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

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.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

SILS sigmoidectomy versus multiport laparoscopic sigmoidectomy for diverticulitis

Background and Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Resident training in single-incision laparoscopic colectomy

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

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

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

Review of single incision laparoscopic surgery in colorectal surgery

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

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

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

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

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

Single-incision laparoscopy: a review of the indications, techniques and results after more than 700 procedures

Single-incision laparoscopy (SIL) gained in popularity in the last 5-7 years, as a new philosophy has emerged to reduce the invasiveness of minimally invasive surgery. Various abdominal procedures using fewer and smaller trocars in order to obtain pure SIL have been described. To overcome some known problems of SIL, such as establishing the conventional multiport laparoscopic working triangulation, the non-ergonomic positioning of the surgeon, and the increased cost of each procedure, a particular SIL technique has been developed. The technique involves reusable trocars along with specially designed DAPRI curved reusable instruments introduced through the same incision but laterally to the optical system. Hence, the main principle of conventional multiport laparoscopy--working in an appropriate triangulation while maintaining the scope in the center--is respected. The final scar is 15 mm and the cost of the procedure remains unchanged because reusable materials are used. All the abdominal procedures, including upper and lower gastrointestinal, colorectal, hepatobiliopancreatic, solid organs, gynecologic and abdominal wall hernia repair, are here reported, as are the indications for and the results after 740 procedures. In conclusion, SIL has to be considered as one of the most attractive techniques of the new minimally invasive era.

Single incision laparoscopic right colectomy: a systematic review and meta-analysis

AIM

A meta-analysis was performed to compare the outcome of single incision laparoscopic right hemicolectomy with standard multiport laparoscopic right hemicolectomy.

METHOD

A systematic search of databases was carried out to extract comparative studies (randomized and non-randomized, prospective and retrospective). Data were analysed according to Cochrane Collaboration guidelines. A meta-analysis was performed when the data permitted this form of analysis.

RESULTS

Nine comparative studies were retrieved comprising 241 patients with single incision and standard laparoscopy. None of these was randomized. There was no significant difference between the two methods for the primary end-points of mortality, morbidity and cancer-specific parameters and for the secondary end-points of operation time, blood loss, ileus, hospital stay and conversion. It was not possible to analyse pain and cosmetics data owing to insufficient information.

CONCLUSION

Single incision laparoscopic right hemicolectomy is comparable with standard multiport laparoscopic right hemicolectomy in primary and secondary outcomes. Given current information it is justified to use single incision laparoscopic right hemicolectomy, but there is a need for a prospective randomized study.

Three ports laparoscopic resection for colorectal cancer: a step on refining of reduced port surgery

Background. Reduced port surgery (RPS) is becoming increasingly popular for some surgeries. However, the application of RPS to the field of colectomy is still underdeveloped. Patients and Methods. In this series, we evaluated the outcome of laparoscopic colorectal resection using 3 ports technique (10 mm umbilical port plus another two ports of either 5 or 10 mm) for twenty-four cases of colorectal cancer as a step for refining of RPS. Results. The mean estimated blood loss was 70 mL (40–90 mL). No major intraoperative complications have been encountered. The mean time for passing flatus after surgery was 36 hours (12–48 hrs). The mean time for oral fluid intake was 36 hours and for semisolid food was 48 hours. The mean hospital stay was 5 days (4–7 days). The perioperative period passed without events. All cases had free surgical margins. The mean number of retrieved lymph nodes was 14 lymph nodes (5–23). Conclusion. Three ports laparoscopy assisted colorectal surgeries looks to be safe, effective and has cosmetic advantages. The procedure could maintain the oncologic principles of cancer surgery. It's a step on the way of refining of reduced port surgery.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Suprapubic single-incision laparoscopic right hemicolectomy with intracorporeal anastomosis

BACKGROUND

Single-incision laparoscopy (SIL) has gained significance recently. The umbilicus has been the preferred access site for SIL. Suprapubic access site (SAS) can be an alternative, especially for a right hemicolectomy (RH).

METHODS

Between November 2011 and July 2012, 7 consecutive patients underwent suprapubic SIL RH (SSILRH). The median age was 53 years, and the median body mass index was 23.9 kg/m2. Indications for surgery included appendicular tumor (1) and adenocarcinoma of the right colon (6). Three reusable trocars were used, and the resection was performed through the SAS. An intracorporeal linear stapled anastomosis was performed, the mesenteric defect was closed, and the access site was used for specimen extraction.

RESULTS

No patient required additional trocars or conversion to an open surgery. The median laparoscopic time was 222 minutes, and the median final incision length was 50 mm. The median Visual Analogue Scale score (0-10) at 6, 18, 30, 42, 54, 66, and 78 postoperative hours was 6, 6, 2, 2, 2, 2, and 2, respectively. The median hospital stay was 4 days.

CONCLUSIONS

SSILRH is useful because the SAS can be enlarged for extraction of the specimen without compromising the cosmetic outcome. The mesocolic and mesenteric dissections are on the same axis as the access site. The intracorporeal anastomosis can be performed without traction. Finally, positioning of the operative table improves exposure of the operative field and allows the surgeon to maneuver the colon and small bowel intracorporeally.

Single-incision (with multi-input single-port) laparoscopic colorectal procedures: Early results

OBJECTIVE

Single incision laparoscopic surgery (SILS) is a "scar-less" new surgical technique which has been gaining popularity over recent years. In comparison to conventional multiport laparoscopic surgery, SILS is introduced as a less invasive method. This technique has also been applied to colorectal surgery. The aim of the presenting study is to investigate the applicability of SILS and report short term results.

MATERIAL AND METHODS

We evaluated prospectively collected data of 24 patients who had been operated with "Single Incision Laparoscopic Colon Resection (SILCR)" in our clinic between June 2011-June 2013. Informed consent was obtained from all patients before surgery. Patient data such as ASA and BMI values, need for additional surgery, tumors, number of lymph nodes resected, length of hospital stay, length of surgery, timing of flatus, time to start oral feeding and complications were recorded.

RESULTS

SILCR was performed in 24 patients. In 13 patients, SILCR was performed for cancer treatment. There was no need for extra ports, conversion to open surgery and stoma creation was also not necessary. Drain was placed in 4 patients. Overall complication rate was 12.5%. The mean number of lymph nodes in 13 patients who underwent SILCR for tumor was found to be 23 (14-33). The mean operative time and length of hospital stay was 177 minutes (110-363) and 5.35 days (4-11) respectively. Anastomotic leakage was not seen in any of the patients. In one patient, urinoma formation due to ureteral leakage was seen which resulted from thermal injury.

CONCLUSION

When we compare other series with almost the same number of patients' reported SILS results in the literature, we believe that we could draw conclusions from our data. SILS appears to have comparable results to conventional multiport laparoscopic surgery in the hands of experienced surgeons. It seems advantegous as it can be done with conventional laparoscopic instruments in a "scar-less" manner. Prospective randomized trials are necessary to define the benefits of one procedure over the other.

Systematic review of single-incision laparoscopic colonic surgery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Single-incision right hemicolectomy for malignancy: a feasible technique with standard laparoscopic instrumentation

AIM

Single-incision laparoscopy is a rapidly evolving technique in the spectrum 'standard laparoscopy-natural orifice transluminal endoscopic surgery (NOTES)'. From a commercial perspective, purchase of articulating instruments is advised. However, here we present our early experience with single-incision laparoscopy for right hemicolectomy with standard laparoscopic instrumentation.

METHOD

Between June 2010 and December 2011, 25 patients presenting with malignant disease underwent single-incision laparoscopy for right hemicolectomy. Four different ports (SILS™ port, Covidien; SSL(®) Access system, Ethicon; X-Cone/S-Portal(®) , Storz; and OCTO™ port, AFS Medical) were used. Patients were recruited prospectively and all data were processed retrospectively.

RESULTS

Twenty-five patients were included in our study (and their characteristics, described later in this paragraph, are expressed as median (range)). Four conversions to standard laparoscopy were performed. The age of patients was 69 (36-89) years, and they had a body mass index (BMI) of 24.5 (19.1-34.2). The duration of surgery was 110 (70-148) min with a healed skin incision length of 35 (20-60) mm. Hospital stay was 5 (2-15) days. In four patients discharge was delayed because of comorbidity. One patient suffered an overwhelming pneumonia.

CONCLUSION

Single-incision laparoscopy using standard laparoscopic instruments appears to be a safe and feasible technique for malignant disease requiring right hemicolectomy. Randomized, prospective trials are ongoing to prove the benefits of this technique and to compare its oncological outcome measures with those of conventional laparoscopy. In our experience, a low-profile port with a wide intra-abdominal range of motion is most preferable.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Single-incision laparoscopic colectomy: technical aspects and short-term results

Single-incision laparoscopic surgery (SILS) is currently regarded as the next major advance in the progress of minimally invasive techniques in colorectal surgery. We describe our initial experience using SILS for the management of colorectal disease and present preliminary short-term results. Between February 2010 and April 2011, 7 patients (4 females and 3 males, mean age 55 years, range 32–74) underwent SILS for either benign or malignant colorectal disease. Preoperative diagnosis was diverticular disease of the sigmoid colon in two patients, malignant polyps of the sigmoid colon in two other patients and large villous tumor of the right colon in three patients. Surgical procedures, 4 anterior resections of the rectum and 3 right hemicolectomies, were performed through a 3 cm single umbilical incision using a SILS multi port device with conventional or articulated laparoscopic instruments. There were no intraoperative complications or conversions in the standard laparoscopic procedure. The mean operative time for anterior resections was 160.0 ± 10.6 min, whereas it was 160.6 ± 20 for right hemicolectomies. Blood loss was minimal. No postoperative complications were reported in any of the patients. The overall mean hospital stay was 4.8 ± 0.2 days (range 4–5). For the subset of patients with malignant or pre-malignant disease, the mean number of retrieved lymph nodes was 15.6 ± 4.4 (range 6–31). Cosmetic results were considered excellent by all the patients after 15 days. In conclusion, our preliminary experience shows that SILS for colorectal disease is feasible and safe with potential reproducible oncologic results.

Pearls and pitfalls in SILS colectomy

Single-incision laparoscopic colectomy has developed into a viable option for the treatment of benign and malignant colorectal diseases with the innovation of new access devices, instrumentation, and surgical techniques. Although cosmesis has been highly touted as the most apparent advantage of the approach, the single-incision platform also affords the potential for enhanced recovery, early hospital discharge, and reduction in postoperative wound complications. Despite increasing evidence demonstrating the safety and efficacy of single-incision laparoscopic colectomy, wide-ranging adaptation has been tempered in part as a result of the technical demands of the approach. We aim to describe our surgical pearls for overcoming various pitfalls and technical challenges experienced during single-incision laparoscopic colectomy to facilitate successful application of this technique.

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

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

Single-incision laparoscopic surgery: outcomes from 224 colonic resections performed at a single center using SILS

BACKGROUND

Compared with single-incision laparoscopy, multiport laparoscopy is associated with greater risk of postoperative wound pain, infection, incisional hernias, and suboptimal cosmetic outcomes. The feasibility of minimally invasive single-incision laparoscopic surgery (SILS) for colorectal procedures is well-established, but outcome data remain limited.

METHODS

Patients with benign diverticular disease, Crohn's disease, or ulcerative colitis admitted to Klinikum Leverkusen, Germany, for colonic resection between July 2009 and March 2011 (n = 224) underwent single-incision laparoscopic surgery using the SILS port system. Surgeons had ≥7 years' experience in laparoscopic colon surgery but no SILS experience. Patient demographic and clinical data were collected prospectively. Pain was evaluated by using a visual analog scale (0-10). Data were analyzed by using the SPSS PASW Statistics 18 database.

RESULTS

The majority of patients underwent sigmoid colectomy with high anterior resection (AR) or left hemicolectomy (n = 150) for diverticulitis. Our conversion rate to open surgery was 6.3 %, half in patients undergoing sigmoid colectomy with high AR or left hemicolectomy, 95 % of whom had diverticulitis. Mean operating time was 166 ± 74 (range, 40-441) min in the overall population, with shorter times for single-port transanal tumor resection (SPTTR; 89 ± 51 min; range, 40-153 min) and longer times for proctocolectomy (325 min; range, 110-441 min). Mean hospital stay was approximately 10 days, longer after abdominoperineal rectal resection or proctocolectomy (12-16 days). Most complications occurred following sigmoid colectomy with high AR or left hemicolectomy [19/25 (76 %) of early and 4/5 (80 %) of late complications, respectively]. Pain was <4 on a scale of 0-10 in all cases on postoperative day 1, and typically decreased during the next 2 days.

CONCLUSIONS

Our findings support the feasibility and tolerability of colorectal surgery, conducted by experienced laparoscopic surgeons without specific training in use of the SILS port.

Conventional laparoscopic versus single-incision laparoscopic right hemicolectomy: a case cohort comparison of short-term outcomes in 144 consecutive cases

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a recent development of minimally invasive surgery for colorectal disease. The literature comparing it against conventional laparoscopic colectomy remains limited.

METHODS

A retrospective case-cohort study compared the benefits and outcomes of SILS right hemicolectomy (SRH) with those of conventional laparoscopic right hemicolectomy (LRH). The medical records of consecutive patients from a prospectively collected database were reviewed. Demographic data, operative details, recovery parameters, and details of resected specimens were obtained and analyzed in an intention-to-treat manner.

RESULTS

From January 2006 to March 2011, 104 elective LRHs (72 %) and 40 elective SRHs (28 %) were performed. The demographics for these two groups were comparable in terms of gender, age, ethnicity, body mass index (BMI), comorbidities and American Society of Anesthesiology score. As the records showed, 62 % of the LRHs and 57 % of the SRHs were performed for malignancies (p = 0.536). Seven of the LRH cases (7 %) were converted to open procedure, whereas two of the SILS cases (5 %) were converted. Three SILS cases (7 %) were completed with additional laparoscopic ports. The two groups did not differ significantly in terms of wound length, mean operative time, lymph node clearance, or margins of resected specimen. The recovery parameters (pain score, hospital length of stay, and complications rate) also were equivalent between the two groups.

CONCLUSION

As a feasible and safe procedure with early postoperative outcomes equivalent to those for LRH, SRH is a suitable alternative. The possible advantages of SILS over conventional laparoscopic surgery may be validated only with randomized controlled trials in the future.

Feasibility and safety of single-incision laparoscopic colectomy: a systematic review

OBJECTIVE

The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic colectomy (SILC).

METHODS

We conducted a comprehensive review for the years 1983 to March 2011 to retrieve all relevant articles.

RESULTS

A total of 23 studies with 378 patients undergoing SILC were reviewed. All studies except 2 used a commercially available single-port device. Range of body mass index was 20.9 to 30.0 kg/m². Ranges of operative times and estimated blood losses were 83 to 225 minutes and 0 to 115 mL, respectively. Of 378 cases, a total of 6 cases (1.6%) were converted to open, 6 (1.6%) to hand-assisted laparoscopic (HALC), and 14 (4.0%) to conventional (multiport) laparoscopic colectomy (MLC) (overall conversion rate, 6.9%). An additional laparoscopic port was used in 4.9% (12/247) cases. Range of harvested lymph nodes number for malignant cases was 13.5 to 27 and surgical margins were negative in all cases. Overall mortality and morbidity rates were 0.5% (2/378) and 12.9% (45/349), respectively. The length of hospital stay (LOS) varied across reports (1.9-9.8 days). Among 4 case-matched studies, 2 showed shorter LOS after SILC than after HALC (2.7 vs 3.3 days) or after MLC/HALC (3.4 vs 4.6/4.9 days). Furthermore, one of these studies reported that maximum pain score on postoperative days 1 and 2 was significantly lower in SILS than in MLC and HALC.

CONCLUSIONS

In early series of highly selected patients, SILC appears to be feasible and safe when performed by surgeons who are highly skilled in laparoscopy. Despite technical difficulties, there may be potential benefits associated with SILC over MLC/HALC but it is yet to be proven objectively.

Single-incision laparoscopic resection of Bismuth I hilar cholangiocarcinoma

INTRODUCTION

Laparoscopic hilar cholangiocarcinoma is rarely performed because of its aggressive growth and complicated anatomy. The authors successfully performed single-incision laparoscopic resection of Bismuth I hilar cholangiocarcinoma in 2 cases.

METHOD

Two cases with Bismuth I cholangiocarcinoma were chosen for the laparoscopic surgery. Segmental bile duct resection and hepatoduodenal ligament lymphadenectomy were performed using single-incision laparoscopic technique with conventional instruments.

RESULTS

Two operations were successfully performed without conversion. The operation time was 300 and 350 minutes, respectively. The margins of proximal and distal bile ducts were negative. The hospital stay was 6 and 9 days, respectively. One dosage of analgesic was administered after surgery. The abdominal wound recovered very well with good cosmesis.

CONCLUSION

Single-incision laparoscopic surgery cholangiocarcinoma resection can be optional in strictly selected patients with Bismuth I cholangiocarcinoma. Long-term follow-up and more data are needed to evaluate its benefits.

Single-port laparoscopic right hemicolectomy: the first 100 resections

BACKGROUND

Single-port laparoscopy remains a novel technique in the field of colorectal surgery. Several small series have examined its safety for colon resection.

OBJECTIVE

Our aim was to analyze our entire experience and short-term outcomes with single-port laparoscopic right hemicolectomy since its introduction at our institution. We assert that this approach is feasible and safe for the wide array of patients and indications encountered by a colorectal surgeon.

DESIGN

This is a retrospective analysis of prospectively gathered data for all patients who underwent single-port laparoscopic right hemicolectomy with the use of standard laparoscopic instrumentation, for malignant or benign disease, between July 2009 and November 2010 in a high-volume, academic, colorectal surgery practice.

MAIN OUTCOME MEASURES

Demographic, clinical, operative, and pathologic factors were reviewed and analyzed. All conversions to conventional laparoscopic or open operations were considered in this analysis.

RESULTS

One hundred patients underwent single-port laparoscopic right hemicolectomy during the study period. Mean age was 63 years, and 61% of the patients were men. Forty-three percent had undergone previous abdominal surgery, and the median body mass index was 26 (range, 18-46). Median ASA classification was 3 (range, 1-4). Five percent of the operations were performed urgently, and 56% were performed for carcinoma, of which half were T3 or T4 tumor stage. Median operative duration was 105 (range, 64-270) minutes. Mean and median blood loss was 106 and 50 mL. Two percent required conversion to multiport laparoscopy, and 4% converted to the open approach. Median postoperative stay was 4 (range, 2-48) days. Median lymph node number was 18 (range, 11-42). There was one mortality in this series. Morbidity, including wound infection, was 13%.

CONCLUSIONS

This represents the largest experience with single-port laparoscopic right hemicolectomy to date. This technique was used with acceptable morbidity and mortality and without compromise of conventional oncologic parameters by colorectal surgeons experienced in minimally invasive technique. These findings support the use of a single-port approach for patients requiring right hemicolectomy.

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.