Single-Incision Versus Three-Port Conventional Laparoscopic Right Hemicolectomy: Is There Any Real Need to Go Single?

Introduction

Laparoscopic colectomy (LC) has been shown in several prospective randomized trials to be a valid alternative to open colectomy, offering some benefits over open colectomy. ¹ They include reduction in postoperative pain, faster return of bowel function, improved cosmesis, shorter hospital stay, and similar short and long-term oncological outcomes. ² In order to develop more minimally invasive surgical techniques surgeons have tried to reduce the number of skin incisions. In fact, conventional LC requires three to five abdominal accesses, and each of these has potential risk of bleeding, internal organ damage, postoperative chronic pain, or hernia formation.

Single-incision laparoscopic surgery (SILS), as a consequence, has been introduced to minimize the invasiveness of laparoscopy. It has been applied to several surgical fields,^3–6 but it has been reported only in small case series in the field of colorectal surgery, especially because of loss of triangulation.^7–9 Preliminary results showed some benefits of SILS over conventional LC, including better cosmesis, less postoperative pain, and faster recovery, but these results need further confirmation.^7–9 In addition, the literature still lacks comparative studies between the two approaches to prove the above-mentioned advantages of SILS over conventional laparoscopy and, most importantly, its equivalent effectiveness in terms of initial oncological results (distal tumor-free margin and harvest of lymph nodes). In particular, there are only a few articles addressing specifically the comparison of short-term results after four-port laparoscopic and SILS right colectomy where the authors concluded that, aside from the smaller length of incision, there were no significant differences in perioperative outcomes or short-term measures of convalescence.^10–14 In this article, we report our experience, comparing the short-term surgical and oncological outcomes after single-incision laparoscopic right hemicolectomy (SIL-RH) and three-port conventional laparoscopic right hemicolectomy (3PCL-RH).

Patients and Methods

Between September 2009 and September 2011, 23 patients with cancer of the right colon amendable to surgery entered the study. Three patients were excluded because of the presence of a T4 lesion. Two consecutive series of 10 patients underwent 3PCL-RH (Group A) and SIL-RH (Group B), respectively. In Group A, one periumbilical 12-mm trocar was used as a camera port, and two 5-mm trocars were placed, respectively, in the right lower quadrant and just on the left of the midline 7–9 cm above the umbilical scar. For SILS procedures a 3-cm periumbilical incision was made, and a SILS™ Port (Covidien, Norwalk, CT) or an Endocone^® system (Karl Storz GmbH & Co. KG, Tuttlingen, Germany) was used in 7 cases and 3 cases, respectively. In 6 female patients a transvaginally assisted approach was used as previously described by the senior author. ¹⁵ All procedures were performed in a medial-to-lateral fashion with an extracorporeal stapled functional end-to-end ileocolic anastomosis performed through the umbilical incision. In Group A traditional laparoscopic instruments were used. In the case of the SILS procedure an articulating dissector and, since June 2011, curved scissors were used together with straight traditional instruments. Vascular control was always obtained by using 5-mm clips. In both groups the specimen was extracted extending the periumbilical incision.

Data were analyzed by using the chi-squared test for categorical values and Student's t test for continual variables. Differences of P<.05 were considered statistically significant.

Results

Demographics data are shown in Table 1. The distributions of gender, age, and body mass index were similar in both groups.

No conversion to open surgery was recorded for both procedures. Operative time was slightly longer in the SILS group, but the differences were not statistically significant. Analysis of perioperative (Table 2) and postoperative (Table 3) outcomes revealed no significant differences between the two groups. In the SILS group an anastomotic leakage occurred, which was conservatively treated by continuous drainage, total parental nutrition, and antibiotic therapy. The analysis of oncological outcomes showed no differences in terms of length of distal tumor-free margin and harvest of lymph nodes (Table 4).

Discussion

Conventional laparoscopic right hemicolectomy has been demonstrated to be a valid alternative to open colectomy, showing improved postoperative course and equivalent effectiveness on long-term cancer outcome.^1,2 However, three to five incisions are needed for port placement, and each wound contributes to potential postoperative morbidity, which includes pain, hemorrhage, abdominal organ injury, or postoperative hernia formation. In the attempt to minimize invasiveness of laparoscopy, SILS has been introduced. The rationale of its introduction and its implementation is to reduce trauma of access and improve cosmetic results, allowing the camera and the operative instruments to be introduced into the abdomen through the same incision. However, some concerns exist about its real advantages over LC and about its oncological outcomes. In theory, the reduction in maneuvering space and the lack of triangulation could compromise surgical exposure with the potential risk for the surgeon to not fulfill oncological criteria.

Very few reports exist on single-incision laparoscopic colorectal surgery because of the complexity of these procedures, where restricted degree of instrument triangulation and lack of tissue retraction by an assistant surgeon are very limiting. However, right hemicolectomy seems to be suited for SILS because it requires an incision for specimen removal. Different solutions have been suggested in order to introduce the camera and the operative instruments through the umbilicus. Bucher et al. ¹¹ used a 12-mm umbilical port, a 10-mm laparoscope with a 6-mm working channel, and some transparietal stitches anchored to the colon to obtain suspension and exposition. Merchant and Lin ¹² used a GelPoint™ single-incision system (Applied Medical, Rancho Santa Margarita, CA), introducing up to three or four instruments including the laparoscope and performing intracorporeally all the steps of the operation. Remzi et al. ¹³ reported one right hemicolectomy using the Uni-X single-port access laparoscopic system (Pnavel Systems, Morganville, NJ) with a multichannel cannula and specially designed curved laparoscopic instrumentation. Ostrowitz et al. ¹⁴ reported on three robotic-assisted single-incision right hemicolectomies using one 12-mm and two 8-mm robotic ports placed through a 2–4-cm umbilical incision in 2 cases and through the SILS Port in 1 case. Chen et al. ¹⁶ used three adjacent 5-mm umbilical trocars kept at different heights to reduce crowding. In our SILS experience we used one of the disposable multiports available on the market in 7 cases and a reusable one in the remaining 3 cases.

SIL-RH has been found to be feasible and safe. However, often patients who undergo SILS colectomy are selected excluding high body mass index and previous surgery. In our study the only exclusion criterion was the presence of a T4 lesion, which in our practice currently represents a contraindication also for LC. Even if exclusion criteria were very limited, we did not have any conversion to LC or open surgery or intraoperative complications even if there was a trend toward longer procedures in the case of patients with a body mass index >30 kg/m². As a consequence our limited experience shows that SILS colectomy is not necessarily contraindicated in cases of obese and previously operated-on patients.

However, no consensus exists about advantages of SILS over LC. In particular, in the present study no statistical difference in postoperative pain was recorded, probably because the 3PCL-RH and the SILS technique differed only in the use of two extra 5-mm ports.

There are only three articles addressing specifically the comparison of short-term results after LC and SILS right colectomy where the authors concluded that, aside from the smaller length of incision, there are no significant differences in perioperative outcomes or short-term measures of convalescence.^16–18 As for the studies mentioned above and a few others,^9,10,16–18 all patients in the present study had an R0 resection with histologically negative margins and satisfactory harvest of lymph nodes, confirming the feasibility of SIL-RH to perform oncological resection. Although these studies demonstrated that SIL-RH is feasible with comparable outcomes to conventional LC, it remains a very challenging technique that should be attempted only by very experienced surgeons. Routine use of SILS in right hemicolectomies and in colorectal surgery needs a new generation of multiport access trocars and instruments designed to overcome the limited degree of instrument triangulation associated with this kind of approach.

Conclusions

Despite its feasibility for right hemicolectomy and its equivalent short-term surgical and oncological outcome compared with conventional laparoscopy, SILS demonstrated no significant advantages in terms of surgical incision length and postoperative course (pain management, recovery, and hospital stay) compared with 3PCL-RH. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of SIL-RH.