Single-Port Laparoscopic Colorectal Surgery: Early Clinical Experience

Abstract

Background:

Single-port laparoscopic surgery (SPLS) for colorectal pathology is an advanced technique wherein laparoscopic surgery is carried out through a single small incision hidden in the umbilicus. Advantages of this technique over standard laparoscopy are still under investigation. This study reports the initial experience and short-term outcomes of colorectal SPLS procedures in a single academic-based institution.

Subjects and Methods:

All patients who underwent SPLS for colorectal procedures between February 2010 and March 2011 were recruited into this prospective study. Patients' demographics, pathology, and intraoperative and postoperative outcomes were collected. Time to first flatus and bowel movement, postoperative pain, duration of hospital stay, and complications were also measured.

Results:

Twenty patients underwent colorectal SPLS: 17 patients underwent right hemicolectomy, and 3 patients had sigmoid resection. Mean age was 66±14 years, and body mass index was 25±4 kg/m². Median operative time for right hemicolectomy was 120 minutes (range, 110–136 minutes), and that for sigmoid resection was 158 minutes (range, 86–177 minutes). Mean measured incision length was 4.2±1.2 cm (range, 2.5–7 cm). Two cases were converted to standard multiport laparoscopy, and 1 was converted to open surgery Postoperatively, there was no mortality. Intra-abdominal abscess was observed in 3 patients. Median postoperative stay was 3 days (range, 3–3 days). Median number of lymph nodes extracted was 15 (range, 12–23).

Conclusions:

The SPLS is technically feasible with proper patient selection for a variety of applications in colorectal surgery. Improvement in instrumentation and technology is likely to expand the role of SPLS in minimally invasive surgery. It is important to audit outcomes as this novel approach is introduced.

Introduction

Laparoscopic surgery has steadily become a safe and practical option in the field of colorectal surgery.^1–4 Based on the motivation of the desire to innovate and improve surgical techniques, to improve cosmesis, and to accelerate recovery, single-port laparoscopic surgery (SPLS) has been implemented. The applications of SPLS in general surgery were initiated in appendectomy and cholecystectomy.^5,6 The SPLS technique is rapidly evolving in the field of minimally invasive surgery. Only more recently has this technique been applied to colorectal surgery, and it has been concluded to be feasible^7–9 and safe in colectomy procedures.^10–13 In addition to potentially improving overall cosmesis and decreasing wound pain, it allows easy conversion to conventional laparoscopy when required. On the other hand, drawbacks include loss of “triangulation” and decreased freedom of movement of the surgical instruments. This article describes our surgical technique and early outcomes for SPLS colectomy. The aim of this study is to look at safety and feasibility of SPLS in colectomy.

Subjects and Methods

We performed SPLS procedures in 20 consecutive patients presenting with benign or malignant pathology in a single academic institution (McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada). The study period was between February 2010 and March 2011. The patients' data were entered prospectively into an electronic database using Microsoft^® (Redmond, WA) Excel 2008. Patient factors and demographics were assessed, including age, gender, body mass index (BMI), and prior abdominal surgery. Intraoperative factors were assessed, including estimated blood loss, operative time (skin incision to closure), and conversion to laparoscopy or open. Pathology and location of the lesion were recorded. The American Society of Anesthesiologists classification was used as a surrogate for operative risk. Oncology adequacy was assessed in operations using the overall number of lymph nodes and the proportion of positive margins. Finally, postoperative factors were extracted, including duration of hospital stay, morbidity, readmission rate, time to flatus and bowel movement, pain score, and overall mortality at 30 days.

All procedures were performed using the SILS™ port (Covidien, Mansfield, MA) and a combination of standard and articulating instruments. Eligibility criteria for patients were as follows: agreement with a written informed consent, BMI<40 kg/m², no evidence of intraabdominal sepsis, and no metastasis. Each patient undergoing the single-port access approach was informed of the alternative conventional approach. The McGill Institutional Review Board approved the study.

Data are presented as absolute number (percentage) or either mean±standard deviation or median (interquartile range) when data are not normally distributed. Statistical analysis was performed using SPSS version 18 for Windows (SPSS Inc., Chicago, IL).

Perioperative Management

All patients were managed according to an identical Enhanced Recovery Program, which was implemented in this institution in 2008. The major components of this program are composed of preoperative education to reduce surgical stress, reduction of preoperative fasting and unnecessary bowel preparation, control of normothermia and avoidance of excess intravenous fluid infusion. Postoperatively, nasogastric tubes are not used, and urinary catheters are removed on the morning of postoperative Day 1. Patients are encouraged to drink clear fluids and are mobilized on their return to the surgical ward. After 24 hours, a full diet is introduced.

Anesthesia and analgesia

No premedication was administered. All patients were positioned supine with both arms tucked to the side and underwent the same protocol of standard general anesthesia. The choice of postoperative analgesia varied with the individual judgment of the anesthesiologists.

Surgical technique

Right hemicolectomy

The patients were placed in supine position, and a bean bag is used to stabilize the patient. A 2.5-cm transumbilical incision was used to insert the SILS access port. This port includes an insufflation attachment and three access ports. These ports can be stretched to accommodate up to two 5-mm ports and a 12-mm port. A flexible tip 5-mm scope (Olympus, Tokyo, Japan) was used in most of the patients as well as one articulated grasper (Roticulator™; Covidien), and the rest of the instruments are similar to those used in standard multiport laparoscopic colon resection. In all cases, a lateral-to-medial approach was used. The ligation of the ilecolic pedicle was done extracorporeally; however, this could be done intracorporeally using a vessel-sealing device or a laparoscopic vascular stapler. The fascial incision was further extended depending on the size of the tumor, and a wound protector was introduced for extracting the colon. A functional end-to-end, side-to-side, stapled extracorporeal ileocolic anastomosis was performed. The fascia was then closed with a #1 polydioxanone suture, and the skin incision was closed with 4-0 monocryl subcuticular sutures.

Sigmoidectomy

SPLS sigmoidectomy was performed using a medial-to-lateral approach using the same SILS port. The patient was placed on the operating table in a split-leg position. A transumbilical incision was conducted similar to the SPLS right hemicolectomy technique. We used instruments similar to those used in SPLS right hemicolectomy. Mesocolic dissection and inferior mesenteric pedicle isolation and control were performed using either a vessel-sealing devise or laparoscopic vascular stapler after identifying the left ureter in the retroperitoneum. The distal bowel resection through the upper rectum was performed using Endo GIA™ staplers (3.5 mm load; Covidien). Once the distal bowel resection is completed, the distal bowel is grasped with a bowel grasper, and the SILS port is removed. A wound protector is placed prior to extracting the colon. The proximal bowel is prepared and divided extracorporeally with a linear stapler. The anvil of a circular stapler was placed through the antimesenteric side of the bowel for a side-to-end colorectal anastomosis after the proximal bowel is returned to the abdomen. The anastomosis then achieved by transanal insertion of a 29-mm circular stapler (CDH; Ethicon Endo-surgery, Blue Ash, OH).

Results

Twenty patients undergoing SPLS were recruited in this study. Patients' demographic data are presented in Table 1. Seventeen patients underwent SPLS right hemicolectomy, and 3 underwent SPLS sigmoid resection. Twelve patients (60%) had undergone prior abdominal procedures. The most common pathology in this study was malignancy in 10 (50%) patients (adenocarcinoma [n=9] and carcinoid tumor [n=1]); the tumor was benign in the other 10 patients (50%). The resection margins were negative in all patients, and the median number of harvested lymph nodes was 15 (range, 9–43 nodes). The median operative time was 120 minutes for right hemicolectomy and 158 minutes for sigmoidectomy. Mean incision length was 4.2±1.2 cm. The estimated blood loss was 100 mL (range, 50–188 mL) (Table 2). Two patients were converted to multiport laparoscopy in the right hemicolectomy group; Patient 17 (Table 3), who had previously had a open subcostal cholecystectomy incision, was converted to laparotomy because of bleeding while adhesions were dissected at the hepatic flexure. Because the entire right colon had already been mobilized, this patient required only a small extension to the SPLS incision to control the bleeding from the mesentery, and the bowel was exteriorized from the same incision. Patient 20, with a BMI of 38 kg/m² and adhesions from his previous abdominal surgery, was converted to laparoscopy. Patient 13, who had SPLS sigmoidectomy with a higher BMI (30 kg/m²), was converted to laparoscopy because of difficulty while taking down the splenic flexure.

Table 1.

Patients' Demographic Data

Characteristic	Total (n=20)
Gender
Male	8 (40%)
Female	12 (60%)
Age (years)	66±14
BMI (kg/m²)	25±4
ASA
1	5 (25%)
2	14 (70%)
4	1 (5%)
Pathology
Adenocarcinoma	9 (45%)
Adenoma	7 (35%)
Diverticulitis	2 (10%)
Carcinoid tumor	1 (5%)
Crohn's disease	1 (5%)
Type of procedure
Right hemicolectomy	17 (85%)
Sigmoid resection	3 (15%)
Previous abdominal surgery (%)	12 (60%)

Data are presented as absolute number (%) or mean±standard deviation.

ASA, American Society of Anesthesiologists; BMI, body mass index.

Table 2.

Intraoperative Outcomes and Pathology

Intraoperative outcome or pathology	Total (n=20)
Intraoperative
Incision length	4.2±1.2
Range (cm)	2.5–7.0
Operating time^a
Right hemicolectomy (n=15)	120 (110–136)
Sigmoid resection (n=2)	158 (86–177)
Estimated blood loss (mL)	100 (50–188)
Conversion (%)	3 (15%)
Multiport laparoscopy	2 (10%)
Laparotomy	1 (5%)
Pathology
Lymph node extraction	15 (12–23)
Range	9–43

Data are presented as mean±standard deviation or median (interquartile range).

Excludes the patients who had conversion to laparoscopy or laparotomy.

Table 3.

Summary of the Demographic, Intraoperative, and Postoperative Parameters

Patient	Age (years)	ASA	Gender	BMI (kg/m²)	Procedure	Prior abdominal procedure	Location of lesion	Pathology	OT (minutes)	EBL (mL)	LOS (days)	IL (cm)	LN harvested
1	52	1	F	24.6	RH	No	Cecum	Tubulovillous adenoma	136	50	3	3.3	0/17
2	47	2	F	19.85	RH	No	Ileocecal	Crohn's disease	95	100	7	2.8	—
3	57	2	F	20.3	RH	Yes	Appendix	Carcinoid	129	100	3	3.5	6/14
4	55	1	M	28.1	Sig	No	Sigmoid	Diverticulitis	201	150	3	3.4	0/16
5	78	2	M	24.3	RH	Yes	Cecum	Tubulovillous adenoma	121	50	3	4	0/12
6	76	2	M	26.6	RH	Yes	Cecum	Adenocarcinoma (T3, N1)	105	100	3	5	1/15
7	66	1	F	28.25	RH	Yes	Ascending colon	Adenocarcinoma (T3, N0)	120	50	3	5.5	0/43
8	62	2	M	22.5	RH	No	Cecum	Adenocarcinoma (T3, N0)	110	100	3	4	0/19
9	87	2	F	27.9	RH	Yes	Ascending colon	Adenocarcinoma (T3, N0)	142	300	3	4	0/20
10	74	2	F	24.4	RH	No	Cecum	Tubular adenoma	115	200	2	4.4	0/9
11	56	1	F	19.8	RH	No	Ascending colon	Tubulovillous adenoma	115	50	4	2.5	0/12
12	74	2	F	27.4	RH	Yes	Transverse colon	Adenocarcinoma (T2,N0)	158	200	3	5	0/12
13	44	2	M	30	Sig	No	Sigmoid	Diverticulitis	300	600	3	C	0/12
14	87	4	M	23	LH	No	Sigmoid	Adenocarcinoma (T3,N0)	115	100	38	6	0/14
15	41	2	M	23.4	RH	Yes	Cecum	Villous adenoma	145	25	3	5.5	0/26
16	70	2	F	24.6	RH	No	Cecum	Villous adenoma	126	40	3	4.5	0/12
17	77	2	F	27.8	RH	Yes	Ascending colon	Adenocarcinoma (T3,N1)	140	500	5	C	2/38
18	79	1	M	22.5	RH	Yes	Ascending colon	Adenocarcinoma (T3,N0)	105	20	3	4.5	0/41
19	80	2	F	21.5	RH	Yes	Cecum	Tubulovillous adenoma	103	40	2	3.5	0/16
20	49	1	M	37.8	RH	Yes	Cecum	Adenocarcinoma (T1,N0)	165	150	2	C	0/14

ASA, American Society of Anesthesiologists; BMI, body mass index; C, converted either laparoscopy or laparotomy; EBL, estimated blood loss; F, female; IL, incision length; LH, left hemicolectomy; LN, lymph node; LOS, length of stay; M, male; OT, operative time; RH, right hemicolectomy; Sig, sigmoidectomy.

There was no mortality in this series. The median time to first flatus and time to first bowel movement was 2 days. The median length of stay was 3 days (range, 2–38 days) (Table 4). There were no wound infections; however, Patient 2, with Crohn's disease on high-dose steroids, developed a 2-cm intra-abdominal abscess, which was treated with intravenous antibiotics only. Patient 5 had bleeding from the staple line, requiring 2 units of blood, and he also developed a 3-cm intra-abdominal abscess, which was treated with intravenous antibiotics, Neither patient required drainage. Patient 14 developed an anastomotic leak after sigmoid resection, requiring laparotomy and diversion on postoperative Day 2, resulting in a prolonged hospital stay (38 days).

Table 4.

Postoperative Outcomes

Postoperative	SPLS (n=17)^a
Time (days) to
First flatus	2 (1–2)
First bowel movement	2 (2–3)
VRS pain at
24 hours	2.5 (1.25–3)
48 hours	1 (0–2)
72 hours	1.5 (0–3)
Length of hospital stay (days)	3 (3–3)
Complication
Intra-abdominal abscess/leak	3 (17%)
Bleeding	1 (6%)
Infection	0 (0%)

Data are absolute number (%) or median (interquartile range).

Excludes the patients who had conversion to laparoscopy or laparotomy.

SPLS, single-port laparoscopic surgery (colectomy); VRS, verbal rating scale.

Discussion

Minimally invasive surgical procedures through single incisions have been described for cholecystectomy, appendectomy, bariatric procedures, and urological procedures.^14–17 The adoption of the single-incision approach has recently emerged for colorectal surgery as case reports and small case series.^{7–9,17–20} The feasibility and safety of this technique have been shown in these studies. These reports have demonstrated improved cosmesis as the primary benefit. Gandhi et al.¹¹ have shown benefits for SPLS compared with hand-assisted laparoscopic colectomy: SPLS resulted in smaller incision length and shorter length of hospital stay but longer operative time.

SPLS for right hemicolectomy and sigmoidectomy has been shown to be feasible for oncologic surgery.^11–13 We present our operative experience with 20 consecutive patients who underwent SPLS sigmoid colectomy and right hemicolectomy to understand the advantages, challenges, and disadvantages of this technique.

During the study period we used three 5-mm camera types, including a 50-cm-long 30° bariatric scope, a standard 30° scope, and a flexible tip scope. Although we were able to conduct the procedure with all of them, we found that the flexible tip scope was the best option for these procedures. We used the SILS port, which was the only commercially available device at the start of the study period. The SILS port was easily adopted by the surgeons, offered simple and convenient placement through a transumbilical incision, facilitated easy exchange of 5- and 12-mm ports during the procedure, and maintained adequate pneumoperitoneum. We found that using one articulated grasper during the procedure helped to overcome the limitation of triangulation.

The mean operative time for SPLS right hemicolectomy was 120 minutes, which is comparable with previously published reports, which ranged from 115 to 180 minutes.^10,13,19 Our mean incision length was 4.2 cm, which is also comparable with previously published reports.^10,13,19 We found that the SPLS approach to sigmoidectomy was more challenging, especially to take down the splenic flexure; our mean operating time was 158 minutes for these cases.

Our conversion rate to laparoscopy or laparotomy is 15% (3 cases). We had converted 2 cases to traditional laparoscopy; both patients had higher BMI and previous abdominal surgeries (Patients 13 and 20). One patient with previous abdominal surgery and adhesions required conversion to open surgery because of bleeding from a mesenteric vessel (Patient 17).

We adhered to the same oncological principles as during standard laparoscopic surgery. Ten of the 20 patients had malignant disease, and pathologic analysis showed adequacy of the oncological resections and a median lymph node harvest of 15. Several reports have similarly demonstrated the feasibility of this procedure for performing ontological resections.^11–13

Conclusions

In this feasibility study, SPLS is feasible for selected patients in an experienced laparoscopic colorectal center. It is technically more challenging than multiport laparoscopic colectomy, but it may provide cosmetic advantages and improved pain in comparison with multiport laparoscopic colectomy. To determine SPLS potential benefits, larger comparative studies to multiport laparoscopic colectomy with cost analysis, oncologic outcomes, and long-term follow-up will be necessary.

Footnotes

Disclosure Statement

No competing financial interests exist.

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