Surg Today DOI 10.1007/s00595-015-1154-y
ORIGINAL ARTICLE
A case‑matched comparison of single‑incision versus multiport laparoscopic right colectomy for colon cancer On Suzuki1,2 · Fumitaka Nakamura1 · Nobuichi Kashimura1 · Toru Nakamura1 · Minoru Takada1 · Yoshiyasu Ambo1
Received: 3 September 2014 / Accepted: 3 March 2015 © Springer Japan 2015
Abstract Purpose To minimize the parietal trauma associated with multiple surgical access sites, single-incision laparoscopic surgery for colectomy has been emerging with the improvements in instrumentation and surgical techniques. The purpose of this study was to compare the clinicopathological outcomes between single-incision laparoscopic right colectomy (SILC) and multiport laparoscopic right colectomy (MLC) for right colon cancer. Methods Thirty-five consecutive patients undergoing SILC from a prospective single-institution database were case matched according to demographic data to an equivalent number of patients who underwent MLC. Results The SILC patients had decreased scores for maximal pain assessed by a visual analog scale on postoperative days 1 and 3, and used fewer postoperative systemic narcotics. The median length of the hospital stay for the SILC patients was significantly shorter compared with the MLC patients. The postoperative morbidity rates were similar between the groups. The oncological findings were not significantly different between the groups. Conclusion SILC is a feasible and safe alternative to conventional MLC for patients with right colon cancer.
* On Suzuki [email protected] 1
Department of Surgery, Teine-Keijinkai Hospital, 1‑jo 12‑chome, Maeda, Teine‑ku, Sapporo, Hokkaido 006‑8555, Japan
2
Department of Gastroenterological Surgery, IMS Sapporo Digestive Disease Center General Hospital, 2‑jo Nishi 1‑chome, Hachiken, Nishi‑ku, Sapporo, Hokkaido 063‑0842, Japan
Keywords Laparoscopy · Single incision · Colon cancer · Right colectomy
Introduction Compared with open surgeries, minimally invasive laparoscopic procedures have proven to be advantageous for the treatment of colon and rectal diseases, per randomized prospective studies and retrospective series [1–4]. Multiport laparoscopic colectomy (MLC) has, therefore, achieved wide acceptance for the management of benign and malignant colonic diseases. In an attempt to minimize the parietal trauma associated with multiport insertions during this conventional laparoscopic colectomy, single-incision laparoscopic colectomy (SILC) has been emerging as an almost scarless surgery, yielding the potential benefits of improved cosmesis, less postoperative pain, a shorter hospital stay, an earlier return to normal activity and fewer incisional hernias [5–16]. In Japan, this reduced-port surgery has also recently been performed for various other types of surgeries, such as herniorrhaphy, adhesiolysis for adhesive small bowel obstruction and gastric resection [17–19]. Despite expectations for the benefits of SILC, the true superiority of SILC over MLC remains largely unclear, and SILC has not yet been standardized. This study compares the clinicopathological outcomes of our initial series of SILC patients with those of MLC patients for right malignant colon disorders in a casematched manner.
Patients and methods Thirty-five consecutive patients with cancer of the right colon initially underwent SILC between March 2010 and
13
June 2011 in the Department of Surgery of Teine-Keijinkai Hospital. Two experienced, board-certified laparoscopic colorectal surgeons performed all of the surgeries; neither of them had any prior experience with SILC before initiating this study. The inclusion criteria included cecal and ascending colon cancer, while patients with colonic obstruction, perforation, distant metastasis, bulky mesenteric lymph nodes near the tumor and involvement of the abdominal wall were excluded. This study did not exclude obese patients or those who had undergone previous abdominal surgeries. The institutional review board approved this study. Prior to surgery, patients were informed of the details of the procedure, including the advantages, disadvantages, and possibility of conversion to MLC or open conventional surgery; they then all provided written consent for the procedures. Seventy-five patients underwent MLC from February 2008 to October 2009, prior to the introduction of SILC at the institution, for cancer of the right colon. Of these, 35 patients were identified to serve as the historical control group. Thirtyfive patients who underwent SILC were case matched with 35 patients who underwent MLC performed by the same surgeons. The individual matching criteria were as follows: patient’s age (±5 years), gender, body mass index (BMI) (±3 kg/m2), American Society of Anesthesiologists (ASA) physical status score, number of previous abdominal surgeries and location of the lesion. The following data were collected in a prospective database: the length of the surgery, estimated blood loss, incision length, conversion rate, postoperative complications, pain determined using a visual analog scale (VAS) on postoperative days (POD) 1 and 3, the postoperative intravenous analgesia use, time to the first passage of flatus, length of hospital stay, 30-day readmission rate, mortality rate and the pathological and oncological findings, including the size of the tumor, proximal and distal free margins, number of lymph nodes harvested and the TNM stage. Conversion from SILC to MLC or open laparotomy was defined as MLC with any unplanned additional insertion of ports or laparotomy to support adequate counter-traction; conversion from MLC to open laparotomy was defined as any unplanned laparotomy to facilitate adequate exposure. Extensions of the wound for the sole exteriorization of large tumors were not included as conversion to laparotomy in this study. Both patient groups were placed on identically standardized postoperative recovery pathways, including the absence of a nasogastric tube, early feeding and ambulation and early removal of the urethral catheter. Postoperative pain was evaluated by a VAS and use of postoperative analgesia. The nursing staff recorded the VAS score (0 = no pain; 10 = maximal pain) on POD 1 and 3; intravenous analgesia (flurbiprofen axetil, 50 mg) was given in cases of intractable pain. The discharge criteria included tolerance of regular meals, a return of bowel function, the absence of
13
Surg Today
abdominal distention and adequate pain control with oral analgesics (loxoprofen sodium, 60 mg).
Techniques SILC An incision 2.5–3 cm long was made in the umbilicus for the placement of a single-incision device (SILS™ Port, Covidien, Mansfield, MA). The ileocolic vessels were clipped and divided at their roots. All the procedures were performed with a parallel method using the traditional non-articulating laparoscopic instruments. The right-sided colon and terminal ileum were extracted; if deemed necessary, the incision was extended to a comparable length of the size of the tumor or the thickness of the mesentery. Ileotransverse anastomosis was performed extracorporeally using standard surgical staplers. The wound was then closed with absorbable sutures. MLC The insertions of four to five standard ports were made at the following locations: a 12-mm trocar was inserted under the umbilicus as a camera port, 5- or 12-mm trocars were inserted in the left side of the abdomen, a 5-mm trocar was inserted in the right lower side of the abdomen and a 5-mm trocar was inserted in the cranial midline above the pubis (Endopath Xcel™ trocar, Ethicon Endo-Surgery, Cincinnati, OH). Surgical procedures including the resection and anastomosis were performed similarly to SILC. For extraction of the specimen, the umbilicus port wound was extended to a 3- to 4-cm incision based on the size of the tumor or the thickness of the mesentery.
Statistical analysis The data were analyzed by the χ2 test for categorical variables and the Mann–Whitney U test for continuous variables. p values
ORIGINAL ARTICLE
A case‑matched comparison of single‑incision versus multiport laparoscopic right colectomy for colon cancer On Suzuki1,2 · Fumitaka Nakamura1 · Nobuichi Kashimura1 · Toru Nakamura1 · Minoru Takada1 · Yoshiyasu Ambo1
Received: 3 September 2014 / Accepted: 3 March 2015 © Springer Japan 2015
Abstract Purpose To minimize the parietal trauma associated with multiple surgical access sites, single-incision laparoscopic surgery for colectomy has been emerging with the improvements in instrumentation and surgical techniques. The purpose of this study was to compare the clinicopathological outcomes between single-incision laparoscopic right colectomy (SILC) and multiport laparoscopic right colectomy (MLC) for right colon cancer. Methods Thirty-five consecutive patients undergoing SILC from a prospective single-institution database were case matched according to demographic data to an equivalent number of patients who underwent MLC. Results The SILC patients had decreased scores for maximal pain assessed by a visual analog scale on postoperative days 1 and 3, and used fewer postoperative systemic narcotics. The median length of the hospital stay for the SILC patients was significantly shorter compared with the MLC patients. The postoperative morbidity rates were similar between the groups. The oncological findings were not significantly different between the groups. Conclusion SILC is a feasible and safe alternative to conventional MLC for patients with right colon cancer.
* On Suzuki [email protected] 1
Department of Surgery, Teine-Keijinkai Hospital, 1‑jo 12‑chome, Maeda, Teine‑ku, Sapporo, Hokkaido 006‑8555, Japan
2
Department of Gastroenterological Surgery, IMS Sapporo Digestive Disease Center General Hospital, 2‑jo Nishi 1‑chome, Hachiken, Nishi‑ku, Sapporo, Hokkaido 063‑0842, Japan
Keywords Laparoscopy · Single incision · Colon cancer · Right colectomy
Introduction Compared with open surgeries, minimally invasive laparoscopic procedures have proven to be advantageous for the treatment of colon and rectal diseases, per randomized prospective studies and retrospective series [1–4]. Multiport laparoscopic colectomy (MLC) has, therefore, achieved wide acceptance for the management of benign and malignant colonic diseases. In an attempt to minimize the parietal trauma associated with multiport insertions during this conventional laparoscopic colectomy, single-incision laparoscopic colectomy (SILC) has been emerging as an almost scarless surgery, yielding the potential benefits of improved cosmesis, less postoperative pain, a shorter hospital stay, an earlier return to normal activity and fewer incisional hernias [5–16]. In Japan, this reduced-port surgery has also recently been performed for various other types of surgeries, such as herniorrhaphy, adhesiolysis for adhesive small bowel obstruction and gastric resection [17–19]. Despite expectations for the benefits of SILC, the true superiority of SILC over MLC remains largely unclear, and SILC has not yet been standardized. This study compares the clinicopathological outcomes of our initial series of SILC patients with those of MLC patients for right malignant colon disorders in a casematched manner.
Patients and methods Thirty-five consecutive patients with cancer of the right colon initially underwent SILC between March 2010 and
13
June 2011 in the Department of Surgery of Teine-Keijinkai Hospital. Two experienced, board-certified laparoscopic colorectal surgeons performed all of the surgeries; neither of them had any prior experience with SILC before initiating this study. The inclusion criteria included cecal and ascending colon cancer, while patients with colonic obstruction, perforation, distant metastasis, bulky mesenteric lymph nodes near the tumor and involvement of the abdominal wall were excluded. This study did not exclude obese patients or those who had undergone previous abdominal surgeries. The institutional review board approved this study. Prior to surgery, patients were informed of the details of the procedure, including the advantages, disadvantages, and possibility of conversion to MLC or open conventional surgery; they then all provided written consent for the procedures. Seventy-five patients underwent MLC from February 2008 to October 2009, prior to the introduction of SILC at the institution, for cancer of the right colon. Of these, 35 patients were identified to serve as the historical control group. Thirtyfive patients who underwent SILC were case matched with 35 patients who underwent MLC performed by the same surgeons. The individual matching criteria were as follows: patient’s age (±5 years), gender, body mass index (BMI) (±3 kg/m2), American Society of Anesthesiologists (ASA) physical status score, number of previous abdominal surgeries and location of the lesion. The following data were collected in a prospective database: the length of the surgery, estimated blood loss, incision length, conversion rate, postoperative complications, pain determined using a visual analog scale (VAS) on postoperative days (POD) 1 and 3, the postoperative intravenous analgesia use, time to the first passage of flatus, length of hospital stay, 30-day readmission rate, mortality rate and the pathological and oncological findings, including the size of the tumor, proximal and distal free margins, number of lymph nodes harvested and the TNM stage. Conversion from SILC to MLC or open laparotomy was defined as MLC with any unplanned additional insertion of ports or laparotomy to support adequate counter-traction; conversion from MLC to open laparotomy was defined as any unplanned laparotomy to facilitate adequate exposure. Extensions of the wound for the sole exteriorization of large tumors were not included as conversion to laparotomy in this study. Both patient groups were placed on identically standardized postoperative recovery pathways, including the absence of a nasogastric tube, early feeding and ambulation and early removal of the urethral catheter. Postoperative pain was evaluated by a VAS and use of postoperative analgesia. The nursing staff recorded the VAS score (0 = no pain; 10 = maximal pain) on POD 1 and 3; intravenous analgesia (flurbiprofen axetil, 50 mg) was given in cases of intractable pain. The discharge criteria included tolerance of regular meals, a return of bowel function, the absence of
13
Surg Today
abdominal distention and adequate pain control with oral analgesics (loxoprofen sodium, 60 mg).
Techniques SILC An incision 2.5–3 cm long was made in the umbilicus for the placement of a single-incision device (SILS™ Port, Covidien, Mansfield, MA). The ileocolic vessels were clipped and divided at their roots. All the procedures were performed with a parallel method using the traditional non-articulating laparoscopic instruments. The right-sided colon and terminal ileum were extracted; if deemed necessary, the incision was extended to a comparable length of the size of the tumor or the thickness of the mesentery. Ileotransverse anastomosis was performed extracorporeally using standard surgical staplers. The wound was then closed with absorbable sutures. MLC The insertions of four to five standard ports were made at the following locations: a 12-mm trocar was inserted under the umbilicus as a camera port, 5- or 12-mm trocars were inserted in the left side of the abdomen, a 5-mm trocar was inserted in the right lower side of the abdomen and a 5-mm trocar was inserted in the cranial midline above the pubis (Endopath Xcel™ trocar, Ethicon Endo-Surgery, Cincinnati, OH). Surgical procedures including the resection and anastomosis were performed similarly to SILC. For extraction of the specimen, the umbilicus port wound was extended to a 3- to 4-cm incision based on the size of the tumor or the thickness of the mesentery.
Statistical analysis The data were analyzed by the χ2 test for categorical variables and the Mann–Whitney U test for continuous variables. p values
