Comparison of single-incision plus one additional port laparoscopy-assisted anterior resection with conventional laparoscopy-assisted anterior resection for rectal cancer. World J Surg. 2014;38:2716-2723. [PMID: 24852437 DOI: 10.1007/s00268-014-2642-8]

Single-Incision Combined Laparoscopic Right Hemicolectomy and Cholecystectomy: A Case Report

Minimally invasive surgery has transformed the management of complex procedures, offering reduced postoperative pain, faster recovery time, and improved cosmetic outcomes. Despite the growing use of minimally invasive techniques, literature specifically addressing single-incision laparoscopic surgery (SILS) for combined hemicolectomy and cholecystectomy is limited. This report seeks to fill this gap by detailing the successful management of a patient case through a single-incision combined laparoscopic right hemicolectomy and cholecystectomy. A 66-year-old female was referred to surgical consultation following a routine screening colonoscopy that identified a greater than 5 cm sessile polyp in the ascending colon. A follow-up computed tomography (CT) scan of the abdomen and pelvis revealed a non-metastatic mass in the ascending colon and gallstones correlating with the patient's reported abdominal discomfort. The decision was made to proceed with a single-incision laparoscopic right hemicolectomy and cholecystectomy. The cholecystectomy and subsequent right hemicolectomy were both performed through a 3 cm umbilical incision using the advanced access platform. Postoperative recovery was uneventful, with the patient passing flatus by day three, starting a clear liquid diet, and being discharged by day four. Pathological analysis of specimens revealed chronic cholecystitis with cholelithiasis and a tubulovillous adenoma of the colon without high-grade dysplasia or metastatic carcinoma. At the 15-day follow-up, the patient reported a full resumption of normal activities and was highly satisfied with the cosmetic results. This case report highlights the benefits of combining SILS right hemicolectomy and cholecystectomy through reducing multiple abdominal procedures, surgical trauma, operating time, and recovery period, all while achieving excellent cosmetic outcomes. Further research and advanced training in SILS combined procedures are needed for broader applicability in more complex cases.

New Exploration of Single-Incision Plus Two Ports Laparoscopic Pancreaticoduodenectomy Based on the Principle of Enhanced Recovery after Surgery

Background: Despite single-incision laparoscopic surgery (SILS) being a standard procedure, its main shortcomings include narrow operating space and instrument collisions. Although the proposal of single-incision plus one-port laparoscopic surgery (SILS + 1) reduces the operational difficulty, laparoscopic pancreaticoduodenectomy (LPD) involves complex digestive tract resection and anastomosis. To reduce the number of incisions while ensuring the quality of LPD, we propose a single-incision plus two ports LPD (SILPD + 2) procedure wherein a surgeon uses two trocars with a traditional layout while the assistant and scope assistant conduct subumbilical incision. Methods: Retrospective analysis was performed of the perioperative data of 64 patients who underwent total LPD at our department from January to June 2023, including their age, gender, surgical operation time, estimated bleeding loss, and postoperative complications. Based on the number of inserted trocars, the patients were assigned to the conventional LPD (CLPD) group (n = 55) with five incisions and the new SILPD + 2 group (n = 9). Results: A total of 64 patients were included in this study, including 55 in the CLPD group and 9 in the SILPD + 2 group. The SILPD + 2 group patients had lower age and body mass index when compared to the CLPD group patients, albeit there was no statistical significance. In both groups of patients, laparoscopic surgery was completed. Regarding the operation time, estimated blood loss, and intraoperative blood transfusion, the SILPD + 2 group showed no significant disadvantage. Conclusion: When compared to CLPD, SILPD + 2 reduced the surgical difficulty by reducing incisions, and there was no significant difference in the short-term prognosis outcomes.

Single-incision plus one-port laparoscopy surgery versus conventional multi-port laparoscopy surgery for colorectal cancer: a systematic review and meta-analysis

OBJECTIVE

The efficacy of single-incision plus one-port laparoscopic surgery (SILS + 1) versus conventional laparoscopic surgery (CLS) for colorectal cancer treatment remains unclear. This study compares the short-term and long-term outcomes of SILS + 1 and CLS using a high-quality systematic review and meta-analysis.

METHOD

Literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, drawing from PubMed, Embase, Web of Science, and the Cochrane Library until December 10, 2023. Statistical analysis was conducted using RevMan and Stata.

RESULT

The review and meta-analysis included seven studies with 1740 colorectal cancer patients. Compared to CLS, SILS + 1 showed significant improvements in operation time (WMD =  - 18.33, P < 0.00001), blood loss (WMD =  - 21.31, P < 0.00001), incision length (WMD =  - 2.07, P < 0.00001), time to first defecation (WMD =  - 14.91, P = 0.009), time to oral intake (WMD =  - 11.46, P = 0.04), and time to ambulation (WMD =  - 11.52, P = 0.01). There were no significant differences in lymph node harvest, resection margins, complications, anastomotic leakage, hospital stay, disease-free survival, overall survival, and postoperative recurrence.

CONCLUSIONS

Compared to CLS, SILS + 1 demonstrates superiority in shortening the surgical incision and promoting postoperative recovery. SILS + 1 can provide a safe and feasible alternative to CLS.

Clinical application of two-port laparoscopic surgery in sigmoid colon and upper rectal cancer resection

Background

In the field of minimally invasive surgery, the two-port laparoscopic surgery is on the rise. This study investigated the safety and efficacy of two-port laparoscopic surgery (TLS) for resecting sigmoid colon and upper rectal cancers compared with conventional laparoscopic surgery (CLS).

Methods

The clinical data of patients undergoing laparoscopic sigmoid colon cancer and upper rectal cancer resection at the Department of General Surgery of the First Affiliated Hospital of Gannan Medical College between July 2019 and January 2022 were retrospectively collected. Grouped according to different laparoscopic surgery. Based on the inclusion and exclusion criteria,A total of 81 patients were enrolled, of the 25 patients from the TLS group,and of the 56 patients from the CLS group. We mainly compared whether there were statistical differences between the two groups in terms of operative time, intraoperative bleeding, incision length, time to first ambulation, time to first flatus, time to first defecation, postoperative complication rate, and other surgical outcomes.

Results

There was no statistical difference between the two groups in terms of baseline clinical characteristics (P > 0.05). In terms of the surgical outcomes, there were statistical differences in the total incision length (TLS: 6.21 ± 0.67 cm, CLS: 8.64 ± 1.08 cm, P < 0.001)), time to first ambulation (TLS: 2.0 ± 0.7 d, CLS:3.1 ± 0.9 d, P < 0.001), time to first flatus (TLS: 2.5 ± 0.8 d, CLS: 3.0 ± 0.8 d, P = 0.028), time to first defecation (TLS: 3.8 ± 1.3 d, CLS: 5.1 ± 2.1 d, P = 0.010), and time for liquid diet (TLS: 4.3 ± 1.4 d, CLS: 5.3 ± 1.9 d, P = 0.021). There was no statistical difference between the two groups in terms of the pathology (P > 0.05).

Conclusion

In terms of safety, TLS in sigmoid colon and upper rectal cancer resection is comparable to CLS. However, its incision is smaller and more aesthetic, and it causes lesser trauma than CLS. Additionally, it is also superior to CLS in postoperative recovery.

Exploration of the advantages of minimally invasive surgery for clinical T4 colorectal cancer compared with open surgery: A matched-pair analysis

The indications of minimally invasive surgery (MIS) for T4 colorectal cancer are controversial because the advantages of MIS are unclear. Therefore, we compared overall survival (OS) and recurrence-free survival (RFS) as the primary endpoint, and short-term outcome, alteration in perioperative laboratory data, and the interval of postoperative chemotherapy from operation as secondary endpoints, between MIS and open surgery (OPEN) using a matched-pair analysis. We explored the advantages of MIS for T4 colorectal cancer. In this retrospective single-institution study, we included 125 patients with clinical T4 colorectal cancer who underwent curative-intent surgery of the primary tumor between October 2010 and September 2019. Conversion cases were excluded. MIS patients were matched to OPEN patients (ratio of 1:2) according to tumor location, clinical T stage, and preoperative treatment. We identified 25 and 50 patients who underwent OPEN and MIS, respectively, including 31 with distant metastasis. Both groups had similar background characteristics. The rate of major morbidities (Clavien-Dindo grade > III) was comparable between the 2 groups (P = .597), and there was no mortality in either group. MIS tended to result in shorter postoperative hospitalization than OPEN (P = .073). Perioperative alterations in laboratory data revealed that MIS suppressed surgical invasiveness better compared to OPEN. Postoperative chemotherapy, especially for patients with distant metastasis who underwent primary tumor resection, tended to be started earlier in the MIS group than in the OPEN group (P = .075). OS and RFS were comparable between the 2 groups (P = .996 and .870, respectively). In the multivariate analyses, MIS was not a significant prognostic factor for poor OS and RFS. MIS was surgically safe and showed similar oncological outcomes to OPEN-with the potential of reduced invasiveness and enhanced recovery from surgery. Therefore, patients undergoing MIS might receive subsequent postoperative treatments earlier.

Effect of single-incision plus one port laparoscopic surgery assisted with enhanced recovery after surgery on colorectal cancer: study protocol for a single-arm trial

Background

Studies have proved that the enhanced recovery after surgery (ERAS) protocol can significantly improve the recovery course of patients during the perioperative period. The application of minimally invasive surgery is a critical component of ERAS protocol. Single-incision plus one port laparoscopic surgery (SILS plus one) could achieve further minimally invasive surgical results than conventional laparoscopic surgery (CLS). The objective of this trial is to evaluate the safety and feasibility of SILS plus one with ERAS protocol in colorectal cancer.

Methods

This is a prospective, single-center, open-label, single-arm trial. A total of 120 eligible patients with colorectal cancer will receive SILS plus one followed by the ERAS management during the perioperative period. The primary endpoint is postoperative hospital stay. The secondary endpoints include rehabilitative rate of the fourth postoperative day, postoperative medical cost, postoperative pain score, postoperative recovery indexes, inflammatory immune response indexes, compliance with ERAS measures, 6 min postoperative walking test (6MWT), hospital readmissions, and early postoperative complications.

Discussion

This trial will be the first to evaluate the short-term outcomes of SILS plus one assisted with ERAS protocol for patients with colorectal cancer and will provide valuable clinical evidence on the benefit of the combination of these two techniques, hopefully, to provide patients with more safe, economic, feasible, and rapid surgery and perioperative strategies.

Trial Registration

Clinical Trial Registry, NCT0426829. Registered February 15, 2020 (https://clinicaltrials.gov/ct2/show/NCT04268290).

A learning curve in using organ retractor for single-incision laparoscopic right colectomy

Single-incision laparoscopic surgery (SILS) has the potential to improve perioperative outcomes, including less postoperative pain, shorter operation time, less blood loss, and shorter hospital stay. However, SILS is technically difficult and needs a longer learning curve. Between April 2016 and September 2019, a total of 198 patients with clinical stage I/II right colon cancer underwent curative resection. In the case of the SILS approach, an organ retractor was usually used to overcome SILS-specific restrictions. The patients were divided into two groups by surgical approach: the SILS with organ retractor group (SILS-O, n = 33) and the conventional laparoscopic surgery group (LAC, n = 165). Clinical T status was significantly higher in the LAC group (p = 0.016). Operation time was shorter and blood loss was lower in the SILS-O group compared to the LAC group (117 vs. 197 min, p = 0.027; 10 vs. 25 mL, p = 0.024, respectively). In the SILS-O group, surgical outcomes including operation time, blood loss, number of retrieved lymph nodes, and postoperative complications were not significantly different between those performed by experts and by non-experts. Longer operation time (p = 0.041) was significantly associated with complications on univariate and multivariate analyses (odds ratio 2.514, 95%CI 1.047-6.035, p = 0.039). SILS-O was safe and feasible for right colon cancer. There is a potential to shorten the learning curve of SILS using an organ retractor.

Epidermoid cyst of the cecum resected by single-incision laparoscopic colectomy: a case report

Background

Epidermoid cyst arising from the cecum is extremely rare. Single-incision laparoscopic surgery is the latest innovation in minimally invasive surgery, and shortens incisions, improves cosmesis, and reduces postoperative pain. We report here the first description of a patient with epidermoid cyst of the cecum treated by ileocecal resection by single-incision laparoscopic surgery.

Case presentation

A 20-year-old woman presented to our hospital with abdominal pain in the right lower quadrant. Abdominal contrast-enhanced computed tomography showed a 56 × 35-mm cystic mass in the ileocecal area. Magnetic resonance imaging revealed a 56 × 43-mm, T1-hypointense, T2-hyperintense mass attached to the cecum. Gastrointestinal tumor or duplication cyst was suspected, and ileocecal resection was performed using single-incision laparoscopic surgery. Intraoperative examination showed the tumor as a round, whitish mass arising from the cecum. Operation time was 162 min, and intraoperative blood loss was 10 ml. Macroscopic examination showed a 56 × 45-mm elastic-hard, whitish, round mass arising from the cecal wall. Microscopic examination revealed the cyst wall lined by keratinized stratified squamous epithelium. No malignant findings were identified. The final diagnosis was epidermoid cyst of the cecum. The postoperative course was uneventful and she was discharged on postoperative day 5.

Conclusions

A rare case of cecal epidermoid cyst is reported. Single-incision laparoscopic colectomy using an organ retractor represents a promising option for treating cecal epidermoid cyst.

Short- And medium-term outcomes of reduced-port laparoscopic surgery in elderly patients with upper rectal cancer: A retrospective cohort study

Background

To investigate the short‐ and medium‐term outcomes of using a reduced‐port laparoscopic surgery (RPLS), compared to multi‐port laparoscopic surgery (MPLS), for the treatment of upper rectal cancer (URC) among elderly patients.

Methods

We conducted a retrospective analysis of the clinical and follow‐up data of 181 elderly patients with URC, who underwent radical laparoscopic surgery at our hospital, between January 2015 and January 2019. Among these 181 cases, 62 underwent RPLS and 119 MPLS.

Results

Compared to MPLS, RPLS decreased the length of surgical incision, lower pain on postoperative days 1 and 2, decreased the time to first flatus after surgery, as well as the time to mobilization after surgery. There was no difference between the short‐term outcomes between the two laparoscopic approaches, and no difference in the 3‐year disease‐free and overall survival rate.

Conclusion

Compared to MPLS, RPLS provides several advantages for the treatment of URC among elderly individuals, including a shorter length of surgical incision, reduced postoperative pain, shorter time to first flatus after surgery, earlier mobilization, and better cosmetic outcomes. These advantages are achieved with no difference in the length of surgery, nor in the 3‐year disease‐free and overall survival rate, compared to MPLS.

Single-incision laparoscopic total colectomy using an organ retractor: A case report

Introduction

Single-incision laparoscopic surgery (SILS) has benefits, including less postoperative pain, a shorter incision, and improved cosmesis. However, SILS is technically difficult because of the limited movement. An organ retractor is an instrument that has the potential to overcome these limitations.

Presentation of case

An 85-year-old woman with hematochezia was referred to our hospital. Emergency endoscopy showed diverticulosis of the entire colon and active bleeding from the ascending colon. Despite endoscopic clipping, the bleeding continued. SILS total colectomy using an organ retractor was performed due to uncontrollable diverticular bleeding. A 3-cm incision was placed in the umbilicus, and three conventional ports were inserted into the single umbilical incision. An organ retractor was used for hepatocolic ligament transection, transection of the ileocolic vessels, and transection of the mesentery of the sigmoid colon. For each transection, the tension was adjusted to provide a good operative view. The patient's postoperative course was uneventful.

Conclusion

An organ retractor was effective for SILS total colectomy to maintain an adequate operative view, which enabled safe dissection.

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.

Short-term outcomes of single-incision plus one-port laparoscopic versus conventional laparoscopic surgery for rectosigmoid cancer: a randomized controlled trial

OBJECTIVE

The objective of the study is to evaluate the short-term outcomes of single-incision plus one-port surgery (SILS + 1) compared with conventional laparoscopic surgery (CLS) for colonic cancer.

BACKGROUND

At present, single-incision laparoscopic colectomy remains technically challenging. The use of SILS + 1 as an alternative has gained increasing attention; however, its safety and efficacy remain controversial.

METHODS AND PATIENTS

Between April 2014 and July 2016, 198 patients with clinical stage T1-4aN0-2 M0 rectosigmoid cancer were enrolled. The participants were randomly assigned to either SILS + 1 (n = 99) or CLS (n = 99). The morbidity and mortality within 30 days, operative and pathologic outcomes, postoperative recovery course, inflammation and immune responses, and pain intensity were compared.

RESULTS

There was no significant difference in overall complications between the two groups (17.2 vs. 16.3%, P = 1.000). The total operating time for the SILS + 1 group was significantly shorter (100.8 ± 30.4 vs. 116.6 ± 36.6, P = 0.002). Blood loss was significantly greater in the CLS group (20 vs. 50, P < 0.001). Thirteen patients (14%) in the CLS group required additional postoperative analgesics, which was significantly more than four patients in the SILS + 1 group. Notably, on postoperative day three, the visual analogue scale score of the CLS group was greater than that of the SILS + 1 group (1.3 ± 1.1 vs. 1.7 ± 1.3, P = 0.023). Tumor diameter, pathologic stage, length of the proximal and distal margins, and number of lymph nodes harvested were similar, other values were also similar between the two groups.

CONCLUSION

Our findings suggest that SILS + 1 might be safe and feasible for rectosigmoid cancer when performed by experienced surgeons. It offers minimal invasiveness without compromising oncologic treatment principles. Trial Registration This trial was registered on ClinicalTrials.gov (NCT02117557).

The effect of increased body mass index values on surgical outcomes after radical resection for low rectal cancer

PURPOSES

This study aimed to explore the effect of increased body mass index (BMI) values (overweight: BMI ≥ 25-30 kg/m²; obese: BMI ≥ 30 kg/m²) on surgical outcomes after radical resection for low rectal cancer (LRC).

METHODS

Patients with LRC who underwent radical surgery from January 2009 to December 2013 were included. The patients were divided into three groups according to their BMI values (control group: BMI < 25 kg/m²; overweight group: BMI 25 to < 30 kg/m²; obese group: BMI ≥ 30 kg/m²). The patients' clinicopathological characteristics and survival data were collected and analyzed.

RESULTS

A total of 792 patients were enrolled in this study finally (control, n = 624; overweight, n = 147; obese, n = 21). The baseline characteristics of the three groups were similar. We found that an increased BMI was associated with a longer operative time (P < 0.001) and length of postoperative hospital stay (P = 0.032). Patients with increased BMI values had a significantly higher incidence of postoperative complications, including pulmonary infection (P = 0.008), anastomotic leakage (P = 0.029), allergy (P = 0.017) and incisional hernia (P = 0.045). The limited data showed that the pathological outcomes of the three groups did not differ to a statistically significant extent. A multivariate analysis showed that increased BMI was not associated with poorer OS or DFS.

CONCLUSION

In LRC resection, an increased BMI was associated with a longer operative time, postoperative hospital stay, and an increased number of postoperative complications. However, it did not contribute to poorer pathological or survival outcomes.

Reduced-Port Laparoscopic Surgery for Patients With Proximal Transverse Colon Cancer With Situs Inversus Totalis: A Case Report

Situs inversus is a rare hereditary disorder in which various anomalies have been reported with internal rotation abnormalities. This case involved an 85-year-old woman who had been diagnosed with transverse colon cancer and who underwent reduced-port laparoscopic surgery. All intra-abdominal organs were reversed left to right and right to left. The aberrant midcolic artery was identified during surgery. The total surgery time was 170 minutes, and the patient lost 20 mL of blood. The patient was discharged on the 8th postoperative day without complications.

The Balance Between Surgical Resident Education and Patient Safety in Laparoscopic Colorectal Surgery: Surgical Resident's Performance has No Negative Impact

OBJECTIVE

This study aimed to evaluate the feasibility and effectiveness of a comprehensive theoretical and hands-on training program in performing laparoscopic colonic resections under supervision of an expert surgeon.

MATERIALS AND METHODS

Laparoscopic right colectomy was performed in 78 patients (10 with benign disease, 68 with carcinoma). Demographic, intraoperative, pathologic examination, and short-term outcome data were retrospectively compared between 25 patients operated by surgical residents (R group) and 53 patients operated by senior surgeons (S group). The residents who performed surgeries in the R group had between 1 and 6 years after graduation; no experience with open or laparoscopic colorectal surgery was necessary. The residents completed a training program under supervision of a single expert laparoscopic colorectal surgeon, which included 6 steps, from basic skills to certification.

RESULTS

There were no differences in patient age, sex, and body mass index between the R and S groups. Significantly more patients in the R group had early cancer and benign lesions (P<0.05). Thirteen of the 16 residents (81.2 %) had not had prior experience with colonic resection. The time of suturing and knot tying in the dry box did not differ between residents and senior surgeons (68 and 69 s, respectively). All the residents performed laparoscopic right colectomy without intraoperative complications. There were no significant differences in operating time (R group: 173±34 min, S group: 172±52 min), mean estimated blood loss (50±111 vs. 49±100 mL), number of lymph nodes dissected (20.8±12.8 vs. 17.1±9.0), and mean postoperative hospital stay (9.1±3.3 vs. 10.7±4.1 d). On the basis of the year of their residency period, all 3 residents at 6 years after graduation had far greater experience than the other residents and therefore performed the surgery with minor verbal support from the expert. However, residents with 1 or 2 years after graduation had to receive guidance provision by the expert during surgery.

CONCLUSIONS

When supervised and led by an expert laparoscopic surgeon, surgical residents are capable of performing laparoscopic surgery without negative effects on outcomes.

Six Cases of Simultaneous Reduced Port Laparoscopic Surgery for Synchronous Gastric and Colorectal Cancer

We report 6 cases of simultaneous resection of synchronous gastric and colorectal cancer using a multichannel port and an additional 5-mm port. This is the first report of simultaneous gastric and colorectal resection using a reduced port technique. A multichannel port was inserted into an umbilical incision, and another 5-mm port in the right flank region. We named this approach “dual port surgery.” This report includes a 76-year-old man who underwent total gastrectomy and left hemicolectomy, a 70-year-old woman who underwent distal gastrectomy and high anterior resection, a 75-year-old man who underwent distal gastrectomy and right hemicolectomy, a 72-year-old man who underwent total gastrectomy and sigmoidectomy, a 67-year-old man who underwent distal gastrectomy and high anterior resection, and a 57-year-old woman who underwent distal gastrectomy and right hemicolectomy. All operations were successful. All patients recovered quickly, and were discharged without any intra- or postoperative complications. On a median follow-up of 14.5 months, all patients remain well with no evidence of recurrent malignancy. This is the first report of simultaneous reduced port laparoscopic surgery for synchronous gastric and colorectal cancer. This procedure was performed safely and successfully.

Multidimensional analyses of the learning curve for single-incision plus one port laparoscopic surgery for sigmoid colon and upper rectal cancer

BACKGROUND AND OBJECTIVES

Single-incision plus one port surgery (SILS + 1) provides the advantages of being minimally invasive and easier to perform than pure single-incision laparoscopic surgery. The aim of this study was to investigate the learning curve (LC) for SILS + 1 for sigmoid colon and upper rectal cancer.

METHOD

From November 2012 to May 2014, a series of 85 consecutive patients underwent selective SLIS + 1 for sigmoid colon and upper rectal cancer performed by a single surgeon at Nanfang Hospital. The LC for SILS + 1 was evaluated using cumulative sum control chart (CUSUM) and risk-adjusted CUSUM methods. Data for all the perioperative variables and pathologic results among the phases were compared.

RESULTS

The LC had three phases: phase 1 (cases 1-13) was the initial learning period; phase 2 (cases 14-44) was the learning plateau period; and phase 3 (cases 45-85) was the competent period. The differences in total operating time among the three phases were significant. The number of harvested lymph nodes increased along with increases in the surgeon's experience.

CONCLUSIONS

For experienced CLS surgeons, the learning process reached the plateau period after the 13th case, and technical competence was achieved after the 44th case.

Safety and feasibility of single-port laparoscopic low anterior resection for upper rectal cancer

BACKGROUND

Single-port surgery for rectal cancer is challenging and controversial. The aim of this study was to compare the short-term outcomes of single-port laparoscopic low anterior resection (S-LAR) to multi-port laparoscopic low anterior resection (M-LAR) for upper rectal cancer.

METHODS

From January 2011 to December 2015, a total of 93 patients who underwent S-LAR (n = 44) or M-LAR (n = 49) without protective diverting ileostomy for upper rectal cancer were identified. Tumors were located between the inferior margin of the second sacral vertebra and the peritoneal reflection. Short-term outcomes were compared between groups.

RESULTS

S-LAR was successful in 75% of cases: 25% of cases required one additional port. Operative factors, perioperative outcomes, oncological outcomes did not differ significantly between groups. In patients with stage I-III disease, the 3-year relapse-free survival rate was significantly higher in the S-LAR group than in the M-LAR group (p = 0.032). The 3-year overall survival rate was similar between groups.

CONCLUSIONS

S-LAR is safe, feasible and can provide satisfactory oncological outcomes in selected patients with upper rectal cancer.

Single Port and Conventional Laparoscopy in Colorectal Surgery: Comparison of Two Techniques

BACKGROUND

Single-incision laparoscopic surgery (SILS) was introduced to further the enhanced outcome of conventional multiport laparoscopy (CML). We compared their short- and long-term outcomes in colorectal surgery.

MATERIALS AND METHODS

Retrospective review of patients who underwent elective laparoscopic colorectal surgery during 3-year period. Patients' data, surgery outcomes, and oncological results were compared.

RESULTS

Sixty-one patients (33 male, 28 female), mean age 67.4 years, underwent laparoscopic colonic resections: 28 SILS and 33 CML. Twenty-three (37.7%) patients had previous abdominal surgery. There were 19 (31.2%) right, 9 (14.7%) left, and 2 (3.3%) total colectomies, 16 (26.2%) sigmoidectomies, 13 (21.3%) anterior and 2 (3.3%) abdominoperineal resections. Colonic malignancy was a main indication for the surgery in 51 (83.6%) patients. Mean surgery time and postoperative stay were 92.0 minutes and 9 days, respectively. Pathological examination revealed stage I colon cancer in 16 (32%), stage II in 22 (44%), stage III in 10 (20%), and stage IV in 2 (4%) patients. Mean number of retrieved lymph nodes was 19 ± 13.5. No differences were found between groups in demographic data, type of surgery, surgery time and hospital stay, pathological results and tumor staging, and disease-free and overall survivals. In the SILS group, placement of additional trocar was required in 7 (25%) and conversion in 3 (10.7%) cases compared with 1 (3%) case of conversion to formal laparotomy in the CML group. Overall postoperative morbidity was 16.4%. There was no mortality in both the groups. During the study period, 3 patients from the CML group had cancer recurrence.

CONCLUSIONS

SILS is a feasible and safe technique compared with CML in terms of surgical and oncological outcomes.

Assessment of treatment options for rectosigmoid cancer: single-incision plus one port laparoscopic surgery, single-incision laparoscopic surgery, and conventional laparoscopic surgery

BACKGROUND

The advantages of reduced-port laparoscopic surgery (RPLS) for rectosigmoid cancer treatment have been disputed. This study evaluated the outcomes of RPLS compared to conventional laparoscopic surgery (CLS) for rectosigmoid cancer.

METHODS

Data from 211 patients who underwent a selective sigmoidectomy or anterior resection from August 2011 to June 2014 at a single institution were collected and analyzed via propensity score matching. Operative outcomes, inflammatory responses, pain intensity, oncologic outcomes, quality of life, and cosmetic results were compared between groups.

RESULTS

After matching, 96 patients (48 CLS and 48 RPLS) were evaluated. Sixteen RPLS cases underwent single-incision laparoscopic surgery (SILS), and 32 underwent single-incision plus one port laparoscopic surgery (SILS + 1). Baseline clinical characteristics were comparable between the RPLS and the CLS groups. Morbidity, pathologic outcomes, and 3-year disease-free survival and overall survival rates were also comparable between the 2 groups. Compared with the CLS group, the RPLS group had a shorter total incision length (p < 0.001); shorter time to liquid diet (p = 0.027), ambulation (p = 0.026), and discharge (p < 0.001); and lower visual analogue scale scores during mobilization at postoperative days 3-5 (p < 0.05). The total operation times, C-reactive protein levels at 24 h and 96 h, and interleukin-6 levels at 24 h postoperatively were significantly lower in the SILS + 1 group than those in the CLS and SILS groups (p < 0.05). Compared with the CLS group, the RPLS group showed better social functioning at 6 months postoperatively (p = 0.011). The SILS and SILS + 1 groups showed similar cosmetic results, and both groups showed better results than the CLS group (p < 0.001).

CONCLUSIONS

RPLS for rectosigmoid cancer is feasible, with short-term safety and long-term oncological safety comparable to that of CLS. Better cosmesis and accelerated recovery can be expected. SILS + 1 is a better choice than CLS or SILS for rectosigmoid cancer because it minimizes invasiveness and reduces technical difficulties.

Two-port laparoscopic anterior resection through a self-made glove device versus conventional laparoscopic anterior resection for rectal cancer: a comparison of short-term surgical results

Background

The laparoscopic approach has become increasingly incorporated into the development of new surgical procedures. An ever-increasing number of surgeons desire methods that minimize surgical trauma and provide improved cosmetic outcomes. Since 2014, we have performed two-port laparoscopic surgery using a transumbilical multichannel glove port and a 12-mm port. The aim of this study was to compare the short-term surgical results of two-port laparoscopic anterior resection (TPLAR) with those of conventional laparoscopic anterior resection (CLAR) for rectal cancer.

Methods

Between January 2014 and May 2014, a total of 27 patients underwent TPLAR and 30 patients underwent CLAR for the treatment of rectal cancer. The short-term surgical results of these two groups of patients were analyzed retrospectively.

Results

The differences in operative time, blood loss, conversion rate, complication rate, distal resection margin, number of harvested lymph nodes, duration until ambulation, duration until first flatus, length of postoperative hospital stay, and overall hospital costs between the two groups were not significant. The median (range) length of the abdominal incisions of the TPLAR patients was shorter than the length of the CLAR patients (5.1 (4.5–16.3) cm vs 8.2 (7.0–10.0) cm, respectively; p < 0.001). The respective median (range) postoperative pain scores were lower in the TPLAR than in the CLAR patients at 24 h (4 (1–6) h vs 5 (2–8) h; p = 0.045), 48 h (3 (1–4) h vs 4 (range 1–8) h; P = 0.004) and 72 h (1 (0–3) h vs 2 (1–5) h; p = 0.010). The median overall score on the satisfaction-with-abdominal-incision questionnaire of the TPLAR patients was significantly higher (better) than the score of the CLAR patients.

Conclusions

TPLAR for rectal cancer is safe and feasible, with short-term perioperative and oncological outcomes similar to those of CLAR. TPLAR provides less postoperative pain and better cosmetic outcomes.

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.

Successful treatment of rectovaginal fistula and rectal stenosis due to perianal Crohn's disease by dual-port laparoscopic abdominoperineal resection: a report of two cases

BACKGROUND

The incidence of rectovaginal fistula in women with Crohn's disease has been reported to be 3-10 %. Although rectovaginal fistulas can be managed medically and surgically, they have high rates of recurrence and complications. Rectal stenosis is another condition that occurs due to perianal Crohn's disease. A novel, minimally invasive procedure, dual-port laparoscopic abdominoperineal resection using a multichannel port, has been shown effective in patients with lower rectal cancer and patients with medically uncontrolled ulcerative colitis. This report describes the use of the same method for two patients with Crohn's disease-related rectovaginal fistula and rectal stenosis.

CASE PRESENTATION

The first patient, a 22-year-old woman, was diagnosed with rectovaginal fistula and rectal stenosis due to perianal Crohn's disease 2 years earlier. Induction therapy with infliximab and endoscopic balloon dilatation did not improve her symptoms. The second patient, a 33-year-old woman, was also diagnosed with rectovaginal fistula and rectal stenosis due to perianal Crohn's disease, and medical treatment was also unsuccessful. Both patients underwent dual-port laparoscopic abdominoperineal resection using a multichannel port, with no perioperative and postoperative complications.

CONCLUSION

These findings show that this reduced port method can be used to successfully treat patients with Crohn's disease-associated rectovaginal fistula and rectal stenosis.

Epidermal Sutureless Closure of the Umbilical Base Following Laparoscopic Colectomy for Colon Cancer

At our institute, a non-suturing method for closure of the umbilical epidermis has been used in laparoscopic colorectal resection to prevent umbilical wound infection. We performed a retrospective evaluation of the incidence of umbilical wound infection using this technique for patients with colorectal cancer. From 2010 to 2014, 178 consecutive patients underwent elective laparoscopic resection of colorectal cancer. The umbilical fascia was closed using interrupted multifilament absorbable sutures. The skin surface of the umbilicus was compressed using a cotton ball and sealed by water vapor-permeable film. Three (1.7 %) patients required conversion from laparoscopic to open surgery. The mean surgery time was 174 ± 48 min, intraoperative blood loss was 29 ± 75 mL, and postoperative hospital stay was 10.5 ± 6.7 days. According to the Centers for Disease Control and Prevention criteria, umbilical superficial wound infection occurred in two (1.1 %) patients. The two patients recovered from their wound infections after a few days of drainage, and their hospital discharge was not delayed. Deep umbilical wound infection did not occur in any patient. Our non-suturing closure technique appeared to be effective in preventing wound infection after laparoscopic resection of colon cancer.

Postoperative analgesia using fentanyl plus celecoxib versus epidural anesthesia after laparoscopic colon resection

PURPOSE

Effective postoperative analgesia is essential to a patient's recovery after laparoscopic colon resection (LCR). We introduce a new analgesic protocol using fentanyl plus celecoxib following LCR.

METHODS

The subjects of this retrospective comparative study were 137 patients who underwent LCR, 63 of whom were treated with 72 h of epidural anesthesia (group E), and 74 of whom were treated with 24 h of fentanyl intravenous injection followed by 7 days of oral celecoxib (group FC). We evaluated the safety and efficacy of this new protocol.

RESULTS

The combination of fentanyl and celecoxib maintained a low postoperative pain score (<1.5, evaluated by the FACES Pain Scale) and reduced the need for rescue analgesic drugs for 7 days (groups E vs. FC: 5.39 ± 3.77 vs. 2.79 ± 2.92, p < 0.001). The postoperative hospital stay was almost equal for the two groups (E vs. FC: 11.1 ± 4.5 vs. 10.3 ± 4.8 days, p = 0.315). The operating room stay other than for surgery was significantly shorter for group FC (E vs. FC: 128.7 ± 30.5 vs. 107.2 ± 17.0 min, p < 0.001). Neither group experienced complications, apart from one group FC patient, who suffered transient nausea and vertigo.

CONCLUSIONS

The new analgesic protocol using fentanyl plus celecoxib is an effective and time-saving strategy for LCR.

Does reduced-port laparoscopic surgery for medically uncontrolled ulcerative colitis do more harm than good?

INTRODUCTION

Reduced-port laparoscopic surgery is a novel minimally invasive surgery. However, reduced-port surgery for ulcerative colitis (UC) remains controversial. Here, we describe the clinical outcomes of single-incision plus one port laparoscopic surgery (SILS + 1) for medically uncontrolled UC.

METHODS

Between May 2011 and September 2014, 10 UC patients underwent SILS + 1 port surgery. All procedures were performed with the use of a SILS port and either a 5-mm or a 12-mm port placed at the planned ileostomy site.

RESULTS

The median age of patients was 32 years (range, 22-53 years). Six patients underwent two-stage SILS + 1 port restorative proctocolectomy with ileal pouch-anal anastomosis, two patients underwent SILS + 1 total proctocolectomy, and the remaining two patients underwent SILS + 1 subtotal colectomy with subsequent three-stage SILS + 1 ileal pouch-anal anastomosis. The median operative time was 363.1 min (range, 253-465 min) and the median estimated blood loss was 29 mL (range, 0-100 mL). There were no conversions or additional ports required. Two patients previously underwent SILS + 1 subtotal colectomy, and in one of those patients, SILS + 1 ileal pouch-anal anastomosis was performed successfully 6 months after the previous surgery. There were no intra-abdominal adhesions, and no extra wounds were necessary because the previous stoma site had been used to access the SILS port. The median postoperative period was 24 months, during which five patients had their ileostomies closed. No patients reported occasional minor daily soiling or the need to wear a pad.

CONCLUSION

Reduced-port laparoscopic surgery for medically uncontrolled UC is a feasible and safe procedure when performed by skilled surgeons.

Review of 500 single incision laparoscopic colorectal surgery cases - Lessons learned

Single incision laparoscopic surgery (SILS) is a minimally invasive platform with specific benefits over traditional multiport laparoscopic surgery. The safety and feasibility of SILS has been proven, and the applications continue to grow with experience. After 500 cases at a high-volume, single-institution, we were able to standardize instrumentation and operative steps, as well as develop adaptations in technique to help overcome technical and ergonomic challenges. These technical adaptations have allowed the successful application of SILS to technically difficult patient populations, such as pelvic cases, inflammatory bowel disease cases, and high body mass index patients. This review is a frame of reference for the application and wider integration of the single incision laparoscopic platform in colorectal surgery.

Single-incision laparoscopic surgery for rectal cancer: early results and medium-term oncological outcome

AIM

Conventional laparoscopic surgery for rectal cancer management is now widely accepted as an alternative to open surgery, bestowing specific advantages without causing detriment to oncological outcome. Evolving from this, single-incision laparoscopic surgery (SILS) has been successfully utilized for the removal of colonic tumours, but the literature lacks data analysing the suitability of SILS for rectal cancer resection, particularly on oncological outcome. We report the medium-term oncological outcome from a prospective observational study of SILS for rectal cancer, including high and low anterior resections.

METHOD

A prospective electronic database was collated of all patients undergoing SILS rectal cancer resection in our institution, between 2009 and 2014. In addition to patient, tumour and operative data, histopathological and medium-term oncological end-points were recorded. Kaplan-Meier curves were used to analyse survival.

RESULTS

Sixty-one patients underwent SILS for rectal cancer by high anterior resection (n = 34), low anterior resection with total mesorectal excision (TME) (n = 24) and low anterior resection with TME and hand-sewn colo-anal anastomosis (n = 3). The median operation time was 105 (37-280) min and 92% of cases were completed by SILS. The mean interval to resuming oral feeding was 11 h and the median length of stay was 2 (1-8) days. The median number of lymph nodes found by the histopathologist in the resected specimen was 18 (6-44) and all operations completely removed the tumour (R0 resection). At a median follow-up of 46 (16-64) months, eight (13%) patients developed metastatic disease, of whom three had local recurrence. Overall, three patients have died, of whom all had metastatic disease.

CONCLUSION

Anterior resection with TME for rectal cancer can be safely performed using the SILS technique, with acceptable histopathological results and good oncological outcome.

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).

SILS v SILS+1: a Case-Matched Comparison for Colorectal Surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) is safe and feasible for benign and malignant colorectal diseases. SILS has comparable or improved outcomes compared to multiport laparoscopy but technical limitations when operating in the pelvis. To address these limitations, we developed an innovative SILS+1 approach using a single Pfannenstiel incision for pelvis access with one additional umbilical port. Our goal was to compare outcomes for SILS and SILS+1 in lower abdominal and pelvic colorectal surgery.

METHODS

Review of a prospectively maintained database identified patients who underwent an elective reduced port laparoscopic lower abdominal/pelvic colorectal procedure from 2009 to 2014. Cases were stratified by approach: SILS versus SILS+1 then matched 1:2 on age, gender, body mass index (BMI), comorbidity, and procedure. Demographic, perioperative, and postoperative outcome variables were evaluated. The main outcome measures were operative time, conversion rate, length of stay, complication, morbidity, and mortality rates.

RESULTS

One hundred thirty-two reduced port AR/LAR patients were evaluated-44 SILS and 88 SILS+1. The groups were similar in age, gender, BMI, and ASA class. The primary diagnosis in both cohorts was diverticulitis (90.9 % SILS, 87.5 % SILS+1), and main procedure performed an anterior rectosigmoidectomy (86.4 % SILS, 88.2 % SILS+1). Significantly more SILS+1 patients had previous abdominal surgery (p = 0.01). The operative time was significantly shorter in SILS+1 (mean 166.6 [SD 48.4] vs. 178.0 [SD 70.0], p = 0.03). The conversion rate to multiport or open surgery was also significantly lower with SILS+1 compared to SILS (1.1 vs. 11.4 %, p = 0.02). Postoperatively, the length of stay across the groups was similar. SILS trended towards higher complication and readmission rates (NS). There were no unplanned reoperations or mortality in either group.

CONCLUSIONS

SILS+1 facilitates pelvic and lower abdominal colorectal surgery, with shorter operative times and lower conversion rates. The additional port improved visualization and outcomes without any impact on length of stay, readmission, or complication rates.

Dual-port laparoscopic abdominoperineal resection using the intended stoma site as the multichannel port

We describe a novel minimally invasive procedure: dual-port laparoscopic abdominoperineal resection using a SILS port, and report our experience of using this to treat ten patients with lower rectal cancer. A SILS port was placed in the left lower quadrant at the intended colostomy site. A 5-mm trocar was inserted at the umbilicus at the subsequent drain site. Via a standard laparoscopic medial-to-lateral approach, the inferior mesenteric artery and vein were ligated and total mesorectal excision was performed. Via a perineal approach, the specimen was retrieved from the perineal wound, and a sigmoid colostomy was created at the site of the SILS port. Ten consecutive patients with lower rectal cancer at clinical stage T3 or lower underwent the procedure at our institution. The procedure was completed successfully in all patients, without any intraoperative problems and all postoperative outcomes were satisfactory. Thus, dual-port laparoscopic abdominoperineal resection can be performed safely and feasibly in selected patients.

Comparison of short-term surgical results of single-port and multi-port laparoscopic rectal resection for rectal cancer

BACKGROUND

Single-port surgery is a recent advancement in minimally invasive techniques for colon disease. However, single-port laparoscopic rectal resection (SPLR) is rare. The aim of this study was to compare the short-term results of SPLR with those of multi-port laparoscopic rectal resection (MPLR) for rectal cancer.

METHODS

Patients who underwent SPLR (n = 50) or MPLR (n = 50) for rectal cancer from July 2010 to March 2014 were analyzed. Patients with tumor diameter less than 40 mm and body mass index less than 30 kg/m(2) were matched for age, sex, tumor location, and preoperative evaluation. Operative parameters and outcomes were compared between groups. Patients with lower rectal cancer were excluded.

RESULTS

SPLR was successful in 98.0% of cases. Operative procedure, operative time, blood loss, field of lymph node dissection, and rate of postoperative complications did not differ significantly. Length of hospital stay was shorter with SPLR than with MPLR (8 vs 10 days, respectively; P = .018). Oncological outcomes did not differ significantly between the 2 groups.

CONCLUSION

SPLR is safe and feasible in selected patients with rectal cancer.