Sealed Orifice Laparoscopic or Endoscopic (SOLE) Surgery: technology and technique convergence for next-step colorectal surgery

Clinical outcomes of laparoscopic-assisted synchronous bowel anastomoses for synchronous colorectal cancer: initial clinical experience

The primary aim of this study was to explore the safety and feasibility of laparoscopic-assisted synchronous bowel anastomoses (LSBA) for synchronous colorectal cancer (SCRC). All patients who underwent LSBA for SCRC were retrospectively reviewed and analyzed for clinical and pathological features, technical feasibility and short-term as well as long-term oncological outcomes. Between July 2008 and January 2012, a series of 11 consecutive SCRC patients underwent LSBA. Six patients underwent laparoscopic-assisted right hemicolectomy and anterior resection. Five patients had laparoscopic-assisted right hemicolectomy and sigmoidectomy. There were no intraoperative complications that required open conversions. Mean operation time was 233 (range, 195–285) minutes, and mean estimated blood loss was 224 (range, 100–300) mL. The postoperative course of the patients was uneventful with the mean return to oral intake was 6.9 (range 5–12) days, and mean length of hospital stay was 12.6 (range 9–17) days. All surgical wounds showed good cosmetic outcome, and the mean incision length was 4.1 (range 3.5-5.0) cm. During a median follow-up period of 76 months, no local tumor recurrences were found. LSBA is a potentially feasible and safe procedure for SCRC when performed by an experienced surgeon. Further large clinical controlled trials are warranted to confirm the findings.

Transanal minimally invasive surgery (TAMIS) with a GelPOINT® Path for lower rectal cancer as an alternative to transanal endoscopic microsurgery (TEM)

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique. However, TEM has not yet achieved widespread use. Recently, transanal minimally invasive surgery (TAMIS) using single-port surgery devices has been reported. In the present study, TAMIS using a GelPOINT^® Path was performed in six patients with lower rectal cancer. A complete full-thickness excision was performed in all cases. The patient characteristics, operative techniques and operative outcomes were evaluated. The mean age of the patients was 63.0 years (range: 48-76). The mean operating time and blood loss were 86 min (range: 55-110) and 5 ml (range 0-10), respectively. There were no instances of morbidity or mortality. Additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. The mean Wexner score was 0.6 (range: 0-3; n=5) at 6 months, and 0 (range: 0; n=4) at 12 months. TAMIS using a GelPOINT^® Path was revealed to be easy and safe to perform. Although only a small number of cases were treated, the anal function following surgery was shown to be favorable, and the operation was demonstrated to be sufficiently feasible. Based on these results, TAMIS may, in time, assume a major role in the resection of large adenomas and early rectal cancers.

Single port laparoscopic surgery for patients with complex and recurrent Crohn's disease

BACKGROUND

Single port laparoscopic surgery (SPLS) is a modified access technique allowing grouping of instruments at a single parietal site. It is intuitively appealing specifically for patients with Crohn's disease (CD) as its minimal invasiveness favors cosmesis and facilitates any future (re)operation.

METHODS

Consecutive patients presenting either electively or urgently for resectional surgery for CD over a 36 month period were considered for SPLS using, by preference, a transumbilical 'Surgical Glove Port'. Standard, straight laparoscopic instrumentation was used without additional resources.

RESULTS

Of 33 consecutive, unselected patients, 28 (92%) had their procedure initiated by SPLS including those needing urgent intervention (n=15) and those with prior abdominal operation (n=8), obstruction (n=7), mass (n=6), fistula (n=6) and/or abscess (n=4). The median (range) age and BMI of the patients were 31 (17-69) years and 21.3 (18.6-28) kg/m2 respectively. 31 had ileocolonic resection (6 with recurrent disease) while two underwent segmental colectomy. No-one suffered intraoperative or anastomotic complication. Both conversion (15%) and postoperative complication (13 Clavian-Dindo complications - I: 8; II: 2; IIIa: 3) rates were predominantly reflective of patient and disease complexity. Median (range) postoperative day of discharge was 6 (3-33) overall and 5 (3-18) in those completed by SPLS. There was one early readmission (for infectiouscolitis) and median follow-up is now 21 months.

CONCLUSIONS

Complex and recurrent Crohn's resections can be performed by SPLS in the majority of patients presenting elective or urgently for surgery. The Surgical Glove Port performs capably and, by minimizing cost, can facilitate broad embrace of this approach.

Single-incision laparoscopic ileorectal anastomosis

AIM

Minimally invasive approaches for stoma closure offer considerable benefits for patients. Single port access via an end ileostomy site after stoma take-down in patients with prior total colectomy and a rectal stump remnant could allow restoration of ileorectal continuity by anastomosis but has not been detailed previously.

METHODS

After mobilisation of the end ileostomy, the anvil of a circular stapler is secured into the open end of the distal ileum and the intestine returned into the abdominal cavity. A single port access device (in this description, a 'surgical glove port') is placed then into the stoma site and full laparoscopy performed. Once the rectal stump is identified and prepared, an intracorporeal anastomosis can be constructed in a tension-free manner using a Knight-Griffin technique. Leak-testing can also be performed and the operation concluded with closure of the solitary incision.

RESULTS

In selected cases, adhesiolysis and anastomosis can be safely performed in toto. If the peritoneal environment is challenging, access can be escalated to multiport laparoscopy or even laparotomy.

CONCLUSION

Initiation of ileorectal anastomosis construction by single port laparoscopy at least allows peritoneal assessment but can provide for the operation's completion. This can confer maximum patient benefit for the most minimally invasive option.

Advanced laparoscopic surgery for colorectal disease: NOTES/NOSE or single port?

Laparoscopic surgery for colorectal disease is an evolving, dynamic subject undergoing constant adaptation. Hence there are significant ongoing advances in technique and technology as has been seen with the emergence of single port and Natural Orifice Transluminal Endoscopic operations with already considerable ramifications for many aspects of minimal access surgery. Most recently single port technologies and expertise have synergized with Transanal Endoscopic (TEM/TEO) experience to allow their convergence out of their respective niches so that pelvic surgery can be laparoendoscopically performed from both its abdominal and perineal aspects. Distinct from wound-related benefits, such capacity for high resolution and multi-dimensional imaging relates significant benefit to the operating team and patient. This state of the art review demonstrates the crucial perspective that advanced practices and performance capabilities are intrinsically complimentary rather than competitive. All surgeons need therefore to participate in adapting their practice styles to allow technical step-advance across the discipline.

Transanal glove port is a safe and cost-effective alternative for transanal endoscopic microsurgery

BACKGROUND

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of rectal tumours that avoids conventional pelvic resectional surgery along with its risks and side-effects. Although appealing, the associated cost and complex learning curve limit TEM utilization by colorectal surgeons. Single-port laparoscopic principles are being recognized as transferable to transanal work and hybrid techniques are in evolution. Here the clinical application of a new technique for transanal access is reported.

METHODS

Consecutive non-selected patients eligible for TEM over a 3-month period (and selected patients thereafter) were offered a procedure performed via a 'glove TEM port'. This access device was constructed on-table using a circular anal dilator (CAD), wound retractor and standard surgical glove, along with standard, straight laparoscopic trocar sleeves and instruments.

RESULTS

Fourteen patients underwent full-thickness resection of benign (8) or malignant (6) rectal pathology. CAD insertion failed in one patient and conventional TEM assistance was needed in another, leaving 12 procedures completed successfully by glove TEM alone as planned (completion rate 86 per cent overall, 92 per cent after initiation). The median (range) duration of operation and resected specimen area were 93 (30-120) min and 12 (3-152) cm(2) respectively. There was no intraoperative and minimal postoperative morbidity, with a median follow-up of 5.7 (2.7-9.4) months.

CONCLUSION

The glove TEM port is a safe, inexpensive and readily available access tool that may obviate the use of specialized equipment for transanal resection of rectal lesions.

Implementation and usefulness of single-access laparoscopic segmental and total colectomy

AIM

Single-access laparoscopic surgery is a recent vogue in the field of minimally invasive colorectal surgery. While selected series have indicated feasibility, we prospectively examined its usefulness for resectional surgery in routine practice.

METHOD

All patients undergoing laparoscopic colorectal resection over a 12-month period were considered for a single-access approach by a single surgical team in a university hospital. This utilized a 'glove' port via a 3-5 cm periumbilical or stomal site incision, with standard rigid laparoscopic instruments then being used.

RESULTS

Of 76 planned laparoscopic colorectal resections, 35 (47%) were performed by this single-incision laparoscopic modality without disruption of theatre list efficiency or surgical training obligations. The mean (range) age and body mass index of these 25 consecutive right-sided resections, eight total colectomies (seven urgent operations) and two anterior resections was 58 (22-82) years and 23.9 (18.6-36.2) kg/m(2) , respectively. The modal postoperative day of discharge was 4. For right-sided resections, the mean (range) postoperative stay in those undergoing surgery for benign disease was 4.0 days, while for those undergoing operation for neoplasia (n=18, mean age 71 years) it was 5.8 days and the average lymph node harvest was 13. Use of the glove port reduced trocar cost by 58% (€60/£53) by allowing the use of trocar sleeves alone without obturators.

CONCLUSION

Single-incision laparoscopic surgery is an effective option for abdominal surgery and seems especially suited for laparoscopic-assisted right-sided colonic resections. The glove port technique facilitates procedural frequency and familiarity and proves economically favourable.

Transanal endoscopic video-assisted (TEVA) excision

BACKGROUND

Transanal endoscopic video-assisted (TEVA) excision represents an alternative approach for the surgical treatment of middle and upper rectal lesions not amenable to colonoscopic removal. Utilizing principles of single-incision laparoscopic surgery, this novel minimally invasive approach optimizes access for safe and complete removal of these lesions without the need for a formal rectal resection. We describe our technique and early outcomes with TEVA excision.

METHODS

Between March 2010 and September 2011, TEVA excision was performed for patients presenting for management of rectal lesions not amenable to colonoscopic or standard transanal removal. Patients were selected if they presented with benign disease or superficial adenocarcinoma, and the proximal extent of the lesion extended beyond 8 cm from the anal verge. Demographic, intraoperative, and postoperative data were assessed. A SILS™ port was placed in the anal canal for access in all cases. Standard laparoscopic instruments were utilized for visualization, full-thickness transanal excision, and primary closure.

RESULTS

Twenty patients (50% male) with a mean age of 64.6 ± 10.9 years, mean body mass index of 28.2 ± 4.9 kg/m(2), and median American Society of Anesthesiologist score of 2 underwent TEVA excision. Fourteen patients (70%) presented with benign disease and six patients (30%) presented with malignant disease. The mean size of the lesions was 3.0 ± 1.4 cm, and the mean distance from the anal verge was 10.6 ± 2.4 cm. All excisions were successfully completed with a mean operative time of 79.8 ± 25.1 (range, 45-135) min. The mean length of hospital stay was 1.1 ± 0.7 (range, 0-3) days.

CONCLUSIONS

TEVA excision is a safe and feasible approach for local excision of rectal lesions not otherwise amenable to standard techniques. Continued investigation and development will be important to establish its role in minimally invasive colorectal surgery.