ing a complete cleansing of the region. The descending colon is then mobilized so that it can reach the site of the colostomy without tension, i.e. the site in which the left tro- car had previously been positioned. The proximal section of colon is transected with a mechanic stapler. The seg- ment to be resected is put into the pelvic cavity. The per- ineal phase of a laparoscopic Miles operation follows the same sequences as in traditional surgery. The perineal wound is closed with separate stitches after the specimen has been delivered transanally. A drain is positioned in this site. It must be noted that the bony structure of the pelvis permits laparoscopic inspection without creating a pneu- moperitoneum as well, allowing a check of hemostasis even when the incision is open. RESULTS There were 117 laparoscopic procedures completed out of 158 patients (74.1%): 103 resections, 95 of which were for malignant disease and 18 for benign disease, 7 Hartmann's procedures for malignant neoplasias, 3 reversal of Hartmann's procedures (two for a benign lesion and one for a malignant one), 1 rectopexy and 3 ileotransversos- tomies (Table 1). There were 41 conversions out of 158 cases (25.9%); 19 cases (12%), however, were converted to a laparoscopic-facilitated procedure. The mortality rate was 1.9% (3/158), because of one anastomotic leak and one res- piratory insufficiency in two laparoscopic facilitated proce- dures, and because of one cerebral ischemia in a convert- ed case. The most frequent causes of conversion were bulky tumors, tumors contaminating adjacent structures (16/158), adhesions due to previous surgical operations (8/158), or patient obesity (5/158) (Table 2). As one can see, the percentage of feasibility decreases significantly in resections of the rectum, dropping to 63-3% (Table 1). In our series, this was due to anatomic or pathological rea- sons, such as large neoplasias, contamination of surround- ing structures, or the patient's obesity, occurrences that made vision and laparoscopic moves in the pelvic cavity difficult. There were 31 complications (15%), only three during the operation; one because of a vesicle injury, solved intraoperatively, another because of an ureteral injury at the beginning of our experience which required conversion, and another because of damage to the epigas- tric vessels caused by a trocar and managed with a tran- scutaneous suture (Table 3). There was only one (0.9%) wall recurrence, 15 months after the operation, at both tro- car and drainage sites, with peritoneal carcinomatosis, in a patient with rectal neoplasia, who suffered a perforation of the rectum during dissection, with bowel spillage. The average number of lymph nodes harvested in resected specimens was 12.8 (range 1-41); the mean distance of the tumor from the proximal margin of resection was 11.5 cm, from the distal margin, 7.5 cm (range 1-25). The postoper- ative stage was: Dukes' A 15 pts; Dukes' B1 8 pts; Dukes' B2 45 pts; Dukes' C1 2 pts; Dukes' C2 33 pts; Dukes' D 9 pts. The mean operative time was 165 minutes (range 40- 360). The average hospital stay was 9.2 days (range 6-40). The administration of narcotics was remarkably reduced compared to open surgery, and was limited to non-mor- phinic analgesics for no longer than two days after the operation. On postoperative day two, after the passage of flatus, liquids via phleboclysis came to an end, and patients were placed on a liquid diet. On postoperative days three and four they resumed a regular diet. Patients could be dis- charged on postoperative day four, but we usually pre- ferred to protract their hospital stay until the eighth day, to monitor any anastomotic leak. The patients were allowed to perform physical activity 10 or 15 days after surgery including heavy labor. Heavy physical activity occurred at least 50 days earlier than in open surgery. CONCLUSIONS We can affirm that the activity of Italian surgeons in this field began with only a few followers in 1992. This approach has rapidly interested other centers, stirred by the issue of feasibility. However, each has followed his own path, and scant attention has been paid to the issue of establishing a standard technique. This issue is of primary importance in order to generate reproducible data and be able to compare results. Nevertheless, case reports have grown richer and richer, and patient selection has become more accurate. Most of all, a thorough laparoscopic explo- ration can be performed and accurate staging of neoplastic disease made at the beginning of each operation, leading to better identification of those patients that will benefit from this technique. The technique of laparoscopic colectomy as described by us lends itself to standardization and respects the highest oncologic principles. It is difficult to develop a barrier for endoluminal contamination, but failure to do so can be ascribed, in our opinion, to improper or imperfect surgical technique. There is in minimally invasive surgery, and most of all in advanced cases, an extended learning curve for the sur- geon who has to practice for a long period of time before reaching that level of manual dexterity and expertise nec- essary to complete the same kind of operation performed in an open fashion. This must not, however, dissuade the surgeon from performing an oncologic operation. It is important at this juncture for laparoscopic colon surgery to remain in the hands of selected and highly specialized cen- ters, because of the necessity for controlled clinical studies. It will be the primary duty of institutions responsible for surgical training to ensure that this approach becomes widespread, and maintain that rigor and adherence to the oncologic principles of exeresis that must be observed. JSLS (1997)1:217-224 223