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

Comparison of clinical efficacy of single-incision and traditional laparoscopic surgery for colorectal cancer: A meta-analysis of randomized controlled trials and propensity-score matched studies

Background

Single-incision laparoscopy surgery (SILS) is a new laparoscopic technique that has emerged in the past decade. Whether it has advantages over conventionl laparoscopy surgery (CLS) is inconclusive. This article aimed to compare the short- and long-term outcomes of single-incision laparoscopic surgery and conventional laparoscopic surgery for colorectal cancer through high-quality literature text mining and meta-analysis.

Methods

Relevant articles were searched on the PubMed, Embase, and Cochrane Library databases from January 2012 to November 2021. All data was from randomized controlled trials (RCTs) in order to increase the confidence of the analytical results.The main outcomes were intraoperative and postoperative complications.

Results

A total of 10 RCTs were included, involving 1609 patients. The quality of the included studies was generally high. No significant difference was found between SILS and CLS in the postoperative complications, operation time, postoperative hospital stay, number of lymph nodes removed, readmission, reoperation, complication level I- II, complication level IIIa, complication level IIIb, prolonged Ileus, blood loss, infection, anastomotic leakage and operation time. The results showed that SILS group had a higher rate of intraoperative complications, but it had lower incision length and better cosmetic effects.

Conclusion

These results indicate that SILS did not have a comprehensive and obvious advantage over the CLS. On the contrary, SILS has higher intraoperative complications, which may be related to the more difficulty of SILS operation, but SILS still has better cosmetic effects, which is in line with the concept of surgical development. Therefore, the SILS needs to be selected in patients with higher cosmetic requirements and performed by more experienced surgeons.

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.

Single-Incision vs. Conventional Laparoscopic Surgery for Colorectal Cancer: An Update of a Systematic Review and Meta-Analysis

Background: Although the advantages of single-incision laparoscopic surgery have been reported in several meta-analyses, the low quality of studies included in the meta-analyses limits the reliability of such a conclusion. In recent years, the number of randomized controlled trials on the efficacy of SILS in colorectal cancer has been on the rise. This update systematic review and meta-analysis of RCTs aims to compare efficacy and safety of SILS and CLS in the patients with colorectal cancer. Methods: Relevant data was searched on the CNKI, Wanfang, VIP, Sinomed, PubMed, Embase, and Cochrane CENTRAL databases from inception until February 5th, 2021. All RCTs comparing SILS and CLS were included. The main outcomes were 30 days of mortality, postoperative complications, intraoperative complications, whereas secondary outcomes were the number of lymph nodes removed, duration of hospital stay, intraoperative blood loss, abdominal incision length, reoperation, readmission, conversion to laparotomy, operation time and anastomotic leakage. Results: A total of 10 RCTs were included, involving 1,133 participants. The quality of the included studies was generally high. No significant difference was found between SILS and CLS in the 30 days mortality rate. The results showed that SILS group had a lower rate of postoperative complications (RR = 0.67, 95% CI: 0.49-0.92), higher rate of intraoperative complications (RR = 2.26, 95%CI: 1.00-5.10), shorter length of abdominal incision (MD = -2.01, 95% CI:-2.42-1.61) (cm), longer operation time (MD = 11.90, 95% CI: 5.37-18.43) (minutes), shorter hospital stay (MD = -1.12, 95% CI: -1.89-0.34) (days) compared with CLS group. However, intraoperative blood loss (MD = -8.23, 95% CI: -16.75-0.29) (mL), number of lymph nodes removed (MD = -0.17, 95% CI: -0.79-0.45), conversion to laparotomy (RR=1.31, 95% CI: 0.48-3.60), reoperation (RR = 1.00, 95% CI: 0.30-3.33) and readmission (RR =1.15, 95% CI: 0.12-10.83) and anastomotic leakage were not significantly different between the two groups. Conclusion: These results indicate that SILS did not has a comprehensive and obvious advantage over the CLS. Surgeons and patients should carefully weigh the pros and cons of the two surgical procedures. Further RCTs are needed to prove long-term outcomes of SILS in colorectal cancer.

Effectiveness and safety of reduced-port laparoscopic surgery vs conventional multi-port laparoscopic surgery in the treatment of gastric diseases: A meta-analysis

This study aimed to compare the effectiveness and safety of reduced-port laparoscopic surgery (RPLS) and conventional multi-port laparoscopic (CMPLS) surgery in the treatment of gastric diseases.The PubMed, Embase, Cochrane Library, Web of Science, and Chinese Biomedical Literature databases were systematically searched for randomized controlled trials, cohort studies, and case control studies on the use of RPLS vs conventional multi-port laparoscopic surgery in treating gastric diseases from their inception until March 10, 2019. The evaluated outcomes were the operative time, blood loss, length of hospital stay, number of dissected lymph nodes, postoperative complications, and conversions. All of these were compared using Stata software version 12.0.A total of 18 studies were included, which involved 2938 patients. In studies referring to the comparison between RPLS and CMPLS in treating gastric diseases, the former showed significantly inferior in terms of operative time (P = .011) and number of dissected lymph nodes (P = .031); but superior results in terms of the estimated blood loss (P = .000) and length of hospital stay (P = .001) than the latter did; however, the rates of postoperative complications (P = .830) and conversions (P = .102) were not statistically significant between the 2 groups.RPLS and CMPLS showed comparable effectiveness and safety in the treatment of gastric diseases in our meta-analysis. Based on the current evidence, we believe that RPLS is an efficacious surgical alternative to CMPLS in the management of gastric diseases because of the shorter hospital stay and reduced blood loss. However, large-scale, well-designed, multicenter studies are needed to further confirm the results of this study.

Systematic review and meta-analysis of single-incision versus conventional multiport laparoscopic splenectomy

BACKGROUND

There is no consensus that single-incision laparoscopic surgery splenectomy (SILS-SP) is on a par with conventional multiport laparoscopic surgery splenectomy (CMLS-SP).

AIMS

The aim of this systematic review and meta-analysis was to assess feasibility and safety of SILS-SP when compared with CMLS-SP.

MATERIALS AND METHODS

Eligible articles were identified by searching several databases including PubMed, EMBASE, CNKI (China) and the Cochrane Library, up until February 2016. Studies were reviewed independently and rated by Newcastle-Ottawa Quality Assessment Scale. Evaluated outcomes were complications, operative time, post-operative hospital stay, blood loss, starting diet, post-operative pain scores, conversion and analgesic requirements.

RESULTS

Ten retrospective studies met the eligibility criteria. Overall, there was no significant difference between SILS-SP and CMLS-SP in complications, operative time, post-operative hospital stay, blood loss, starting diet, post-operative pain scores, conversion and analgesic requirements.

CONCLUSIONS

SILS-SP is feasible and safe in certain patients, with no obvious advantages over CMLS-SP. Therefore, it may be considered an alternative to CMLS-SP. We await high-quality, double-blind RCTs. These should include clear statements on standard scores of post-operative pain and cosmetic results, longer follow-up assessment and cost-benefit analysis.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Single-incision 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.

Extraumbilical single-incision laparoscopic cholecystectomy with standard laparoscopic instruments

BACKGROUND AND AIM

Single-incision laparoscopic surgery is a rapidly progressing field as it combines some advantages such as cosmesis and less incisional pain. However, it also has some disadvantages such as limitation of movement and clashing of the hand instruments, which increase the complexity and technical challenges of the operation. In this study, we describe a pilot trial of single-incision laparoscopic cholecystectomy through a paramedian access site.

MATERIAL AND METHODS

A total of 25 patients underwent single-incision laparoscopic cholecystectomy with this method. Acute cases with empyema and patients with history of previous abdominal surgery were excluded. Single-incision is established on the right upper quadrant, right latero-superior of the umbilicus, so that trocar sites and projection of the gallbladder on the abdominal wall are on the same vertical line. Standard laparoscopic instruments were placed into the abdominal cavity providing triangulation. Once the laparoscope, grasper, and dissector are in place, the overall procedures are similar to the standard laparoscopic cholecystectomy.

RESULTS

Single-incision laparoscopic cholecystectomy through an extraumbilical access site was successfully completed in all 25 patients without conversion to open surgery. Additional skin incisions and trocar access were required only in two patients. The mean operative time was 39.3 min (range: 20-75 min). The mean body mass index was 27.2. Postoperative course was uneventful in all patients. The mean postoperative hospital stay was shorter than 24 h, and all patients were discharged at first day postoperatively. No postoperative complications including seroma, wound infection, and trocar-site hernia were observed at 6-month follow-up.

CONCLUSION

We described a new access site for single-incision laparoscopic cholecystectomy using standard laparoscopic instruments. We believe that this type of access site overcomes the technical difficulties of performing single-incision laparoscopic cholecystectomy, and it is a promising alternative method for the treatment of patients with symptomatic gallstone disease as a minimal invasive abdominal surgery.

Single-Incision Robotic Colectomy (SIRC) case series: initial experience at a single center

BACKGROUND

Laparoscopic colectomy has been associated with favorable outcomes when compared to open colectomy. Single-Incision Robotic Colectomy (SIRC) is a novel procedure hypothesized to improve upon conventional three-port laparoscopic colectomy. We hereby present and analyze our institution's initial experience with SIRC.

METHODS

We performed a retrospective review of 59 patients who underwent SIRC between May 2010 and September 2013, attempting to identify factors associated with conversion rate and postoperative complication rate.

RESULTS

Our study included 34 males (57.6%) and 25 females (42.4%). The mean age was 60.3 years (range 29-92 years), and the mean BMI was 26.6 kg/m(2) (range 14.9-39.7 kg/m(2)). We identified 31 right hemicolectomies (53.4%), 20 sigmoid colectomies (34.5%), 5 left hemicolectomies (1.7%), 2 low anterior resections (3.5%), and 1 total colectomy (1.7%). The overall median operative time was 188 min with an interquartile range of 79 min. Surgical indications included diverticulitis (n = 23, 39.0%), benign colonic mass (n = 18, 30.5%), colon cancer (n = 16, 27.1%), familial adenomatous polyposis (n = 1, 1.7%), and Crohn's disease (n = 1, 1.7%). There were four conversions to open procedure (6.8%), three conversions to multiport robotic procedure (5.1%), and one conversion to single-port laparoscopic procedure (1.7%). Reasons for conversions include difficulty mobilizing the colon and robotic equipment malfunction. Conversions were associated with both higher complication rates (62.5 vs 25.5%, p = 0.035) and longer LOS (7.4 vs 4.0 days, p = 0.0003). Postoperative complications occurred in 16 of the 59 cases (27.1%). Higher BMI was the only significant risk factor for postoperative complications. The overall median LOS was 4 ± 2 days, while the median estimated blood loss was 100 ± 90 ml.

CONCLUSIONS

Our experience has shown that SIRC can be a safe and feasible procedure for both benign and malignant disease. Patient selection is the key to improving surgical outcomes in SIRC.

Single-access laparoscopic rectal cancer surgery using the glove technique

INTRODUCTION

Single-access laparoscopic surgery has been widely adopted in many kinds of surgery including laparoscopic cholecystectomy and laparoscopic colectomy. Performing single-access rectal surgery, however, has technical drawbacks such as instrument collision and endostaple application issues. The glove technique is likely to mitigate these problems.

METHODS

Fourteen patients with anal canal to mid-rectum cancers were recruited and underwent single-access laparoscopic surgery via the glove technique. An incision was made at the paraumbilicus to insert a wound protector with surgical gloves. The operation was medial to lateral and inferior mesenteric artery and inferior mesenteric vein were identified and controlled. Total mesorectal excision was performed while keeping traction and countertraction down to the pelvic floor.

RESULTS

Average operative time was 251.66 min (range, 180-300 min). Hospital stay ranged from 5 to 8 days (median, 7 days). No serious early postoperative surgical problems related to complications were observed. The pathologic results showed good mesorectal capsule grading. The mean lymph node harvest was 14 nodes (range, 7-26 nodes), and the mean wound length was 5 cm (range, 4-6 cm).

CONCLUSIONS

In rectal surgery, the glove technique for single-access laparoscopic surgery is feasible and is comparable to commercial single-port techniques in terms of oncologic results.

Single-incision laparoscopic hernioplasty versus multi-incision laparoscopic hernioplasty: a meta-analysis

BACKGROUND

Laparoscopic hernioplasty is the gold standard treatment for inguinal hernias. Recently, single-incision laparoscopic hernioplasty (SILH) has been suggested as an alternative technique. It is not evident whether the benefits of this procedure overcome the potential increased risk.

OBJECTIVE

The aim of this study was to compare the outcomes of SILH with conventional multi-incision laparoscopic hernioplasty (MILH) using a meta-analysis of available controlled clinical trials.

METHODS

Eligible articles were identified by searching several databases including Embase, Cochrane, PubMed and Google Scholar databases, up until May 2013. Evaluated outcomes were operative time, post-operative hospital stay, complications, conversion and recurrence.

RESULTS

Eight controlled clinical trials on 926 patients were randomized to either SILH (495 patients) or MILH (431 patients) for meta-analysis. Overall, there was no significant difference between SILH and MILH in complications, operative time for bilateral inguinal hernia repair, hospital stay, short-term recurrence or conversions. However, the operative time for unilateral inguinal hernia repair was significantly longer for SILH than for MILH (standardized mean difference 0.23 (95% confidence interval: 0.09-0.38); P = 0.00, I(2) = 73.6%).

CONCLUSIONS

Our meta-analysis showed that SILH is feasible and safe in certain patients when compared to MILH, and carries a similar outcome, with the exception of longer operative times for unilateral inguinal hernia repair. Additional high-powered randomized trials are needed to determine whether SILH truly offers any advantages; these future studies should focus particularly on failure of technique, pain score, analgesia requirements, cosmesis and quality of life.