Most surgeons are now convinced of the benefits of the laparoscopic approach in colorectal surgery [
The excitement to develop new techniques, to improve cosmesis and hasten recovery, has given rise to the natural orifice transluminal endoscopic surgery (NOTES), and more recently to single incision laparoscopic surgery (SILS). The initial applications of SILS in gastrointestinal surgery were appendicectomy and cholecystectomy [
The aim of this paper was to analyze the current literature on single incision laparoscopic colectomy (SILC) including safety, techniques and feasibility and to assess the potential benefits of this new technique.
Databases consulted to carry out the search for relevant articles were Medline, The Cochrane Database of Systematic Reviews and Controlled Trials Register, The York Centre for Reviews and Dissemination,
Inclusion criteria were original articles, case reports, and technical notes, adult human patients, colorectal surgery, and robotic-assistance or not, without restriction of operative indication, disease, or surgical procedure. Exclusion criteria were editorials, congress abstracts, letters, experimental studies (cadaver, animal), minilaparotomy, multiport and hand-assisted laparoscopic surgery, natural orifice transluminal endoscopic surgery (NOTES), and transanal endoscopic microsurgery (TEM).
Data were extracted by the same surgeon reviewer (F Leblanc) experienced in laparoscopic colorectal surgery. Expected assessment criteria were: preoperative bowel preparation, surgical material, operative technique, operative time, conversion, incision length, complications, and hospitalization duration. Parametric data were expressed as mean
The primary search identified 131 potentially relevant studies (Figure
Review of single incision laparoscopic colorectal surgery: included studies.
Study [ref] | Article | Cases (sex) | Age | BMI (kg/m2) | Indication | Colectomy |
---|---|---|---|---|---|---|
Remzi et al. [ | Original | 1 (F) | 67 | 35 | Polyp | Right |
Bucher et al. [ | Case | 1 (ns) | 81 | ns | Polyp | Right |
Bucher et al. [ | TN | 1 (F) | 34 | 22 | EM | Sigmoid |
Bucher et al. [ | TN | 1 (M) | 56 | 26 | Polyp | Left |
Leroy et al. [ | TN | 1 (F) | 40 | 21 | DV | Sigmoid |
Merchant and Lin [ | TN | ns | ns | ns | ns | Right |
Brunner et al. [ | TN | 2 (F) | 56 | ns | DV | 2 sigmoid |
42 | EM | |||||
Rieger and Lam [ | Series | 7 (6M-1F) | (60–83) | (22–28) | 4 cancers | 6 right |
2 Polyps | 1 left flexure | |||||
Ostrowitz et al. [ | Original | 3 (2M-1F) | (74–82) | ns | 1 cancer | 3 right |
2 villous |
TN: technical note; EM: endometriosis; DV: diverticulitis; ns: not specified.
Single incision laparoscopic colorectal surgery: studies selection.
A preoperative bowel preparation was reported in 3 studies and not specified in 6 studies (Tables
Four surgical teams used a single port system, and three teams used trocars inserted directly through the skin incision (Table
Single incision laparoscopic colorectal surgery: material required.
Study [ref] | Port system | Laparoscope | Graspers/Scissors | |||
Single port (diameter, mm) | Trocars (diameter, mm) | Tip | Diameter (mm) | Degree | ||
Brunner et al. [ | None | 3 trocars (5, 5, 5) | Rigid/Straight | 5 | 30° | AR–ST/ns |
Remzi et al. [ | Triport (5, 5, 5) | None | Flexible | 5 (incorporated light source) | ns | Curved/Curved |
Rieger and Lam [ | None | 3 trocars (12, 5, 5) | ns/ns | 10 | 30° | ST/AR |
Merchant and Lin [ | Gelport | 3 trocars (10, 5, 5) | Rigid/Straight | 5 | 30° | AR/ns |
Bucher et al. [ | None | 2 trocars (12, 5) | Rigid/Angular | 10 (6 mm working channel) | ns | AR/ST |
Rigid/Straight | 5 | 30° | ||||
Leroy et al. [ | Triport (10, 5, 5) | None | Rigid/Angular | 10 | 0° | AR/AR |
Rigid/ns | 3 | 0° | ||||
Ostrowitz et al. [ | Triport (12, 8, 8) | 3 trocars (12, 8, 8) | ns/ns | 12 | ns | AR#/ns |
Third case | Two first cases |
TN: technical note; EM: endometriosis; DV: diverticulitis; ns: not specified.
Techniques step by step of single incision laparoscopic right colectomy.
Study [ref] | Bowel preparation | Exposure | Mesenteric dissection | Vessels ligation | Proximal section | Distal section | Anastomosis |
---|---|---|---|---|---|---|---|
Remzi et al. [ | ns | Grasping | Lateral to medial | Electrothermal | Extracorporeal | Extracorporeal | Extracorporeal |
Scissors | Stapled | Stapled | Stapled | ||||
Merchant and Lin [ | ns | Grasping | Medial to lateral | Stapled | Intracorporeal | Intracorporeal | Intracorporeal |
Stapled | Stapled | Stapled | |||||
Bucher et al. [ | ns | Grasping | Medial to lateral | Knotting | ns | ns | Extracorporeal |
Transparietal stitches | Scissors/Hook/Ultrasound | Stapled | |||||
Rieger and Lam [ | None* | Grasping | Lateral to medial | Electrothermal | ns | ns | Extracorporeal |
Scissors | Knotting | Stapled | |||||
Ostrowitz et al. [ | ns | Grasping# | Medial to lateral | Electrothermal | Extracorporeal | Extracorporeal | Extracorporeal |
Hook# | Stapled | Stapled | Stapled |
Techniques step by step of single incision laparoscopic sigmoid and left colectomies.
Study [ref] | Bowel preparation | Exposure | Mesenteric dissection | Vessels ligation | Proximal section | Distal section | Anastomosis |
---|---|---|---|---|---|---|---|
Brunner et al. [ | ns | Grasping | Medial to lateral | Electrothermal | Extracorporeal | Intracorporeal | Intracorporeal |
Transparietal stitches | Electrothermal | ns | Stapled | Stapled | |||
Bucher et al. [ | ns# | Grasping | Medial to lateral | Electrothermal | ns | Intracorporeal | Intracorporeal |
Transparietal stitches | Scissors/Hook | Stapled | Stapled | ||||
fiber-free diet | Grasping | Lateral to medial | Electrothermal | Intracorporeal | Intracorporeal | Intracorporeal | |
Leroy et al. [ | PEG | Sigmoidoscopy | Electrothermal | Stapled | Stapled | Stapled | |
enema per ano | IL magnetic anvil | ||||||
Rieger* and Lam [ | None# | Grasping | Lateral to medial | Electrothermal | ns | ns | Extracorporeal |
Scissors | Manual |
Single port systems used in the studies selected. (a) SILS Port (Covidien, Norwalk, Connecticut, USA); (b) ASC Triport (Advanced Surgical Concepts, Wicklow, Ireland); (c) Uni-X (Pnavel Systems, Morganville, New Jersey, USA); (d) GelPort (Applied Medical, Rancho Santa Margarita, California, USA).
To insert the port system, the skin incision measured 24 ± 8 mm long in average (
Review of single incision laparoscopic colectomy: results.
Study [ref] | Colectomy | Skin Incision length | Time (min) | Specimen (cm) | Lymph nodes | Stay (day) | |
Initial (mm) | Final (mm) | ||||||
Remzi et al. [ | Right | 35 | 35 | 115 | ns | ns | 4 |
Leroy et al. [ | Sigmoid | 20 | 20 | 90 | 40 | ns | 4 |
Brunner et al. [ | Sigmoid | 20 | ns | 110 | 22 | ns | 7 |
Sigmoid | 20 | ns | 180 | 18 | ns | 6 | |
Right | ns | 30 | 158 | 38 | 33 | ns | |
Bucher et al. [ | Sigmoid | 20 | ns | 125 | 23 | 14 | 2 |
left | 20 | ns | ns | 39 | ns | ns | |
Right | 40 | 40 | 132 | ns | 22 | 4 | |
Ostrowitz et al. [ | Right | 40 | ns | 158 | ns | ns | 3 |
Right | 2.5 | ns | 166 | ns | ns | 4 | |
Right | 25 | 35 | 100 | ns | 10 | ns | |
Right | 25 | 35 | 90 | ns | 26 | ns | |
Right | 25 | 25 | 75 | ns | 16 | ns | |
Rieger and Lam [ | Right | 25 | 45 | 115 | ns | 10 | 11 |
Right | 25 | 30 | 80 | ns | 7 | ns | |
Right | 25 | 25 | 88 | ns | 21 | ns | |
LF | 25 | 25 | 75 | ns | 12 | ns |
TN: technical note; EM: endometriosis; DV: diverticulitis; ns: not specified.
Surgery was performed for a variety of benign and malignant diseases (Table
To date, only single case reports and small case series were available evaluating the success of Single Incision Laparoscopic Colectomy. Although multiple names have been used, Single Incision Laparoscopic Surgery appears to be the most accurate term to describe the variety of techniques utilized. This paper of nine articles analyzes the technical aspects and operative results of SILS for colectomy. It combines data from seven different laparoscopic surgery teams. The data reviewed in this study suggest the safety and feasibility of SILC. The mean operative time in our analysis was 116 minutes. This compares favorably with mean published operative time of 178 minutes for a multiport laparoscopic colectomy in a multicenter trial of 872 patients [
The number of examined nodes and the colonic specimen length to treat malignant or potential malignant tumors appears oncologically satisfactory. Nonetheless, data were inadequate about the colonic margins and the surgical quality of colonic resection to validate the oncologic feasibility of SILC.
Potential advantages of SILC over multiport laparoscopic colectomy include a single small skin incision. The length of the skin incision is dictated in part by specimen size. Extraction difficulties may be encountered for large colonic tumors, or obese patients with thickened mesentery, omentum, or deep abdominal wall. In addition, when the colon is full of stool, it may be difficult to extract. A bowel preparation may reduce the colonic diameter and incision length in these cases. In this paper, the size of the final skin incision was significantly longer than the initial incision, suggesting that analysis of the cosmetic benefits of the SILC should be based on final rather than initial scar length and device diameter. A better indicator of postoperative cosmetic result might be a blinded assessment of the abdomen after recovery from SILC compared with the abdominal incisions after traditional laparoscopic colectomy.
Theoretically, a single midline fascial incision minimizes trauma to the abdominal muscles, epigastric arteries, and parietal nerves created by placement of several trocars, potentially reducing postoperative wall pain. Data were not available to assess any analgesic advantage of SILC. No study included specifics on postoperative pain scores or analgesic requirements.
Furthermore, a single incision may decrease postoperative hernia rate. Published data on port-site hernias after multiport laparoscopic surgery and intraoperative closure are low, with an estimate of 0.14% [
The length of stay did not appear to be decreased using SILS technology. The duration of hospitalization after a multiport laparoscopic colectomy is estimated at 5 days [
SILS presents several disadvantages compared to multiport laparoscopic surgery. Externally, the handling of both straight instruments in parallel with the laparoscope through a small single incision decreases the freedom of motion for the surgeon and complicates the holding of the laparoscope for the assistant. To reduce the lines and cords that clutter the operative table, a small diameter laparoscope with an angular tip and an incorporated light source were used by several teams [
Lastly, SILS presents challenge for teaching laparoscopy. The mechanics of the operation are best suited to a single operator and this may hinder the training of surgeons in SILS. The potential difficulty in training residents and surgeons in this advanced technique needs to be addressed. Despite published benefits of minimally invasive colectomy, a prolonged learning curve had led to low adoption rate. SILS with its new technical and training challenges may not be accessible to most surgeons and most patients in the near future.
For experienced laparoscopic colorectal surgeons, single incision laparoscopic colectomy is safe, feasible although technically more difficult than straight multiport laparoscopic colectomy. SILC may present cosmetic advantages in comparison to the multiport laparoscopic colectomy. Nevertheless, to determine its benefits, larger comparative studies to multiport laparoscopic colectomy with cost analysis, oncologic outcomes, and long-term follow-up will be necessary.