Single incision laparoscopic colorectal resection: Our experience.

BACKGROUND: A prospective case series of single incision multiport laparoscopic colorectal resections for malignancy using conventional laparoscopic trocars and instruments is described.
MATERIALS AND METHODS: Eleven patients (seven men and four women) with colonic or rectal pathology underwent single incision multiport laparoscopic colectomy/rectal resection from July till December 2010. Four trocars were placed in a single transumblical incision. The bowel was mobilized laparoscopically and vessels controlled intracorporeally with either intra or extracorporeal anastomosis.
RESULTS: Three patients had carcinoma in the caecum, one in the hepatic flexure, two in the rectosigmoid, one in the descending colon, two in the rectum and two had ulcerative pancolitis (one with high grade dysplasia and another with carcinoma rectum). There was no conversion to standard multiport laparoscopy or open surgery. The median age was 52 years (range 24-78 years). The average operating time was 130 min (range 90-210 min). The average incision length was 3.2 cm (2.5-4.0 cm). There were no postoperative complications. The average length of stay was 4.5 days (range 3-8 days). Histopathology showed adequate proximal and distal resection margins with an average lymph node yield of 25 nodes (range 16-30 nodes).
CONCLUSION: Single incision multiport laparoscopic colorectal surgery for malignancy is feasible without extra cost or specialized ports/instrumentation. It does not compromise the oncological radicality of resection. Short-term results are encouraging. Long-term results are awaited.

INTRODUCTION

The laparoscopic approach for colorectal surgery has been shown to result in shorter hospital stay, faster return of bowel function, less pain, better cosmetic results and lesser overall morbidity than open surgery.[12] Moreover, randomized controlled trials have shown that the long-term recurrence and survival results of laparoscopic surgery for colon cancer are not different from those of conventional surgery.[3-7] Therefore, laparoscopic surgery is now considered an accepted treatment for colon cancer if the necessary expertise is available. Though NOTES for colon resections have been performed using animals or cadavers,[89] it has not yet been attempted in humans. Single incision laparoscopic surgery has advantages over NOTES in ease of instrument use and operative technique. It decreases the parietal trauma and improves the cosmetic appearance and hence patient satisfaction as compared to standard multiport laparoscopy.[1011] Previous reports of transumblical single incision laparoscopic surgery have shown the feasibility of this approach for colorectal resection for benign diseases as well as early malignancies.[12] This case series was conducted to take single incision laparoscopic surgery a step further by attempting colorectal resections in premalignant, early as well as bulky (T3) but localised colorectal tumours. The aim of the study was to prove that such an approach is feasible without undue cost or specialized instruments while preserving the oncological radicality of resection in such cases.

MATERIALS AND METHODS

This series consisted of 11 patients (seven men and four women). The patients were selected for the procedure after written and informed consent irrespective of their BMI. All patients were of ASA grade 1 or 2. Previous upper or lower abdominal surgery was taken as an exclusion criterion in this case series. Of the 11 patients, three patients underwent right hemicolectomy for carcinoma of caecum, one underwent extended right hemicolectomy for carcinoma of hepatic flexure, two underwent anterior resection for carcinoma of rectosigmoid junction, one left hemicolectomy was done for carcinoma of descending colon, two underwent anterior resection and abdominoperineal resection (APR) respectively for carcinoma of rectum and two underwent total proctocolectomy for ulcerative pancolitis (one with high grade dysplasia another with cancer of rectum). The median age of patients was 52 years (range 24-78 years).

Patients were given preoperative mechanical bowel preparation with polyethylene glycol. Perioperative management included prophylactic antibiotics, antithrombotic stockings and low molecular weight heparin. A urinary catheter was placed before the start of the procedure. The patient was positioned in a semi-lithotomy position under general anaesthesia with left or right lateral tilt as needed. The procedure was performed through a single incision. The incision was vertical, 2.5 cm long, transumblical in location. The incision was deepened up to anterior rectus sheath which was cleared of subcutaneous tissue all around raising the skin flaps [Figure 1]. Thus sufficient space was created for placement of multiple ports achieving a mini triangulation effect. Skin incision was later extended superiorly or inferiorly if necessary to deliver the bowel and perform the anastomosis.

Figure 1

Veress placement after raising skin flaps

Pneumoperitoneum was created by closed Veress needle technique. Four ports were placed. These were a central 10 mm cannula for the scope and three 5-mm trocars, two on either side which were the working ports and one above for retraction. After gas insufflation, abdominal exploration was performed with a 30° 10-mm laparoscope. The surgeon and assistant would stand on the left with the scrub nurse and camera stack to the right for right colectomy and reverse for left sided and rectal resections. For a total proctocolectomy, the position of the surgeon would vary according to the segment of large bowel being mobilised.

In case of right/extended right hemicolectomy, the operative steps were as follows. Dissection was performed with a 5-mm endoshear. A modified medial to lateral procedure was performed, starting with mobilization of the ileocaecal junction. The mesentry medial to gonadal vessels and ureter was identified and mobilised lifting up the right colon creating a retroperitoneal tunnel up to the second and third parts of the duodenum.

The ileocolic vessels were dissected and were divided between clips with 5 mm ligasure. Subsequently, the right colic and right branch of middle colic vessels were divided with harmonic after clipping. In the case of extended right hemicolectomy, the middle colic vessels were dissected to their origin and divided with ligasure. The gastrocolic ligament is divided, hepatic flexure is mobilized and lateral peritoneal attachments of the right colon are divided last. In three cases, the appropriate segment of bowel with tumour was resected and an intracorporeal stapled side to side anastomosis was done with closure of the enterotomy with single layer hand sewn 2-0 PDS suture. The ports then were removed and linea alba incised. A wound protector was placed in the wound and specimen extracted outside. In one case with bulky T3 tumor, the bowel along with tumor was extracted first followed by extracorporeal resection and stapled side-to-side anastomosis with 60 mm linear stapler (blue cartridge). This modified medial to lateral approach for mobilization improves the safety by early visualization of the ureter and at the same time enables adequate lymphadenectomy with control of the vascular pedicle at its origin from the SMA, namely the ileocolic, right colic and middle colic vessels.

For an anterior resection, the medial mobilization was begun by incising the peritoneum at the sacral promontory and by anterior traction on the sigmoid, dissection of the inferior mesenteric vessels at their origin was done. The artery was clipped at its origin and divided with 5 mm ligasure. The vein was similarly clipped and divided [Figure 2]. Dissection was done further laterally with identification of the left ureter and gonadal vessels. The posterior dissection was done distally up to the levator ani in the holy plane with sharp division of the retrosacral ligament. This was followed by lateral and anterior dissection with visualization and preservation of the autonomic nerves. The mobilization was completed by dividing the lateral ligaments and an articulating (Endoflex, Ethicon, USA) linear 60 mm blue stapler with deflectable tip was fired across the rectum at the distal point of resection with adequate margin [Figure 3]. Again, the ports were removed, the linea alba incised, and a wound protector was placed in the wound. The colon was extracted and divided proximally after taking appropriate margin. A purse string suture was taken in the proximal bowel wall after placing the head of a 20 mm circular stapler in the lumen. The circular stapler inserted transanally was used for completing the colorectal anastomosis. For APR, the perineal part of the dissection was done as usual with specimen extraction through the perineal wound after proximal bowel division. The proximal bowel was brought out of the left iliac fossa as an end colostomy.

Figure 2

Dissection of inferior mesenteric vessels, (A) Inferior mesenteric artery, (B) Inferior mesenteric vein, (C) Abdominal aorta, (D) Inferior vena cava

Figure 3

Distal transection of rectum, (A) Endoflex linear stapler, (B) Distal rectum, (C) Levator ani

For the first case of total proctocolectomy, dissection and mobilization of the entire colon and rectum was done using the four ports placed at the transumblical incision following which a 12 mm port was placed at the left iliac fossa at the proposed ileostomy site. This was then used for firing the articulating stapler distally in the lower rectum. After proximal bowel transection at the ileocaecal junction, ports were removed, linea alba incised and the specimen brought out through the umbilical wound and distal ileum brought out for construction of the pouch extracorporeally. Pouch anal anastomosis was then performed using circular stapler as described [Figure 4]. In our second case of TPC, as the growth was located in the lower third of rectum, excision of anal canal with permanent end ileostomy was planned. A single 3 cm transverse incision was made in the right iliac fossa through which four trocars were placed [Figure 5]. After vascular control and bowel mobilization, proximal division was done at the IC junction. The perineal dissection was carried out as in APR, and the specimen extracted through the perineal wound which was closed in layers. The ileostomy was then brought out through the aright iliac fossa leaving no scars in the abdomen [Figure 6].

Figure 4

Ileal pouch anal anastomosis, (A) Ileal pouch

Figure 5

SILS TPC through proposed ileostomy site

Figure 6

Postoperative photograph

Wound was closed with heavy nonabsorbable continuous suture. Skin was closed with absorbable subcuticular sutures. Clear fluids were generally started after 24 h.

RESULTS

This series consisted of 11 patients (seven men and four women). The median age of patients was 52 years (range 24-78 years). The results are summarized in Table 1.

Table 1

Results of cases undergoing single incision laparoscopic colectomy (July to December 2010)

All surgeries were completed with the single incision and there was no case of conversion to standard laparoscopy or open colectomy. The average incision length was 3.2 cm (range 2.5-4.0 cm), and the average operating time was 130 min (range 90-210 min). No patient in the study had any major medical or surgical complication postoperatively. The average length of hospital stay was 4.5 days (range 3-8 days). Histopathology showed adequate tumor resection margins with an average lymph node yield of 25 nodes (range 16-30 nodes).

Seroma formation was noted in the main wound in one patient which resolved with conservative management with no flap/skin necrosis. Cosmetically, all patients were extremely satisfied with the appearance of their scar which was nearly invisible after few weeks. Patients had minimal pain postoperatively and were ambulated on their first postoperative day with analgesics given SOS. Overall, short-term follow showed a high level of patient satisfaction and acceptability to the procedure.

DISCUSSION

Laparoscopic surgery for advanced colon cancer provides increased patient satisfaction with improvements in postoperative pain, cosmetic results, and recovery.[12] However, laparoscopic surgery typically requires 5-6 trocars with 5-12-mm-sized incisions for each trocar, with associated risks for trocar site bleeding, herniation of the viscera, wound infection, wound pain, and poor cosmetic outcomes.[1314] Single port surgery has been reported in nephrectomy, appendectomy, cholecystectomy, adnexal mass resection, and sacrocolpopexy.[15-18] A multidisciplinary consortium of surgeons met at the Cleveland, Ohio in July 2008, and suggested the name “Laparo-endoscopic single-site surgery (LESS)” for all such procedures which used single site for access. Previous case reports and series have described single incision laparoscopy for benign diseases, malignant polyps and early cancers of the colorectum.[12] A recent case series has described single port proctocolectomy with IPAA for ulcerative colitis and FAP patients.[19] This case series report has described the technique of bowel resection in cases of malignancy including localised bulky using conventional laparocopic trocars and instrumentation through single incision and multiple ports. The technique we use is a modified medial to lateral technique for mesenteric mobilization which provides an early view to the ureter thus safeguarding it. It also enables early proximal control of the vascular pedicle thus reducing the bleeding risk with dissection up to the principal lymph nodes. There was an adequate lymph node harvest as in conventional laparoscopic and open colonic resection and there were adequate proximal, distal and circumferential margins of resections.

The advantage of single incision over multiple incision laparoscopic colectomy include a single small skin incision. The length of the skin incision is dictated in part by specimen size. In three cases of right hemicolectomy, we had performed the procedure totally laparoscopically with intracorporeal anastomosis which prevented extension of the skin incision at the time of specimen extraction. Theoretically, a single midline incision minimizes trauma to the abdominal muscles, epigastric arteries, and parietal nerves created by placement of several trocars at different sites, potentially reducing postoperative pain.

Due to lack of use of specialized trocars and instruments, the cost of the procedure was not increased compared to conventional laparoscopy.

The technical difficulty in performance of the procedure was due to lack of instrument triangulation and clash of instruments and trocars outside and inside the abdomen (chopstick effect). These problems were obviated by raising the skin flaps and creating sufficient space for comfortable and strategic placement of operative trocars giving a mini triangulation effect. We used the Endo Eye camera scope viewing system (Olympus, Tokyo, Japan) where the light cable is incorporated into the camera scope assembly which prevents clash with instruments held by the assistant as in case of conventional camera and scopes. However, it requires some practice for the assistant to adapt to this new type of procedure. The problem of manoeuvring the colon during intracorporeal anastomosis was overcome with the maximum use of gravity.Although not used in our series, the plastic screw-in type trocars without the gas channel may provide greater comfort as they require less space and hence prevent the clash between adjacent trocars. Also they reduce the incidence of accidental dislodgement and hence desufflation during the procedure which is problem particularly faced in some of our initial cases. The use of long working instruments and scope typically for bariatric procedures may help in the pelvic dissection part of the procedure.

The larger, single transumbilical fascial incision may increase the midline hernia rate as previous studies have demonstrated a low rate of incisional hernias through the lateral trocars (0.14%) but significantly higher rate through the midline extraction site (up to 17%).[20] However secure closure of the abdominal wound with heavy nonabsorbable suture under vision as in our series makes this unlikely. Single-incision colonic and rectal resections are technically feasible although more challenging than conventional multi-incision laparoscopic surgery. Notably, all the procedures were performed by a single surgeon (first author) with very high experience of laparoscopic resections for the last 20 years. The reproducibility of these procedures has to be assessed in surgeons with lesser experience.

CONCLUSION

The single incision multiport laparoscopic approach to colectomy is feasible both for right and left sided resections, rectal resections as well as total proctocolectomy with no extra costs and specialized instrumentations. Though short term follow up has shown advantages in terms of cosmetic oucome, postoperative pain and hospital stay without compromising the radicality of the procedure, the long term outcomes as compared to open and conventional laparoscopic procedures are yet to be determined and will require larger studies with prolonged follow up periods.