Single Port Laparoscopic Total and Subtotal Colectomies for Inflammatory Bowel Disease in a District General Hospital

Abstract

Background:

Single incision laparoscopic surgery (SILS) is expanding, enhancing the advantages of multi-port laparoscopic surgery (MLS). Limited literature exists regarding SILS total/subtotal colectomies for inflammatory bowel disease (IBD). Aim of the study was to present the initial experience with this type of approach in a district general hospital and extrapolate its feasibility and safety in this specific context based on gold standard outcomes reported in literature.

Materials and Methods:

Preoperative parameters, operative details and surgical outcomes of consecutive patients who underwent colonic SILS for IBD in a 5-year period were reviewed retrospectively. Median length of follow-up was 26 months.

Results:

Fourteen patients underwent SILS subtotal/total colectomy. Median body mass index was 25 (18.1–35). Two patients had previous abdominal surgeries. Median operating time was 202.5 minutes. Two cases were converted to open. Median length of stay was 5 days. Three patients presented complications. Three patients developed parastomal hernias (21.4%). Five out of 12 patients with ulcerative colitis declined further surgery, 3 are awaiting laparoscopic/SILS pouch formation, 1 underwent SILS pouch formation, 1 SILS ileo-rectal anastomosis and 1 patient had SILS completion proctectomy. One patient was not followed up.

Conclusions:

Despite literature data heterogeneity, these results provide support to the feasibility and applicability of SILS in the subgroup of patients who undergo subtotal/total colectomies for IBD, offering the option for subsequent SILS completion or restorative procedures. Further studies are required to explore the benefit of SILS over MLS (including cosmesis and quality of life) and non-inferiority of SILS regarding the parastomal hernia issue and the operative duration.

Introduction

In patients with inflammatory bowel disease (IBD) there seems to be a declining trend in surgical treatment because of the optimization of medical treatment. However, the majority of Crohn's patients and 35% of those with ulcerative colitis (UC) will still require surgical intervention, with indications including refractory disease, medical treatment's side-effects, perforation and obstruction.¹ Over time, multi-port laparoscopic surgery (MLS) has become treatment of choice for UC patients.² MLS for colorectal diseases has been shown to improve postoperative outcomes compared with open surgery regarding pain, recovery time, post-operative analgesia, return to normal activities, complications and cosmesis.^1,3

The first applications of single incision laparoscopic surgery (SILS) on colorectal surgery were in the form of right hemi-colectomies in 2008.^4,5 SILS offers a reasonable approach to minimise trauma and improve cosmesis.^2,6 In comparison to MLS it theoretically provides further advantages regarding pain, port-site related complications, recovery times and length of stay (LOS).^7–9 Studies show that SILS in colorectal surgery is favorable over MLS but with limitations,¹⁰ namely loss of triangulation, restricted number of instruments and working space, difficulty in maintaining pneumoperitoneum and longer training curve.^3,7 Increasing interest in colonic SILS exists, but current literature presents limitations and case selection biases. Colonic SILS is offered to highly selected patients depending on the body mass index (BMI) as indirect predictor of the amount of visceral fat, and the tumour site for cancer cases.^7,11 But, although it has been reported that SILS is feasible and safe for colorectal diseases, only few studies have specifically focused on subtotal or total colectomies for IBD patients and with small number of patients.^1,2,7,12 Aim of the present study was to report the initial experience with single incision laparoscopic subtotal or total colectomy for IBD in a single center and extrapolate its feasibility and safety in this specific context based on gold standard outcomes reported in literature.

Materials and Methods

The records of all consecutive patients who underwent a single incision laparoscopic colectomy in a single center were reviewed retrospectively. IBD patients were selected for SILS based on their BMI (<35), the background of previous surgical abdominal procedures and patient's preference, at the discretion of the operating consultant. Patients who underwent SILS for right colonic disease or non-IBD pathologies were excluded. The parameters studied were age at surgery, gender, previous surgeries, American Society of Anesthesiologists (ASA) score, BMI, duration of diagnosis, indication for surgery, timing, administration of IBD medications pre-operatively, length of operative time, need for intraoperative transfusion, conversion to open surgery, length of intensive care unit (ICU) and hospital stay, post-operative pain score and analgesia, short and long term complications, re-operations and re-admissions, final histology, severity of disease, long term outcomes, in-hospital and overall mortality. IBD medications recorded included steroids, immunosuppressive drugs or other anti-IBD medications given within the last pre-operative week. Re-operations and re-admissions included any acute operations and admissions following hospital discharge, related to the initial operation. The registered maximum pain score on the post-operative inpatient pain scale was used to evaluate the post-operative pain, and the day of maximum pain score was recorded. Evaluation of analgesia included the use of Patient Controlled Analgesia (PCA) and epidural analgesia and the days for which these were continued.

The type of port used was Gelpoint^® Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA). The technique used for SILS subtotal colectomy (SC) involved insertion of the port at the site for the ileostomy, pre-operatively marked by specialist stoma nurses. Although studies describe that the dissection can begin from the right hemi-colon,^2,9 this technique involved early transection of the distal sigmoid at the level of the promontory by use of endostapler (Echelon Flex 60™, Endo Path™ Stapler, Ethicon), followed by distal to proximal dissection of the colon close to the colonic wall. Side-to side tilting of the table and Trendelenburg position were dynamically adjusted during the procedure accordingly. Dissection of the mesocolon, the lateral attachments and the omentum was performed using sealing devices (LigaSure Advance™, Covidien). Extraction of the colon was carried out through the ileostomy site, allowed by limited specimen bulk, followed by extracorporeal transection of the terminal ileum which was then turned into an end-ileostomy after correct orientation of the bowel.^2,9,12

Conduction of this work was fully compliant with local Ethical Regulations and Anonymization standards. Approval from local ethical committee was not required as this was not an interventional study, involving only retrospective analysis of clinical data associated with diagnostic and therapeutic techniques performed without any deviation from institute's local guidelines. The study analyzed data retrospectively thus informed consent from the patients before their inclusion in the study was not required according to local policy. All patients had signed an informed consent for their surgical procedure before their operations.

Results

A total of 14 patients who underwent single port total or subtotal colectomy with end-ileostomy for IBD in a period of 5 years were included in the study. The characteristics of the patients are demonstrated in Table 1. Two patients (14.29%) had previous abdominal surgeries, one having right hemi-colectomy and the second one a defunctioning ileostomy. Eleven patients (78.57%) received steroids and 4 patients (28.57%) received immuno-suppressants (mercaptopurine, azathioprine for the maggiority and infliximab for 1 patient) pre-operatively in addition to steroids. The operative details of the patients and the outcomes are demonstrated in Table 2. Four patients had a 1-day postoperative stay in high dependency unit. Twelve patients were administered analgesia through PCA, for a median duration of 2 days (range 1–6) while no epidural analgesia was used. The day of maximum postoperative pain was postoperative day-1 for 10 out of the 14 patients. Histology revealed UC in 12 cases (6 cases of severe, 5 cases of moderate and 1 case of mild colitis) and 2 cases of Crohn's colitis. One of the patients with Crohn's disease had developed colonic cancer. Postoperatively, 2 patients developed small bowel obstruction and one paralytic ileus, all treated conservatively. Two patients were re-admitted in hospital (1 for abdominal pain and 1 as a result of vomiting and the presence of a pelvic collection). Median length of follow-up was 26 months (range: 3–57). Five out of 12 patients with UC declined further surgery, 1 patient underwent SILS pouch formation, 1 patient underwent multi-port laparoscopic pouch formation, 1 patient had SILS ileo-rectal anastomosis, 1 patient had SILS completion proctectomy for ongoing rectal symptoms, 2 patients are still awaiting multi-port laparoscopic or SILS pouch formation, and 1 patient was lost in follow-up.

Table 1.

Patients' Characteristics

Age at surgery (years)^a	30.5 (17–82)
Male gender^b	7 (50)
Disease duration (months)^a	40.5 (9–180)^c
BMI^a	25 (18.1–35)
Indication for surgery^b
Uncontrolled symptoms	12 (85.71%)
Steroid dependency	2 (14.29%)
Timing of surgery^b
Elective	6 (42.86%)
Semi-elective	5 (35.71%)
Urgent	3 (21.43%)

Median (range).

n (%).

Except 2 patients who had disease duration of >20 years.

BMI, body mass index.

Table 2.

Operative Details and Outcomes

Operating time^a	202.5 (120–360)
Conversion to open^b	2 (14.29%)
Intraoperative blood transfusion^b	0 (0)
Length of hospital stay^a	5 (2–9)
Max pain score post-op^a	5 (3–7)
Histology^b
Ulcerative colitis	12 (85.71%)
Crohn's disease	2 (14.29%)
Complications^b	3 (21.43%)
Acute reoperations^b	0 (0)
Acute readmissions to hospital^b	2 (14.29%)
Mortality^b	0 (0)
Parastomal hernias^b	3 (21.43%)

Median (range).

n (%).

Discussion

Limited literature exists on SILS for IBD due to the challenging nature of the disease and the complexity of patients. Moreover, most studies include mixed populations of colonic resections (right hemi-colectomy, SC, pan-proctocolectomies, cancer, diverticular disease, IBD, polyposis). Various investigators detect certain advantages with SILS in comparison to MLS, which has been the previous gold standard method for this specific pathology in the unit of the present study, although the evidence is not robust. A recent large systematic review and meta-analysis of 3502 patients reported less blood loss, faster recovery of bowel function and shorter skin incision.¹³ Another meta-analysis revealed shorter LOS and less blood loss comparing to MLS but with similar pain scores, recovery time, operative time, morbidity, conversion rates and oncologic outcomes.⁶ Advantages of SILS regarding shorter LOS and skin incisions have further been confirmed, with possible enhanced outcomes in terms of less pain, faster recovery and improved cosmesis described. However, results regarding morbidity, conversion rates and operative time were similar between the two techniques.^1,14 On the other hand, the parastomal hernia rate following colonic SILS as well as the length of operative time compared to MLS are generally considered a drawback.^1,6,8,15 All the above results derive from heterogeneous studies.

In agreement with the authors of the present study, selection of patients for SILS in benign disease in most cases is based on the BMI and the history of previous surgical procedures. Other criteria to select patients for SILS include absence of peritonitis, perforation, megacolon, malignancy, pregnancy and significant commorbidities.^{2,3,7,9,11,12} In a recent systematic review of 38 articles median BMI was 25.8¹⁶ similar to the present study. Pure cohorts of IBD patients who underwent SILS subtotal/total colectomy presented a slightly lower BMI with a mean value between 21.8 and 24.5.^2,12,17

Length of stay

Various authors agree that LOS is lower in SILS compared to MLS,^6,9,10,13,14 with most studies reporting a mean LOS of 2–6 days,³ in line with the current study (median 5 days, range 0–9). Comparison between studies is difficult because of biases and different discharge policies and calculating methods used. Furthermore, most values of LOS refer to mixed cohorts with small percentages of total/subtotal colectomy IBD patients.^9,11,15,18 In pure groups of IBD patients who underwent SILS SC, mean LOS ranged from 4.5 to 5.3 days.^2,12,17 Another study reports a surprisingly long median LOS (20.7 days, range 7–29) in a similar population,⁸ while a mean of 15.3 days (range 9–31) in SILS subtotal colectomies for benign diseases was explained according to other investigators by the differences in hospital discharge practices and the exclusion of right hemi-colectomies.³

Conversion

Two recent studies regarding pure cohorts for UC patients have provided a 0%–3.3% conversion rate.^2,17 The conversion rate of the current study was 14.29% which could be explained by the inclusion of urgent procedures and severe colitis. Other studies describe a rate of 7.2%–23.5%,^1,6,14,18 but including the use of additional ports and in mixed populations. It is difficult to compare studies due to the different terminology and definition of conversion as well as other affecting factors such as surgeon's experience. Overall, main reasons for conversions are adhesions, bleeding, obesity and poor visualization.^7,11,17

Morbidity

Morbidity in literature ranges from 0% to 38%,^1,2,15,17,19 but in heterogeneous populations. Ileus and bowel obstruction are the most common serious complications in line with the present study (n = 3, 21.43%), while wound infections and port-site complications are less likely and lower than in MLS.^6,8 The overall hernia rate needs to be further objectified in the future as there is disagreement in literature.^1,6,8,15 Development of parastomal hernia more specifically is thought to be related to the enlargement of stoma incision and to the specimen extraction through the stoma site.¹ In the unit where this study has taken place the occurrence of parastomal hernia has been recognized as an issue that needs to be addressed. Toward this aim, changes have been implemented in the technique of fashioning the stoma (by narrowing the fascial defect)²⁰ and long term results are awaited. It has been suggested that immuno-suppressants are not related to increased complications,⁸ and they do not represent a contraindication for SILS.⁹ In the present work, 4 patients were given immuno-suppressants of whom 2 had a complication and 1 a readmission, but this could just reflect the severity of the disease. Re-admissions and re-operations are variably described.^9,17 Blood loss and blood transfusion rates are favourable in SILS compared to MLS.^6,21 No blood transfusion was required in the current study. To the authors' knowledge, only one mortality case has been presented in literature.¹⁹

Length of operative time

The operative time required for SILS (median 202.5 minutes, range 120–360) was significantly shorter than median operative time of 363.1 minutes (range 253–465) reported by a similar study on SILS for UC.⁸ A recent systematic review described shorter operative times, either mean or median, ranging from 112 to 206 minutes.⁹ This could be justified by the inclusion of severe cases of colitis and emergency operations, as well as exclusion of shorter procedures contrary to other studies.^8,15 Another group of pure UC cases presented a mean operative time of 216.1 minutes.¹⁷ In general, length of surgery is considered a disadvantage of SILS compared to MLS,^6,8,15 however it is expected to improve with time and experience. In addition Transanal Endoscopic MicroSurgery experience and advanced laparoscopic skills accelerate the learning curve for SILS,¹⁵ and both are performed in the unit where the present study was conducted. A very short mean operative time of 142 minutes (range 110–180) has been also reported in SILS, but in a study with small number of patients which can represent a high patients' selection.²

Postoperative pain

Median maximum pain score was 5, while it was found to be 4 (range 3–6) in another study.¹⁵ SILS is generally well tolerated³ and associated with less pain compared to MLS.⁷ Shorter skin incisions can contribute to this.¹ Other authors showed mean pain score below 4 in SILS on day-1.³ Nevertheless, significant heterogeneity exists in pain scoring and pain management in literature,⁶ and actual benefit is not proven yet.⁷ Moreover, other investigators do not evaluate analgesia requirements postoperatively³ in contrast with the current study.

Quality of life

The authors of the present study use the ileostomy site for extraction of the specimen.⁹ This allows a better postoperative mental status (due to less scars), increasing patients' satisfaction and influencing their quality of life.^1,8 Furthermore, SILS adds the benefit of permitting SILS ileal pouch-anal anastomosis in the future with no extra wounds,^2,8,12 or other scarless procedures (SILS ileo-rectal anastomosis or SILS proctectomy). However, the issues of quality of life, cosmesis and recovery need to be prospectively investigated.

Current literature on SILS SC for IBD consists mainly of heterogeneous cohorts and with small numbers of patients. In this setting, data are not expected to demonstrate normal distribution, thus descriptives should include median rather than mean value, and statistical analysis should be conducted using non-parametric tests. Most studies though report mean values in their calculations (LOS, BMI, pain score, operating time). The authors of this study have carefully analyzed data as non-normally distributed, thus a direct statistical comparison with results of previous studies cannot be performed.

Although data are not robust, in selected patients and performed by experienced laparoscopic surgeons, SILS in colonic surgery is considered safe and feasible.^{1,3,6–8,11,12,14} Technical as well as educational issues can be faced with careful patient selection, ongoing training and experience and improvement of equipment.¹² Cost in SILS is slightly higher than MLS, but this was not evaluated in the present study and only few authors have addressed the issue.^1,6,15 On the other hand, shorter LOS and faster return to work with SILS are cost saving.¹ Other limitations of this study include retrospective design and lack of patient satisfaction and cosmesis data. Nevertheless, this is one of the very few studies focusing specifically on subtotal/total colectomies, indicated for IBD. These results provide support regarding the feasibility and applicability of SILS for the specific subgroup of patients who undergo SILS subtotal/total colectomies for IBD, offering if indicated the option for subsequent SILS completion or restorative procedures. Large sample randomized control trials would be required to prove further the benefit of SILS over standard MLS (including patient satisfaction, cosmesis and quality of life), as well as to investigate the non-inferiority of SILS regarding the parastomal hernia issue and the operative duration,. Toward this aim the present study could provide adequate supporting evidence.

Footnotes

Disclosure Statement

No competing financial interests exist

Funding Information

No funding was received for this article.

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