Single incision laparoscopic right colectomy

Noncosmetic benefits of single-incision laparoscopic sigmoid colectomy for diverticular disease: a case-matched comparison with multiport laparoscopic technique

BACKGROUND

Single-incision laparoscopic (SIL) colectomy has gained significant momentum with anticipated benefit of improved cosmesis. Feasibility and safety of SIL colectomy have been shown; however, benefits are not well defined. The purpose of this study is to directly compare outcomes of SIL sigmoid colectomy for diverticular disease with standard multiport laparoscopic (LAP) technique.

METHODS

SIL sigmoid colectomy cases performed for diverticular disease between August 2009 and July 2011 were case matched for age, gender, body mass index, American Society of Anesthesiologists score, previous abdominal operation, and need to mobilize the splenic flexure and compared with an equal number of LAP cases. Data analyzed included operative time, estimated blood loss, procedure conversion, incision length, length of hospital stay (LOS), 30-d hospital readmission, and postoperative pain scores.

RESULTS

Twenty patients were analyzed in each group with no significant differences found in the six case-matching criteria. Operative time, conversions, estimated blood loss, surgical site infection, and hospital readmissions were similar. The mean incision length for both groups was 5cm (P=0.72). LOS was 3.7d for the SIL group, which was >1d shorter than that for the LAP group (5.0d; P<0.05). Pain score at post-anesthesia care unit discharge and total amount of narcotic pain medication delivered in the post-anesthesia care unit was significantly less in the SIL group (P<0.05), as was maximum visual analog scale pain score on postoperative day 1 and postoperative day 2 (P≤0.01).

CONCLUSIONS

SIL sigmoid colectomy is associated with noncosmetic benefits, including a reduction in early postoperative pain and decreased LOS. These findings may be related to reduced abdominal wall trauma.

Outcomes for case-matched single-port colectomy are comparable with conventional laparoscopic colectomy

AIM

With the introduction of single-port surgery, expected advantages are improved cosmesis, decrease of pain and shorter length of stay. The aim of this study was to compare early outcomes of single-port colectomy with those of conventional laparoscopic colectomy.

METHOD

All consecutive patients undergoing single-port colectomy between January and June 2010 were identified from a prospective database. They were matched for age, sex, body mass index, American Society of Anesthesiology score and type of resection with patients who had conventional laparoscopic colectomy. All perioperative data, analgesic requirement, pain scores and inflammatory response were compared using the Wilcoxon signed-rank and McNemar tests.

RESULTS

Fourteen patients [five men, nine women; median age (interquartile range) 56 (30-73) years, body mass index (interquartile range) 22 (20-24) kg/m2] underwent single-port colectomy and were matched with patients who had conventional laparoscopic colectomy. Median operating times, estimated blood loss, pain scores, analgesic requirement, inflammatory response and length of hospital stay were similar. Median increase in incision length was significantly higher in the single-port group (P=0.004), but maximal incision length for specimen extraction was comparable. There were no anastomotic leaks, wound infections or 30-day readmissions.

CONCLUSION

In a case-matched setting with a small sample size, single-port laparoscopic colectomy has comparable outcomes to conventional laparoscopic colectomy.

Improving the advantages of single port in right hemicolectomy: analysis of the results of pure transumbilical approach with intracorporeal anastomosis

Background. Single-port laparoscopic surgery has recently emerged as a method to improve patient recovery and cosmetic benefits of laparoscopic surgery. The evolution of our technique has led us to move from a periumbilical incision to a transumbilical one, avoiding the use of drain and maintaining a pure single-port approach with intracorporeal anastomosis in order to maintain the incision as smaller as possible. Method. We report a prospective clinical analysis of our first 38 patients. Oncological surgical steps were followed as during the standard laparoscopic approach, performing the anastomosis intracorporeally in all cases. Results. Mean age of 68,39 years old and an average BMI of 27,88%. (range 19,81–41,5). Most lesions were adenocarcinoma (65,8%), while the remaining were polyps (31,5%) and one a mucocele of the appendix. We moved from a periumbilical incision, initial 14 cases, into a transumbilical one, (medium size of the incision 3,25 cm). Average surgical time was 117,42 minutes. Drains was only used in our first 3 cases. Mean hospital stay was 5,2 days, (86,5% stayed less than 5 days). Total morbidity was 13%. Histological exams of the specimens showed that the oncological criteria were preserved. Conclusions. Single-port right hemicolectomy with intracorporeal anastomosis is feasible and safe. The advantages of a total intracorporeal anastomosis include that there is no need to enlarge the umbilical incision and avoid traction of the pedicle of the mesenterium of the transverse colon during the extracorporeal anastomosis. A transumbilical incision offers better cosmetic results, and the use of drains can be avoided, which increase, patient's satisfaction.

Comparison of clinical outcome of single-incision laparoscopic surgery using a simplified access system with conventional laparoscopic surgery for malignant colorectal disease

AIM

Instrument crowding is encountered in single-incision laparoscopic surgery (SILS). Our aim was to compare the results of SILS with those of conventional laparoscopic surgery (CLS) for malignant colorectal disease.

METHODS

The records of 27 patients who received SILS for the treatment of malignant disease using a home-made multiple-port system were compared with those of 68 patients who received CLS performed in a standard manner using four to five trocar sites.

RESULTS

There were no significant differences in age, gender, disease stage, tumour location or tumour size between the SILS and CLS groups. The most common surgery was high anterior resection in both groups (SILS, 63.0%vs CLS, 58.8%). There were no significant differences between the groups in types of surgery performed, length of bowel resected, resection margin, blood loss, duration of surgery or postoperative complications. Postoperative pain scores were significantly higher in the SILS group than in the CLS group (3.07 ± 1.14 vs 2.41 ± 0.63, respectively, P < 0.001).

CONCLUSIONS

SILS is as effective as CLS, and is not associated with increased duration of surgery, blood loss or complications.

Minilaparoscopic colorectal resections: technical note

Laparoscopic colorectal resections have been shown to provide short-term advantages in terms of postoperative pain, general morbidity, recovery, and quality of life. To date, long-term results have been proved to be comparable to open surgery irrefutably only for colon cancer. Recently, new trends keep arising in the direction of minimal invasiveness to reduce surgical trauma after colorectal surgery in order to improve morbidity and cosmetic results. The few reports available in the literature on single-port technique show promising results. Natural orifices endoscopic techniques still have very limited application. We focused our efforts in standardising a minilaparoscopic technique (using 3 to 5 mm instruments) for colorectal resections since it can provide excellent cosmetic results without changing the laparoscopic approach significantly. Thus, there is no need for a new learning curve as minilaparoscopy maintains the principle of instrument triangulation. This determines an undoubted advantage in terms of feasibility and reproducibility of the procedure without increasing operative time. Some preliminary experiences confirm that minilaparoscopic colorectal surgery provides acceptable results, comparable to those reported for laparoscopic surgery with regard to operative time, morbidity, and hospital stay. Randomized controlled studies should be conducted to confirm these early encouraging results.

Safety, feasibility, and short-term outcomes of single port access colorectal surgery: a single institutional case-matched study

BACKGROUND

Feasibility of single port access (SPA) colorectal surgery has been established for various procedures from ileocecal resection to proctectomy. Nevertheless, its benefits compared to conventional laparoscopy still need to be assess. The aim of this study was to compare SPA to conventional colorectal laparoscopic surgery in a single institutional case-matched study.

METHODS

From July 2009 to July 2010, 25 SPA colorectal resections were matched on main predictive risk factors of postoperative complications, in a one to two fashion, with patient having the same procedure for the same indication by conventional laparoscopy.

RESULTS

Patient characteristics were comparable between both groups. SPA was successfully performed in 24 of 25 patients, with a need to conversion to standard laparoscopy in one case (4%). SPA was associated with a significantly shorter median operative time (130 vs 180 min, p = 0.04) and hospital stay (6 vs 7 days, p = 0.005). Postoperative morbidity rates were similar between the two groups (4% vs 16%, p = 0.25).

CONCLUSION

SPA colorectal resection can be safely performed in selected patients with results comparable to those observed after conventional laparoscopic surgery. However, larger studies including randomized controlled trail are needed to demonstrate possible benefits of SPA colorectal resection over conventional colorectal laparoscopic surgery.

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world, an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery. Thus, a certain sized skin incision is required to remove the resected colon. Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction. We present a case characterized by a laterally spreading type of tumor of the cecum. We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy. Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction. The patient was discharged without complications on postoperative day 4. Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique. Although our method is restricted to flat or small lesions, we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.

Laparoscopic colorectal cancer surgery by a colon lifting-up technique that decreases the number of access ports: comparison by propensity scoring of short-term and long-term outcomes with standard multiport laparoscopic surgery

BACKGROUND

Laparoscopic colectomy for colorectal cancer has become established as a minimally invasive surgical approach. However, many disposable instruments are required, and there is an associated disadvantage of cost. We have developed a new technique, which uses a suture string to lift up the colon. This method is expected to reduce the number of access ports required without compromising the radical cure.

OPERATIVE PROCEDURE

A suture string piercing the abdominal wall is passed through the mesocolon. The colon is retracted anteriorly and is fixed at the abdominal wall. The main mesenteric vessels are under tension, and lymph node dissection is performed easily by a medial approach. The working space is more stable because the colon is fixed to the abdominal wall.

METHODS

This study examined the short-term and long-term surgical outcomes of laparoscopic resection for colorectal cancer using our colon lifting-up technique (CLT), compared with the standard multiport technique. The study design was a case-matched control by propensity scoring. Analyzed variables were sex, age, American Society of Anesthesiologists score, cancer in a different organ, multiple colorectal cancer, operator, operative year, tumor location, operative procedure, adjuvant chemotherapy, and International Union Against Cancer TNM stage.

RESULTS

From 2000 to 2010, 301 patients underwent CLT and 436 standard multiport technique, 148 patients were matched by propensity score and analyzed. Regarding short-term outcomes, there was no difference between the 2 groups. The mean number of ports needed was 3.37±0.48 for CLT (93 with 3 ports, 55 with 4). There were no differences in recurrence-free survival and overall survival in long-term follow-up results for each stage. There were neither recurrences nor complications due to CLT.

CONCLUSIONS

The CLT facilitated laparoscopic colectomy without compromising cure rates. It is a useful method to keep a stable view and to conserve medical resources.

Robotic-assisted total mesorectal excision with the aid of a single-port device

INTRODUCTION AND INDICATIONS: Robotic surgery has numerous advantages in rectal cancer surgery. Studies have reported the advantages associated with single-port approaches, such as eliminating the need for additional incisions, as well as the difficulties inherent in this technique. The authors present a hybrid technique that they performed using a robotic total mesorectal excision with the aid of a single port-device. Materials and methods. The authors performed the technique on 2 patients using a single-port device through an umbilical incision and 3 accessory ports for the robotic arms. There was no need to place ports for the assistant's equipment or for an assistant incision.

RESULTS AND COMPLICATIONS

The operation time was 177.5 minutes, and there were no intraoperative or postoperative complications. Both patients were discharged 7 days after the operation.

CONCLUSIONS

This technical variation is an additional step forward for oncological surgery with minimal damage to the abdominal wall.

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

BACKGROUND

Single-incision laparoscopic surgery is a development in the field of minimally invasive surgery that is being increasingly used for colorectal procedures.

OBJECTIVE

We report on the short-term results of single-port laparoscopic ileocolic resection in patients with ileocecal Crohn's disease.

DESIGN

This investigation is a retrospective matched-pair control study. Data were obtained from a prospectively maintained single-institution inflammatory bowel disease database.

SETTINGS

This study was conducted at a tertiary care university hospital.

PATIENTS

Twenty consecutive patients receiving elective single-port ileocolic resection between April 2010 and May 2011 were included (6 male, 14 female; age, 31.6 ± 10.8 years; BMI, 21.5 ± 2.6 kg/m). Their data were compared with the data of 20 individually matched patients who had undergone standard 3-trocar laparoscopic-assisted ileocolic resection between 2007 and 2010 (6 male, 14 female; age, 31.7 ± 10.7 years; BMI, 21.2 ± 2.5 kg/m). All patients had medically refractory stenosis of the terminal ileum in histologically confirmed Crohn's disease.

INTERVENTIONS

Single-port laparoscopic-assisted or standard laparoscopic-assisted ileocolic resection was performed.

MAIN OUTCOME MEASURES

The primary outcomes measured were the surgical details and early outcome.

RESULTS

: The mean length of the paraumbilical single-port incision was 3.8 cm (range, 2.5-5.0 cm). Conversion rates were similar in both groups (1/20 vs 2/20, p = 0.55). Additional strictureplasties or short-segment small-bowel resections were performed in both groups. The overall complication rate was 20% (4/20) in both groups. There were no observed differences in postoperative pain scores and hospital stay duration.

LIMITATIONS

The limitations of this study were as follows: this study was a comparison of 2 different time points with possible selection bias, there was no prestudy power calculation, and the study might be underpowered.

CONCLUSIONS

Single-port ileocolic resection is a safe procedure for the surgical treatment of stenotizing Crohn's disease of the terminal ileum. Avoidance of additional trocars was the only identified benefit.

Laparoendoscopic single site in pelvic surgery

Laparoendoscopic single site (LESS) has recently gained momentum as feasible techniques for minimal access surgery. Our aim is to describe the current status of laparoendoscopic single site (LESS) in pelvic surgery. A comprehensive revision of the literature in LESS pelvic surgery was performed. References for this manuscript were obtained by performing a review of the available literature in PubMed from 01-01-01 to 30-11-11. References outside the search period were obtained selected manuscript΄s bibliography. Search terms included: pelvic anatomy, less in gynecology, single port colectomy, urological less, single port, single site, NOTES, LESS and single incision. 314 manuscripts were initially identified. Out of these, 46 manuscripts were selected based in their pelvic anatomy or surgical content; including experimental experience, clinical series and literature reviews. LESS drastically limit the surgeon's ability to perform in the operative field and the latter becomes hardened by the lack of space in anatomical location like the pelvis. Potential advantages of LESS are gained with the understanding that the surgical procedure is more technically challenging. Pelvic surgical procedures related to colorectal surgery, gynecology and urology have been performed with LESS technique and information available is mostly represented by case reports and short case series. Comparative series remain few. LESS pelvic surgery remain in its very beginning and due to the very specific anatomical conditions further development of LESS surgery in the mentioned area can be clearly be facilitated by using robotic technology. Standardization ad reproducibility of techniques are mandatory to further develop LESS in the surgical arena..

Single-incision laparoscopic colectomy without using special articulating instruments: an initial experience

BACKGROUND

Single-incision laparoscopic colectomy (SILC) was introduced as a novel minimally invasive technique. The benefits of this technique include reducing number of the incision and cosmetic improvement. Unlike the conventional laparoscopic colectomy, majority of previously reported SILC need to be performed using special curved or articulated instruments. The purpose of this study is to demonstrate our initial experience of SILC, which could be performed using the standard laparoscopic instruments.

MATERIAL AND METHODS

Retrospective review of 14 patients who underwent SILC at Siriraj Hospital from May to December 2010, patient's demographic data, perioperative outcomes, early postoperative complications and pathological data were collected and analyzed.

RESULTS

The mean age of all patients was 60 years. The most common operation with SILC was sigmoidectomy (n = 9), followed by right hemicolectomy (n = 2), left hemicolectomy (n = 1), anterior resection (n = 1), and total colectomy (n = 1). The trocar insertion techniques were multi-fascial incision using regular port (n = 11) and GelPOINT(®) (n = 3). The mean operative time was 155 minutes (range 90-280) and the mean estimate blood loss was 32.1 mL (range 10-100). All patients were successfully operated without conversion. The mean length of hospital stay was 9 days (range 5-20). There was no mortality. The pathological results revealed colorectal cancer (n = 12), neoplastic polyp (n = 1) and Familial adenomatous polyposis (FAP) (n = 1). The mean number of lymph nodes retrieval was 16.6 (range 3-34).

CONCLUSION

SILC can successfully and safely be performed with standard laparoscopic instruments. This technique might be an alternative procedure to conventional laparoscopic colectomy with better cosmetic result.

Single-incision laparoscopic colectomy for cancer: assessment of oncologic resection and short-term outcomes in a case-matched comparison with standard laparoscopy

PURPOSE

To compare single-incision laparoscopic (SIL) with multiport laparoscopic (LAP) colectomy in patients with colon cancer to assess oncologic resection and 1-year outcomes.

METHODS

We compared patients who underwent SIL colectomy for colon cancer with an equal number of case-matched LAP colectomy patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, previous abdominal operations, and operation type. Results of oncologic resection included lymph node (LN) yield and margins. One-year outcomes included cancer recurrence and death.

RESULTS

Twenty-six patients were identified for SIL and LAP colectomy groups with no differences in case matching (age, P = .70; gender, P > .99; BMI, P = .74; ASA score, P > .99; previous abdominal operation, P > .99; and operation-type, P > .99). Oncologic resection was similar for both groups. Mean LN yield was 17 (P = .88). There were no positive margins and 2 (8%) patients had proximal/distal margin of <5 cm in each group. The mean follow-up was 13 and 21 months for the SIL and LAP groups, respectively (P < .001), with 2(8%) recurrences in each group, and no port-site recurrences or deaths. Disease-free survival at 1 year was 92% for both groups.

CONCLUSION

These data suggest that SIL colectomy for cancer provides equivalent oncologic resection and 1-year outcomes compared with a standard LAP technique. Further studies are required to determine long-term oncologic outcomes, including recurrence and survival rates.

Single-incision laparoscopic surgery using colon-lifting technique for colorectal cancer: a matched case-control comparison with standard multiport laparoscopic surgery in terms of short-term results and access instrument cost

BACKGROUND

Single-incision laparoscopic surgery (SILS) has been used for colorectal cancer as a minimally invasive procedure. However, there are still difficulties concerning effective triangulation and countertraction. The study's purpose was to clarify the usefulness of the colon-lifting technique (CLT) in SILS for colorectal cancer.

METHODS

SILS was performed for cancer (cT2N0 or less) of the right-sided colon (near the ileocecum), sigmoid, or rectosigmoid. The SILS™ Port was used for transumbilical access. A suture string was inserted through the abdominal wall and passed through the mesocolon. The colon was retracted anteriorly and fixed to the abdominal wall. The main mesenteric vessels were placed under tension. Lymph node dissection was performed by medial approach. Short-term surgical outcomes and access port costs were compared between SILS (using CLT) and the standard multiport technique (MPT). The two groups were case-matched by propensity scoring. Analyzed variables included preoperative Dukes stage and tumor location.

RESULTS

From June 2009 to April 2011, 27 patients underwent SILS, and from April 2005 to April 2011, 85 patients underwent MPT. Propensity scoring generated 23 matched patients per group for SILS versus MPT comparisons. There were no significant differences in operating time, blood loss, early complications, postoperative analgesic frequency, or length of hospital stay. One MPT patient was converted to open surgery (4.5%); no SILS patients were converted. There were no significant differences in the length of distal cut margin and the number of harvested lymph nodes, except incision length (SILS vs. MPT: 33 vs. 55 mm, P < 0.001). Significant differences favored SILS in access instrument cost (SILS vs. MPT: 62,761 vs. 77,130 Japanese yen, P < 0.001).

CONCLUSIONS

SILS performed using CLT was safe and effective in providing radical treatment of cT2N0 cancer in the right-sided colon, sigmoid, or rectosigmoid. SILS was advantageous with respect to cosmesis and lower cost of access instruments.

Transanal single port surgery: selecting a suitable access port in a porcine model

Single port surgery of rectal tumors may be associated with a shorter learning curve and fewer costs than transanal endoscopic microsurgery. The authors aimed to select the most optimal single access port for transanal employment. Four single access ports (GelPOINT, TriPort, SSL Access System, and SILS) were tested in 2 pigs. Insertion feasibility and intraoperative features of each port were assessed. A rectal excision was attempted using the most suitable port. Insertion of GelPOINT was impossible. SILS and TriPort were easily inserted; however, insufficient stability demanded manual fixation. CO2 leaked through the TriPort trocar ports. Insertion of the 2-cm SSL Access System retractor was difficult, but pneumorectum and surgical circumstances were favorable. Single port transanal surgery may be a promising alternative for transanal endoscopic microsurgery. The SSL Access System was found the most suitable for this indication in a porcine model.

Single-incision laparoscopic colorectal surgery, experience with 50 consecutive cases

BACKGROUND

Single-incision laparoscopic surgery (SILS) is one of the most recent developments in laparoscopic surgery. Having proven its effectiveness in cholecystectomy and appendectomy, the feasibility of SILS in more advanced surgery, such as hemicolectomy and low anterior resection, is now a point of discussion.

METHODS

This study reports on the results of the first 50 SILS colorectal operations at our institution. Twenty right hemicolectomies, 16 sigmoid resections, 9 low anterior resections, and 5 total colectomies were performed. Nineteen patients were operated for benign colonic diseases, 31 for malignant disease.

RESULTS

Mean operative time was 130 min, and the median duration of postoperative hospital stay was 6 days. None of the procedures needed conversion to a laparotomy, but four patients were converted to a multiport laparoscopy. In one case, an anastomotic leakage occurred, which was treated by creating a diverting ileostomy laparoscopically. Minor complications were four wound infections and two incisional hernias.

CONCLUSION

SILS colectomy is a safe and feasible procedure even in more complex cases. Comparative studies are needed to demonstrate advantages over traditional laparoscopic surgery.

Natural orifice transluminal endoscopic surgery (NOTES) and colorectal cancer?

Surgical techniques and technologies are rapidly evolving. In the field of colorectal surgery the transanal video-assisted approach was introduced by Buess, 30 years ago, with transanal endoscopic microsurgery (TEM). In more recent years different techniques and technologies have been proposed, including natural orifice specimen extraction (NOSE), natural orifice transluminal endoscopic surgery (NOTES) and single-access surgery. Furthermore, a better understanding of the prognostic and risk factors of rectal cancer has allowed TEM to expand its indications to local resection of selected tumours, and more recently there have been proposals for sentinel node biopsy in colon and rectal cancer.

Total abdominal colectomy for refractory ulcerative colitis. Surgical treatment in evolution

INTRODUCTION

Total abdominal colectomy is the procedure of choice for debilitated patients with acute, medical refractory ulcerative colitis in our practice. A laparoscopic approach has been previously shown to be safe and effective, and has become our preferred strategy. This study illustrates the laparoscopic evolution towards a truly minimally invasive approach comparing three phases of a single colorectal surgeon experience.

MATERIAL AND METHODS

In May 2010 single incision laparoscopy was introduced in our practice and has become our preferred approach. Ten consecutive ulcerative colitis patients were case matched and compared with 10 previous laparoscopic-assisted (Feb 2003-Jan 2007) and 10 hand-assisted (Feb 2006-Apr 2010) total abdominal colectomies. Patient, disease and surgery-related factors were analyzed and short-term outcomes were compared.

RESULTS

Given the study design, there were no differences in demographics, smoking history, disease duration and severity, nutritional and inflammatory parameters, and indication for surgery between groups. Single incision patients were more likely to have received immunosuppressive therapy within 30 days of the surgery (p = 0.016). In the single incision group we noticed significantly shorter duration of surgery (p < 0.001) and faster resumption of solid diet (p = 0.019) compared to the other groups. Other short-term outcomes did not differ between groups.

CONCLUSION

Single incision laparoscopy offers a safe alternative to other laparoscopic approaches. Despite the higher technical complexity, the duration of surgery is shorter with faster resumption of oral intake. Studies with larger sample size and longer follow-up will be required to confirm the benefits of this approach.

Single-incision laparoscopic total abdominal colectomy for refractory ulcerative colitis

BACKGROUND

A three-stage restorative proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for the particularly debilitated patient with medically refractory ulcerative colitis (UC). Laparoscopic surgery has been shown to offer several advantages over the open approach in this setting. Single-incision laparoscopic surgery is an emerging minimally invasive strategy representing a truly scarless procedure for the first surgical step, namely, the total abdominal colectomy (TAC).

METHODS

Nine consecutive patients with medically refractory UC underwent a single-incision laparoscopic TAC between May and October 2010. All patients were on aggressive medical therapy with corticosteroids or immunosuppressors and were selected for this approach on the basis of their body habitus and the absence of relevant comorbidities. The whole operation was performed through a single access to the abdominal cavity, placed at the ostomy site marked preoperatively.

RESULTS

Mean operating time was 142 ± 23 min, with an estimate blood loss of 108 ± 125 ml. No intraoperative complications or conversions to conventional laparoscopy or open surgery occurred. In all cases the postoperative course was uneventful. The return of bowel function was observed on postoperative day 1.7 ± 0.7, and patients could tolerate a solid diet on postoperative day 3 ± 0.5. The mean postoperative length of stay was 5.2 ± 1.3 days.

CONCLUSIONS

In our experience, a single-incision laparoscopic approach to total abdominal colectomy for refractory ulcerative colitis has been shown to be safe and feasible. Initial results suggest that this technique can lead to improvements in short-term outcomes in selected patients.

Single port access proctectomy with total mesorectal excision and intersphincteric resection with a primary transanal approach

AIM

Minimally invasive surgery is advancing with single port access (SPA). We describe a technique for a SPA transabdominal combined with transanal approach to perform laparoscopic proctectomy with total mesorectal excision (TME) and intersphincteric resection of low rectal adenocarcinoma.

METHOD

Transanal intersphincteric resection was followed by laparoscopic abdominal proctectomy with TME. An SPA device was placed at the site of the future stoma through a 2.5-cm incision. A hand-sewn side-to-end coloanal anastomosis was performed and a terminal loop ileostomy was created at the site of the SPA device.

RESULTS

The procedure was performed on two healthy nonobese women who had not had previous abdominal surgery. The operating times were 195 and 210 min, and blood loss < 250 ml. The postoperative course was uneventful, with discharge on postoperative days 5 and 6. Pathological examination revealed adequate surgical margins and lymph node retrieval with an intact mesorectum. Four weeks after stoma closure, the scar in the right lower quadrant was 35 mm in one patient and 45 mm in the other, and the scar from the 5-mm port was barely visible.

CONCLUSION

This preliminary experience shows that proctectomy with TME and intersphincteric resection can be safely performed using only two ports.

Single-port access laparoscopic reversal of Hartmann operation

BACKGROUND

Single-port access offers cosmetic advantages in addition to the well-recognized benefits of standard multiport laparoscopic surgery, and can be performed with the use of standard straight instruments. We describe a technique of single-port access reversal of Hartmann colostomy by use of the colostomy site for access.

METHODS

After routine skin preparation and laparoscopic setup, the colostomy is mobilized from its mucocutaneous border, and the anvil of a circular stapler is secured to the distal lumen. By the use of a GelPoint system with 3 or 4 trocars, the intra-abdominal adhesions are divided and the splenic flexure is mobilized to achieve sufficient access to the abdominal and pelvic cavities and proximal colonic mobility. The rectal stump is mobilized to the mid rectum, starting from the posterior mesorectal fascia around to the anterior rectal wall. A tension-free colorectal anastomosis is secured with a standard circular stapling device inserted transanally, and leak tested. The colostomy wound is closed in standard fashion.

RESULTS

Five patients underwent single-port access reversal of Hartmann resection (4 diverticular perforations and 1 pT3N0 colon cancer), with a mean operating time of 155 (range, 137-187) minutes and a median length of stay of 3 (range, 2-11) days. There were no conversions, major surgical morbidity, or deaths.

CONCLUSION

Single-port access reversal of Hartmann colostomy through the stoma site is safe, and it offers additional cosmetic advantages with no apparent additional morbidity in comparison with standard multiport surgery.

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

BACKGROUND

Single-incision laparoscopic surgery is an emerging modality that has proven to be safe and feasible for colon resection in multiple case reports and series. Nonetheless, comparative analyses with established techniques are limited in the published literature. We evaluated the efficacy of single-incision laparoscopic colectomy (SILC) for the treatment of sigmoid disease through a matched-case comparison with conventional laparoscopic colectomy (CLC).

METHODS

Twenty patients who underwent single-incision laparoscopic sigmoid resection for benign or malignant disease between July 2009 and September 2010 were matched to patients who underwent conventional laparoscopic sigmoid colectomy. Demographic, intraoperative, and postoperative data were assessed.

RESULTS

Twenty SILC and CLC cases each were paired based on gender (p < 1.0), age (p < 0.47), pathology (p < 1.0), and surgical procedure (p < 1.0). Ten patients (50%) in the SILC group and eight patients (40%) in the CLC group had a history of prior abdominal surgery (p < 0.53). There were no conversions to open surgery; however, one SILC procedure (5%) required conversion to CLC (p < 0.31). There was no significant difference in mean operating time between groups (p < 0.80). Mean estimated blood loss was significantly lower for SILC compared to CLC (p < 0.007). Mean lymph node extraction was comparable between groups in the subset of patients with malignant disease (p < 0.68). Two postoperative complications were encountered in each group. The mean length of hospital stay for SILC and CLC was 3.2 ± 1.0 and 3.8 ± 2.1 days, respectively (p < 0.25). There were no readmissions or reoperative interventions in either group.

CONCLUSION

Compared with conventional laparoscopic technique, single-incision laparoscopic surgery results in similar intraoperative and postoperative outcomes. The technique avoids use of multiple trocar sites and may safely be performed in patients with a history of previous abdominal surgery while maintaining a short length of hospital stay and low complication rate.

Early-elective single-incision laparoscopic sigmoidectomy for perforated diverticulitis using a totally reusable single-port device

BACKGROUND

Single-port access (SPA) is an emerging concept in minimally invasive colorectal surgery. The authors report their experience using SPA sigmoidectomy as an early-elective approach to complicated diverticulitis with paracolic abscess.

METHODS

Between September 2009 und April 2010, 4 patients underwent SPA sigmoidectomy for Hinchey-I diverticulitis using the reusable X-Cone device.

RESULTS

After a median time of antibiotic treatment of 8 days, SPA sigmoidectomy was performed successfully in all patients. The median operative time was 200 minutes (range, 187-221 minutes). No intraoperative or postoperative complications were recorded; the median postoperative hospital stay was 7 days (range, 5-7 days). No incisional hernias were observed at midterm follow-up (median, 11.5 months; range, 8-14 months).

CONCLUSIONS

When performed by an experienced laparoscopic surgeon, early-elective SPA sigmoidectomy is a feasible and safe approach to complicated diverticulitis. The reusability of the X-Cone device ensures that the costs of the procedure are not high.

Evaluation of current devices in single-incision laparoscopic colorectal surgery: a preliminary experience in 32 consecutive cases

BACKGROUND

Single-incision laparoscopic colorectal surgery (SILS) suggests a promising alternative to conventional laparoscopic surgery. In this report we describe our initial experience with SILS for both right hemicolectomies and anterior resections.

METHODS

Between June 2009 and May 2010, SILS was performed for 32 consecutive cases with benign and malignant pathology. Demographic data, intraoperative parameters, postoperative data, and pathologic data were assessed.

RESULTS

Twenty-one SILS right hemicolectomies, ten ARs, and one abdominal perineal resection (APR) were performed. For SILS right hemicolectomies, one case required full "conversion" to a laparoscopic procedure. The median operating time was 85 min (range 45-150 min) and the median wound length was 5.0 cm (range 3.0-10.0 cm). Median number of lymph nodes extracted in malignant cases was 17(range 10-30) and the overall median length of stay was 6 days (range 5-11). For left-sided lesions, ten cases of ARs (7 high ARs, 2 low ARs, 1 ultralow AR) and one APR were performed. Three cases were completed successfully via the SILS procedure, four cases required one additional port, and four cases required full "conversion" to a laparoscopic procedure. The median operating time was 120 min (range 65-235 min) and the median wound length was 5.0 cm (range 3.0-7.0 cm). Overall median length of stay was also 6 days (range 5-21). There was one case of anastomotic leak and one case of postoperative bleeding.

CONCLUSION

In our experience, SILS for right hemicolectomies is safe and effective with reproducible oncologic results. SILS AR, however, requires greater modifications in current devices and techniques. SILS AR can be performed for both malignant and benign diseases but additional ports may be necessary for the safe completion of the procedure.

A clinical review of single-incision laparoscopic surgery

Laparoscopic surgery is one of the most significant surgical advances of the twentieth century. Recently, the focus has been on the development of minimally invasive techniques in the form of single-incision laparoscopic surgery. The single-incision technique provides a less invasive alternative to conventional laparoscopic surgery, requiring only one incision disguised within the umbilical folds in contrast to the three to five incisions in conventional laparoscopic surgery. The availability of a number of specialised ports has aided the development of single-incision laparoscopic surgery, and led to its widespread use. The successful use of single-incision laparoscopic surgery has been reported for a number of surgical procedures, and offers several potential benefits versus conventional laparoscopic surgery, including reduced pain, reduced time to recovery and improved cosmesis. This review of international literature assesses the current status, as well as the experience, of single-incision laparoscopic surgery within general, colorectal, bariatric, metabolic, gynaecological and urological surgery. The challenges faced with single-incision laparoscopic surgery are discussed, as well as the clinical studies that are required in order to establish single-incision surgery as a significant improvement to conventional laparoscopic surgery in terms of reduced pain and improved cosmesis.

Single incision ("scarless") laparoscopic total abdominal colectomy with end ileostomy for ulcerative colitis

INTRODUCTION

Total abdominal colectomy with ileal pouch-anal anastomosis is the intervention of choice for patients with medically uncontrolled ulcerative colitis. A three-stage approach is preferred in particularly debilitated patients. In this setting, laparoscopic surgery has shown to be safe, offering several advantages over the open approach. Single incision laparoscopic surgery is a new minimally invasive approach which represents a true scarless procedure for the first step of the restorative proctocolectomy. In this article, we describe our technique in performing the single-incision total abdominal colectomy.

METHODS

The single-access device is inserted through a circular incision made at the ileostomy site, which was marked preoperatively. The procedure is performed with conventional laparoscopic instruments through one 12-mm and three 5-mm trocars introduced in the single-access device gel platform. Good exposure of the operating field is obtained by changing the Trendelenburg position and the lateral tilting of the table. We start the operation by mobilizing the right colon, then proceeding clockwise to the rectosigmoid junction. The ileocolic pedicle is divided after the visualization of the right ureter and duodenum. The right colon is mobilized in the medial-to-lateral fashion. The hepatocolic ligament is taken down, and the transverse mesocolon and the greater omentum are divided to mobilize the transverse colon. Subsequently, the lateral attachments of descending colon are taken sharply, and the avascular line of Toldt is bluntly dissected. Under direct visualization of the left ureter, the inferior mesenteric vein and the branches of the sigmoid arteries are identified, dissected, and divided. After switching to a 5-mm laparoscope, the rectosigmoid junction is divided with an endoscopic stapler. The specimen is exteriorized, and the terminal ileum is divided extracorporeally. Finally, the ileostomy is matured in the standard Brooke fashion.

CONCLUSION

Between May and November 2010, we performed ten single-incision total abdominal colectomies, all completed successfully without complications or need of conversion, with a mean operative time of 139±24 min and an estimated blood loss of 100±120 ml. The postoperative course was unremarkable in all cases, with prompt return of bowel activity and short postoperative stay. In our experience, single-incision total abdominal colectomy has shown to be a safe alternative to standard laparoscopy in selected patients and appears to be a promising technique with the potential to improve short-term outcomes.

Laparoendoscopic single-site totally extraperitoneal adult inguinal hernia repair: initial 100 patients

BACKGROUND

This report aims to describe the authors' initial experience with laparoendoscopic single-site (LESS) totally extraperitoneal (TEP) inguinal hernia repair in 100 patients.

METHODS

Patients who underwent an elective LESS TEP inguinal hernia repair between December 2008 and September 2010 in a single center were enrolled prospectively in this study. Patient demographic data, hernia characteristics, and operative and postoperative outcomes were analyzed. An Alexis wound retractor was placed through the 2-cm subumbilical incision as a homemade transumbilical access platform after the preperitoneal space was created by a balloon dissector. Standard procedures of TEP all were finished using conventional straight laparoscopic instruments.

RESULTS

Of the 100 patients in this study, 2 underwent conversion to LESS transabdominal preperitoneal (TAPP) repair. The remaining 98 patients received successful LESS TEP inguinal hernia repair by a single surgeon. No patient required open or conventional laparoscopic conversion. However, one patient did experience recurrence. The mean operative time was 64.2 min, and the hospital stay was 1.54 days. One patient with a history of bladder surgery had a minor intraoperative bladder injury. No major postoperative complication occurred, but 11 patients had seroma or hematoma, 2 had epididymitis, 2 had urinary tract infection, 1 had wound dehiscence, 1 had wound infection, and 1 had urinary retention. This single-arm observational study was limited by the absence of a control cohort.

CONCLUSIONS

Based on our experience, in the hands of experienced laparoscopic surgeons, LESS TEP repair for adult inguinal hernia using the homemade port as an access platform is feasible and safe and provides acceptable operative outcomes.

Single-incision laparoscopic colectomy: outcomes of an emerging minimally invasive technique

PURPOSE

Single-incision laparoscopic colectomy (SILC) is an emerging procedure in the field of minimally invasive colon and rectal surgery. The purpose of this study was to evaluate the safety and feasibility of this procedure.

METHODS

Between July 2009 and April 2010, SILC was performed for 35 patients presenting with pathology of the colon. Surgical procedures included right hemicolectomy, sigmoid resection, and total colectomy. Demographic data, intraoperative parameters, and short-term postoperative outcomes were assessed.

RESULTS

Thirty two of the 35 patients (91.4%) underwent successful completion of SILC while 3 patients required laparoscopic modifications. The mean incision length was 3.4 cm with a range of 2-6 cm. The mean total operative time (OT) for right, left, and total colectomies was 158.8 ± 31.8 min, 127.0 ± 37.1 min, and 216.3 ± 72.6 min, respectively. Overall, the OT was not significantly different between patients with a body mass index (BMI) ≥ 25 kg/m(2) (147.9 ± 47.9 min) compared to those with a BMI <25 kg/m(2) (123.1 ± 40.9 min). In the subset of patients with malignant disease, the mean lymph node extraction was 23.5 ± 12.0 and all margins were negative. There were no intraoperative complications, and the overall mean length of hospital stay was 2.9 ± 1.0 days (range 2-6 days). The postoperative morbidity rate was 11.4%.

CONCLUSIONS

Single-incision laparoscopic colectomy is a safe and feasible procedure for benign and malignant diseases of the colon. This modality can be successfully applied for various colorectal procedures without conversion to open surgery, resulting in a short length of hospital stay and a minimal short-term complication rate.

Single-incision laparoscopic right colectomy: a case-matched comparison with standard laparoscopic and hand-assisted laparoscopic techniques

BACKGROUND

Single-incision laparoscopic (SIL) colectomy is an advance in minimally invasive colorectal surgical techniques. Feasibility and safety of SIL colectomy has been reported; however, benefits and outcomes are not well-defined. The purpose of this study was to compare outcomes of SIL right colectomy with multiport laparoscopic (LAP) and hand-assisted laparoscopic (HAL) techniques.

METHODS

SIL right colectomy cases performed between August 2009 and April 2010 were case-matched for age, sex, body mass index, American Society of Anesthesiologists score, previous abdominal surgery, and pathology to an equivalent number of LAP and HAL right colectomy cases. Data analyzed included operative time, procedure conversion, incision length, length of hospital stay, 30-day hospital readmission, surgical site infection and maximum postoperative pain score.

RESULTS

Twenty-nine patients were analyzed in each of 3 groups (SIL, LAP, and HAL). The mean age (p = 0.96), body mass index (p = 0.48), American Society of Anesthesiologists score (p = 0.74), and rate of previous abdominal operation (p = 0.95) were similar, and sex and pathology were identical among groups. Operative time and conversion rates were similar. The incision length for SIL (4.5 cm) and LAP (5.1 cm) groups was similar, and both were significantly shorter than HAL group (7.2 cm; p < 0.001). Length of hospital stay was 3.4 days for the SIL group and was more than 1-day shorter than LAP and HAL groups (p < 0.05). Postoperative surgical site infection and hospital readmission were similar among groups. Maximum pain score on postoperative days 1 and 2 was significantly lower in SIL group (p < 0.05).

CONCLUSIONS

SIL right colectomy can improve patient recovery through a decrease in early postoperative pain and shorter length of hospital stay when compared with established laparoscopic techniques.

Single-incision laparoscopic colectomy: a novel approach through a Pfannenstiel incision

BACKGROUND

Single-incision laparoscopic colectomy is evolving as a safe and feasible approach for the management of various diseases of the colon and rectum. The modality affords completion of "scarless" surgery through a transumbilical incision; however, this approach is associated with several limitations when performing colorectal procedures involving the pelvis. Collinear alignment of the camera and instruments through a single umbilical incision results in restricted visualization, inadequate dissection and mobilization, and the potential for inadvertent injury. We have developed an innovative approach utilizing a Pfannenstiel incision for single-incision access to the pelvis.

METHODS

Single-incision laparoscopic colon resection was performed using a single-access device placed through a mini-Pfannenstiel incision.

RESULTS

Three consecutive patients underwent single-incision laparoscopic anterior rectosigmoid resection for recurrent diverticulitis through a 4-cm Pfannenstiel incision. The procedures were performed at 150, 180, and 195 min with an estimated blood loss of 50, 150, and 75 mL, respectively. The resected specimen lengths were 10.5, 20.2, and 15.0 cm, respectively. There were no conversions to multi-port laparoscopic or open surgery. The length of hospital stay was 4 days for patients 1 and 2, and 3 days for patient 3. There were no major complications or readmissions during postoperative follow-up.

CONCLUSION

Single-incision laparoscopic anterior rectosigmoid resection for diverticulitis can be performed successfully through a Pfannenstiel incision. This approach facilitates direct visualization and access for rectal and pelvic dissection while maintaining adequate exposure to the left colon and splenic flexure during the procedure.

Minimal invasive single-site surgery in colorectal procedures: Current state of the art

BACKGROUND

Minimally invasive single-site (MISS) surgery has recently been applied to colorectal surgery. We aimed to assess the current state of the art and the adequacy of preliminary oncological results.

METHODS

We performed a systematic review of the literature using Pubmed, Medline, SCOPUS and Web of Science databases. Keywords used were "Single Port" or "Single-Incision" or "LaparoEndoscopic Single Site" or "SILS™" and "Colon" or "Colorectal" and "Surgery".

RESULTS

Twenty-nine articles on colorectal MISS surgery have been published from July 2008 to July 2010, presenting data on 149 patients. One study reported analgesic requirement. The final incision length ranged from 2.5 to 8 cm. Only two studies reported fascial incision length. There were two port site hernias in a series of 13 patients (15.38%). Two "fully laparoscopic" MISS procedures with preparation and achievement of the anastomosis completely intracorporeally are reported. Future site of ileostomy was used as the sole access for the procedures in three studies. Lymph node harvesting, resection margins and length of specimen were sufficient in oncological cases.

CONCLUSIONS

MISS colorectal surgery is a challenging procedure that seems to be safe and feasible, but the existing clinical evidence is limited. In selected cases, and especially when an ileostomy is planned, colorectal surgery may be an ideal indication for MISS surgery leading to a no-scar surgery. Despite preliminary oncological results showing the feasibility of MISS surgery, we want to stress the need to standardize the technique and carefully evaluate its application in oncosurgery under ethical committee control.

Laparoendoscopic single site (LESS) versus classic video-laparoscopic cholecystectomy: a randomized prospective study

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold-standard for the treatment of gallbladder stone disease. In recent years laparoendoscopic single site surgery (LESS) has gained greater interest and diffusion for the treatment of gallstones and also in bariatric and colonic surgery. However, no randomized controlled trials are present in the literature that confirm the clinical advantages of LESS compared with the classic laparoscopic procedures. For this reason, we present the preliminary results of this randomized prospective study regarding the feasibility and safety of LESS cholecystectomy versus classic laparoscopic technique.

METHODS

Between October 2009 and April 2010, 50 patients were randomly assigned to three-port classic laparoscopic cholecystectomy (n = 25) or LESS procedure (n = 25). Exclusion criteria were: (1) previous abdominal surgery, (2) signs of acute cholecystitis, choledocholithiasis, or acute pancreatitis, (3) ASA grade III or more, (4) lack of written informed consent, and (5) BMI ≥ 30 Kg/m(2).All the patients' details were recorded: age, weight, height, body mass index, operative time, length of hospital stay, patients' pain and wound satisfaction score. Abdominal pain was registered at 6, 12, and 24 h postoperatively. Wound satisfaction score (very unsatisfied = 1, unsatisfied = 2, acceptable = 3, satisfied = 4, very satisfied = 5) was registered for each patient at the seventh postoperative day.

RESULTS

No differences were registered between the two groups about gender, age, weight, height, and BMI. Also postoperative hospital stay was similar (P = 0.71). In three patients (1 in group A and 2 in group B) a 5-mm trocar was added. Intraoperative cholangiography was performed in five patients (2 in group A and 3 in group B). Mean operative time was significantly longer in LESS procedures (41.3 ± 12.0 versus 35.6 ± 5.8; P = 0.04). Abdominal postoperative pain was similar in LC and LESS cholecystectomy. Wound satisfaction score showed statistically significant differences between the two groups: in LESS group, patients were more satisfied with the presence of a small umbilical medication (P < 0.05).

CONCLUSION

In this randomized prospective study, we conclude that LESS cholecystectomy is an excellent alternative to traditional three-port cholecystectomy for patients with uncomplicated disease, and no previous abdominal surgery. Although no differences are present about hospital stay and postoperative pain compared with classic laparoscopic cholecystectomy, in our experience LESS has had a significant impact on patients' wound satisfaction.

Single-incision laparoscopic right colectomy for cancer: a single-centre preliminary experience

The rationale for single-incision laparoscopic surgery (SILS) is minimizing morbidity, as well as improving cosmetic results of laparoscopic approach. This technique has been used for a variety of procedures and has recently been proposed for colonic resections as well. We report our preliminary experience of right colectomy, performed through a SILS approach. Five patients (3 males, 2 females, mean age 81.6 years) were selected to undergo SILS right colectomy for cancer. The procedure was carried out through a SILS multi-port device (SILS™ Port, Covidien Ltd, Norwalk, CT, USA), with either conventional or specially designed instruments. A medial-to-lateral approach and an extra-corporeal anastomosis were performed. In three cases, the procedure was completed through the SILS technique; in two of these cases a combined procedure was carried out (right colectomy plus cholecystectomy, right colectomy plus cholecystectomy plus i.o. colonoscopy and polypectomy). In one case, a switch to standard laparoscopy was necessary because of the large dimension of the tumour, while in the other case an intolerance of pneumoperitoneum was registered, thus requiring a conversion to open surgery. SILS procedures proved to be oncologically correct. No major complications occurred. In selected patients, SILS right colectomy for cancer appears to be feasible and oncologically safe. Beyond the cosmetic advantage, the procedure may reduce postoperative morbidity. Further studies are needed, with larger series and a longer follow-up, to determine the incidence of possible long-term complications and to evaluate possible cost-effectiveness of the procedure.

Resection of stage 0/I colon cancer via a circumferential periumbilical skin incision: relevance to single-incision laparoscopic surgery

BACKGROUND

We have been performing curative resection of colon cancer via a minilaparotomy without utilizing any laparoscopic instruments as an alternative to laparoscopic-assisted approach. Based on our experiences and improved surgical techniques, we have devised a new method for performing resection of stage 0/I colon cancer via a circumferential periumbilical skin incision that is associated with better cosmesis than standard minilaparotomy.

METHODS

The short- and long-term results of curative colectomy via a circumferential periumbilical skin incision without utilizing any laparoscopic instruments performed in selected patients with stage 0/I colon cancer between October 2003 and July 2004 were analyzed.

RESULTS

There were 8 men and 2 women with a median age of 66.5 years (range 61-77 years). Their median body mass index was 22.4 kg/m(2) (range 21.1-27.7 kg/m(2)). Pathological stage according the TNM classification was stage 0 in 4 patients and stage I in 6 patients. Median operative time was 160.5 min (range 135-203 min), and median blood loss was 60 ml (range 5-330 ml). Postoperative complications consisted of seroma in two patients and small bowel obstruction in one patient. After a median follow-up period of 5.7 years, there were no recurrences or wound complications.

CONCLUSION

Curative colectomy via a circumferential periumbilical skin incision seems oncologically safe, yields satisfactory cosmetic results, and may provide an alternative to single-incision laparoscopic surgery in selected patients with colon cancer.