Patient Body Image and Satisfaction with Surgical Wound Appearance After Reduced Port Surgery for Colorectal Diseases

Single-incision versus conventional multiport laparoscopic-assisted surgery for Meckel's diverticulum in children: a single-center propensity score analysis

BACKGROUND

Meckel's diverticulum (MD) is the most common congenital anomaly of the small intestine, and often leads to various complications in children. This study aims to compare the efficacy and safety of single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) in the treatment of MD in children.

METHODS

Retrospective review of patients who underwent laparoscopic surgery for MD at a tertiary pediatric hospital from February 2017 to February 2023 was conducted with registered of demographic information, preoperative laboratory results, operative findings, and postoperative outcomes. Based on the surgical strategy, patients were classified into SILS and CLS groups. Propensity score matching (PSM) was employed to adjust for confounding factors, resulting in 188 matched pairs. Using PSM, the two groups were compared for baseline differences and postoperative outcomes.

RESULTS

Of the 561 patients, the SILS-to-CLS ratio was 301: 260. After one-to-one PSM, results showed that compared with the CLS group, the SILS group had a significantly shorter postoperative hospital stay (P = 0.004), and earlier excretion time and fasting time (P < 0.05). Furthermore, SILS resulted in better scar assessment and higher satisfaction score (both P < 0.05). The two groups had no significant differences in the rates of postoperative complications (P = 0.439) and readmission (P = 0.291). Conversion to open surgery was more common in the SILS group (10.6%) than in the CLS group (6.4%), although this difference was not statistically significant after matching (P = 0.139).

CONCLUSION

Our study aimed to determine the superiority of SILS over CLS in the treatment of pediatric MD. SILS offers distinct advantages over CLS in managing MD in children, including shorter hospital stays and bowel function recovery, without increasing postoperative complications. These findings suggest that SILS may be a preferable approach, warranting its integration into standard clinical practice for MD treatment.

Impact of single-port laparoscopic approach on scar assessment by patients and observers: a multicenter retrospective study

PURPOSE

This study aimed to compare the wound cosmesis of a single-incision approach on scar assessment after laparoscopic surgery for colon cancer.

METHODS

This study included 32 patients undergoing single-port laparoscopic surgery (SPLS) and 61 patients undergoing multiport laparoscopic surgery (MPLS) for colon cancer at 3 tertiary referral hospitals between September 2011 and December 2019. We modified and applied the Korean version of the Patient and Observer Scar Assessment Scale (POSAS) to assess cosmetic outcomes. To assess the interobserver reliability using intraclass correlation coefficient values for the Observer Scar Assessment Scale (OSAS), the surgeons evaluated 5 images of postoperative scars.

RESULTS

No significant differences were observed in the time before the return of normal bowel function, time to sips of water and soft diet initiation, length of in-hospital stay, and postoperative complication rate. The SPLS group had a shorter total incision length than the MPLS group. The POSAS favored the SPLS approach, revealing significant differences in the Patient Scar Assessment Scale (PSAS), OSAS, and overall scores. The SPLS approach was an independent factor influencing the POSAS, PSAS, and OSAS scores. Eleven colorectal surgeons had a significantly substantial intraclass coefficient.

CONCLUSION

The cosmetic outcomes of SPLS as assessed by the patients and surgeons were superior to those of MPLS in colon cancer. Reducing the number of ports is an independent factor affecting scar assessment by patients and observers.

Questionnaire to Survey Cosmetic Outcomes in Laparoscopic Surgery for Colorectal Cancer

Background and objectives

There has been a steady increase in the use of minimally invasive surgery, including conventional multiport laparoscopic surgery (MLS) and single-site laparoscopic surgery (SLS) for colorectal cancer. We aimed to evaluate how important the cosmetic outcome, one of the advantages of SLS, is to patients and whether SLS reflects social needs.

Methods

We used a web-based questionnaire to survey nonmedical and medical workers for what factors were considered on the assumption that respondents undergo colorectal cancer surgery and that the most important person for them undergoes. Five items (curability, safety, pain, length of hospital stay, and cosmetic outcomes) were compared. After paired photographs before and after SLS and MLS were shown, perceptions of body image and cosmesis were assessed using a visual analog scale.

Results

This study included a total of 1352 respondents (990 nonmedical and 362 medical). Curability had the highest score (49.9-53.7 points), followed by safety (23.8-24.7 points). The scores for cosmetic outcomes (6.2-7.1 points) were almost equal to those of the length of hospital stay (6.2-7.1 points), which was associated with medical costs and pain (10.0-11.1 points), one of the main reasons for fear of surgery. Participants who were female, younger, and in the nonmedical group placed great importance on cosmetic outcomes. For all questions regarding body image and cosmesis, SLS had superior scores compared with MLS.

Conclusions

Understandably, curability, and safety were most important in colorectal cancer surgery. However, medical workers should consider cosmetic outcomes, even in malignant cases.

Transverse incision versus longitudinal incision in the implantation of PICC-port: A before-after study

BACKGROUND

The peripherally inserted central catheter-port (PICC-port) technique is an innovation of the standard arm-totally implantable vascular access device. The design of surgical skin incision may have an important impact on the postoperative life of patients, the cosmetic result is important for patient satisfaction as well.

OBJECTIVES

To compare two different incision methods in the implantation of PICC-port.

DESIGN

A before-after study.

SETTINGS AND PARTICIPANTS

A total of 62 adult patients with malignant tumor requiring chemotherapy in Shanghai General Hospital were selected by convenience sampling, 31 in each group. All participants agreed to install PICC-port with signature from 1 Jan to 30 April, 2022.

METHODS

31 patients were given longitudinal incision, about 3 cm below the puncture point obliquely. Another 31 patients were given transverse incision, about 3 cm below the puncture point. T-test, chi-square test and rank sum test were used to compare the differences between the two groups in incision healing, scar score, and operation time.

RESULTS

There was no statistically significant difference in incision healing between the two groups(p > 0.05). The scar scores of patients with transverse incision were higher than that of patients with longitudinal incision at 3 months (p < 0.05). And the operation time of longitudinal incision group was longer than that of transverse incision group(p < 0.05).

CONCLUSIONS

Our study revealed that PICC-port implantation could be considered as safe as PICC insertion conducted by nurse. During our follow-up, all patients with PICC-port implantation had good wound healing, and there were no complications such as local infection happened. The transverse incision was more easier to be operated in bag making in PICC-port implantation.

Single-incision Laparoscopic Colonic Surgery: A Systemic Review, Meta-analysis, and Future Prospect

Although single-incision laparoscopic surgery (SILS) has gained some attention as a feasible alternative to conventional multiport laparoscopic surgery (MPLS) in colonic surgery, it became less prevalent than expected. Hence, we conducted this systematic review to evaluate the feasibility, safety, and oncological outcomes of single-incision laparoscopic colectomy (SILC) with meta-analysis and discussion of the future prospect of SILS. The search was conducted from September to October 2023 using PubMed and the Cochrane Central Register of Controlled Trials. Articles on colorectal cancer comparing SILC with multiport laparoscopic colectomy (MPLC) from all randomized controlled trials and comparative studies with 50 patients or more per arm were examined. The primary outcomes were the intra- and postoperative complication rates, and the secondary outcomes were the perioperative and oncological outcomes. The trends of the SILS number in Japan and the trends of the number of articles on SILS in PubMed were also reviewed. There were no significant differences in perioperative complication rates, operative factors, and oncological outcomes between SILC and MPLC, although heterogeneity was observed mainly in operative factors and the total length of the skin incision was significantly shorter in SILC. Therefore, SILC is technically and oncologically feasible and safe when performed by experienced laparoscopic surgeons. The case number of SILS was gradually increasing but the rate of SILS was decreasing in Japan. The number of articles on SILS was also decreasing. SILS has gained foothold to some extent but has plateaued. The emerging new robotic platform may reappraise the concept of SILS.

Long-term oncological outcome of reduced-port laparoscopic surgery (single-incision plus one port) as a technical option for rectal cancer

BACKGROUND

The purpose of this study was to clarify the oncological safety of reduced-port laparoscopic surgery (single-incision plus one port) (RPS) for patients with rectal cancer.

METHODS

The clinicopathological data of 63 selected patients with clinical Stage I-III (T1-3 and N0-2) rectal cancer who underwent RPS of radical anterior resection between 2012 and 2017 were retrospectively analyzed. The median distance of tumor from anal verge was 11 cm. Ordinarily, a multiport platform with three channels was placed in the 3-cm umbilical incision, and another 5- or 12-mm port was placed in the right lower abdomen.

RESULTS

The median operative time, amount of intraoperative bleeding, number of harvested lymph nodes, and length of distal margin were 272 min, 10 mL, 22 nodes, and 4.0 cm, respectively, and there was one (2%) patient with involvement of the radial margin. There were eight patients (13%) who required additional ports, and one patient (2%) who converted to open surgery. Intra- and postoperative complications occurred in one (2%) and 12 patients (19%), respectively. The median length of postoperative hospital stay was 8 days. The median follow-up period was 79 months, and incisional hernia was observed in 3 (5%) patients at the platform site not the port site, and cancer recurrence occurred in four patients (6%). The 5-year relapse-free and overall survival rates were 100% and 100% in the patients with pathological Stage I disease, 94% and 100% in the patients with pathological Stage II disease, and 83% and 89% in the patients with pathological Stage III disease, respectively.

CONCLUSION

RPS in the selected patients with rectal cancer, performed by an expert laparoscopic surgeon, may be technically safe and oncologically acceptable as well as multiport laparoscopic surgery.

Body Image Issues in Patients With Colorectal Cancer: A Scoping Review

BACKGROUND

Stomas in colorectal cancer (CRC) survivors lead to body image problems. Advances in treatment help reduce the rate of stoma formation, but body image distress is still frequently experienced in CRC survivors.

OBJECTIVES

This review is aimed toward mapping and describing the state of knowledge regarding body image in patients with CRC.

METHODS

A systematic literature search complying with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Screening and data extraction were performed by 2 reviewers independently for all potentially eligible studies.

RESULTS

A total of 56 eligible articles were selected. The majority of these studies were quantitative studies (85%). The eligible studies were classified into 4 broad categories: instruments used to assess body image, prevalence of body image distress, factors related to body image, and impact of body image distress. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-CR38) colorectal questionnaire was the most common measurement tool found among the reviewed studies (70%), and body image distress was reported by 25.5% to 86% of participants. Excluding gender, age, type of surgery, adjuvant therapy, time from diagnosis, social support, and stoma status, changes in bowel habits was identified as affecting the body image of patients with CRC.

CONCLUSION

Changing bowel habits emerged as a significant factor causing body image distress for CRC survivors.

IMPLICATIONS FOR PRACTICE

Clinicians should raise awareness about body image distress in patients with CRC, focus on finding effective measures and interventions intended to help alleviate symptoms of bowel dysfunction, and prepare patients to adapt to altered bowel functions.

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.

Comparison of clinical outcomes of single-incision versus multi-port laparoscopic surgery for rectosigmoid or upper rectal cancer

BACKGROUND

Single-incision laparoscopic surgery (SILS) for rectal cancer is technically challenging, and its clinical impact is unclear. The aim of this study was to evaluate clinical outcomes of SILS for rectal cancer compared with multi-port laparoscopic surgery (MPLS).

PATIENTS AND METHODS

We retrospectively analyzed 357 consecutive patients with stage I-III rectal cancer located in the rectosigmoid or upper rectum who underwent SILS or MPLS between January 2012 and December 2016, using propensity score-matched analysis.

RESULTS

After propensity score-matching, we enrolled 204 patients (n = 102 per group). Before matching, significant group-dependent differences were observed in tumor location (p < 0.001). After matching, preoperative clinical factors were similar between groups. SILS was successful in 73.5% of cases, an additional port was required in 23.5%, and 2.9% were converted to open surgery. Compared to the MPLS group, the SILS group showed shorter operative time (192 vs. 211 min, p = 0.015) and shorter postoperative hospital stay (9 vs. 11 days, p = 0.038). Other operative factors and morbidity rates did not differ significantly between groups. The number of harvested lymph nodes was smaller in the SILS group (24) than in the MPLS group (27, p = 0.008). Postoperative recurrence did not differ between groups, either before or after matching. No significant differences in 3-year disease-free, 3-year local recurrence-free, or 5-year overall survival were found between groups.

CONCLUSIONS

SILS is safe, is feasible, and offers satisfactory oncological outcomes in selected patients with rectosigmoid or upper rectal cancer.

Three-Port with Natural Orifice Specimen Extraction versus Conventional Laparoscopic Anterior Resection for Rectal-Sigmoid Cancer: A Matched Pair Analysis

BACKGROUND

The conventional laparoscopic colorectal surgery requires four or more ports to accomplish the laparoscopic dissection, and a mini-laparotomy to remove the specimen, which is a main cause of postoperative pain and incision complications, and compromise the cosmetic results. Reduced port surgery and natural orifice specimen extraction (NOSE) surgery hold the promise to overcome these drawbacks. This study planned to compare peri-operative outcomes of patients with rectal-sigmoid cancer undergoing three-port laparoscopic anterior resection with NOSE (three-port NOSE LAR) to those of patients receiving conventional LAR.

METHODS

Twenty-five patients with rectal-sigmoid cancer underwent three-port NOSE LAR between December 2018 and October 2020. For comparison, 50 patients with rectal-sigmoid cancer underwent conventional LAR in the same period were matched. The peri-operative outcomes were compared.

RESULTS

Operating time of three-port NOSE group was slightly longer than that of conventional group (135 min vs. 121 min, p = .147). The incision length of three-port NOSE group was shorter than that of conventional group (2.9 cm vs. 7.4 cm, p = .000). Complication rates in three-port NOSE group and conventional group were similar (12.0% vs. 20.0%, p = .524). The tumor size was smaller in three-port NOSE group than the conventional group (2.1 cm vs. 3.5 cm, p = .000). Pain score was lower in three-port NOSE group than the conventional group at postoperative day 1 (1.6 vs. 3.0, p = 0.045) and day 2 (0.2 vs. 2.1, p = .003). The BIQ score was significantly higher in the three-port NOSE group compared to the conventional group (42.9 ± 3.5 vs. 38.2 ± 2.5, p = .002).

CONCLUSIONS

Three-port NOSE LAR for rectal-sigmoid cancer is feasible and provides similar peri-operative outcomes compared to conventional LAR. It reduces postoperative pain and produces better cosmesis.

It is Not Just Cosmesis: Straight Laparoscopy with Stoma Site Extraction Improves Outcomes in Ulcerative Colitis Patients Undergoing Total Colectomy

Minimally invasive approaches to total abdominal colectomy (TAC) in ulcerative colitis (UC) patients include straight laparoscopy (SL), hand-assisted laparoscopic surgery (HALS), and robotics. In this study, short-term outcomes of patients undergoing SL and HALS TAC were compared. Prospectively collected data on UC patients undergoing TAC were tabulated. The study cohort included 36 (27%) patients in the SL group and 95 (73%) patients in the HALS group. The groups were comparable in terms of preoperative characteristics and demographics. The mean operative time was 151 (range, 73–225) minutes in the SL group versus 164 (range, 103–295) minutes in the HALS group ( P = 0.09). Total 48-hour IV morphine use was 30 (range, 0–186) mg in the SL group compared with 56 (0–275) mg in the HALS group ( P < 0.01). Although overall morbidity was comparable between the groups, Clavien-Dindo Class III complications did not occur in any of the SL group patients versus 11 (11%) of the HALS group patients ( P = 0.03). The postoperative length of stay was 3 (3–21) days in the SL group versus 5 (3–15) days in the HALS group ( P < 0.01). Compared with HALS, SL is associated with lower postoperative narcotic use and hospital length of stay in UC patients undergoing TAC.

Cosmesis in Patients after Multiport Laparoscopic Colorectal Surgery: Does the Extraction Incision Matter?

The ideal incision for specimen extraction during laparoscopic colorectal surgery is controversial. The objective of this study was to compare incision types (Pfannenstiel, periumbilical, lower midline, and right upper quadrant transverse) with regard to postoperative scar appearance, symptoms, preference, and satisfaction. This study is a retrospective survey review performed in an urban teaching hospital. The study participants were patients undergoing multiport laparoscopic colorectal surgery. Two web-based questionnaires, the Patient Scar Assessment Questionnaire and Photo-Series Questionnaire, were used to assess study parameters. The main outcome measures were incision symptoms and cosmetic satisfaction. The 112 study patients included 54 patients with a Pfannenstiel incision (Group P) and 58 patients with an alternate incision (Group A). Of the 58 patients in Group A, 19 (33%) had a periumbilical incision, 10 (17%) a lower midline incision, and 29 (50%) a right upper quadrant transverse incision. Although Groups P and Awere comparable in all five subscales of the Patient Scar Assessment Questionnaire, more Group P participants (n = 12; 22%) said their incision felt “fairly numb” than Group A participants (n = 2; 3%) (P = 0.008). There was no significant difference between study groups in all Photo-Series Questionnaire domains; however, after comparing patients’ own incisions with photographs of various alternative incisions, 36 (62%) Group A patients would choose an alternative incision compared with only 11 (19%) Group P patients (P = 0.001). Selection bias, recall bias, external validity, and variability of scar lengths were the limitations of the study. It was concluded that although a Pfannenstiel incision seems to be the optimal cosmetic choice, it is associated with a higher incidence of wound numbness than alternate extraction incisions.

[Minilaparoscopy with 5 mm optics and 3 mm trocars]

Minilaparoscopy was introduced already 20 years ago. In spite of reduced diameter, technical performance of modern trocars and instruments has improved substantially. While carrying out a minilaparoscopic procedure, the required position of the trocars and the surgical strategy remain the same. The most important step towards minilaparoscopy is reduction of the diameter of the laparoscopes from 10 to 5 mm. The 5 mm laparoscopes show high resolution and transport enough energy to properly illuminate the surgical field. Minilaparoscopic procedures help to improve cosmetic results and reduce postoperative pain, but postoperative complication rates are not affected. Use of one 5 mm trocar causes higher tissue tension than two 3 mm trocars and an additionally placed 3 mm trocar will not increase the complication rate. Therefore, a reduced risk of trocar hernia formation may be expected when a minilaparoscopic approach is used. Efficiency has been proven for minilaparoscopic cholecystectomy, appendectomy, and hernioplasty (TAPP/TEP) whereas overall available evidence across the literature remains poor. Further miniaturization is linked directly to video editing: physical limitations in classic optic systems have already been reached; therefore, reduction of optical chip systems could be a possible alternative.