Augmenting Veterinary Minimally Invasive Surgery: Evidence-based Review of Foundational and Novel Devices and Technology

Veterinary minimally invasive surgery continues to grow as a specialty. With increasing experience in this field, comes improved accessibility as well as progressive complexity of procedures performed. Advancement in technology has been both a response to the growth and a necessary driver of continued refinement of this field. Innovative research leading to advancements in surgical equipment has led to the development of novel image acquisition platforms, cannulas, smoke evacuation systems, antifog devices, instrumentation, and ligating/hemostatic devices. These innovations will be reviewed and potential clinical applications are discussed.

Single-incision laparoscopic transabdominal preperitoneal repair in the treatment of adult female patients with inguinal hernia

BACKGROUND

Women have a 3% lifetime chance of developing an inguinal hernia, which is not as common in men. Due to its cosmetic benefits, single-incision laparoscopic transabdominal preperitoneal (SIL-TAPP) inguinal hernia repair is becoming increasingly popular in the management of inguinal hernia in women. However, there are no studies comparing the safety and applicability of SIL-TAPP repair with conventional laparoscopic transabdominal preperitoneal (CL-TAPP) inguinal hernia repair for the treatment of inguinal hernia in women.

AIM

To compare the outcomes of SIL-TAPP and CL-TAPP repair in adult female patients with inguinal hernia and to estimate the safety and applicability of SIL-TAPP repair in adult female inguinal hernia patients.

METHODS

We retrospectively compared the clinical information and follow-up data of female inguinal hernia patients who underwent SIL-TAPP inguinal hernia repair and those who underwent CL-TAPP inguinal hernia repair at the Affiliated Hospital of Nantong University from February 2018 to December 2020 and assessed the long-term and short-term outcomes of both cohorts.

RESULTS

This study included 123 patients, with 71 undergoing SIL-TAPP repair and 52 undergoing CL-TAPP repair. The two cohorts of patients and inguinal hernia characteristics were similar, with no statistically meaningful difference. The rate of intraoperative inferior epigastric vessel injury was lower in patients in the SIL-TAPP cohort (0, 0%) than in patients in the CL-TAPP cohort (4, 7.7%) and was significantly different (P < 0.05). In addition, the median [interquartile range (IQR)] total hospitalization costs were significantly lower in patients in the SIL-TAPP cohort [$3287 (3218-3325)] than in patients in the CL-TAPP cohort [$3511 (3491-3599)]. Postoperatively, the occurrence rate of trocar site hernia was lower in the SIL-TAPP cohort (0, 0%) than in the CL-TAPP cohort (4, 7.7%), and the median (IQR) cosmetic score was significantly higher in the SIL-TAPP cohort [10 (10-10)] than in the CL-TAPP cohort [9 (9-10)].

CONCLUSION

SIL-TAPP repair did not increase the incidence of intraoperative and postoperative complications in female inguinal hernia patients. Moreover, female inguinal hernia patients who underwent SIL-TAPP repair had a lower probability of trocar site hernia and inferior epigastric vessel injury than female inguinal hernia patients who underwent CL-TAPP repair. In addition, female inguinal hernia patients who underwent SIL-TAPP repair reported a more aesthetically pleasing postoperative abdominal incision. Therefore, SIL-TAPP repair is a better option for the treatment of inguinal hernias in women.

Meta‑analysis of single-incision laparoscopic versus multi-trocar laparoscopic totally extraperitoneal inguinal hernia repair

Whether single-incision laparoscopic totally extraperitoneal (SIL-TEP) inguinal hernia repair is similar or superior to multi-trocar laparoscopic totally extraperitoneal (MTL-TEP) inguinal hernia repair is controversial. We conducted this meta-analysis to compare the safety, efficacy and cosmetic effect of the two surgical methods. We systematically searched the Cochrane Library, Embase database and PubMed database for published studies on SIL-TEP and MTL-TEP inguinal hernia repair. The studies were screened and evaluated for quality according to the inclusion and exclusion criteria, and RevMan 5.3 software was used for meta-analysis. Twenty studies were included, including 7 randomized controlled studies and 13 nonrandomized controlled studies. Meta-analysis revealed no significant difference between SIL-TEP and MTL-TEP inguinal hernia repair in terms of unilateral operation time (P = 0.12), bilateral operation time (P = 0.72), pain score on the first day after operation (P = 0.61], chronic pain rate (P = 0.61), total complication rate (P = 0.26), hospital stay (P = 0.72), and recurrence rate (P = 0.83), but the cosmetic effect score (P = 0.002) was higher in the former. These findings demonstrate that SIL-TEP inguinal hernia repair is safe, reliable and feasible. In addition, it can result in a better cosmetic effect of the incision than MTL-TEP inguinal hernia repair. SIL-TEP inguinal hernia repair should be considered for patients with stricter cosmetic requirements.Clinical trial registration: INPLASY2022110085.

Single-incision robotic colorectal surgery with the da Vinci SP® surgical system: initial results of 50 cases

PURPOSE

The da Vinci SP® (dVSP) surgical system (Intuitive Surgical, Sunnyvale, CA, USA), a robotic platform designed for single-incision surgery, overcame the need for multiple ports in traditional robotic surgery and issues including triangulation and retraction in single-incision laparoscopic surgery. However, previous studies only included case reports or series with small sample sizes. The aim of this study was to assess the safety and performance of the dVSP surgical system and its instruments and accessories for colorectal procedures.

METHODS

The medical records of patients who had surgery with the dVSP from March 2019 to September 2021 at Ewha Womans University Seoul Hospital were investigated. The pathologic and follow-up data of patients who had malignant tumors were analyzed separately to evaluate oncological safety.

RESULTS

Fifty patients (26 male and 24 female) with a median age of 59 years (interquartile range 52.5-63.0 years) were enrolled. The procedures included low anterior resection with total mesorectal excision (n = 16), sigmoid colectomy with complete mesocolic excision and central vessel ligation (CME + CVL) (n = 14), right colectomy with CME + CVL (n = 9), left colectomy with CME + CVL (n = 4), right colectomy (n = 6), and sigmoid colectomy (n = 1). Operative time significantly decreased after 25 cases (early phase vs. late phase; operative time 295.0 min vs. 250.0 min, p = 0.015; docking time 16.0 min vs. 12.0 min, p = 0.001; console time 212.0 min vs. 190.0 min, p = 0.019). Planned procedures were successfully completed in all patients. Postoperative outcomes were acceptable with only six cases of mild adverse events through a 3-month follow-up. No local recurrence and only one case of systemic recurrence occurred within 1 year postoperatively.

CONCLUSIONS

This study demonstrated the surgical and oncological safety and feasibility of dVSP, which may be a novel surgical platform for colorectal surgery.

Conventional three-port laparoscopic appendectomy versus transumbilical and suprapubic single-incision laparoscopic appendectomy using only conventional laparoscopic instruments

PURPOSE

Single-incision laparoscopic appendectomy (SILA) is usually performed using single-port instruments, which may restrict its development and application. This study explored the performance of transumbilical SILA (TSILA) and suprapubic SILA (SSILA) using only conventional laparoscopic instruments and compared them with conventional three-hole/port laparoscopic appendectomy (CLA).

METHODS

This retrospective study included 174 patients who underwent CLA, TSILA, or SSILA for acute appendicitis at our hospital between June 2019 and July 2021. Demographic data and clinical outcomes were compared among the three groups.

RESULTS

Compared with CLA, TSILA was associated with significant reductions in postoperative pain, length of hospital stay, and hospital cost, while SSILA was associated with significant reductions in length of hospital stay and hospital cost (all P < 0.05). Significantly more patients in the two SILA groups were cosmetically satisfied than those in the CLA group (all P < 0.05). However, compared with CLA, SSILA required a significantly longer operative time (65.3 ± 24.1 vs 56.5 ± 20.9, P = 0.039). Besides, compared with TSILA, SSILA showed significantly higher postoperative pain score (2 ± 2 vs 3 ± 2, P = 0.006). Mild incisional or intraabdominal infections were noticed in 2 (3.0%) patients in the CLA group, 3 (5.1%) in the TSILA group, and 3 (6.3%) in the SSILA group (P = 0.69).

CONCLUSION

SILA performed with only conventional laparoscopic instruments was associated with reduced hospital stay and cost and higher cosmetic satisfaction in comparison to CLA. However, it is technically demanding and may increase operative time.

Single-incision for breast-conserving surgery through round block technique

AIMS AND OBJECTIVES

The purpose of this study was to assess the feasibility of using the single-incision round block technique in breast-conserving surgery with sentinel lymph node (SLN) retrieval for breast cancer without compromising oncological safety.

MATERIALS AND METHODS

A retrospective observational case-control study was conducted from January 2017 to October 2021. The study population consisted of two groups. In both groups, breast-conserving surgery was carried out through the round-block technique. In group A, SLN retrieval was performed using the round-block incision (study group), while in group B, SLN retrieval was conducted through a second skin incision in the axilla (control group). The study was approved by the local ethics committee Zurich (BASEC-Nr. 2020-02857), and written informed consent was obtained from all participants.

RESULTS

Overall, 134 patients met the inclusion criteria, of whom 86 women underwent breast-conserving surgery and SLN retrieval using the single-incision approach (group A), and 48 women underwent conventional surgery, using two independent incisions for tumour resection and SLN retrieval (group B). The overall success rate in group A regarding SLN retrieval was 97.7%, whereas most tumours were located in the upper outer (47.7%) and upper inner quadrant (27.9%). Although the technique was equally successful in the other quadrants, the share of tumours in the lower outer, and the lower inner quadrant, and the retroareolar region was smaller, representing 17.4%, 3.5% and 3.5%, respectively. The median number of dissected lymph nodes was two, with a positivity rate of 24.4%. The occurrence of axillary neuralgia and axillary skin retraction was significantly higher in group B along with tendentially more axillary seroma formation. There were no significant differences regarding reintervention rates, in terms of complications, resection margins, locoregional recurrences, or deaths with a mean follow-up of 11 months.

CONCLUSIONS

The single-incision method through the round block technique is as safe and effective as the standard two-incision approach regarding nodal staging and resection margins, and seems to be applicable for tumours in all breast quadrants.

Comparison of adjustable and nonadjustable single-incision mini-slings in the treatment of female stress urinary incontinence: An initial experience with 30 cases

OBJECTIVE

Several single-incision mini-slings (SIMSs) have been developed to minimize the potential complications associated with retropubic or transobturator mid-urethral slings. However, few studies compared the efficacy of different types of SIMS. This study compared the outcomes of an adjustable SIMS (Ajust) with a nonadjustable SIMS (Solyx) in the treatment of urodynamic stress incontinence (USI) over postoperative follow-up of 12 months.

MATERIALS AND METHODS

In this study, the surgical outcomes of the first 30 patients receiving Ajust and the first 30 patients undergoing Solyx at a university hospital were reviewed retrospectively, all of whom were diagnosed with USI without coexistent pelvic organ prolapse. Preoperative and postoperative examinations included structured urogynecological questionnaires, 1-hour pad tests, and complete urodynamic testing. Patient demographics, urodynamic parameters, and 12-months surgical outcomes were compared between the Ajust and Solyx groups.

RESULTS

There were no significant differences between the Ajust and Solyx groups in terms of subjective cure rate (93.3% vs 90.0%), objective cure rate (89.3% vs 89.3%), and de novo urgency or urge urinary incontinence (13.3% vs 16.7%) 12 months after surgery. Postoperatively, both Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7 scores were significantly improved in the Ajust and Solyx groups. In comparison with preoperative data, postoperative urodynamic results revealed a significant decrease in maximal urethral closure pressure in the Ajust group (n = 28) and a significant increase in residual urine in the Solyx group (n = 28). However, significant differences were not observed in the postoperative pad test and urodynamic data between the Ajust and Solyx groups, and no major complications occurred in either group.

CONCLUSIONS

In this paper describing the preliminary experience of 30 patients, both adjustable and nonadjustable SIMS performed by an experienced surgeon were safe and effective in correcting USI at 12-month postoperative follow-up.

Oncologic outcomes of single-incision laparoscopic surgery versus conventional laparoscopic surgery for colorectal cancer (CSILS): study protocol for a multicentre, prospective, open-label, noninferiority, randomized controlled trial

Background

In most previous studies, single-incision laparoscopic surgery (SILS) for colorectal cancer (CRC) was feasible and safe in the short term. However, long-term oncologic outcomes remain uncertain, as only a few studies contained long-term survival data. SILS for CRC is still in the early stages of research. Further studies, particularly large-scale, prospective randomized controlled trials, are necessary to assess the value of SILS for CRC.

Methods

This study is a prospective, multicentre, open-label, noninferiority, parallel-group randomized controlled trial that investigates the long-term oncologic outcomes of SILS compared to conventional laparoscopic surgery (CLS) for CRC. A total of 710 eligible patients will be randomly assigned to the SILS group or the CLS group at a 1:1 ratio using a central, dynamic, and stratified block randomization method. Patients with ages ranging from 18 to 85 years old, of both sexes, with CRC above the peritoneal reflection diagnosed as cT1-4aN0-2M0 and a tumour size no larger than 5 cm will be considered for the study. The primary endpoint is 3-year disease-free survival (DFS). The secondary endpoints include: intraoperative outcomes, postoperative recovery, postoperative pain assessment, pathological outcomes, early morbidity and mortality rate, cosmetic effects, quality of life, 3-year overall survival (OS), incidence of incisional hernia, 5-year DFS and 5-year OS. The first two follow-up visits will be scheduled at one month and three months postoperatively, then every three months for the first two years and every six months for the next three years.

Discussion

Currently, no randomized controlled trials (RCTs) have been designed to investigate the long-term oncologic outcomes of SILS for CRC. This study is expected to provide clinical evidence of the oncologic outcomes of SILS compared to CLS for CRC to promote its widespread use.

Trial registration

ClinicalTrials.gov: NCT 04527861 (registered on August 27, 2020).

Single-incision port robot-assisted surgery for thymic carcinoid tumor resection

BACKGROUND

Multiple endocrine neoplasia (MEN) is divided into MEN type 1 (MEN-1) and MEN type 2 (MEN-2). MEN-1 may be associated with thymic carcinoid tumors. We present a case of the surgical removal of a thymic carcinoid associated with MEN-1 via a single-incision port RATS.

CASE PRESENTATION

A 39-year-old male patient with multiple endocrine neoplasia type 1 (MEN-1) who had an anterior mediastinal mass was referred to our hospital. The patient had undergone total parathyroidectomy and auto-transplantation of a partial parathyroid for hyperparathyroidism 6 years ago. Chest computed tomography revealed an isolated anterior mediastinal mass on the thymic gland with a maximum diameter measuring 22 mm. Thymic carcinoid tumor is classified as MEN-1 and has a poor prognosis, so we decided to remove the tumor. Single-incision port RATS was performed, and thymic carcinoid was confirmed in pathology.

CONCLUSIONS

This report demonstrates that thymic carcinoid tumor removal is feasible and easy to perform via single-incision port RATS.

Completion of single-incision laparoscopic cholecystectomy using the modified Konyang standard method

BACKGROUND

To date, a surgical method for single-incision laparoscopic cholecystectomy (SILC) has not been standardized. Therefore, this study aimed to introduce a standardized surgical method for SILC, in addition to reporting our experience over 10 years.

METHODS

Patients who underwent SILC at a single institution between April 2010 and December 2019 were included in this study. We analyzed the patient demographics and surgical outcomes according to the surgical method used: phase 1 (Konyang standard method, KSM) comprising initial 3-channel SILC, phase 2 (modified KSM, mKSM) comprising 4-channel SILC with a snake retractor, and phase 3 (commercial mKSM, C-mKSM) using a commercial 4-channel port.

RESULTS

Of 1372 patients (mean age, 51.3 years; 781 [56.9%] women), 418 (30.5%) surgeries were performed for acute cholecystitis (AC), 33 (2.4%) were converted to multiport or open cholecystectomy, and 49 (3.6%) developed postoperative complications. The mean operation time (OT) and length of postoperative hospital stay (LOS) were 51.9 min and 2.6 days, respectively. Overall, 325 patients underwent SILC with the KSM, 660 with the mKSM, and 387 with the C-mKSM. In the C-mKSM group, the number of patients with AC was the lowest (26.8% vs. 38.2% vs. 20.4%, p < 0.001) and the OT (51.7 min vs. 55.4 min vs. 46.1 min, p < 0.001), estimated blood loss (24.5 mL vs. 15.5 mL vs. 6.1 mL, p < 0.001), and LOS (2.8 days vs. 2.5 days vs. 2.3 days, p = 0.001) were significantly improved. The surgical outcomes were better in the non-AC group than in the AC group.

CONCLUSION

Based on our 10 year experience, C-mKSM is a safe and feasible method of SILC in selected patients, although there were lower percentage of patients with AC compared to other groups.

Gasless single-port laparoscopic cholecystectomy

PURPOSE

Single-port laparoscopic surgery is anticipated to become the future of minimally invasive surgery. We have devised an alternative approach for laparoscopic cholecystectomy by inserting a single port at the umbilicus and using the abdominal wall-lifting method, without establishing pneumoperitoneum.

METHODS

Retrospective analysis of 130 patients undergoing laparoscopic cholecystectomy was done to compare the conventional laparoscopic cholecystectomy (CLC) (n = 69) and the novel single-port laparoscopic cholecystectomy (SLC) using the abdominal wall-lifting method (n = 61). The surgical procedures were as follows. A 2- to 3-cm transumbilical incision was made, and a wound retractor was inserted into the abdomen without difficulty. Abdominal distension was obtained using a fan-shaped retractor without the use of carbon dioxide insufflations. A 5-mm flexible scope and modified curved graspers and dissectors were used to give the feeling of triangulation during dissection.

RESULTS

The SLC group consisted of 25 males and 36 females with a mean age of 58.1 ± 7.2 years and a mean body mass index of 23.1 ± 3.2 kg/m². The two groups were comparable for mean age, sex, disease, American Society of Anesthesiologists physical status classification, and comorbidity. Likewise, the duration of operation, postoperative hospital stays, complications, the number of use of analgesics, and conversion rate to open technique were not significantly different in the two groups.

CONCLUSION

The impaired view in single-port laparoscopic surgery can be improved by using articulating instruments that can be rotated out of the field of view. This novel gasless method is cost-effective and produces minimal postoperative discomfort with no additional scars.

Left Hypochondrium or Transumbilical Single-Incision Laparoscopic Sleeve Gastrectomy for the Treatment of Severe Obesity: Surgical Technique and Results of a Tertiary Referral Bariatric Center

BACKGROUND

Technical aspects of single-incision laparoscopic sleeve gastrectomy (SILSG) vary depending on surgeon's experience and availability of surgical equipment. We have performed more than 3000 SILSGs using standardized technique with left hypochondrium or transumbilical access. The aim of this study is to describe the SILSG technique in a stepwise manner providing technical tips and pitfalls for a left hypochondrium or transumbilical approach and report results of SILSG experience in a tertiary referral bariatric center.

METHODS

A detailed description of left hypochondrium and transumbilical SILSG is provided. Data from all consecutive patients who underwent SILSG between August 2010 and August 2017 were prospectively collected and retrospectively analyzed and reported.

RESULTS

One thousand eight hundred patients underwent SILSG, from which 384 (21.3%) using a transumbilical approach. Mean age was 42.3 years, median BMI 45.3 kg/m², and median operative time 88 min. An additional port was required in 89 patients (4.9%). Postoperative mortality and morbidity rates were 0.05% and 7.5%, respectively. Relaparoscopy and/or endoscopic treatment were required for intra-abdominal bleeding in 27 patients (1.5%) and staple-line leakage in 35 patients (1.9%). Mean excess weight losses were 71.1%, 73.7%, and 70.4% at 1, 2, and 4 years after SILSG, respectively. Two years after SILSG, sustained statistical significant remission of major obesity-related comorbidities was noted. Incisional hernia occurred in 39 patients (2.1%).

CONCLUSIONS

The use of specific instruments allows standardization of left hypochondrium SILSG, which can be routinely performed for the treatment of severe obesity. Transumbilical approach for SILSG should be reserved for well-selected patients and experienced bariatric surgeons.

Reversal of left-sided colostomy utilizing single-port laparoscopy a multicenter European audit and overview of the literature

Background

Stoma reversal surgery can result in considerable morbidity and even mortality. Feasibility of utilizing single-port laparoscopy through the stoma fenestration have been shown before. Aim of the present observational study is to evaluate multicenter experiences of single-port reversal of left-sided colostomy (SPRLC) throughout Europe and to provide an overview of available literature on this topic.

Methods

All patients undergoing SPRLC in four different teaching hospitals throughout Europe are included. Primary outcome was 30-day postoperative complication rate. Secondary outcomes were postoperative length of stay (LOS), single-port success rate and conversion rates. Appraisal of the available literature in PubMed was performed.

Results

Of 156 SPRLC procedures, 98.7% of them were technically successful and 71.8% were without postoperative complications. No postoperative mortality was encountered. Superficial site infection occurred in 14.7%, anastomotic leakage in 3.9% and major complications in 8.3%. Median LOS was 4.0 days (1–69), single-port success rate was 64.7%, 12.8% and 21.2% (33/154) were converted to an open and multiport laparoscopic procedure, respectively. Literature shows equally favorable results in 131 patients divided over 5 cohorts with morbidity ranging from 0 to 30.4% and mortality from 0 to 2.2% and median LOS of 4–8 days.

Conclusion

This study confirms the safety, feasibility and favorable results of the use of single-port approach in the reversal of left-sided colostomy in different centers in Europe with laparoscopic experienced colorectal surgeons. The available literature on this topic support and show equally favorable results using single-port laparoscopy for left-sided colostomy reversal surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08657-x.

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.

Single-incision robotic colectomy versus single-incision laparoscopic colectomy: A matched case control study

BACKGROUND

Single incision laparoscopic colectomy (SILC) and single incision robotic colectomy (SIRC) are both advanced minimally invasive operative techniques. However, studies comparing these two surgical methods have not been published. The purpose of this study is to compare and evaluate the short-term outcomes of SIRC with those of SILC.

METHODS

A total of 21 consecutive patients underwent SIRC and 136 consecutive patients underwent SILC in separate institutes between January 2013 and December 2019. We used retrospective cohort matching to analyze these patients.

RESULTS

Prior to matching, patients who underwent SIRC had a lower percentage of American Society of Anesthesiologists (ASA) grades III-IV (5% vs. 19%, P = 0.11) compared with patients who underwent SILC. The SIRC group revealed a higher proportion of sigmoid colon lesions and anterior resections than the SILC group (61% vs. 45%, P = 0.16). After 1:4 cohort matching, 21 patients were enrolled in the SIRC group and 84 patients were enrolled in the SILC group. No statistically significant difference in terms of operative time (SIRC: 185 ± 46 min, SILC: 208 ± 53 min; P = 0.51), estimated blood loss (SIRC: 12 ± 22 ml, SILC: 85 ± 234 ml; P = 0.12), and complications (SIRC: 4.7%, SIRC: 7.1%; P = 0.31) was observed between these groups. Length of postoperative hospital stay (SIRC: 8.3 ± 1.7 days, SILC: 9.3 ± 6.5; P = 0.10) and number of harvested lymph nodes (SIRC: 21.3 ± 10.3, SILC: 21.3 ± 9.5; P = 0.77) were also similar between the two groups. In subgroup analysis, numbers of harvested lymph node is less in SIRC than SILC (SIRC: 18.1 ± 4.7 vs. SILC: 18.9 ± 8.1, P = 0.04) in anterior resection.

CONCLUSION

SIRC and SILC are safe and feasible procedures with similar surgical and pathological outcomes for right- and left-side colectomy.

Single-incision versus conventional multiport laparoscopic cholecystectomy: a current meta-analysis of randomized controlled trials

BACKGROUND

We performed this study to compare the safety and feasibility of single-incision laparoscopic cholecystectomy (SILC) with conventional multiple-port laparoscopic cholecystectomy (MPLC).

METHODS

We searched PubMed, Embase, Web of Science, the Cochrane Controlled Register of Trials (CENTRAL), and ClinicalTrials.gov for randomized controlled trials comparing SILC versus MPLC. We evaluated the pooled outcomes for complications, pain scores, and surgery-related events. This study was performed in accordance with PRISMA guidelines.

RESULTS

A total of 48 randomized controlled trials involving 2838 patients in the SILC group and 2956 patients in the MPLC group were included in this study. Our results showed that SILC was associated with a higher incidence of incisional hernia (relative risk = 2.51; 95% confidence interval = 1.23-5.12; p = 0.01) and longer operation time (mean difference = 15.27 min; 95% confidence interval = 9.67-20.87; p < 0.00001). There were no significant differences between SILC and MPLC regarding bile duct injury, bile leakage, wound infection, conversion to open surgery, retained common bile duct stones, total complication rate, and estimated blood loss. No difference was observed in postoperative pain assessed by a visual analogue scale between the two groups at four time points (6 h, 8 h, 12 h, and 24 h postprocedure).

CONCLUSIONS

Based on the current evidence, SILC did not result in better outcomes compared with MPLC and both were equivalent regarding complications. Considering the additional surgical technology and longer operation time, SILC should be chosen with careful consideration.

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

[Short-term evaluation of Altis® single-incision sling in women stress urinary incontinence]

INTRODUCTION

Midurethral slings are the main surgical treatment of stress urinary incontinence. Altis is a minimally invasive single-incision sling system. The aim of this study is to report the safety and efficacity results during a year of follow up.

MATERIALS AND METHODS

This single-centre and retrospective study has been performed in a university hospital, between February 2015 and May 2018. We included women aged more than 18, complaining a stress urinary incontinence with a urethral hypermobility and positive support maneuvers, who had failed from non surgical treatment. A prospective data collection has been done at the moment of inclusion, peroperative time, at 6 weeks, 6 months and a year after the procedure. The main evaluation criteria was the cure rate at twelve months.

RESULTS

Thirty patients were included in our study. The mean age was 45,4±12,9 years old, the mean ICIQ-UI score was 13,5±4,06 and the median pad test was at 12g. Ninety three percent of the procedures were done as ambulatory surgery. The average operating time was at 22,2minutes. Overall, 75% of our patients were objectively cured and 14,2% were in fail of this treatment.

CONCLUSION

The short term results show a good efficacity and safety of this procedure. But its place remains to be defined in relation to other techniques, TVT, TOT and non-prosthetic techniques.

LEVEL OF EVIDENCE

3.

Systematic review of single-incision versus conventional multiport laparoscopic surgery for sigmoid colon and rectal cancer

Objectives

To explore whether single-incision laparoscopic surgery (SILS) has the better short-term clinical and pathological outcomes than conventional multiport laparoscopic surgery (CLS) for sigmoid colon and rectal cancer.

Methods

A literature investigation of MEDLINE, PubMed, Ovid, Embase, Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chinese Biological Medicine (CBM), and Wanfang databases for relevant researches was performed. Fixed effects and random effects models were used to calculate the corresponding outcomes. Standardized mean difference and risk ratio were calculated for continuous and dichotomous variables separately.

Results

Nine clinical controlled trials were composed of two randomized clinical trials and seven non-randomized clinical trials with a total of 829 patients. Two hundred ninety-nine (36.1%) patients underwent SILS, and 530 (63.9%) patients underwent CLS. The meta-analysis showed that SILS had more lymph node resection (SMD − 0.25, 95% CI − 0.50 to − 0.002) and less defecation time (SMD − 0.46, 95% CI − 0.75 to − 0.17), exhaust time (SMD − 0.46, 95% CI − 0.75 to − 0.18), and hospital stay (SMD − 0.30, 95% CI − 0.45 to − 0.15 than CLS. SILS was also accompanied with shorter incision length (SMD − 2.46, 95% CI − 4.02 to − 0.90), less pain score (SMD − 0.56, 95% CI − 0.91 to − 0.21), and lower complication rate (RR 0.66, 95% CI 0.47 to 0.91). Blood loss, operative time, distal margin, conversion rate, anastomotic fistula, readmission, local recurrence, and distant metastasis showed no statistical differences in two groups. In all subgroup analysis, SILS also had advantages of incision length, operative time, defecation time, exhaust time, and hospitalization time than CLS.

Conclusion

SILS could be a more safe and reliable surgical technique than CLS for sigmoid colon and rectal cancer. However, further high-quality studies between these two techniques need to be further developed.

Single-incision laparoscopic hysterectomy using conventional laparoscopic instruments: initial experience with 25 cases

PURPOSE

To evaluate the feasibility and safety of single-incision laparoscopic hysterectomy using conventional instruments.

METHODS

Twenty-five patients undergoing single-incision laparoscopic hysterectomy (SI-LAH) using conventional instruments at West China Second University Hospital between July, 2017 and December, 2017 were selected for participation. Another 25 cases undergoing traditional multi-port laparoscopic hysterectomy (MP-LAH) matched with similar uterine size were selected as controls. Characteristics and clinical data of patients including operative time, estimated blood loss, hospital stay, catheter retention time, and intraoperative and postoperative complications were compared between the two groups.

RESULTS

The baseline characteristics of the two groups were comparable. The estimated blood loss was less in SI-LAH with respect to MP-LAH (30 mL [range 20-50] vs 50 mL [range 10-200], P < 0.05), with no statistically significant difference in terms of decrease of hemoglobin level (17 g/dL [range 2-24] vs 18 g/dL [range 5-28], P > 0.05). There were no significant differences between the two groups in terms of operative time (150 min [range 85-225] vs 145 min [range 100-220], P > 0.05), intraoperative injury, catheter retention time, time to exhausting, postoperative hospital stay. In all cases, no additional port incision was needed and no conversion to laparotomy was necessary in two groups. No patient had development of intraoperative or postoperative complications. After a follow-up of 2 months, no incisional hernia occurred in all patients.

CONCLUSIONS

Single-incision laparoscopic hysterectomy using conventional instruments is a feasible and safe technique for patients with uterine size less than 12 weeks of pregnancy and no serious pelvic adhesion, requiring for more experienced skill of surgeons.

Evolution of the Konyang Standard Method for single incision laparoscopic cholecystectomy: the result from a thousand case of a single center experience

Purpose

Single incision laparoscopic cholecystectomy (SILC) is increasingly performed worldwide. Accordingly, the Konyang Standard Method (KSM) for SILC has been developed over the past 6 years. We report the outcomes of our procedures.

Methods

Between April 2010 and December 2016, 1,005 patients underwent SILC at Konyang University Hospital. Initially 3-channel SILC with KSM was changed to 4-channel SILC using a modified technique with a snake retractor for exposure of Calot triangle; we called this a modified KSM (mKSM). Recently, we have used a commercial 4-channel (Glove) port for simplicity.

Results

SILC was performed in 323 patients with the KSM, in 645 with the mKSM, and in 37 with the commercial 4-channel port. Age was not significantly different between the 3 groups (P = 0.942). The postoperative hospital days (P = 0.051), operative time (P < 0.001) and intraoperative bleeding volume (P < 0.001) were significantly improved in the 3 groups. Drain insertion (P = 0.214), additional port insertion (P = 0.639), and postoperative complications (P = 0.608) were not significantly different in all groups. Postoperative complications were evaluated with the Clavien-Dindo classification. There were 3 cases (0.9%) over grade IIIb (bile duct injury, incisional hernia, duodenal perforation, or small bowel injury) with KSM and 3 (0.5%) with mKSM.

Conclusion

We evaluated the evolution of the KSM for SILC. The use of the mKSM with a commercial 4-channel port may be the safest and most effective method for SILC.

Single-incision laparoscopic versus conventional laparoscopic right colectomy: A systematic review and meta-analysis

BACKGROUND

Single-incision laparoscopic surgery has gained widespread attention because of its potential benefits such as less skin incision and faster recovery. Up to now, only one meta-analysis (performed in 2013; including 9 studies, a total of 585 cases) compared single-incision laparoscopic right colectomy (SILRC) with conventional laparoscopic right colectomy (CLRC). An updated meta-analysis was undertaken to explore more convinced comparative findings between SILRC and CLRC.

MATERIALS AND METHODS

The search for studies that compared SILRC with CLRC was done on PubMed, Embase, Web of Science, and the Cochrane Library. A total of 17 studies (including 1778 cases) were identified, the data of appointed outcomes were extracted and analyzed.

RESULTS

Patient demographics (age, gender, body mass index and previous abdominal operation) did not differ significantly. No significant differences were found between SILRC and CLRC in operative time, conversion, reoperation, perioperative complications, postoperative mortality, and 30-days readmission. Pathological outcomes, including lymph nodes harvested, proximal resection margin, and distal resection margin, were similar. SILRC showed less estimated blood loss (weighted mean difference [WMD]: -15.67 ml; 95% confidence interval [CI], -24.36 to -6.98; p = 0.0004), less skin incisions (WMD: -1.56 cm; 95%CI, -2.63 to -0.49; p = 0.004) and shorter hospital stay (WMD: -0.73d; 95%CI, -1.04 to -0.41; p < 0.00001), without publication bias.

CONCLUSION

SILRC may provide a safe and feasible alternative to CLRC with similar short-term outcomes and aesthetic advantage of less skin incision. Well-designed randomized controlled trials, involving large cases and carrying long-term outcomes, are needed.

Hybrid Single-Port Cholecystectomy Vs Four-Port Cholecystectomy in Children

Background and Objectives:

Evidence is increasing that single-port or single-incision laparoscopic cholecystectomy is a safe and feasible alternative for cholecystectomy in children. In this study, we sought to compare the single-port hybrid technique, which we originally reported in 2012, with the conventional 4-port approach, in regards of complications, outcome, operative time and cost.

Methods:

A retrospective, single-center comparison of hybrid single-port versus conventional 4-port laparoscopic cholecystectomy was performed in 98 consecutive pediatric patients between January 2010 and October 2014. Patient characteristics, intra- and postoperative outcomes, operative costs, and total hospitalization costs were compared between the 2 approaches using univariate and multivariate analyses.

Results:

The single-port technique was utilized in 56 (57%) pediatric patients who underwent laparoscopic cholecystectomy. The operative time for single-port procedures was shorter than that of the conventional technique (median, 85 minutes vs 114 minutes; P = .003). Patients with single-port procedures were less likely to have a cholangiogram compared to patients who underwent 4-port cholecystectomy. (9% vs 40%; P < .001). No statistically significant differences between the 2 cohorts were observed for intra- or postoperative outcomes. Although the 2 groups shared nearly the same median duration of hospitalization (22 hours vs 21 hours; P = .70), the single-port group demonstrated a lower total cost of hospitalization (median cost, $7438 vs $8783; P = .030) and lower operative cost (median, $3918 vs $4647; P < .001).

Conclusion:

Hybrid single-port laparoscopic cholecystectomy in children with uncomplicated gallbladder disease is feasible and equally safe, with similar intra- and postoperative outcomes compared with the conventional 4-port approach. It can contribute to global cost reduction because of lower operative and total hospitalization costs.

Single-incision laparoscopic cholecystectomy is responsible for increased adverse events: results of a meta-analysis of randomized controlled trials

BACKGROUND

Over the last decade, single-incision laparoscopic cholecystectomy (SLC) has gained popularity, although it is not evident if benefits of this procedure overcome the potential increased risk. Aim of the study is to compare the outcome of SLC with conventional multi-incision laparoscopic cholecystectomy (MLC) in a meta-analysis of randomized controlled trials only.

METHODS

A systematic Medline, Embase, and Cochrane Central Register of Controlled Trials literature search of articles on SLC and MLC for any indication was performed in June 2017. The main outcomes measured were overall adverse events, pain score (VAS), cosmetic results, quality of life, and incisional hernias. Linear regression was used to model the effect of each procedure on the different outcomes.

RESULTS

Forty-six trials were included and data from 5141 participants were analysed; 2444 underwent SLC and 2697 MLC, respectively. Mortality reported was nil in both treatment groups. Overall adverse events were higher in the SLC group (RR 1.41; p < 0.001) compared to MLC group, as well severe adverse events (RR 2.06; p < 0.001) and even mild adverse events (RR 1.23; p = 0.041). This was confirmed also when only trials including 4-port techniques (RR 1.37, p = 0.004) or 3-port techniques were considered (RR 1.89, p = 0.020). The pain score showed a standardized mean difference (SMD) of - 0.36 (p < 0.001) in favour of SLC. Cosmetic outcome by time point scored a SMD of 1.49 (p < 0.001) in favour of SLC. Incisional hernias occurred more frequently (RR 2.97, p = 0.005) in the SLC group.

CONCLUSIONS

Despite SLC offers a better cosmetic outcome and reduction of pain, the consistent higher rate of adverse events, both severe and mild, together with the higher rate of incisional hernias, should suggest to reconsider the application of single incision techniques when performing cholecystectomy with the existing technology.

Single incision pediatric flexible intramedullary tibial nailing

BACKGROUND

There has been a trend towards flexible intramedullary nailing for unstable tibial shaft fractures in the pediatric population, traditionally, utilizing a 2-incision technique with passage of one nail medially and one nail laterally. Our study aims to compare a single incision approach for flexible nailing of unstable tibial shaft fractures in pediatric patients to the traditional 2-incision approach.

METHODS

Patients were selected for operative fixation if they had a length unstable tibial shaft fracture confirmed by fluoroscopy. Exclusion criteria included length stable tibial fractures that could undergo nonoperative treatment. Single incision technique utilized the medial incision only. Patients were monitored in the hospital for one postoperative day and followed up at 4 week, 8 week, and 12 week marks. Radiographic analysis was performed to evaluate for malunion or nonunion. Operative times, infection rates and complications were recorded and analyzed.

RESULTS

All patients achieved complete fracture healing at the 12-week follow up. There were no delayed unions, nonunions or malunions in either treatment group.

CONCLUSIONS

Single medial incision for tibial flexible nails had equivalent outcomes with no difference in primary healing rate, malunion or nonunion rate when compared to the dual incision technique.

Single-incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy: a systematic review and meta-analysis

Background

Single-incision laparoscopic cholecystectomy (SILC) might maximize the advantages of laparoscopic cholecystectomy (LC) by reducing postoperative pain and improving cosmesis. However, the safety and feasibility of SILC has not yet been established. This study assesses safety, patient reported outcome measures and feasibility of SILC versus conventional LC.

Methods

Literature search for RCT’s comparing SILC with conventional LC in gallstone-related disease was performed in PubMed and Embase. The conventional LC was defined as two 10-mm and two 5-mm ports. Study selection was done according to predefined criteria. Two reviewers assessed the risk of bias. Pooled outcomes were calculated for adverse events, pain, cosmesis, quality of life and feasibility using fixed-effect and random-effects models.

Results

Nine RCT’s were included with total of 860 patients. No mortality was observed. More mild adverse events (RR 1.55; 95% CI 0.99–2.42) and significantly more serious adverse events (RR 3.00; 95% CI 1.05–8.58) occurred in the SILC group. Postoperative pain (MD -0.46; 95% CI -0.74 to -0.18) and cosmesis (SMD 2.38; 95% CI 1.50–3.26) showed significantly better results for the SILC group, but no differences were observed in quality of life. Operating time (MD 23.12; 95% CI 11.59–34.65) and the need for additional ports (RR 11.43; 95% CI 3.48–37.50) were significantly higher in the SILC group. No difference was observed in conversion to open cholecystectomy or hospital stay longer than 24 h.

Conclusions

SILC does not provide any clear advantages over conventional LC except for less postoperative pain and improved cosmesis. It is questionable whether these advantages outweigh the higher occurrence of adverse events and shortcomings in feasibility. Considering considerable heterogeneity and low methodological quality of the studies it is advisable to perform well-designed RCT’s in the future to address the safety and clinical benefits of SILC.

Single-incision laparoscopy surgery: a systematic review

Background

Laparoscopic surgery is a modern surgical technique in which operations are performed far from their location through small incisions elsewhere in the body.

Objective

This systematic review is aimed to overview single-incision laparoscopy surgery.

Methods

This systematic review was carried out by searching studies in PubMed, Medline, Web of Science, and IranMedex databases. The initial search strategy identified about 87 references. In this study, 54 studies were accepted for further screening and met all our inclusion criteria [in English, full text, therapeutic effects of single-incision laparoscopy surgery and dated mainly from the year 1990 to 2016]. The search terms were “single-incision,” “surgery,” and “laparoscopy.”

Results

Single-incision laparoscopy surgery is widely used for surgical operations in cholecystectomy, sleeve gastrectomy, cholecystoduodenostomy, hepatobiliary disease, colon cancer, obesity, appendectomy, liver surgery, rectosigmoid cancer, vaginal hysterectomy, vaginoplasty, colorectal lung metastases, pyloroplasty, endoscopic surgery, hernia repair, nephrectomy, rectal cancer, colectomy and uterus-preserving repair, bile duct exploration, ileo-ileal resection, lymphadenectomy, incarcerated inguinal hernia, anastomosis, congenital anomaly, colectomy for cancer.

Conclusion

Based on the findings, single-incision laparoscopy surgery is a scarless surgery with minimal access. Although it possesses lots of benefits, including less incisional pain and scars, cosmesis, and the ability to convert to standard multiport laparoscopic surgery, it has some disadvantages, for example, less freedom of movement, fewer number of ports that can be used, and the proximity of the instruments to each other during the operation.

conventional four-port laparoscopic cholecystectomy

OBJECTIVE

We aimed to investigate the technical feasibility of single-incision laparoscopic cholecystectomy (SILC) with our new facilitative maneuver and to compare it with the gold standard four-port laparoscopic cholecystectomy (LC).

MATERIAL AND METHODS

Operation time, cosmetic score and incisional hernia rates between LC (n=20) and SILC-1 (first 20 consecutive operations with the new technique) and 2 (subsequent 20 operations with the new technique) were compared.

RESULTS

The median operation time for LC, SILC-1 and SILC-2 were; 35 min (12-75), 47.5 min (30-70), and 30 min (12-80), respectively (p=0.005). The operation duration was similar in LC and SILC-2 (p=0.277) groups. Wound seroma rate was higher in SILC-1 (45%) and SILC-2 (30%) groups than LC (5%) group (p=0.010). Cosmetic score was similar between all the groups. Hernia rates were 15.8% and 5.3% in the SILC-1 and SILC-2 groups, respectively, while there was no hernia in the LC group.

CONCLUSION

SILC with new facilitating maneuver is comparable with classical four-port laparoscopic cholecystectomy in terms of ease, operation time, reproducibility and safety. Besides these advantages, the single-incision access technique must be optimized to provide comparable wound complication and postoperative hernia rates before being recommended to patients.

A new glove port for single incision procedure

Single-incision laparoscopic surgery has gained increasing attention due to its potential to improve the benefits of laparoscopic surgery. However, inconvenience remains for inexperienced surgeons during surgery when instruments conflict with each other, and a glove port is used hesitantly for such diagnosis related groups (DRG) because of its high cost. Authors made a new glove port by an odd surgical gloves and one wound protectors. This glove port is ease to make besides being convenient to us, and inexpensive. This new glove port has the benefit of easy utilization and cost effectiveness for surgeons performing single-incision laparoscopic surgery.

Left lower sleeve lobectomy and systematic lymph node dissection by single-incision video-assisted thoracic surgery

Sleeve lobectomy for selected cases of intratracheal tumor has better parenchyma preservation compared to pneumonectomy. And the left lower sleeve lobectomy is considered one of the most complex resections. Thanks to the advancement of equipment and accumulation of skills, video-assisted thoracic surgery (VATS) sleeve lobectomy has become safe and feasible. Typically, 3-4 ports are used, but the surgery can also be completed through one incision. A 51-year-old male patient with left lower central lung cancer underwent sleeve lobectomy and systematic mediastinal lymphadenectomy by single-incision VATS and recovered uneventfully. Sleeve lobectomy by single-incision video-assisted thoracic surgery is feasible and safe.

Single-incision laparoscopic cholecystectomy with curved versus linear instruments assessed by systematic review and network meta-analysis of randomized trials

BACKGROUND

Single-incision laparoscopic surgery poses significant ergonomic limitations. Curved instruments have been developed in order to address the issue of lack of triangulation. Direct comparison between single-incision laparoscopic surgeries with conventional linear and curved instruments has not been performed to date.

METHODS

MEDLINE, CENTRAL and OpenGrey were searched to identify relevant randomized trials. A network meta-analysis was applied to compare operative risks, conversion, duration of surgery and the need for placement of an adjunct trocar in single-incision laparoscopic cholecystectomy with linear and curved instruments. The random-effects model was applied for two sets of comparisons, with conventional laparoscopic cholecystectomy as the reference treatment. Odds ratios, mean differences and 95% confidence intervals were calculated.

RESULTS

Twenty-three randomized trials encompassing 1737 patients were included. The use of curved instruments was associated with increased operative time (mean difference 32.53 min, 95% CI 24.23-40.83) and higher odds for the use of an adjunct trocar (odds ratio 22.81, 95% CI 16.69-28.94) compared to the use of linear instruments. Perioperative risks could not be comparatively assessed due to the low number of events.

CONCLUSION

Single-incision laparoscopic cholecystectomy with curved instruments may be associated with an increased level of operative difficulty, as reflected by the need for auxiliary measures for exposure and increased operative time as compared to the use of linear instruments. Current instrumentation requires further improvement, tailored to the features of single-incision laparoscopic surgery (CRD42015015721).

Learning curves for single incision and conventional laparoscopic right hemicolectomy: a multidimensional analysis

PURPOSE

This study aimed to compare the learning curves and early postoperative outcomes for conventional laparoscopic (CL) and single incision laparoscopic (SIL) right hemicolectomy (RHC).

METHODS

This retrospective study included the initial 35 cases in each group. Learning curves were evaluated by the moving average of operative time, mean operative time of every five consecutive cases, and cumulative sum (CUSUM) analysis. The learning phase was considered overcome when the moving average of operative times reached a plateau, and when the mean operative time of every five consecutive cases reached a low point and subsequently did not vary by more than 30 minutes.

RESULTS

Six patients with missing data in the CL RHC group were excluded from the analyses. According to the mean operative time of every five consecutive cases, learning phase of SIL and CL RHC was completed between 26 and 30 cases, and 16 and 20 cases, respectively. Moving average analysis revealed that approximately 31 (SIL) and 25 (CL) cases were needed to complete the learning phase, respectively. CUSUM analysis demonstrated that 10 (SIL) and two (CL) cases were required to reach a steady state of complication-free performance, respectively. Postoperative complications rate was higher in SIL than in CL group, but the difference was not statistically significant (17.1% vs. 3.4%).

CONCLUSION

The learning phase of SIL RHC is longer than that of CL RHC. Early oncological outcomes of both techniques were comparable. However, SIL RHC had a statistically insignificant higher complication rate than CL RHC during the learning phase.

Single-incision laparoscopic-assisted anorectoplasty using conventional instruments for children with anorectal malformations and rectourethral or rectovesical fistula

BACKGROUND

This study aims to evaluate the safety and efficacy of single-incision laparoscopic-assisted anorectoplasty (SILAARP) for children with anorectal malformations (ARM) and rectourethral or rectovesical fistula.

METHODS

Children with ARMs and rectourethral or rectovesical fistula who underwent SILAARP between May 2011 and December 2012 were reviewed. The operative time, early postoperative and follow-up results were analyzed.

RESULTS

Thirty-one patients (ARM with rectovesical vs. rectoprostatic fistula vs. rectobulbar fistula: 9/6/16) successfully underwent SILAARPs without conversions. Mean ages at operation were similar in 2 groups (ARM with rectovesical or rectoprostatic fistula vs. ARM with rectobulbar fistula: 4.94 months vs. 5.67 months, p=0.46). Average operative time in ARM children with rectobulbar fistula was 1.94 hours, which did not differ from 1.78 hours in ARM children with rectovestical or rectoprostatic fistula (p=0.39). All patients resumed feeding on postoperative day 1. The median follow-up period was 20 months. No injuries of vessels, urethral or vas deferens occurred in operations. No mortality or morbidities of wound infection, rectal retraction, recurrent fistula, urethral diverticulum, anal stenosis, or rectal prolapse was encountered.

CONCLUSIONS

SILAARP is safe, feasible and effective for ARM with rectourethral or rectovesical fistula. One-stage SILAARP may offer a viable alternative treatment for ARM children with rectourethral or rectovesical fistula.

Single-incision laparoscopic appendectomy for treating appendicitis in a patient with gastrointestinal malrotation

INTRODUCTION

Intestinal malrotation is a rare congenital anomaly, and acute appendicitis associated with intestinal malrotation is extremely rare. PRESENTATION OF CASE We report a rare case of a 47-year-old Japanese woman diagnosed with barium-related perforated appendicitis associated with intestinal malrotation. We used a transumbilical single-incision laparoscopic approach to resect the appendix, and the procedure was completed successfully without perioperative complications.

DISCUSSION

To our knowledge, single-incision laparoscopic surgery for appendicitis associated with intestinal malrotation has not been reported yet. In cases with mobile cecum such as this one, mobilization from inflammatory adhesion of the surrounding structures is easy.

CONCLUSION

We conclude that transumbilical single-incision laparoscopic appendectomy is a simple and less invasive method for treating appendicitis associated with intestinal malrotation.

Challenges and strategies for single-incision laparoscopic Roux-en-Y hepaticojejunostomy in managing giant choledochal cysts

BACKGROUND/PURPOSE

Giant choledochal cyst (CDC) is thought to be a challenge for one-stage single-incision laparoscopic hepaticojejunostomy (SILH). We herewith designed the strategies for SILH in surgical management of giant CDC children, and reported its outcomes.

METHODS

Twenty-eight patients with giant CDCs successfully underwent SILH between April 2011 and October 2013. With guidance of an extra-long 5-mm 30° laparoscope, anterior cyst wall was punctured extra-corporeally using a 20-gauge angiocatheter. Cyst content was evacuated to create working space. A series of trans-abdominal retraction sutures were placed through serosa of gallbladder fundus, common hepatic duct and proximal to distal portion of anterior cyst wall to facilitate dissection. Cyst excision and hepaticojejunostomy was performed.

RESULTS

Mean age at operation was 6.24 months. Mean operative time was 3.18 h, significantly shorter than 6.3 h in our historical group undergone conventional laparoscopic hepaticojejunostomy. No blood transfusion was required. Post-operative recovery was comparable to that of our historical CLH controls. Median follow-up period was 24 months. No mortality or morbidities of anastomotic stenosis, bile leak, cholangitis or pancreatic leak was observed. Liver function normalized post-operatively.

CONCLUSIONS

Following the strategy, SILH for giant CDCs is safe and one can achieve outcomes comparable to those of CLH in experience hands.

Single port laparoscopic appendectomy in children using glove port and conventional rigid instruments

PURPOSE

To further improve the advantages of minimally invasive surgery, single port laparoscopic techniques continue to be developed. We report our initial experience with single port laparoscopic appendectomy (SPLA) in children and compare its outcomes to those of conventional laparoscopic appendectomy (CLA).

METHODS

Clinical data were prospectively collected for SPLA cases performed at Chung-Ang University Hospital by a single surgeon between March 2011 and December 2011, including operative time, perioperative complications, conversion rate, and length of hospital stay. Each case of SPLA was performed using conventional laparoscopic instruments through Glove port placed into the single umbilical incision. To compare outcomes, a retrospective review was performed for those patients who underwent CLA between March 2010 and December 2010.

RESULTS

Thirty-one patients underwent SPLA and 114 patients underwent CLA. Mean age (10.5 years vs. 11.1 years, P = 0.43), weight (48.2 kg vs. 42.9 kg, P = 0.27), and operation time (41.8 minutes vs. 37.9 minutes, P = 0.190) were comparable between both groups. Mean hospital stay was longer for CLA group (2.6 days vs. 3.7 days, P = 0.013). There was no conversion to conventional laparoscopic surgery in SPLA group. In CLA group, there were nine complications (7.9%) with 3 cases of postoperative ileuses and 6 cases wound problems. There was one complication (3.2%) of umbilical surgical site infection in SPLA group (P = 0.325).

CONCLUSION

The results of this study demonstrated that SPLA using conventional laparoscopic instruments is technically feasible and safe in children. SPLA using conventional laparoscopic instruments might be popularized by eliminating the need for specially designed instruments.

Patient and parental scar assessment after single incision versus standard 3-port laparoscopic appendectomy: long-term follow-up from a prospective randomized trial

BACKGROUND

Single site laparoscopy for appendectomy is a technique with several case series suggesting a cosmetic advantage, but without prospective comparative data. We conducted a prospective, randomized trial comparing single site laparoscopic appendectomy to the standard 3-port approach, including scar assessment at early and long-term follow-up.

METHODS

Enrolled patients over 12years old and parents of patients less than 12years old were asked to complete the validated Patient Scar Assessment Questionnaire (PSAQ) at early follow-up around 6weeks and by phone after 18months. The PSAQ consists of 4 scored subscales: Appearance, Consciousness, Appearance Satisfaction, and Symptom Satisfaction. Each subscale has a set of questions with a 4-point categorical response (1=most favorable, 4=least favorable). The sum of the scores quantifies each subscale.

RESULTS

Early questionnaires were obtained from 98 3-port and 100 single-site patients with the single-site approach producing superior overall scar assessment (P=0.003). By telephone follow-up, questionnaires were completed by 49 3-port and 56 single-site patients at a median of 25 (18-32) months. In this longer-term follow-up, overall scar assessment was not significantly different between groups (P=0.06).

CONCLUSION

Patients or parents express superior scar assessment with the single site approach at early follow-up, but this difference disappears in the long-term.

Meta-analysis of randomized trials on single-incision laparoscopic versus conventional laparoscopic appendectomy

BACKGROUND

Single-incision laparoscopic appendectomy has emerged as a less invasive alternative to conventional laparoscopic surgery. High-quality relevant evidence is limited.

METHODS

A systematic review of electronic information sources was undertaken, with the objective of identifying randomized trials that compared single-incision with conventional laparoscopic appendectomy. Outcome measures included 30-day morbidity, abdominal abscess, wound infection, open conversion, reoperation, operative time, length of hospital stay, and postoperative pain. Fixed-effects and random-effects models were used to calculate combined overall effect sizes of pooled data. Data are presented as odds ratios or weighted mean differences with 95% confidence intervals (CIs).

RESULTS

Five randomized trials were identified, with a total of 746 patients. Thirty-day morbidity (9.6% vs 8.6%; odds ratio, 1.14; 95% CI, .69 to 1.89) and wound infection rates were similar between single-incision and conventional laparoscopy (4.0% vs 4.8%; odds ratio, .83; 95% CI, .41 to 1.68), whereas the duration of surgery was longer in the single-incision group (46.3 vs 40.7 minutes; weighted mean difference, 6.01; 95% CI, 2.26 to 9.76). Available data were not adequately robust to reach conclusions regarding the remaining outcome measures.

CONCLUSIONS

Similar postoperative morbidity and wound infection rates for single-incision and conventional laparoscopic appendectomy are supported by the current literature, but single-incision surgery requires longer operative time.

Single-port versus multiport laparoscopic ileocecal resection for Crohn's disease

BACKGROUND AND AIMS

Several case series have demonstrated the feasibility of single-port laparoscopic ileocecal resection in Crohn's disease. However, only a few studies compared the single-port with a multiport laparoscopic ileocecal approach. The aim of this study was to compare short term surgical outcome parameters between single-port and multiport laparoscopic ileocecal resections for Crohn's disease.

METHODS

Twenty-one patients who underwent single-port laparoscopic ileocecal resection between March 2010 and September 2012 were prospectively registered. A matched comparison on a 1:2 basis was performed with patients who underwent multiport laparoscopic ileocecal resection from January 1999 to March 2010. Matching parameters were BMI, length of diseased bowel resected and the presence of fistulas. Endpoints were the length of postoperative hospital stay, operative time, conversions, complications, postoperative pain scores and postoperative analgesia consumption.

RESULTS

Twenty-one patients undergoing single-port resection were matched to 42 patients undergoing multiport resection. The postoperative stay (4 days, iqr 4-5 vs. 5 days, iqr 4-6; p=0.033), operative time (103 min, iqr 94.0-121.0 vs. 123.5 min, iqr 100.0-157.0; p=0.036) and morphine use on the first postoperative day (12.5 mg, iqr 5.0-33.3 vs. 28 mg, 15.0-50.0; p=0.012) differed significantly. Postoperative pain scores and complications were similar in both groups. This study was limited by potential selection bias.

CONCLUSIONS

Single-port laparoscopic ileocecal resection is safe and feasible in Crohn's disease and is associated with less need for pain medication postoperatively as opposed to multiport laparoscopic ileocecal resection.

Single-incision mini-slings versus retropubic tension-free vaginal tapes: a multicenter clinical trial

STUDY OBJECTIVE

To compare single-incision mini-slings (SIMSs) and retropubic tension-free vaginal tape (r-TVT) in terms of the long-term efficacy and safety for the treatment of female stress (SUI) or mixed urinary incontinence (MUI).

DESIGN

Prospective multicenter cohort trial (registration number NCT00751088) (Canadian Task Force II).

SETTINGS

Department of Obstetrics and Gynecology, Italy.

PATIENTS

Two hundred-forty women with SUI/MUI.

INTERVENTIONS

SIMS or r-TVT.

MEASUREMENTS AND MAIN RESULTS

The operative time and the use of analgesic tablets were significantly (p < .001) higher and lower, respectively, in the r-TVT group versus the SIMS group. After 24 months of follow-up, no difference between the study arms was observed in terms of the complication rate (30/120 [25%] vs 19/120 [15.8%] for the r-TVT and SIMS arms, respectively; relative risk = 1.58; 95% confidence interval, 0.94-2.65; p = .083), whereas the subjective cure rate was significantly lower in the SIMS arm than in the r-TVT arm (57/103 [55.3%] vs 89/106 [84.0%] for the r-TVT and SIMS arms, respectively; relative risk = 0.66; 95% confidence interval, 0.54-0.80]; p < .001). The proportion of retreated patients for SUI/MUI was significantly higher in the SIMS arm than in the r-TVT arm (37/103 [34.9%] vs 12/106 [11.3%] for SIMS and r-TVT arm, respectively; p < .001).

CONCLUSION

SIMS has no advantage in terms of safety over r-TVT and was found to be less effective than r-TVT. Thus, its use in the clinical practice should be questioned.

Single-incision laparoscopic versus conventional laparoscopic endorectal pull-through for Hirschsprung's disease: a comparison of short-term surgical results

BACKGROUND

Single-incision laparoscopy has recently become a popular procedure in pediatric surgery. The current series is the largest study to evaluate the operative complications and results of single-incision laparoscopic endorectal pull-through (SILEP) for the treatment of HD through a retrospective comparison with conventional laparoscopic endorectal pull-through (CLEP).

METHODS

Twenty eight patients who underwent single-incision laparoscopic endorectal pull-through for HD between July 2010 and August 2011 were compared to thirty patients who underwent CLEP. Patient age, gender, transitional zone, operative time, blood loss, intraoperative and postoperative complications, as well as short-term results, were assessed.

RESULTS

A total of 28 patients were included for SILEP, and historical reported 30 patients were completed by CLEP. The SILEP and CLEP groups were similar in regard to age, gender, transition zone, operative time, blood loss, hospital stay, and intraoperative complications. Postoperative results were not different, including equal daily defecation frequency and early postoperative complications. No patients with recurrent constipation were seen. Two patients with the transitional zone in the descending colon in the SILEP group had a 3mm trocar added in the left abdomen, and there were no conversions in the conventional laparoscopic group.

CONCLUSION

We have shown that in selected HD patients, the SILEP technique was safe and technically feasible in experienced hands. It results in similar operative results compared with conventional laparoscopic endorectal pull-through. However, the operation is more difficult if the transition zone was higher than the rectosigmoid.

Single-incision vs three-port laparoscopic cholecystectomy: Prospective randomized study

AIM: To compare the clinical outcome of single-incision laparoscopic cholecystectomy (SILC) with three-port laparoscopic cholecystectomy (TPLC).

METHODS: Between 2009 and 2011, one hundred and two patients with symptomatic benign gallbladder diseases were randomized to SILC (n = 49) or TPLC (n = 53). The primary end point was post operative pain score (at 6 h and 7 d). Secondary end points were blood loss, operation duration, overall complications, postoperative analgesic requirements, length of hospital stay, cosmetic result and total cost. Surgical techniques were standardized and all operations were performed by one experienced surgeon, who had performed more than 500 laparoscopic cholecystectomies.

RESULTS: One patient in the SILC group required conversion to two-port LC. There were no open conversions or major complications in either treatment groups. There were no differences in terms of estimated blood loss (mean ± SD, 14 ± 6.0 mL vs 15 ± 4.0 mL), operation duration (mean ± SD, 41.8 ± 17.0 min vs 38.5 ± 22.0 min), port-site complications (contusion at incision: 5 cases vs 4 cases and hematoma at incision: 2 cases vs 1 case), total cost (mean ± SD, 12 075 ± 1047 RMB vs 11 982 ± 1153 RMB) and hospital stay (mean ± SD, 1.0 ± 0.5 d vs 1.0 ± 0.2 d) , respectively. TPLC had a significantly worse visual analogue pain score at 8 h after surgery (mean ± SD, 3.5 ± 1.6 vs 2.0 ± 1.5), however, the scores were similar on day 7 (mean ± SD, 2.5 ± 1.4 vs 2.0 ± 1.3). Cosmetic satisfaction, as determined by a survey at 2 mo follow-up favored SILC (mean ± SD, 8 ± 0.4 vs 6 ± 0.2).

CONCLUSION: SILC is a safe and feasible approach in selected patients. The main advantages are a better cosmetic result and less pain.