Application of Fast-Track Recovery Protocols in Single-Port Laparoscopic Surgery Versus Multiport Laparoscopic Surgery for Colon Resection

Introduction

Laparoscopic surgery is the chosen technique for determined digestive surgical diseases. Similar oncological results have been obtained in comparison to open surgery, as well as other benefits such as less postoperative pain, shorter length of stay, and faster recovery and return to normal daily activities and work. ¹ However, surgery is constantly evolving, and after conventional laparoscopic surgery already instituted itself among surgeons, there have been recent reported series in which another step is taken in regard to this evolution: the single-port laparoscopic surgery, mainly in colorectal surgery, where results are similar to conventional multiport laparoscopic surgery. ²

Detractors and skeptics have some issues according to know whether this is a reproducible and feasible technique. In the beginning of conventional laparoscopic surgery, this was also a matter of controversy for many surgeons. However, time has shown that laparoscopic surgery is a reproducible technique; being taught successfully to many surgeons in training and it is applicable to many complex surgeries, such as the donor liver resection in living-donor transplantation. ³

Since the first reports in 2008 about single-port laparoscopic surgery, many surgeons published their cases, which make us think that it is a technique with broad applicability, and time will tell if it can become the standard of care for determined surgical diseases

If we focus in the colorectal disease, there are many meta-analyses published in which the oncological outcomes and postoperative morbidity are similar, with improved esthetic results and shorter length of stay, adding the socioeconomic benefits that this represents.^4,5

The application of the so-called fast-track (FT) programs has been also applied to gastrointestinal laparoscopic surgery ⁶ and more precisely to laparoscopic colorectal surgery, which has undoubtedly contributed to earlier postoperative recoveries. ⁷ Nevertheless, there is not enough evidence about the reproducibility and applicability in single-port surgery. It is for this reason that we present a retrospective study with a prospective analysis of our first FT protocol results applied to conventional laparoscopy and single-port laparoscopy in patients with colorectal disease.

Materials and Methods

Retrospective study with a prospective analysis in a single center of 83 patients included in the FT protocol: 28 consecutive patients treated with single-port laparoscopic surgery (SP-FT) and 55 patients treated with conventional multiport laparoscopic surgery (MP-FT) from January 2013 to December 2014. FT is applied in our hospital based on the protocol established by the Spanish Working Group in Fast-Track Surgery (GERM). Exclusion criteria are emergency surgery, ASA IV, and medical history of partial gastrectomy. Before surgery, there is a preoperative educational visit with the nurse, the anesthetist, and the surgeon, who explains the intervention that will be performed and expected postoperative course, having made sure the patient understands the plan. Patients are admitted to the hospital the same day of the surgery. Intraoperatively there are many items such as maintenance of normothermia, strict fluid balance, or use of epidural catheter for left hemicolectomy. Use of nasogastric tube and abdominal drains must be avoided. Postoperative outcome includes early mobilization, oral feeding, and respiratory physiotherapy during the first 24 hours, epidural catheter (if needed) and urinary catheter remain in place for 48 hours. Oral analgesia is prescribed the third or fourth postoperative day and the patient is discharged 24 hours later.

Variables evaluated were as follows: age, sex, ASA score, type of intervention, size of the tumor, number of nodes, length of hospital stay, postoperative morbidity (Clavien-Dindo classification), and number of hospital readmissions. For the single-port laparoscopy, an incision of 4–5 cm in the umbilicus or at the upper circumference of the umbilicus is made to introduce the Single-port device (Gel Point Applied^®) and two or three trocars of 5 mm and one trocar of 12 mm are placed (Fig. 1). Patients' position is modified to achieve a better traction and countertraction of the tissues. Intracorporeal or extracorporeal anastomosis is performed depending on surgeon's operative preferences. The same incision is used for specimen retrieval with an Alexis wound protector (Alexis Wound Retractor System™; Applied Medical^®) (Fig. 2).

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FIG. 1.

Single-Port device (Gel Point Applied^®).

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FIG. 2.

Cosmetic outcome 6-month follow-up.

Descriptive values are in median and range or mean and standard deviation. Categorical variables were compared using the χ² test or Fisher's test, and continuous variables were compared using Mann–Whitney U test. We considered a P value <.05 to be statistically significant (SPSS v.12.0).

Results

The median age was 62 (11–85) years in the SP-FT group and 72 (57–84) in the MP-FT group (P = .014). There were 14 women and 14 men in the SP-FT group, 24 women and 31 men in the MP-FT group. ASA score was as follows: SP-FT ASA 2 15 patients, ASA 3 12 patients, and ASA 4 1 patient; MP-FT ASA 2 30 patients and ASA 3 25 patients. (P = .932). Baseline characteristics of the patients are presented in Table 1. Single-port procedures included 20 right resections (6 ileocolic resections and 14 right colectomies), 5 left resections (2 left colectomies and 3 sigmoidectomies), and 3 subtotal colectomies. The MP-FT included 26 right colectomies, 28 left resections (2 left hemicolectomies and 26 sigmoidectomies), and 1 subtotal colectomy (P = .006). Mean operative time (minutes) was shorter in the SP-FT group, but no significant difference was observed (151 ± 47.9 versus 182 ± 50.7; P = .141). No cases were converted to open surgery (Table 2).

Complications occurred within 30 days of surgery were ranked according to Clavien-Dindo's classification (Table 3) and no significant difference was observed (P = .670). In the SP-FT group, two patients were reoperated: one patient to drain a hematoma, while the other one because of anastomotic leakage confirmed at surgery. In the FT-MP group, four patients underwent surgery: two patients to drain an intra-abdominal collection, one patient by anastomosis dehiscence, and a fourth one by evisceration. Length of hospital stay was significantly different between the SP-FT and MP-FT groups (4.5 versus 7 days, respectively; P = .005).

Pathology report provided a tumor size quite similar in both groups: SP-FT 4 (2–7) cm and MP-FT 3 (2–12) cm (P = .535), and no significant difference in the number of lymph nodes harvested was observed (P = .076) (Table 4).

Discussion

One of the greatest progresses of digestive surgery, and in particular colorectal surgery, lies in the introduction of laparoscopy. ⁸ Today the benefits are undeniable, among which stands less postoperative pain and improved quality of life for patients.

Single-port surgery for colon, first published in 2008, ⁹ has already been described on numerous occasions, ¹⁰ demonstrating that this is a feasible and reproducible technique. Subsequently, improved technique in surgery of the right colon describing the transumbilical incision with intracorporeal anastomosis, according to the authors, avoid pulling the transverse mesocolon that occurs with extracorporeal anastomosis, and also achieve less postoperative pain and superior esthetic results. ¹¹ There are studies in which single-port surgery in the right colon compared with conventional multiport laparoscopic surgery, has similar oncological results and an earlier recovery.^12,13 However, we must not ignore the importance of the establishment of multimodal rehabilitation programs in the early recovery of these patients. The study of Basse et al. ¹⁴ published in 2005 (FT-conventional surgery versus FT-laparoscopic surgery) did not find significant differences suggesting that perioperative care plays an essential role in these patients, even more than the type of surgery performed. On the other hand, the multimodal rehabilitation, in addition to reducing hospital stay as already mentioned, reduces hospital costs in both laboratory tests and radiology and pharmacy. ¹⁵

Despite the importance that has already proven multimodal rehabilitation programs, the study of Kehlet et al. ¹⁶ demonstrated that, both in Europe and the United States, those measures that are effective in the postoperative period such as no colon preparation, oral tolerance, and early mobilization, among others, have no wide applicability. More recently, H. Kehlet has published an editorial to denote that more complicated enhanced recovery after surgery programs can contribute to delayed implementation. ¹⁷

If we look at our results, there was no conversion to open surgery in any group and there was no increase in postoperative morbidity in the single-port group, demonstrating the safety and feasibility of both techniques. However, the aim of the study is not to prove the superiority of single-port surgery versus conventional laparoscopic surgery, but analyze whether FT protocols can be applied to these patients. In our hospital, indeed, we have observed that multimodal rehabilitation programs in colon surgery, applied since 2012, have achieved a shorter hospital stay in patients undergoing colon resection. However, we have also implemented FT protocols in our patients since we started single-port surgery for colon disease in 2012. We found significant differences in age and the type of surgery performed in the two groups, which could translate into a lack of homogeneity among them. However, when comparing both groups, we observed that patients undergoing single-port surgery remained fewer days, which is statistically significant (P = .005).

It is noteworthy that the multiport group has an average length of stay of 7 days, which could be explained by two reasons: there are more left hemicolectomies in that group, and the hospital stay length was analyzed taking into account the day when the patient left the hospital instead of when we think that patients can be discharged (oral feeding and bowel movements). We should involve the patients with a detailed explanation of how the recovery will be, trying to make them participate and collaborate with us in a quickly postoperative recovery.

Somehow, a limitation of our work is not being a prospective randomized study. Significant differences in the independent variables would be expected with a larger N in the SP-FT group. Even though, we perform more right colon resections than left colon resections, it is noteworthy that we apply this technique in both surgeries, even in subtotal colectomy.

Our results indicate that FT protocols can be applied to these patients safely, without more morbidity and successfully reducing hospital stay.

Conclusions

Single-port surgery is a feasible technique, offers some advantages over conventional multiport laparoscopic surgery, and moreover the multimodal rehabilitation can be applied safely to this type of technique. Indeed, single-port surgery could enhance benefits observed with FT protocols, although further randomized studies are needed to confirm these results.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector.