Single-access laparoscopic left and right hemicolectomy combined with extracorporeal magnetic retraction

Validation of safety for self-retracting intraperitoneal device for small bowel in minimally invasive surgery

BACKGROUND

Modernly, abdominal surgery has shifted to minimally invasive techniques with an inclination towards fewer incisions. This has made intra-abdominal retraction more challenging. Despite development in retracting instrumentation for solid organs, the mobilization of the bowel remains challenging due to its friable nature. Therefore, there is a need to investigate the safety profile of internal retractors such as the EndoGrab for small-bowel retraction.

METHODS

Twenty locations of small bowel were selected for EndoGrab retraction in two pigs. The locations were studied for iatrogenic injury at acute and delayed stages. Evaluation of injury was assessed clinically and histologically.

RESULTS

After the EndoGrab application, no immediate signs of perforation or ischemia were observed. The clinical post-operative course was uncomplicated. Histopathology findings included serosal compression and minimal mucosal ulceration. Long-term changes showed mild changes of focal edema and fibrosis, with inter-individual variability in severity.

CONCLUSION

While there were no signs of overt macroscopic acute injury, minimal microscopic changes were evident. According to this small-scale study, the EndoGrab can provide an effective and safe solution for small-bowel self-retractors. More research is needed to acquire a higher level of evidence for safety. Such a solution could eliminate ports or assistants previously designed for retraction only.

First prospective clinical trial of reduced incision bariatric procedures using magnetic liver retraction

BACKGROUND

Exposure of the surgical field is an essential component of minimally invasive surgery. Liver retraction is an important element of bariatric procedures because visualization of the stomach and gastroesophageal junction is key. The magnetic surgical system provides a well-tolerated and effective option for adjustable liver retraction without the use of a dedicated port.

OBJECTIVE

The purpose of this study was to evaluate the safety profile and effectiveness of the magnetic surgical system in patients undergoing bariatric procedures.

SETTING

Two investigational sites in Chile.

METHODS

A prospective, single-arm study (ClinicalTrials.govNCT03508674) with adherence to Good Clinical Practices and ISO 14155:2011(E) was undertaken to evaluate the safety profile and effectiveness of the magnetic surgical system in patients undergoing bariatric surgery. Patient follow-up occurred at 7 and 30 days postprocedure.

RESULTS

A total of 50 patients who met the inclusion criteria had a body mass index ranging from 28.4 to 58.2 kg/m². All procedures were completed without complications or conversions. The average overall procedure time was 61 minutes, and the amount of coupling time between the magnetic controller and the detachable grasper was 37 minutes. In all cases the device was able to adequately retract the liver to achieve an effective exposure of the target tissue and perform the bariatric procedure. A total of 24 adverse effects were reported throughout the course of the study. All device-related adverse effects were mild in severity and resolved with no clinical sequelae.

CONCLUSION

The magnetic surgical system is a well-tolerated and effective option for liver retraction in minimally invasive and bariatric surgery in patients with a varying range of body mass indexes.

Single-Center Experience with Magnetic Retraction in Colorectal Surgery

Background: Appropriate tissue retraction is essential in laparoscopic surgery, and colorectal operations often require an additional incision and trocar that can disturb visualization and maneuverability. Each incision carries an increased risk for complications as well as increased pain and cosmetic issues. Magnetic devices have been developed for a less invasive retraction. The objective of this study is to report our initial experience using magnet retraction. Methods: Ten consecutive patients who underwent laparoscopic colorectal procedures by a single surgeon using a magnetic retractor (Levita Magnetics^® Surgical System, San Mateo, CA) between October 2017 and June 2018 at Duke Regional Hospital in Durham, NC, were included. Results: The cases included four single-port right colectomies, one sigmoidectomy, and five rectopexies. Nine cases were completed laparoscopically, as one right colectomy required conversion due to adhesions and bulky specimen. Indications included adenocarcinoma, diverticular disease, and rectal prolapse. The magnet was successfully used for uterus, colon, or colonic pedicle retraction. No intraoperative or 30-day complications were observed. Conclusion: Magnetic surgical retractors are a safe, dynamic, and incision-less option for surgical field exposure during laparoscopic colorectal surgery. Reduced trocars decrease tissue trauma, enhances maneuverability, and potentially improves outcomes; however, further studies are required.

Surgical Endoscopy Versus Endoscopic Surgery for Obesity

BACKGROUND

Obesity treatment options are of great interest worldwide with major developments in the past 20 years. From general surgery to natural orifice transluminal endoscopic surgery intervention nowadays, obesity surgical therapies have surely developed and are now offering a variety of possibilities.

AREAS OF UNCERTAINTY

Although surgery is the only proven approach for weight loss, a joint decision between the physician and patient is required before proceeding to such a procedure. With a lot of options available, the treatment should be individualized because the benefits of surgical intervention must be weighed against the surgical risks.

DATA SOURCES

Medline search to locate full-text articles and abstracts with obvious conclusions by using the keywords: obesity, surgical endoscopy, gastric bypass, bariatric surgery, and endoscopic surgery, alone and in various combinations. Additional relevant publications were also searched using the reference lists of the identified articles as a starting point.

RESULTS

Laparoscopic Roux-en-Y gastric bypass still is the most effective, less invasive, bariatric surgical intervention, although there are various complications encountered, such as postoperative hemorrhage (1.9%-4.4%), internal hernias, anastomotic strictures (2.9%-23%), marginal ulcerations (1%-16%), fistulas (1.5%-6%), weight gain, and nutritional deficiencies. However, the absence of parietal incisions, less pain, decreased risk of infection, and short hospital stay make room for endoscopic surgery as a possible valid option for obesity for both the doctors' and the patients' perspective.

CONCLUSIONS

The current tendency is to promote surgical treatment of obesity to a status of less invasive scars therefore promoting minimally invasive surgical techniques.

Does Transumbilical Incision Influence Surgical Site Infection Rates of the Laparoscopic Sigmoidectomy and Anterior Resection?

Laparoscopic surgery is widespread and is safe and effective for the management of patients with colorectal cancer. However, surgical site infection (SSI) remains an unresolved complication. The present study investigated the comparative effect of supraumbilical incision versus transumbilical incision (TU) on the incidence of SSI in patients undergoing laparoscopic surgery for colon cancer. Medical records from patients with colorectal cancer who underwent laparoscopic sigmoid and rectosigmoid colon surgeries with either supraumbilical incision (n = 150) or TU (n = 150) were retrospectively reviewed. There was no difference in demographics, comorbidities, or operative variables between the two groups. The transumbilical group and the supraumbilical group were comparable with regards to overall SSI (6.0% vs 4.0%; P = 0.4062), superficial SSI (6.0% vs 3.3%; P = 0.2704), and deep SSI (0% vs 0.7%; P = 0.2385). SSI developed after laparoscopic sigmoid and rectosigmoid colon cancer surgery in 15 (5.0%) of the 300 patients. Of these superficial SSI, all wounds were in the left lower quadrant incision, and the transumbilical port sites did not become infected. Univariate analysis failed to identify any risk factors for SSI. Avoidance of the umbilicus offers no benefit with regard to SSI compared with TU.

Systematic Review of Retraction Devices for Laparoscopic Surgery

Background. Retraction plays a vital role in optimizing the field of vision in minimal-access surgery. As such, a number of devices have been marketed to aid the surgeon in laparoscopic retraction. This systematic review explores the advantages and disadvantages of the different instruments in order to aid surgeons and their institutions in selecting the appropriate device. Primary outcome measures include operation time, length of stay, use of staff, patient morbidity, ease of use, conversion rates to open surgery, and cost. Methods. Systematic literature searches were performed in MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials, and ClinicalTrials.gov. The search strategy focused on studies testing a retraction device. The selection process was based on a predefined set of inclusion and exclusion criteria. Data were then extracted and analyzed. Results. Out of 1360 papers initially retrieved, 12 articles were selected for data extraction and analysis. A total of 10 instruments or techniques were tested. Devices included the Nathanson’s liver retractor, liver suspension tape, the V-List technique, a silicone disk with or without a snake retractor, the Endoloop, the Endograb, a magnetic retractor, the VaroLift, a laparoscope holder, and a retraction sponge. None of the instruments reported were associated with increased morbidity. No studies found increased rates of conversion to open surgery. All articles reported that the tested instruments might spare the use of an assistant during the procedure. It was not possible to determine the impact on length of stay or operation time. Conclusions. Each analyzed device facilitates retraction, providing a good field of view while allowing reduced staff numbers and minimal patient morbidity. Due to economic and environmental advantages, reusable devices may be preferable to disposable instruments, although the choice must be primarily based on clinical judgement.

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 laparoscopic colorectal surgery for cancer: State of art

A number of clinical trials have demonstrated that the laparoscopic approach for colorectal cancer resection provides the same oncologic results as open surgery along with all clinical benefits of minimally invasive surgery. During the last years, a great effort has been made to research for minimizing parietal trauma, yet for cosmetic reasons and in order to further reduce surgery-related pain and morbidity. New techniques, such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy (SIL) have been developed in order to reach the goal of “scarless” surgery. Although NOTES may seem not fully suitable or safe for advanced procedures, such as colectomies, SIL is currently regarded as the next major advance in the progress of minimally invasive surgical approaches to colorectal disease that is more feasible in generalized use. The small incision through the umbilicus allows surgeons to use familiar standard laparoscopic instruments and thus, perform even complex procedures which require extraction of large surgical specimens or intestinal anastomosis. The cosmetic result from SIL is also better because the only incision is made through the umbilicus which can hide the wound effectively after operation. However, SIL raises a number of specific new challenges compared with the laparoscopic conventional approach. A reduced capacity for triangulation, the repeated conflicts between the shafts of the instruments and the difficulties to achieve a correct exposure of the operative field are the most claimed issues. The use therefore of this new approach for complex colorectal procedures might understandingly be viewed as difficult to implement, especially for oncologic cases.

Current and future practices in surgical retraction

Retraction of tissues and anatomical structures is an essential component of all forms of surgery. The means by which operative access is gained through retraction are many and diverse. In this article, the various forms of retraction methods currently available are reviewed, with special reference to hand held, self-retaining and compliant techniques. The special challenges posed by laparoscopic surgery are considered and future developments in new retraction techniques are anticipated.

Retraction techniques in laparoscopic colorectal surgery: a literature-based review

AIM

To systematically review the published literature and describe the various techniques of bowel and mesentery retraction available for use in laparoscopic colorectal resection.

METHOD

A comprehensive search of the literature was undertaken using MESH terms 'retraction', 'laparoscopic' and 'colorectal'. All articles describing methods of retraction in laparoscopic colorectal surgery were included.

RESULTS

Twelve methods of retraction in laparoscopic colorectal surgery were described. Five case-based series and three case studies were reported on 108 patients. Techniques were classified into those offering retraction of the small or large bowel or according to the mode of retraction.

CONCLUSION

Many retraction methods are available to the surgeon varying in cost, invasiveness and complexity. Adequate retraction remains a challenge for optimal exposure and dissection during laparoscopic colorectal surgery.

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.

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-access laparoscopic colectomy utilizing gravity in the lateral decubitus position

BACKGROUND

Only a limited number of instruments can be used in single-access laparoscopic colectomy, and triangulation must be forfeited to avoid instrument collision. We investigated whether this problem could be overcome by performing laparoscopic colectomy by the use of the lateral decubitus position, making full use of gravity.

OBJECTIVE

The aim of this study was to determine whether single-access laparoscopic colectomy could be achieved while maintaining patients in the lateral decubitus position.

DESIGN

This was a prospective study.

SETTING

This single-center study was conducted in a hospital.

PATIENTS

Ten consecutive patients (4 men and 6 women) with stage II or III colon cancer were included.

INTERVENTIONS

Each patient was placed in the lateral decubitus position. Single-port access to the abdomen was provided by a 3.0-cm incision at the umbilicus. The roots of the supplying or draining vessels were isolated and divided for lymphadenectomy. Next, the colon was dissected from a lateral approach, without the help of the assistant. The specimen was extracted from the single-access incision. Extracorporeal or intracorporeal anastomosis was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was the feasibility of single-access laparoscopic colectomy in the lateral decubitus position.

RESULTS

There were no intraoperative complications and no need for conversions to conventional laparoscopic surgery, open surgery, or the supine position. The median total surgical time was 154 minutes (interquartile range, 135-220 minutes). Surgical blood loss was slight (<20 mL) in all patients. No postoperative complications occurred. The median postoperative hospital stay was 7 days (interquartile range, 5-7 days).

LIMITATIONS

The sample size was small.

CONCLUSIONS

Our results show that single-access laparoscopic colectomy in the lateral decubitus position is safe and feasible.

Systematic review of single-incision laparoscopic colonic surgery

BACKGROUND

Randomized clinical trials (RCTs) have shown multiport laparoscopic surgery to be safe compared with open surgery in elective colonic disease. Single-incision laparoscopic surgery (SILS) represents the latest advance in laparoscopic surgery. The aim of this systematic review was to establish the safety and complication profile of colonic SILS.

METHODS

The search was performed in October 2011 using PubMed, MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. Search terms were 'colorectal', 'colon', 'colectomy', 'rectal' and single incision/port/trocar/site/scar. Only pure single-incision laparoscopic colonic surgery for benign and malignant colonic disease was included. Primary outcomes were the early postoperative complication profiles of colonic SILS. Secondary outcomes were duration of operation, lymph node yields, conversion rate and duration of hospital stay.

RESULTS

Colonic SILS data were compared with data from a Cochrane review on the short-term outcomes of laparoscopic colonic surgery and four main RCTs on laparoscopic colonic surgery. Median operating times and time to first bowel motion for colonic SILS were comparable with those for laparoscopic colonic surgery. The median lymph node retrieval for malignant disease achieved with SILS was acceptable. Evidence for a reduction in postoperative pain with SILS was conflicting. There was no significant reduction in length of hospital stay with SILS. Most patients selected for colonic SILS had a low body mass index, non-bulky tumours and were operated on by experienced laparoscopic surgeons. There was significant heterogeneity in study group characteristics, indications for surgery, research methodology, operative techniques and follow-up time.

CONCLUSION

Colonic SILS should be restricted to highly selected patients; operations should be performed by experienced laparoscopic surgeons, with critical appraisal of clinical outcomes.

Single-incision right hemicolectomy for malignancy: a feasible technique with standard laparoscopic instrumentation

AIM

Single-incision laparoscopy is a rapidly evolving technique in the spectrum 'standard laparoscopy-natural orifice transluminal endoscopic surgery (NOTES)'. From a commercial perspective, purchase of articulating instruments is advised. However, here we present our early experience with single-incision laparoscopy for right hemicolectomy with standard laparoscopic instrumentation.

METHOD

Between June 2010 and December 2011, 25 patients presenting with malignant disease underwent single-incision laparoscopy for right hemicolectomy. Four different ports (SILS™ port, Covidien; SSL(®) Access system, Ethicon; X-Cone/S-Portal(®) , Storz; and OCTO™ port, AFS Medical) were used. Patients were recruited prospectively and all data were processed retrospectively.

RESULTS

Twenty-five patients were included in our study (and their characteristics, described later in this paragraph, are expressed as median (range)). Four conversions to standard laparoscopy were performed. The age of patients was 69 (36-89) years, and they had a body mass index (BMI) of 24.5 (19.1-34.2). The duration of surgery was 110 (70-148) min with a healed skin incision length of 35 (20-60) mm. Hospital stay was 5 (2-15) days. In four patients discharge was delayed because of comorbidity. One patient suffered an overwhelming pneumonia.

CONCLUSION

Single-incision laparoscopy using standard laparoscopic instruments appears to be a safe and feasible technique for malignant disease requiring right hemicolectomy. Randomized, prospective trials are ongoing to prove the benefits of this technique and to compare its oncological outcome measures with those of conventional laparoscopy. In our experience, a low-profile port with a wide intra-abdominal range of motion is most preferable.

Single-incision laparoscopy for colorectal resection: a systematic review and meta-analysis of more than a thousand procedures

AIM

Single-incision laparoscopy for colorectal surgery is of growing importance. The experience of colorectal resection through single-incision laparoscopic surgery was assessed, including the patient outcomes.

METHOD

A meta-analysis was performed of studies comparing single-incision laparoscopic with multiport laparoscopy. Endpoints included conversion to laparotomy, operation time, postoperative morbidity, length of skin incision and length of hospital stay. The MEDLINE database was searched and only comparative studies were included in the meta-analysis. Data were retrieved from full-text manuscripts. Meta-analysis was performed according to the Mantel-Haenszel method for random effects.

RESULTS

From October 2008 to December 2011, 1026 colorectal resections including 921 colonic and 105 rectal procedures using single-incision laparoscopic surgery were reported in 64 studies. Meta-analysis of the 15 comparative studies, including a total of 1075 procedures (494 single-incision and 581 multiport laparoscopies), showed no difference in conversion to open laparotomy [odds ratio (OR) 0.58 (0.24, 1.38); P=0.22], morbidity [OR 0.84 (0.61, 1.15); P=0.27] or operation time [weighted mean difference (WMD) -0.27 (-6.50, 5.95); P=0.93], but a significantly shorter total skin incision [WMD -0.52 (-0.79, -0.25); P<0.001] and a significantly shorter postoperative length of stay [WMD -0.75 (-1.30, -0.20); P=0.008] after single-incision laparoscopic surgery compared with a multiport laparoscopic approach.

CONCLUSION

Although only 15 nonrandomized comparative studies of varying methodology have been reported, this systematic review and meta-analysis of more than 1000 colorectal procedures suggest that single-incision laparoscopic colorectal surgery is feasible and safe.

Pearls and pitfalls in SILS colectomy

Single-incision laparoscopic colectomy has developed into a viable option for the treatment of benign and malignant colorectal diseases with the innovation of new access devices, instrumentation, and surgical techniques. Although cosmesis has been highly touted as the most apparent advantage of the approach, the single-incision platform also affords the potential for enhanced recovery, early hospital discharge, and reduction in postoperative wound complications. Despite increasing evidence demonstrating the safety and efficacy of single-incision laparoscopic colectomy, wide-ranging adaptation has been tempered in part as a result of the technical demands of the approach. We aim to describe our surgical pearls for overcoming various pitfalls and technical challenges experienced during single-incision laparoscopic colectomy to facilitate successful application of this technique.

Feasibility and safety of single-incision laparoscopic colectomy: a systematic review

OBJECTIVE

The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic colectomy (SILC).

METHODS

We conducted a comprehensive review for the years 1983 to March 2011 to retrieve all relevant articles.

RESULTS

A total of 23 studies with 378 patients undergoing SILC were reviewed. All studies except 2 used a commercially available single-port device. Range of body mass index was 20.9 to 30.0 kg/m². Ranges of operative times and estimated blood losses were 83 to 225 minutes and 0 to 115 mL, respectively. Of 378 cases, a total of 6 cases (1.6%) were converted to open, 6 (1.6%) to hand-assisted laparoscopic (HALC), and 14 (4.0%) to conventional (multiport) laparoscopic colectomy (MLC) (overall conversion rate, 6.9%). An additional laparoscopic port was used in 4.9% (12/247) cases. Range of harvested lymph nodes number for malignant cases was 13.5 to 27 and surgical margins were negative in all cases. Overall mortality and morbidity rates were 0.5% (2/378) and 12.9% (45/349), respectively. The length of hospital stay (LOS) varied across reports (1.9-9.8 days). Among 4 case-matched studies, 2 showed shorter LOS after SILC than after HALC (2.7 vs 3.3 days) or after MLC/HALC (3.4 vs 4.6/4.9 days). Furthermore, one of these studies reported that maximum pain score on postoperative days 1 and 2 was significantly lower in SILS than in MLC and HALC.

CONCLUSIONS

In early series of highly selected patients, SILC appears to be feasible and safe when performed by surgeons who are highly skilled in laparoscopy. Despite technical difficulties, there may be potential benefits associated with SILC over MLC/HALC but it is yet to be proven objectively.

Single-scar laparoscopic colectomy with intracorporeal attachable and detachable instruments

BACKGROUND

In single-access laparoscopic colectomy, the number of instruments that can be inserted through the single-access site is limited by instrument collision. To compensate, triangulation is necessary, but the operative field becomes inadequate. To overcome this problem, intracorporeal attachable and detachable instruments can broaden the field of visceral tissue by retracting from at least 2 points.

OBJECTIVE

We tested this new procedure for colon cancer surgery.

DESIGN

This is a prospective study.

SETTING

This study was conducted at a single-center hospital.

PATIENTS

Ten consecutive patients (3 male and 7 female) with stage II or III colon cancer underwent the procedure.

INTERVENTIONS

All patients received a 3.0-cm incision at the umbilicus or right iliac fossa. At least 2 clips and a suspending bar were inserted through a 12-mm port in a multiport access device. The clips grasped the mesocolon at different points and were retracted with either an extracorporeal magnet or fine-loop retractors; this broadened the operative field in the mesocolon by at least 2 points. The mesocolon was dissected with a medial to lateral approach. The suspended bar was tied to 2 fine-loop retractors and manipulated to enlarge the operative field in the mesocolon. The roots of the vascular pedicles were isolated and divided during lymph node dissection. After extracting the specimen, an anastomosis was performed.

MAIN OUTCOME MEASURES

Intra- and postoperative complications due to inadequate access were the primary outcomes measured.

RESULTS

There were no intraoperative complications and no need for conversions to open surgery or second access ports. The median total surgical time was 182 minutes (range, 122-245). Surgical blood loss was slight (range, 1-20 mL) in all patients. No postoperative complications occurred. The postoperative hospital stay was 5 to 7 days.

LIMITATIONS

The sample size was small.

CONCLUSIONS

This study showed that intracorporeal attachable and detachable instruments were safe and feasible for this procedure.

Outcomes for case-matched single-port colectomy are comparable with conventional laparoscopic colectomy

AIM

With the introduction of single-port surgery, expected advantages are improved cosmesis, decrease of pain and shorter length of stay. The aim of this study was to compare early outcomes of single-port colectomy with those of conventional laparoscopic colectomy.

METHOD

All consecutive patients undergoing single-port colectomy between January and June 2010 were identified from a prospective database. They were matched for age, sex, body mass index, American Society of Anesthesiology score and type of resection with patients who had conventional laparoscopic colectomy. All perioperative data, analgesic requirement, pain scores and inflammatory response were compared using the Wilcoxon signed-rank and McNemar tests.

RESULTS

Fourteen patients [five men, nine women; median age (interquartile range) 56 (30-73) years, body mass index (interquartile range) 22 (20-24) kg/m2] underwent single-port colectomy and were matched with patients who had conventional laparoscopic colectomy. Median operating times, estimated blood loss, pain scores, analgesic requirement, inflammatory response and length of hospital stay were similar. Median increase in incision length was significantly higher in the single-port group (P=0.004), but maximal incision length for specimen extraction was comparable. There were no anastomotic leaks, wound infections or 30-day readmissions.

CONCLUSION

In a case-matched setting with a small sample size, single-port laparoscopic colectomy has comparable outcomes to conventional laparoscopic colectomy.

Magnetic compression ostomy as new cystostomy technique in the rat: magnacystostomy

OBJECTIVE

To report the first creation of magnetic compression cystostomy (magnacystostomy) using an easy and simple new technique in rats. Magnetic compression anastomoses (magnamosis) have been previously described for gastrointestinal, biliary, urinary, and vascular anastomoses.

METHODS

Female rats were randomized into 2 groups (n = 10 each): a magnetic cystostomy group and a formal surgical cystostomy group as the control group. In the magnetic cystostomy group, a very small cylindrical magnet was inserted into the bladder. The external magnetic ball was placed subcutaneously into the suprapubic region, and the 2 magnets were coupled together strongly. On postoperative day 20 in the magnetic cystostomy group and day 10 in the surgical cystostomy group, the rats were killed, and the cystostomies were evaluated macroscopically, histopathologically, and by mechanical burst testing.

RESULTS

In the surgical cystostomy group, 3 rats died. In the remaining rats, no evidence of complications was observed. However, mild adhesion in 1 rat in the magnetic cystostomy group and moderate adhesions in all the rats in the surgical cystostomy group were observed. No significant difference was found in burst pressure between the 2 groups (mean 162 mm Hg in the magnetic cystostomy group [n = 6] and 185 mm Hg in the surgical cystostomy [n = 5] group). However, the procedure time between the magnetic cystostomy group (7.70 ± 1.64 minutes) and surgical cystostomy group (18.50 ± 2.01 minutes) was significantly different (P < .001).

CONCLUSION

Magnacystostomy is easy and safe in the rat model and could be useful for some suprapubic cystostomy procedures in humans.

Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison

OBJECTIVE

The aim of this study was to compare single-incision laparoscopic colectomy (SILC) to multiport laparoscopic colectomy (MLC) when performed by experienced laparoscopic surgeons.

BACKGROUND

Recent case reports and single institution series have demonstrated the feasibility of SILC. Few comparative studies for MLC and SILC have been reported.

METHODS

Patients from 5 institutions undergoing SILC were entered into an IRB approved database from November 2008 to March 2010. SILC patients were matched with those undergoing MLC for gender, age, disease, surgery, BMI, and surgeon. The primary endpoint was length of stay and secondary endpoints included operative time, conversion, complications and postoperative pain scores.

RESULTS

Three hundred thirty patients (SILC = 165, MLC = 165) were evaluated. Operative time (135 ± 45 min vs. 133 ± 56 min; P = 0.85) and length of stay (4.6 ± 1.6 vs. 4.3 ± 1.4; P = 0.35) were not significantly different. Maximum postoperative day one pain scores were significantly less for SILC (4.9 vs. 5.6; P = 0.005). Eighteen (11%) patients undergoing SILC were converted to multiport laparoscopy. There was no statistical difference between groups for conversions to laparotomy, complications, re-operations, or re-admissions.

CONCLUSIONS

SILC is feasible when performed on select patients by surgeons with extensive laparoscopic experience. Outcomes were similar to MLC, except for a reduction in peak pain score on the first postoperative day. Prospective randomized trials should be performed before incorporation of this technology into routine surgical care.

Patient reported outcomes and their importance in the development of novel surgical techniques

INTRODUCTION

Although traditional quality measures such as morbidity and mortality outcomes still pay an important role in the assessment of health care quality, greater emphasis is now being placed on patient-reported outcome measures such as patient satisfaction. This area is especially important for novel surgical technologies such as single-incision laparoscopic surgery (SILS) and natural orifice translumenal endoscopic surgery (NOTES). These new innovations are able to minimize or abolish surgical scarring and are likely to have most benefit in the area of patient satisfaction as opposed to traditional outcome measures. Therefore, it is important to gauge the public opinion regarding these new techniques, as continued public interest can help support further research in this up-and-coming field.

METHODS

A questionnaire study was carried out with members of the general public. Questions were asked regarding preference for surgical techniques, including open surgery, laparoscopic surgery, NOTES, and SILS, in the situation of acute appendicitis.

RESULTS

The questionnaire was completed by 1006 individuals. Results indicated that an established safety profile was necessary before the introduction of these new techniques into general practice. The concept of scarless surgery did appeal to the public, with SILS being the treatment of choice in the scenario of acute appendicitis.

DISCUSSION

The patient perspective on health care is an important aspect of health care quality assessment. This is especially important with regard to the development of novel surgical techniques such as SILS and NOTES. With these techniques, the potential benefits are most likely to be found in the realms of reduced scarring and improved patient satisfaction. The findings from this study demonstrate the public's interest in these new techniques and thus give further support to continued research and development in this area.

Single-incision laparoscopic surgery using colon-lifting technique for colorectal cancer: a matched case-control comparison with standard multiport laparoscopic surgery in terms of short-term results and access instrument cost

BACKGROUND

Single-incision laparoscopic surgery (SILS) has been used for colorectal cancer as a minimally invasive procedure. However, there are still difficulties concerning effective triangulation and countertraction. The study's purpose was to clarify the usefulness of the colon-lifting technique (CLT) in SILS for colorectal cancer.

METHODS

SILS was performed for cancer (cT2N0 or less) of the right-sided colon (near the ileocecum), sigmoid, or rectosigmoid. The SILS™ Port was used for transumbilical access. A suture string was inserted through the abdominal wall and passed through the mesocolon. The colon was retracted anteriorly and fixed to the abdominal wall. The main mesenteric vessels were placed under tension. Lymph node dissection was performed by medial approach. Short-term surgical outcomes and access port costs were compared between SILS (using CLT) and the standard multiport technique (MPT). The two groups were case-matched by propensity scoring. Analyzed variables included preoperative Dukes stage and tumor location.

RESULTS

From June 2009 to April 2011, 27 patients underwent SILS, and from April 2005 to April 2011, 85 patients underwent MPT. Propensity scoring generated 23 matched patients per group for SILS versus MPT comparisons. There were no significant differences in operating time, blood loss, early complications, postoperative analgesic frequency, or length of hospital stay. One MPT patient was converted to open surgery (4.5%); no SILS patients were converted. There were no significant differences in the length of distal cut margin and the number of harvested lymph nodes, except incision length (SILS vs. MPT: 33 vs. 55 mm, P < 0.001). Significant differences favored SILS in access instrument cost (SILS vs. MPT: 62,761 vs. 77,130 Japanese yen, P < 0.001).

CONCLUSIONS

SILS performed using CLT was safe and effective in providing radical treatment of cT2N0 cancer in the right-sided colon, sigmoid, or rectosigmoid. SILS was advantageous with respect to cosmesis and lower cost of access instruments.

Single-incision laparoscopic sigmoidectomy and rectopexy case series

Single-incision laparoscopic surgery has recently been investigated as a novel approach to colorectal pathology. This article describes 3 cases of single-incision laparoscopic sigmoidectomy with rectopexy for the treatment of rectal prolapse. We demonstrate our surgical approach and results from these initial patients treated with this novel technique.

Single-incision versus conventional laparoscopic sigmoid colectomy: a case-matched series

BACKGROUND

Single-incision laparoscopic surgery is an emerging modality that has proven to be safe and feasible for colon resection in multiple case reports and series. Nonetheless, comparative analyses with established techniques are limited in the published literature. We evaluated the efficacy of single-incision laparoscopic colectomy (SILC) for the treatment of sigmoid disease through a matched-case comparison with conventional laparoscopic colectomy (CLC).

METHODS

Twenty patients who underwent single-incision laparoscopic sigmoid resection for benign or malignant disease between July 2009 and September 2010 were matched to patients who underwent conventional laparoscopic sigmoid colectomy. Demographic, intraoperative, and postoperative data were assessed.

RESULTS

Twenty SILC and CLC cases each were paired based on gender (p < 1.0), age (p < 0.47), pathology (p < 1.0), and surgical procedure (p < 1.0). Ten patients (50%) in the SILC group and eight patients (40%) in the CLC group had a history of prior abdominal surgery (p < 0.53). There were no conversions to open surgery; however, one SILC procedure (5%) required conversion to CLC (p < 0.31). There was no significant difference in mean operating time between groups (p < 0.80). Mean estimated blood loss was significantly lower for SILC compared to CLC (p < 0.007). Mean lymph node extraction was comparable between groups in the subset of patients with malignant disease (p < 0.68). Two postoperative complications were encountered in each group. The mean length of hospital stay for SILC and CLC was 3.2 ± 1.0 and 3.8 ± 2.1 days, respectively (p < 0.25). There were no readmissions or reoperative interventions in either group.

CONCLUSION

Compared with conventional laparoscopic technique, single-incision laparoscopic surgery results in similar intraoperative and postoperative outcomes. The technique avoids use of multiple trocar sites and may safely be performed in patients with a history of previous abdominal surgery while maintaining a short length of hospital stay and low complication rate.

Single-incision laparoscopic colectomy: outcomes of an emerging minimally invasive technique

PURPOSE

Single-incision laparoscopic colectomy (SILC) is an emerging procedure in the field of minimally invasive colon and rectal surgery. The purpose of this study was to evaluate the safety and feasibility of this procedure.

METHODS

Between July 2009 and April 2010, SILC was performed for 35 patients presenting with pathology of the colon. Surgical procedures included right hemicolectomy, sigmoid resection, and total colectomy. Demographic data, intraoperative parameters, and short-term postoperative outcomes were assessed.

RESULTS

Thirty two of the 35 patients (91.4%) underwent successful completion of SILC while 3 patients required laparoscopic modifications. The mean incision length was 3.4 cm with a range of 2-6 cm. The mean total operative time (OT) for right, left, and total colectomies was 158.8 ± 31.8 min, 127.0 ± 37.1 min, and 216.3 ± 72.6 min, respectively. Overall, the OT was not significantly different between patients with a body mass index (BMI) ≥ 25 kg/m(2) (147.9 ± 47.9 min) compared to those with a BMI <25 kg/m(2) (123.1 ± 40.9 min). In the subset of patients with malignant disease, the mean lymph node extraction was 23.5 ± 12.0 and all margins were negative. There were no intraoperative complications, and the overall mean length of hospital stay was 2.9 ± 1.0 days (range 2-6 days). The postoperative morbidity rate was 11.4%.

CONCLUSIONS

Single-incision laparoscopic colectomy is a safe and feasible procedure for benign and malignant diseases of the colon. This modality can be successfully applied for various colorectal procedures without conversion to open surgery, resulting in a short length of hospital stay and a minimal short-term complication rate.

Single-access laparoscopic low anterior resection with vertical suspension of the rectum

PURPOSE

Single-access laparoscopic surgery was first introduced for colectomy and later adapted for anterior resection. During single-access laparoscopic pelvic procedures, such as total mesorectal excision, it is often difficult to obtain an adequate operative field. By suspending the rectum vertically, we were able to execute a total mesorectal excision with single-access laparoscopy. We describe here the use of this new procedure to treat rectal cancer.

METHODS

The selected 7 patients (1 male and 6 female) with stage II or III rectal cancer underwent the procedure. Single-port access to the abdomen was provided by a 3.0-cm incision at the right iliac fossa. The descending mesocolon was dissected by use of a medial approach, and a columnar magnet was placed on the surface of the abdominal wall to restore triangulation. The inferior mesenteric artery was skeletonized and the superior rectal artery divided during lymph node dissection. The total mesorectal excision extended to the pelvic floor and the rectum was vertically retracted with a suspending bar in collaboration with an extracorporeal magnet tool. The rectum was then transected below the reflection of the peritoneum. Intracorporeal anastomosis was performed with the double-stapling technique. Two pelvic drains were inserted through the single incision and the anus, respectively, for all patients. A defunctioning ileostomy was not created in any patient.

RESULTS

Median total surgical time was 205 minutes (range, 175-245 min). Intraoperative blood loss was minimal in all patients (range, 1-20 mL). None of the cases required conversion to open surgery or addition of a second port. The only preoperative or postoperative complication occurred in one patient with clinical anastomotic leakage.

CONCLUSION

Low anterior single-access laparoscopic resection seems safe and feasible when the rectum is suspended like a swing to ensure an adequate operative field.

Minimally invasive single-site surgery for the digestive system: A technological review

Minimally Invasive Single Site (MISS) surgery is a better terminology to explain the novel concept of scarless surgery, which is increasingly making its way into clinical practice. But, there are some difficulties. We review the existing technologies for MISS surgery with regards to single-port devices, endoscope and camera, instruments, retractors and also the future perspectives for the evolution of MISS surgery. While we need to move ahead cautiously and wait for the development of appropriate technology, we believe that the "Ultimate form of Minimally Invasive Surgery" will be a hybrid form of MISS surgery and Natural Orifice Transluminal Endoscopic Surgery, complimented by technological innovations from the fields of robotics and computer-assisted surgery.

New developments in colorectal surgery

PURPOSE OF REVIEW

New developments in colorectal surgery have been driven primarily by technical innovations, which in turn are responsible for changes in practice. This review examines recent publications that describe and have contributed to these changes.

RECENT FINDINGS

We identified and reviewed recent publications in the areas of fecal incontinence, constipation, single incision and robotic surgical techniques, complex anal fistulas, diverticulitis, local excision techniques for rectal neoplasms, surgical care improvement, use of mechanical bowel preparation, and magnetic resonance imaging after neoadjuvant chemoradiotherapy for rectal cancer.

SUMMARY

New technologies and practice innovations will enhance patient outcomes and quality of life. Multiinstitutional studies, randomized when practical, will be necessary to further define the safety and efficacy of these new surgical techniques and to further define best practices in colon and rectal surgery.

Minimal invasive single-site surgery in colorectal procedures: Current state of the art

BACKGROUND

Minimally invasive single-site (MISS) surgery has recently been applied to colorectal surgery. We aimed to assess the current state of the art and the adequacy of preliminary oncological results.

METHODS

We performed a systematic review of the literature using Pubmed, Medline, SCOPUS and Web of Science databases. Keywords used were "Single Port" or "Single-Incision" or "LaparoEndoscopic Single Site" or "SILS™" and "Colon" or "Colorectal" and "Surgery".

RESULTS

Twenty-nine articles on colorectal MISS surgery have been published from July 2008 to July 2010, presenting data on 149 patients. One study reported analgesic requirement. The final incision length ranged from 2.5 to 8 cm. Only two studies reported fascial incision length. There were two port site hernias in a series of 13 patients (15.38%). Two "fully laparoscopic" MISS procedures with preparation and achievement of the anastomosis completely intracorporeally are reported. Future site of ileostomy was used as the sole access for the procedures in three studies. Lymph node harvesting, resection margins and length of specimen were sufficient in oncological cases.

CONCLUSIONS

MISS colorectal surgery is a challenging procedure that seems to be safe and feasible, but the existing clinical evidence is limited. In selected cases, and especially when an ileostomy is planned, colorectal surgery may be an ideal indication for MISS surgery leading to a no-scar surgery. Despite preliminary oncological results showing the feasibility of MISS surgery, we want to stress the need to standardize the technique and carefully evaluate its application in oncosurgery under ethical committee control.

Single site laparoscopic right hemicolectomy: an oncological feasible option

INTRODUCTION

We present the first 7 cases of single site right hemicolectomy in Asia using the new Single Site Laparoscopy (SSL) access system from Ethicon Endo-surgery.

METHODS

Right hemicolectomy was performed using the new Single Site Laparoscopy (SSL) access system. Patient demographics, operative time, histology and post operative recovery and complications were collected and analysed.

RESULTS

The median operative time was 90 mins (range 60 - 150 mins) and a median wound size of 2.5 cm (range 2 to 4.5 cm). The median number of lymph nodes harvested was 24 (range 20 to 34 lymph nodes). The median length of proximal margin was 70 mm (range 30 to 145 mm) and that of distal margin was 50 mm (35 to 120 mm). All patients had a median hospital stay of 7 days (range 5 to 11) and there were no significant perioperative complications except for 1 patient who had a minor myocardial event.

CONCLUSION

Right hemicolectomy using SSL access system is feasible and safe for oncologic surgery.