Feasibility and safety of single-incision laparoscopic colectomy: a systematic review. Ann Surg. 2012;255:667-676. [PMID: 22258065 DOI: 10.1097/sla.0b013e31823fbae7]

Robotic single-site versus laparoscopic cholecystectomy: Which is cheaper? A cost report and analysis

OBJECTIVE

There is a need for a comparison of costs of robotic single-site cholecystectomy (RSSC) and laparoscopic cholecystectomy (LC) in the US healthcare model. Cholecystectomy is one of the most common procedures in general surgery. Single-incision laparoscopic surgery is beneficial but cumbersome. Robotic surgery is ergonomic but expensive. Costs of RSSC and LC have not been compared within the US healthcare model.

METHODS

Cost categories were compared between RSSC and LC in consecutive outpatient-elective cases during the same period. Cost efficiency of outpatient-elective cases before and after the first 50 institutional RSSC cases (including outpatients, inpatients, emergent, and elective) were compared to investigate for a learning curve that would subsequently affect cost.

RESULTS

A total of 458 cases included 177 RSSCs and 281 LCs. Non-emergent non-admitted cases included in cost analysis were 46 RSSCs and 175 LCs. Costs were less with RSSC: median total ($1319 vs. $1710, p < 0.001), driven mainly by cost category "Supplies" ($913 vs. $1244, p < 0.001), and to a lesser extent "Operating room" ($196 vs. $232, p < 0.001), and "Anesthesiology" ($127 vs. $168, p < 0.001). Supplies were responsible for 87% of median total cost reduction. Other cost categories were not significantly different. There were 11 and 9% drops (p < 0.006) in RSSC OR times and costs, respectively, after our 50th institutional case.

CONCLUSION

In a hospital that has already acquired infrastructure for robotic surgery, we observed procedural costs for RSSC that were lower than LC. This decreased cost was mainly driven by cutting down on supplies (87% of median total cost reduced), and to a lesser extent OR time. A steep learning curve exists after which RSSC OR times can be significantly shortened. A randomized study is needed.

A Randomized Controlled Study to Evaluate the Impact of Instrument and Laparoscope Length on Performance and Learning Curve in Single-Incision Laparoscopic Surgery

INTRODUCTION

The proximity of instrumentation in single-incision laparoscopic surgery (SILS) creates ergonomic challenges. An innovative method to reduce external collisions between instruments and handles is to use instruments of different lengths. This study evaluated the impact of instrument and laparoscope length on simulated SILS performance.

METHODS

Performance was assessed using peg transfer (PEG) and pattern cutting (CUT) tasks from the Fundamentals of Laparoscopic Surgery (FLS) curriculum. Following baseline testing, surgeons were randomized into 3 trial arms: Control--standard length instruments and standard length laparoscope; group 1--one long instrument, one standard length instrument and standard length laparoscope; and group 2--standard length instruments and long laparoscope. Two phases were undertaken using a validated SILS-modified FLS box trainer: phase 1--25 repetitions of PEG and phase 2--5 repetitions of CUT. FLS scoring parameters measured performance and the Imperial College Surgical Assessment Device (ICSAD) captured motion analysis of hands.

RESULTS

Twenty-three surgeons were recruited--control (n = 7), group 1 (n = 9), and group 2 (n = 7). No significant differences were observed in operative experience or baseline skills performance. Phase 1: Peak FLS score was significantly higher in group 1 compared with control (P = .009). Comparison of learning curves revealed learning plateau was significantly higher in group 1 compared with control (P = .010). Phase 2: Group 1 revealed a trend toward higher peak FLS scores over the control (P = .067). No significant differences in motion analysis of hands were demonstrated using ICSAD.

CONCLUSIONS

This study demonstrates that using instruments of different lengths can improve simulated SILS performance.

Laparoscopic complete mesocolic excision via reduced port surgery for treatment of colon cancer

BACKGROUND

Laparoscopic colectomy has become accepted for resection of colon cancer, and laparoscopic complete mesocolic excision (CME) has proved feasible and safe. We have evaluated the safety, efficacy, and feasibility of laparoscopic CME via reduced port surgery (RPS) in patients with colon cancer.

METHODS

We prospectively assessed 17 consecutive patients with colon cancer undergoing laparoscopic CME via RPS between February 2012 and January 2014. Video recordings were used to assess the quality of the surgery, including CME completion. We also assessed operative data, complications, pathological findings, visual analog scale (VAS), cosmesis, and the hospital length of stay.

RESULTS

All patients underwent en bloc resection of mesocolon with CME completion. The median surgical duration and blood loss were 298 min and 41 ml, respectively. No intraoperative complications occurred in any patient. The median number of lymph nodes retrieved was 20, with lymph node metastasis identified in eight patients. The mean VAS scores for postoperative days 1, 3, and 7 were 3.2, 1.5, and 0, respectively. All patients were satisfied with their cosmesis. The median postoperative hospital stay was 11 days.

CONCLUSIONS

Laparoscopic CME via RPS for colon cancer is a safe and feasible surgical procedure with cosmetic advantages.

Single-Access Laparoscopic Rectal Resection Versus the Multiport Technique

Background. Single-access laparoscopic surgery is not used routinely for the treatment of colorectal disease. The aim of this retrospective cohort study is to compare the results of single-access laparoscopic rectal resection (SALR) versus multiaccess laparoscopic rectal resection with a mean follow-up of 24 months. Methods. This retrospective cohort study enrolled 42 patients. Between January 2010 and June 2012, 21 SALRs were performed. These patients were compared with a group of 21 other patients who had undergone multiport laparoscopic rectal resection. This control group had the same exclusion criteria and patient demographics. Short-term outcomes were reassessed with a mean follow-up of 2 years. Statistical analysis included the Student t test and Fisher’s exact test. Finally, we performed a differential cost analysis between the 2 procedures. Results. Exclusion criteria, patient demographics, and indication for surgery were similar in both groups. The conversion rate was 0% in both groups. There were no intraoperative complications or deaths. Bowel recovery was similar in both groups. No interventions, readmissions, or deaths were recorded at 30 days’ follow-up. At a mean follow-up of 24 months, all the patients with a preoperative diagnosis of cancer are still alive and disease free. Considering the selected 3 items, the mean cost per patient for single-access laparoscopic surgery and multiple-access laparoscopic surgery were estimated as 7213 and 7495 Euros, respectively. Conclusion. We think that SALR could be performed in selected patients by surgeons with high multiport laparoscopic skills. It is compulsory by law to evaluate outcomes and cost-effectiveness by using randomized controlled trials.

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

Single-Incision Robotic Colectomy (SIRC) case series: initial experience at a single center

BACKGROUND

Laparoscopic colectomy has been associated with favorable outcomes when compared to open colectomy. Single-Incision Robotic Colectomy (SIRC) is a novel procedure hypothesized to improve upon conventional three-port laparoscopic colectomy. We hereby present and analyze our institution's initial experience with SIRC.

METHODS

We performed a retrospective review of 59 patients who underwent SIRC between May 2010 and September 2013, attempting to identify factors associated with conversion rate and postoperative complication rate.

RESULTS

Our study included 34 males (57.6%) and 25 females (42.4%). The mean age was 60.3 years (range 29-92 years), and the mean BMI was 26.6 kg/m(2) (range 14.9-39.7 kg/m(2)). We identified 31 right hemicolectomies (53.4%), 20 sigmoid colectomies (34.5%), 5 left hemicolectomies (1.7%), 2 low anterior resections (3.5%), and 1 total colectomy (1.7%). The overall median operative time was 188 min with an interquartile range of 79 min. Surgical indications included diverticulitis (n = 23, 39.0%), benign colonic mass (n = 18, 30.5%), colon cancer (n = 16, 27.1%), familial adenomatous polyposis (n = 1, 1.7%), and Crohn's disease (n = 1, 1.7%). There were four conversions to open procedure (6.8%), three conversions to multiport robotic procedure (5.1%), and one conversion to single-port laparoscopic procedure (1.7%). Reasons for conversions include difficulty mobilizing the colon and robotic equipment malfunction. Conversions were associated with both higher complication rates (62.5 vs 25.5%, p = 0.035) and longer LOS (7.4 vs 4.0 days, p = 0.0003). Postoperative complications occurred in 16 of the 59 cases (27.1%). Higher BMI was the only significant risk factor for postoperative complications. The overall median LOS was 4 ± 2 days, while the median estimated blood loss was 100 ± 90 ml.

CONCLUSIONS

Our experience has shown that SIRC can be a safe and feasible procedure for both benign and malignant disease. Patient selection is the key to improving surgical outcomes in SIRC.

Single incision laparoscopic colectomy for colorectal cancer: comparison with conventional laparoscopic colectomy

Purpose

The aim of this retrospective study was to evaluate the feasibility of single incision laparoscopic surgery (SILS), and to compare the short-term surgical outcomes with those of conventional laparoscopic surgery for colorectal cancer.

Methods

Forty-four patients who underwent SILS were compared with 263 patients who underwent conventional laparoscopic surgery for colorectal adenocarcinoma between November 2011 and September 2012.

Results

In the SILS group, eleven cases (25.0%) of right hemicolectomy, 15 (34.1%) anterior resections, and 18 (40.9%) low anterior resections were performed. Additional ports were required in 10 rectal patients during SILS operation. In the 32 patients with rectosigmoid and rectal cancer in the SILS group, patients with mid and lower rectal cancers had a tendency to require a longer operation time (168.2 minutes vs. 223.8 minutes, P = 0.002), additional ports or multiport conversion (P = 0.007), than those with rectosigmoid and upper rectal cancer. Both SILS and conventional groups had similar perioperative outcomes. Operation time was longer in the SILS group than in the conventional laparoscopic surgery group (185.0 minutes vs. 139.2 minutes, P < 0.001). More diverting stoma were performed in the SILS group (64.7% vs. 24.2%, P = 0.011). Multivariate analysis showed that tumor location in the rectum (95% confidence interval [CI], 1.858-10.560; P = 0.001), SILS (95% CI, 3.450-20.233; P < 0.001), diverting stoma (95% CI, 1.606-9.288; P = 0.003), and transfusion (95% CI, 1.092-7.854; P = 0.033) were independent risk factors for long operation time (>180 minutes).

Conclusion

SILS is a feasible, not inferior treatment option for colorectal cancer, and appears to have similar results as standard conventional multiport laparoscopic colectomy, despite the longer operative time.

Evaluation of technical feasibility and safety of Single-Site™ robotic right colectomy: three case reports

BACKGROUND

Robotic Single-Site™ surgery overcomes the technical constraints of single-access laparoscopy. After performing over 130 Single-Site robotic cholecystectomies and stabilizing operative times, we applied this technology to right colon surgery.

METHODS

We successfully completed three Single-Site robotic right colectomies (SSRRCs) using the da Vinci Si Surgical System(®) with a Single-Site kit (© Intuitive Surgical™) inserted through a suprapubic incision.

RESULTS

Overall SSRRC operative time was 218.3 ± 75.9 min. A side-to-side anisoperistaltic anastomosis was fashioned intracorporeally (two cases) or extracorporeally (one case). All patients were discharged within 5 days. There were no complications and oncological principles were satisfied. There were no recurrences up to 12 months.

CONCLUSIONS

This is the first report of SSRRC with intracorporeal anastomosis using the da Vinci(®) Single-Site™ port inserted through a suprapubic incision. This approach is feasible and safe, with oncological outcomes potentially equivalent to those of robotic or laparoscopic multiport surgery.

Laparoscopic reduced port surgery for schwannoma of the sigmoid colon: a case report

A 74-year-old woman who developed schwannoma of the sigmoid colon was referred to our hospital for colonography to determine the cause of her stool occult blood. Colonoscopy revealed a submucosal tumor, which measured 3 cm in diameter, in the sigmoid colon. Endoscopic ultrasonography revealed a low echoic, homogeneous and demarcated submucosal tumor that continued into the fourth layer of the colonic wall. Gastrointestinal stromal, myogenic or neurogenic tumor was suspected, and thus, laparoscopic sigmoidectomy was carried out. We used two ports during the operation, a SILS Port in the umbilical region and a 12-mm port in the right lower abdominal wall, and performed sigmoidectomy with D2 lymph node dissection. Histological findings revealed spindle-like tumor cells with multiform nuclei. The tumor was diagnosed by immunostaining as benign schwannoma of the sigmoid colon. The conventional surgical treatment for schwannoma of the digestive tract is partial resection, but if preoperative diagnosis is unknown, radical resection with lymphadenectomy is acceptable for submucosal tumors in the digestive tract. In this case, laparoscopic reduced port surgery using only one or two ports may be more feasible and beneficial with regard to cosmesis and reduced postoperative pain than conventional laparoscopic colectomy.

The application of McBurney's single-incision laparoscopic colectomy alleviates the response of patients to postoperative wound pain

BACKGROUND

Single-incision laparoscopic colectomy (SILC) is one of several promising operation choices. Our previous study demonstrated that SILC with a self-made glove-port system both improves the feasibility of SILC and decreases the cost expense of surgery. Because the incision site for SILC could be made at either the umbilicus or McBurney's point, we are interested in whether the incision site affects the outcomes of patients, which is a less explored topic. The purpose of this study is not only to show the results of SILC with a self-made glove-port system for supporting its feasibility, but also to compare the short-term surgical outcomes between SILC with the incision made at the umbilicus and at McBurney's point.

SUBJECTS AND METHODS

We collected and reviewed the medical records of patients who received SILC with a self-made glove-port system for tumors in the left side of the colon from August 2009 to March 2011. All operations were performed by a single surgeon. Comparisons of the demographic characteristics, perioperative data, and clinical outcomes between umbilical and McBurney's SILCs were performed. Postoperative pain was assessed by a visual analog scale and opiate demand.

RESULTS

In total, 61 patients were enrolled in this retrospective study. Five of 48 (10.4%) tumors in the umbilical SILC group and 5 of 13 (38.5%) tumors in the McBurney's SILC group were located below the peritoneal reflection. The tumor location was significantly different between these two groups (P=.015). Patients in the umbilical SILC group had significantly higher frequency of opiate demand than those in the McBurney's SILC group (0.4±0.7 versus 1.4±1.8, respectively; P=.002).

CONCLUSIONS

This study further provides evidence for supporting the safety and feasibility of SILC in treating colorectal diseases. More important is that McBurney's SILC not only alleviates the patient response to wound pain, but also provides the same site for a diverting enterostomy to avoid creating an additional wound.

Evaluation of invasiveness in single-site laparoscopic colectomy, using "the PainVision™ system" for quantitative analysis of pain sensation

BACKGROUND

Single-site laparoscopic colectomy (SLC) is increasingly performed for colon cancer. There are few reports on invasiveness in SLC. This study aimed to evaluate the postoperative pain from SLC, as compared to conventional multiport laparoscopic colectomy (MLC).

METHODS

We compared postoperative pain among patients from the SLC group (n = 11) with those from the MLC group (n = 11) who underwent laparoscopic surgery for colon cancer at our institution between May and October 2013. Patients were specifically matched for gender, age, body mass index, tumor size, and performance status. Postoperative pain was evaluated at rest and during mobilization, using a visual analog scale (VAS) on postoperative days (PODs) 1-7, and by postoperative frequency of analgesics; pain intensity was evaluated at rest, using the Pain Vision™ system on PODs 1-7. Other operative outcomes of the two groups were also recorded.

RESULTS

Patient demographics, operative outcomes, time duration before first flatus, and C-reactive protein and WBC count on POD 1 showed no significant differences between groups. Results of sequential VAS during mobilization until POD 7 were significantly less in the SLC group than in the MLC group (p = 0.009). However, sequential VAS at rest did not differ between the two groups (p = 0.11). Measured with the Pain Vision™ system, the difference in pain intensity at rest was statistically significant for the postoperative period (p = 0.003). Total requests for analgesics until POD 7 were reduced in the SLC group compared to that in the MLC group, but lacked statistical significance (three vs. seven, respectively, p = 0.07).

CONCLUSIONS

In both quantitative and objective measurements using the Pain Vision™ system, SLC significantly reduced postoperative pain. SLC is a promising procedure, associated with less invasiveness than MLC.

What should we intend for minimally invasive treatment of colorectal cancer?

Non-inferiority of laparoscopic treatment of colorectal cancer (CRC) has been demonstrated in randomized controlled trials although operative and perioperative management varies widely among centers. Literature data in English language published up to April 15, 2014 were analyzed in order to give an up to date analysis that would highlights the key aspects of a modern and factual minimally invasive treatment of CRC. Laparoscopic resection is the first choice treatment of colon cancer. Laparoscopic resection of rectal cancer should be considered an investigational procedure to be performed in high volume centers with special interest in laparoscopy and colorectal surgery. Less invasive approaches should be taken into account with the aim of reducing surgical stress. The adoption of ERAS programs has demonstrated to optimize short-term results. Future research should be directed to prove possible long-term advantages, in terms of overall and disease-free survival, of minimally invasive treatment of CRC.

Feasibility and Safety of Laparoscopic Colon Surgery Performed Under Intravenous Sedation and Local Anesthesia Using Microinvasive (<3 mm) Instruments: An Acute and Survival Study on Porcine Model

PURPOSE

The purpose of the study was to evaluate the feasibility and safety of performing laparoscopic intestinal surgery using local anesthesia and intravenous sedation with instruments <3 mm in diameter.

METHODS

Porcine model with acute (n = 2) and the survival studies (n = 8): all female pigs, weight (median 36.4 kg, range 33.2-38.4 kg). Surgeries were performed using only intravenous sedation with ketamine-midazolam and local anesthetic infiltration at the sites of trocar insertion, with airway protection. CO2 pneumoperitoneum was maintained using pressure of 3 to 5 mm Hg. Commercially available instruments, sizes <3 mm in diameter were used. Surgical steps were as follows: (a) exploration of all quadrants of the abdomen and pelvis, (b) "running" the entire length of small bowel, (c) dissection of bowel attachments to the peritoneal sidewall, and (d) creating a 2.5 cm enterotomy in the colon and suture repair of this defect.

RESULTS

All 10 surgeries were completed successfully. Animals tolerated the procedure well, with no requirement of intubation. There were no decrements in vital signs during pneumoperitoneum or surgery. Despite spontaneous respiration movements, all planned surgical maneuvers were feasible. The median length of operations was 74 minutes (range 56-165 minutes). All survival animals had an uneventful recovery; there were no infectious complications, oral intake and bowel function returned within 24 hours.

CONCLUSIONS

It appears feasible and safe to perform simple laparoscopic intestinal procedures using instruments <3 mm in diameter and low CO2 insufflation pressure under local anesthesia and intravenous sedation. This methodology holds promise in the development of new approaches to intestinal surgery and disease diagnosis.

Single-incision laparoscopic cecectomy for low-grade appendiceal mucinous neoplasm after laparoscopic rectectomy

In this case report, we discuss single-incision laparoscopic cecectomy for low-grade appendiceal neoplasm after laparoscopic anterior resection for rectal cancer. The optimal surgical therapy for low-grade appendiceal neoplasm is controversial; currently, the options include appendectomy, cecectomy, right hemicolectomy, and open or laparoscopic surgery. Due to the risk of pseudomyxoma peritonei, complete resection without rupture is necessary. We have encountered 5 cases of low-grade appendiceal neoplasm and all 5 patients had no lymph node metastasis. We chose the appendectomy or cecectomy without lymph node dissection if preoperative imaging studies did not suspect malignancy. In the present case, we performed cecectomy without lymph node dissection by single-incision laparoscopic surgery (SILS), which is reported to be a reduced port surgery associated with decreased invasiveness and patient stress compared with conventional laparoscopic surgery. We are confident that SILS is a feasible alternative to traditional surgical procedures for borderline tumors, such as low-grade appendiceal neoplasms.

Successful total shift from multiport to single-port laparoscopic surgery in low anterior resection of colorectal cancer

OBJECTIVE

To assess the possibility of using single-port low anterior resection (LAR) in place of conventional laparoscopic LAR.

BACKGROUND

Though single-port LS is gradually evolving, the application of single-port LS techniques in LAR have been viewed with skepticism due to technical difficulties.

METHODS

Data from patients who had undergone either conventional laparoscopic LAR (n = 49) or single-port LAR (n = 67) for colorectal cancers between March 2006 and March 2013 were analyzed retrospectively.

RESULTS

In single-port LAR group, oncologic outcomes were satisfactory with respect to attainment of lymph nodes (23.4 ± 15.3) and surgical margins (proximal cut margin: 7.1 ± 4.6 cm, distal cut margin: 7.7 ± 5.7 cm). Single-port LAR showed acceptable clinical outcomes manifested by comparable outcomes of post-operative analgesics requirement and length of hospital stay, and by low incidence of post-operative complications (conventional laparoscopic LAR group: 30.6% vs. single-port LAR group: 14.9%; P < 0.01). Operative time was comparable between groups (conventional laparoscopic LAR group: 309 ± 93 min vs. single-port LAR group: 277 ± 106 min; P = 0.097). Throughout a series of 67 consecutive single-port LARs, no conversion to multiport or open surgery was occurred.

CONCLUSION

This study shows that single-port LAR is both safe and feasible for use in resection of colorectal cancer when performed by surgeons who are trained in conventional laparoscopic technique. If further and more extensive studies support our results, then single-port LAR can be an acceptable alternative to conventional laparoscopic LAR for treatment of colorectal cancer.

Single-site laparoscopic colorectal surgery provides similar lengths of hospital stay and similar costs compared with standard laparoscopy: results of a retrospective cohort study

BACKGROUND

The present study sought to compare the length of stay (LOS) and hospital costs for elective single-site (SSL) and standard laparoscopic (SDL) colorectal resections performed at a tertiary referral center.

METHODS

An IRB-approved, retrospective cohort study of all elective SDL and SSL colorectal resections performed from 2008 to 2012 was undertaken. Patient charges and inflation adjusted hospital costs (US dollars) were compared with costs subcategorized by operating room expense, room and board, and pharmacy and radiology utilization.

RESULTS

A total of 149 SDL and 111 SSL cases were identified. Compared with SSL, SDL surgeries were associated with longer median operative times (SSL: 153 min vs. SDL: 189 min, p = 0.001); however, median operating room costs were similar (p > 0.05). Median postoperative LOS was similar for both groups (SSL: 3 days; SDL: 4 days; p > 0.05). There was no difference between SSL and SDL with respect to either total patient charges (SSL: $34,847 vs. SDL: $38,306; p > 0.05) or hospital costs (SSL: $13,051 vs. SDL: $12,703; p > 0.05). Median costs during readmission were lower for SSL patients (SSL: $3,625 vs. SDL: $6,203, p = 0.04).

CONCLUSIONS

SSL provides similar LOS as well as similar costs to both patients and hospitals compared with SDL, making it a cost-feasible alternative.

Wound complications in 1145 consecutive transumbilical single-incision laparoscopic procedures

OBJECTIVE

To evaluate the wound complication rate in patients undergoing transumbilical single-incision laparoscopic (SIL) surgery.

BACKGROUND

SIL surgery claims to be less invasive than conventional laparoscopy. Small SIL series have raised concerns toward a higher wound complication rate related to the transumbilical incision.

METHODS

In a 44-month period, 1145 consecutive SIL procedures were included. The outcomes were assessed according to the intention-to-treat analysis principle. All procedures were followed for a minimum of 6 months postoperatively, and wound complications were recorded as bleeding, infection (superficial/deep), or hernia. Patients were classified as having a wound complication or not. For all comparisons, significance level was set at P<0.05.

RESULTS

Pure transumbilical SIL surgery was completed in 92.84%, and additional trocars were used in 7.16%. After a median follow-up of 22.1 (range, 7.67-41.11) months, 29 wound complications (2.53%) had occurred [bleeding 0%/infection 1.05% (superficial 0.9%/deep 0.17%)/early-onset hernia 0.09%/late-onset hernia 1.40%, respectively]. Factors associated with complications were higher patient body mass index (28.16±4.73 vs 26.40±4.68 kg/m; P=0.029), longer skin incisions (3.77±1.62 vs 2.96±1.06 cm; P=0.012), and multiport SIL versus single-port SIL (8.47% vs 2.38%; P=0.019) in complicated versus uncomplicated procedures. Furthermore, a learning curve effect was noted after 500 procedures (P=0.015).

CONCLUSIONS

With transumbilical SIL surgery, the incidence of wound complications is acceptable low and is further reduced once the learning curve has been passed.

Laparoscopy for colorectal cancer

The laparoscopic approach for colorectal cancer resection has been evolved from an experimental procedure with oncological concerns to routine daily practice within a period of two decades. Numerous randomized controlled trials and meta-analyses have shown that laparoscopic resection results in faster recovery with similar oncological outcome compared to an open approach, both for colon and rectal cancer. Besides improved cosmesis, other long-term advantages seem to be less adhesion related small bowel obstruction and reduced incisional hernia rate. Adequate patient selection and surgical experience are of crucial importance. Experience can be gradually expanded step by step, by increasing the complexity of the procedure. A decision to convert should be made early in the procedure, because the outcome after a reactive conversion is worse than initial open resection or strategic conversion. The additive value of new techniques such as robotic surgery has to be proven in randomized studies including a cost-effectiveness assessment.

Feasibility of single-site laparoscopic colectomy with complete mesocolic excision for colon cancer: a prospective case-control comparison

Background

Single-site laparoscopic colectomy (SLC) is an emerging concept that, compared with conventional multiport laparoscopic colectomy (MLC), yields reduced postoperative pain and improved cosmesis. Complete mesocolic excision (CME) is a novel concept for colon cancer surgery that provides improved oncologic outcomes; however, there are no reports of SLC with CME. We conducted a prospective case–control study to evaluate the feasibility and safety of SLC with CME for colon cancer.

Methods

Prospectively collected data of patients with stage I-III colon cancer who underwent SLC (n = 150) or MLC (n = 150) between June 2008 and March 2012 were analyzed. Patients who underwent SLC were, in terms of clinical characteristics and tumor location, matched as closely as possible with those undergoing MLC. Within each group, patients were classified as having right-sided (n = 69 in each group) or left-sided (n = 81 in each group) colon cancer, and short-term outcomes were compared between the two procedures overall and per side.

Results

Overall perioperative outcomes, including operation time, blood loss, number of lymph nodes harvested, length of the resected specimen, and complications, were similar between the two procedures, whereas postoperative pain was significantly lower with SLC. Operation time for right-sided SLC was significantly shortened. SLC with CME was completed successfully in 94 % (65/69) of right-sided cases and in 88 % (71/81) of left-sided cases. Conversion rates were 1.4 % (1/69) and 1.1 % (1/81), respectively. The umbilical scars were nearly invisible 3 months after the procedure, and most patients reported being quite satisfied with the cosmetic outcomes.

Conclusions

SLC with CME for colon cancer is feasible when performed by experienced surgeons in selected patients. Excellent cosmesis and reduced postoperative pain as well as oncologic clearance can be expected. A large-scale, prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over MLC with CME.

Single-incision laparoscopic hernioplasty versus multi-incision laparoscopic hernioplasty: a meta-analysis

BACKGROUND

Laparoscopic hernioplasty is the gold standard treatment for inguinal hernias. Recently, single-incision laparoscopic hernioplasty (SILH) has been suggested as an alternative technique. It is not evident whether the benefits of this procedure overcome the potential increased risk.

OBJECTIVE

The aim of this study was to compare the outcomes of SILH with conventional multi-incision laparoscopic hernioplasty (MILH) using a meta-analysis of available controlled clinical trials.

METHODS

Eligible articles were identified by searching several databases including Embase, Cochrane, PubMed and Google Scholar databases, up until May 2013. Evaluated outcomes were operative time, post-operative hospital stay, complications, conversion and recurrence.

RESULTS

Eight controlled clinical trials on 926 patients were randomized to either SILH (495 patients) or MILH (431 patients) for meta-analysis. Overall, there was no significant difference between SILH and MILH in complications, operative time for bilateral inguinal hernia repair, hospital stay, short-term recurrence or conversions. However, the operative time for unilateral inguinal hernia repair was significantly longer for SILH than for MILH (standardized mean difference 0.23 (95% confidence interval: 0.09-0.38); P = 0.00, I(2) = 73.6%).

CONCLUSIONS

Our meta-analysis showed that SILH is feasible and safe in certain patients when compared to MILH, and carries a similar outcome, with the exception of longer operative times for unilateral inguinal hernia repair. Additional high-powered randomized trials are needed to determine whether SILH truly offers any advantages; these future studies should focus particularly on failure of technique, pain score, analgesia requirements, cosmesis and quality of life.

Initial experience of single-port surgery assisted by percutaneous instruments for gastric bypass: a combination of safety and minimally invasive surgery

BACKGROUND

We present here the first reported cases of patients undergoing gastric bypass with a hybrid technique that involves a new concept of percutaneous instruments and provides the advantages of minimally invasive single-port surgery while maintaining the triangulation, safety, and timing of operative procedures.

METHODS

This was a prospective pilot study of eight patients selected for gastric bypass between December 2011 and January 2012 and treated by a technique that combined single SSL port and percutaneous surgical set PPS. We performed hand-sewn gastrojejunostomy in all cases. We analyzed preliminary results at 1 month and focused on the feasibility of the technique, duration of surgery, perioperative complications, and cosmetic results. The Ethics Committee of our institution approved this study and we obtained the informed consent of each patient.

RESULTS

We completed the procedure successfully in all patients. No conversions to laparotomy or classic laparoscopy were required. The average time of surgery was 112 min (85-155). Length of hospital stay was 4 days (3-5). One patient was re-admitted on the seventh postoperative day for gastrointestinal bleeding from the gastrojejunostomy suture and treated by endoscopic clipping. Residual scars were less than 2 cm for the single midline port and 2 mm for the percutaneous instruments.

CONCLUSIONS

This new technique combines the advantages of single-port surgery with the safety of conventional laparoscopy by using percutaneous instruments and leaves minimal scarring. It is likely that the use of percutaneous instrumentation will become widespread in all areas of laparoscopic surgery.

Totally laparoscopic anterior resection with transvaginal assistance and transvaginal specimen extraction: a technique for natural orifice surgery combined with reduced-port surgery

Background

Natural orifice specimen extraction (NOSE) has been developed as a means of decreasing the incidence of surgical wound complications. However, NOSE performed using a conventional multiport technique has been reported previously. The current authors performed totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) using the reduced-port surgery (RPS) technique. The Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) and Free Access (Top Corporation, Tokyo, Japan) were attached to the transvaginal route for transvaginal assistance and smooth specimen extraction. The authors documented this simple and safe technique and its short-term results.

Methods

Data were prospectively collected for five patients who underwent totally laparoscopic anterior resection with TVSE for colorectal cancer between June 2012 and December 2012. A multiport access device (GelPOINT advanced-access platform; Applied Medical) was inserted into the navel, and a 5-mm port was inserted into the right lower quadrant to be used as a drain site. Transverse transvaginal posterior colpotomy then was performed. One ring of an Alexis ring pair was inserted into the peritoneal cavity through the vagina. The other white ring was placed outside of the vagina and then covered with a Free Access to maintain the pneumoperitoneum for insertion of a 12-mm port. Lymph node dissection and transection of the distal colon were performed with transvaginal assistance. The specimen then was extracted transvaginally. After the Alexis had been removed, the vaginal incision was closed transvaginally. End-to-end colorectal anastomosis was performed using the double-stapling technique.

Results

Transvaginal extraction was completed in all five cases. The median operation time was 235 min. One case was complicated by chyloperitoneum. The median hospital stay was 6 days. Only one patient required intravenous analgesics once on postoperative day 1. All the patients remained disease free.

Conclusion

Totally laparoscopic anterior resection using TVSE with RPS appears to be feasible, safe, and oncologically acceptable for selected cases.

Single-site robotic cholecystectomy: efficiency and cost analysis

BACKGROUND

Single-incision surgery has gained in popularity, and the recent development of specialized robotic and laparoscopic instruments may remove some of the ergonomic and technical difficulties associated with this approach. However, questions of cost and efficiency remain.

METHODS

We prospectively collected perioperative outcome and efficiency (operative time, case volume) data for our single-site robotic cholecystectomy cases and retrospectively reviewed data for our single-incision laparoscopic cholecystectomy cases.

RESULTS

There were no differences in patient characteristics or perioperative outcomes between the robotic (n = 20) and laparoscopic (n = 10) groups; operative times were equivalent (84.6 vs 85.5 min; p = 0.8737) and blood loss and complications were minimal. There was a higher robotic case volume, with an average of two robotic cases (range 1-4)/day vs one/day for laparoscopic cases (range 1-1; p = 0.0306). Streamlined instrument costs were essentially equivalent.

CONCLUSIONS

Robotic single-site cholecystectomy is a safe, cost-effective alternative to single-incision laparoscopic cholecystectomy in a robot-existing model.

Single-incision laparoscopic versus traditional multiport laparoscopic colorectal surgery--a cumulative meta-analysis and systematic review

PURPOSE

The published data on the evaluation of feasibility and safety of single-incision laparoscopic colorectal surgery (SILC) compared with traditional multiport laparoscopic colorectal surgery (MLC) remained controversial. The present cumulative meta-analysis and systematic review were performed to provide a more objective and precise estimate.

MATERIALS AND METHODS

PubMed, the Cochrane Library, and also, manual searches were employed to identify potentially eligible studies which were published before June 7, 2012. The association was assessed by odds ratio (OR) and means with 95 % confidence intervals (CI).

RESULTS

A total of 20 comparative studies were included, with 670 patients underwent SILC and 838 patients underwent MLC. For overall pooled estimates, no evidence of between trial differences was found in overall conversion rate (OR, 1.7; 95 % CI, 0.97 to 3.01), overall complication rate (OR, 0.82; 95 % CI, 0.63 to 1.08), and operative time (mean, -3.59; 95 % CI, -10.95 to 3.77); significantly between trial differences were found in estimated blood loss (mean, -18.61; 95 % CI, -31.33 to -5.90) and post-operative hospital stay (mean, -0.54; 95 % CI, -0.95 to -0.12). The cumulative meta-analysis identified a potentially increased conversion rate of SILC compared with MLC with the increased percentage of malignancies, but no significant differences could be identified in overall complication rate.

CONCLUSION

This meta-analysis suggested the feasibility and safety of SILC performed by experienced hands, though potentially higher overall conversion rate occurred in malignancies. SILC will benefit the patients much more with its superiority over MLC.

Single-incision laparoscopic colectomy: training the next generation

BACKGROUND

Single-incision laparoscopic colectomy (SILC) is touted to be an improved approach for minimally invasive surgery although no data currently exists regarding the acquisition of skills for the safe performance of this technique. The authors report their early experience with proctoring of surgical residents in SILC by experienced colorectal surgeons.

METHODS

Data regarding patient demographics, operative data, and short-term outcomes were prospectively collected at two surgical training hospitals. Residents and staff independently rated individual components of this technique to compare them with learning standard multiport colectomy (MP).

RESULTS

A total of 31 SILC cases (15 men; mean age 53 years) were managed. The average BMI was 26.5 kg/m(2) (range 16-39 kg/m(2)). The surgical indications included cancer (n = 13), polyps (n = 8), diverticular disease (n = 4), Crohn's disease (n = 2), familial adenomatous polyposis (n = 2), volvulus (n = 1), and rectal prolapse (n = 1). The average operative time was 164 ± 86 min, and the mean blood loss was 80 ± 83 mL. The mean incision length was 4.1 ± 1.1 cm. One case required additional trocar placement (stoma creation), and three cases required conversion to open procedure because of failure to progress, difficult colorectal anastomosis, or poor visualization. The median hospital stay was 5.7 ± 1.3 days. The 30-day morbidity included minor wound infections (9.7 %), ileus (6.5 %), blood transfusion (3.2 %), and intraabdominal abscess (3.2 %). No deaths occurred. Residents rated vascular pedicle isolation, mobilization, critical structure exposure, instrument conflict/handling, and ergonomics as significantly more difficult with SILC.

CONCLUSIONS

Senior-level residents can safely perform SILC under appropriate experienced supervision. The required advanced skills reflect complex laparoscopic training occurring during residency. Opportunities exist for better preparation and training of surgical residents to perform this complex surgery independently and safely at completion of residency.

Recent advances in laparoscopic surgery

Laparoscopic surgery has been widely adopted and new technical innovation, procedures and evidence based knowledge are persistently emerging. This review documents recent major advancements in laparoscopic surgery. A PubMed search was made in order to identify recent advances in this field. We reviewed the recent data on randomized trials in this field as well as papers of systematic review. Laparoscopic cholecystectomy is the most frequently performed procedure, followed by laparoscopic bariatric surgery. Although bile duct injuries are relatively uncommon (0.15%-0.6%), intraoperative cholangiography still plays a role in reducing the cost of litigation. Laparoscopic bariatric surgery is the most commonly performed laparoscopic gastrointestinal surgery in the USA, and laparoscopic Nissen fundoplication is the treatment of choice for intractable gastroesophageal reflux disease. Recent randomized trials have demonstrated that laparoscopic gastric and colorectal cancer resection are safe and oncologically correct procedures. Laparoscopic surgery has also been widely developed in hepatic, pancreatic, gynecological and urological surgery. Recently, SILS and robotic surgery have penetrated all specialties of abdominal surgery. However, evidence-based medicine has failed to show major advantages in SILS, and the disadvantage of robotic surgery is the high costs related to purchase and maintenance of technology. Laparoscopic surgery has become well developed in recent decades and is the choice of treatment in abdominal surgery. Recently developed SILS techniques and robotic surgery are promising but their benefits remain to be determined.

Comparison of short-term surgical outcomes after single-incision laparoscopic versus multiport laparoscopic right colectomy: a two-center, prospective case-controlled study of 100 patients

BACKGROUND

Recent case studies have demonstrated the feasibility of single-incision laparoscopic colectomy (SILC). Few comparative studies for SILC and multiport laparoscopic colectomy (MLC) have been conducted. The aim of this case-controlled study was to compare the short-term surgical outcomes between SILC and MLC for right-sided colectomies.

METHODS

Between January 2010 and February 2012, data from the first 50 consecutive patients that underwent right SILS at one of the two institutions were compared with a group of 50 consecutive patients that underwent right MLC in the same period.

RESULTS

Median operative time was significantly shorter in SILC (97 vs. 112 min; p < 0.001). Between both groups, no statistically significant differences were found regarding number and nature of short-term complications, number of reoperations [4 (8%) vs. 6 (12%)], and mortality rate [1 (2%) vs. 2 (4%)]. Median postoperative hospital stay was 6 days for both groups.

CONCLUSION

SILC is a safe and feasible procedure when performed by experienced laparoscopic surgeons. Length of hospital stay and overall complication rates are comparable with MLC. Until today, no clear advantages of SILC over MLC have been demonstrated. However, due to its smaller incisional trauma, SILC could be a major step in improving cosmetic outcomes.

Suprapubic single-incision laparoscopic right hemicolectomy with intracorporeal anastomosis

BACKGROUND

Single-incision laparoscopy (SIL) has gained significance recently. The umbilicus has been the preferred access site for SIL. Suprapubic access site (SAS) can be an alternative, especially for a right hemicolectomy (RH).

METHODS

Between November 2011 and July 2012, 7 consecutive patients underwent suprapubic SIL RH (SSILRH). The median age was 53 years, and the median body mass index was 23.9 kg/m2. Indications for surgery included appendicular tumor (1) and adenocarcinoma of the right colon (6). Three reusable trocars were used, and the resection was performed through the SAS. An intracorporeal linear stapled anastomosis was performed, the mesenteric defect was closed, and the access site was used for specimen extraction.

RESULTS

No patient required additional trocars or conversion to an open surgery. The median laparoscopic time was 222 minutes, and the median final incision length was 50 mm. The median Visual Analogue Scale score (0-10) at 6, 18, 30, 42, 54, 66, and 78 postoperative hours was 6, 6, 2, 2, 2, 2, and 2, respectively. The median hospital stay was 4 days.

CONCLUSIONS

SSILRH is useful because the SAS can be enlarged for extraction of the specimen without compromising the cosmetic outcome. The mesocolic and mesenteric dissections are on the same axis as the access site. The intracorporeal anastomosis can be performed without traction. Finally, positioning of the operative table improves exposure of the operative field and allows the surgeon to maneuver the colon and small bowel intracorporeally.

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

OBJECTIVE

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

METHODS

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

RESULTS

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD) = -0.68; 95 % CI = -1.20 to -0.16; p = 0.0099), shorter incision length (pooled WMD = -1.37; 95 % CI = -2.74 to 0.000199; p = 0.05), less estimated blood loss (pooled WMD = -20.25; 95 % CI = -39.25 to -1.24; p = 0.037), and more lymph nodes harvested (pooled WMD = 1.75; 95 % CI = 0.12 to 3.38; p = 0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio = 0.83; 95 % CI = 0.57 to 1.20; p = 0.33) or operative time (pooled WMD = 5.06; 95 % CI = -2.91 to 13.03; p = 0.21).

CONCLUSION

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.

New developments in colorectal surgery

PURPOSE OF REVIEW

The field of colorectal surgery continues to move forward as technical innovations emerge and as surgeons ask critical questions. The results of subsequent investigations often lead to changes in practice. This review examines recent publications that describe these practice changes.

RECENT FINDINGS

We identified and reviewed recent publications in the areas of rectal cancer controversies, genetic risk profiling, practice improvements, diverticulitis, enhanced recovery protocols, fecal incontinence, and single incision laparoscopic surgery.

SUMMARY

New technologies and practice innovations will continue to enhance patient outcomes. Multiinstitutional studies, randomized when able, are necessary to further define the safety and efficacy of new surgical techniques and to further define best practices in colorectal surgery.

A historical comparison of single incision and conventional multiport laparoscopic right hemicolectomy

AIM

Single incision laparoscopic surgery (SILS) is specially suited for surgery of the right colon. This study presents the results of a historical controlled trial comparing single incision and multiport laparoscopic surgery (MLS) for right hemicolectomy.

METHOD

A review of outcome data from 149 patients who underwent laparoscopic right hemicolectomy was performed from the Concord Hospital laparoscopic colorectal database.

RESULTS

Between July 2006 and December 2011, 149 consecutive laparoscopic right hemicolectomies were performed. The first 74 were performed by MLS and from February 2009 all cases were performed by SILS (n = 75).The median ages in the MLS and SILS groups were 74 and 68 years. The median body mass index was 27 kg/m(2) in both groups. Patients were hospitalized for a median of 8 days in the MLS group compared with 5 days in the SILS group. The median length of the extraction wound was 50 mm in the MLS group compared with 43 mm in the SILS group. The indications for surgery were similar in both groups, being 67% and 68%. One patient in each group required conversion to open laparotomy, and no patient in the SILS group required conversion to a conventional multiport technique. Postoperative morbidity was similar in both groups.

CONCLUSION

SILS offers a safe minimally invasive approach to right colon resection. In our series SILS patients had a shorter extraction wound size and shorter length of stay in hospital.

Ergonomics in laparoendoscopic single-site surgery: survey results

BACKGROUND

Ergonomic issues are frequently reported by surgeons performing laparoendoscopic single-site (LESS) surgery. However, few studies have analysed this issue.

METHODS

We used a web format survey to evaluate the opinion of surgeons with experience in this laparoscopic technique. This survey collected demographic information, surgical experience, physical and psychological symptoms, and technical problems related to this type of surgery.

RESULTS

Some 78 surgeons filled out the questionnaire. All participants had clinical experience in this type of laparoscopic approach, and 68 % had performed more than 30 procedures. Two or more musculoskeletal symptoms were reported during or after performing LESS surgery by 81 % of all surgeons. Surgeons with more experience in this approach reported fewer symptoms and technical difficulties.

CONCLUSIONS

LESS surgery is accompanied by musculoskeletal problems and technical difficulties for surgeons. Technological advancements and greater surgical experience in the technique will alleviate these issues. More in-depth ergonomic studies are needed.

Transanal endoscopic total mesorectal excision combined with single-port laparoscopy

BACKGROUND

Rectal dissection using a conventional multiport laparoscopic approach involves risks due to technical difficulties, particularly in patients with a low tumor, a narrow pelvis, or obesity.

OBJECTIVE

We describe a technique of transanal endoscopic low and middle rectal dissection with subsequent coloanal anastomosis via single-port laparoscopy, with the aim of reducing technical problems, increasing safety, and improving cosmesis after resection of rectal cancer.

DESIGN AND SETTING

This was an observational study conducted in a large, tertiary care cancer center in France.

PATIENTS

Consecutive patients with rectal adenocarcinoma requiring total mesorectal excision with a coloanal anastomosis were evaluated for eligibility to undergo the procedure. Patients were selected if they had 1 or more of the following risk factors: narrow pelvis, a voluminous prostate, or obesity.

INTERVENTION

After an anal mucosectomy, the rectal wall was circumferentially transected above the external sphincter and a transanal trocar was introduced. The dissection of the mesorectum was completely performed via endoscopy up to the Douglas rectovesical pouch. A single port was inserted at the future site of the transient ileostomy, and a left colectomy and a lymphadenectomy were performed. The upper rectum dissection enabled joining the transanal rectal plane of dissection. Then the splenic flexure was completely mobilized and the specimen was extracted through the site of the future ileostomy.

OUTCOME MEASURES

Operative time, blood loss, duration of hospital stay, and histopathologic variables (margins, number of harvested lymph nodes, grade of the mesorectal fascia dissection) were recorded, and the quality of the surgical plane was assessed. The Cleveland Clinic Florida (Wexner) fecal incontinence questionnaire was administered after ileostomy closure.

RESULTS

Four consecutive male patients with rectal cancer in a narrow pelvis were treated with this new approach. No conversion (by laparotomy or multiport laparoscopy) was necessary. The pathologic variables were satisfactory and the Wexner scores indicated no severe incontinence after ileostomy closure. The postoperative follow-up was uneventful except for an anastomotic fistula which developed in 1 patient and was treated without reoperation.

LIMITATIONS

The study was limited by the small number of patients and the fact that no women and no obese patients were included.

CONCLUSIONS

Rectal resection via the transanal approach combined with single-port laparoscopic assistance may be easier and safer than the traditional approach, especially in male patients who have a narrow pelvis. More data are needed in order to draw conclusions concerning oncologic results and before selecting the most appropriate indications for this technique.

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

OBJECTIVE

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

METHODS

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

RESULTS

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD) = -0.68; 95 % CI = -1.20 to -0.16; p = 0.0099), shorter incision length (pooled WMD = -1.37; 95 % CI = -2.74 to 0.000199; p = 0.05), less estimated blood loss (pooled WMD = -20.25; 95 % CI = -39.25 to -1.24; p = 0.037), and more lymph nodes harvested (pooled WMD = 1.75; 95 % CI = 0.12 to 3.38; p = 0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio = 0.83; 95 % CI = 0.57 to 1.20; p = 0.33) or operative time (pooled WMD = 5.06; 95 % CI = -2.91 to 13.03; p = 0.21).

CONCLUSION

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.

Single-incision laparoscopic surgeries for colorectal diseases: early experiences of a novel surgical method

Objectives. This paper aims to analyze the feasibility and safety of single-incision laparoscopic colectomy (SILC) and its potential benefits. Methods. Systematic review was performed for the years 1983-August 2011 to retrieve all relevant literature. A total of 21 studies with 477 patients undergoing SILC were selected. Results. Range of operative times and estimated blood losses were 75-229 min and 0-100 mL, respectively. Overall conversion rate was 5.9% (28/477) and an additional laparoscopic port was used in 4.9% (16/329) cases. Range of lymph node number for malignant cases was 12-24.6 and surgical margins were all negative. Overall mortality and morbidity rate was 0.4% (2/477) and 11.7% (43/368), respectively. The length of hospital stay (LOS) varied across reports (2.7-9.2 days). Among 6 case-matched studies, one showed less blood loss in SILC as compared to LAC and 2 showed shorter LOS after SILC versus HALC or LAC/HALC groups. In addition, one study reported maximum pain score on postoperative days 1 and 2 was lower in SILS compared to LAC and HALC. Conclusions. SILC procedure is feasible and safe when performed by surgeons highly skilled in laparoscopy. In spite of technical difficulties, there may be potential benefits associated with SILC over LAC/HALC.

Single-port laparoscopic surgery for inflammatory bowel disease

Background. Single Port Laparoscopic Surgery (SPLS) is being increasingly employed in colorectal surgery for benign and malignant diseases. The particular role for SPLS in inflammatory bowel disease (IBD) has not been determined yet. In this review article we summarize technical aspects and short term results of SPLS resections in patients with Crohn's disease or ulcerative colitis. Methods. A systematic review of the literature until January 2012 was performed. Publications were assessed for operative techniques, equipment, surgical results, hospital stay, and readmissions. Results. 34 articles, published between 2010 and 2012, were identified reporting on 301 patients with IBD that underwent surgical treatment in SPLS technique. Surgical procedures included ileocolic resections, sigmoid resections, colectomies with end ileostomy or ileorectal anastomosis, and restorative proctocolectomies with ileum-pouch reconstruction. There was a wide variety in the surgical technique and the employed equipment. The overall complication profile was similar to reports on standard laparoscopic surgery in IBD. Conclusions. In experienced hands, single port laparoscopic surgery appears to be feasible and safe for the surgical treatment of selected patients with IBD. However, evidence from prospective randomized trials is required in order to clarify whether there is a further benefit apart from the avoidance of additional trocar incisions.

[Single incision laparoscopic surgery: analysis of the national register]

INTRODUCTION

Laparoscopic surgery through a single incision is an innovative concept which is a challenge for surgeons to implement and develop. The interest aroused by these techniques in Spain led to the Endoscopy Section of the Spanish Association of Surgeons (AEC) to start a National Register for Single-Incision Surgery (RNCIU). The aim of this study was to collect the primary clinical data, techniques, and the possible complications of these techniques in Spain.

MATERIAL AND METHODS

Data were gathered using a form available on the AEC website. The forms included in this study correspond to those received between June 2010 and June 2011.

RESULTS

A total of 35 centers had taken part during the study period, with 1,198 forms being collected. The surgeries performed included 62.2% cholecystectomies, 22% appendectomies, and 7.8% colectomies. Procedures on solid organs (3.4%), bariatric surgery (2.7%), and various hernia repairs (1.9%), were also registered. The overall incidence of complications was 0.8%. The mortality rate in the series was 0.1%.

CONCLUSIONS

Single incision laparoscopic surgery is a novel concept that is not beyond our scientific community. The results of the Register demonstrate the feasibility of numerous effective and safe procedures. Finally, the RNCIU is an important data source to be able to study sub-groups of diseases in detail, with the aim of advancing the knowledge of these techniques and generating scientific evidence.