Single incision laparoscopic (SILS) restorative proctocolectomy with ileal pouch-anal anastomosis

LongTerm Outcomes of Three-Port Laparoscopic Right Hemicolectomy Versus Five-Port Laparoscopic Right Hemicolectomy: A Retrospective Study

Purpose

The aim of this study is to compare the long-term outcomes of three-port laparoscopic right hemicolectomy (TPLRC) and five-port laparoscopic right hemicolectomy (FPLRC) with retrospective analysis.

Methods

A total of 182 patients who accepted laparoscopic right hemicolectomy with either three ports (86 patients) or five ports (96 patients) from January 2012 to June 2017 were non-randomly selected and analyzed retrospectively.

Results

More lymph nodes were harvested in the TPLRC group than in the FPLRC group [17.5 (7), 14 (8) ml, p < 0.001]. There was less blood loss in the TPLRC group [50 (80) vs. 100 (125) ml, p = 0.015]. There were no significant differences in the other short-term or oncological outcomes between the two groups. The overall survival and disease-free survival were equivalent.

Conclusions

TPLRC is recommendable as it guarantees short- and long-term equivalent outcomes compared with FPLRC.

Ileal pouch–anal anastomosis—a personal experience reevaluating complications, pouch survival, and quality of life

Background

Ileal pouch–anal anastomosis (IPAA) is the gold standard for proctocolectomy. The present study evaluates surgical outcomes of the authors’ operations over a 30-year period, including pouch survival and quality of life (QOL).

Methods

Records of patients undergoing IPAA between 1986 and 2015 were retrospectively analyzed regarding early and late complications and pouch survival. An online survey assessed QOL.

Results

Of 119 patients, 84 had chronic inflammatory bowel disease (IBD) and 35 non-inflammatory bowel disease (non-IBD). Pouch construction was simultaneous with proctocolectomy in 69% and metachronous in 31%. Double-stapler anastomosis with purse string suture was performed in 100 patients. With temporary transanal decompression by catheter insertion in all patients, loop ileostomy (LIS) was selectively omitted in 68%. Three anastomotic insufficiencies occurred both without (4.4%) and with LIS (9.4%). Perioperative morbidity for LIS closure was substantial (33.3%). In the long-term course, 36 patients (30.5%) required revision (cumulative probability after 15 years: 59.1%). IPAA was discontinued in 16 patients (13.6%), reducing cumulative continence preservation to 72.9% after 15 years. By converting the pouch to a continent ileostomy (CI) in 6 patients with uncorrectable functional complications, cumulative pouch survival reached 81.8% after 27 years. The online survey revealed significant improvements in occupation, sports, and travel vs. before proctocolectomy, but no change in sexual life. Physical, psychological, and social scores were still below the age-matched norm values. Whereas >90% were satisfied with the surgical outcome, only 3/25 had no functional improvement requests.

Conclusion

IPAA in double-stapler technique is safe, even without protective LIS. However, short- and long-term morbidity is considerable, with a non-negligible risk of continence loss. Conversion to CI for purely functional complications can significantly reduce definite pouch failure. Despite patients’ high subjective satisfaction, QOL remains objectively compromised.

Single access laparoscopic total colectomy for severe refractory ulcerative colitis

BACKGROUND

Single port laparoscopic surgery allows total colectomy and end ileostomy for medically uncontrolled ulcerative colitis solely via the stoma site incision. While intuitively appealing, there is sparse evidence for its use beyond feasibility.

AIM

To examine the usefulness of single access laparoscopy (SAL) in a general series experience of patients sick with ulcerative colitis.

METHODS

All patients presenting electively, urgently or emergently over a three-year period under a colorectal specialist team were studied. SAL was performed via the stoma site on a near-consecutive basis by one surgical team using a “surgical glove port” allowing group-comparative and case-control analysis with a contemporary cohort undergoing conventional multiport surgery. Standard, straight rigid laparoscopic instrumentation were used without additional resource.

RESULTS

Of 46 consecutive patients requiring surgery, 39 (85%) had their procedure begun laparoscopically. 27 (69%) of these were commenced by single port access with an 89% completion rate thereafter (three were concluded by multi-trocar laparoscopy). SAL proved effective in comparison to multiport access regardless of disease severity providing significantly reduced operative access costs (> 100€case) and postoperative hospital stay (median 5 d vs 7.5 d, P = 0.045) without increasing operative time. It proved especially efficient in those with preoperative albumin > 30 g/dL (n = 20). Its comparative advantages were further confirmed in ten pairs case-matched for gender, body mass index and preoperative albumin. SAL outcomes proved durable in the intermediate term (median follow-up = 20 mo).

CONCLUSION

Single port total colectomy proved useful in planned and acute settings for patients with medically refractory colitis. Assumptions regarding duration and cost should not be barriers to its implementation.

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40^th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Trends and Outcomes for Minimally Invasive Surgery for Inflammatory Bowel Disease

BACKGROUND

The relapsing and remitting nature of inflammatory bowel disease (IBD) predisposes patients to the development of fibrotic strictures, which must often be managed surgically. Laparoscopy provides the potential for enhanced perioperative care. Previous studies comparing morbidity and trends of open versus laparoscopic resection have been constrained by length of study and sample size.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, patients with primary diagnosis of IBD undergoing surgical resection from 2005 to 2015 were identified. Morbidity and mortality rates were then compared between open and laparoscopic resections using multiple logistic regression analyses.

RESULTS

A total of 10,699 resections were performed on IBD patients; 4816 (45.0%) of which were performed laparoscopically. The use of laparoscopy increased annually from 20.9% in 2005 to 55.4% in 2015. Comparing laparoscopic versus open, all 30-d outcomes tended to favor laparoscopy with the exception of operating room time, which was equal between the two groups. The difference in 30-d outcomes was statistically significant in laparoscopy versus open technique for pneumonia (1.0% versus 2.0%), ventilator use >48 h (0.6% versus 1.9%), acute renal failure (0.1% versus 0.4%), renal insufficiency (0.2% versus 0.6%), superficial surgical site infection (4.6% versus 7.7%), deep incisional surgical site infection (1.1% versus 1.8%), organ space infection (5.4% versus 7.3%), urinary tract infection (1.3% versus 2.2%), death (0.2% versus 0.7%), and length of hospital stay (6.4 versus 9.4 d).

CONCLUSIONS

These data not only display trends that indicate that the number of laparoscopic resections for IBD have increased over time but are associated with favorable complication rates, operating time, and length of hospital stay, suggesting that laparoscopy may be a safer option for treatment of fibrotic strictures associated with IBD.

Clinical outcomes of laparoscopic-assisted synchronous bowel anastomoses for synchronous colorectal cancer: initial clinical experience

The primary aim of this study was to explore the safety and feasibility of laparoscopic-assisted synchronous bowel anastomoses (LSBA) for synchronous colorectal cancer (SCRC). All patients who underwent LSBA for SCRC were retrospectively reviewed and analyzed for clinical and pathological features, technical feasibility and short-term as well as long-term oncological outcomes. Between July 2008 and January 2012, a series of 11 consecutive SCRC patients underwent LSBA. Six patients underwent laparoscopic-assisted right hemicolectomy and anterior resection. Five patients had laparoscopic-assisted right hemicolectomy and sigmoidectomy. There were no intraoperative complications that required open conversions. Mean operation time was 233 (range, 195–285) minutes, and mean estimated blood loss was 224 (range, 100–300) mL. The postoperative course of the patients was uneventful with the mean return to oral intake was 6.9 (range 5–12) days, and mean length of hospital stay was 12.6 (range 9–17) days. All surgical wounds showed good cosmetic outcome, and the mean incision length was 4.1 (range 3.5-5.0) cm. During a median follow-up period of 76 months, no local tumor recurrences were found. LSBA is a potentially feasible and safe procedure for SCRC when performed by an experienced surgeon. Further large clinical controlled trials are warranted to confirm the findings.

Single-Port Surgery in Inflammatory Bowel Disease: A Review of Current Evidence

The majority of patients with Crohn’s disease and up to 35 % of patients with ulcerative colitis will ultimately require surgery during the course of their disease. Over the past few years, surgical techniques and experience in minimal invasive surgery have evolved resulting in single-incision laparoscopic surgery. The aim of this approach is to diminish the surgical trauma by reducing the number of incision sites. This review discusses the benefits and disadvantages of single-port surgery in various procedures in patients with inflammatory bowel disease (IBD). Short-term postoperative results, functional outcome, and costs available in the literature will be discussed. Single-port surgery in IBD has several benefits when compared to multi-port laparoscopic surgery. By using fewer incisions, a potential reduction of postoperative pain with less morphine use can be accomplished. In addition, accelerated postoperative recovery can result in a shorter hospital stay. Furthermore, a superior cosmesis can be reached with placement of the port at the future ostomy site or at the umbilicus. Literature on single-port surgery in IBD consists mainly of case series and a few matched case series. These studies demonstrated that single-port surgery seems to be a safe and feasible approach for the surgical treatment of IBD patients.

Restorative Proctocolectomy in Elderly IBD Patients: A Multicentre Comparative Study on Safety and Efficacy

BACKGROUND AND AIMS

Restorative proctocolectomy in elderly inflammatory bowel disease [ IBD] patients is controversial and limited data are available on the outcomes of surgery. The aim of this study was to evaluate the safety, efficacy, and long-term results of ileal-pouch-anal anastomosis in elderly patients, in a multicentre survey from European referral centres.

METHODS

The International Pouch Database [IPD] combined 101 variables. Patients aged ≥ 65 years were matched on the basis of open versus laparoscopic surgery with a control group of consecutive younger unselected patients with a ratio of 1:2. Statistical analysis was performed using two-tailed t test, chi square and Fisher's exact tests, Kaplan-Meier function, and log-rank tests where appropriate.

RESULTS

In the IPD, 77 patients aged ≥ 65 years [Group A] and 154 control patients [Group B] were identified. Elderly patients had more comorbidities [p = 0.0001], longer disease duration [p = 0.001], less extensive disease [p = 0.006], more previous abdominal operations [p = 0.0006], surgery for cancer or dysplasia more frequently [p = 0.0001], fewer single-stage procedures [p = 0.03], more diversions after ileal pouch-anal anastomosis [IPAA] [p = 0.05], and a higher laparoscopic conversion rate [p = 0.04]. Postoperative complications and pouch failure were similar between the groups, but Group A had more Clavien-Dindo IV-V complications [p = 0.04], and longer length of stay [p = 0.007]. Laparoscopy was associated with a shorter duration of surgery [p = 0.0001], and length of stay [p = 0.0001], and the same complication rate as open surgery.

CONCLUSIONS

Restorative proctocolectomy can be performed in selected elderly patients, but there is a higher risk of postoperative complications and longer length of stay in this group. Laparoscopy is associated with shorter operating time and length of stay.

[The technique of restorative proctocolectomy with ileal J‑pouch : Standards and controversies]

BACKGROUND

Restorative proctocolectomy (RPC) is the standard of care in the case of medically refractory disease and in neoplasia in ulcerative colitis (UC).

OBJECTIVES

This review aims at providing an overview of the current evidence on standards, innovations, and controversies with regard to the surgical technique of RPC.

RESULTS

RPC is the standard of care in the surgical management of UC refractory to medical treatment and in neoplasia. Due to its simplicity and good functional outcomes, the J‑pouch is the most used pouch design. RPC is usually performed as a two-stage procedure. In the presence of risk factors, a three-stage procedure should be performed. The technically more demanding mucosectomy and hand sewn anastomosis does not seem to result in a better oncologic outcome than stapled anastomosis. Functional results appear marginally better after stapled anastomosis, but the rectal cuff should not exceed 2 cm in this reconstruction. The laparoscopic approach is at least as good as the open approach. For the new, innovative surgical approaches such as robotics and transanal surgery, only feasibility but no advantages have yet been demonstrated.

CONCLUSION

The evidence in regard to controversial points remains limited.

Minimally invasive surgery for inflammatory bowel disease: Review of current developments and future perspectives

Patients with inflammatory bowel disease (IBD) comprise a population of patients that have a high likelihood of both surgical treatment at a young age and repetitive operative interventions. Therefore surgical procedures need to aim at minimizing operative trauma with best postoperative recovery. Minimally invasive techniques have been one of the major advancements in surgery in the last decades and are nowadays almost routinely performed in colorectal resections irrespective of underlying disease. However due to special disease related characteristics such as bowel stenosis, interenteric fistula, abscesses, malnutrition, repetitive surgeries, or immunosuppressive medications, patients with IBD represent a special cohort with specific needs for surgery. This review summarizes current evidence of minimally invasive surgery for patients with Crohn’s disease or ulcerative colitis and gives an outlook on the future perspective of technical advances in this highly moving field with its latest developments in single port surgery, robotics and trans-anal techniques.

Single-site laparoscopic surgery for inflammatory bowel disease

Background and Objectives:

Single-site laparoscopic colorectal surgery has been firmly established; however, few reports addressing this technique in the inflammatory bowel disease population exist.

Methods:

We conducted a case-matched retrospective review of 20 patients who underwent single-site laparoscopic procedures for inflammatory bowel disease compared with 20 matched patients undergoing multiport laparoscopic procedures. Data regarding these patients were tabulated in the following categories: demographic characteristics, operative parameters, and perioperative outcomes.

Results:

A wide range of cases were completed: 9 ileocolic resections, 7 cases of proctocolectomy with end ileostomy or ileal pouch anal anastomosis, 2 cases of proctectomy with ileal pouch anal anastomosis, and 2 total abdominal colectomies with end ileostomy were all matched to equivalent multiport laparoscopic cases. No single-incision cases were converted to multiport laparoscopy, and 2 single-incision cases (10%) were converted to an open approach. For single-incision cases, the mean length of stay was 7.7 days, the mean time to oral intake was 3.3 days, and the mean period of intravenous analgesic use was 5.0 days. There were no statistically significant differences between single-site and multiport cases.

Conclusions:

Single-site laparoscopic surgery is technically feasible in inflammatory bowel disease. The length of stay and period of intravenous analgesic use (in days) appear to be higher than those in comparable series examining outcomes of single-site laparoscopic colorectal surgery, and the outcomes are comparable with those of multiport laparoscopy. This may be because of the nature of inflammatory bowel disease, limiting the benefits of a single-site approach in this population.

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.

Reduced-port laparoscopic restorative proctocolectomy without diverting ileostomy

INTRODUCTION

We introduced a reduced-port procedure for laparoscopic restorative proctocolectomy without diverting ileostomy for patients with familial adenomatous polyposis and ulcerative colitis.

MATERIALS AND SURGICAL TECHNIQUE

A multichannel port was inserted through a 2.5-cm umbilical incision. A 12-mm port in the right lower abdomen and a 3- or 5-mm port were also employed. A proctocolectomy was performed intracorporeally, and the entire colon and rectum were delivered through the umbilical incision. An ileal J-pouch was made extracorporeally following division of the mesenteric vessels. Ileal j-pouch-anal anastomosis was performed intracorporeally or transanally after rectal mucosectomy. A drain was inserted through the 12-mm port incision, and a transanal decompression tube was placed in the pouch. Two women and one man underwent this surgery, and their postoperative recovery was uneventful.

DISCUSSION

Laparoscopic restorative proctocolectomy without a diverting stoma by a reduced-port technique is feasible and provides excellent cosmetic outcomes in selected patients.

Single-Site Laparoscopic Colorectal Surgery Provides Similar Clinical Outcomes Compared With Standard Laparoscopic Surgery: An Analysis of 626 Patients

BACKGROUND

Compared with standard laparoscopy, single-site laparoscopic colorectal surgery may potentially offer advantages by creating fewer surgical incisions and providing a multifunctional trocar. Previous comparisons, however, have been limited by small sample sizes and selection bias.

OBJECTIVE

The purpose of this study was to compare 60-day outcomes between standard laparoscopic and single-site laparoscopic colorectal surgery patients undergoing elective and urgent surgeries.

DESIGN

This was an unselected, retrospective cohort study comparing patients who underwent elective and unplanned standard laparoscopic or single-site laparoscopic colorectal resections for benign and malignant disease between 2008 and 2014. Outcomes were compared using univariate analyses.

SETTINGS

This study was conducted at a single institution.

PATIENTS

A total of 626 consecutive patients undergoing laparoscopic colorectal surgery were included.

MAIN OUTCOME MEASURES

Morbidity and mortality rates within 60 postoperative days were measured.

RESULTS

A total of 318 (51%) and 308 patients (49%) underwent standard laparoscopic and single-site laparoscopic procedures. No significant differences were noted in mean operative time (standard laparoscopy, 182.1 ± 81.3 vs single-site laparoscopy, 177.0 ± 86.5; p = 0.30) or postoperative length of stay (standard laparoscopy, 4.8 ± 3.4 vs single-site laparoscopy, 5.5 ± 6.9; p = 0.14). Conversions to laparotomy and 60-day readmissions were also similar for both cohorts across all of the procedures performed. A significant difference was identified in the number of patients who developed postoperative complications (standard laparoscopy, 19.2% vs single-site laparoscopy, 10.7%; p = 0.004), especially with respect to surgical-site infections (standard laparoscopy, 11.3% vs single-site laparoscopy, 5.8%; p = 0.02).

LIMITATIONS

This was a retrospective, single institution study.

CONCLUSIONS

Single-site laparoscopic colorectal surgery demonstrates similar results to standard laparoscopic colorectal surgery with regard to operative time, length of stay, and readmissions. Single-site laparoscopic colorectal surgery may provide advantages in limiting the development of certain complications, such as superficial surgical-site infections.

Single-incision laparoscopic surgery for diverticulitis in overweight patients

AIM

Single-incision laparoscopic surgery (SILS) has been introduced as a new technique for the treatment of various colorectal diseases. Recurrent or complicated diverticulitis of the sigmoid colon is a frequent indication for minimally invasive sigmoid colectomy. The aim of this study was to investigate the impact of obesity on the outcome of SILS sigmoid colectomy.

METHODS

From September 2009 to October 2014, data from 377 patients who had intended SILS sigmoid colectomy for diverticulitis at our institution were collected in a prospective database. The patients were categorized in the following subgroups: group 1 (normal weight, body mass index (BMI) < 25 kg/m(2)), group 2 (overweight, BMI 25-29.9 kg/m(2)), group 3 (obesity, BMI 30-34.9 kg/m(2)), and group 4 (morbid obesity, BMI > 35 kg/m(2)).

RESULTS

The groups were equivalent for sex, age, status of diverticulitis, the presence of acute inflammation in the specimen, and the percentage of teaching operations, but the percentage of patients with accompanying diseases was significantly more frequent in groups 2, 3, and 4 (p = 0.04, 0.008, and 0.018, respectively). As compared to group 1, the conversion rate was significantly increased in groups 2 and 4 (2.3 vs. 9.3% (p = 0.013) and 2.3 vs. 12.5% (p = 0.017), respectively). The duration of surgery, hospitalization, and morbidity did not differ between the four groups.

CONCLUSION

Up to a body mass index of 35 kg/m(2), increased body weight does not significantly reduce the feasibility and outcome of single-incision laparoscopic surgery for diverticulitis.

Minimally invasive surgery for inflammatory bowel disease

Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohn's disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic "incisionless," single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.

Single-incision laparoscopic surgery for colorectal malignancy--results of a matched-pair comparison to conventional surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a new minimally invasive technique which has frequently been applied for treatment of benign colorectal diseases. However, there is still little experience with this technique for the treatment of colorectal cancer.

METHODS

Sixty-eight patients with SILS resections for colon (n = 25) or rectal cancer (n = 43) were compared to a group of conventionally operated patients who were matched for surgical procedure, tumor stage and tumor location, and the use of preoperative radiochemotherapy.

RESULTS

Both groups were comparable for lymph node harvest, specimen length, and the duration of surgery. No significant differences were observed for the number of positive circumferential resection margins, or the distance of the tumor to both the aboral or lateral resection margin, but two positive resection margins were only present after SILS and not after conventional surgery. Hospitalization tended to be shorter after SILS (p = 0.097). Overall, morbidity was equivalent between the two groups, with a difference for colon cancer where it was significantly lower after SILS as compared to open surgery (p = 0.025) mainly due to a lower rate of wound complications.

CONCLUSION

SILS might be an acceptable alternative to open surgery for the treatment of colon cancer. For rectal cancer, no apparent benefit could be documented. As no sufficient data on the oncologic quality are available, single-incision laparoscopic surgery can yet not be recommended for the treatment of rectal cancer out of clinical trials.

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

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

Laparoscopic surgery for ulcerative colitis: a review of the literature

Despite the development of new therapies, including anti-TNF alpha antibodies and immunosuppressants, a substantial proportion of patients with ulcerative colitis (UC) still require surgery. Restorative proctocolectomy with ileal-pouch anal anastomosis is the standard surgical treatment of choice for UC. With the advent of laparoscopic techniques for colorectal surgery, ileal-pouch anal anastomosis has also been performed laparoscopically. This paper reviews the history and current trends in laparoscopic surgery for UC. The accumulation of experience and improvement of laparoscopic devices have shifted the paradigm of UC surgery towards laparoscopic surgery over the past decade. Although laparoscopic surgery requires a longer operation, it provides significantly better short and long-term outcomes. The short-term benefits of laparoscopic surgery over open surgery include shorter hospital stays and fasting times, as well as better cosmesis. The long-term benefits of laparoscopy include better fecundity in young females. Some surgeons favor laparoscopic surgery even for severe acute colitis. More efforts are being made to develop newer laparoscopic methods, such as reduced port surgery, including single incision laparoscopic surgery and robotic surgery.

Minimal access laparoscopic surgery for treatment of ulcerative colitis and familial adenomatous polyposis coli in children and adolescents

BACKGROUND

Laparoscopic restorative proctocolectomy is standard surgical treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis coli (FAP). Scar burden can be minimized by reducing the number of laparoscopic ports. The aim of this study is to review the authors' experience with reduced-port laparoscopy in this setting and to compare it with conventional laparoscopy using multiple ports.

MATERIALS AND METHODS

Charts of pediatric patients undergoing colectomy for UC or FAP between 2009 and 2012 were retrospectively reviewed. Patients who had the operation performed through one or two multichannel ports were assigned to the minimal access (MA) study group. Patients who had four or five single-channel ports with or without an additional small laparotomy were assigned to the LAP group.

RESULTS

Twenty-two patients were identified. Ages at first operation were 2-18 years (median, 13.5 years). There were no conversions to laparotomy and no mortality. Mean operative times for the MA and LAP groups, respectively, were 250 and 284 minutes for abdominal colectomy with end ileostomy (P=.15), 198 and 301 minutes for completion proctectomy with diverting loop ileostomy (DLI) (P=.26), and 455 and 414 minutes for proctocolectomy with ileal pouch-anal anastomosis and DLI (P=.72). A major complication requiring laparotomy occurred in 1 patient (9%) in the MA group and in 2 patients (18%) in the LAP group.

CONCLUSIONS

Minimal access laparoscopic surgery for UC and FAP is safe and feasible. A slightly larger incision at the ostomy site facilitates extraction of the specimen and extracorporeal construction of a J-pouch. Operative times and hospital stay are comparable to those with multiport laparoscopy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

The potential benefits and disadvantages of laparoscopic surgery for ulcerative colitis: A review of current evidence

Up to 35% of patients with ulcerative colitis will require surgery during the course of their disease. Nowadays, a total colectomy with ileal pouch-anal anastomosis is the preferred procedure, which can be performed open or via laparoscopic approach. Since the early '90s, minimally invasive techniques have gained popularity, but the extend of restorative procedures in these patients has restricted the use of laparoscopic approaches mainly to elective procedures in specialised centres. This review discusses the benefits and disadvantages of laparoscopic surgery when compared to open surgery. It presents the current evidence on short-term and long-term post-operative results, functional outcome, fecundity, and costs, for both elective and emergency indications. In addition, the value of new techniques (including single port surgery) and alternative laparoscopic approaches (e.g. ileo-rectal anastomosis, Kock-pouch and appendectomy) will be discussed.

Surgical management of IBD--from an open to a laparoscopic approach

Surgery is a key feature of IBD management. Up to 70% of patients with Crohn's disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohn's disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.

Comparison of single-incision laparoscopic high anterior resection with standard laparoscopic high anterior resection

AIM

Single-incision laparoscopic surgery (SILS) is gaining momentum. The aim of the present study was to compare the outcome of SILS for high anterior resection with that of standard laparoscopic resection (StdLS).

METHOD

Patients undergoing laparoscopic high anterior resection were prospectively entered into an institutional approved database. Patients treated with SILS were compared with those undergoing StdLS.

RESULTS

Between April 2000 and April 2009, 327 (143 cancer) consecutive unselected patients underwent StdLS; there were three (1%) conversions and 12 (3.6%) covering ileostomies. After April 2009, 55 (29 cancer) consecutive, unselected patients underwent SILS; there were two conversions to a three-port technique (3.6%), no conversions to open resection and two (3.6%) covering ileostomies. There were no significant differences in age, sex, body mass index, hospital of operation or American Society of Anesthesiology (ASA) grade between the two groups. The operating time for SILS was significantly shorter (113 ± 44 min for StdLS vs 79 ± 37 min for SILS; P < 0.0001). SILS patients tolerated a normal diet earlier [10 (2-24) h for SILS vs 18 (2-96) h for StdLS] and were discharged faster [1 (1-8) days for SILS vs 3 (1-24) days for StdLS]. There were no significant differences in return to theatre, readmissions or 30-day mortality.

CONCLUSION

SILS for high anterior resection is feasible, safe and quicker to perform than standard three-port laparoscopic colectomy. It seems to be associated with a faster recovery and earlier discharge.

Systematic review of single-incision laparoscopic colonic surgery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

Single-port laparoscopic surgery for inflammatory bowel disease

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

Role of ileostomy in restorative proctocolectomy

Restorative proctocolectomy (RP) is the treatment of choice in patients affected with refractory ulcerative colitis or familial adenomatous polyposis. Surgery in elective settings is often performed in 2 stages, fashioning an ileostomy which is closed 2-3-mo later. It is still debated whether omitting ileostomy could offer advantages in the management of patients undergoing RP.