 (14.6)
0 (0)
1 (3.8)
4 (19.0)
1 (5.6)
4 (0.08)
97 (7.4)

66 (11.7); 43 (7.7)
62 (34.4); 27 (15)
18 (15.5); 12 (10.3)
11 (10.8); 7 (6.9)
7 (7.4); 8 (8.5)
11 (16.2); 7 (10.3)
15 (30.6); 4 (8.2)
4 (12.5); 0 (0)
1 (3.8); 0 (0)
7 (33.3); 2 (9.5)
3 (16.7); 1 (5.6)
8 (16.6); 3 (6.25)
213 (16.2); 114 (8.7)

The most common procedure was sigmoid resection in

562 patients. In 180 cases, low anterior resections were performed both for diverticular disease and rectal cancer. Rectosigmoid resections were performed in 94 cases, most of them for
benign diseases where the upper third of the rectum and the
sigmoid was involved. Rectum resection (68) was defined as
resection of the mid and upper part of the rectum. Proctocolectomy was performed in 21 patients and 134 patients underwent
laparoscopic hemicolectomy (116 right and 18 left). In 102
cases, a simultaneous rectopexy with sigmoid resection was
performed, whereas a laparoscopic sutured vaginal retrofixation
was carried out in 26 patients. Laparoscopic excision of the
rectum was done in 49 patients because of rectal cancer (Table 3).
The data show that the type of colon procedure had
significant influence on the intra- and postoperative complication rates. Although the overall intraoperative complication
rate was 7.4%, the complications during low anterior resection (17.2%), rectum amputation (14.6%), and proctocolectomy (19%) were much higher. These results are comparable
with data from the literature and can be explained by the
complexity of the surgical procedure and the severity of
underlying diseases. The specific postoperative rate of surgical (16.2%) und medical (8.7%) complications for each
surgical procedure is also shown in Table 3. The postoperative surgical complication rate after proctocolectomy
(33.3%), low anterior resection (34.4%), and rectum amputation (30.6%) is much higher than the average. Concerning
the medical postoperative complication rates (8.7%), the
complex surgical procedures did not show higher complication rates except the rate after low anterior resection that was
significantly higher (15%). Cecum resection and retrofixation
vaginae had no medical complications at all.
Intraoperative complications were observed in 97 patients (7.4%). There were 27 bowel lesions, 17 bleeding
episodes, 15 urethral injuries, 16 anastomotic problems, and
11 anesthesiological complications documented. In 4 cases
more than 1 intraoperative complication occurred and 7 other
complications were documented.
Altogether, 327 postoperative complications occurred in
289 patients (morbidity 22%). The most common surgical com 2008 Lippincott Williams & Wilkins

plications were anastomotic leakage, surgical site infections, and

postoperative bleeding. Pneumonia and cardiac insufficiency
were the major medical complications. The 30-day mortality
rate was 1.8% (24 patients). The detailed intra- and postoperative complications are listed in Tables 4 and 5.
Tables 6 and 7 show the perioperative factors recorded
prospectively from 1993 to 2006. These factors were anaTABLE 4. Intraoperative Complications, N (%)
Intraoperative complications
Bowel injury
Urethral injury
Bleeding
Anastomotic problems
Anesthesia problems
More than 1 complication
Other

97 (7.4)
27 (32.1)
15 (15.4)
17 (20.2)
16 (19)
11 (13.1)
4 (4.8)
7 (8.4)

TABLE 5. Postoperative Complications, N (%)

Surgical complications
Anastomotic leakage
Surgical site infection
Bleeding
Douglas abscess
Perineal abscess
Wound dehiscence
Other
More than 1 complication
Medical complications
Pneumonia
Cardiac complications
Pulmonary embolism
Deep vein thrombosis
Other
More than 1 complication
Overall morbidity
Overall mortality (30 d)

213 (16.2)
59 (27.7)
49 (23)
29 (13.6)
13 (6.1)
11 (5.1)
12 (5.6)
29 (13.6)
21 (9.8)
114 (8.7)
49 (42.9)
29 (25.4)
7 (6.1)
2 (1.8)
19 (16.6)
17 (14.9)
289 (22)
24 (1.8)

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Kirchhoff et al

TABLE 6. Risk Factors for Overall Intra- and Postoperative Complications*

Variables

Experience 70/70 cases

Age 75 yr
BMI 30
BMI 17
Gender (female/male)
ASA score III
pT status
pN status
Liver disease
Diabetes
Anemia HB 12 g/L
Prior myocardial infarct
Prior heart failure
Vascular disease
Cerebrovascular disease
Dementia
Chronic lung disease
Renal insufficiency (Creatinine 260 mol/L)
Neoplasia
Metastasis of a solid tumor

872
335
167
18
790/526
305
289
289
26
57
241
55
167
78
36
17
57
6
413
54

Intraoperative
Complications

Postoperative
Complications
Overall

11.4

0.001

19.9/26.1
29.6

0.01
0.001

6.2/9.1
10.5

0.048
0.020

17.0/29.5
30.4

0.001
0.001

12.1

0.001

29.5
32.7
31.1

0.002
0.049
0.002

31.4

0.001

*Empty cells are not significantly predictive for intra- and/or postoperative complications.
ASA indicates American Society of Anesthesiology; BMI, body mass index.

TABLE 7. Risk Factors for Medical and Surgical Postoperative Complications

Postoperative Surgical
Complications
Variables
Experience 70/70 cases
Age 75/75 yr
BMI 30/30
BMI 17
Gender (female/male)
ASA Score III/III
pT-status
pN status
Liver disease
Diabetes (no/yes)
Anemia HB 12/12 g/L
Prior myocard infarct (no/yes)
Prior heart failure (no/yes)
Vascular disease (no/yes)
Cerebro vascular disease
Dementia
Chronic lung disease (no/yes)
Renal insufficiency (no/yes)
Neoplasia (no/yes)
Metastasis of a solid tumor

262

n
872
335
167
18
790/526
305
289
289
26
57
241
55
167
78
36
17
57
6
413
54

15.2/23.4

0.007

11.3/23.6
14.6/20.9

0.001
0.007

15.4/21.6

12.8/23.7

0.032

0.001

Postoperative Medical
Complications
%

7.2/11.5
6/16.1

0.007
0.001

7.2/10.8
7.2/13.7

0.015
0.001

8.3/15.8
7.0/16.2
8.2/18.2
7.4/17.4
8.1/16.7

0.05
0.001
0.01
0.001
0.009

8.3/15.8
8.5/33.3
6.8/12.6

0.05
0.031
0.01

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Complications in Laparoscopic Colorectal Procedures

lyzed in a univariate and multivariate way to detect their

influence on intra- and postoperative complications.

Univariate Analysis
Whereas between the surgeons, there was no difference
concerning intra- and postoperative results, the experienced
surgeons (70 laparoscopic procedures) had significantly less
postoperative complications (19.9% in the experienced group vs.
26.1% in the less experienced group). Intraoperative complications did not differ significantly between these groups.
Patients older than 75 years had overall more intra- and
postoperative complications than younger patients. Obese
patients (BMI 30) had significant higher surgical complications. Malnourished (BMI 17) patients were not at a
higher significant risk for intra- and postoperative complications. Both intra- and postoperative complications occurred
more often in men than in women (intraoperative complications 9.1% vs. 6.2%, postoperative complications 29.5% vs.
17%) in the univariate analysis. Although classes I to IV of
the ASA score were separately not observed as significant for
intra- or postoperative complications, the patient group that
graded ASA class III and higher were at significant risk to
develop intraoperative problems and postoperative surgical
and medical complications in comparison with the patients
ranked lower than ASA class III. Different tumor progression
rates and lymph node status had no influence on the postoperative 30-day follow-up.
Preoperative anemia (HB 12 g/L), prior heart failure,
and history of myocardial infarction had significant influence
on postoperative outcome, although intraoperative complica-

TABLE 8. Specific Variables and Related Surgical

Postoperative Complications

Bleeding
Variables
Age 75/75 yr
BMI 30/30
Gender
(female/male)
Malignant
neoplasia
(no/yes)

1.4/3.4

0.013

Surgical
Site
Infection

Anastomotic
Leakage
%

3.9/8.4
2.3/7.8

0.001
0.001

2.4/8.9

0.001

2.9/6.3

0.04

tions were not influenced. Only prior heart failure had significant influence on postoperative surgical complication rate.
Interestingly, renal insufficiency and presence of vascular
disease led to significant medical postoperative problems.
Chronic lung disease and diabetes also had the tendency to cause
more postoperative medical problems (P 0.05). The diagnosis
of a neoplasia increased intra- and postoperative complication
rates significantly. Hepatic diseases, cerebrovascular disease,
and dementia seemed to have no influence on the intra- or
postoperative course (data shown in Tables 6 and 7).
In Table 8 significant predictive parameters for specific
postoperative surgical problems are listed. Male patients are at
significant higher risk of postoperative bleeding (P 0.013).
BMI 30 (P 0.001), male gender (P 0.001), and presence
of neoplasia (P 0.001) are predictive for postoperative anastomotic leakage. Surgical site infection is only increased significantly in patients older than 75 years (P 0.04).

Multivariate Analysis
After univariate analysis, those variables with a P value
less than 0.05 were selected for multivariate analysis using a
stepwise logistic regression model. Table 9 summarizes the
results of the multivariate analysis. Patients older than 75
years and presence of neoplasia were predictive of developing intra- and postoperative complications in laparoscopic
colorectal surgery. Additionally ASA class III, male gender, and lack of surgical experience (70 procedures) also
were independent predictors for postoperative outcome.

DISCUSSION
The feasibility and safety of laparoscopic colorectal
surgery has been reported numerous times in current surgical
literature. The standard of quality and improvements in the
perioperative clinical course should always be taken into
consideration by the surgical team. The perioperative period
can be more successful if we know which factors have
influence on the patients outcome. Therefore, there exists a
need to provide the surgeon with an objective means of
assessment for individual patients especially in laparoscopic
colorectal surgery.
In our series of 1316 patients, using a univariate and
multivariate analysis, we examined 20 perioperative factors
and defined risk factors, which proved to be significant in
predicting an increase of intra- and postoperative complications. These included in the multivariate analysis the age 75

TABLE 9. Multivariate Logistic Regression Analysis of Variable Associated With

Intra- and Postoperative Complications
Intraoperative Complications
Variable
Experience 70 cases
Age 75 yr
Male gender
ASA III
Neoplasia

OR

95% CI

1.69

1.092.62

1.5

1.201.80

Postoperative Complications

OR

95% CI

0.019
0.109
0.217
0.001

0.72
1.57
1.99
1.48
1.31

0.540.95
1.152.13
1.502.62
1.082.01
1.131.51

0.024
0.004
0.001
0.012
0.001

CI indicates confidence interval; OR, odds ratio; ASA, American Society of Anesthesiology.

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Kirchhoff et al

years, experience of the surgeon, male gender, ASA score

III, and neoplasia. The overall morbidity in our patient
population was 22%, and the mortality rate was 1.8%. In the
literature, morbidity rates for laparoscopic colorectal surgery
of between 6% and 31% are reported, and are thus comparable with our data. This also applies to the reported mortality
rates that vary between 0% and 4.5% in the published
literature.7,8
No large study has been conducted to investigate the
risk factors for perioperative complications undergoing laparoscopic colorectal surgery and until now most studies have
concentrated on a few factors with small sample sizes. Also
the influence of the patients weight on perioperative complication rates in open and laparoscopic major visceral surgery was extensively examined but the results are still controversial.9,10 Here, we show that obesity (BMI 30) has
increased the risk of surgical postoperative complications
such as anastomotic leakage but interestingly has no influence
on medical complication and intraoperative outcome. Moloo
et al11 showed that obese patients have a higher conversion
rate to open surgery, although the converted cases seem not to
have higher morbidity rates than the laparoscopically finished
cases. In open colorectal surgery, preoperative risk factors
such as emergency operation, age 75 years, abdominal
radiation, hypoalbuminemia, COPD, prior MI, and diabetes
mellitus were already validated in 1992.12 In our study, prior
myocardial infarction, chronic lung disease, and renal insufficiency only increases the risk for medical complications but
did not influence the rate of postoperative surgical complications. However, none of the studies differentiated between
intra- and postoperative complications and medical and surgical problems, which is important for the outcome and
therefore guiding the surgical team.
One large study on 1421 patients aimed at identifying
risk factors for postoperative complications combined data
from open and laparoscopic surgery. They found that patients age (70 years), neurologic or cardiopulmonary comorbidity, hypoalbuminemia, long duration of operation, and
peritoneal contamination independently increased the risk of
postoperative complications. Recently, the same group published a score (AFC-score), which is a pertinent predictive
score of postoperative mortality after colorectal surgery.
Despite the interesting results and feasibility of this score, it
does not include morbidity and gives no information about
intraoperative risk factors.13,14 Longo et al concluded that
patients with an ASA class III, serum sodium 145
mmol/L, and ascites had an increased morbidity or mortality
rate after colectomy.15,16 Because of a recently published
study by our group that evaluates predictive factors for
complications in laparascopic colorectal surgery by an expert
survey on patients with liver cirrhosis and renal failure, which
showed a strong association with high perioperative risk,
although this has to be evaluated in a further analysis.17 In our
hospital, patients suffering from liver and renal failure were
few. This might be a reason that these factors in our institution are not significantly increasing the perioperative morbidity in our study. Hospitals having more HPB cases or patients
with renal failure undergoing laparoscopic colorectal surgery

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Annals of Surgery Volume 248, Number 2, August 2008

might observe a correlation of increased perioperative complication rates.

Because in our multivariate analysis, the predictive
factors such as age, neoplasia, gender, and ASA class III
cannot be influenced perioperatively, it helps the surgeon to
be aware of increased risk and therefore choose the safest
treatment for the patient. The experience of the surgeon plays
a significant role in complex cases. This fact favors a welltrained surgeon rather than a teaching operation for a resident. Interestingly, the univariate analysis revealed 11 predictive risk factors for medical complications. Preoperative
anemia should be corrected and also diagnostic and improvement of decompensated comorbidities should be properly
adjusted before elective surgery to minimize risk. In addition,
the different risk factors should be kept in mind before the
planned surgical procedure (eg, proctocolectomy) so as not to
potentiate the risk for perioperative complications.
In conclusion, this study provides the first evidence of
predictive risk factors for intra- and postoperative complications in patients undergoing laparoscopic colorectal surgery
and differentiation of medical from surgical complications.
Also, it shows for the first time influencing risk factors on the
intraoperative course in surgery. This might help the surgeon
in making perioperative decisions and could indicate that an
experienced surgeon should be involved in the decision
making progress and during the operation so as to lower the
patients risk and improve the outcome. As patient outcome is
never predictable, these data should help to elucidate the
quite complex interactions and may lead the surgeon to a
feasible and simple score that helps to minimize risk and
maximize the patients benefit from laparoscopic colorectal
surgery.
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