Single-incision laparoscopic surgery through the umbilicus is associated with a higher incidence of trocar-site hernia than conventional laparoscopy: a meta-analysis of randomized controlled trials

Preliminary experience in using the lateral single-incision laparoscopic totally extraperitoneal approach for inguinal hernia repair

To evaluate the feasibility, safety, and efficacy of the lateral single-incision laparoscopic totally extraperitoneal (L-SILTEP) approach in patients with inguinal hernia who had contraindications to the midline approach. This study included 58 patients who underwent L-SILTEP. Data on their baseline characteristics and perioperative details were collected. Quality of life and cosmetic satisfaction assessments were performed. Of the evaluated patients, 25.9% had a history of middle and lower abdominal surgery and 10.3% had skin diseases around the umbilicus. The mean surgical duration, blood loss volume, and incision length were 53.5 (± 22.3) min, 7.2 (± 9.7) mL, and 2.0 (± 0.13) cm, respectively. Additionally, 29.3% of patients experienced intraoperative peritoneal rupture, and one patient had epigastric vessel bleeding. The 6-, 24-, and 48-h postoperative pain scores were 3.0 (± 0.6), 1.6 (± 0.6), and 1.1 (± 0.4), respectively. Postoperative complications included seroma (n = 3), hematoma (n = 1), and scrotal edema (n = 1). The surgical incision in the L-SILTEP approach was more aesthetically pleasing than that in previous surgeries. Approximately 17.2%, 8.6%, and 10.3% of patients reported pain, mesh sensation, and movement limitation, respectively. Severe or disabling symptoms were not reported, and there were no cases of 30-day readmissions. Hernia recurrence or incisional hernia was not observed over a mean follow-up duration of 14.6 (± 6.1) months. L-SILTEP can be used for patients with contraindications to the midline approach. Furthermore, it is a safe and effective procedure.

Dome-type extracorporeal manual morcellation during laparoscopic uterine surgery: Two years' experience in a teaching hospital

OBJECTIVE

This study aims to describe the dome-type manual morcellation technique, a modified form of C-type incision, its comparative advantages over existing morcellation methods, the perioperative outcomes of trainees with varying experience levels, and the variables influencing morcellation speed based on our two years of experience.

METHODS

This retrospective cohort study included women who underwent laparoscopic myomectomy or hysterectomy using dome-type morcellation for tissue extraction at a tertiary teaching hospital between May 2020 and September 2022. Morcellation was performed by either a single surgeon or a trainee (resident). Basic patient characteristics, perioperative outcomes, and morcellation time and speed were compared between the surgeon and trainee group. Regression models were employed to analyze variables influencing morcellation speed.

RESULTS

A total of 41 women were enrolled. Among them, 20 procedures were performed by a surgeon alone, while the remaining 21 procedures were completed by trainees under the surgeon's supervision. The median weight of the specimens was 378 g (range 91-1345 g), and the median time for morcellation was 10 min (range 1-55 min). The median morcellation speed of surgeon and trainees was 70.25 and 31.7 g/min, respectively. Trainees' level of experience was found to be associated with morcellation speed, particularly for soft specimens. Additionally, both incision size and specimen stiffness were significantly associated with morcellation speed. No morcellation-related complications or bag ruptures were observed.

CONCLUSION

Dome-type manual morcellation is an intuitive, efficient and safe method for specimen removal and is easy to learn for beginners.

Postoperative Incisional Complications in Gynaecologic Single-Incision Laparoscopic Surgery: Comparing Closure Techniques

OBJECTIVES

Single-incision laparoscopic surgery (SILS) and robotic SILS (rSILS) have been found to be safe, minimally invasive techniques in gynaecology. However, one major perceived drawback of these techniques is the increased risk of incisional hernia, compared to multiport laparoscopy or robotic surgery. This study's aim was to determine the optimal technique to reduce postoperative incisional complications such as hernia.

METHODS

A retrospective cohort study was performed at an academic centre from November 2014 to June 2022 on 1036 women who underwent SILS and rSILS gynaecologic procedures with various closure techniques. Techniques included running absorbable sutures without tagging incision apices (standard closure) and tagging incision apices at the beginning of surgery with the use of permanent suture, absorbable suture, or a combination.

RESULTS

Rates of hernia (primary outcome) and incisional issues (secondary outcome) such as separation or infection were analyzed by technique. Hernia rates were lower when incision apices were tagged compared to when not tagged (P < 0.001). Cellulitis/abscess rates were not significantly different. Incision separation was higher when apices were tagged with absorbable and a combination of permanent and absorbable sutures than if apices were tagged with all permanent sutures or not at all. In multivariate analysis, hernia rate decreased in groups with tagged apices, although other incision complications did not vary.

CONCLUSIONS

The incidence of incisional hernia after SILS procedures is low, though it does vary by technique. Tagging apices for closure, regardless of suture type, can mitigate one of the biggest concerns of performing SILS by reducing postoperative incisional hernia risk.

Safety Issues in the Development of an Innovative Medical Parallel Robot Used in Renal Single-Incision Laparoscopic Surgery

Robotic-assisted single-incision laparoscopic surgery (SILS) is becoming an increasingly widespread field worldwide due to the benefits it brings to both the patient and the surgeon. The goal of this study is to develop a secure robotic solution for SILS, focusing specifically on urology, by identifying and addressing various safety concerns from an early design stage. Starting with the medical tasks and protocols, the technical specifications of the robotic system as well as potential; hazards have been identified. By employing competitive engineering design methods such as Analytic Hierarchy Process (AHP), Risk assessment, and Failure Mode and Effects Analysis (FMEA), a safe design solution is proposed. A set of experiments is conducted to validate the proposed concept, and the results strongly support the development of the experimental model. The Finite Element Analysis (FEA) method is applied to validate the mechanical architecture within a set of simulations, demonstrating the compliance of the robotic system with the proposed technical specifications and its capability to safely perform SILS procedures.

Robotic inguinal hernia repair: is the new Da Vinci single port platform providing any benefit?

BACKGROUND

The utilization of the robot for inguinal hernia repairs has increased in the past years. The new Da Vinci Single Port (SP) system provides the benefits of single-incision procedures and might overcome the technical difficulties of previous single-incision techniques. The aim of this study was to evaluate the safety and feasibility of the SP transabdominal preperitoneal inguinal hernia repair (SP-TAPP) and compare its outcomes to the robotic multiport technique (MP-TAPP).

METHODS

A prospective cohort of patients who underwent a robotic SP-TAPP and MP-TAPP between 2012 and 2022 was analyzed. Primary endpoints were same-day discharge, morbidity, and inguinal recurrence rates. Secondary endpoints included conversion, operative time, port-site incisional hernia, and chronic pain.

RESULTS

MP-TAPP and SP-TAPP were performed in 378 (81.3%) and 87 (18.7%) patients, respectively. Demographics were similar between groups. There were no conversions or intraoperative complications. Mean operative (MP-TAPP: 93.2 vs. SP-TAPP: 78.1 min, p = 0.003) and recovery time (MP-TAPP: 160.8 vs SP-TAPP: 112.6 min, p < 0.001) were significantly shorter in the SP group. Same-day discharge rate was higher (MP-TAPP: 86.5% vs. SP-TAPP: 97.7%, p = 0.001) after SP-TAPP; 30-day morbidity, readmissions, and chronic pain rates were similar between groups. After a mean follow-up of 30.6 months for MP-TAPP and 13.3 months for SP-TAPP, inguinal hernia recurrence and port-site incisional rates were similar between groups.

CONCLUSION

Robotic SP-TAPP is safe and feasible. When compared to MP-TAPP, it showed similar postoperative morbidity, higher same-day discharge rates, and a quicker postoperative recovery. Further studies are needed to confirm the benefits of the SP platform.

Effects of Umbilical Preparation Before Trans-umbilical Laparo-endoscopic Single-site Surgery on Umbilical Wounds Healing: a Randomized Controlled Trial

OBJECTIVE

The umbilicus is the only anatomic entrance and incision site for trans-umbilical laparoendoscopic single-site surgery (TU-LESS). Data on incisional surgical site infections (ISSI) and incision healing in TU-LESS are lacking. Therefore, we aimed to observe umbilical incision healing and possible hernia after TU-LESS and explore the efficacy of preoperative umbilicus preparation on ISSI.

SUBJECTS AND METHODS

Consecutive patients aged 18 to 65 years, who were scheduled to undergo TU-LESS at a teaching hospital between March 2020 and November 2021, were enrolled in this prospective study. All patients were randomized to the study group with preoperative umbilicus preparation 30 minutes before patients were sent to the operating room and to the control group without preparation. The umbilical dimple was disinfected twice using povidone-iodine in both groups before the skin incision. The primary outcome was ISSI within 30 days of surgery. Umbilical hernia at 3 months after surgery and perioperative data such as operation time, complications, and incision healing were recorded and compared.

RESULTS

A total of 400 patients were recruited for this study. TU-LESS was performed in all patients without major complications. ISSI occurred in 5 patients in the study group (2.5%) and 3 patients in the control group (1.5%), with no significant differences between both groups ( P =0.479). No umbilical hernia occurred in any patient during the 3 months follow-up. Six patients in the study group (3.1%) and 1 in the control group (0.5%) experienced excessive scarring, a relatively high incidence in the study group, though the difference was not statistically significant ( P =0.067).

CONCLUSIONS

TU-LESS-related umbilical hernias are rare with existing suturing methods. Umbilicus preparation before TU-LESS could not decrease ISSI; however, it increased the nursing workload, which should be avoided.

Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies

BACKGROUND

Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia.

METHODS

A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative.

RESULTS

Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised.

CONCLUSION

These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

Evaluation of Closure Technique on Incidence of Incisional Hernia Following Single Port Laparoscopy in Gynecologic Oncology Surgery

STUDY OBJECTIVE

To evaluate incidence and risk factors for incisional hernia in women undergoing single-port laparoscopy (SPL) for gynecologic oncology indications with a standardized fascia closure (SC) technique versus historical controls (HC).

DESIGN

Retrospective cohort study.

SETTING

Single academic institution.

PATIENTS

Women who underwent SPL from 6/1/2017-12/31/2019 for gynecologic oncology indications with SC were compared to HC who underwent SPL from 1/1/2009-12/31/2015.

INTERVENTIONS

Data was collected for patient demographics, postoperative outcomes, and incisional hernia development. Univariate analysis and multivariable regression models were built for predictors of incisional hernia.

MEASUREMENTS AND MAIN RESULTS

Of 1,163 patients, 242 (20.8%) patients had SC and 921 (79.2%) patients had HC. SC cohort had lower rates of diabetes versus HC (10.3% vs. 15.3%; p = .049) but no differences in hypertension (36.8% vs. 43.0% p = .081) and obesity (42.6% vs. 36.9%, p = .11). 1,123 (96.6%) patients did not undergo conversion to multi-port laparoscopy or laparotomy, of whom 7.2% (n=81) of patients developed an incisional hernia; there was no difference in incisional hernia development for SC with SPL (n= 237) versus HC with SPL (n= 886) (9.7% vs. 6.5%, p = .095). On multivariable analysis, increased BMI (OR 1.06; 95% CI 1.03-1.09, p < .001) and diabetes (OR 2.41; CI 1.34-4.32, p = .003) were associated with incisional hernia, but age (OR 1.00; CI .98-1.02, p = .92), length of surgery (OR 1.00; CI 1.00-1.01, p = .62), and hypertension (OR .89; CI .52-1.53, p = .68) were not. Patients with prior abdominal surgeries (OR 1.92; CI 1.14-3.26, p = .015) and hand-assist surgery (OR 3.17; CI 1.48-6.80, p = .003) were significantly associated with incisional hernia.

CONCLUSION

Implementation of a SC protocol did not decrease rate of incisional hernia versus HC during SPL. Risk of incisional hernia must be considered for SPL planning in patients with complex medical comorbidities and prior abdominal surgery.

Long-term follow-up of the incisional hernia rate after single-incision laparoscopic cholecystectomy: a prospective observational study

PURPOSE

To evaluate the long-term occurrence rate of incisional hernias following single-incision laparoscopic cholecystectomy (SILC).

BACKGROUND

Since the 90 s, SILC has emerged as a less invasive alternative to standard laparoscopic cholecystectomy in selected patients. But concerns over port-incisional hernias have not been addressed.

METHODS

Between February 2009 and February 2011, 142 patients referred for gallstones who agreed to undergo SILC were included in a monocenter prospective observational study. All of the procedures were carried out using a single-port access technique. The occurrence rates of incisional hernias were analyzed with the Kaplan-Meier actuarial method. Statistical significance was set at p < .05.

RESULTS

A total of 142 patients with gallbladder pathology were included in the study; 138 of them underwent SILC and 4 were converted to standard multiport cholecystectomy. Twelve patients (8%) were found to have developed a port-site incisional hernia (PSH) by physical examination or by imaging. The Kaplan-Meier curve showed that the rate of PSH development was 83% in the first 2 years after surgery. After 2 years, this risk becomes quite low.

CONCLUSIONS

Our results indicate that the SILC procedure is a safe option for treatment of benign gallbladder diseases for selected patients, albeit with a high incisional hernia rate.

Long-term oncologic outcomes of single-incision laparoscopic surgery for colon cancer

BACKGROUND

Studies find similar perioperative outcomes between single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) for colon cancer. However, few have reported long-term outcomes of SILS versus CLS. We aimed to compare long-term postoperative and oncologic outcomes as well as perioperative outcomes between SILS and CLS for colon cancer.

METHODS

A total of 641 consecutive patients who underwent laparoscopic surgery for colon cancer from July 2009 to September 2014 were eligible for the study. Data from 300 of these patients were used for analysis after propensity score-matching (n = 150 per group). Variables associated with short- and long-term outcomes were analyzed.

RESULTS

The SILS group had a shorter mean total incision length, less postoperative pain, and a similar mean rate of incisional hernia (2.7% versus 3.3%) compared with the CLS group. The 7-year overall and disease-free survival rates were 92.7% versus 94% (p = 0.673) and 85.3% versus 84.7% (p = 0.688) in the SILS and CLS groups, respectively.

CONCLUSIONS

Compared with CLS, SILS for colon cancer appeared to be safe in terms of perioperative and long-term postoperative and oncologic outcomes. The results suggested that SILS is a reasonable treatment option for colon cancer for a selected group of patients.

Laparoscopic surgery and robotic surgery for single-incision cholecystectomy: an updated systematic review

The role of single-incision laparoscopic cholecystectomy (SILC) and single-incision robotic cholecystectomy (SIRC) is still unclear. We update the summarization of the feasibility and safety of SILC and SIRC. A comprehensive search of SILC and SIRC of English literature published on PubMed database between January 2015 and November 2020 was performed. A total of 70 articles were included: 41 covering SILC alone, 21 showing SIRC alone, 7 reporting both, and 1 study not specified. In total, 7828 cases were recorded (SILC/SIRC/not specified, 6234/1544/50); and the gender of 7423 cases was definitively reported: the female rate was 64.0% (SILC/SIRC/not specified, 62.1%/71.5%/74.0%). The weighted mean for body mass index (BMI), operative time, blood loss and post-operative hospital stay was 25.5 kg/m² (SILC/SIRC, 25.0/27.0 kg/m²), 73.8 min (SILC/SIRC, 68.2/88.8 min), 12.6 mL (SILC/SIRC, 12.1/14.8 mL) and 2.5 days (SILC/SIRC, 2.8/1.9 days), respectively. The pooled prevalence of an additional port, conversion to open surgery, post-operative complications, intraoperative biliary injury, and incisional hernia was 4.1% (SILC/SIRC, 4.7%/1.9%), 0.9% (SILC/SIRC, 0.7%/1.5%), 5.9% (SILC/SIRC, 6.2%/4.1%), 0.1% (SILC/SIRC, 0.2%/0.09%), and 2.1% (SILC/SIRC, 1.4%/4.8%), respectively. Compared with conventional laparoscopic cholecystectomy, SIRC has experienced more postoperative incisional hernias (risk difference = 0.05, 95% confidence interval 0.02-0.07; P < 0.0001). By far, SILC and SIRC have not been considered a standard procedure. With the innovation of medical devices and gradual accumulation of surgical experience, feasibility and safety of performing SILC and SIRC will improve.

Trocar Site HERnias After Bariatric Laparoscopic Surgery (HERBALS): a Prospective Cohort Study

Background

The exact prevalence of trocar site hernias after bariatric procedures is not yet known. Recent metaanalysis data indicated concerning rates of up to 25%. We conducted a prospective cohort study to estimate the prevalence and analyze the role of fascia closure in the development of trocar hernias.

Method

A total of 365 patients who were operated for obesity in our department between 2009 and 2018 were included. All patients were invited for a follow-up ultrasonography scan in order to detect abdominal wall defects. The role of intraoperative fascia closure in the development of trocar site hernias was evaluated, and a logistic regression analysis was performed to detect potential risk factors.

Results

The overall prevalence of trocar hernias detected by ultrasonography was 34%. The prevalence of abdominal wall defects in patients who received a fascia closure was 37% compared with 34% in patients who did not receive a fascia closure (p = 0.37). The only factor that was associated with a higher risk for trocar site hernias was high excessive weight loss (p = 0.05).

Conclusion

Trocar site hernias are an underestimated complication of minimally invasive, multiportal bariatric surgery, and the prevalence of asymptomatic hernias is probably higher than initially expected. In this study, fascia closure did not protect against trocar hernias. However, opposing evidence from similar trials suggests closing the fascia. This clinical problem should therefore be further assessed in a prospective randomized setting.

Low long-term incidence of incisional hernia after cholecystectomy: A systematic review with meta-analysis

BACKGROUND

Various surgical approaches are available for cholecystectomy, but their long-term outcomes, such as incidence of incisional hernia, are largely unknown. Our aim was to investigate the long-term incidence of incisional hernia after cholecystectomy for different surgical approaches.

METHODS

This systematic review and meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42020178906). Three databases were searched for original studies on long-term complications of cholecystectomy with n > 40 and follow-up ≥6 months for incisional hernia. Risk of bias within the studies was assessed using the Newcastle-Ottawa Scale and the Cochrane "risk of bias" tool. Meta-analysis of the incidence of incisional hernia after 6 and 12 months was conducted when possible.

RESULTS

We included 89 studies. Of these, 77 reported on multiport or single-incision laparoscopic cholecystectomy. Twelve studies reported on open cholecystectomy and 4 studies on robotic cholecystectomy. Weighted mean incidence proportion of incisional hernia after multi-port laparoscopic cholecystectomy was 0.3% (95% confidence interval 0-0.6) after 6 months and 0.2% after 12 months (95% confidence interval 0.1-0.3). Weighted mean incidence of incisional hernia 12 months postoperatively was 1.5% (95% confidence interval 0.4-2.6) after open cholecystectomy and 4.5% (95% confidence interval 0.4-8.6) after single-incision laparoscopic cholecystectomy. No meta-analysis could be conducted for robotic cholecystectomy, but incidences ranged from 0% to 16.7%.

CONCLUSION

We found low 1-year incidences of incisional hernia after multiport laparoscopic and open cholecystectomy, whereas risks of incisional hernia were considerably higher after single-incision laparoscopic and robotic cholecystectomy.

A cable-driven distal end-effector mechanism for single-port robotic surgery

PURPOSE

The development of surgery is to be minimally invasive and collaborative with robot systems, which has caught increasing attention in recent years. However, the narrow access routes and confined working spaces in vivo usually make distal end-effectors of surgical systems not easy to operate. To overcome this problem, a novel cable-driven distal end-effector mechanism designed for single-port robotic surgery was proposed.

METHODS

A cable-driven joint structure and the corresponding methods of threading cables were proposed which can maintain the length and even the tension force of cables constant during operation. Based on the proposed joint structure, the cable-driven distal end-effector mechanism consists of a parallelogram mechanism and a snake mechanism. The parallelogram mechanism is used to enlarge its reachable workspace through establishing the triangulation of operation. The snake mechanism is used to achieve the expected pose through providing sufficient bending degrees of freedom. All of the degrees of freedom can be decoupled at the expense of a slightly more tedious process of threading cables.

RESULTS

The primary prototype and its miniature assembled and threaded manually performed as expected regardless of bend, translation and their combination. But the inadequate tension force of cables and assembly errors affect the load capacity and accuracy, which need to be improved by automatic assembly.

CONCLUSION

A cable-driven distal end-effector mechanism composed of a parallelogram mechanism, and a snake mechanism used for single-port robotic surgery was proposed. The mechanism adopts a novel cable-driven joint structure and corresponding methods of threading cables to keep the length and even the tension force of cables constant during surgery.

Single-incision versus four-port laparoscopic cholecystectomy in an ambulatory surgery setting: A prospective randomised double-blind controlled trial

Background:

Single-incision laparoscopic cholecystectomy (SILC) can be done as a day-case procedure and may have advantages over conventional laparoscopic cholecystectomy (LC). We present the results of our study looking at post-operative pain and post-operative recovery time.

Methods:

This was a single-institution randomised double-blind controlled trial. Seventy-three patients with symptomatic cholelithiasis were randomized to SILC (n = 37) or LC (n = 36). The primary endpoint was to compare post-operative pain. We also compared surgical time, procedural difficulty, adverse events, additional ports used and conversion rate, success of day surgery process, return to work, aesthetic satisfaction, quality of life and 4-year incisional hernia rate.

Results:

In the SILC group, post-operative analgesic requirements were lower on day 7, there was an earlier return to work and cosmetic satisfaction was significantly higher. The SILC procedure presented a higher technical difficulty. Operative time, surgical complications, post-operative pain, success of the day-case process, return to normal activity, quality of life scores and incisional hernia rates were similar for both the procedures.

Conclusions:

SILC has advantages over LC in terms of late post-operative analgesic requirements and aesthetic results; however, it is technically harder to perform. There was no benefit in terms of day surgery outcomes.

Incisional hernia after 2498 single-port access (SPA) gynecologic surgery over a 10-year period

The present study was conducted to report the perioperative outcomes of single-port access (SPA) laparoscopic gynecologic surgeries with focus on the incidence of postoperative incisional hernia from our cumulative data of 2498 patients. A retrospective review was performed on the women who had received SPA surgeries from 2008 to 2018. Patient characteristics and perioperative outcomes including the incidence of postoperative incisional hernia were analyzed. There were 2498 Korean patients who received SPA surgeries for various gynecologic diseases. The median age of the patients was 40.3 ± 9.2 years, and the mean body mass index (BMI) was 22.6 ± 3.2 kg/m². A total of 3 postoperative incisional hernia occurred during the study period. Two patients whose fascial layers were closed in running sutures developed hernias 6 and 8 months after their operations. One patient whose fascial layers were closed in interrupted sutures developed hernia 11 months after her operation. The incidence of postoperative incisional hernia following SPA surgery is low in Asian women whose BMI is relatively lower than other patient populations. Interrupted suture technique may reduce postoperative incisional hernia by providing a distinct visualization of fascial layers during closure. Detailed descriptions of our surgical techniques of closing the port incision are provided.

Special type trocar-site hernia with evisceration of the appendix following laparoscopic repair of a perforated duodenal ulcer

Trocar-site hernia is an uncommon complication of laparoscopic surgery and can be classified as early-onset, late-onset or special type. Special type hernias usually occur in the early postoperative period and result in evisceration of intra-abdominal contents through all layers of the abdominal wall without an overlying hernia sac. We present a case of special type herniation of the appendix through a 5-mm trocar site in the right iliac fossa following laparoscopic repair of a perforated duodenal ulcer. In this case, herniation occurred after removal of a drain inserted through the trocar site intraoperatively and was treated with emergent open appendicectomy. A number of patient and technical factors may be associated with an increased risk of trocar-site herniation including increasing age, elevated body mass index, increasing trocar size, longer procedure duration and absence of fascial closure. These factors must be borne in mind when planning trocar placement and number to reduce the risk of herniation.

Feasibility of Single-Incision Plus One Port Laparoscopic Low Anterior Resection for Rectal Cancer

PURPOSE

Single-incision laparoscopic surgery is a recently developed minimally invasive surgical technique. We aimed to compare the feasibility and safety of single-incision plus one port laparoscopic low anterior resection (S+1-LAR) with those of multi-port laparoscopic low anterior resection (M-LAR) for mid-to-low rectal cancer.

METHODS

We retrospectively reviewed patient characteristics and surgical outcomes by assessing data collected from the medical records of patients who underwent elective laparoscopic low anterior resection for mid-to-low rectal cancer at the Gangneung Asan Hospital.

RESULTS

From April 2015 to April 2019, 52 patients underwent S+1-LAR (n=28) or M-LAR (n=24) for mid-to-low rectal cancer at Gangneung Asan Hospital. There were no significant between-group differences in clinical characteristics. The mean postoperative 1-day pain score was significantly lower in the S+1-LAR group. Surgical outcomes and postoperative complications did not differ significantly between the two groups.

CONCLUSION

S+1-LAR is a feasible and safe technique and is comparable with M-LAR in terms of surgical outcomes of patients with mid-to-low rectal cancer.

Laparoendoscopic radical prostatectomy (LRP): stepwise transition from multi-site to single-site with the aid of the transurethral port

PURPOSE

To describe our initial experience with laparoendoscopic radical prostatectomy (LRP) and a stepwise transition towards transurethral assisted laparoendoscopic single-site RP (TU-LESS RP).

PATIENTS AND METHODS

From Jan. 2007 to Dec. 2016, 195 patients underwent RP, of which 89 patients were performed by LRP (Group A), 106 by TU-LESS RP (Group B). The peri-operative data were collected and analyzed. All data referring to patient demographics, surgery, pathology, and peri-operative outcomes were recorded. The cosmetic result was investigated by the Patient Scar Assessment Questionnaire (PSAQ). Analysis of variance or Chi squared test were adopted to analyze the data.

RESULTS

195 procedures were completed successfully. The operation time (109.6 ± 31.9 vs. 151.5 ± 87.3, P = 0.025) and anastomosis time (10.1 ± 4.8 vs. 21.8 ± 9.9, P < 0.001) of Group B was significantly reduced compared with Group A. Estimated blood loss in Group B was significantly lower than that in Group A (95.9 ± 11.1 vs. 180.2 ± 99.7, P = 0.006). About perioperative complications, Group B was also less compared with Group A (1.9% vs. 7.9%, P = 0.047). As to the usage of postoperative analgesics, Group B apparently used less than that in Group A (6.6% vs. 62.9%, P < 0.001), which is consistent with the visual analogue scale (VAS) of the two groups (1.7 ± 1.3 vs. 7.8 ± 1.1, P < 0.001). Patients in Group B were significantly more satisfied with incision healing than in group A (74.9 ± 9.3 vs. 49.7 ± 5.8, P < 0.001). There was no significant difference both in BCR rate and time between Group B and Group A. In urination control, more patients in Group B did not have urinary incontinence 3 month after RP compared with Group A (81.1% vs. 67.4%, P = 0.028).

CONCLUSIONS

LESS RP is proved to be feasible for the proper patients, but it is difficult to popularized due to inconvenient operation. While by means of TU-LESS, operating difficulty can be significantly decreased. TU-LESS RP will be wildly accepted by surgeons and patients because of cosmetic satisfaction and quicker recovery.

Evaluation of umbilical anatomy via computed tomography prior to single-incision laparoscopy

Laparoscopic surgery performed through a single incision is relatively new. Here, we investigated the importance of radiological anatomical evaluation of the umbilicus prior to such surgery.Umbilical images of 500 patients who underwent computed tomography (CT) in 2019 were evaluated retrospectively, using both transverse and sagittal sections.Spearman rank correlation analysis indicated a significant positive relationship between age and the sagittal and transverse umbilical measurements (all patients: P < .01; men: P = .001; women: P < .01). Mean transverse and sagittal measurements were 5.63 ± 1.9 and 6.2 ± 2.0 mm in women and 5.49 ± 1.9 and 6.2 ± 1.8 mm in men.Umbilical anatomy can be evaluated radiologically as a component of preoperative evaluation.

Randomized controlled trial of single incision versus conventional multiport laparoscopic cholecystectomy with long-term follow-up

Background

Within the last years, single-incision laparoscopic cholecystectomy (SLC) emerged as an alternative to multiport laparoscopic cholecystectomy (MLC). SLC has advantages in cosmetic results, and postoperative pain seems lower. Overall complications are comparable between SLC and MLC. However, long-term results of randomized trials are lacking, notably to answer questions about incisional hernia rates, long-term cosmetic impact and chronic pain.

Methods

A randomized trial of SLC versus MLC with a total of 193 patients between December 2009 and June 2011 was performed. The primary endpoint was postoperative pain on the first day after surgery. Secondary endpoints were conversion rate, operative time, intraoperative and postoperative morbidity, technical feasibility and hospital stay. A long-term follow-up after surgery was added.

Results

Ninety-eight patients (50.8%) underwent SLC, and 95 patients (49.2%) had MLC. Pain on the first postoperative day showed no difference between the operative procedures (SLC vs. MLC, 3.4 ± 1.8 vs. 3.7 ± 1.9, respectively; p = 0.317). No significant differences were observed in operating time or the overall rate of postoperative complications (4.1% vs. 3.2%; p = 0.731). SLC exhibited better cosmetic results in the short term. In the long term, after a mean of 70.4 months, there were no differences in incisional hernia rate, cosmetic results or pain at the incision between the two groups.

Conclusions

Taking into account a follow-up rate of 68%, the early postoperative advantages of SLC in relation to cosmetic appearance and pain did not persist in the long term. In the present trial, there was no difference in incisional hernia rates between SLC and MLC, but the sample size is too small for a final conclusion regarding hernia rates.

Trial registration

German Registry of Clinical Trials DRKS00012447

Trocar-site hernia after gynecological laparoscopic surgery: a 20-year, single-center experience

Background:

Trocar-site hernia (TSH) is a serious complication after laparoscopic procedures. Although it is a rare entity, it can have life-threatening consequences. This study aimed to retrospectively analyze the potential associated factors for TSH following gynecologic laparoscopy and summarize prevention strategies based on our experience.

Methods:

We searched for gynecological laparoscopic surgeries in the medical records system of Peking Union Medical College Hospital (PUMCH) from August 1998 to July 2018 and further sifted through the results for cases involving TSH. All included patients were divided into different groups according to patient characteristics, and the rate of TSH was compared among groups. Moreover, the detailed information of all patients with TSH was recorded and analyzed. Statistical analyses were performed with GraphPad Prism 6.

Results:

The approximate total rate of post-operative TSH among gynecologic laparoscopy procedures performed at PUMCH in the last 20 years was 0.016% (9/55,244). The rate of TSH was significant higher in elder patients (≥60 years old; 3/2686, 0.112%) than in younger patients (<60 years old, 6/52,558; 0.011%, P = 0.008). Moreover, the approximate rate of TSH was significantly higher after single-incision laparoscopic surgery (SILS, 2/534, 0.357%) than conventional laparoscopic surgery (7/54,710, 0.013%, P = 0.003). The average age of patients with TSH was 53.4 years (range, 35.0–79.0 years). Two of the nine patients had late-onset TSH following SILS; the other seven had early-onset TSH following conventional laparoscopy. Five TSH cases occurred at right lateral port sites, and the remaining three occurred at the umbilical port site. All patients underwent repair surgery, and one required small bowel resection.

Conclusion:

Older age and SILS are potential associated factors for TSH development, while reducing excessive manipulation and improving suturing skills, especially at the umbilical trocar site following SILS and the right lateral trocar site, can avoid herniation.

Clinical and oncological outcomes of single-incision vs. conventional laparoscopic surgery for rectal cancer

BACKGROUND

To evaluate the clinical and oncological outcomes of single-incision laparoscopic surgery (SILS) vs. conventional laparoscopic surgery (CLS) for patients with rectal cancer (RC) who underwent total mesorectal excision (TME) surgery.

METHODS

This was a retrospective case-control study of patients with RC operated between 12/2013 and 12/2017 in Ruijin Hospital North, Shanghai Jiaotong University School of Medicine. In total, 177 patients who underwent CLS and 51 who underwent SILS met the inclusion and exclusion criteria and were matched 1:1 using propensity score matching method (PSM).

RESULTS

Compared with the CLS group, the SILS group showed shorter operation time [105 (40) vs. 125 (55) min, P = 0.045], shorter total incision length [4 (1) vs. 6.5 (1.5) cm, P < 0.001], lower VAS score on POD2 [1 (1) vs. 2 (1), P < 0.001], shorter time to soft diet [7 (1) vs. 8 (2) days, P = 0.048], and shorter length of hospital stay [9 (2) vs. 11 (3) days, P < 0.001]. The postoperative complications were similar between two groups [1(2%) vs. 5 (9.8%), P = 0.205]. No readmissions or mortality in either group occurred within 30 days of surgery. All 102 specimens met the requirements of TME. No significant differences were observed in the pathologic outcomes between the two groups. The median follow-up period was 32.6 months in the SILS group and 36.8 months in the CLS group (P = 0.053). The 3-year disease-free survival rates and overall survival rates of the SILS and CLS groups were 89.8% vs. 96.0% (P = 0.224) and 90.9% vs. 96.9% (P = 0.146), respectively.

CONCLUSIONS

Compared with CLS, TME surgery for rectal cancer can be performed safely and effectively using the SILS technique with better cosmetic results, less postoperative pain, faster postoperative recovery, and acceptable clinical and oncological outcomes.

Incidence and Risk Factors of Incisional Hernia After Single-Incision Endoscopic Surgery

Introduction: Abdominal wall complications are one of the most controversial issues regarding single-incision endoscopic surgery. The aim of this study was to analyze the incidence and risk factors of incisional hernia after single-incision endoscopic cholecystectomy. Materials and Methods: An observational retrospective study was performed, on a cohort of patients cholecystectomized laparoscopically through a transumbilical single incision due to gallbladder lithiasis or polyps. Postoperative complications were analyzed, with special interest in the incisional hernia rate, whose results were assessed in the long-term follow-up. Univariate and multivariate analyses were also performed to evaluate possible variables associated with the appearance of incisional hernia. Cumulative sum charts (CUSUM) were used to identify trends in the incisional hernia risk. Results: Some 109 patients were included in the study. With a mean follow-up of nearly 38 months, an incisional hernia incidence of 5.5% was found, with 67% being diagnosed during the first year of follow-up. In the Cox regression analysis, two variables showed an independent association with the emergence of incisional hernia, body mass index (hazard ratio [HR] 1.30; 95% confidence interval [CI 1.053-1.606]; P .015), and wound infection (HR 26.32; [3.186-217.40]; P .002]. CUSUM charts showed a decrease in the risk of incisional hernia after the first 10 cases. Conclusions: Single-incision endoscopic cholecystectomy is associated with a substantially high risk of postoperative incisional hernia (5.5%).

LESS with Suture Suspension for Early-Stage Adnexa Cancer Staging

Background and Objective:

Laparoendoscopic single-site surgery has been used in treating gynecologic diseases including early-stage cervical and endometrial cancer, but less so in early-stage adnexal cancer. We aimed to demonstrate the use of laparoendoscopic single-site surgery with suture suspension for staging of early-stage ovarian/fallopian-tube cancer and describe the study results.

Methods:

Seven patients with early-stage adnexal cancer underwent staging surgery via laparoendoscopic single-site surgery at West China Second University Hospital of Sichuan University from November 2017 to September 2018.

Results:

All cases were successfully staged via this technique. Two patients underwent the high-level para-aortic lymphadenectomy up to the infrarenal vein, and four patients underwent para-aortic lymphadenectomy at the level of the inframesenteric artery; one patient underwent the para-aortic lymph node sampling. The operation time was 305–365 minutes. The estimated intraoperative blood loss was 50–200 mL. No intra-operative complications occurred; one patient developed pneumonia 48 hours postoperation. The number of pelvic and para-aortic nodes was 15–39 and 1–18, respectively. Pain scores 12 and 24 hours postsurgery were 2–3 and 1–2 with the use of butorphanol tartrate, respectively. On 4–14 months followup, the umbilical incision had good cosmesis; no umbilical hernia or vaginal dehiscence and no neoplasm recurrence were noted.

Conclusion:

Laparoendoscopic single-site surgery may be a feasible and safe technique for staging early-stage ovarian/tubal cancer. This approach has some advantages included providing easier access to the upper abdominal regions when performing high-level infrarenal para-aortic lymphadenectomy; the 2-cm elastic incision favors fast specimen extraction and colpotomy are avoided. However, the long-term oncologic outcomes need to be further investigated.

Long-term follow-up after single-incision laparoscopic surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) is growing in popularity. The increased diameter of the umbilical incision might raise questions about the possibility of a greater risk of postoperative incisional hernia in comparison to conventional laparoscopy. This study aims to disclose the frequency of incisional hernia after SILS in long-term follow-up as well as to reveal the factors predisposing patients to this feared complication.

METHODS

The patient collective consists of cholecystectomy and appendectomy patients, who were operated on using SILS technique. Follow-up was achieved through letter correspondence, telephone interview, and clinical examination. Effects of demographic variables and operative parameters including age, sex, BMI, ASA score, duration of surgery, pre-existing hernia as well as postoperative incidence of incisional hernia were investigated using univariate and multivariate analyses.

RESULTS

A total of 286 cases with complete follow-up were included in the analyses. Mean follow-up duration was 58.4 months. 192 patients (67.1%) underwent cholecystectomy; 94 (32.9%) had an appendectomy. The study collective consisted of 218 women (76.2%) and 68 men (23.8%). Mean age at the date of the operation was 38.5 (median 36, range 13-74). In 5 cases (1.7%), the surgical approach was converted into conventional laparoscopy. Intraoperative complication rate was 0.3% and postoperative complication rate was 5.9%. 7 patients (2.4%) developed an incisional hernia. Obese patients had an incisional hernia incidence of 10.9%. 3 out of 19 patients (15.8%) with a pre-existing umbilical hernia developed an incisional hernia during follow-up. Obesity and pre-existing umbilical hernia proved to have a significant association with incisional hernia incidence in univariate and multivariate analyses. Sex, age, procedure (appendectomy vs cholecystectomy), presence of acute inflammation, and duration of surgery did not show a statistically significant association with incisional hernia.

CONCLUSION

Detection of incisional hernia necessitates a long follow-up duration. Obesity and pre-existing umbilical hernia are associated with a higher incidence of this complication. Following a careful patient selection, SILS offers a safe approach for cholecystectomy and appendectomy procedures.

Clinical outcomes and inflammatory response to single-incision laparoscopic (SIL) colorectal surgery: a single-blinded randomized controlled pilot study

AIM

Single-incision laparoscopic (SIL) surgery is expanding, but its benefits, efficacy and safety compared with conventional laparoscopic (CL) surgery remain unclear. This pilot study examined clinical outcomes and biochemical markers of inflammation for colorectal resections by SIL and CL in a randomized controlled pilot trial.

METHOD

Fifty patients undergoing elective colorectal resection were randomized to either SIL or CL. Primary outcomes were operating time and length of stay (LoS); secondary outcomes included combined length of scars, pain scores, complications, Quality of Life EQ5D-VAS and the inflammatory markers interleukin-6 (IL-6), IL-8 and C-reactive protein (CRP) at baseline, 2, 6, 24 and 72 h.

RESULTS

There was no difference in age, gender, body mass index, indications and site of surgery, American Society of Anesthesiologists grade or incidence of previous surgery between the groups. Except for one conversion from SIL to open surgery, surgery was completed as intended. No difference between SIL and CL was found for operating time [median 130 (72-220) vs 130 (90-317) min, respectively, P = 0.528], LoS [median 4 (3-8) vs 4 (2-19)days, P = 0.888] and time to first flatus [2 (1-4) vs 2 (1-5) days, P = 0.374]. The combined length of scars was significantly shorter for SIL [4 (2-18) vs 7 (5-8) cm, P < 0.001]; in each group, four postoperative complications occurred (16%). Postoperative pain scores were similar [mean 7.67 (interquartile range 4) vs 7.25 (interquartile range 3.75), P = 0.835] to day 3. EQ5D-VAS was no different for both groups at discharge [72.5 (40-90) vs 70 (30-100), P = 0.673] but slightly higher for CL at 3 months [79 (45-100) vs 90 (50-100), P = 0.033].The IL-6, IL-8 and CRP levels between both groups showed similar peaks and no significant differences.

CONCLUSION

SIL colorectal surgery by experienced laparoscopic surgeons appears to be safe and equivalent to CL, with no discernible difference in its effect on the physiological response to surgical trauma.

A Concealed “Natural Orifice”: Umbilicus Anatomy for Minimally Invasive Surgery

Introduction. A recent development in minimally invasive surgery (MIS) is single-port surgery, where a single large multiport trocar is placed in the umbilicus. All medical schools require that students complete an anatomy course as part of the medical curriculum. However, there is limited instruction regarding the detailed parts of the “umbilicus.” In several famous anatomy atlases, the umbilicus is not dissected at all and is merely represented as a button. Until now, the true nature of the umbilicus has not been anatomically demonstrated. Methods. Five cadavers were obtained from the Osaka Medical College medical student anatomy class. The umbilicus was dissected in the anatomy laboratory, to demonstrate all the layers. A detailed dissection was performed, focusing on the exact center of the umbilicus, in order to ascertain whether there exists a “natural orifice” or a fascial defect. Results. In all cadavers, a small defect of fascia was identified just below the center of the umbilicus. Yellow fatty tissue was present just below the skin in the exact center of the umbilicus. A probe placed exactly in the middle of this defect passes easily through into the abdominal cavity. Conclusions. With the widespread use of MIS, umbilical incision is commonly used to reduce pain and improve cosmetic results. This study consistently revealed a natural defect of fascia in the center of the umbilicus. Therefore, the umbilicus can be called a concealed “natural orifice.” It is important to recognize and utilize this defect effectively to minimize unnecessary tissue trauma during MIS.

Clinical and oncologic outcomes of single-incision laparoscopic surgery for right colon cancer: a propensity score matching analysis

BACKGROUND

Single-incision laparoscopic surgery (SILS) for right colon cancer is going to be considered as a new option. The potential benefits, clinical, and oncologic outcomes are still controversial. The aim of this study was to investigate clinical and oncologic outcomes of single-incision laparoscopic surgery (SILS) compared to conventional laparoscopic surgery (CLS) for right colon cancer using propensity score matching analysis.

METHODS

From December 2013 to June 2017, 174 patients underwent laparoscopic radical right hemicolectomy through a single-incision (n = 32) or a conventional (n = 142) approach. The data were prospectively collected and the patients were matched at a radio of 1:1 according to age, sex, body mass index (BMI), previous abdominal surgeries, comorbidities, ASA score (≤ 2/> 2), and pathologic stage.

RESULTS

No significant differences were observed in estimated blood loss, time to diet, postoperative pain score, length of hospital stay between the SILS and CLS groups. However, the SILS group showed longer operation time (175 (40) vs 145 (52.5), p = 0.011) and shorter incision length (4 (1.4) vs 7 (1.9), p < 0.001). There were 2 (6.3%) postoperative complications in the SILS group and 5 (15.6%) in the CLS group (p = 0.426). The pathologic outcomes were similar between two groups. The median follow-up period was 26.5 months in the SILS group and 34.9 months in the CLS group (p = 0.002). There were 3 recurrences (9.4%) in the SILS group and 3 (9.4%) in the CLS group. The 3-year disease-free survival rates were 92.4 and 93.8% (p = 0.984), and overall survival rates were 92.3 and 93.0% (p = 0.884) in the SILS and the CLS groups, respectively. No incisional hernia was observed during the follow-up period.

CONCLUSIONS

Though single-incision laparoscopic surgery for right colon cancer showed longer operation time in this study, it appears to be a safe and feasible option with comparable clinical and oncologic outcomes to conventional laparoscopic surgery.

Robotic-assisted versus laparoscopic cholecystectomy for benign gallbladder diseases: a systematic review and meta-analysis

BACKGROUND

Robotic surgery, an emerging technology, has some potential advantages in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted cholecystectomy (RAC) is still a controversial issue on its comparative merit compared with conventional laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the safety and efficacy of RAC compared with LC for benign gallbladder disease.

METHODS

A systematic literature search was conducted using the PubMed, EMBASE, and Cochrane Library databases (from their inception to December 2017) to obtain comparative studies assessing the safety and efficacy between RAC and LC. The quality of the literature was assessed, and the data analyzed using R software, random effects models were applied.

RESULTS

Twenty-six studies, including 5 RCTs and 21 NRCSs (3 prospective plus 18 retrospective), were included. A total of 4004 patients were included, of which 1833 patients (46%) underwent RAC and 2171 patients (54%) underwent LC. No significant differences were found in intraoperative complications, postoperative complications, readmission rate, hospital stay, estimated blood loss, and conversion rate between RAC and LC groups. However, RAC was related to longer operative time compared with LC (MD = 12.04 min, 95% CI 7.26-16.82) in RCT group, which was consistent with NRCS group; RAC also had a higher rate of incisional hernia in NRCS group (RR = 3.06, 95% CI 1.42-6.57), and one RCT reported that RAC was similar to LC (RR = 7.00, 95% CI 0.38-129.84).

CONCLUSIONS

The RAC was not found to be more effective or safer than LC for benign gallbladder diseases, which indicated that RAC is a developing procedure instead of replacing LC at once. Given the higher costs, the current evidence is in favor of LC in cholecystectomy.

COMPARISON BETWEEN INCIDENCE OF INCISIONAL HERNIA IN LAPAROSCOPIC CHOLECYSTECTOMY AND BY SINGLE PORT

Background:

Surgeries with single port access have been gaining ground among surgeons who seek minimally invasive procedures. Although this technique uses only one access, the incision is larger when compared to laparoscopic cholecystectomy and this fact can lead to a higher incidence of incisional hernias.

Aim:

To compare the incidence of incisional hernia after laparoscopic cholecystectomy and by single port.

Methods:

A total of 57 patients were randomly divided into two groups and submitted to conventional laparoscopic cholecystectomy (n=29) and laparoscopic cholecystectomy by single access (n=28). The patients were followed up and reviewed in a 40.4 month follow-up for identification of incisional hernias.

Results:

Follow-up showed 21,4% of incisional hernia in single port group and 3.57% in conventional technique.

Conclusions:

There was a higher incidence of late incisional hernia in patients submitted to single port access cholecystectomy compared to conventional laparoscopic cholecystectomy.

Incisional hernia prevention and use of mesh. A narrative review

Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.

Incisional Outcomes of Umbilical vs Suprapubic Mini-laparotomy for Tissue Extraction: A Retrospective Cohort Study

STUDY OBJECTIVE

To compare outcomes following umbilical minilaparotomy and suprapubic minilaparotomy for tissue extraction.

DESIGN CLASSIFICATION

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Two large academic medical centers.

PATIENTS

Women who underwent a minilaparotomy for tissue extraction following a laparoscopic hysterectomy or myomectomy between 2014 and 2016.

INTERVENTIONS

Umbilical or suprapubic minilaparotomy for tissue extraction.

MEASUREMENTS AND MAIN RESULTS

A total of 374 women underwent laparoscopic hysterectomy or myomectomy with minilaparotomy, including 289 (77.3%) with an umbilical minilaparotomy and 85 (22.7%) with a suprapubic minilaparotomy. The 2 groups were similar in terms of age, body mass index, parity, surgical history, procedure type, surgical approach, and surgical indication. The size of the minilaparotomy incision and the specimen weight were significantly smaller in the umbilical minilaparotomy group (mean, 3.3 ± 0.8 cm vs 4.2 ± 0.6 cm [p < .001] and 472.6 ± 357.1 g vs 683.0 ± 475.7 g [p < .001], respectively). Two women in the suprapubic minilaparotomy group sustained a bladder injury during creation of the incision. There were no other complications related to the minilaparotomy in either group. Postoperative outcomes related to the minilaparotomy incision were compiled using the medical record and a follow-up survey. Of the 374 women in this cohort, 163 responded to a detailed survey about their minilaparotomy incision (response rate, 43.5%). With regard to the minilaparotomy, 52.7% of women reported incisional symptoms; 25.9% had increased pain at the incision, 8.3% had an incisional infection, and 2.7% reported an incisional hernia. There was no significant between-group difference in incisional outcomes; however nearly 3 times as many women in the umbilical minilaparotomy group reported concerns about incisional hernia (3.1% vs 1.2%; p = .833). These findings were maintained in a multivariable logistic regression analysis. No patient or procedure characteristics were significantly associated with the development of hernia.

CONCLUSION

There were no significant difference in incisional symptoms, pain, or infection following umbilical minilaparotomy vs a suprapubic minilaparotomy for tissue extraction. Although not statistically significant, the rate of incisional hernia was higher at the umbilical site compared with the suprapubic site.

Comparison of Single-Port Versus Standard Multiport Left Lateral Liver Sectionectomy

It remains unclear if single incision laparoscopic liver surgery is superior to standard multiport resections and in what regard patients might benefit from this approach. We retrospectively analyzed the course of all patients undergoing laparoscopic left lateral sectionectomy at our center between 2009 and 2017. In total, 11 single incision and 31 multiport left lateral sectionectomies were performed at our center between July 2009 and May 2017. Six patients were excluded due to multivisceral resections. Indications included adenoma (n = 7 vs n = 2), focal nodular hyperplasia (n = 4 vs n = 3), hepatocellular carcinoma (n = 4 vs n = 4), colorectal liver metastasis (n = 4 vs n = 0), noncolorectal metastasis (n = 2 vs n = 1), hemangioma (n = 3 vs n = 0), abscess (n = 1 vs n = 0), and cysts (n = 1 vs n = 0). Length of operation was significantly shorter in the single incision group (206 vs 137 minutes, P = .003). One complication was observed in the single incision group (grade IIIb, n = 1) while 3 patients in the multiport group suffered from postoperative complications (grade II, n = 1; grade IIIa, n = 2), resulting in a morbidity rate of 12.5% and 11.5%, respectively. No mortality was observed in both groups. Length of hospital stay did not significantly differ in both groups (median 7 vs 7 days, P = .513). The single incision approach is safe and has become the standard approach for the left lateral sectionectomy at our center. Shorter operation times technique might well be due to the easy retrieval of the liver specimen via the umbilical incision with no need for a Pfannenstiel incision.

Single-port laparoscopy in gynecologic oncology: seven years of experience at a single institution

BACKGROUND

Single-port laparoscopy has gained popularity within minimally invasive gynecologic surgery for its feasibility, cosmetic outcomes, and safety. However, within gynecologic oncology, there are limited data regarding short-term adverse outcomes and long-term hernia risk in patients undergoing single-port laparoscopic surgery.

OBJECTIVE

The objective of the study was to describe short-term outcomes and hernia rates in patients after single-port laparoscopy in a gynecologic oncology practice.

STUDY DESIGN

A retrospective, single-institution study was performed for patients who underwent single-port laparoscopy from 2009 to 2015. A univariate analysis was performed with χ² tests and Student t tests; Kaplan-Meier and Cox proportional hazards determined time to hernia development.

RESULTS

A total of 898 patients underwent 908 surgeries with a median follow-up of 37.2 months. The mean age and body mass index were 55.7 years and 29.6 kg/m², respectively. The majority were white (87.9%) and American Society of Anesthesiologists class II/III (95.5%). The majority of patients underwent surgery for adnexal masses (36.9%) and endometrial hyperplasia/cancer (37.3%). Most women underwent hysterectomy (62.7%) and removal of 1 or both fallopian tubes and/or ovaries (86%). Rate of adverse outcomes within 30 days, including reoperation (0.1%), intraoperative injury (1.4%), intensive care unit admission (0.4%), venous thromboembolism (0.3%), and blood transfusion, were low (0.8%). The rate of urinary tract infection was 2.8%; higher body mass index (P = .02), longer operative time (P = .02), smoking (P = .01), hysterectomy (P = .01), and cystoscopy (P = .02) increased the risk. The rate of incisional cellulitis was 3.5%. Increased estimated blood loss (P = .03) and endometrial cancer (P = .02) were independent predictors of incisional cellulitis. The rate for surgical readmissions was 3.4%; higher estimated blood loss (P = .03), longer operative time (P = .02), chemotherapy alone (P = .03), and combined chemotherapy and radiation (P < .05) increased risk. The rate of incisional hernia rate was 5.5% (n = 50) with a mean occurrence at 570.2 ± 553.3 days. Higher American Society of Anesthesiologists class (P = .04), diabetes (P < .001), hypertension (P = .043), increasing age (P = .017; hazard ratio [HR], 1.03), and body mass index (P < .001; HR, 1.08) were independent predictors for incisional hernia development. Previous abdominal surgeries (P = .24) and hand assist (P = .64) were not associated with increased risk for incisional hernia. Patients with American Society of Anesthesiologists class III/IV had a 3 year hernia rate of 12.8% (HR, 1.81). Patients with diabetes mellitus had a 3 year hernia rate of 23.0% (HR, 3.60).

CONCLUSION

In this large cohort of patients undergoing single-port laparoscopy, the incidence of short-term adverse outcomes is low. While the rate of incisional hernia was 5.5%, incidence reached 23.0% at 3 years in high-risk groups. Previous studies with short follow-up duration may underestimate the risk of hernia, especially in patients with significant comorbidities.

Single Port and Conventional Laparoscopy in Colorectal Surgery: Comparison of Two Techniques

BACKGROUND

Single-incision laparoscopic surgery (SILS) was introduced to further the enhanced outcome of conventional multiport laparoscopy (CML). We compared their short- and long-term outcomes in colorectal surgery.

MATERIALS AND METHODS

Retrospective review of patients who underwent elective laparoscopic colorectal surgery during 3-year period. Patients' data, surgery outcomes, and oncological results were compared.

RESULTS

Sixty-one patients (33 male, 28 female), mean age 67.4 years, underwent laparoscopic colonic resections: 28 SILS and 33 CML. Twenty-three (37.7%) patients had previous abdominal surgery. There were 19 (31.2%) right, 9 (14.7%) left, and 2 (3.3%) total colectomies, 16 (26.2%) sigmoidectomies, 13 (21.3%) anterior and 2 (3.3%) abdominoperineal resections. Colonic malignancy was a main indication for the surgery in 51 (83.6%) patients. Mean surgery time and postoperative stay were 92.0 minutes and 9 days, respectively. Pathological examination revealed stage I colon cancer in 16 (32%), stage II in 22 (44%), stage III in 10 (20%), and stage IV in 2 (4%) patients. Mean number of retrieved lymph nodes was 19 ± 13.5. No differences were found between groups in demographic data, type of surgery, surgery time and hospital stay, pathological results and tumor staging, and disease-free and overall survivals. In the SILS group, placement of additional trocar was required in 7 (25%) and conversion in 3 (10.7%) cases compared with 1 (3%) case of conversion to formal laparotomy in the CML group. Overall postoperative morbidity was 16.4%. There was no mortality in both the groups. During the study period, 3 patients from the CML group had cancer recurrence.

CONCLUSIONS

SILS is a feasible and safe technique compared with CML in terms of surgical and oncological outcomes.

Postoperative Outcomes after Single-port Laparoscopic Removal of Adnexal Masses in Patients Referred to Gynecologic Oncology at a Large Academic Center

STUDY OBJECTIVE

To report surgical and pathologic outcomes after single-port laparoscopy (SPL) for adnexal masses in patients referred to a gynecologic oncology practice at a single academic institution.

DESIGN

A retrospective analysis (Canadian Task Force Classification II.2).

SETTING

A single academic institution with multiple hospital centers.

PATIENTS

Women who underwent at least 1 single-port laparoscopic surgery for the treatment of an adnexal mass from 2009 to 2015 after referral to a gynecologic oncology practice.

INTERVENTION

Data were collected on the surgical procedure, patient demographic variables, 30-day surgical outcomes, and hernia development.

MEASUREMENTS AND MAIN RESULTS

Three hundred twenty-five surgeries were performed in 322 patients with a median follow-up of 42.7 months. The median age was 54.5 years, and the median body mass index was 28.1 kg/m². All patients underwent unilateral or bilateral salpingectomy or oophorectomy with or without hysterectomy (26.5%). The median operative time was 90.0 minutes. The median mass dimension was 6.4 cm with 17.9% (n = 60) greater than 10 cm. Masses were categorized as simple (11.4%) and complex (69.5%). Although the majority (87.4%) of masses were benign, 7.4% were malignant, and 5.2% were borderline. Benign masses were physiologic (16.6%), serous cystadenomas (19.1%), mucinous cystadenomas (6.8%), endometriomas (12.3%), myomas (12.3%), and mature teratomas (9.2%). In malignant cases (7.4%), serous carcinoma was the most frequent histology (58.3%). The rate of adverse outcomes within 30 days, including reoperation (0.0%), intraoperative injury (1.5%), venous thromboembolism (0.3%), and transfusion (0.6%), was low. The development of incisional cellulitis was 4.6%. The rate of incisional hernia was 4.0%, with a median occurrence of 18.3 months. Diabetes mellitus (p = .03) and obesity (p = .04) were significant predictors for a hernia, but mass complexity (p = .28), American Society of Anesthesiologists class (p = .83), and smoking (p = .82) were not.

CONCLUSION

In patients undergoing SPL for the removal of adnexal masses in a gynecologic oncology practice, the rate of benign disease is high. SPL removal of adnexal masses is feasible and safe with favorable surgical outcomes, rare short-term adverse outcomes, and a low incisional hernia rate.

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.

Effectiveness and safety of single-port versus multi-port laparoscopic surgery for treating liver diseases: a meta-analysis

OBJECTIVE

To compare the effectiveness and safety of single-port versus multi-port laparoscopic surgery for treating liver diseases.

METHODS

Several databases were systematically searched for randomized controlled trials, cohort studies, and case-control studies on the use of single-port versus multi-port laparoscopic surgery to treat liver diseases from their inception until March 24, 2016. The primary outcomes were the operative time, volume of intraoperative blood loss, rate of postoperative complications, median length of postoperative stay, recovery time of gastrointestinal function, volume of postoperative drainage, and postoperative drainage time. The study-specific effect sizes and their 95 % confidence interval were all combined to calculate the pooled value by using a random-effects model.

RESULTS

A total of nine studies were included, which involved 277 patients. The total and subgroup data were combined by meta-analysis. This meta-analysis showed that single-port and multi-port laparoscopic liver surgery for treating liver diseases did not differ in terms of operative time (P = 0.48), rate of postoperative complications (P = 0.56), median length of postoperative stay (P = 0.80), and recovery time of gastrointestinal function (P = 0.54). For liver diseases, the single-port group exhibited a lower volume of intraoperative blood loss than that presented by the multi-port group (P = 0.0006). In the hepatic resection subgroup, a lower volume of intraoperative blood loss was noted in the single-port group (P < 0.0001). By contrast, in the hepatic cyst subgroup, the single-port group showed a higher volume of intraoperative blood loss (P = 0.02) but a shorter median length of postoperative stay (P = 0.02). The findings of the potential subgroup analysis in these outcomes were consistent with the total data.

CONCLUSION

Compared with multi-port laparoscopic surgery, the single-port method showed comparable effectiveness and safety for the treatment of liver diseases in terms of current evidence.