Aesthetic benefit of single-port laparoscopic ileo-caecal resection for Crohn's disease: a comparative study

BACKGROUND

Single-port laparoscopy has been mainly studied for colonic cancer or cholecystectomy. Little is known about the cosmetic outcome for patients with Crohn's disease who are the best candidates for single-port surgery. This study aimed to assess cosmetic outcomes with single-port laparoscopy (SPL) vs. multiport laparoscopy (MPL) after ileocolic resection for Crohn's disease.

METHODS

This was a retrospective case-control study of a consecutive monocentric cohort. The study was conducted at a tertiary colorectal surgery referral centre. All consecutive patients who underwent an ileocolic resection by laparoscopy between 2012 and 2020 were included. The main outcomes measures, body image and cosmesis after surgery, were evaluated with a validated questionnaire. Secondary endpoints were conversion, morbidity, length of hospital stay and incisional hernia.

RESULTS

Two hundred and six patients were included (SPL, n = 65, 32%). Most patients were operated on for stricturing disease (64%). Conversion rate to laparotomy was 0% in the SPL group and 17.7% in the MPL group (p < 0.001). The complication rate was similar in both groups (SPL, 29.2%; MPL, 38.3%; p = 0.21) as was length of stay (5 days [4-7] in both groups). In total 124 (71%) responded to the questionnaire (MPL, n = 74, 67%; SPL, n = 50, 78%; p = 0.11). The SPL group scored better on the cosmesis scale (21.1 vs. 18.4, p < 0.001). In the SPL group, body image scale scores were better for patients with an intraumbilical incision (intraumbilical 5.2 (± 0.6) vs. periumbilical 6.4 (± 2), p = 0.04). After matching, body image scale scores were similar in both groups (SPL, 6; MPL, 6.4; p = 0.24), but cosmesis scale scores remained better in the SPL group (21.1 vs. 19.3, p = 0.03).

CONCLUSION

Ileocolic resection for Crohn's disease with single-port laparoscopy has better cosmetic outcomes than with the multiport approach. Postoperative complications and long-term incisional hernia rate are similar. Routine use of an intraumbilical incision could improve cosmetics.

Suprapubic Cholecystectomy Improves Cosmetic Outcome Compared to Classic Cholecystectomy

Currently, cholecystectomy is performed laparoscopically. While the conventional approach (CA) with four access ports persists, other methods seek to reduce trauma or to optimize cosmetic results. In this study, the safety and cosmetic outcome of a suprapubic approach (SA) were evaluated. Between 2015 and 2016, patients undergoing elective cholecystectomy either by CA or by a suprapubic approach (SA) at our institution were included. The cosmetic outcome, postoperative morbidity, operative time and length of stay were evaluated. Pictures of the site of intervention were taken 6−12 months postoperatively and rated on a scale from 1 (unsatisfying aesthetic result) to 5 (excellent aesthetic result). Five “non-medical” and five “medical” raters as well as one board-certified plastic surgeon performed the ratings. A total of 70 patients were included (n = 28 SA, n = 42 CA). The two groups did not differ in baseline characteristics (age, gender, BMI). The SA group showed a significantly better aesthetic outcome compared to the CA group 4.8 (4.8−4.9) vs. 4.2 (3.8−4.4), (p > 0.001). Medical raters: 4.0 (3.8−4.2) vs. 4.8 (4.6−5.0), (p < 0.001); non-medical raters: 4.2 (3.8−4.6) vs. 5.0 (4.8−5.0), (p < 0.001); plastic surgeon: 4.0 (4.0−4.0) vs. 5.0 (5.0−5.0), (p < 0.001). Fair interrater consistency was demonstrated with an ICC of 0.47 (95% CI = 0.38−0.57). No significant difference in the complication rate (1 (3.5%) in SA vs. 6 (14%) in CA, (p = 0.3)), or the operating time 66 (50−86) vs. 70 (65−82) min, (p = 0.3), were observed. Patients stayed for a median of three (3−3) days in the SA group and 3 (3−4) days in the CA group (p = 0.08). This study demonstrated that the suprapubic approach is an appropriate alternative to conventional laparoscopic cholecystectomy, presenting a better cosmetic outcome with a similar complication rate.

Can Upstream Patient Education Improve Fracture Care in a Digital World? Use of a Decision Aid for the Treatment of Displaced Diaphyseal Clavicle Fractures

BACKGROUND

The increasing proportion of telemedicine and virtual care in orthopaedic surgery presents an opportunity for upstream delivery of patient facing tools, such as decision aids. Displaced diaphyseal clavicle fractures (DDCFs) are ideal for a targeted intervention because there is no superior treatment, and decisions are often dependent on patient's preference. A decision aid provided before consultation may educate a patient and minimize decisional conflict similarly to inperson consultation with an orthopaedic traumatologist.

METHODS

Patients with DDCF were enrolled into 2 groups. The usual care group participated in a discussion with a trauma fellowship-trained orthopaedic surgeon. Patients in the intervention group were administered a DDCF decision aid designed with the International Patient Decision Aid Standards. Primary comparisons were made based on a decisional conflict score. Secondary outcomes included treatment choice, pain score, QuickDASH, and opinion toward cosmetic appearance.

RESULTS

A total of 41 patients were enrolled. Decisional conflict scores were similar and low between the 2 groups: 11.8 (usual care) and 11.4 (decision aid). There were no differences in secondary outcomes between usual care and the decision aid.

DISCUSSION

Our decision aid for the management of DDCF produces a similarly low decisional conflict score to consultation with an orthopaedic trauma surgeon. This decision aid could be a useful resource for surgeons who infrequently treat this injury or whose practices are shifting toward telemedicine visits. Providing a decision aid before consultation may help incorporate patient's values and preferences into the decision-making process between surgery and nonoperative management.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.