Single-incision laparoscopic surgery for ileocolic resection in Crohn's disease

The Role of Minimally Invasive Surgery in the Management of Inflammatory Bowel Disease: Current Trends and Future Directions

Minimally invasive surgery (MIS) provides superior results in the surgical treatment of inflammatory bowel disease (IBD). There exist various minimally invasive procedures, each possessing its own set of benefits and drawbacks. This literature review outlines these methodologies and underscores their importance in enhancing the outcomes of patients with IBD. A grand total of 192 studies were carefully chosen and succinctly summarized. Conventional multiport laparoscopy is the most widely used MIS for IBD, with single-incision laparoscopy showing even better results. Robotic surgery offers comparable results but at higher costs and longer operation times. In the future, there will be widespread acceptance of single-incision laparoscopy and robotic surgery due to improved training and reduced expenses. Further research into the technology's utility in different IBD presentations could increase its usage.

Single-incision versus multi-port laparoscopic ileocolic resections for Crohn's disease: Systematic review and meta-analysis

Introduction

The aim of this systematic review and meta-analysis is to compare the outcomes of single-incision laparoscopic surgery (SILS) versus multi-port laparoscopy for ileocolic resection in patients with Crohn's disease (CD).

Patients and Methods

A systematic search of multiple electronic databases was conducted. The peri- and post-operative outcomes were evaluated between Crohn's patients undergoing SILS versus multi-port laparoscopy for ileocolic resection. The primary outcomes included operative time, anastomotic leak rate, post-operative wound infections and length of hospital stay. Analysed secondary outcomes were conversion rates, ileus occurrence, intra-abdominal abscess formation, return to theatre and re-admissions. Revman 5.3 was used to perform the statistical analysis.

Results

Five observational studies with 521 patients (SILS: 211; multi-port: 310) were included in the data synthesis. Patients undergoing SILS had a reduced total operative time compared to multi-port laparoscopy (mean difference [MD]: -16.14, 95% confidence interval: [CI] -27.23 - 5.05, P = 0.004). Post-operative hospital stay was also found to be significantly less in the SILS group (MD: -0.57, 95% CI: -0.73--0.42, P < 0.0001). No significant difference was seen in the anastomotic leak rate (MD: -16.14, 95% CI: 0.18-1.71, P = 0.004) or post-operative wound infections (odds ratio: 0.78, 95% CI: 0.24 - 2.47, P = 0.67) between the two groups. Moreover, all the measured secondary outcomes were comparable.

Conclusion

SILS seems to be a feasible alternative to multi-port laparoscopic surgery for ileocolic resection in patients with CD. Improved outcomes in terms of total operative time and length of hospital stay were observed in patients undergoing SILS surgery. Adopting this procedure into routine clinical practice constitutes the next step in the development of minimally invasive surgery.

The Revival of Surgery in Crohn's Disease-Early Intestinal Resection as a Reasonable Alternative in Localized Ileitis

Crohn's disease (CD) represents a heterogeneous and complex disease with no curative therapeutic option available to date. Current therapy is mainly antibody-based focusing on the immune system while other treatment alternatives such as surgery are considered to be "last options". However, medical therapy for CD results in mild to severe side effects in a relevant amount of patients and some patients do not respond to the medication. Following that, quality of life is often significantly reduced in this patient cohort, thus, therapeutic alternatives are urgently needed. Updated evidence has revealed that surgery such as ileocecal resection (ICR) might be a potential therapeutic option in case of localized terminal ileitis since resection at early time points improves quality of life and significantly reduces the postoperative need for immunosuppressive medication with low rates of morbidity. In addition, new surgical approaches such as Kono-S anastomosis or inclusion of the mesentery result in significantly reduced rates of disease recurrence and reoperation. Based on the new evidence, the goal of this review is to provide an update on the role of surgery as a reasonable alternative to medical therapy in the interdisciplinary treatment of patients with CD.

A Systematic Review of Comparing Single-incision Versus Traditional Laparoscopic Right Hemicolectomy For Right Colon Diseases

BACKGROUND

Single-incision laparoscopic right hemicolectomy (SILS) has been promoted in clinic since 2008, but a systematic review of comparing SILS and traditional laparoscopic right hemicolectomy (TLS) with long-term follow-up is rare. Here, in this study, comparison of SILS and TLS with long-term follow-up was evaluated by a meta-analysis method.

METHODS

All studies about SILS and TLS for right hemicolectomy from 2010 to 2018 were searched from databases including Medline, Embase, Cochrane Library, and Wanfang. Operation index, recovery, and midterm follow-up data were evaluated by fixed-effects models, random-effects models, and Begg test.

RESULTS

We collected 22 studies with 2218 patients. SILS groups contained 1038 (46.7%) patients, and 1180 (53.3%) patients were observed in the TLS group. Patients' baseline data were similar in the 2 groups. Compared with TLS, SILS had shorter operation duration [standardized mean difference (SMD): -0.35, 95% confidence interval (CI): -0.61 to -0.08, P<0.001, χ=49.40], shorter hospitalization time (SMD: -0.27, 95% CI: -0.37 to -0.16, P<0.001, χ=9.17), slightly less blood loss (SMD: -0.23, 95% CI: -0.36 to -0.10; P<0.001; χ=5.36), and smaller incision length (SMD: -2.19, 95% CI: -3.66 to -0.71, P<0.001; χ=316.1). No statistical differences were observed in other figures.

CONCLUSION

SILS is more convenient and has better efficacy than TLS and could provide a promising surgical approach for right colon diseases.

Meta-analysis of early bowel resection versus initial medical therapy in patient's with ileocolonic Crohn's disease

BACKGROUND

Early bowel resection (EBR) in ileocolonic Crohn's disease (CD) may be associated with more durable remission compared with initial medical therapy (IMT) even when biologic therapy is included.

AIM

To compare the efficacy of EBR versus IMT for ileocolonic CD METHODS: A systematic search was performed to identify studies that compared EBR (performed < 1 year from initial diagnosis) or IMT for the management of ileocolonic CD. Log hazard ratios (InHR) for relapse-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots and pooled using the inverse-variance method. Dichotomous variables were pooled as odds ratios (OR). Quality assessment of the included studies was performed using the Newcastle-Ottawa (NOS) and Jadad scales.

RESULTS

A total of 7 studies with 1863 CD patients (EBR n = 581, 31.2%; IMT n = 1282, 68.8%) were eligible for inclusion. There was a moderate-to-high risk of bias. The median NOS was 8 (range 7-9). There was a reduced likelihood of overall (OR, 0.53; 95% confidence interval (95% CI), 0.34, 0.83; p = 0.005) and surgical (OR, 0.47; 95% CI, 0.24, 0.91; p = 0.03) relapse with EBR. There was also a less requirement for maintenance biologic therapy (OR, 0.24; 95% CI, 0.14, 0.42; p < 0.0001). Patients who underwent EBR had a significantly improved RFS than those who underwent IMT (HR, 0.62; 95% CI, 0.52, 0.73; p < 0.001). There was no difference in morbidity (OR, 1.67; 95% CI, 0.44, 6.36; p = 0.45) between the groups.

CONCLUSION

EBR may be associated with less relapse and need for maintenance biologic therapy than IMT. 'Upfront' or early resection may represent a reasonable and cost-effective alternative to biologic therapy, especially in biologic-resistant subpopulations.

Minimally Invasive Surgery in Complex Crohn's Disease

Minimally invasive approaches are safe, feasible, and often recommended as the initial choice in the surgical management of Crohn's disease. However, a consensus has not been reached as the ideal approach in the surgical treatment of complex and recurrent Crohn's disease. Laparoscopy may provide advantages such as shorter length of stay and decreased postoperative pain and result in less adhesion formation in patients with complex disease. Robotic techniques may be beneficial in selected patients for completion proctectomy, providing better visualization in the narrow pelvis and increased dexterity. Decision of surgical technique should be made on a case-by-case basis.

A review of reports on single-incision laparoscopic surgery for Crohn's disease

The aim of this review was to analyze the currently available literature on single-incision laparoscopic surgery (SILS) for Crohn's disease (CD) with respect to surgical indications, surgical techniques, feasibility, and possible benefits of SILS for CD. A systematic query of articles published from January 2010 to July 2018 was performed. The studies were assessed for patient's age, gender, body mass index, disease type, SILS procedure, surgical procedure, incision length, operation time, rates of conversion to open surgery, postoperative complications, mortality, length of hospital stay, and rates of reoperation. After an initial review, 11 reports were selected. The surgical techniques and instruments showed wide variation. The mean operation time for SILS tended to be shorter than that for multiport laparoscopic surgery (MLS). The reported rates of conversion to open surgery and postoperative complications were not very different from those reported for MLS. In conclusion, the present review suggests that the SILS technique may be feasible and safe for select patients with CD. However, because we reviewed only a few studies with small sample sizes, prospectively designed trials with a large number of patients are required to clarify the true benefits of SILS for CD.

Changing trends in surgery for abdominal Crohn's disease

AIM

The introduction of biological agents and laparoscopy are, arguably, the most important developments for the treatment of Crohn's disease (CD) in the last two decades. Due to the efficacy of biological agents in treating mild disease, it is likely that the percentage of surgery for complex cases may have increased. The objective of this study was to analyse the changing characteristics and results of the surgical treatment of patients with CD over the past 13 years.

METHODS

All patients who underwent abdominal surgery for CD between 2004 and 2016 were retrospectively identified. Data were compared between two periods (2004-2010 and 2011-2016).

RESULTS

A total of 908 procedures were performed (48% men, mean age 43 ± 16 years). Demographic and CD characteristics changed significantly over time: comorbidities were more frequent (35% vs 46%, P < 0.0001), and preoperative steroids (28% vs 36%, P < 0.01) and anti-tumour necrosis factor (20% vs 40%, P < 0.0001) treatments were more frequently used in the second period. Smoking (14% vs 8%, P < 0.0001) and use of immunosuppressors (32% vs 22%, P < 0.001) decreased significantly. More cases of penetrating disease (22% vs 32%, P < 0.001) were operated upon in the second period. The laparoscopic approach (49% vs 57%, P < 0.04) was more frequently performed and mean blood loss (167 ± 222 vs 123 ± 243 ml, P < 0.01) decreased significantly. Postoperative morbidity did not change between the two periods.

CONCLUSION

Despite a higher incidence of comorbidities and the use of biologics postoperative morbidity remained unchanged. An increased use of laparoscopy and a decreased intra-operative blood loss may have contributed to offsetting the impact of increased comorbidity.

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.

Single-incision laparoscopic versus conventional laparoscopic right colectomy: A systematic review and meta-analysis

BACKGROUND

Single-incision laparoscopic surgery has gained widespread attention because of its potential benefits such as less skin incision and faster recovery. Up to now, only one meta-analysis (performed in 2013; including 9 studies, a total of 585 cases) compared single-incision laparoscopic right colectomy (SILRC) with conventional laparoscopic right colectomy (CLRC). An updated meta-analysis was undertaken to explore more convinced comparative findings between SILRC and CLRC.

MATERIALS AND METHODS

The search for studies that compared SILRC with CLRC was done on PubMed, Embase, Web of Science, and the Cochrane Library. A total of 17 studies (including 1778 cases) were identified, the data of appointed outcomes were extracted and analyzed.

RESULTS

Patient demographics (age, gender, body mass index and previous abdominal operation) did not differ significantly. No significant differences were found between SILRC and CLRC in operative time, conversion, reoperation, perioperative complications, postoperative mortality, and 30-days readmission. Pathological outcomes, including lymph nodes harvested, proximal resection margin, and distal resection margin, were similar. SILRC showed less estimated blood loss (weighted mean difference [WMD]: -15.67 ml; 95% confidence interval [CI], -24.36 to -6.98; p = 0.0004), less skin incisions (WMD: -1.56 cm; 95%CI, -2.63 to -0.49; p = 0.004) and shorter hospital stay (WMD: -0.73d; 95%CI, -1.04 to -0.41; p < 0.00001), without publication bias.

CONCLUSION

SILRC may provide a safe and feasible alternative to CLRC with similar short-term outcomes and aesthetic advantage of less skin incision. Well-designed randomized controlled trials, involving large cases and carrying long-term outcomes, are needed.

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.

Totally robotic intracorporeal side-to-side isoperistaltic strictureplasty for Crohn's disease

The development of bowel-sparing techniques (strictureplasties) for extended stricturing Crohn's disease (CD) and the increased use of minimally invasive surgery (wound sparing) represent the two most important improvements in inflammatory bowel disease surgery from the origin. Nevertheless, the minimally invasive approach for extended stricturing forms is usually avoided primarily because of difficulties in performing complex intracorporeal sutures. We describe a totally intracorporeal robotic ileocecal resection with a yet described modified side-to-side isoperistaltic strictureplasty for an extended ileocecal CD. The strictureplasty was 6 cm long including the stricture in its middle part. Adopting this approach, the preserved small bowel was about 10 cm longer. Operative time was about 4 h, with a blood loss of about 50 ml. The patients' post-operative course was uneventful, enteral nutrition started at post-operative day 2 and gradual oral food intake from day 3. She was discharged on post-operative day 6. Histology confirmed a stricturing CD, and the patient is recurrence free at 34 months' follow-up. Our report suggests that robotic-assisted intracorporeal strictureplasty is feasible and that robotics could represent an interesting instrument for allowing the intersection between minimally invasive and bowel-sparing surgery for CD.

Single port laparoscopic ileocaecal resection for Crohn's disease: a multicentre comparison with multi-port laparoscopy

AIM

Single port (SP) ileocaecal resection (ICR) is an established technique but there are no large studies comparing SP and multi-port (MP) laparoscopic surgery in Crohn's disease (CD). The aim of this study was to compare postoperative pain scores and analgesia requirements after SP and MP laparoscopic ICR for CD.

METHOD

This was a retrospective study of patients undergoing SP or MP ICR for CD in three tertiary referral centres from February 1999 to October 2014. Baseline characteristics (age, sex, body mass index and indication for surgery) were compared. Primary end-points were postoperative pain scores, analgesia requirements and short-term postoperative outcomes.

RESULTS

SP ICR (n = 101) and MP ICR (n = 156) patients were included in the study. Visual analogue scale scores were significantly lower after SP ICR on postoperative day 1 (P = 0.016) and day 2 (P = 0.04). Analgesia requirements were significantly reduced on postoperative day 2 in the SP group compared with the MP group (P = 0.007). Duration of surgery, conversion to open surgery and stoma rates were comparable between the two groups. Surgery was more complex in terms of additional procedures when MP was adopted (P = 0.001). There were no differences in postoperative complication rates, postoperative food intake, length of stay and readmissions.

CONCLUSION

These data suggest that in comparison to standard laparoscopic surgery SP ICR might be less painful and patients might require less opioid analgesia.

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.

Indications and surgical options for small bowel, large bowel and perianal Crohn's disease

Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.

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.

European Crohn's and Colitis Organisation Topical Review on Prediction, Diagnosis and Management of Fibrostenosing Crohn's Disease

This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focused on prediction, diagnosis, and management of fibrostenosing Crohn's disease [CD]. The objective was to achieve evidence-supported, expert consensus that provides guidance for clinical practice.

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-incision laparoscopic surgery (SILS) for children with Crohn's disease

PURPOSE

Single-incision laparoscopic surgery (SILS) has been described in adults with Crohn's disease, but its use in pediatric Crohn's patients has been limited. The purpose of this study was to review our experience with SILS in pediatric patients with Crohn's disease.

METHODS

A retrospective review was performed for patients diagnosed with Crohn's disease who underwent small bowel resection or ileocecectomy at a freestanding children's hospital from 2006 to 2014. Data collected included demographic data, interval from diagnosis to surgery, operative time, length of stay, and postoperative outcomes.

RESULTS

Analysis identified 19 patients who underwent open surgery (OS) and 41 patients who underwent SILS. One patient (2.4 %) within the SILS group required conversion to OS. Demographic characteristics were similar between the 2 cohorts. The most common indication for surgery was stricture/obstruction (SILS 70.7 % vs. OS 68.4 %, p = 0.86), and ileocecectomy was the most common primary procedure performed (SILS 90.2 % vs. OS 100 % OS). Operative times were longer for SILS (135 ± 50 vs. 105 ± 37 min, p = 0.02). However, when the last 20 SILS cases were compared to all OS cases, the difference was no longer statistically significant (SILS 123.3 ± 34.2 vs. OS 105 ± 36.5, p = 0.12). No difference was noted in postoperative length of stay (SILS 6.5 ± 2.2 days vs. OS 7.4 ± 2.2 days, p = 0.16) or overall complication rate (SILS 24.4 % vs. OS 26.3 %, p = 0.16).

CONCLUSION

SILS ileocecectomy is feasible in pediatric patients with Crohn's disease, achieving outcomes similar to OS. As experience increased, operative times also became comparable.

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.

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

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

Single-Incision Laparoscopic Colon and Rectal Surgery

Single-incision laparoscopic surgery (SILS) was introduced to further the enhanced outcomes of multiport laparoscopy. Multiple studies have demonstrated the safety and feasibility of SILS for both benign and malignant colorectal disease. SILS provides the potential for improved cosmesis, postoperative outcomes, and patient quality of life. However, widespread use has been limited by technical demands and lack of an evidence and competency-based curriculum.

Review of single incision laparoscopic surgery in colorectal surgery

As surgical techniques continue to move towards less invasive techniques, single incision laparoscopic surgery (SILS), a hybrid between traditional multiport laparoscopy and natural orifice transluminal endoscopic surgery, was introduced to further the enhanced outcomes of multiport laparoscopy. The safety and feasibility of SILS for both benign and malignant colorectal disease has been proven. SILS provides the potential for improved cosmesis, postoperative pain, recovery time, and quality of life at the drawback of higher technical skill required. In this article, we review the history, describe the available technology and techniques, and evaluate the benefits and limitations of SILS for colorectal surgery in the published literature.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Oversewing staple lines to prevent anastomotic complications in primary ileocolic resections for Crohn's disease

BACKGROUND

Oversewing staple lines may be a novel way to reduce anastomotic complications after primary ileocolic resections for Crohn's disease (CD).

STUDY DESIGN

This is a single-institution, non-concurrent cohort study of CD patients undergoing primary ileocolic resections (ICR) with stapled anastomoses from 2007 to 2013. Demographic and clinical characteristics were collected. Propensity scores were calculated for oversewing versus not. Postoperative outcomes within 30 days of surgery were collected. Anastomotic leak, intra-abdominal abscess, small bowel obstruction, and anastomotic bleed were considered major anastomotic complications (MACs). Multivariate analysis controlling for inverse probability weights was used to identify predictors of MACs.

RESULTS

A total of 269 patients were included, of which 120 had undergone oversewing (OS). After controlling for propensity scores, not oversewing (NOS) and OS groups were similar in all preoperative characteristics with the exception of more laparoscopic resections and intracorporeal anastomoses in the NOS group. On univariate analysis, OS was protective against MACs (odds ratio (OR) 0.29, p < 0.01). In a multivariable model using inverse propensity weights and controlling for laparoscopic and intracorporeal approaches, oversewing remained a significant predictor of reduced MACs (OR 0.37, p < 0.001), while intracorporeal anastomoses increased their likelihood (OR 3.7, p < 0.001).

CONCLUSIONS

After controlling for clinical and surgical factors, oversewing staple lines in primary ICRs for CD is correlated with reduced MACs.

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.

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.

Single port laparoscopic surgery for patients with complex and recurrent Crohn's disease

BACKGROUND

Single port laparoscopic surgery (SPLS) is a modified access technique allowing grouping of instruments at a single parietal site. It is intuitively appealing specifically for patients with Crohn's disease (CD) as its minimal invasiveness favors cosmesis and facilitates any future (re)operation.

METHODS

Consecutive patients presenting either electively or urgently for resectional surgery for CD over a 36 month period were considered for SPLS using, by preference, a transumbilical 'Surgical Glove Port'. Standard, straight laparoscopic instrumentation was used without additional resources.

RESULTS

Of 33 consecutive, unselected patients, 28 (92%) had their procedure initiated by SPLS including those needing urgent intervention (n=15) and those with prior abdominal operation (n=8), obstruction (n=7), mass (n=6), fistula (n=6) and/or abscess (n=4). The median (range) age and BMI of the patients were 31 (17-69) years and 21.3 (18.6-28) kg/m2 respectively. 31 had ileocolonic resection (6 with recurrent disease) while two underwent segmental colectomy. No-one suffered intraoperative or anastomotic complication. Both conversion (15%) and postoperative complication (13 Clavian-Dindo complications - I: 8; II: 2; IIIa: 3) rates were predominantly reflective of patient and disease complexity. Median (range) postoperative day of discharge was 6 (3-33) overall and 5 (3-18) in those completed by SPLS. There was one early readmission (for infectiouscolitis) and median follow-up is now 21 months.

CONCLUSIONS

Complex and recurrent Crohn's resections can be performed by SPLS in the majority of patients presenting elective or urgently for surgery. The Surgical Glove Port performs capably and, by minimizing cost, can facilitate broad embrace of this approach.

Laparoscopic surgery in the management of Crohn's disease

Crohn’s disease is a chronic inflammatory bowel disease with surgery still frequently necessary in its treatment. Since the 1990’s, laparoscopic surgery has become increasingly common for primary resections in patients with Crohn’s disease and has now become the standard of care. Studies have shown no difference in recurrence rates when compared to open surgery and benefits include shorter hospital stay, lower rates of wound infection and decreased time to bowel function. This review highlights studies comparing the laparoscopic approach to the open approach in specific situations, including cases of complicated Crohn’s disease.

Laparoscopic surgery for crohn disease: a brief review of the literature

Crohn disease remains a challenging clinical entity, both medically and surgically. It frequently presents in early adulthood and imposes a lifetime exposure to chronic inflammation that can affect the entire gastrointestinal tract. Although the mainstay of therapy is treatment with immunomodulating drugs, ∼70 to 90% of patients with Crohn disease will ultimately require surgery. Furthermore, there are high rates of symptomatic recurrences that may also require surgical intervention over time. There is no definitive cure for Crohn disease and surgery is reserved for failed medical therapy or the complications of the disease, namely, obstruction, septic complications (abscess, perforation), and fistulas. However, the robust inflammatory environment during these periods is not always conducive to a minimally invasive surgical approach. Despite the inherent technical challenges, the literature has increasingly shown that laparoscopy for Crohn disease, in the appropriate setting, is feasible and safe. In fact, it offers many advantages, which are particularly beneficial to this subset of patients, such as fewer wound complications, a shortened hospital course, less tissue trauma and subsequent adhesion formation, and earlier resumption of oral intake and bowel function.

Single-incision laparoscopic ileocecectomy in children with Crohn's disease

INTRODUCTION

We previously reported our experience with standard laparoscopic ileocecectomy, but we have recently used a single-incision laparoscopic approach.

PATIENTS AND METHODS

We conducted a retrospective review of a single surgeon's experience from 2009 to 2013.

RESULTS

Twenty-eight children 11-18 years of age (mean, 15.5 years) with a mean body mass index of 18.9±3 kg/m(2) underwent single-incision laparoscopic ileocecectomy for Crohn's disease. Mean operative time was 86.5±25.9 minutes (range, 56-166 minutes). There were no extra ports placed or conversions to open surgery. Five children (18%) were on parenteral nutrition at time of surgery, 14 (50%) were on steroids, and 9 (32%) were on tumor necrotic factor inhibitors. A stapled extracorporeal anastomosis was performed in all children. Complications included abscess (n=4), small bowel obstruction (n=3), superficial wound infection (n=3), and small bowel perforation (n=1). Some patients had more than one complication. Of those with complications, 5 (56%) were on steroids, 5 (56%) were on tumor necrotic factor inhibitors, and 1 patient was on both. The perforation occurred at a point of adhesiolysis also involved with Crohn's disease. There were no anastomotic leaks. Median follow-up was 17 months (range, 1-47 months).

CONCLUSIONS

Single-incision laparoscopic ileocecectomy is safe and feasible in pediatric patients with Crohn's disease.

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.

Advanced laparoscopic surgery for colorectal disease: NOTES/NOSE or single port?

Laparoscopic surgery for colorectal disease is an evolving, dynamic subject undergoing constant adaptation. Hence there are significant ongoing advances in technique and technology as has been seen with the emergence of single port and Natural Orifice Transluminal Endoscopic operations with already considerable ramifications for many aspects of minimal access surgery. Most recently single port technologies and expertise have synergized with Transanal Endoscopic (TEM/TEO) experience to allow their convergence out of their respective niches so that pelvic surgery can be laparoendoscopically performed from both its abdominal and perineal aspects. Distinct from wound-related benefits, such capacity for high resolution and multi-dimensional imaging relates significant benefit to the operating team and patient. This state of the art review demonstrates the crucial perspective that advanced practices and performance capabilities are intrinsically complimentary rather than competitive. All surgeons need therefore to participate in adapting their practice styles to allow technical step-advance across the discipline.

Single-port versus multiport laparoscopic ileocecal resection for Crohn's disease

BACKGROUND AND AIMS

Several case series have demonstrated the feasibility of single-port laparoscopic ileocecal resection in Crohn's disease. However, only a few studies compared the single-port with a multiport laparoscopic ileocecal approach. The aim of this study was to compare short term surgical outcome parameters between single-port and multiport laparoscopic ileocecal resections for Crohn's disease.

METHODS

Twenty-one patients who underwent single-port laparoscopic ileocecal resection between March 2010 and September 2012 were prospectively registered. A matched comparison on a 1:2 basis was performed with patients who underwent multiport laparoscopic ileocecal resection from January 1999 to March 2010. Matching parameters were BMI, length of diseased bowel resected and the presence of fistulas. Endpoints were the length of postoperative hospital stay, operative time, conversions, complications, postoperative pain scores and postoperative analgesia consumption.

RESULTS

Twenty-one patients undergoing single-port resection were matched to 42 patients undergoing multiport resection. The postoperative stay (4 days, iqr 4-5 vs. 5 days, iqr 4-6; p=0.033), operative time (103 min, iqr 94.0-121.0 vs. 123.5 min, iqr 100.0-157.0; p=0.036) and morphine use on the first postoperative day (12.5 mg, iqr 5.0-33.3 vs. 28 mg, 15.0-50.0; p=0.012) differed significantly. Postoperative pain scores and complications were similar in both groups. This study was limited by potential selection bias.

CONCLUSIONS

Single-port laparoscopic ileocecal resection is safe and feasible in Crohn's disease and is associated with less need for pain medication postoperatively as opposed to multiport laparoscopic ileocecal resection.

Single-port laparoscopic right hemicolectomy: intermediate results

Single-port right hemicolectomy may be safely performed in patients who are candidates for conventional laparoscopic hemicolectomy with similar efficacy, safety, and oncologic outcomes.

Background:

Single-port laparoscopic colectomy was first described in 2008 as a new technique for colorectal surgery.¹ No available reports have stated the intermediate- or long-term outcome. We report our intermediate results for the first 20 single-port laparoscopic right hemicolectomies performed by a single laparoscopically trained surgeon at our institution.

Design:

Between February 2009 and September 2010, 20 consecutive patients with an indication for right hemicolectomy who were candidates for laparoscopic surgery underwent a single-port laparoscopic approach. The only exclusion was a previous midline laparotomy. The patients were followed for outcomes after a median of 27 months (range: 15 to 35).

Results:

The mean age was 65 years (range: 59 to 88). The mean body mass index was 28 (range: 20 to 35). Seventy-five percent of patients had significant comorbidities, with an American Society of Anesthesiologists class of III or IV. The median estimated blood loss was 25 mL (range: 25 to 250). The mean number of lymph nodes was 13 (range: 0 to 29). There was one conversion to hand-assisted laparoscopic colectomy and one to open colectomy secondary to bleeding. The mean hospital stay was 5 days (range: 3 to 7). Thirty-day postoperative complications included 1 wound infection, 1 patient with alcohol withdrawal, and 1 incidence of colitis caused by Clostridium difficile infection.

At a median follow-up of 27 months, there were no local recurrences or distant metastases. One death occurred at 17 months from myocardial infarction. Two patients developed incisional hernias, with one requiring a laparoscopic hernia repair. One patient required a completion proctocolectomy for a pathological diagnosis of hyperplastic polyposis syndrome.

Conclusions:

Single-port laparoscopic right hemicolectomy has been safely performed in patients who are candidates for conventional laparoscopic hemicolectomy. This small series indicates that intermediate-term results are similar to conventional laparoscopic surgery in efficacy, safety, and oncological outcomes. Larger datasets are necessary to determine cost-effectiveness, differences in postoperative outcomes, and patient satisfaction.

Current status of laparoscopic surgery for patients with Crohn's disease

PURPOSE

Minimally invasive surgery is increasingly utilized in treatment for refractory or complicated Crohn's disease, and new developments aim at further reducing the abdominal trauma and improving the outcome. This review evaluates current literature about minimally invasive surgery for patients with Crohn's disease, latest advances in single-incision surgery, and methods of specimen extraction.

METHODS

Literature was reviewed with focus on the following topics: indications, surgical procedures, conversions, complications, and short- as well as long-term outcomes of laparoscopic compared to open surgery for refractory, complicated, and recurrent Crohn's disease.

RESULTS

Short-term benefits such as shorter hospital stay and faster postoperative recovery are accompanied by long-term benefits such as better cosmetic results and lower treatment-associated morbidity. Single-incision surgery and minimally invasive methods of specimen extraction help to further reduce the surgical trauma and are gradually implemented in the treatment.

CONCLUSION

In experienced centers, laparoscopic surgery for Crohn's disease is safe and as feasible as open operations, even for selected cases with operations for complicated or recurrent disease. However, accurate analysis of the data is complicated by the heterogeneity of clinical presentations as well as the variety of performed procedures. Additional long-term data are needed for evaluation of true benefits of the new techniques.

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.

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-port laparoscopic right hemicolectomy: the learning curve

BACKGROUND AND OBJECTIVES

Single-port laparoscopic colectomy is described as a new technique in colorectal surgery. The initial case reports show the safety and feasibility, but the learning curve for this technique is unknown.

METHODS

Between July 2009 and September 2010, 20 consecutive patients with an indication for right hemicolectomy underwent a single-port laparoscopic approach without bias in selection. The only exclusion criterion was a prior midline laparotomy. The patients were followed up for 30 days. Chart review was completed for up to 35 months to assess long-term morbidity and mortality rates.

RESULTS

The median age was 65 years (range, 59-88 years). Ninety percent of patients were men. The median body mass index was 28 kg/m(2) (range, 20-35 kg/m(2)). Seventy-five percent of patients had significant comorbidities with an American Society of Anesthesiologists class of 3 or 4. The estimated blood loss was 25 mL (range, 25-250 mL). The median number of pathologic lymph nodes for patients diagnosed with adenocarcinoma was 16 (range, 8-23). There was one conversion to hand-assisted laparoscopic (case 6) and one to open colectomy (case 9) because of the inability to achieve safe vessel ligation. The median hospital stay was 4.5 days (range, 3-7 days). The length of stay for the first 10 patients was 5.1 days, and it was 3.9 days for the last 10 patients (P = .045). There were no significant postoperative complications within 30 days. The mean operative time for the first 10 cases was 198 minutes (range, 148-272 minutes), and it was 123 minutes (range, 98-150 minutes) for the subsequent 10 cases (P = .0001). All intraoperative complications (minor bleeding) occurred within the first 10 patients, with no significant bleeding recorded for the last 10 cases.

CONCLUSION

Single-port laparoscopic right hemicolectomy can be safely performed in patients who are candidates for conventional or hand-assisted right hemicolectomy with very low intraoperative and postoperative complication rates. The 30-day morbidity rate remained low with this technique. The higher technical difficulty compared with conventional laparoscopy is reflected in the longer initial operative times. The learning curve for a surgeon with advanced laparoscopic skills and adequate procedure numbers seems to be short, requiring approximately 10 cases to decrease operative times to baseline. The role and feasibility of broad adaptation for single-incision laparoscopy in colorectal surgery need to be further evaluated in larger case series and trials.