Early Experience with Single-Incision Laparoscopic Total Abdominal Colectomy in Children

Introduction

Conventional multiport laparoscopy for the treatment of colorectal disease has been shown to be safe and effective in adults and children.^1,2 As the field of minimally invasive surgery continues to evolve and surgeons strive to become less invasive, many laparoscopic procedures are being performed through a single incision, including appendectomy, fundoplication, cholecystectomy, splenectomy, and nephrectomy. ³ Several pediatric surgeons have performed single-incision laparoscopic total abdominal colectomy (SIL-TAC) in children with colorectal disease; however, the data are sparse.^4–6 The purpose of this pilot study was to review our initial experience with SIL-TAC with end ileostomy and discuss the operative technique and outcomes.

Materials and Methods

After obtaining Institutional Review Board approval (No. 00086317), a retrospective review of all patients who underwent SIL-TAC with end ileostomy from 2013–2015 was performed. The medical records of these patients were reviewed and the following data were collected: age, gender, height, weight, diagnosis, operative time, length of hospital stay, postoperative pain scores, days of patient-controlled analgesia (PCA) use, time to initiation of a diet, 30-day visits to the emergency department (ED), 30-day hospital readmissions, duration of follow-up, and short- and long-term complications. Short-term complications were those occurring less than 30 days after surgery, whereas long-term complications were those occurring after 30 days. Duration of follow-up was determined by the date of operation and the date of last clinic visit. Data are presented as median and range.

Results

Five patients underwent SIL-TAC with end ileostomy between 2013 and 2015. One patient underwent an emergent open total abdominal colectomy (TAC) during this time period due to bleeding and was not included in this description. There were two females and three males included. Table 1 shows patient demographic and clinical information. The median age was 13.5 years (8.5–19.4 years) and median BMI percentile was 77.4 (2.2–98). Four patients had a diagnosis of ulcerative colitis (UC) and had failed medical management and one had colonic dysmotility. Two patients had preoperative lengths of stay of 5 and 38 days and the others were admitted on the day of operation. Two patients were receiving steroids at the time of operation. One patient received parenteral nutrition preoperatively. Three patients required blood transfusions preoperatively. The failed medication regimens each included steroids, a tumor necrosis factor antagonist, and a combination of anti-inflammatories and immunosuppressants. All patients with UC underwent a staged surgical approach due to failure of medical management in the setting of immunosuppressive therapy.

Table 2 shows operative information and outcome data. The median operative time was 182 minutes (163–244 minutes). One patient was converted to open due to a difficult dissection. There were no intraoperative complications or transfusion requirements. The median postoperative self-reported pain score, including Wong–Baker FACES and 0–10 scales, was 2.8 (1.2–4.5). The median time to initiation of a diet was 2 days (1–8 days). The median length of hospital stay was 5 days (3–11 days).

There were no 30-day complications or readmissions. Two patients returned to the ED within 30 days: one for skin breakdown around the ostomy and one for emesis who was discharged home after a negative workup. Median follow-up was 4 months (1–25 months). There were no long-term complications.

Discussion

As technology continues to evolve, single-incision laparoscopic surgery is being performed more often and for a greater variety of procedures. ⁷ In the adult population, it is commonly performed for colorectal disease and has been shown to be a potential alternative to conventional laparoscopy with reported benefits, including decreased postoperative pain, length of stay, earlier return to activity, fewer port-site complications, and an improved cosmetic result. ¹ A recent meta-analysis in adults compared single-incision laparoscopic colectomy with conventional multiport laparoscopic colectomy and found that the single-incision group had a shorter length of stay, less blood loss, and shorter incision length with no significant difference in operative time or complications. ⁸ Data in the pediatric population are less extensive; however, the results of our study agree with others and show that single-incision laparoscopic colectomy is feasible and safe.^4–6

Despite this being our initial experience with SIL-TAC, our median operative time of 182 minutes is similar to what other authors have reported.^4–6 This suggests that the learning curve is minimal for an experienced laparoendoscopist and that with experience, SIL-TAC has the potential to be an even shorter procedure. Schlager et al. reported a mean operative time of 242 minutes in a series of 6 patients compared with 262 minutes for multiport laparoscopic colectomy. ⁴ Potter et al. reported a comparable operative time of 254 minutes in a series of 3 patients. ⁵ Perger et al. compared minimal access (1–2 ports) TAC with traditional laparoscopic TAC in 7 patients and had operative times of 250 and 284 minutes, respectively. ⁶

Our postoperative length of stay of 5 days was similar to what other authors have reported (5–6.3 days) in the pediatric literature.^4,6 Two patients received a PCA postoperatively, and all patients received IV narcotics as needed with transition to enteral narcotics when tolerating a clear liquid diet. There is a lack of data in the adult and pediatric literature regarding postoperative pain after SIL-TAC. Schlager et al. reported a mean postoperative opiod use of 4.0 days. ⁴ Potter et al. described a low parenteral narcotic requirement, with patients in his series using IV narcotics for ∼1 day. ⁵ A meta-analysis in the adult literature comparing single-incision and multiport laparoscopic colectomy was unable to compare pain due to lack of data and different scoring methods reported. ⁸

The acceptance of single-incision laparoscopic surgery for the management of UC has been relatively slow, and this has been attributed to the magnitude of the operation and the generally poor medical condition of the patients. ⁹ However, in our series, we found SIL-TAC to be feasible and safe in pediatric patients with UC. There were no short- or long-term complications in our series. Three patients with UC subsequently underwent multiport laparoscopic proctectomy and ileal pouch-anal anastomosis at a median time of 217 days after TAC (91–581 days). The fourth patient with UC has not yet undergone reconstruction and is considered lost to follow-up. One may question the benefit of performing a single-incision procedure followed by a multiport procedure; however, we believe that this is an opportunity to further develop minimally invasive skills that may enable us to perform both stages through a single-incision laparoscopic site. In addition, performing the first stage through a single incision may reduce the incidence of port-site complications.

Although randomized controlled trials are a more rigorous way of evaluating new operative techniques, retrospective reviews can provide evidence of safety and efficacy. Our study provides support for the single-incision approach to TAC; however, it does have weaknesses inherent to a retrospective review. The small size of the study is an additional weakness. Although this is a small series, our initial experience with SIL-TAC in pediatric patients with colorectal disease provides encouragement to continue to advance this technique. Not only is single-incision TAC feasible and safe but it also offers a cosmetic benefit.