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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
Single-access laparoscopic rectal cancer surgery using the glove technique Siripong Sirikurnpiboon Colorectal Surgery Unit, General Surgery Department, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
Keywords Laparoscopic rectum cancer surgery; laparoscopic single access-surgery; laparoscopic single-port surgery Correspondence Siripong Sirikurnpiboon, Colorectal Surgery Unit, General Surgery Department, Rajavithi Hospital, College of Medicine, Rangsit University, 2, Phayathai Road, Rajadevi, Bangkok 10400, Thailand. Tel: +66 2 354 8108 (ext 3149) Fax: +66 2 354 8080 Email: [email protected] Received: 20 January 2014; revised 11 February 2014; accepted 18 February 2014 DOI:10.1111/ases.12099
Abstract Introduction: Single-access laparoscopic surgery has been widely adopted in many kinds of surgery including laparoscopic cholecystectomy and laparoscopic colectomy. Performing single-access rectal surgery, however, has technical drawbacks such as instrument collision and endostaple application issues. The glove technique is likely to mitigate these problems. Methods: Fourteen patients with anal canal to mid-rectum cancers were recruited and underwent single-access laparoscopic surgery via the glove technique. An incision was made at the paraumbilicus to insert a wound protector with surgical gloves. The operation was medial to lateral and inferior mesenteric artery and inferior mesenteric vein were identified and controlled. Total mesorectal excision was performed while keeping traction and countertraction down to the pelvic floor. Results: Average operative time was 251.66 min (range, 180–300 min). Hospital stay ranged from 5 to 8 days (median, 7 days). No serious early postoperative surgical problems related to complications were observed. The pathologic results showed good mesorectal capsule grading. The mean lymph node harvest was 14 nodes (range, 7–26 nodes), and the mean wound length was 5 cm (range, 4–6 cm). Conclusions: In rectal surgery, the glove technique for single-access laparoscopic surgery is feasible and is comparable to commercial single-port techniques in terms of oncologic results.
Introduction It is generally accepted that laparoscopic techniques in colon cancer have both short-term and long-term advantages over open surgery. Short-term benefits include early bowel recovery, reduced pain and shorter hospital stay (1), and long-term advantages include lower recurrence rates and improved overall survival (2). In laparoscopic rectum cancer surgery, other reported benefits include no difference in anastomosis leakage (3), oncologic outcome or recurrence rate compared with open surgery (4). Recently, studies in single-access laparoscopic surgery (SALS) in rectum cancer have reported some drawbacks such as instrument collision and endostaple application problems. In recent studies, Livraghi et al. and Hayashi et al. used an innovative technique, the glove technique,
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in various types of intra-abdominal operations with promising short-term results and easy composition of instruments (5,6). In this study, the author adapted this technique for use in rectum cancer operations and reported the short-term results.
Materials and Methods Inclusion criteria included the following: (i) patients diagnosed with cancer at the middle and low rectum and anal canal; (ii) tumor width less than 6 cm from radiologic study (CT or MRI); and (iii) patients did not meet clinical T4 lesion exclusion criteria (i.e. patients who are unfit for surgery, failed to follow up, had contraindications for anesthesia, or had asymptomatic stage 4 disease).
Asian J Endosc Surg 7 (2014) 206–213 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Single-port laparoscopic rectal surgery
S Sirikurnpiboon
Operative technique All the procedures were performed by a colorectal surgeon. All of the patients underwent bowel preparation 1 day before the operation with either 4-L polyethylene glycol electrolyte solution or 90-mL sodium phosphate solution depending on their comorbid disease. Surgical procedures were performed through a 4–6-cm single paraumbilical incision, and the glove technique was used with a small wound protector (Alexis wound protector/retractor; Applied Medical, Rancho Santa Margarita, USA) and size 7 latex or non-latex sterile surgical gloves. A 5-mm trocar port (LiNA port; LiNA Medical, Glostrup, Denmark) was used for the working space, a 5-mm trocar port for a camera port and gas insufflations, and a 10-mm trocar was added later for the endostapler. Instruments were connected by cable tie as shown in Figure 1. The camera was a 0° flexible videolaparoscope (LTF-VP; Olympus Medical Systems Corp, Tokyo, Japan). The surgeon and cameraman both stood on the right side of the patient, who was placed in the reverse Trendelenburg with a semi-right lateral position. The operation was performed using the standard laparoscopic technique with a medial to lateral approach. The
inferior mesenteric vessel was skeletonized and controlled by Hem-o-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. Lateral mobilization was then performed from the sigmoid to the splenic flexure. During anterior dissection, the author added another endo-clinch to pull up the peritoneal reflection vertically as shown in Figure 2. During low anterior resection (LAR), the rectum was transected using an endoscopic linear stapler (Endo-GIA, Covidien, Dublin, Ireland), and we placed an endoscopic linear stapler vertically as shown in Figure 3. The proximal colon was extracted via the paraumbilical incision. Resection was achieved following extracorporealization, after which 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. A pelvic drainage tube was inserted at a new incision at the right lower quadrant under laparoscopic view. In abdominoperineal resection (APR) cases, the author started the perineal resection phase after finishing the
Figure 1 Instrument for the glove technique. (a) Instruments included a small wound protector and 5-mm trocar ports. One 5-mm trocar port was used to enable gas insufflation. (b) Building the instrument with cable ties. The camera port with gas insufflation was assigned to the middle finger and two working ports were assigned to the thumb and little finger. (c) Glove technique in the operative field. The surgeon and cameraman stood in the same place.
Figure 2 An operative technique. (a) By the medial to lateral approach, mesenteric window was created from the sacral promontory and, the inferior mesenteric artery (IMA) was controlled with clips. (b) Posterior rectal mobilization. An endo-clinch was used to push the rectum up and dissect downward in a semicircular motion. (c) Anterior rectal mobilization. An endo-clinch was used to pull up a peritoneal reflection.
Asian J Endosc Surg 7 (2014) 206–213 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
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Spleen Figure 3 An operative technique. (a) Splenic mobilization. Tension was created with an endo-clinch to pull the descending colon to medial. (b) Applying an endolinear stapler vertically. A 10-mm trocar was added using the ring finger of the glove.
intraperitoneal phase using the standard technique. In the author’s institute, cylindrical APR is not routinely performed. In the postoperative phase, nurses asked patients’ about their pain using the visual analog scale and recorded the amount of intravenous analgesia (pethidine) each patient used. On the day of the operation, the author prescribed pethidine 25 mg every 6 hours intravenously and then as requested by patients on subsequent days. When a patient had bowel movement, oral analgesia was prescribed. Patient satisfaction about cosmesis was not collected. Data collection Demographic data including patients’ age, sex, underlying disease and BMI were tabulated together with the history of prior abdominal surgery. Intraoperative parameters including operative time, estimated blood loss, and intraoperative complications were collected. Pathologic characteristics including depth invasion, lymph node retrieval, circumferential margin, distal margin, and mesorectal capsule status were reviewed. The postoperative outcomes including length of stay in hospital and 30-day complications were recorded.
Results From October 2012 to October 2013, a total of 17 patients were recruited. Of these, three were excluded: one refused laparoscopic surgery, another was unfit for surgery due to severe comorbidity, and the third presented in an emergency condition due to colonic obstruction. The remaining 14 patients (8 women, 6 men), with a mean age of 58 (range, 23–82 years), were included in the study. Two of the patients were conversions to laparotomy: one had suffered a torn diaphragm during splenic mobilization and another had severe intra-abdominal adhesions as a result of a previous operation. The other 12 patients underwent SALS using
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the glove technique for middle rectum to anal canal cancer. The average BMI was 21.25 (range, 13.60– 26.67). The median ASA classification was class 2. The locations of the cancers were the anal canal (three patients), lower rectum (four), and middle rectum (five). The preoperative clinical continence status was normal in seven patients, gas incontinence in three, and liquid incontinence in two. The median preoperative staging was stage III (range, 2–3). Three of the patients had had previous operations: one had had a cesarean section, the second had had open cholecystectomy, and the third had had intestinal resection due to abdominal trauma. The procedures included seven APR, four LAR and one intersphincteric resection. The average operative time was 251.66 min (range, 180–300 min), and the average blood loss was 170.83 mL (range, 50–300 mL). There were no intraoperative or immediate postoperative complications (Table 1). One patient’s immediate postoperative wound and its appearance at 1-month follow-up are shown in Figure 4. The pathological results showed that the median T stage was stage 3 (range, 2–4), an average of 14 lymph nodes (range, 7–26 nodes) were harvested, the median mesorectal grading was 3 (range, 2–3), and the median pathologic staging was stage 3 (range, 2–3) (Table2). The median hospital stay was 7 days (range, 5–8 days), the median bowel recovery time was 3 days, and the mean wound length was 5 cm (range, 4–6 cm). The average pethidine dose was 200 mg in the APR and LAR groups, while the mean dose in the individual groups was 246 mg in the APR group and 135 mg in the LAR group. In this study, three patients had early postoperative complications: the first was exacerbated gouty arthritis; the second was lung atelectasis; and the third was atrial fibrillation. All were able to be discharged from hospital in good condition. There was one 30-day complication: this patient experienced angina pectoris 10 days after being discharged, was admitted to another hospital, and revisited 1 week later (Table 3).
Asian J Endosc Surg 7 (2014) 206–213 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Single-port laparoscopic rectal surgery
S Sirikurnpiboon
Table 1 Patients’ demographic data Case number
Age (years)
Sex
BMI
ASA classification
Previous operation
Location of tumor
Operation
Operative time (min)
1 2 3 4 5 6 7 8 9 10 11 12
64 54 68 54 82 53 23 68 77 57 53 47
Female Female Female Male Male Female Female Male Male Male Female Male
21.97 13.60 24.53 24.49 19.84 26.67 20.29 20.20 21.23 20.09 26.26 15.80
2 2 2 2 3 2 1 2 3 1 3 3
None None None C/S Abdominal trauma None None None OC None None None
Anal canal Anal canal Lower rectum Lower rectum Middle rectum Middle rectum Middle rectum Lower rectum Lower rectum Anal canal Middle rectum Middle rectum
APR APR APR APR LAR LAR LAR APR APR APR LAR ISR
180 180 240 240 300 240 300 200 300 240 300 300
APR, abdominoperineal resection; C/S, cesarean section; ISR, intersphincteric resection; LAR, low anterior resection; OC, open cholecystectomy.
Table 2 Pathological results Case number
T stage
N stage
Lymph nodes harvested (n)
Mesorectal grading
Circumferential margin
1 2 3 4 5 6 7 8 9 10 11 12
4 3 3 3 2 2 3 2 3 2 3 2
1 0 0 1 1 1 1 1 0 1 1 2
7 26 12 10 8 8 12 14 18 16 16 22
3 3 3 2 3 3 3 2 3 3 3 3
Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative
Figure 4 The postoperative wound. (a) An immediate postoperative wound in a patient who had low anterior resection with ileostomy. An ileostomy was created in the right lower quadrant area with a new incision. (b) The wound immediately postoperative. It was 5 cm in length. Wounds were closed by skin staple or suture. (c) The postoperative wound at 1 month follow-up. The scar is small and blends with the umbilicus. However, the wound is still recognizable.
Discussion Laparoscopic surgery is continuing to evolve with the aim of reducing postoperative morbidity and increasing quality of life while at the same time maintaining oncologic principles. One of its aims is to eliminate the use of incisions altogether.
NOTES is a widely accepted laparoscopic technique that reduces both the number of wounds and postoperative pain, but the development of this kind of technique is slow due to limitations in instrument development and the need for long-term skill training (7). Recently, a hybrid combination of NOTES and SALS has been reported (8). SALS is another cutting-edge technique in
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Table 3 Postoperative details and complications Mean length of hospital stay, days (range) Immediate postoperative complications (n) Gouty arthritis Atelectasis Atrial fibrillation Mean port-site wound length, cm (range) 30-day complications (n) Angina pectoris 30-day mortality
7 (5–8) 1 1 1 5 (4–6) 1 0
laparoscopic surgery, but it presents challenges for surgeons. Currently, SALS is widely used in many operations such as cholecystectomy (9), appendectomy (10), and colectomy (11). A comparative study between SALS and conventional laparoscopic surgery by Chao et al. showed that differences in conversion rates, operative times and postoperative complications were not statistically significant, but the SALS group had a statistically significant shorter hospital stay (12). A report on laparoscopic rectal surgery by Leroy et al. showed that oncologic outcomes from laparoscopic surgery were not significantly different from those of open surgery (13). The first report of SALS in LAR from Hamzaoglu et al. showed excellent results (14). Technical problems encountered in SALS in previous reports were instrument collision, limited laparoscopic view, total mesorectal excision technique, and difficulties in applying endostaples (14–17). Instrument collision was caused by failure to maintain triangulation during operations (18). Possible ways to resolve this problem include using articulated instruments and flexible laparoscopes. During the operations in this study, the crossover and parallel-hand techniques were used. Sometimes in deep pelvis dissection, it is necessary to remove and reinsert instruments for realignment. A 0° flexible tip laparoscope was chosen in the present study to avoid collision, as the tip can be adjusted and enables the surgeon to watch the operative field as the shaft deviates out. As for the limited laparoscopic view, which is mostly encountered during splenic mobilization, this problem may be resolved by using a flexible laparoscope. However, the most important factor in this step is to ensure that dissection is slowly and carefully performed. In total mesorectal excision, the key point is to keep traction on the rectum and sigmoid. Many maneuvers have been suggested such as hanging with a suspension tie (13), suspending a bar with an extracorporeal magnet (15), and suturing the sigmoid and rectum to the abdominal wall (19). As for the problem of applying the
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endostaples, the suggestions were to add another port at a new incision at the right lower quadrant area (16), add another port in a multichannel port, and use a prolapsing technique (20,21) Initial experience with the glove technique has shown acceptable operating times and pathological results without additional morbidity. With regard to oncologic results in laparoscopic rectal surgery and single-access laparoscopic rectal surgery, a few reports have been published showing excellent outcomes (14–17,22–26). Previous studies in single-access or single-port laparoscopic rectal surgery are described on Table 4. In addition, Table 5 describes previous studies in conventional and standard laparoscopic surgery. Assessment of the technical procedure has been made by evaluating blood loss, the operative time, and the pathology findings, such as mesorectal grading and harvested lymph nodes, in order to determine the quality of oncologic outcomes (33–35). In our series, there were no cases of tumor involvement at the distal or circumferential resection margins. For lymph node evaluation, the number of nodes is the first fact to be considered, but it is affected by many other factors such as tumor location, the pathologist, the surgeon, and the method of specimen preparation. However, many recent reports have examined lymph node ratios as predictors of probability of survival (36,37). With regard to mesorectal completeness, a report from Quirke et al. showed a significant link between survival and completeness of mesorectal resection (27), but a later report from Nagtegaal et al. showed no prognostic difference between patients with a complete mesorectum compared to those with a nearly complete mesorectum (38). However, patients with an incomplete mesorectum had a significantly higher risk of local recurrence compared to patients who had a complete mesorectum. The advantages found with the glove technique were that it provides an additional working port, reduces instrument collision due to the extra space it provides in the multichannel port, facilitates extraction of the proximal colon to join with the anvil in circular anastomosis, and it is inexpensive to perform. The disadvantages were that the glove can be torn easily during operations, the procedure results in a bigger wound compared with commercial port systems, and there is no fixed point or fulcrum. Limitations of this study include the lack of difference in postoperative pain control and long-term oncologic results. In conclusion, the initial short-term result for SALS using the glove technique for rectum cancer surgery indi-
Asian J Endosc Surg 7 (2014) 206–213 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Single-port laparoscopic rectal surgery
S Sirikurnpiboon
Table 4 Previous studies in single-access or single-port laparoscopic rectal surgery Author
Patient number
Hamzaoglu et al. (14)
4
Uematsu et al. (15)
7
Operation
Port type
Mean operative time (min)
Disease stage
Mean wound length (cm)
Quirke mesorectal grade
4 LAR 1 TAE LAR
TRIport
347
3.5
3
Self- innovation
205
2 stage III 2 stage I 2 stage II 5 stage III 0 stage 0 3 stage I 3 stage II 7 stage III 2 stage IV 3 stage I 1 stage II 6 stage III
3
NA
2.8
NA
2.5
NA
NA 5.5
NA 8 grade 3 2 grade 2 10 grade 3 2 grade 2
Hirano et al. (16)
15
AR
EZ lap protector + 12-mm port
276
Bulut et al. (25)
10
SILS
240
Hua-Feng et al. (17) Sirikurnpiboon & Jivapaisarnpong (26) Present study
20 10
6 LAR 2 AR 1 APR 1 Hartmann procedure APR 9 APR 1 LAR 7 APR 4 LAR 1 ISR
Self-innovation Glove port
138 269
Glove technique
251
12
NA 4 stage II 6 stage III 3 stage II 9 stage III
5
AR, anterior resection; APR, abodominoperineal resection; ISR, intersphincteric resection; LAR, low anterior resection; TAE, transabdominal anal excision.
Table 5 Previous studies using conventional or standard laparoscopic rectal cancer surgery Author
Patients (n)
Operation
Operative time, min (mean ± SD)
Median of lymph node harvest, n (range)
Bretagnol et al. (27) Morino et al. (28)
44 100
LAR LAR
NA 250.0 ± 31.2
9 (0–29) 12.8 (6–93)
Breukink et al. (29)
25
19 LAR 6 APR 202 AR 24 APR 77 LAR 24 APR LAR 151 LAR 19 APR
NA
11 (3–25)
NA 20 stage I 29 stage II 30 stage III 8 stage IV NA
254.0 ± 58.4
14.4 ± 4.6‡
NA
193.7 ± 45.1
13.63†
NA
166.0 ± 26 244.9 ± 75.4
18.9† 17 (12–22)
NA 59 stage I,II 111 stage III
Staudacher et al. (30)
226
Lujan et al. (31)
101
Gouvas et al. (32) Kang et al. (24)
45 170
Disease stage
†Mean figures. ‡Mean ± SD. APR, abdominoperineal resection; AR, anterior resection; LAR, low anterior resection.
cate that it can be performed safely with acceptable oncologic results and with no additional incision for specimen removal. However, patient selection is a critical step, and operating on patients with a bulky tumor or high BMI may present difficulties.
Acknowledgment The author has no conflict of interest or financial relationship to disclose.
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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
Single-access laparoscopic rectal cancer surgery using the glove technique Siripong Sirikurnpiboon Colorectal Surgery Unit, General Surgery Department, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
Keywords Laparoscopic rectum cancer surgery; laparoscopic single access-surgery; laparoscopic single-port surgery Correspondence Siripong Sirikurnpiboon, Colorectal Surgery Unit, General Surgery Department, Rajavithi Hospital, College of Medicine, Rangsit University, 2, Phayathai Road, Rajadevi, Bangkok 10400, Thailand. Tel: +66 2 354 8108 (ext 3149) Fax: +66 2 354 8080 Email: [email protected] Received: 20 January 2014; revised 11 February 2014; accepted 18 February 2014 DOI:10.1111/ases.12099
Abstract Introduction: Single-access laparoscopic surgery has been widely adopted in many kinds of surgery including laparoscopic cholecystectomy and laparoscopic colectomy. Performing single-access rectal surgery, however, has technical drawbacks such as instrument collision and endostaple application issues. The glove technique is likely to mitigate these problems. Methods: Fourteen patients with anal canal to mid-rectum cancers were recruited and underwent single-access laparoscopic surgery via the glove technique. An incision was made at the paraumbilicus to insert a wound protector with surgical gloves. The operation was medial to lateral and inferior mesenteric artery and inferior mesenteric vein were identified and controlled. Total mesorectal excision was performed while keeping traction and countertraction down to the pelvic floor. Results: Average operative time was 251.66 min (range, 180–300 min). Hospital stay ranged from 5 to 8 days (median, 7 days). No serious early postoperative surgical problems related to complications were observed. The pathologic results showed good mesorectal capsule grading. The mean lymph node harvest was 14 nodes (range, 7–26 nodes), and the mean wound length was 5 cm (range, 4–6 cm). Conclusions: In rectal surgery, the glove technique for single-access laparoscopic surgery is feasible and is comparable to commercial single-port techniques in terms of oncologic results.
Introduction It is generally accepted that laparoscopic techniques in colon cancer have both short-term and long-term advantages over open surgery. Short-term benefits include early bowel recovery, reduced pain and shorter hospital stay (1), and long-term advantages include lower recurrence rates and improved overall survival (2). In laparoscopic rectum cancer surgery, other reported benefits include no difference in anastomosis leakage (3), oncologic outcome or recurrence rate compared with open surgery (4). Recently, studies in single-access laparoscopic surgery (SALS) in rectum cancer have reported some drawbacks such as instrument collision and endostaple application problems. In recent studies, Livraghi et al. and Hayashi et al. used an innovative technique, the glove technique,
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in various types of intra-abdominal operations with promising short-term results and easy composition of instruments (5,6). In this study, the author adapted this technique for use in rectum cancer operations and reported the short-term results.
Materials and Methods Inclusion criteria included the following: (i) patients diagnosed with cancer at the middle and low rectum and anal canal; (ii) tumor width less than 6 cm from radiologic study (CT or MRI); and (iii) patients did not meet clinical T4 lesion exclusion criteria (i.e. patients who are unfit for surgery, failed to follow up, had contraindications for anesthesia, or had asymptomatic stage 4 disease).
Asian J Endosc Surg 7 (2014) 206–213 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Single-port laparoscopic rectal surgery
S Sirikurnpiboon
Operative technique All the procedures were performed by a colorectal surgeon. All of the patients underwent bowel preparation 1 day before the operation with either 4-L polyethylene glycol electrolyte solution or 90-mL sodium phosphate solution depending on their comorbid disease. Surgical procedures were performed through a 4–6-cm single paraumbilical incision, and the glove technique was used with a small wound protector (Alexis wound protector/retractor; Applied Medical, Rancho Santa Margarita, USA) and size 7 latex or non-latex sterile surgical gloves. A 5-mm trocar port (LiNA port; LiNA Medical, Glostrup, Denmark) was used for the working space, a 5-mm trocar port for a camera port and gas insufflations, and a 10-mm trocar was added later for the endostapler. Instruments were connected by cable tie as shown in Figure 1. The camera was a 0° flexible videolaparoscope (LTF-VP; Olympus Medical Systems Corp, Tokyo, Japan). The surgeon and cameraman both stood on the right side of the patient, who was placed in the reverse Trendelenburg with a semi-right lateral position. The operation was performed using the standard laparoscopic technique with a medial to lateral approach. The
inferior mesenteric vessel was skeletonized and controlled by Hem-o-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. Lateral mobilization was then performed from the sigmoid to the splenic flexure. During anterior dissection, the author added another endo-clinch to pull up the peritoneal reflection vertically as shown in Figure 2. During low anterior resection (LAR), the rectum was transected using an endoscopic linear stapler (Endo-GIA, Covidien, Dublin, Ireland), and we placed an endoscopic linear stapler vertically as shown in Figure 3. The proximal colon was extracted via the paraumbilical incision. Resection was achieved following extracorporealization, after which 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. A pelvic drainage tube was inserted at a new incision at the right lower quadrant under laparoscopic view. In abdominoperineal resection (APR) cases, the author started the perineal resection phase after finishing the
Figure 1 Instrument for the glove technique. (a) Instruments included a small wound protector and 5-mm trocar ports. One 5-mm trocar port was used to enable gas insufflation. (b) Building the instrument with cable ties. The camera port with gas insufflation was assigned to the middle finger and two working ports were assigned to the thumb and little finger. (c) Glove technique in the operative field. The surgeon and cameraman stood in the same place.
Figure 2 An operative technique. (a) By the medial to lateral approach, mesenteric window was created from the sacral promontory and, the inferior mesenteric artery (IMA) was controlled with clips. (b) Posterior rectal mobilization. An endo-clinch was used to push the rectum up and dissect downward in a semicircular motion. (c) Anterior rectal mobilization. An endo-clinch was used to pull up a peritoneal reflection.
Asian J Endosc Surg 7 (2014) 206–213 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
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Spleen Figure 3 An operative technique. (a) Splenic mobilization. Tension was created with an endo-clinch to pull the descending colon to medial. (b) Applying an endolinear stapler vertically. A 10-mm trocar was added using the ring finger of the glove.
intraperitoneal phase using the standard technique. In the author’s institute, cylindrical APR is not routinely performed. In the postoperative phase, nurses asked patients’ about their pain using the visual analog scale and recorded the amount of intravenous analgesia (pethidine) each patient used. On the day of the operation, the author prescribed pethidine 25 mg every 6 hours intravenously and then as requested by patients on subsequent days. When a patient had bowel movement, oral analgesia was prescribed. Patient satisfaction about cosmesis was not collected. Data collection Demographic data including patients’ age, sex, underlying disease and BMI were tabulated together with the history of prior abdominal surgery. Intraoperative parameters including operative time, estimated blood loss, and intraoperative complications were collected. Pathologic characteristics including depth invasion, lymph node retrieval, circumferential margin, distal margin, and mesorectal capsule status were reviewed. The postoperative outcomes including length of stay in hospital and 30-day complications were recorded.
Results From October 2012 to October 2013, a total of 17 patients were recruited. Of these, three were excluded: one refused laparoscopic surgery, another was unfit for surgery due to severe comorbidity, and the third presented in an emergency condition due to colonic obstruction. The remaining 14 patients (8 women, 6 men), with a mean age of 58 (range, 23–82 years), were included in the study. Two of the patients were conversions to laparotomy: one had suffered a torn diaphragm during splenic mobilization and another had severe intra-abdominal adhesions as a result of a previous operation. The other 12 patients underwent SALS using
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the glove technique for middle rectum to anal canal cancer. The average BMI was 21.25 (range, 13.60– 26.67). The median ASA classification was class 2. The locations of the cancers were the anal canal (three patients), lower rectum (four), and middle rectum (five). The preoperative clinical continence status was normal in seven patients, gas incontinence in three, and liquid incontinence in two. The median preoperative staging was stage III (range, 2–3). Three of the patients had had previous operations: one had had a cesarean section, the second had had open cholecystectomy, and the third had had intestinal resection due to abdominal trauma. The procedures included seven APR, four LAR and one intersphincteric resection. The average operative time was 251.66 min (range, 180–300 min), and the average blood loss was 170.83 mL (range, 50–300 mL). There were no intraoperative or immediate postoperative complications (Table 1). One patient’s immediate postoperative wound and its appearance at 1-month follow-up are shown in Figure 4. The pathological results showed that the median T stage was stage 3 (range, 2–4), an average of 14 lymph nodes (range, 7–26 nodes) were harvested, the median mesorectal grading was 3 (range, 2–3), and the median pathologic staging was stage 3 (range, 2–3) (Table2). The median hospital stay was 7 days (range, 5–8 days), the median bowel recovery time was 3 days, and the mean wound length was 5 cm (range, 4–6 cm). The average pethidine dose was 200 mg in the APR and LAR groups, while the mean dose in the individual groups was 246 mg in the APR group and 135 mg in the LAR group. In this study, three patients had early postoperative complications: the first was exacerbated gouty arthritis; the second was lung atelectasis; and the third was atrial fibrillation. All were able to be discharged from hospital in good condition. There was one 30-day complication: this patient experienced angina pectoris 10 days after being discharged, was admitted to another hospital, and revisited 1 week later (Table 3).
Asian J Endosc Surg 7 (2014) 206–213 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Single-port laparoscopic rectal surgery
S Sirikurnpiboon
Table 1 Patients’ demographic data Case number
Age (years)
Sex
BMI
ASA classification
Previous operation
Location of tumor
Operation
Operative time (min)
1 2 3 4 5 6 7 8 9 10 11 12
64 54 68 54 82 53 23 68 77 57 53 47
Female Female Female Male Male Female Female Male Male Male Female Male
21.97 13.60 24.53 24.49 19.84 26.67 20.29 20.20 21.23 20.09 26.26 15.80
2 2 2 2 3 2 1 2 3 1 3 3
None None None C/S Abdominal trauma None None None OC None None None
Anal canal Anal canal Lower rectum Lower rectum Middle rectum Middle rectum Middle rectum Lower rectum Lower rectum Anal canal Middle rectum Middle rectum
APR APR APR APR LAR LAR LAR APR APR APR LAR ISR
180 180 240 240 300 240 300 200 300 240 300 300
APR, abdominoperineal resection; C/S, cesarean section; ISR, intersphincteric resection; LAR, low anterior resection; OC, open cholecystectomy.
Table 2 Pathological results Case number
T stage
N stage
Lymph nodes harvested (n)
Mesorectal grading
Circumferential margin
1 2 3 4 5 6 7 8 9 10 11 12
4 3 3 3 2 2 3 2 3 2 3 2
1 0 0 1 1 1 1 1 0 1 1 2
7 26 12 10 8 8 12 14 18 16 16 22
3 3 3 2 3 3 3 2 3 3 3 3
Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative
Figure 4 The postoperative wound. (a) An immediate postoperative wound in a patient who had low anterior resection with ileostomy. An ileostomy was created in the right lower quadrant area with a new incision. (b) The wound immediately postoperative. It was 5 cm in length. Wounds were closed by skin staple or suture. (c) The postoperative wound at 1 month follow-up. The scar is small and blends with the umbilicus. However, the wound is still recognizable.
Discussion Laparoscopic surgery is continuing to evolve with the aim of reducing postoperative morbidity and increasing quality of life while at the same time maintaining oncologic principles. One of its aims is to eliminate the use of incisions altogether.
NOTES is a widely accepted laparoscopic technique that reduces both the number of wounds and postoperative pain, but the development of this kind of technique is slow due to limitations in instrument development and the need for long-term skill training (7). Recently, a hybrid combination of NOTES and SALS has been reported (8). SALS is another cutting-edge technique in
Asian J Endosc Surg 7 (2014) 206–213 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
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Table 3 Postoperative details and complications Mean length of hospital stay, days (range) Immediate postoperative complications (n) Gouty arthritis Atelectasis Atrial fibrillation Mean port-site wound length, cm (range) 30-day complications (n) Angina pectoris 30-day mortality
7 (5–8) 1 1 1 5 (4–6) 1 0
laparoscopic surgery, but it presents challenges for surgeons. Currently, SALS is widely used in many operations such as cholecystectomy (9), appendectomy (10), and colectomy (11). A comparative study between SALS and conventional laparoscopic surgery by Chao et al. showed that differences in conversion rates, operative times and postoperative complications were not statistically significant, but the SALS group had a statistically significant shorter hospital stay (12). A report on laparoscopic rectal surgery by Leroy et al. showed that oncologic outcomes from laparoscopic surgery were not significantly different from those of open surgery (13). The first report of SALS in LAR from Hamzaoglu et al. showed excellent results (14). Technical problems encountered in SALS in previous reports were instrument collision, limited laparoscopic view, total mesorectal excision technique, and difficulties in applying endostaples (14–17). Instrument collision was caused by failure to maintain triangulation during operations (18). Possible ways to resolve this problem include using articulated instruments and flexible laparoscopes. During the operations in this study, the crossover and parallel-hand techniques were used. Sometimes in deep pelvis dissection, it is necessary to remove and reinsert instruments for realignment. A 0° flexible tip laparoscope was chosen in the present study to avoid collision, as the tip can be adjusted and enables the surgeon to watch the operative field as the shaft deviates out. As for the limited laparoscopic view, which is mostly encountered during splenic mobilization, this problem may be resolved by using a flexible laparoscope. However, the most important factor in this step is to ensure that dissection is slowly and carefully performed. In total mesorectal excision, the key point is to keep traction on the rectum and sigmoid. Many maneuvers have been suggested such as hanging with a suspension tie (13), suspending a bar with an extracorporeal magnet (15), and suturing the sigmoid and rectum to the abdominal wall (19). As for the problem of applying the
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endostaples, the suggestions were to add another port at a new incision at the right lower quadrant area (16), add another port in a multichannel port, and use a prolapsing technique (20,21) Initial experience with the glove technique has shown acceptable operating times and pathological results without additional morbidity. With regard to oncologic results in laparoscopic rectal surgery and single-access laparoscopic rectal surgery, a few reports have been published showing excellent outcomes (14–17,22–26). Previous studies in single-access or single-port laparoscopic rectal surgery are described on Table 4. In addition, Table 5 describes previous studies in conventional and standard laparoscopic surgery. Assessment of the technical procedure has been made by evaluating blood loss, the operative time, and the pathology findings, such as mesorectal grading and harvested lymph nodes, in order to determine the quality of oncologic outcomes (33–35). In our series, there were no cases of tumor involvement at the distal or circumferential resection margins. For lymph node evaluation, the number of nodes is the first fact to be considered, but it is affected by many other factors such as tumor location, the pathologist, the surgeon, and the method of specimen preparation. However, many recent reports have examined lymph node ratios as predictors of probability of survival (36,37). With regard to mesorectal completeness, a report from Quirke et al. showed a significant link between survival and completeness of mesorectal resection (27), but a later report from Nagtegaal et al. showed no prognostic difference between patients with a complete mesorectum compared to those with a nearly complete mesorectum (38). However, patients with an incomplete mesorectum had a significantly higher risk of local recurrence compared to patients who had a complete mesorectum. The advantages found with the glove technique were that it provides an additional working port, reduces instrument collision due to the extra space it provides in the multichannel port, facilitates extraction of the proximal colon to join with the anvil in circular anastomosis, and it is inexpensive to perform. The disadvantages were that the glove can be torn easily during operations, the procedure results in a bigger wound compared with commercial port systems, and there is no fixed point or fulcrum. Limitations of this study include the lack of difference in postoperative pain control and long-term oncologic results. In conclusion, the initial short-term result for SALS using the glove technique for rectum cancer surgery indi-
Asian J Endosc Surg 7 (2014) 206–213 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Single-port laparoscopic rectal surgery
S Sirikurnpiboon
Table 4 Previous studies in single-access or single-port laparoscopic rectal surgery Author
Patient number
Hamzaoglu et al. (14)
4
Uematsu et al. (15)
7
Operation
Port type
Mean operative time (min)
Disease stage
Mean wound length (cm)
Quirke mesorectal grade
4 LAR 1 TAE LAR
TRIport
347
3.5
3
Self- innovation
205
2 stage III 2 stage I 2 stage II 5 stage III 0 stage 0 3 stage I 3 stage II 7 stage III 2 stage IV 3 stage I 1 stage II 6 stage III
3
NA
2.8
NA
2.5
NA
NA 5.5
NA 8 grade 3 2 grade 2 10 grade 3 2 grade 2
Hirano et al. (16)
15
AR
EZ lap protector + 12-mm port
276
Bulut et al. (25)
10
SILS
240
Hua-Feng et al. (17) Sirikurnpiboon & Jivapaisarnpong (26) Present study
20 10
6 LAR 2 AR 1 APR 1 Hartmann procedure APR 9 APR 1 LAR 7 APR 4 LAR 1 ISR
Self-innovation Glove port
138 269
Glove technique
251
12
NA 4 stage II 6 stage III 3 stage II 9 stage III
5
AR, anterior resection; APR, abodominoperineal resection; ISR, intersphincteric resection; LAR, low anterior resection; TAE, transabdominal anal excision.
Table 5 Previous studies using conventional or standard laparoscopic rectal cancer surgery Author
Patients (n)
Operation
Operative time, min (mean ± SD)
Median of lymph node harvest, n (range)
Bretagnol et al. (27) Morino et al. (28)
44 100
LAR LAR
NA 250.0 ± 31.2
9 (0–29) 12.8 (6–93)
Breukink et al. (29)
25
19 LAR 6 APR 202 AR 24 APR 77 LAR 24 APR LAR 151 LAR 19 APR
NA
11 (3–25)
NA 20 stage I 29 stage II 30 stage III 8 stage IV NA
254.0 ± 58.4
14.4 ± 4.6‡
NA
193.7 ± 45.1
13.63†
NA
166.0 ± 26 244.9 ± 75.4
18.9† 17 (12–22)
NA 59 stage I,II 111 stage III
Staudacher et al. (30)
226
Lujan et al. (31)
101
Gouvas et al. (32) Kang et al. (24)
45 170
Disease stage
†Mean figures. ‡Mean ± SD. APR, abdominoperineal resection; AR, anterior resection; LAR, low anterior resection.
cate that it can be performed safely with acceptable oncologic results and with no additional incision for specimen removal. However, patient selection is a critical step, and operating on patients with a bulky tumor or high BMI may present difficulties.
Acknowledgment The author has no conflict of interest or financial relationship to disclose.
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