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

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.

Short- and long-term outcomes of single-incision laparoscopic surgery for right colon cancer: A multicenter propensity score-matched analysis

INTRODUCTION

Single-incision laparoscopic surgery (SILS) for colon cancer is a recent innovation in minimally invasive surgery that can improve short-term outcome. However, several biases exist in current favorable comparisons of SILS with conventional laparoscopic (CL) surgery. Moreover, the oncological outcomes in SILS remain unclear. The aim of this study was to identify outcomes following SILS and CL for right colectomy using a propensity score-matched analysis.

METHODS

A total of 553 patients underwent curative resection for right colon cancer (58 SILS and 495 CL). After propensity score matching, 58 patients in each group were matched.

RESULTS

Before matching, median age was younger (p = 0.037) and clinical stage was lower (p < 0.001) in the SILS group. After matching, operation time was shorter (172 versus 193 min, p = 0.007) and blood loss was less (12 versus 20 mL, p = 0.037) in the SILS group. Most of the SILS cases were performed (43.1%) or supervised (51.7%) by an expert surgeon. Median follow-up duration was 30 and 37 mo in the SILS and CL groups, respectively. Three-year relapse-free survival was 92.5% and 92.4% (p = 0.781); and overall survival was 100% versus 98.1% (p = 0.177).

CONCLUSIONS

Under the control of expert surgeons, SILS appeared to be a safe and feasible approach and had similar oncological outcomes compared with CL in a propensity score-matched cohort of patients with right-sided colon cancer.

Long-term Outcomes of a Randomized Controlled Trial of Single-incision Versus Multi-port Laparoscopic Colectomy for Colon Cancer

OBJECTIVE

The aim of this study was to evaluate the long-term outcomes that were the secondary endpoints of a RCT of multi-port laparoscopic colectomy (MPC) versus SILC in colon cancer surgery.

SUMMARY OF BACKGROUND DATA

The actual long-term outcomes, such as the 5-year RFS, OS, and recurrence patterns after surgery, have not been evaluated by a RCT.

METHODS

Patients with histologically proven colon carcinoma located in the cecum, ascending, sigmoid or rectosigmoid colon clinically diagnosed as stage 0-III were eligible for this study. Patients were preoperatively randomized and underwent complete mesocolic excision. The 5-year RFS, OS, and recurrence patterns were analyzed (UMIN-CTR 000007220).

RESULTS

Between March 1, 2012, and March 31, 2015, a total of 200 patients were randomly assigned to either the MPC arm (n = 100) or SILC arm (n = 100). The median follow-up for all patients was 61.0 months. An intention-to-treat analysis showed that the 5-year RFS was 91.0% [95% confidence interval (CI) 85.1%-96.9%] in the MPC arm and 88.0% (95% CI 82.1%-93.9%) in the SILC arm (hazard ratio: 1.37; 95% CI 0.58-3.24; P = 0.479). The 5-year OS was 95.0% (95% CI 91.1%-98.9%) in the MPC arm and 93.0% (87.1%-98.9%) in the SILC arm (hazard ratio: 1.39; 95% CI 0.44-4.39; P = 0.568). There were no significant differences in the recurrence patterns between the 2 arms.

CONCLUSIONS

Even though the results of the 5-year OS and RFS in this trial were exploratory and underpowered, there were no statistically significant differences between the SILC and MPC arms. SILC may be an acceptable treatment option for select patients with colon cancer.

Single-incision versus conventional multiport laparoscopic surgery for colorectal cancer: a meta-analysis of randomized controlled trials and propensity-score matched studies

PURPOSE

To compare single-incision laparoscopic surgery (SILS) and multiport laparoscopic surgery (MLS) for colorectal cancer in terms of short- and long-term outcomes.

METHODS

A systematic literature search was performed in PubMed, Web of Science, and Embase. Randomized controlled trials (RCTs) and propensity-score matched (PSM) studies comparing SILS and MLS for colorectal cancer were enrolled. Outcomes of interests included intraoperative, postoperative, pathological, and survival outcomes.

RESULTS

Sixteen studies (6 RCTs and 10 PSM studies) published between 2012 and 2020 with a total of 2425 patients were enrolled. Compared with MLS, SILS was associated with less postoperative pain at postoperative day (POD) 1 (P = 0.02, MWD = -0.73, 95%CI: -1.37, -0.09) and POD2 (P < 0.001, MWD= -1.10, 95%CI: -1.45, -0.74) and shorter length of total incision length (P < 0.001, MWD = -3.31, 95%CI: -3.95, -2.67). No differences were observed in terms of operative time, blood loss, intraoperative and postoperative complications, incision hernia, and pathological or survival outcomes between SILS and MLS. Subgroup analysis for right-sided colon cancer, sigmoid colon cancer, and rectosigmoid colon cancer showed that the SILS group was only associated with less postoperative pain and shorter total incision length. The surgical and pathological outcomes were comparable between SILS and MLS.

CONCLUSIONS

SILS is a beneficial alternative to MLS in select colorectal cancer patients, especially for right-sided colon cancer, sigmoid colon cancer, and rectosigmoid cancer, with better cosmetic effects and less postoperative pain. Simultaneously, SILS does not compromise intraoperative and postoperative complications, surgical quality, or long-term outcomes.

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.

Hernia incidence following a randomized clinical trial of single-incision versus multi-port laparoscopic colectomy

BACKGROUND

The short-term results of single-incision laparoscopic colectomy (SILC) showed the safety, feasibility, and effectiveness when performed by skilled laparoscopic surgeons. However, the long-term complications, such as SILC-associated incisional hernia, have not been evaluated. The aim of this study was to determine the incidence of incisional hernia after SILC compared with multi-port laparoscopic colectomy (MPC) for colon cancer.

METHODS

From March 2012, to March 2015, a total of 200 patients were enrolled in this study. The patients were randomized to the MPC arm and SILC arm. A total of 200 patients (MPC arm; 100 patients, SILC arm; 100 patients) were therefore analyzed. In all cases the specimen was extracted through the umbilical port, which was extended according to the size of the specimen. A diagnosis of incisional hernia was made either based on a physical examination or computed tomography.

RESULTS

The baseline factors were well balanced between the arms. The median follow-up period was 42.4 (range 9.4-70.0) months. Twenty-one patients were diagnosed with incisional hernia, giving an incidence rate of 12.1% in the MPC arm and 9.0% in the SILC arm at 36 months (P = 0.451). In the multivariate analysis, the body mass index (≥ 25 kg/m²) (hazard ratio [HR] 3.03; 95% confidence interval [CI] 1.03-8.92; P = 0.044), umbilical incision (≥ 5.0 cm) (HR 3.22; 95% CI 1.16-8.93; P = 0.025), and history of umbilical hernia (HR 3.16; 95% CI 1.02-9.77; P = 0.045) were shown to be correlated with incisional hernia.

CONCLUSIONS

We found no significant difference in the incidence of incisional hernia after SILC arm versus MPC arm with a long-term follow-up. However, this result may be biased because all specimens were harvested through the umbilical port. The study was registered with the Japanese Clinical Trials Registry as UMIN000007220.

Suprapubic single-port approach for complicated diverticulitis

BACKGROUND

Laparoscopic sigmoidectomy is the gold standard for elective surgical treatment of diverticulitis. A periumbilical single-port technique reduces the size of the access wound, usually to 3-4 cm. However, in the presence of large phlegmon or fistulae, the risk of conversion is higher and the extraction site might be enlarged. A suprapubic Pfannenstiel incision reduces the risk of incisional hernia compared to umbilical access and might provide the possibility to perform sigmoidectomy with a hybrid technique. The aim of the present study was to investigate the feasibility of laparoscopic sigmoidectomy through a single suprapubic transverse access for large diverticular phlegmon.

METHODS

Consecutive patients with a diverticular inflammatory mass ≥ 5 cm, with or without sigmoid-vesical fistula, were considered candidates for laparoscopic sigmoidectomy through a 5-cm single-port suprapubic (SPSP) access, extended (if required) to match the size of the inflammatory mass.

RESULTS

Twenty patients underwent SPSP sigmoidectomy at our institution in April 2014-April 2017. All procedures were completed by SPSP access, with no intraoperative complications or need for additional trocar placement. Eight patients had a sigmoid-vesical fistula (bladder sutured in three patients). The splenic flexure was mobilized in nine patients. Median operative time was 178 min and median hospital stay was 5.5 days (iqr 4-6). Postoperative complications occurred in four patients and included one subcutaneous hematoma, one urinary tract infection, and two superficial wound infections. After a median follow-up time of 25 months (interquartile range 15-38), all patients experienced complete resolution of symptoms, with no incisional hernias reported.

CONCLUSIONS

SPSP sigmoidectomy for diverticulitis is feasible and effective, minimizing the size of the access wound and avoiding increased risk of hernia. This approach might be especially valuable for the management of large diverticular phlegmon and sigmoid-vesical fistula.

Meta-analysis of randomized controlled trials only exploring the role of single incision laparoscopic surgery versus conventional multiport laparoscopic surgery for colorectal resections

Background

The objective of this article is to evaluate the surgical outcomes in patients undergoing single incision laparoscopic surgery (SILS) versus conventional multi-incision laparoscopic surgery (MILS) for colorectal resections.

Methods

The data retrieved from the published randomized controlled trials (RCTs) reporting the surgical outcomes in patients undergoing SILS versus MILS for colorectal resections was analysed using the principles of meta-analysis. The combined outcome of dichotomous data was represented as risk ratio (RR) and continuous data was shown as standardized mean difference (SMD).

Results

Five RCTs on 525 patients reported the colorectal resections by SILS versus MILS technique. In the random effects model analysis using the statistical software Review Manager 5.3, the operation time (SMD, 0.20; 95% CI, -0.11 to 0.52; z=1.28; P=0.20), length of in-patient stay (SMD, -0.18; 95% CI, -0.51 to 0.14; z=1.10; P=0.27) and lymph node harvesting (SMD, 0.09; 95% CI, -0.14 to 0.33; z=0.76; P=0.45) were comparable between both techniques. Furthermore, post-operative complications (RR, 1.00; 95% CI, 0.65-1.54; z=0.02; P=0.99), post-operative mortality, surgical site infection rate (RR, 3.00; 95% CI, 0.13-70.92; z=0.68; P=0.50), anastomotic leak rate (RR, 0.43; 95% CI, 0.11-1.63; z=1.24; P=0.21), conversion rate (P=0.13) and re-operation rate (P=0.43) were also statistically similar following SILS and MILS.

Conclusions

SILS failed to demonstrate any superiority over MILS for colorectal resections in all post-operative surgical outcomes.

The single-incision laparoscopic surgery technique has questionable advantages in colorectal surgery

Background

Laparoscopic procedures have increasingly been accepted as standard in surgical treatment of benign and malignant entities, resulting in a continuous evolution of operative techniques. Since one of the aims in laparoscopic colorectal surgery is to reduce access trauma, one possible way is to further reduce the surgical site by the single-incision laparoscopic surgery technique (SLS). One of the main criticisms concerning the use of SLS is its questionable benefit combined with its technical demands for the surgeon. These questions were addressed by comparing SLS versus conventional laparoscopic multitrocar surgery (LMS) in benign and malignant conditions with respect to technical operative parameters and early postoperative outcome of the patients.

Methods

Between 2010 and 2013, we performed SLS for colorectal disease. Of the 111 patients who underwent colorectal resection, 47 patients were operated by SLS and 31 using the LMS technique. The collected data for our patients were compared according to operating time, postoperative morbidity and mortality, pain score numeric rating scale on day 1 and day 5 postoperatively and postoperative hospital stay. To complement the pain scores, the required pain medication for adequate pain relief on these days was given.

Results

There was no significant difference in age, BMI or sex ratio between the two groups. The intraoperative and early postoperative course was comparable as well. Postoperative hospital stay was the only parameter with a significant difference, showing an advantage for SLS.

Conclusion

SLS is a feasible surgical method and a technical option in laparoscopic colorectal surgery. However, we were not able to identify substantial advantages of SLS that would favor this technique.

Multicenter, randomized single-port versus multiport laparoscopic surgery (SIMPLE) trial in colon cancer: an interim analysis

BACKGROUND

Single-port laparoscopic surgery (SPLS) was recently introduced as an innovative minimally invasive surgery method. Retrospective studies have revealed the safety and feasibility of SPLS for colon cancer treatment. However, no prospective randomized trials have been performed. The multicenter, randomized SIMPLE (single-port versus multiport laparoscopic surgery) trial aimed to investigate short-term perioperative outcomes of SPLS for colon cancer treatment, compared with multiport laparoscopic surgery (MPLS).

METHODS

Between August 2011 and April 2014, a total of 194 patients with colon cancer were recruited from seven hospitals in Korea. Patients were randomly allocated into the SPLS group (n = 99) or MPLS group (n = 95). The primary endpoint was postoperative complications. Operative, postoperative, and pathologic outcomes were analyzed after 50% of the patient study population had been recruited.

RESULTS

The patients' demographic characteristics, operative times, estimated blood volume losses, numbers of harvested lymph nodes, and lengths of both resection margins were not significantly different between groups. In the SPLS group, the rates of conversion to MPLS and open surgery were 12.9 and 2.2%, respectively. Postoperative complications occurred in 10.8% of the SPLS, and 12.5% of the MPLS patients (p = 0.714). Times to functional recovery, pain scores, and amounts of analgesia were similar between groups.

CONCLUSION

The results of this interim analysis suggested that SPLS is technically safe and appropriate when used for radical resection of colon cancer. (ClinicalTrials.gov Identifier: NCT01480128).

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.

Short-Term Outcomes of Single-Incision Versus Conventional Laparoscopic Surgery for Colorectal Diseases: Meta-Analysis of Randomized and Prospective Evidence

BACKGROUND

Conventional laparoscopic surgery (CLS) has been established as an alternative to open surgery for colorectal diseases (CRDs); simultaneously, single-incision laparoscopic surgery (SILS) is gaining popularity.

OBJECTIVE

The aim of this study was to compare the short-term efficacy and safety of SILS with CLS for CRDs.

METHODS

MEDLINE, EMBASE, and the Cochrane Library were searched for relevant randomized and prospective studies. Reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases were also screened. Outcome measures included surgical parameters, postsurgical recovery, pain, and adverse events. Meta-analysis was conducted where appropriate, comparing items using weighted mean differences (WMDs) and risk ratios (RRs) according to data type.

RESULTS

A total of nine prospective (three randomized and six non-randomized) researches published from 2011 to 2015 were identified. The overall pooled results showed compared to CLS, SILS was associated with fewer blood transfusions, shorter incision length, and slighter postoperative pain, but more extra ports. All the other parameters were comparable. Randomized evidence supported SILS was associated with less blood loss, and shorter hospital stay, but longer operative time. For only colectomy cases, SILS was associated with more conversions to open surgery. SILS was associated with longer surgical time for Easterners, but not for Westerners. The detected differences were clinically insignificant.

CONCLUSIONS

The results based on randomized and prospective evidence provide convincing support for the clinical similarity that SILS is basically as applicable, effective, and safe as CLS when dealing with colorectal lesions, but not for superiority.

Single-incision Plus One Port Laparoscopic Total Mesorectal Excision and Bilateral Pelvic Node Dissection for Advanced Rectal Cancer--A Medial Umbilical Ligament Approach

We prove the safety and feasibility of single-incision plus 1 port (SILS+1) laparoscopic total mesorectal excision (TME) + lateral pelvic lymph node dissection (LPLD) via a medial umbilical approach for rectal cancer. Only a few reports have been published about single-incision multiport laparoscopic low anterior resection with LPLD. Recently, minimally invasive surgery such as single-incision plus 1 port (SILS + 1) for advanced rectal cancer has been reported as safe and feasible. To our knowledge, this is the first reported case of SILS + 1 used for LPLD. A wound protector was inserted through a 30-mm transumbilical incision. Next, a single-port access device was mounted to the wound protector and 3 ports (5 mm each) were placed. A 12-mm port was inserted in the right lower quadrant. Super-low anterior resection of the rectum and bilateral LPLD and temporary ileostomy were performed with SILS + 1, with a blood loss of 50 mL and a total surgical time of 525 minutes. The time for right lateral dissection was 74 minutes; the time for left lateral dissection was 118 minutes. The total number of dissected lymph nodes was 57 and the number of lateral lymph nodes dissected was 21 (8 left pelvic lymph nodes, 13 right pelvic lymph nodes). No postoperative anastomotic insufficiency or voiding dysfunction was observed. We have documented the safety and feasibility of SILS + 1-TME + LPLD via a medial umbilical approach for rectal cancer.

Single-incision plus one-port laparoscopic abdominoperineal resection with bilateral pelvic lymph node dissection for advanced rectal cancer: a case report

With regard to laparoscopic and robotic abdominoperineal resection (APR) for primary rectal malignancies, limited data have been published in the literature. Single-incision laparoscopic surgery (SLS) has been successfully introduced for treating colorectal cancer. Here we describe our experience of APR with SLS plus one port (SLS + 1) for treating advanced rectal cancer. A 65-year-old man underwent the procedure, which involved a 35-mm incision in the left side of the umbilicus for the insertion of a single multichannel port as well as the insertion of a 5-mm port into the right lower quadrant. The sigmoid colon and rectum were mobilized from the pelvic floor using a medial and lateral approach. After the rectum with the mesorectum was completely mobilized according to the total mesorectal excision, the sigmoid colon was intracorporeally transected. The specimen was removed through the perineal wound. Terminal colostomy was fashioned at the left lower trocar site. Lateral pelvic lymph node dissection was bilaterally performed. There were no perioperative complications. The total operating time was 592 minutes, and the estimated blood loss was 180 mL. To our knowledge, this is the first reported case of SLS + 1 APR with lateral pelvic lymph node dissection for treating rectal cancer. We conclude that SLS + 1 APR is a technically promising alternative method for treating selected patients with advanced rectal cancer.

Single-incision versus standard multi-incision laparoscopic colectomy in patients with malignant or benign colonic disease: a systematic review, meta-analysis and assessment of the evidence

BACKGROUND

Single-incision laparoscopic colectomy (SILC) requires only one umbilical port site and (depending on technique) a specimen extraction site. The aim of this study was the assessment of the available evidence for the comparison of SILC to conventional multi-port laparoscopic colectomy (MLC) in adult patients, in whom elective colectomy is indicated because of malignant or benign disease. First, previous meta-analyses on this topic were assessed. Secondly, a systematic review and meta-analysis of randomised controlled trials, was performed.

METHODS

Electronic literature searches (CENTRAL, MEDLINE and EMBASE; up to March 2016) were performed. Additionally, we searched clinical trials registries and abstracts from surgical society meetings. For meta-analysis, risk ratios (RR) or mean differences (MD) with 95 % confidence intervals were calculated and pooled. The quality of previous meta-analyses was evaluated against established criteria (AMSTAR) and their reported results were investigated for consistency.

RESULTS

We identified 6 previous meta-analyses of mostly low methodological quality (AMSTAR total score: 2 - 5 out of 11 items). To fill the evidence gaps, all these meta-analyses had included non-randomised studies, but usually without assessing their risk of bias. In our systematic review and meta-analysis of randomised controlled trials exclusively, we included two randomised controlled trials with a total of 82 colorectal cancer patients. There was insufficient evidence to clarify whether SILC leads to less local complications (RR = 0.52, 95 % CI 0.14 - 1.94) or lower mortality (1 death per treatment group). Length of hospital stay was significantly shorter in the SILC group (MD = -1.20 days, 95 % CI -1.95 to -0.44). One of the two studies found postoperative pain intensity to be lower at the first day. We also identified 7 ongoing trials with a total sample size of over 1000 patients.

CONCLUSION

The currently available study results are too sparse to detect (or rule out) relevant differences between SILC and MLC. The quality of the current evidence is low, and the additional analysis of non-randomised data attempts, but does not solve this problem. SILC should still be considered as an experimental procedure, since the evidence of well-designed randomised controlled trials is too sparse to allow any recommendation.

Randomized clinical trial of single-incision versus multiport laparoscopic colectomy

BACKGROUND

The efficacy and safety of single-incision laparoscopic colectomy (SILC) for colonic cancer remain unclear. The aim of this study was to determine the outcomes of SILC compared with multiport laparoscopic colectomy (MPLC) for colonic cancer.

METHODS

Patients with histologically proven colonic carcinoma located in the caecum, ascending, sigmoid or rectosigmoid colon, clinically diagnosed as stage 0-III by CT, were eligible for this study. Patients were randomized before surgery and underwent tumour dissection with complete mesocolic excision. Safety analyses were conducted according to randomization groups.

RESULTS

A total of 200 patients were enrolled and randomized to the MPLC (100 patients) or SILC (100 patients) arm. Surgical outcomes were similar between the MPLC and SILC arms, including duration of operation (mean 162 versus 156 min respectively; P = 0·273), blood loss (mean 8·8 versus 21·4 ml; P = 0·102), conversion to open laparotomy (2·0 versus 1·0 per cent; P = 0·561), reoperation (3·0 versus 3·0 per cent; P = 1·000), time to first flatus (both median 1 day; P = 0·155) and postoperative hospital stay (both median 6; P = 0·372). The total skin incision length was significantly shorter in the SILC arm (mean 4·4 cm versus 6·8 cm in the MPLC arm; P < 0·001). The median duration of analgesia use was 5 days in the MPLC and 4 days in the SILC arm (P = 0·485). Overall complication rates were equivalent (15·0 versus 12·0 per cent respecitvely; P = 0·680).

CONCLUSION

SILC is not superior to MPLC.

REGISTRATION NUMBER

UMIN000007220 (http://www.umin.ac.jp/ctr/index.htm).

Single-port versus multi-port laparoscopic surgery for colon cancer in elderly patients

The safety of single-incision laparoscopic surgery (SLS) in elderly patients with colorectal cancer has not been established. The aim of the current study was to compare the outcomes of SLS and multi-port laparoscopic surgery (MLS) and to assess the feasibility of SLS in colorectal cancer patients aged ≥70 years. A retrospective case-control study of colon cancer patients undergoing elective surgical intervention between 2011 and 2014 was conducted. A total of 129 patients with colon cancer underwent surgery and were included in the analysis. Data regarding patient demographics, surgical variables, oncological outcomes and short-term outcomes were evaluated for statistical significance to compare MLS (n=79) and SLS (n=50) in colon cancer patients. No significant differences were observed in patient characteristics. No case required re-admission within 30 days post surgery. The mean surgery times were similar for the MLS and SLS groups when cases with left and right hemicolectomies were combined (207.7 and 215.9 min, respectively; P=0.47). In addition, overall perioperative outcomes, including blood loss, number of lymph nodes harvested, size of the surgical margin and complications, were similar between these groups. Thus, we suggest that SLS can be performed safely in elderly patients with colon cancer.

Single-Incision Laparoscopy Could Be Better than Standard Laparoscopy in Right Colectomy for Cancer

BACKGROUND

Human natural orifice transluminal endoscopic surgery (NOTES) is slowed down by technical hurdles. Concomitantly, single-incision laparoscopy has been increasingly reported as an alternative. By reducing the invasiveness of standard laparoscopy, we may further reduce postoperative pain, decrease morbidity, preserve abdominal wall, and enhance cosmesis. Such techniques have been widely applied, including in colorectal surgery. The aim of this multicenter study is to compare the results of single-incision right colectomy (SIRC) with the results of the standard laparoscopic right colectomy (SLRC) in patients with colon cancer.

METHODS

The files of patients who underwent right colectomy for cancer in five hospitals between January 2010 and December 2013 have been reviewed. Exclusion criteria were open surgery, emergency setting, and American Society of Anesthesiologists (ASA) score >3. Patients were distributed in Groups A (SIRC) or B (SLRC).

RESULTS

Five hundred ninety-two patients were included in this study, 336 in Group A and 256 in Group B. Mean operative time was 129.0 minutes (range 65-245) in Group A and 168.1 minutes in the Group B (range 70-290), respectively (P < .001). No mortality occurred in either group. The overall 30-day morbidity rates were 21.4% in Group A and 25% in Group B, respectively (P = .64). The median length of hospital stay was 4.95 days (range 3-14) in Group A and 5.5 days in Group B (range 3-12), respectively (P = .28). Conversion to laparotomy occurred in four patients in each group (P = 1). Length of skin incision was significantly shorter in Group A than in Group B (2.99 ± 0.63 cm versus 4.94 ± 0.65 cm, P < .001). Histological analysis of the operative specimens showed no significant differences.

CONCLUSION

SIRC is feasible and sure for patients with colon cancer. As compared with SLRC, SIRC may offer some advantages, including lower operative morbidity, shorter hospital stay, and better cosmoses, without compromising the oncological quality of the resected specimen.

SILS sigmoidectomy versus multiport laparoscopic sigmoidectomy for diverticulitis

Background and Objectives:

In this single-institution study, we aimed to compare the safety, feasibility, and outcomes of single-incision laparoscopic sigmoidectomy (SILSS) with multiport laparoscopic sigmoidectomy (MLS) for recurrent diverticulitis.

Methods:

Between October 2011 and February 2013, 60 sigmoidectomies were performed by the same surgeon. Forty patients had a MLS and 20 patients had a SILSS. Outcomes were compared.

Results:

Patient characteristics were similar. There was no difference in morbidity, mortality or readmission rates. The mean operative time was longer in the SILSS group (P = .0012). In a larger proportion of patients from the SILSS group, 2 linear staplers were needed for transection at the rectum (P = .006). The total cost of disposable items was higher in the SILSS group (P < .0001). No additional ports were placed in the SILSS group. Return to bowel function or return to oral intake was faster in the SILSS group (P = .0446 and P = .0137, respectively). Maximum pain scores on postoperative days 1 and 2 were significantly less for the SILSS group (P = .0014 and P = .047, respectively). Hospital stay was borderline statistically shorter in the SILSS group (P = .0053). SILSS was also associated with better cosmesis (P < .0011).

Conclusion:

SILSS is feasible and safe and is associated with earlier recovery of bowel function, a significant reduction in postoperative pain, and better cosmesis.

Resident training in single-incision laparoscopic colectomy

Single-incision laparoscopic colectomy (SLC) is touted as an improved approach to minimally invasive surgery, although no data currently exist regarding the acquisition of this technique. The aim of this study was to evaluate resident performance and outcomes in patients undergoing SLC performed by residents vs. staff colorectal surgeons. A retrospective case-control study was conducted, including 220 patients who underwent elective surgical intervention with multiport laparoscopic colectomy (MLC, n=141) or SLC (n=79) for colon cancer over a 24-month period at Yao Municipal Hospital (Yao, Japan). Data on patient demographics, operative data, oncological outcomes and short-term outcomes were evaluated for statistical significance. To investigate issues regarding the surgical procedures, the entire operation was recorded on video for all patients and was divided into 6 procedures, with each procedure measured in seconds. Senior-level residents were able to safely perform MLC under appropriate experienced supervision. For SLC, 1 case required conversion to an open procedure. No case required additional trocar placement. The mean operative times were similar for the staff and resident groups for total colon cancer (192.5 and 217.5 min, respectively; P=0.88), whereas the operative times of the staff group for right-sided colon cancer were significantly longer, and the operative times of the resident group for left-sided colon cancer were significantly longer. In addition, the overall perioperative outcomes, including blood loss, number of harvested lymph nodes, length of the surgical margin and complications, were similar between the two groups. When video recordings were evaluated by dividing the surgical process for the right colon into 4 procedures and that for the left colon into 6 procedures, the results demonstrated that the residents required more time to close the mesenteric margin for the left colon compared with the staff performing the same procedure (3,470.1±1,258.5 vs. 5,218.6±2,341.2 sec; P=0.01). Therefore, senior-level residents were able to safely perform SLC under appropriate experienced supervision. For the left colon, the main challenge for the residents appeared to be the closure of the mesenteric margin. Our data support that it is possible to train senior residents to complete a SLC safely and with the same efficacy as staff surgeons.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

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 Plus One Port Laparoscopic Total Pelvic Exenteration After Neoadjuvant Chemotherapy for Advanced Primary Rectal Cancer: A Case Report

Limited data on laparoscopic and robotic total pelvic exenteration (TPE) for gynecologic, urologic, and rectal malignancies have been published in the literature. Single-incision laparoscopic surgery (SILS) has been successfully introduced for colon cancer. Here, we describe our experience of TPE with SILS + 1 port (SILS+1) for advanced rectal cancer. A 64-year-old man was referred to our hospital with anemia. Computed tomography (CT) revealed a rectal tumor that was contiguous with the seminal vesicle and bladder. Rectoscopy revealed an ulcerated, bleeding, and stricturing lesion in the rectum, which was defined as an adenocarcinoma with a moderate degree of differentiation on histologic examination. The patient received neoadjuvant chemotherapy using capecitabine, oxaliplatin, and bevacizumab. After 3 courses of chemotherapy, a rectovesical fistula was suspected from examination of CT images. CT demonstrated intramural gas in the urinary bladder, which suggested a diagnosis of emphysematous cystitis. Thus, we constructed a transverse loop colostomy. Two months after the last administration of chemotherapy, we performed SILS+1 TPE. The procedure involved a 35-mm incision in the right side of the umbilicus for the insertion of a single multichannel port, and insertion of a 12-mm port into the right lower quadrant. Total operating time was 751 minutes, and estimated blood loss was 1100 mL (including urine). SILS+1 TPE is a technically promising alternative method for the treatment of selected patients with advanced rectal cancer.

Single-incision laparoscopic right hemicolectomy: inferior-to-superior approach with intracorporeal anastomosis

BACKGROUND

Single-incision laparoscopic right hemicolectomy has been shown to be safe and feasible; however, it remains technically demanding. We present a single-incision laparoscopic right hemicolectomy with an inferior-to-superior approach with intracorporeal anastomosis. This approach may help overcome some of the technical challenges of the conventional technique.

TECHNIQUE

With the patient in steep Trendelenburg and right-side elevated, a single-incision device is placed at the umbilicus. The small bowel is mobilized out of the pelvis, exposing the ileocolic peritoneal attachments. The peritoneum is divided and the retroperitoneal plane is established in a cranial and medial fashion until the duodenum is exposed. The ileocolic pedicle is readily identified and divided. Further exposure of the retroperitoneal plane is developed and the right branch of the middle colic vessel is isolated and divided. Attention is drawn to the remaining attachments of the hepatic flexure, which is then taken down. The resection margins of the transverse colon and terminal ileum are identified and a side-to-side intracorporeal anastomosis using a double-stapled technique is performed.

CONCLUSIONS

Technical challenges of the single-incision laparoscopic right hemicolectomy may be overcome utilizing an inferior-to-superior approach with intracorporeal anastomosis by affording optimal exposure, retraction, and dissection of the tissue planes.

Genetics, diagnosis and management of colorectal cancer (Review)

Colorectal cancer (CRC) is the third most common type of cancer worldwide and a leading cause of cancer death. Surgery represents the mainstay of treatment in early cases but often patients are primarily diagnosed in an advanced stage of disease and sometimes also distant metastases are present. Neoadjuvant therapy is therefore needed but drug resistance may influence response and concur to recurrent disease. At molecular level, it is a very heterogeneous group of diseases with about 30% of hereditary or familial cases. During colorectal adenocarcinomas development, epithelial cells from gastrointestinal trait acquire sequential genetic and epigenetic mutations in specific oncogenes and/or tumour suppressor genes, causing CRC onset, progression and metastasis. Molecular characterization of cancer associated mutations gives valuable information about disease prognosis and response to the therapy. Very early diagnosis and personalized care, as well as a better knowledge of molecular basis of its onset and progression, are therefore crucial to obtain a cure of CRC. In this review, we describe updated genetics, current diagnosis and management of CRC pointing out the extreme need for a multidisciplinary approach to achieve the best results in patient outcomes.

Single-site laparoscopic colectomy for rectosigmoid cancer with middle aortic syndrome: report of a case

Introduction

Single-site laparoscopic colectomy (SLC) is a promising minimally invasive and safe treatment for colorectal cancer. Improvements of the working instruments and procedures for SLC have helped to overcome challenges regarding the difficulty of operation, supporting the gradual acceptance of this technique. In contrast, narrow working space of the abdominal cavity sometimes prevents securing an adequate surgical view. To obtain precise anatomical information and enable complete mesocolic excision (CME), we routinely perform three-dimensional computed tomography prior to SLC.

Case presentation

A 69-year-old Japanese woman was clinically diagnosed with rectosigmoid cancer. Unexpectedly, preoperative examination revealed asymptomatic stenosis of the great artery, which was diagnosed as middle aortic syndrome. Because radical colectomy requires dissection of vessels that supply blood flow to the legs, a vascular stent was inserted prior to operation. We chose SLC due to the reduced risk of damaging epigastric arteries, which may eventually become collaterals in the event of stent re-stenosis. We accomplished SLC with CME, and the patient was discharged on the tenth day after operation without complications.

Conclusion

The present case is the first to proceed by SLC for colorectal cancer complicated by vascular obstructive disease. Preoperative imaging enabled us to identify an unexpected rare disease and to still accomplish SLC with CME, thus reinforcing the importance of preoperative imaging to optimize the use of SLC. In addition, SLC may become one of the most adequate procedures for patients complicated by vascular obstructive disease.

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

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

Single-incision versus conventional multiport laparoscopic colorectal surgery-systematic review and pooled analysis

BACKGROUND

The aim of this pooled analysis is to determine the effect of single-incision laparoscopic colorectal surgery (SILC) on short-term clinical and oncological outcomes compared with conventional multiport laparoscopic colorectal surgery (CLC).

METHODS

An electronic search of Embase, Medline, Web of Science, and Cochrane databases was performed. Weighted mean differences (WMD) were calculated for the effect size of SILC on continuous variables and pooled odds ratios (POR) were calculated for discrete variables.

RESULTS

No significant differences between the groups were noted for mortality or morbidity including anastomotic leak, reoperation, pneumonia, wound infection, port-site hernia, and operative time. The benefits of a SILC approach included reduction in time to return of bowel function (WMD = -1.11 days; 95 % C.I. -2.11 to -0.13; P = 0.03), and length of hospital stay (WMD = -1.9 days; 95 % C.I. -2.73 to -1.07; P < 0.0001). Oncological surgical quality was also shown for SILC for the treatment of colorectal cancer with a similar average lymph node harvest, proximal and distal resection margin length compared to CLC.

CONCLUSIONS

SILC can be performed safely by experienced laparoscopic surgeons with similar short-term clinical and oncological outcomes to CLC. SILC may further enhance some of the benefits of minimally invasive surgery with a reduction in blood loss and length of hospital stay.

A randomized pilot study on single-port versus conventional laparoscopic rectal surgery: effects on postoperative pain and the stress response to surgery

BACKGROUND

Potential benefits of single-port laparoscopic surgery may include improved cosmetic results, less postoperative pain, surgical trauma and faster recovery. Results of randomized prospective studies with a focus on single-port rectal surgery have not yet been presented. The aim of the present study was to compare single-port and conventional laparoscopic surgery for rectal cancer in terms of short-term outcomes including postoperative pain and trauma-induced changes in certain bioactive substances.

METHODS

Patients with non-metastasized rectal cancer were prospectively randomized to single-port (n = 20) or conventional laparoscopic rectal surgery (n = 20). Postoperative pain was assessed at rest, at coughing and during mobilization, with a numeric pain ranking score and was recorded at 6 h after the operation and subsequently every morning daily for 4 days. Levels of C-reactive protein (CRP), interleukin-6 (IL-6) and tissue inhibitor of metalloproteinases-1 (TIMP-1) were determined. Blood samples were collected preoperatively (baseline), and 6, 24, 48, 72 and 96 h after skin incision.

RESULTS

Pain scores were significantly reduced in the single-port group on postoperative days 2, 3 and 4 during coughing and mobilization. In addition, the patients in the single-port group suffered significantly less pain at rest at 6 h after surgery and on postoperative days 1, 3 and 4. The levels of the three markers increased significantly after surgery. The increase was similar between groups for plasma IL-6 and TIMP-1 at all time points, while the CRP levels were significantly lower in the single-port group at 6 (p < 0.001) and 24 h (p < 0.05) after skin incision. Abdominal incisions lengths were significantly shorter in the single-port group (p = 0.001). There was no significant difference between groups in operating time and blood loss, morbidity or mortality rate. The short-term oncological outcome in the two groups was similar.

CONCLUSIONS

Single-port rectal surgery may reduce postoperative pain. Although CRP levels were lower at some time points, results of the present randomized, pilot study suggest that the trauma-induced inflammatory response of single-port operations may be similar to the trauma-induced inflammatory response of conventional laparoscopic surgery.

Single-incision laparoscopic colorectal surgery for cancer: State of art

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

Natural orifice specimen extraction using prolapsing technique in single-incision laparoscopic colorectal resections for colorectal cancers

INTRODUCTION

It is often technically difficult to cut the lower rectum with an endoscopic linear stapler in single-incision laparoscopic colorectal resections (SILC) because some surgical devices are inserted through the same access platform. If the rectum is cut incorrectly, it may cause anastomotic leakage. We recently applied natural orifice specimen extraction (NOSE) using the prolapsing technique to overcome this technical difficulty in SILC procedures in selected patients.

MATERIALS AND SURGICAL TECHNIQUE

The access platform is placed in the small umbilical incision area. SILC is performed using a surgical technique similar to the conventional laparoscopic medial-to-lateral approach. The proximal part of the tumor site is transected with laparoscopic staplers. Then, the tumor lesion and bowel are pulled out of the body through the anus by means of inversion. Next, the distal side of the bowel is cut with a stapler and the rectal stump is reinforced with sutures under direct vision. The distal side of the bowel is then pushed back into the body. NOSE with prolapsing technique is then complete. After that, the anvil is attached to the proximal part of the bowel at the umbilical incision site, and intracorporeal anastomosis is performed.

DISCUSSION

NOSE with prolapsing technique was applied in 14 SILC procedures for colorectal cancer patients. All procedures were successful, and there were no anastomotic leakages in the series. This technique enabled us to perform pure SILC safely without affecting cosmesis, even in cases where we needed to cut the lower rectum.

Feasibility of single-site laparoscopic colectomy with complete mesocolic excision for colon cancer: a prospective case-control comparison

Background

Single-site laparoscopic colectomy (SLC) is an emerging concept that, compared with conventional multiport laparoscopic colectomy (MLC), yields reduced postoperative pain and improved cosmesis. Complete mesocolic excision (CME) is a novel concept for colon cancer surgery that provides improved oncologic outcomes; however, there are no reports of SLC with CME. We conducted a prospective case–control study to evaluate the feasibility and safety of SLC with CME for colon cancer.

Methods

Prospectively collected data of patients with stage I-III colon cancer who underwent SLC (n = 150) or MLC (n = 150) between June 2008 and March 2012 were analyzed. Patients who underwent SLC were, in terms of clinical characteristics and tumor location, matched as closely as possible with those undergoing MLC. Within each group, patients were classified as having right-sided (n = 69 in each group) or left-sided (n = 81 in each group) colon cancer, and short-term outcomes were compared between the two procedures overall and per side.

Results

Overall perioperative outcomes, including operation time, blood loss, number of lymph nodes harvested, length of the resected specimen, and complications, were similar between the two procedures, whereas postoperative pain was significantly lower with SLC. Operation time for right-sided SLC was significantly shortened. SLC with CME was completed successfully in 94 % (65/69) of right-sided cases and in 88 % (71/81) of left-sided cases. Conversion rates were 1.4 % (1/69) and 1.1 % (1/81), respectively. The umbilical scars were nearly invisible 3 months after the procedure, and most patients reported being quite satisfied with the cosmetic outcomes.

Conclusions

SLC with CME for colon cancer is feasible when performed by experienced surgeons in selected patients. Excellent cosmesis and reduced postoperative pain as well as oncologic clearance can be expected. A large-scale, prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over MLC with CME.

Critical appraisal of learning curve for single incision laparoscopic right colectomy

BACKGROUND

Single-incision laparoscopic colectomy (SILC) has emerged as a viable minimally invasive surgical approach with benefits and limitations yet to be fully elucidated. Although shown to be safe and feasible, characterization of the learning curve has not been addressed. Our aim was to identify a learning curve for SILC right hemicolectomy and to determine the incidence of operative failure and complication rates during this phase.

METHODS

Over a 2-year period, data from 54 consecutive SILC cases performed by the same surgeon were tabulated in an institutional review board-approved database. A learning curve was generated utilizing cumulative sum (CUSUM) methodology to assess changes in total operative time (OT) across the case sequence. A separate learning curve was generated utilizing risk-adjusted CUSUM analysis, taking into account patient risk factors (i.e., age, American Society of Anesthesiologists score, body mass index, prior abdominal surgeries, and tumor size for malignant cases) and operative failure (i.e., prolonged OT, conversion to open surgery, intraoperative and 30-day postoperative complications, prolonged length of stay, reoperation, readmission, and mortality).

RESULTS

Patients had a mean age of 63.6 ± 11.5 years, mean body mass index of 27.3 ± 3.9 kg/m(2), and median American Society of Anesthesiologists score of 2. Mean OT and length of stay were 123.5 ± 28.9 min and 3.9 ± 2.4 days, respectively. There were no conversions or oncologic failures. Six patients developed 30-day postoperative complications. CUSUM analysis of OT identified achievement of the learning phase after 30 cases. When taking into account both analyses, the rate of operative failure was not statistically different between the initial 30 and the final 24 cases.

CONCLUSIONS

In our experience, the learning curve is achieved between 30 to 36 cases. Offering this minimally invasive surgical approach does not result in increased complications or harmful results even in the early phases of the learning curve.

Single-incision laparoscopic colectomy for cancer: short-term outcomes and comparative analysis

Introduction. Single-incision laparoscopic colectomy (SILC) is a viable and safe technique; however, there are no single-institution studies comparing outcomes of SILC for colon cancer with well-established minimally invasive techniques. We evaluated the short-term outcomes following SILC for cancer compared to a group of well-established minimally invasive techniques. Methods. Fifty consecutive patients who underwent SILC for colon cancer were compared to a control group composed of 50 cases of minimally invasive colectomies performed with either conventional multiport or hand-assisted laparoscopic technique. The groups were paired based on the type of procedure. Demographics, intraoperative, and postoperative outcomes were assessed. Results. With the exception of BMI, demographics were similar between both groups. Most of the procedures were right colectomies (n = 33) and anterior resections (n = 12). There were no significant differences in operative time (127.9 versus 126.7 min), conversions (0 versus 1), complications (14% versus 8%), length of stay (4.5 versus 4.0 days), readmissions (2% versus 2%), and reoperations (2% versus 2%). Oncological outcomes were also similar between groups. Conclusions. SILC is an oncologically sound alternative for the management of colon cancer and results in similar short-term outcomes as compared with well-established minimally invasive techniques.

Single-incision laparoscopic versus traditional multiport laparoscopic colorectal surgery--a cumulative meta-analysis and systematic review

PURPOSE

The published data on the evaluation of feasibility and safety of single-incision laparoscopic colorectal surgery (SILC) compared with traditional multiport laparoscopic colorectal surgery (MLC) remained controversial. The present cumulative meta-analysis and systematic review were performed to provide a more objective and precise estimate.

MATERIALS AND METHODS

PubMed, the Cochrane Library, and also, manual searches were employed to identify potentially eligible studies which were published before June 7, 2012. The association was assessed by odds ratio (OR) and means with 95 % confidence intervals (CI).

RESULTS

A total of 20 comparative studies were included, with 670 patients underwent SILC and 838 patients underwent MLC. For overall pooled estimates, no evidence of between trial differences was found in overall conversion rate (OR, 1.7; 95 % CI, 0.97 to 3.01), overall complication rate (OR, 0.82; 95 % CI, 0.63 to 1.08), and operative time (mean, -3.59; 95 % CI, -10.95 to 3.77); significantly between trial differences were found in estimated blood loss (mean, -18.61; 95 % CI, -31.33 to -5.90) and post-operative hospital stay (mean, -0.54; 95 % CI, -0.95 to -0.12). The cumulative meta-analysis identified a potentially increased conversion rate of SILC compared with MLC with the increased percentage of malignancies, but no significant differences could be identified in overall complication rate.

CONCLUSION

This meta-analysis suggested the feasibility and safety of SILC performed by experienced hands, though potentially higher overall conversion rate occurred in malignancies. SILC will benefit the patients much more with its superiority over MLC.

Single incision vs conventional laparoscopic anterior resection for sigmoid colon cancer: a case-matched study

BACKGROUND

The purpose of the study was to evaluate the safety and effects of single-incision laparoscopic anterior resection (SILAR) for sigmoid colon cancer by comparing it with conventional laparoscopic anterior resection (CLAR).

METHODS

Twenty-four patients who underwent SILAR between April 2010 and July 2011 were case matched 1:2 with patients who underwent CLAR, with respect to age, sex, body mass index, tumor location, and history of abdominal surgery.

RESULTS

Two patients in the SILAR group and 1 patient in the CLAR group experienced anastomotic leakage. The operative time was longer in the SILAR group than in the CLAR group (251 ± 50 vs 237 ± 49 minutes; P = .253). The number of harvested lymph nodes (19.6 ± 10.7 vs 20.8 ± 7.7; P = .630) was not different. The postoperative hospital stay was shorter in the SILAR group (7.1 ± 3.4 days) than in the CLAR group (8.1 ± 3.5 days) (P = .234).

CONCLUSIONS

On the basis of the early outcomes, we conclude that SILAR is feasible and safe. Moreover, the adequate lymph node harvest and free margins support the use of this procedure.

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

BACKGROUND

Single-port laparoscopic surgery has attracted attention in the field of minimally invasive colorectal surgery. We hypothesized that an experienced laparoscopic surgeon could perform single-port surgery for colon cancer eligible for conventional laparoscopic anterior resection. Our aim was to analyze our initial experience and immediate surgical outcomes of single-port anterior resection.

METHODS

A total of 37 consecutive patients with presumed sigmoid colonic cancer underwent single-port anterior resection with standard laparoscopic instruments between May 2009 and June 2010. Each operation was performed by one of two experienced colorectal surgeons. A cohort of patients who had undergone conventional laparoscopic surgery (CLS) for the same duration a year earlier (August 2007 to September 2008) was used as a historical control. Patient demographics and perioperative outcomes were analyzed and compared with those of CLS.

RESULTS

There were no significant differences in mean estimated blood loss, mean length of the resection margin, or morbidity between the two groups, but operative time for the single-port group was significantly shorter (118 ± 41 vs. 140 ± 42 min; p = 0.017). Single-port laparoscopic surgery was successfully performed in 78.4% (29/37) of the patients treated in 2010, and CLS was successfully completed in all of the patients treated the previous year (p = 0.000). The main causes of single-port surgery failure were adhesion and tumor location.

CONCLUSIONS

Single-port anterior resection is a feasible and safe procedure with immediate outcomes comparable to those of conventional laparoscopy. Further studies are required to determine the feasibility of single-port surgery for colonic tumors outside the sigmoid colon and the long-term outcome.

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

OBJECTIVE

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

METHODS

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

RESULTS

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD) = -0.68; 95 % CI = -1.20 to -0.16; p = 0.0099), shorter incision length (pooled WMD = -1.37; 95 % CI = -2.74 to 0.000199; p = 0.05), less estimated blood loss (pooled WMD = -20.25; 95 % CI = -39.25 to -1.24; p = 0.037), and more lymph nodes harvested (pooled WMD = 1.75; 95 % CI = 0.12 to 3.38; p = 0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio = 0.83; 95 % CI = 0.57 to 1.20; p = 0.33) or operative time (pooled WMD = 5.06; 95 % CI = -2.91 to 13.03; p = 0.21).

CONCLUSION

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.

Single-port laparoscopic colectomy

Single-port laparoscopy (SPL) for colorectal surgery was first described for a right hemicolectomy in 2008. Since then, technology and experience have advanced, and SPL is now reported for a variety of colorectal procedures. Multiple case series and reports have demonstrated the adequate safety of SPL, but there are few reports of a measurable benefit of the technique. SPL is a difficult procedure to learn, it may have relatively high costs, and it is more difficult to perform as well as more physically and mentally taxing on the surgeon. Despite the difficulty and potentially increased cost, SPL suits colorectal patients well as they commonly have a stoma or extraction site adequate in size for a single port. There are cosmetic advantages to this technique, but they apply to a small subset of patients requiring colorectal surgery. There are many tips to incorporate SPL into practice successfully, but the procedure requires patience and experience. As surgeons become more facile with this technique, a group that derives a clear benefit beyond cosmesis will arise, likely a subset of reoperative patients requiring fecal diversion. The accompanying video demonstrates, step by step, the authors' technique of total proctocolectomy and ileo-anal pouch using a single-port device.

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 laparoscopic sigmoid resection: a technical video of a standardized approach

BACKGROUND

Initially described in 2008, single-incision laparoscopic colectomy has evolved into a safe and feasible surgical approach. Noted advantages include elimination of trocar-site incisions and improved cosmesis. Additional benefits including reduced abdominal wall trauma, diminished pain, and shorter length of hospitalization have been proposed. Following utilization in over 150 colectomies, we present a standardized approach and describe our technique for single-incision laparoscopic sigmoid resection through a single-port access device.

TECHNIQUE

A 2.5-cm umbilical incision is used for insertion of the single-incision access device. A 30° 5-mm camera with a right-angle light cord adaptor and 2 bowel graspers are inserted through the access device. Exploration and lysis of adhesions are performed before placing the patient in a steep Trendelenburg position with 20° left-sided elevation. Dissection commences in a medial-to-lateral fashion, developing the presacral avascular plane while ensuring nerve preservation. The retroperitoneal plane is established from the sacral promontory to the lateral peritoneal reflection. After identification of the left ureter and isolation of the vascular pedicle, the inferior mesenteric artery is isolated and ligated. The lateral attachments of the left colon and rectosigmoid are then divided, followed by additional pelvic dissection along the presacral avascular plane. The mesentery of the distal resection margin is divided before transection of the corresponding bowel using a stapling device. The bowel is then extracted and resected at the site of the single-incision access device. An intracorporeal primary end-to-end anastomosis is fashioned.

CONCLUSION

We present a dynamic article with video illustrating a standardized medial-to-lateral approach for single-incision laparoscopic sigmoid resection. The technique effectively avoids the use of multiple trocar sites, maintains basic oncologic principles of resection, and affords the benefits of minimally invasive surgery.

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.

Umbilical incision laparoscopic colectomy with one additional port for colorectal cancer

BACKGROUND

Recently, laparoscopic colorectal surgery using a single incision usually made at the umbilical area has emerged as a tool to minimize the numbers of scars and provide better cosmetic results. But experience in laparoscopic skills is needed to maintain the oncologic principles of colorectal cancer surgery with the restricted operating field during the procedure. Adding an additional port to single-incision laparoscopic colorectal surgery (SILS) may be a bridge between conventional multiport laparoscopic surgery and SILS. The present study was undertaken to investigate whether umbilical incision laparoscopic colorectal cancer surgery with one additional port (ULAP) could be performed in a similar manner to conventional multiport surgery.

METHODS

One hundred and sixty-three patients with colorectal adenocarcinoma underwent laparoscopic colectomy between February 2011 and August 2011. Forty of these patients underwent ULAP and were compared with the other 123 patients who had conventional laparoscopic surgery. Demographic, intraoperative, and postoperative data were analyzed.

RESULTS

Both groups were similar in age (p = 0.438), gender (p = 0.818), body mass index (p = 0.149), American Society of Anesthesiologists (ASA) scores (p = 0.417), history of previous abdominal operation (p = 0.503), and tumor location (p = 0.051). Operation time was longer in the ULAP group (255.5 min) than in the conventional laparoscopic surgery group (144.6 min) (p < 0.001). No significant differences were evident between groups for estimated blood loss (p = 0.263), transfusion requirements (p = 0.841), conversion to open procedures (p = 0.40), length of umbilical incisions (4.6 vs. 4.4 cm, p = 0.628), postoperative hospital stay (p = 0.862), tumor size (p = 0.455), number of harvested lymph nodes (p = 0.203), proximal margins (p = 0.189), and distal resection margins (p = 0.151). Postoperative morbidity (p = 0.736) was similar in both groups. There was no mortality postoperatively.

CONCLUSIONS

Umbilical incision laparoscopic colorectal cancer surgery with an additional port is a feasible and safe approach, although it is more time consuming than conventional laparoscopic colectomy.