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Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Comparison between the perioperative results of single-access and conventional laparoscopic surgery in rectal cancer Siripong Sirikurnpiboon Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
Keywords Conventional laparoscopic surgery; single-access laparoscopic surgery Correspondence Siripong Sirikurnpiboon, Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand. Tel: +66-2-3548108 ext 3149, 3150 Fax: +66-2-3548108 ext 3149,3150 Email: [email protected] Received 19 July 2015; revised 15 September 2015; accepted 5 October 2015 DOI:10.1111/ases.12254
Abstract Introduction: Laparoscopic surgery for rectal cancer has low rates of morbidity and mortality and achieves comparable pathologic outcomes. With improved instruments and surgical techniques, many surgeons have recently begun using single-access laparoscopic surgery (SALS) to minimize scars and pain. Since 2011, most reports of SALS for rectal cancer have shown comparable pathologic outcomes to those of conventional laparoscopic surgery (CLS). However, SALS is said to be superior to CLS in reducing complications, producing less discomfort, and faster recovery rates. This study aimed to compare the technical feasibility and early postoperative outcomes of these approaches. Methods: From January 2011 to January 2014, 78 cases of adenocarcinoma of the rectum and anal canal were enrolled in the study. Anterior, low anterior, intersphincteric, and abdominoperineal resections were performed. Data collected included technical feasibility and outcomes of operation, such as morbidity, mortality, severity of pain, analgesic usage, and length of hospital stay. Results: SALS was performed on 35 patients, and CLS was performed in 36 cases. Demographic data, including age, sex, BMI, ASA classification and clinical staging, were similar between the groups. Operative time, blood loss, and conversion rate were similar (P > 0.05). Postoperatively, the only significant difference between the groups was pain score, which was significantly lower in the SALS group (P < 0.001). Conclusion: SALS and CLS for rectal and anal cancer had the same intraoperative, pathologic, and early postoperative results. However, SALS patients had slightly better pain scores in the first 24 and 48 h postoperatively.
Introduction Laparoscopic surgery is a generally accepted surgical technique for a variety of procedures, and it has become the standard treatment for many types of operations, such as cholecystectomy and hernioplasty (1,2). In the early years of laparoscopic cancer surgery, many surgeons worried about this type of surgery because they were unsure of its oncologic outcome. Subsequently, many reports showed that laparoscopic surgery had outcomes comparable to those of open techniques, and lapa-
44
roscopic surgery is now accepted in many types of cancer operations, including for colorectal cancer (3,4). Since its introduction, single-access laparoscopic surgery (SALS) has become more advanced. A 2011 report claimed it was superior to conventional laparoscopic surgery (CLS) in that it improved outcomes by reducing complications, producing less discomfort, and achieving earlier recovery. Comparative studies of SALS with CLS are still limited, so the aim of this research was to compare the technical feasibility and early postoperative outcomes of the two techniques.
Asian J Endosc Surg 9 (2016) 44–51 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.
S Sirikurnpiboon
Materials and Methods This was a retrospective study of minimally invasive operations for rectal cancer performed from January 2011 to January 2014. There were 78 patients with a preoperative diagnosis of adenocarcinoma of the rectum and anal canal; each case was confirmed by tissue diagnosis, and neoadjuvant treatment was not provided. During the preoperative period, four patients were excluded from the study: one refused laparoscopic surgery; one required an emergency operation for colonic obstruction; and two were unable to undergo the operation because of severe medical diseases. During operation, three patients were converted to open techniques because of severe adhesion, and they were then excluded from the study. Of the 71 remaining patients, SALS was performed in 35 cases and CLS in the other 36. There were more female patients than male patients (38 vs 33), and the median age of subjects was 63 years (range: 23–86 years). Most cases were tumor stage III (>75%), and abdominoperineal resection (APR) was the most common procedure in the SALS group whereas low anterior resection (LAR) was predominant in the CLS group. Data were collected in three phases. First, preoperative (demographic) data from patients in both groups, such as age, gender, BMI, underlying medical conditions, and previous history of operation, were collated (Table 1). Second, intraoperative data relating to type of operation, operative time, blood loss volume, and conversion rate were recorded. Finally, postoperative data, including complications, pain score using the visual analog scale, analgesic usage, wound length, hospital stay, and pathologic reports, were reported. This study was reviewed and approved by the Rajavithi Hospital Ethics Board Committee. Statistical analysis SPSS version 17.0 (SPSS Inc. Chicago ,IL, USA) was used to analyze the data. A univariate comparison of categorical data was analyzed by χ2 or Fisher’s exact test. The Mann-Whitney U-test or t-test was used to compare quantitative variables. Operative techniques In the SALS group, the author used either a Glove PortSingle Port (Nelis Ltd., Bucheon, South Korea) or the glove technique with a SILS Port (Covidien, Dublin, Ireland) (5,6). Figure 1a shows the trocar placement with glove technique, and Figure 1b shows this with the Glove Port-Single Port. A 3–6-cm incision was made in the para-umbilcal area for port placement; the incision length varied depending on the port used. In the CLS group the port was placed as shown in Figure 2. The camera was a 0°
Single and conventional laparoscopic in rectum
Table 1 Demographic data
Age, mean ± SD (years) Sex (male : female) BMI, mean ± SD (kg/m2) Underlying disease (n) Cardiovascular disease Hypertension (HT) Coronary heart disease (CHD) HT and CHD Diabetic mellitus Non-dialysis chronic kidney disease Gouty arthritis Thallasemia ASA Physical Classification Class I Class II Class III Clinical staging Stage I Stage II Stage III Distance from anal verge, mean ± SD (cm)
SALS (n = 35)
CLS (n = 36)
P-value
63.00 ± 13.37 16 : 19 21.78 ± 3.95 26 (74.3%) 22 16 2 4 2 1
62.02 ± 13.06 17 : 20 23.00 ± 2.50 28 (77.8%) 17 12 2 3 6 2
0.57 0.73 0.13 0.73
1 0
1 2 0.60
7 (20.0%) 22 (62.9%) 6 (17.1%)
8 (22.2%) 26 (72.2%) 3 (8.3%)
0 (0.0%) 6 (17.1%) 29 (82.9%) 4.83 ± 2.91
1 (2.8%) 9 (25.0%) 27 (75.0%) 6.00 ± 1.92
0.48
0.047*
*Statistic significantly with p < 0.05. CLS, conventional laparoscopic surgery; SALS, single-access laparoscopic surgery.
flexible video-laparoscope (LTF-VP; Olympus Medical Systems, Tokyo, Japan). The operation used a medial-tolateral approach in both groups. The inferior mesenteric artery and vein were skeletonized and controlled by Hemo-lok (Teleflex Medical, Durham, USA) or Liga Clip (Johnson & Johnson, New Brunswick, USA), divided by scissors, and then dissected downward from the mesenteric window to the pelvis in a semicircular motion until the pelvic floor was reached; this was consistent with the total mesorectal excision technique. Lateral mobilization was then performed from the sigmoid to the splenic flexure. In LAR or anterior resection, the rectum was transected with an endoscopic linear stapler (Endo GIA; Covidien). In the SALS group, the proximal colon was extracted via the para-umbilical incision, and resection was achieved after extracorporealization. In the CLS group, a suprapubic incision was created to retrieve the proximal colon. Anastomosis was performed with the double stapling technique using a transanally inserted circular stapler (CDH29; Ethicon Endo-Surgery, Cincinnati, USA), and protective ileostomy was routinely performed. In the SALS group, a pelvic drain was placed via a new incision in the lower left quadrant area. With regard to APR, the author performed a perineal resection phase after the intraperitoneal phase using a standard technique; cylindrical APR was not routinely performed.
Asian J Endosc Surg 9 (2016) 44–51 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.
45
Single and conventional laparoscopic in rectum
S Sirikurnpiboon
Figure 1 Trocar placement in the single-access laparoscopic group.
Figure 2 Port position in the conventional laparoscopic group.
In the postoperative period, nurses recorded patients’ pain levels using the visual analog scale and noted the amount of intravenous analgesia (pethidine) that each patient used. On the day of the operation, the author prescribed pethidine 25 mg intravenously every 6 h and then as requested by patients on subsequent days. Once a patient had a bowel movement, oral analgesia was prescribed. Patient satisfaction with wound cosmesis was not collected.
Results This study enrolled and analyzed 71 patients. There were 35 cases in the SALS group and 36 in the CLS group. Of the 35 cases in the SALS group, there were 16 men and 19 women with a mean ± SD age of 63.00 ± 13.37 years and a mean BMI ± SD of 21.78 ± 3.95 kg/m2. With regard to ASA classification, class II was the most common, with 22 patients (62.9%), with underlying disease found in 26 patients (74.3%). The CLS group had nearly the same male-to-female ratio (17:20) with a mean age ± SD
46
of 62.02 ± 13.06 years and a mean BMI ± SD of 23.00 ± 2.50 kg/m2. ASA class II was the most prevalent with 26 patients (72.2%), and underlying disease was found in 28 patients (77.8%). No difference was found in clinical staging. The demographic data of the two groups were comparable (Table 1). Intraoperative data showed a difference in operation type: APR was the most common procedure in the SALS group, whereas LAR was most common in the CLS group. These figures were statistically significant (P = 0.001). Other factors such as operative time, volume of blood loss, and conversion rate were comparable. Intraoperative data are shown in Table 2. Pathologic results showed that staging and the number of nodes harvested were comparable between the groups, but there were some differences in T stage, tumor size, circumferential margin (CRM), distal rectal margin, and length of specimen. These differences were statistically significant (Tables 3,4). All patients had a negative CRM and distal rectal margin. With regard to postoperative complications, morbidities occurred in nine patients. In the SALS group, there was one case each of wound infection, exacerbation of gouty arthritis, thrombophlebitis, and atrial fibrillation in different individuals, and there were two cases of delirium. In the CLS group, there were two cases of wound infection and one of thrombophlebitis. Postoperative complications are shown in Table 5. In the early postoperative period in the SALS group, there was less pain with earlier recovery of bowel movement and shorter hospital stay. These differences were statistically significant, but analgesic (pethidine) usage did not significantly differ. Perioperative data are shown in Table 6. Figures 3 and 4 show an example of a postoperative wound at 30-day follow up.
Discussion In the last decade, colorectal cancer has progressed from being the ninth most common cancer in Thailand to being the second most prevalent, and its incidence, especially that of rectal cancer, is close to that of other developing
Asian J Endosc Surg 9 (2016) 44–51 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.
Single and conventional laparoscopic in rectum
S Sirikurnpiboon
Table 2 Intraoperative data SALS (n = 35) Operation (n) Anterior resection Low anterior resection Intersphincteric resection Abdominoperineal resection Operative time (min) Mean ± SD Median (min–max) Blood loss time (mL) Mean ± SD Median (min–max) Conversion (n)
CLS (n = 36)
P-value
2 (5.7%) 8 (22.9%) 0 (0.0%) 25 (71.4%)
0 (0.0%) 22 (61.1%) 1 (2.8%) 13 (36.1%)
264.57 ± 51.30 300 (180–360)
245.56 ± 53.48 240 (150–360)
0.24
Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Comparison between the perioperative results of single-access and conventional laparoscopic surgery in rectal cancer Siripong Sirikurnpiboon Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
Keywords Conventional laparoscopic surgery; single-access laparoscopic surgery Correspondence Siripong Sirikurnpiboon, Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand. Tel: +66-2-3548108 ext 3149, 3150 Fax: +66-2-3548108 ext 3149,3150 Email: [email protected] Received 19 July 2015; revised 15 September 2015; accepted 5 October 2015 DOI:10.1111/ases.12254
Abstract Introduction: Laparoscopic surgery for rectal cancer has low rates of morbidity and mortality and achieves comparable pathologic outcomes. With improved instruments and surgical techniques, many surgeons have recently begun using single-access laparoscopic surgery (SALS) to minimize scars and pain. Since 2011, most reports of SALS for rectal cancer have shown comparable pathologic outcomes to those of conventional laparoscopic surgery (CLS). However, SALS is said to be superior to CLS in reducing complications, producing less discomfort, and faster recovery rates. This study aimed to compare the technical feasibility and early postoperative outcomes of these approaches. Methods: From January 2011 to January 2014, 78 cases of adenocarcinoma of the rectum and anal canal were enrolled in the study. Anterior, low anterior, intersphincteric, and abdominoperineal resections were performed. Data collected included technical feasibility and outcomes of operation, such as morbidity, mortality, severity of pain, analgesic usage, and length of hospital stay. Results: SALS was performed on 35 patients, and CLS was performed in 36 cases. Demographic data, including age, sex, BMI, ASA classification and clinical staging, were similar between the groups. Operative time, blood loss, and conversion rate were similar (P > 0.05). Postoperatively, the only significant difference between the groups was pain score, which was significantly lower in the SALS group (P < 0.001). Conclusion: SALS and CLS for rectal and anal cancer had the same intraoperative, pathologic, and early postoperative results. However, SALS patients had slightly better pain scores in the first 24 and 48 h postoperatively.
Introduction Laparoscopic surgery is a generally accepted surgical technique for a variety of procedures, and it has become the standard treatment for many types of operations, such as cholecystectomy and hernioplasty (1,2). In the early years of laparoscopic cancer surgery, many surgeons worried about this type of surgery because they were unsure of its oncologic outcome. Subsequently, many reports showed that laparoscopic surgery had outcomes comparable to those of open techniques, and lapa-
44
roscopic surgery is now accepted in many types of cancer operations, including for colorectal cancer (3,4). Since its introduction, single-access laparoscopic surgery (SALS) has become more advanced. A 2011 report claimed it was superior to conventional laparoscopic surgery (CLS) in that it improved outcomes by reducing complications, producing less discomfort, and achieving earlier recovery. Comparative studies of SALS with CLS are still limited, so the aim of this research was to compare the technical feasibility and early postoperative outcomes of the two techniques.
Asian J Endosc Surg 9 (2016) 44–51 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.
S Sirikurnpiboon
Materials and Methods This was a retrospective study of minimally invasive operations for rectal cancer performed from January 2011 to January 2014. There were 78 patients with a preoperative diagnosis of adenocarcinoma of the rectum and anal canal; each case was confirmed by tissue diagnosis, and neoadjuvant treatment was not provided. During the preoperative period, four patients were excluded from the study: one refused laparoscopic surgery; one required an emergency operation for colonic obstruction; and two were unable to undergo the operation because of severe medical diseases. During operation, three patients were converted to open techniques because of severe adhesion, and they were then excluded from the study. Of the 71 remaining patients, SALS was performed in 35 cases and CLS in the other 36. There were more female patients than male patients (38 vs 33), and the median age of subjects was 63 years (range: 23–86 years). Most cases were tumor stage III (>75%), and abdominoperineal resection (APR) was the most common procedure in the SALS group whereas low anterior resection (LAR) was predominant in the CLS group. Data were collected in three phases. First, preoperative (demographic) data from patients in both groups, such as age, gender, BMI, underlying medical conditions, and previous history of operation, were collated (Table 1). Second, intraoperative data relating to type of operation, operative time, blood loss volume, and conversion rate were recorded. Finally, postoperative data, including complications, pain score using the visual analog scale, analgesic usage, wound length, hospital stay, and pathologic reports, were reported. This study was reviewed and approved by the Rajavithi Hospital Ethics Board Committee. Statistical analysis SPSS version 17.0 (SPSS Inc. Chicago ,IL, USA) was used to analyze the data. A univariate comparison of categorical data was analyzed by χ2 or Fisher’s exact test. The Mann-Whitney U-test or t-test was used to compare quantitative variables. Operative techniques In the SALS group, the author used either a Glove PortSingle Port (Nelis Ltd., Bucheon, South Korea) or the glove technique with a SILS Port (Covidien, Dublin, Ireland) (5,6). Figure 1a shows the trocar placement with glove technique, and Figure 1b shows this with the Glove Port-Single Port. A 3–6-cm incision was made in the para-umbilcal area for port placement; the incision length varied depending on the port used. In the CLS group the port was placed as shown in Figure 2. The camera was a 0°
Single and conventional laparoscopic in rectum
Table 1 Demographic data
Age, mean ± SD (years) Sex (male : female) BMI, mean ± SD (kg/m2) Underlying disease (n) Cardiovascular disease Hypertension (HT) Coronary heart disease (CHD) HT and CHD Diabetic mellitus Non-dialysis chronic kidney disease Gouty arthritis Thallasemia ASA Physical Classification Class I Class II Class III Clinical staging Stage I Stage II Stage III Distance from anal verge, mean ± SD (cm)
SALS (n = 35)
CLS (n = 36)
P-value
63.00 ± 13.37 16 : 19 21.78 ± 3.95 26 (74.3%) 22 16 2 4 2 1
62.02 ± 13.06 17 : 20 23.00 ± 2.50 28 (77.8%) 17 12 2 3 6 2
0.57 0.73 0.13 0.73
1 0
1 2 0.60
7 (20.0%) 22 (62.9%) 6 (17.1%)
8 (22.2%) 26 (72.2%) 3 (8.3%)
0 (0.0%) 6 (17.1%) 29 (82.9%) 4.83 ± 2.91
1 (2.8%) 9 (25.0%) 27 (75.0%) 6.00 ± 1.92
0.48
0.047*
*Statistic significantly with p < 0.05. CLS, conventional laparoscopic surgery; SALS, single-access laparoscopic surgery.
flexible video-laparoscope (LTF-VP; Olympus Medical Systems, Tokyo, Japan). The operation used a medial-tolateral approach in both groups. The inferior mesenteric artery and vein were skeletonized and controlled by Hemo-lok (Teleflex Medical, Durham, USA) or Liga Clip (Johnson & Johnson, New Brunswick, USA), divided by scissors, and then dissected downward from the mesenteric window to the pelvis in a semicircular motion until the pelvic floor was reached; this was consistent with the total mesorectal excision technique. Lateral mobilization was then performed from the sigmoid to the splenic flexure. In LAR or anterior resection, the rectum was transected with an endoscopic linear stapler (Endo GIA; Covidien). In the SALS group, the proximal colon was extracted via the para-umbilical incision, and resection was achieved after extracorporealization. In the CLS group, a suprapubic incision was created to retrieve the proximal colon. Anastomosis was performed with the double stapling technique using a transanally inserted circular stapler (CDH29; Ethicon Endo-Surgery, Cincinnati, USA), and protective ileostomy was routinely performed. In the SALS group, a pelvic drain was placed via a new incision in the lower left quadrant area. With regard to APR, the author performed a perineal resection phase after the intraperitoneal phase using a standard technique; cylindrical APR was not routinely performed.
Asian J Endosc Surg 9 (2016) 44–51 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.
45
Single and conventional laparoscopic in rectum
S Sirikurnpiboon
Figure 1 Trocar placement in the single-access laparoscopic group.
Figure 2 Port position in the conventional laparoscopic group.
In the postoperative period, nurses recorded patients’ pain levels using the visual analog scale and noted the amount of intravenous analgesia (pethidine) that each patient used. On the day of the operation, the author prescribed pethidine 25 mg intravenously every 6 h and then as requested by patients on subsequent days. Once a patient had a bowel movement, oral analgesia was prescribed. Patient satisfaction with wound cosmesis was not collected.
Results This study enrolled and analyzed 71 patients. There were 35 cases in the SALS group and 36 in the CLS group. Of the 35 cases in the SALS group, there were 16 men and 19 women with a mean ± SD age of 63.00 ± 13.37 years and a mean BMI ± SD of 21.78 ± 3.95 kg/m2. With regard to ASA classification, class II was the most common, with 22 patients (62.9%), with underlying disease found in 26 patients (74.3%). The CLS group had nearly the same male-to-female ratio (17:20) with a mean age ± SD
46
of 62.02 ± 13.06 years and a mean BMI ± SD of 23.00 ± 2.50 kg/m2. ASA class II was the most prevalent with 26 patients (72.2%), and underlying disease was found in 28 patients (77.8%). No difference was found in clinical staging. The demographic data of the two groups were comparable (Table 1). Intraoperative data showed a difference in operation type: APR was the most common procedure in the SALS group, whereas LAR was most common in the CLS group. These figures were statistically significant (P = 0.001). Other factors such as operative time, volume of blood loss, and conversion rate were comparable. Intraoperative data are shown in Table 2. Pathologic results showed that staging and the number of nodes harvested were comparable between the groups, but there were some differences in T stage, tumor size, circumferential margin (CRM), distal rectal margin, and length of specimen. These differences were statistically significant (Tables 3,4). All patients had a negative CRM and distal rectal margin. With regard to postoperative complications, morbidities occurred in nine patients. In the SALS group, there was one case each of wound infection, exacerbation of gouty arthritis, thrombophlebitis, and atrial fibrillation in different individuals, and there were two cases of delirium. In the CLS group, there were two cases of wound infection and one of thrombophlebitis. Postoperative complications are shown in Table 5. In the early postoperative period in the SALS group, there was less pain with earlier recovery of bowel movement and shorter hospital stay. These differences were statistically significant, but analgesic (pethidine) usage did not significantly differ. Perioperative data are shown in Table 6. Figures 3 and 4 show an example of a postoperative wound at 30-day follow up.
Discussion In the last decade, colorectal cancer has progressed from being the ninth most common cancer in Thailand to being the second most prevalent, and its incidence, especially that of rectal cancer, is close to that of other developing
Asian J Endosc Surg 9 (2016) 44–51 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.
Single and conventional laparoscopic in rectum
S Sirikurnpiboon
Table 2 Intraoperative data SALS (n = 35) Operation (n) Anterior resection Low anterior resection Intersphincteric resection Abdominoperineal resection Operative time (min) Mean ± SD Median (min–max) Blood loss time (mL) Mean ± SD Median (min–max) Conversion (n)
CLS (n = 36)
P-value
2 (5.7%) 8 (22.9%) 0 (0.0%) 25 (71.4%)
0 (0.0%) 22 (61.1%) 1 (2.8%) 13 (36.1%)
264.57 ± 51.30 300 (180–360)
245.56 ± 53.48 240 (150–360)
0.24
