Systematic review of single-incision laparoscopic colonic surgery

Perioperative outcomes for single-port robotic versus single-incision laparoscopic surgery: a comparative analysis in colorectal cancer surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) may offer improved cosmesis, reduced postoperative pain and faster recovery than conventional platforms, but widespread implementation was limited by technical demands. A single-port robotic platform was recently introduced, with components that further enhance SILS benefits without the technical challenges. No study to date has compared the two platforms to validate benefits. Our goal was to compare outcomes of SP robotics and SILS in colorectal cancer (CRC).

METHODS

A prospective cancer registry was reviewed for CRC patients undergoing curative resection through a SILS or SP robotic approach from 2010 to 2022. Patient and cancer demographics, intraoperative, and postoperative outcomes were compared in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. The main outcome measures were complications, operative time, and oncologic quality measures.

RESULTS

Matching resulted 50 SP robotic and 50 SILS patients. Cohorts were well matched in all demographics, but SP robotic rectal cancer cases were significantly closer to the anorectal ring than SILS (1.8 cm vs. 3.4 cm, p = 0.018). SP robotic and SILS platforms had similar operative times. Intraoperative conversions was comparable, but more SILS cases required additional ports to be placed (p = 0.040). The intraoperative complications rate, complete total mesorectal excision rates, and lymph node yield were not statistically significantly different. There were no positive margins in either group. Postoperatively, groups had analogous day of return of bowel function, comparable morbidity, and discharge destination. There was no mortality in either group. The length of stay was significantly shorter with SP robotics than SILS (mean 4.135 vs. 5.282 days, median 4 (2-8) vs. 5 (2-14) days; p = 0.045).

CONCLUSIONS

Single-port robotics provided high quality oncologic surgery, adding the technical benefits of robotics to clinical and cosmetic benefits of single-port surgery. There were comparable operative time, complication rates, and oncologic outcomes in CRC cases, with shorter hospital stays with SP robotics. This early data is encouraging for expansion SP robotic technology.

Short-term outcomes of da Vinci SP versus Xi for colon cancer surgery: a propensity-score matching analysis of multicenter cohorts

Recent advancements in robotic systems have led to the introduction of the da Vinci SP system, which allows surgeons to perform colon cancer surgery through fewer ports. This study aimed to evaluate the perioperative outcomes of colon cancer surgeries conducted using the da Vinci SP and Xi systems. Patients who underwent robotic colon cancer surgeries between November 2020 and December 2022 at two tertiary referral centers were considered for inclusion. Following propensity-score matching, short-term outcomes between the two systems were retrospectively analyzed. Out of 189 patients included in the study, 106 from 53 propensity-score matched pairs were analyzed. Patients operated on with the SP system exhibited smaller incision lengths (5.0 cm vs. 9.4 cm, p < 0.001) experienced less pain at 8 h (3.0 vs. 3.5, p < 0.001) and at 24 h post-operation (2.9 vs. 3.3, p = 0.001) and had a shorter duration of hospital stay (5 days vs. 6 days, p = 0.002). The overall rate of postoperative complications was 10.4%, with no significant difference between the SP and Xi groups (7.5% vs. 13.2%). Robotic-assisted colon cancer surgery using the da Vinci SP system is feasible and demonstrates favorable short-term outcomes. Compared to the Xi system, the SP system offers advantages in terms of cosmesis, postoperative pain, and recovery duration for colon cancer patients.

Single incision laparoscopy versus conventional multiport laparoscopy for colorectal surgery: a systematic review and meta-analysis

INTRODUCTION

There has been an increase in colorectal cancer resections worldwide and in the UK. Initially conducted as an open procedure, this was replaced with the conventional multiport technique. Laparoscopic colectomy became the standard surgical technique in 1991. With innovation in surgical technology, single incision laparoscopy (SIL) has attracted more attention as the possible next step in colorectal resection. The aim of this review was to compare outcomes between SIL and conventional laparoscopy (CL).

METHODS

A literature search was carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. The PubMed®, MEDLINE®, Embase®, Google Scholar™ and Cochrane Library databases were used to extract randomised controlled trials (RCTs) published between January 2000 and May 2021. Statistical analysis was performed with RevMan software.

RESULTS

A total of 11 RCTs were extracted with 1,370 patients (686 SIL, 684 CL). There was no significant difference between SIL and CL for operative time (standardised mean difference [SMD]: 0.01, 95% confidence interval [CI]: -0.19 to 0.22, z=0.11, p=0.91), length of hospital stay (SMD: -0.10, 95% CI: 0.22 to 0.02, z=1.61, p=0.11) or overall complications (odds ratio [OR]: 0.99, 95% CI: 0.75 to 1.30, z=0.09, p=0.93). SIL had a shorter mean incision (SMD: -0.99, 95% CI: -1.35 to -0.62, z=5.25, p<0.00001). Patients undergoing SIL had a higher conversion rate to CL or an open approach (OR: 3.10, 95% CI: 0.95 to 10.14, z=1.87, p=0.06) but this just missed statistical significance.

CONCLUSIONS

SIL can be considered a safe alternative to CL if performed by experienced surgeons.

Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery-a narrative review

Background

Minimally invasive (MI) surgery has revolutionised surgery, becoming the standard of care in many countries around the globe. Observed benefits over traditional open surgery include reduced pain, shorter hospital stay, and decreased recovery time. Gastrointestinal surgery in particular was an early adaptor to both laparoscopic and robotic surgery. Within this review, we provide a comprehensive overview of the evolution of minimally invasive gastrointestinal surgery and a critical outlook on the evidence surrounding its effectiveness and safety.

Methods

A literature review was conducted to identify relevant articles for the topic of this review. The literature search was performed using Medical Subject Heading terms on PubMed. The methodology for evidence synthesis was in line with the four steps for narrative reviews outlined in current literature. The key words used were minimally invasive, robotic, laparoscopic colorectal, colon, rectal surgery.

Conclusion

The introduction of minimally surgery has revolutionised patient care. Despite the evidence supporting this technique in gastrointestinal surgery, several controversies remain. Here we discuss some of them; the lack of high level evidence regarding the oncological outcomes of TaTME and lack of supporting evidence for robotic colorectalrectal surgery and upper GI surgery. These controversies open pathways for future research opportunities with RCTs focusing on comparing robotic to laparoscopic with different primary outcomes including ergonomics and surgeon comfort.

Single-port laparoscopic versus single-port robotic right hemicolectomy: Postoperative short-term outcomes

BACKGROUND

This study aimed to compare the short-term postoperative outcomes of single-port robotic (SPR) using da Vinci SP^® system and single port laparoscopic (SPL) right hemicolectomy and determine whether the novel SPR system is safe and feasible.

METHODS

From January 2019 to December 2020, a total of 141 patients (41 patients for SPR and 100 patients for SPL) who electively underwent right hemicolectomy for colon cancer performed by a single surgeon were included in the study.

RESULTS

The time to the first bowel movement was 3 (range, 1-4) days after surgery in the SPR group and 3 (2-9, range) days in the SPL group (p = 0.017). However, there were no differences in pathologic outcomes or postoperative complications.

CONCLUSIONS

SPR is a safe and feasible surgical technique and has an advantage in the time to first postoperative bowel movement over SPL with no other complications.

Is laparoscopy a reliable alternative to laparotomy in Hartmann's reversal? An updated meta-analysis

BACKGROUND

The aim of this study was to perform a systematic review of the literature on and updated meta-analysis of surgical postoperative complications after laparoscopic Hartmann's reversal (LHR) and open Hartmann's reversal (OHR).

METHODS

Studies comparing LHR versus OHR published from inception until June 2020 were selected and submitted to a systematic review and meta-analysis. Articles were searched in the MEDLINE and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0.

RESULTS

Twenty-three retrospective comparative studies (including 5 case-controlled studies) with a total of 3139 patients with LHR and a total of 10,325 patients with OHR were included. Meta-analysis showed that LHR was significantly associated with a decreased rate of revision surgery (OR = 0.73, 95% CI = 0.60-0.89, p < 0.001), anastomotic leakage (OR = 0.61, 95% CI = 0.49-0.75, p < 0.00001), postoperative morbidity (OR = 0.53, 95% CI = 0.47-0.58, p < 0.00001), intra-abdominal abscess (OR = 0.67 [0.52-0.87], 95% CI = , p = 0.003), wound abscess (OR = 0.53 [0.46-0.61], 95% CI = , p < 0.00001), and postoperative ileus (OR = 0.46, 95% CI = 0.29-0.72, p = 0.0008), respectively. Conversely, mortality was comparable between LHR and OHR.

CONCLUSIONS

These results suggest that LHR significantly improved surgical postoperative outcomes. However, considering the low level of evidence, further randomized trials are required to validate these findings.

Incidence and risk factors for umbilical incisional hernia after reduced port colorectal surgery (SIL + 1 additional port)-is an umbilical midline approach really a problem?

PURPOSE

Umbilical midline incisions for single incision- or reduced port laparoscopic surgery are still discussed controversially because of a higher rate of incisional hernia compared to conventional laparoscopic techniques. The aim of this study was to evaluate incidence and risk factors for incisional hernia after reduced port colorectal surgery.

METHODS

A total 241 patients underwent elective reduced port colorectal surgery between 2014 and 2020. Follow-up was achieved through telephone interview or clinical examination. The study collective was examined using univariate and multivariate analysis.

RESULTS

A total of 150 patients with complete follow-up were included into this study. Mean follow-up time was 36 (IQR 24-50) months. The study collective consists of 77 (51.3%) female and 73 (48.7%) male patients with an average BMI of 26 kg/m² (IQR 23-28) and an average age of 61 (± 14). Indication for surgery was diverticulitis in 55 (36.6%) cases, colorectal cancer in 65 (43.3%) patients, and other benign reasons in 30 (20.0%) cases. An incisional hernia was observed 9 times (6.0%). Obesity (OR 5.8, 95% CI 1.5-23.1, p = 0.02) and pre-existent umbilical hernia (OR 161.0, 95% CI 23.1-1124.5, p < 0.01) were significant risk factors for incisional hernia in the univariate analysis. Furthermore, pre-existent hernia is shown to be a risk factor also in multivariate analysis.

CONCLUSION

We could demonstrate that reduced port colorectal surgery using an umbilical single port access is feasible and safe with a low rate of incisional hernia. Obesity and pre-existing umbilical hernia are significant risk factors for incisional hernia.

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Single Incision Laparoscopic Surgery (SILS) in Small Animals: A Systematic Review and Meta-Analysis of Current Veterinary Literature

In veterinary surgery, single incision laparoscopic surgery (SILS) techniques have been described since 2009, and, in recent decades, many authors have reported the application of SILS in small animals, thus, promoting the wide dissemination of this novel approach among veterinary laparoscopists. The aim of this literature review is to provide a critical evaluation of the scientific reports on SILS in the field of small animal laparoscopic surgery. A comprehensive literature review was performed including from 1 January 2009 to 1 July 2020. The following data were recorded from each study: the design, year of publication, surgical procedure, species, number of animals included, and surgical time. The type of SILS technique and type of control group technique were evaluated. In total, 90 articles were identified through database searches and manual searches. The qualitative analysis showed that most of the articles were retrospective studies, without a control group or case series. A meta-analysis was performed on the eight controlled studies, showing that SILS ovariectomy and gastrointestinal procedures had a comparable surgical time to multiport techniques. The study of the articles available in the veterinary literature did not allow for an adequate meta-analysis of the published results, especially regarding post-operative pain, evaluations of surgical times, and post-operative complications in comparison to multiport techniques. Therefore, veterinary surgeons who want to employ these techniques must consider the real advantages of SILS techniques.

Initial experience with transanal proctectomy in children

BACKGROUND

The use of transanal proctectomy may have particular advantages for pediatric patients with small pelvic working space. We report short-term outcomes of transanal completion proctectomy (taCP) during surgery for inflammatory bowel disease.

METHODS

All patients (age≤19) underwent taCP from January 1, 2018 to December 31, 2019. Prior total abdominal colectomy (TAC) was performed using a single-incision technique. At operation, patients underwent single-incision laparoscopy with taCP. Patient demographics, pre and perioperative details, and postoperative complications were abstracted.

RESULTS

Seven patients (n = 6) with a median age of 18 years [Range: 13-19] were included in this initial series. All patients had a prior TAC with end-ileostomy with taCP occurring a median of 6 [Range: 3-89] months after TAC. Six of 7 had a diagnosis of ulcerative colitis (UC) while 1 patient had Crohn's colitis. For patients with UC, taCP was part of an ileal pouch-anal anastomosis with the majority (n = 4) proceeding as a modified-two stage and the remaining (n = 2) a three-stage approach. Single-incision laparoscopy through the prior ileostomy site was used in all IPAA patients. Median operative time was 226 [Range: 150-264] minutes with no conversions to more invasive technique. Median hospital length of stay (LOS) was 5 [Range: 2-8] days. In-hospital complications occurred in two patients who had watery diarrhea that prolonged LOS but resolved postdischarge. One patient was readmitted for bowel obstruction that resolved with placement of red rubber catheter at the ileostomy site. Of the 4 patients with a functioning ileal pouch, 1 patient reported 6-10 bowel movements per day, while 3 others reported ≤5 bowel movements per day. Half (n = 2) reported 1-2 nocturnal bowel movements at their first postoperative visit. No patients reported soiling or leakage, though one patient had a single episode of incontinence.

CONCLUSION

In this pilot series, transanal proctectomy was effective and safe. Future work should compare traditional MIS completion proctectomy to taCP for applications in pediatric inflammatory bowel disease.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

IV.

Single-dermatome single-incision laparoscopic right hemicolectomy

We describe a novel single-incision laparoscopy right hemicolectomy technique using a single-dermatomal, muscle-splitting approach through a 4-cm incision located between the right anterior superior iliac spine and pubic tubercle. This new technique may be superior to traditional single-incision laparoscopy colectomy with the potential benefits of less post-operative pain, lower opioid requirements, lower risk of incisional hernia and better cosmesis but requires further validation.

Initial clinical experience of single-incision robotic colorectal surgery with da Vinci SP platform

BACKGROUND

The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) was introduced to overcome the limitations of single-incision laparoscopic surgery, which is challenging due to its restrictions regarding triangulation and retraction. The purpose of this article is to describe the initial experience with single-incision surgery using the da Vinvci Single-Port Platform (dVSP).

METHODS

The medical records of patients with colorectal disease, who underwent single-incision robotic surgery using the dVSP, were retrospectively reviewed.

RESULTS

Five patients with appendiceal and colorectal cancer, and two with diverticulitis were enrolled. All procedures were completed using a pure single-incision approach, with an exception for low anterior resection. There were two minor complications. For patients with colorectal cancer, the number of retrieved lymph nodes and status of the resection margin were acceptable, and cosmetic results were satisfactory.

CONCLUSION

The dVSP is a novel surgical platform that can be used as an alternative surgical modality for colorectal surgery.

Single Port Laparoscopic Total and Subtotal Colectomies for Inflammatory Bowel Disease in a District General Hospital

Background: Single incision laparoscopic surgery (SILS) is expanding, enhancing the advantages of multi-port laparoscopic surgery (MLS). Limited literature exists regarding SILS total/subtotal colectomies for inflammatory bowel disease (IBD). Aim of the study was to present the initial experience with this type of approach in a district general hospital and extrapolate its feasibility and safety in this specific context based on gold standard outcomes reported in literature. Materials and Methods: Preoperative parameters, operative details and surgical outcomes of consecutive patients who underwent colonic SILS for IBD in a 5-year period were reviewed retrospectively. Median length of follow-up was 26 months. Results: Fourteen patients underwent SILS subtotal/total colectomy. Median body mass index was 25 (18.1-35). Two patients had previous abdominal surgeries. Median operating time was 202.5 minutes. Two cases were converted to open. Median length of stay was 5 days. Three patients presented complications. Three patients developed parastomal hernias (21.4%). Five out of 12 patients with ulcerative colitis declined further surgery, 3 are awaiting laparoscopic/SILS pouch formation, 1 underwent SILS pouch formation, 1 SILS ileo-rectal anastomosis and 1 patient had SILS completion proctectomy. One patient was not followed up. Conclusions: Despite literature data heterogeneity, these results provide support to the feasibility and applicability of SILS in the subgroup of patients who undergo subtotal/total colectomies for IBD, offering the option for subsequent SILS completion or restorative procedures. Further studies are required to explore the benefit of SILS over MLS (including cosmesis and quality of life) and non-inferiority of SILS regarding the parastomal hernia issue and the operative duration.

Single Incision Pediatric Endoscopic Surgery: From Myth to Reality a Case Series

Laparoscopic surgery has continued to evolve to minimize access sites and scars in both the adult and pediatric populations. In children, single-incision pediatric endoscopic surgery (SIPES) has been shown to be effective, feasible, and safe with comparative results to multiport equivalents. Thus, the use of SIPES continues over increasingly complex cases, however, conceptions of its efficacy continue to vary greatly. In the present case series and discussion, we review the history of SIPES techniques and its current application today. We present this in the setting of five common myths about SIPES techniques: limitations against complex cases, restrictions to specialized training, increased morbidity outcomes, increased operative lengths, and increased operative costs. Regarding the myth of SIPES being limited in application to simple cases, examples were highlighted throughout the literature in addition to the authors’ own experience with three complex cases including resection of a lymphatic malformation, splenectomy with cholecystectomy, and distal pancreatectomy with splenectomy. A review of SIPES learning curves shows equivalent operative outcomes to multiport learning curves and advancements towards practical workshops to increase trainee familiarity can help assuage these aptitudes. In assessing comorbidities, adult literature reveals a slight increase in incisional hernia rates, but this does not correlate with single-incision pediatric data. In experienced hands, operative SIPES times average approximate multiport laparoscopic equivalents. Finally, regarding expenses, SIPES represents an equivalent alternative to laparoscopic techniques.

Outcome Comparison of Single-port Versus Multiport Versus Under Direct View Completion Proctectomy With Ileal-Pouch Anal Anastomosis for Patients With Ulcerative Colitis

PURPOSE

Whether the reported theoretical benefits of single-port laparoscopic (SPL) approach can be converted to superior clinical outcomes is still unknown for ulcerative colitis (UC) patients undergoing second-stage proctectomy. This study aimed to compare the short-term postoperative and long-term pouch-related functional outcomes of SPL, multiport laparoscopic (MPL), and direct view (DV) completion proctectomy with ileal-pouch anal anastomosis (CP/IPAA).

MATERIALS AND METHODS

Patients who underwent either SPL, MPL, or under DV CP/IPAA for UC between August 2009 and August 2014 were identified from an institutional review board-approved, prospectively maintained institutional database and reviewed. Demographics, patient characteristics, short-term and long-term complications, and morbidity were compared between the 3 groups. Multivariate logistic or Cox regression analysis was conducted for covariate adjustments.

RESULTS

Groups (SPL: n=36; MPL: n=67; DV: n=97) were comparable in terms of preoperative characteristics and demographics except for age. The SPL group was associated with reduced estimated blood loss, reduced length of stay compared with the MPL and DV groups, and shorter operating time compared with the MPL group (P<0.001). Similar short-term postoperative and long-term pouch-related functional outcomes were noted without significant differences in quality of life scores among the 3 groups.

CONCLUSIONS

SPL CP/IPAA for UC can be safely performed with superior short-term outcomes such as reduced intraoperative blood loss and length of hospital stay compared with MPL and under direct view approaches, and shorter operating time compared with MPL.

Feasibility of needlescopic surgery for colorectal cancer: safety and learning curve for Japanese Endoscopic Surgical Skill Qualification System-unqualified young surgeons

BACKGROUND

Needlescopic surgery (NS) is a minimally invasive technique for colorectal cancer. NS may be easier to perform than other minimally invasive surgery such as single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery because the port setting is the same while the shafts are thinner than in conventional laparoscopic surgery. We evaluated the capability of introducing this surgery for sigmoid and rectosigmoid colon cancer by assessing the learning curve in Japanese Endoscopic Surgical Skill Qualification System (JESSQS)-unqualified surgeons.

METHODS

In this retrospective study, 112 cases of sigmoidectomy and anterior resection were performed by NS from October 2011 to December 2015 in our institution. Surgical outcomes including operation time, blood loss, postoperative hospital stay, perioperative complications, and overall survival were compared between JESSQS-qualified surgeons (Group A) and JESSQS-unqualified surgeons (Group B). The learning curve for NS was established using the average operation times in JESSQS-unqualified surgeons.

RESULTS

Groups A and B comprised of 41 and 71 patients, respectively. Ninety patients underwent sigmoidectomy and 22 patients underwent anterior resection. No conversion to open surgery occurred. The operation time was significantly shorter in Group A than B (P = 0.0080). There were no significant differences in blood loss, the postoperative hospital stay, perioperative complications, or overall survival between the two groups. These variables were similar even when NS was considered relatively difficult, as in patients with obesity (body mass index of ≥ 25 kg/m²), bulky tumors (tumor size of ≥ 50 mm), and stage III/IV cancer. The average operation time in JESSQS-unqualified young surgeons was significantly shorter in the ninth and tenth cases than in the first and second cases of NS (P = 0.0282).

CONCLUSIONS

NS for sigmoid and rectosigmoid colon cancer was performed safely by both JESSQS-qualified surgeons and JESSQS-unqualified surgeons. Even JESSQS-unqualified young surgeons might be able to quickly learn NS techniques.

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

Background

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

Methods

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

Results

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

Conclusions

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

Optimal literature search for systematic reviews in surgery

BACKGROUND

The aim of the present study was to determine empirically which electronic databases contribute best to a literature search in surgical systematic reviews.

METHODS

For ten published systematic reviews, the systematic literature searches were repeated in the databases MEDLINE, Web of Science, CENTRAL, and EMBASE. On the basis of these reviews, a gold standard set of eligible articles was created. Recall (%), precision (%), unique contribution (%), and numbers needed to read (NNR) were calculated for each database, as well as for searches of citing references and of the reference lists of related systematic reviews (hand search).

RESULTS

CENTRAL yielded the highest recall (88.4%) and precision (8.3%) for randomized controlled trials (RCT), MEDLINE for non-randomized studies (NRS; recall 92.6%, precision 5.2%). The most effective combination of two databases plus hand searching for RCT was MEDLINE/CENTRAL (98.6% recall, NNR 97). Adding EMBASE marginally increased the recall to 99.3%, but with an NNR of 152. For NRS, the most effective combination was MEDLINE/Web of Science (99.5% recall, NNR 60).

CONCLUSIONS

For surgical systematic reviews, the optimal literature search for RCT employs MEDLINE and CENTRAL. For surgical systematic reviews of NRS, Web of Science instead of CENTRAL should be searched. EMBASE does not contribute substantially to reviews with a surgical intervention.

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hybrid Single-Incision Laparoscopic Colon Cancer Surgery Using One Additional 5 mm Trocar

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a feasible and safe procedure for colorectal cancer. However, SILS has some technical limitations such as collision between instruments and inadequate countertraction. We present a hybrid single-incision laparoscopic surgery (hybrid SILS) technique for colon cancer that involves use of one additional 5 mm trocar.

METHODS

Hybrid SILS for colon cancer was attempted in 70 consecutive patients by a single surgeon between August 2014 and July 2016 at Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine. Using prospectively collected data, an observational study was performed on an intention-to-treat basis.

RESULTS

Hybrid SILS was technically completed in 66 patients, with a failure rate of 5.7% (4/70). One patient was converted to open surgery for para-aortic lymph node dissection. Another was converted to open surgery due to severe peritoneal adhesion. An additional trocar was inserted for adhesiolysis in the other two cases. Median lengths of proximal and distal margins were 12.8 cm (interquartile range [IQR], 10.0-18.6), and 8.2 cm (IQR, 5.5-18.3), respectively. Median total number of lymph nodes harvested was 24 (IQR, 18-33). Overall rate of postoperative morbidity was 12.9%, but there were no Clavien-Dindo grade III or IV complications. There was no postoperative mortality or reoperation. Median postoperative hospital stay was 6 days (IQR, 5-7).

CONCLUSIONS

Hybrid SILS using one additional 5 mm trocar is a safe and effective minimally invasive surgical technique for colon cancer. Experienced laparoscopic surgeons can perform hybrid SILS without a learning curve based on the formulaic surgical techniques presented in this article.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks

While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of "tunnel vision" and "instrument clashing." Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.

Single-incision laparoscopic ileocecal resection using an organ retractor

INTRODUCTION

Single-incision laparoscopic surgery has been reported to be a safe and feasible technique for colorectal cancer. However, the technique needs skill due to the limitations of the device. An organ retractor is a new grasp device that has the potential to overcome these limitations.

PRESENTATION OF CASE

A 63-year-old woman with a tumor palpated in the right lower quadrant of the abdomen presented to hospital. Colonoscopy showed a type 2 mass with nearly complete stenosis, and a biopsy specimen showed well-differentiated adenocarcinoma. Single-incision laparoscopic surgery ileocecal resection was performed using an organ retractor. A 3-cm incision was placed in the umbilicus, and three conventional ports were inserted. An organ retractor was used for hepatocolic ligament resection, resection of the ileocolic vessels, and resection of the insertion of the mesentery proper. For each resection, the trailer line's tension was adjusted to provide a good operative view. The patient's postoperative course was good, and she was discharged 7days after surgery.

DISCUSSION

An organ retractor was effective for single-incision laparoscopic surgery technique not only to maintain a good operative view, but also to change trailer line tension, which enabled safe dissection.

CONCLUSION

An organ retractor could facilitate single-incision laparoscopic surgery.

Single center cost analysis of single-port and conventional laparoscopic surgical treatment in colorectal malignant diseases

BACKGROUND AND PURPOSE

Single-port laparoscopy (SPL) is a relatively new technique, used in various procedures. There is limited knowledge about the cost effectiveness and the learning curve of this technique. The primary aim of this study was to compare hospital costs between SPL and conventional laparoscopic resections (CLR) for colorectal cancer; the secondary aim was to identify a learning curve of SPL.

METHODS

All elective colorectal cancer SPL and CLR performed in a major teaching hospital between 2011 and 2012 that were registered in the Dutch Surgical Colorectal Audit were included (n = 267). The economic evaluation was conducted from a hospital perspective, and costs were calculated using time-driven activity-based costing methodology up to 90 days after discharge. When looking at SPL only, the introduction year (2011) was compared to the next year (2012).

RESULTS

SPL (n = 78) was associated with lower mortality, lower reintervention rates, and more complications as compared to CLR (n = 189); however, none of these differences were statistically significant. A significant shorter operating time was seen in the SPL. Total costs were higher for SPL group as compared to CLR; however, this difference was not statistically significant. For the SPL group, most clinical outcomes improved between 2011 and 2012; moreover, total hospital costs for SPL in 2012 became comparable to CLR.

CONCLUSION

No significant differences in financial outcomes between SPL and CLR were identified. After the introduction period, SPL showed similar results as compared to CLR. Conclusions are based on a small single-port group and the conclusions of this manuscript should be an impetus for further research.

Initial experience of restorative proctocolectomy for ulcerative colitis by transanal total mesorectal rectal excision and single-incision abdominal laparoscopic surgery

AIM

Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single-incision platform (SIP).

METHOD

Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment.

RESULTS

The procedure was performed on 16 patients with a median age of 46 (26-70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3-20) days. The median operation time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-day surgical complication rate was 37.5% (Clavien-Dindo 1 in four patients, 2 in one patient and 3 in one patient). One patient developed anastomotic leakage 2 weeks postoperatively.

CONCLUSION

This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis for UC.

ECSPECT prospective multicentre registry for single-port laparoscopic colorectal procedures

BACKGROUND

The international multicentre registry ECSPECT (European Consensus of Single Port Expertise in Colorectal Treatment) was established to evaluate the general feasibility and safety of single-port colorectal surgery with regard to preoperative risk assessment.

METHODS

Consecutive patients undergoing single-port colorectal surgery were enrolled from 11 European centres between March 2010 and March 2014. Data were analysed to assess patient-, technique- and procedure-dependent parameters. A validated sex-adjusted risk chart was developed for prediction of single-port colorectal surgery-related conversion and complications.

RESULTS

Some 1769 patients were enrolled, 937 with benign and 832 with malignant conditions. Procedures were completed without additional trocars in 1628 patients (92·0 per cent). Conversion to open surgery was required in 75 patients (4·2 per cent) and was related to male sex and ASA fitness grade exceeding I. Conversions were more frequent in pelvic procedures involving the rectum compared with abdominal procedures (8·1 versus 3·2 per cent; odds ratio 2·69, P < 0·001). Postoperative complications were observed in a total of 224 patients (12·7 per cent). Independent predictors of complications included male sex (P < 0·001), higher ASA grade (P = 0·006) and rectal procedures (P = 0·002). The overall 30-day mortality rate was 0·5 per cent (8 of 1769 patients); three deaths (0·2 per cent; 1 blood loss, 2 leaks) were attributable to surgical causes.

CONCLUSION

The feasibility and safety, conversion and complication profile demonstrated here provides guidance for patient selection.

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.

Single-Incision Multiport/Single Port Laparoscopic Abdominal Surgery (SILAP): A Prospective Multicenter Observational Quality Study

Background

Increasing experience with minimally invasive surgery and the development of new instruments has resulted in a tendency toward reducing the number of abdominal skin incisions. Retrospective and randomized prospective studies could show the feasibility of single-incision surgery without any increased risk to the patient. However, large prospective multicenter observational datasets do not currently exist.

Objective

This prospective multicenter observational quality study will provide a relevant dataset reflecting the feasibility and safety of single-incision surgery. This study focuses on external validity, clinical relevance, and the patients’ perspective. Accordingly, the single-incision multiport/single port laparoscopic abdominal surgery (SILAP) study will supplement the existing evidence, which does not currently allow evidence-based surgical decision making.

Methods

The SILAP study is an international prospective multicenter observational quality study. Mortality, morbidity, complications during surgery, complications postoperatively, patient characteristics, and technical aspects will be monitored. We expect more than 100 surgical centers to participate with 5000 patients with abdominal single-incision surgery during the study period.

Results

Funding was obtained in 2012. Enrollment began on January 01, 2013, and will be completed on December 31, 2018. As of January 2016, 2119 patients have been included, 106 German centers are registered, and 27 centers are very active (>5 patients per year).

Conclusions

This prospective multicenter observational quality study will provide a relevant dataset reflecting the feasibility and safety of single-incision surgery. An international enlargement and recruitment of centers outside of Germany is meaningful.

Trial Registration

German Clinical Trials Register: DRKS00004594; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004594 (Archived by WebCite at http://www.webcitation.org/6jK6ZVyUs)

Randomized clinical trial of single-incision versus multiport laparoscopic colectomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

SILC is not superior to MPLC.

REGISTRATION NUMBER

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

Minimally Invasive Surgery for the Treatment of Colorectal Cancer

BACKGROUND

Reduction in operative trauma along with an improvement in endoscopic access has undoubtedly occupied surgical minds for at least the past 3 decades. It is not at all surprising that minimally invasive colon surgery has come a long way since the first laparoscopic appendectomy by Semm in 1981. It is common knowledge that the recent developments in video and robotic technologies have significantly furthered advancements in laparoscopic and minimally invasive surgery. This has led to the overall acceptance of the treatment of benign colorectal pathology via the endoscopic route. Malignant disease, however, is still primarily treated by conventional approaches.

METHODS AND RESULTS

This review article is based on a literature search pertaining to advances in minimally invasive colorectal surgery for the treatment of malignant pathology, as well as on personal experience in the field over the same period of time. Our search was limited to level I and II clinical papers only, according to the evidence-based medicine guidelines. We attempted to present our unbiased view on the subject relying only on the evidence available.

CONCLUSION

Focusing on advances in colorectal minimally invasive surgery, it has to be stated that there are still a number of unanswered questions regarding the surgical management of malignant diseases with this approach. These questions do not only relate to the area of boundaries set for the use of minimally invasive techniques in this field but also to the exact modality best suited to the treatment of every particular case whilst maintaining state-of-the-art oncological principles.

Single-Site Robotic Cholecystectomy: The Timeline of Progress

AIM

To investigate the learning curve and perioperative outcomes of single-site robotic cholecystectomy during the first 102 cases by a single surgeon.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database was performed on the first 102 cases of single-site robotic cholecystectomy. Patients were divided into five chronological groups based on the date of surgery, with 20 patients in each group except the 5th group which had 22 patients. The groups were compared by docking time, robotic dissection time, and overall surgery time. A P value of 0.05 was used as statistically significant.

RESULTS

The female to male ratio was 2:1. The mean age was 51 years (18-87) and the mean BMI was 28.26 (18-41). Overall, 69 % of the patients underwent elective cholecystectomy and 31 % required urgent surgery. In all, 17 % of patients had previous abdominal surgeries. In total, 45 % of procedures were regarded as same day surgery. The total mean length of stay was 1.97 days (0-8). The mean operative time was 110 min (36-265), mean robotic console time 70 min (26-179), and mean docking time 9 min (1-26). The overall conversion rate was 3.9 % and the complication rate was 4 %. The docking time, robotic time, and average operative time were significantly different in the first group as compared to the remaining the five groups (P = 0.001).

CONCLUSION

Single-site robotic cholecystectomy is safe in both elective and urgent conditions, and in patients with previous abdominal surgeries. It has a short learning curve.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

SILS sigmoidectomy versus multiport laparoscopic sigmoidectomy for diverticulitis

Background and Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Overview of robotic colorectal surgery: Current and future practical developments

Minimal access surgery has revolutionised colorectal surgery by offering reduced morbidity and mortality over open surgery, while maintaining oncological and functional outcomes with the disadvantage of additional practical challenges. Robotic surgery aids the surgeon in overcoming these challenges. Uptake of robotic assistance has been relatively slow, mainly because of the high initial and ongoing costs of equipment but also because of limited evidence of improved patient outcomes. Advances in robotic colorectal surgery will aim to widen the scope of minimal access surgery to allow larger and more complex surgery through smaller access and natural orifices and also to make the technology more economical, allowing wider dispersal and uptake of robotic technology. Advances in robotic endoscopy will yield self-advancing endoscopes and a widening role for capsule endoscopy including the development of motile and steerable capsules able to deliver localised drug therapy and insufflation as well as being recharged from an extracorporeal power source to allow great longevity. Ultimately robotic technology may advance to the point where many conventional surgical interventions are no longer required. With respect to nanotechnology, surgery may eventually become obsolete.

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

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

Early experience of duet laparoscopic distal gastrectomy (duet-LDG) using three abdominal ports for gastric carcinoma: surgical technique and comparison with conventional laparoscopic distal gastrectomy

BACKGROUND

Reduced port laparoscopic surgery may lead to less pain and better cosmetic outcome than conventional surgery. Also, it requires fewer assistants and abdominal ports. Recently, some experts have reported operative techniques and outcomes of reduced port laparoscopic gastrectomy. In this study, we sought to introduce our techniques of duet laparoscopic distal gastrectomy (duet-LDG) using three abdominal ports and surgical outcomes of early experience of this procedure.

METHODS

Between 2010 and 2014, 431 patients undergoing LDG for gastric carcinoma were retrospectively reviewed. Among them, 49 patients underwent duet-LDG. During duet-LDG, an operator performed all the procedures using two abdominal ports with an additional umbilical laparoscopy port. Short-term surgical outcomes of duet-LDG were compared with conventional LDG groups.

RESULTS

The mean age of the duet-LDG group was 61.1 years with 38 males and 11 females. Forty patients underwent Billroth II, and 9 patients underwent Roux-en-Y reconstruction. The mean operating time was 147 min, and the mean intraoperative blood loss was 49 ml. Duet-LDG was successfully completed without intraoperative complications or open conversion in all patients. After an operation, six patients (12.2 %) developed postoperative complications, and no mortality occurred. The mean hospital stay was 8.6 days. When compared with the conventional LDG groups, patients who underwent duet-LDG showed no significant differences in short-term surgical outcomes including morbidity, mortality, and the duration of hospital stay.

CONCLUSIONS

Duet-LDG is a viable alternative to conventional LDG for treating early gastric carcinoma providing comparable surgical outcomes. Less operative pain and scar, reduced medical cost, and requiring fewer assistants may benefit patients as well as surgeons. Finally, the efficacy of duet-LDG needs to be evaluated in diverse clinical aspects.

Laparoscopy Versus Robotic Surgery for Colorectal Cancer: A Single-Center Initial Experience

Background Minimally invasive approach has gained interest in the treatment of patients with colorectal cancer. The purpose of this study is to analyze the differences between laparoscopy and robotics for colorectal cancer in terms of oncologic and clinical outcomes in an initial experience of a single center. Materials and Methods Clinico-pathological data of 100 patients surgically treated for colorectal cancer from March 2008 to April 2014 with laparoscopy and robotics were analyzed. The procedures were right colonic, left colonic, and rectal resections. A comparison between the laparoscopic and robotic resections was made and an analysis of the first and the last procedures in the 2 groups was performed. Results Forty-two patients underwent robotic resection and 58 underwent laparoscopic resection. The postoperative mortality was 1%. The number of harvested lymph nodes was higher in robotics. The conversion rate was 7.1% for robotics and 3.4% for laparoscopy. The operative time was lower in laparoscopy for all the procedures. No differences were found between the first and the last procedures in the 2 groups. Conclusions This initial experience has shown that robotic surgery for the treatment of colorectal adenocarcinoma is a feasible and safe procedure in terms of oncologic and clinical outcomes, although an appropriate learning curve is necessary. Further investigation is needed to demonstrate real advantages of robotics over laparoscopy.

Single-incision laparoscopic surgery for rectal cancer: early results and medium-term oncological outcome

AIM

Conventional laparoscopic surgery for rectal cancer management is now widely accepted as an alternative to open surgery, bestowing specific advantages without causing detriment to oncological outcome. Evolving from this, single-incision laparoscopic surgery (SILS) has been successfully utilized for the removal of colonic tumours, but the literature lacks data analysing the suitability of SILS for rectal cancer resection, particularly on oncological outcome. We report the medium-term oncological outcome from a prospective observational study of SILS for rectal cancer, including high and low anterior resections.

METHOD

A prospective electronic database was collated of all patients undergoing SILS rectal cancer resection in our institution, between 2009 and 2014. In addition to patient, tumour and operative data, histopathological and medium-term oncological end-points were recorded. Kaplan-Meier curves were used to analyse survival.

RESULTS

Sixty-one patients underwent SILS for rectal cancer by high anterior resection (n = 34), low anterior resection with total mesorectal excision (TME) (n = 24) and low anterior resection with TME and hand-sewn colo-anal anastomosis (n = 3). The median operation time was 105 (37-280) min and 92% of cases were completed by SILS. The mean interval to resuming oral feeding was 11 h and the median length of stay was 2 (1-8) days. The median number of lymph nodes found by the histopathologist in the resected specimen was 18 (6-44) and all operations completely removed the tumour (R0 resection). At a median follow-up of 46 (16-64) months, eight (13%) patients developed metastatic disease, of whom three had local recurrence. Overall, three patients have died, of whom all had metastatic disease.

CONCLUSION

Anterior resection with TME for rectal cancer can be safely performed using the SILS technique, with acceptable histopathological results and good oncological outcome.

Does Transumbilical Incision Influence Surgical Site Infection Rates of the Laparoscopic Sigmoidectomy and Anterior Resection?

Laparoscopic surgery is widespread and is safe and effective for the management of patients with colorectal cancer. However, surgical site infection (SSI) remains an unresolved complication. The present study investigated the comparative effect of supraumbilical incision versus transumbilical incision (TU) on the incidence of SSI in patients undergoing laparoscopic surgery for colon cancer. Medical records from patients with colorectal cancer who underwent laparoscopic sigmoid and rectosigmoid colon surgeries with either supraumbilical incision (n = 150) or TU (n = 150) were retrospectively reviewed. There was no difference in demographics, comorbidities, or operative variables between the two groups. The transumbilical group and the supraumbilical group were comparable with regards to overall SSI (6.0% vs 4.0%; P = 0.4062), superficial SSI (6.0% vs 3.3%; P = 0.2704), and deep SSI (0% vs 0.7%; P = 0.2385). SSI developed after laparoscopic sigmoid and rectosigmoid colon cancer surgery in 15 (5.0%) of the 300 patients. Of these superficial SSI, all wounds were in the left lower quadrant incision, and the transumbilical port sites did not become infected. Univariate analysis failed to identify any risk factors for SSI. Avoidance of the umbilicus offers no benefit with regard to SSI compared with TU.

Reduced-port laparoscopic restorative proctocolectomy without diverting ileostomy

INTRODUCTION

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

MATERIALS AND SURGICAL TECHNIQUE

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

DISCUSSION

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

Single-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.