Initial experience of single-port laparoscopic surgery for sigmoid colon cancer

Learning curve for single-port robot-assisted rectal cancer surgery

Purpose

We analyzed the learning curve of single-port robotic (SPR)-assisted rectal cancer surgery.

Methods

Fifty-seven consecutive SPR-assisted rectal cancer surgery cases performed by the same surgeon were considered in surgical interventions for rectal cancer. Total operation time (OT), docking time (DT), and surgeon console time (SCT) measured during surgery were used to parametrize the learning curve. The parameters representing the learning curve were evaluated using the cumulative sum (CUSUM).

Results

The mean value of total OT was 241.8 ± 91.7 minutes, the mean value of DT was 20.6 ± 19.1 minutes, and the mean value of SCT was 135.9 ± 66.7 minutes. The learning curve was divided into phase 1 (initial 16 cases), phase 2 (second 16 cases), and phase 3 (subsequent 25 cases). The peak on the CUSUM graph occurred in the 21st case. The longest OT among phases was in phase 2. Complications were most frequent in phase 2. However, complications of Clavien-Dindo (CD) grade IIIb were most frequent in phase 3 with 2 patients. The most common complications were fluid collection and urinary retention (7 patients each). Complications of CD grade IIIb required one stomal revision due to stoma obstruction and one irrigation and loop ileostomy due to anastomosis leakage.

Conclusion

Improvement in surgical performance of SPR assisted rectal cancer operation was achieved after 21 cases. The three phases identified in the cumulative sum analysis showed a significant decrease in operative time after the middle stage of the learning curve without an increase in the complication rate.

Single-incision robotic colectomy versus single-incision laparoscopic colectomy: A matched case control study

BACKGROUND

Single incision laparoscopic colectomy (SILC) and single incision robotic colectomy (SIRC) are both advanced minimally invasive operative techniques. However, studies comparing these two surgical methods have not been published. The purpose of this study is to compare and evaluate the short-term outcomes of SIRC with those of SILC.

METHODS

A total of 21 consecutive patients underwent SIRC and 136 consecutive patients underwent SILC in separate institutes between January 2013 and December 2019. We used retrospective cohort matching to analyze these patients.

RESULTS

Prior to matching, patients who underwent SIRC had a lower percentage of American Society of Anesthesiologists (ASA) grades III-IV (5% vs. 19%, P = 0.11) compared with patients who underwent SILC. The SIRC group revealed a higher proportion of sigmoid colon lesions and anterior resections than the SILC group (61% vs. 45%, P = 0.16). After 1:4 cohort matching, 21 patients were enrolled in the SIRC group and 84 patients were enrolled in the SILC group. No statistically significant difference in terms of operative time (SIRC: 185 ± 46 min, SILC: 208 ± 53 min; P = 0.51), estimated blood loss (SIRC: 12 ± 22 ml, SILC: 85 ± 234 ml; P = 0.12), and complications (SIRC: 4.7%, SIRC: 7.1%; P = 0.31) was observed between these groups. Length of postoperative hospital stay (SIRC: 8.3 ± 1.7 days, SILC: 9.3 ± 6.5; P = 0.10) and number of harvested lymph nodes (SIRC: 21.3 ± 10.3, SILC: 21.3 ± 9.5; P = 0.77) were also similar between the two groups. In subgroup analysis, numbers of harvested lymph node is less in SIRC than SILC (SIRC: 18.1 ± 4.7 vs. SILC: 18.9 ± 8.1, P = 0.04) in anterior resection.

CONCLUSION

SIRC and SILC are safe and feasible procedures with similar surgical and pathological outcomes for right- and left-side colectomy.

Effects of needlescopic surgery on postoperative pain in intersphincteric or abdominoperineal resection

PURPOSE

Laparoscopic surgery allows minimally invasive treatment of rectal cancer, and needlescopic surgery (NS) offers even more minimally invasive operations beyond the scope of conventional laparoscopic surgery (CS). The aim of this study was to compare short-term outcomes of NS for intersphincteric resection (ISR) or abdominoperineal resection (APR) to treat anal or rectal cancer without an abdominal incision for specimen extraction and to measure abdominal wound pain compared to CS.

METHODS

Between September 2014 and December 2016, a total of 134 patients underwent laparoscopic ISR or APR. Of these, 26 patients underwent NS, and 108 patients underwent CS. Postoperative abdominal wound pain was estimated using the numerical rating scale. Short-term outcomes were compared between NS and CS.

RESULTS

No conversion to CS or open surgery was required. Median operation time was significantly shorter with NS (295 min) than with CS (331.5 min; p = 0.020). Median estimated blood loss was significantly lower with NS (30 ml) than with CS (50 ml; p = 0.011). Postoperative pain score on postoperative day (POD)5 was significantly lower with NS than with CS (p = 0.025), and frequencies of analgesic use were significantly lower with NS than with CS on POD0, POD2, and POD3 (p = 0.032, p = 0.017, p = 0.045, respectively). The postoperative complications occurred at similar frequencies between groups (p = 0.655).

CONCLUSION

NS for ISR or APR offers comparable short-term outcomes to CS, with better pain outcomes.

Single-incision Laparoscopy Versus Multiport Laparoscopy for Colonic Surgery: A Multicenter, Double-blinded, Randomized Controlled Trial

OBJECTIVE

To compare outcome of single-port laparoscopy (SPL) and multiport laparoscopy (MPL) laparoscopy for colonic surgery.

SUMMARY OF BACKGROUND DATA

Benefits of SPL over MPL are yet to be demonstrated in large randomized trials.

METHODS

In this prospective, double-blinded, superiority trial, patients undergoing laparoscopic colonic resection for benign or malignant disease were randomly assigned to SPL or MPL (NCT01959087). Primary outcome was length of theoretical hospital stay (LHS).

RESULTS

One hundred twenty-eight patients were randomized and 125 analyzed: 62 SPL and 63 MPL, including 91 right (SPL: n = 44, 71%; MPL: n = 47, 75%) and 34 left (SPL: n = 18, 29%; MPL: n = 16, 25%) colectomies, performed for Crohn disease (n = 53, 42%), cancer (n = 36, 29%), diverticulitis (n = 21, 17%), or benign neoplasia (n = 15, 12%). Additional port insertion was required in 5 (8%) SPL patients and conversion to laparotomy occurred in 7 patients (SPL: n = 3, 5%; MPL: n = 4, 7%; P = 1.000). Total length of skin incision was significantly shorter in the SPL group [SPL: 56 ± 41 (range, 30-300) mm; MPL: 87 ± 40 (50-250) mm; P < 0.001]. Procedure duration, intraoperative complication rate, postoperative 30-day morbidity, postoperative pain, and time to first bowel movement were similar between the groups, leading to similar theoretical LHS (SPL: 6 ± 3 days; MPL: 6 ± 2; P = 0.298). At 6 months, quality of life was similar between groups, but patients from the SPL group were significantly more satisfied with their scar aspect than patients from the MPL group (P = 0.003).

CONCLUSION

SPL colectomy does not confer any additional benefit other than cosmetic result, as compared to MPL.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

BACKGROUND

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

METHODS

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

RESULTS

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

CONCLUSIONS

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Systematic review of single-incision versus conventional multiport laparoscopic surgery for sigmoid colon and rectal cancer

Objectives

To explore whether single-incision laparoscopic surgery (SILS) has the better short-term clinical and pathological outcomes than conventional multiport laparoscopic surgery (CLS) for sigmoid colon and rectal cancer.

Methods

A literature investigation of MEDLINE, PubMed, Ovid, Embase, Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chinese Biological Medicine (CBM), and Wanfang databases for relevant researches was performed. Fixed effects and random effects models were used to calculate the corresponding outcomes. Standardized mean difference and risk ratio were calculated for continuous and dichotomous variables separately.

Results

Nine clinical controlled trials were composed of two randomized clinical trials and seven non-randomized clinical trials with a total of 829 patients. Two hundred ninety-nine (36.1%) patients underwent SILS, and 530 (63.9%) patients underwent CLS. The meta-analysis showed that SILS had more lymph node resection (SMD − 0.25, 95% CI − 0.50 to − 0.002) and less defecation time (SMD − 0.46, 95% CI − 0.75 to − 0.17), exhaust time (SMD − 0.46, 95% CI − 0.75 to − 0.18), and hospital stay (SMD − 0.30, 95% CI − 0.45 to − 0.15 than CLS. SILS was also accompanied with shorter incision length (SMD − 2.46, 95% CI − 4.02 to − 0.90), less pain score (SMD − 0.56, 95% CI − 0.91 to − 0.21), and lower complication rate (RR 0.66, 95% CI 0.47 to 0.91). Blood loss, operative time, distal margin, conversion rate, anastomotic fistula, readmission, local recurrence, and distant metastasis showed no statistical differences in two groups. In all subgroup analysis, SILS also had advantages of incision length, operative time, defecation time, exhaust time, and hospitalization time than CLS.

Conclusion

SILS could be a more safe and reliable surgical technique than CLS for sigmoid colon and rectal cancer. However, further high-quality studies between these two techniques need to be further developed.

Reduced port laparoscopic surgery for colon cancer is safe and feasible in terms of short-term outcomes: comparative study with conventional multiport laparoscopic surgery

Purpose

Laparoscopic surgery was previously accepted as an alternative surgical option in treatment for colorectal cancer. Nowadays, single-port laparoscopic surgery (SPLS) is introduced as a method to maximize advantages of minimally invasive surgery. However, SPLS has several limitations compared to conventional multiport laparoscopic surgery (CMLS). To overcome those limitations of SPLS, reduced port laparoscopic surgery (RPLS) was introduced. This study aimed at evaluating the short-term outcomes of RPLS.

Methods

Patients who underwent CMLS and RPLS of colon cancer between August 2011 and December 2013 were included in this study. Short-term clinical and pathological outcome were compared between the 2 groups.

Results

Thirty-two patients underwent RPLS and 217 patients underwent CMLS. Shorter operation time, less blood loss, and faster bowel movement were shown in RPLS group in this study. In terms of postoperative pain, numeric rating scale (NRS) of RPLS was lower than that of CMLS. Significant differences were shown in terms of tumor size, harvested lymph node, perineural invasion, and pathological stage. No significant differences were confirmed in terms of other surgical outcomes.

Conclusion

In this study, RPLS was technically feasible and safe. Especially in terms of postoperative pain, RPLS was comparable to CMLS. RPLS may be a feasible alternative option in selected patients with colon cancer.

Short-term outcomes following reduced-port, single-port, and multi-port laparoscopic surgery for colon cancer: tailored laparoscopic approaches based on tumor size and nodal status

PURPOSE

Surgeons have recently developed more minimally invasive surgical procedures to reduce surgical stress and improve cosmesis. Although single-port laparoscopic colectomy (SPLC) has potential benefits over multi-port laparoscopic colectomy (MPLC), there are concerns about the increased technical difficulties associated with SPLC. Therefore, we attempted reduced-port laparoscopic colectomy (RPLC). The purpose of this study was to evaluate the difference in perioperative outcome following tailored laparoscopic approaches for colon cancer on the basis of tumor characteristics.

METHODS

The prospectively collected data of 170 patients who underwent only minimally invasive colectomy for colon cancer from July 2010 to June 2013 were reviewed. The MPLC, SPLC, and RPLC groups comprised 92 (54.1 %), 40 (23.5 %), and 38 (22.4 %) patients, respectively.

RESULTS

The number of harvested lymph nodes was significantly higher in the RPLC group than in the MPLC and SPLC groups (29.9 ± 21.5, 21.9 ± 12.1, and 24.2 ± 13.8, respectively; p = 0.027). The mean operating time was significantly different among the MPLC, SPLC, and RPLC groups (243.5 ± 59.0, 207.2 ± 49.6, and 216.2 ± 53.7 min, respectively; p = 0.001). The time to first flatus was also significantly different among the MPLC, SPLC, and RPLC groups (3.1 ± 1.2, 3.6 ± 1.3, and 3.4 ± 1.1 days, respectively; p = 0.039). No significant differences in the other short-term surgical outcomes were observed among the three groups.

CONCLUSIONS

SPLC and RPLC according to tailored laparoscopic approaches for colon cancer appear to be beneficial in terms of operative time and lymph node retrieval, and may be considered as surgical options in laparoscopic colectomy for colon cancer patients with favorable tumor characteristics.

A safety study of transumbilical single incision versus conventional laparoscopic surgery for colorectal cancer: study protocol for a randomized controlled trial

BACKGROUND

Single-incision laparoscopic surgery (SILS) is an emerging minimally invasive surgery to reduce abdominal incisions. However, despite the increasing clinical application of SILS, no evidence from large-scale, randomized controlled trials is available for assessing the feasibility, short-term safety, oncological safety, and potential benefits of SILS compared with conventional laparoscopic surgery (CLS) for colorectal cancer.

METHODS/DESIGN

This is a single-center, open-label, noninferiority, randomized controlled trial. A total of 198 eligible patients will be randomly assigned to transumbilical single incision plus one port laparoscopic surgery (SILS plus one) group or to a CLS group at a 1:1 ratio. Patients ranging in age from 18 to 80 years with rectosigmoid cancer diagnosed as cT1-4aN0-2 M0 and a tumor size no larger than 5 cm are considered eligible. The primary endpoint is early morbidity, as evaluated by an independent investigator. Secondary outcomes include operative outcomes (operative time, estimated blood loss, and incision length), pathologic outcomes (tumor size, length of proximal and distal resection margins, and number of harvested lymph nodes), postoperative inflammatory and immune responses (white blood cells [WBC], neutrophil percentage [NE %], C-reactive protein [CRP], interleukin-6 [IL-6], and tumor necrosis factor-α [TNF-α]), postoperative recovery (time to first ambulation, flatus, liquid diet, soft diet, and duration of hospital stay), pain intensity, body image and cosmetic assessment, 3-year disease free survival (DFS), and 5-year overall survival (OS). Follow-up visits are scheduled for 1 and 3 months after surgery, then every 3 months for the first 2 years and every 6 months for the next 3 years.

DISCUSSION

This trial will provide valuable clinical evidence for the objective assessment of the feasibility, safety, and potential benefits of SILS plus one compared with CLS for the radical resection of rectosigmoid cancer. The hypothesis is that SILS plus one is feasible for the radical resection of rectosigmoid cancer and offers short-term safety and long-term oncological safety comparable to that of CLS, and that SILS plus one offers better cosmetic results and faster convalescence compared to CLS.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02117557 (registered on 16 April 2014).

Lymph node harvest in single incision laparoscopic surgery for colorectal malignancy

AIM

Single incision laparoscopic surgery (SILS) has not been sufficiently evaluated with respect to its oncological equivalence to conventional laparoscopic or open surgery.

METHOD

Of 507 patients who had SILS for colorectal diseases in our institution, 87 had segmental resection for colorectal adenocarcinoma. For each of the surgical specimens the number of lymph nodes which can be expected to be identified by the pathologist was calculated using the ACPGBI lymph node harvest model, which was developed from a nationwide database of 5845 surgical specimens. The predicted number of lymph nodes was compared with the number identified in our SILS specimens.

RESULTS

The median predicted number of lymph nodes was 11 (4.5-14.8) compared with 18 (5-44) in the SILS specimens (P < 0.001). In all subgroups analysed for various operations, the lymph node harvest in the SILS specimens was significantly higher than predicted.

CONCLUSION

In terms of lymph node harvest SILS seems to be comparable to conventional open or laparoscopic surgery.

Single-port laparoscopic total mesorectal excision with transanal resection (transabdominal transanal resection) for low rectal cancer: initial experience with 22 cases

BACKGROUND

Total mesorectal excisions (TME) with transanal resection and coloanal anastomosis (CAA) represent one of the standard surgical treatments for low rectal cancers. We report our initial experiences with trans-abdominal trans-anal resections (TATAR) with TME, performed using a single-port laparoscopic surgeries (SPLS) approach for low rectal cancers.

METHODS

Between June 2009 and April 2011, 22 low rectal cancer patients underwent SPLS TATAR with TME. SPLS was performed transumbilically or through predetermined stoma sites. Conventional laparoscopic instruments were used, and the intracorporeal procedures and range of operation did not differ. After a full laparoscopic TME to the pelvic floor muscles, the specimen was pulled through the anus. CAA was completed with transanal hand sewn sutures. Patient and tumor characteristics and operative, pathologic, and postoperative outcomes were studied.

RESULTS

SPLS TATAR with TME was successful in all patients. No additional incisions for trocars or conversions to open surgery were performed. The median incision length, operative time, and postoperative length of stay were 2.0 cm (range: 1.5-2.5), 260 min (range: 190-380), and 6 days (range: 4-16), respectively. The median number of harvested lymph nodes was 22 (range: 9-42). The median distal margin from the tumor was 2.0 cm (range: 0.3-4.0). No intraoperative complications were noted.

CONCLUSIONS

SPLS TATAR with TME was safe and feasible. In addition to cosmetic advantages, oncologic requirements for specimens, including adequate margins and sufficient lymph node harvesting could be fulfilled entirely. However, the technique and oncologic safety warrant further evaluation and prospective randomized studies.

Single-incision (with multi-input single-port) laparoscopic colorectal procedures: Early results

OBJECTIVE

Single incision laparoscopic surgery (SILS) is a "scar-less" new surgical technique which has been gaining popularity over recent years. In comparison to conventional multiport laparoscopic surgery, SILS is introduced as a less invasive method. This technique has also been applied to colorectal surgery. The aim of the presenting study is to investigate the applicability of SILS and report short term results.

MATERIAL AND METHODS

We evaluated prospectively collected data of 24 patients who had been operated with "Single Incision Laparoscopic Colon Resection (SILCR)" in our clinic between June 2011-June 2013. Informed consent was obtained from all patients before surgery. Patient data such as ASA and BMI values, need for additional surgery, tumors, number of lymph nodes resected, length of hospital stay, length of surgery, timing of flatus, time to start oral feeding and complications were recorded.

RESULTS

SILCR was performed in 24 patients. In 13 patients, SILCR was performed for cancer treatment. There was no need for extra ports, conversion to open surgery and stoma creation was also not necessary. Drain was placed in 4 patients. Overall complication rate was 12.5%. The mean number of lymph nodes in 13 patients who underwent SILCR for tumor was found to be 23 (14-33). The mean operative time and length of hospital stay was 177 minutes (110-363) and 5.35 days (4-11) respectively. Anastomotic leakage was not seen in any of the patients. In one patient, urinoma formation due to ureteral leakage was seen which resulted from thermal injury.

CONCLUSION

When we compare other series with almost the same number of patients' reported SILS results in the literature, we believe that we could draw conclusions from our data. SILS appears to have comparable results to conventional multiport laparoscopic surgery in the hands of experienced surgeons. It seems advantegous as it can be done with conventional laparoscopic instruments in a "scar-less" manner. Prospective randomized trials are necessary to define the benefits of one procedure over the other.