COLORECTAL ANZJSurg.com
Single incision and reduced port laparoscopic low anterior resection for rectal cancer: initial experience in 96 cases Kyung Uk Jung,* Seong Hyeon Yun,† Yong Beom Cho,† Hee Cheol Kim,† Woo Yong Lee† and Ho-Kyung Chun* *Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea and †Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Key words colorectal neoplasms, laparoscopy, laparoscopic low anterior resection, reduced port surgery, single incision laparoscopic surgery. Correspondence Professor Seong Hyeon Yun, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea. Email: [email protected] K. U. Jung MD; S. H. Yun MD, PhD; Y. B. Cho MD, PhD; H. C. Kim MD, PhD; W. Y. Lee MD, PhD; H. K. Chun MD, PhD. This study was presented at the 20th International Congress of the European Association for Endoscopic Surgery, Brussels, Belgium in 2012. Accepted for publication 9 June 2014. doi: 10.1111/ans.12775
Abstract Background: Although a single incision laparoscopic (SIL) technique has been used increasingly in colorectal surgery, there are only a few reports on the clinical availability of this approach coupled with low anterior resection (SIL–LAR) for colorectal cancers. We report here 96 consecutive cases of SIL–LAR and reduced port LAR cases, of which the initial approach was SIL. Methods: This is a retrospective review of prospectively collected data of SIL–LAR cases performed by a single surgeon in Samsung Medical Center between June 2011 and June 2012. Results: Out of 96 cases, 28 were finished as ‘pure’ SIL–LAR. Sixty-four cases were performed with one additional port, and four needed two more ports. There was no open conversion. The median duration of operation was 165 min. Proximal and distal resection margins were negative in all cases. Circumferential resection margins were positive in four cases. The median duration of postoperative stay was 7 days and the complication rate was 20%. There were six cases of anastomosis leakage (6%). Conclusion: The SIL–LAR technique can be applied safely with the optional use of an additional port. One additional port in the right suprapubic area is useful for obtaining a secure distal division and a safe total mesorectal excision, especially in patients with lower lesions or history of neoadjuvant chemoradiation.
Introduction
Methods
The single incision laparoscopic (SIL) technique has been used increasingly in colorectal surgery. Up to 20 reports about SIL colectomy including a meta-analysis of >1000 colorectal procedures have concluded that ileocolic resection, right hemicolectomy and anterior resection via SIL was safe and feasible.1–4 However, there is little evidence for the clinical availability of SIL coupled with low anterior resection (SIL–LAR). Although there have been several studies reporting successful cases of SIL–LAR,5,6 there were too few patients to make any definite conclusion. Here, we have compiled our collective experience of patients with colorectal cancer treated with SIL–LAR for a year after its introduction at our institution. To examine the safety and effectiveness of this approach, we analysed the short-term outcomes of SIL–LAR and reduced port LAR of which the initial approach was SIL.
Patients and data collection
© Australasian College College of of Surgeons Surgeons © 2014 2014 Royal Australasian
The institutional review board of Samsung Medical Center approved this study. This series is a retrospective review of prospectively collected data regarding a consecutive series of patients with colorectal cancer undergoing planned SIL–LAR in Samsung Medical Center by a single surgeon between June 2011 and June 2012. Patients were included in this series regardless of final operative method when the initial approach was SIL–LAR. Because of the retrospective nature of the study, the selection criteria for SIL–LAR were not determined strictly and changed as time went by. In the early phase, we carefully selected patients with upper rectal cancers at a relatively early stage, without a history of neoadjuvant concurrent chemoradiation (CCRT). However, after several successful cases, the indication extended to that of conventional laparoscopy. ANZ J Surg (2014) ••–•• ANZ J Surg 86•• (2016) 403–407
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Jung et al.
Fig. 1. Custom-made glove port and mounting. (a) It usually comprised a powder-free left-hand surgical glove and three disposable trocars. (b) Unlike other ready-made ports for single incision laparoscopic surgery, the trocars of this custom-made glove port do not intrude into the skin incision. This can reduce the collision between instruments.
Surgical techniques The patient was placed in the lithotomy position. The skin incision was made in the midline transumbilically or at the future ileostomy site, which was marked preoperatively by a qualified enterostomal therapist. The surgeon decided whether to create a diverting ileostomy before making the incision, considering the location of the mass, preoperative treatment history and the patient’s general condition. The initial incision was about 2–4 cm long, reflecting the patient’s body shape and mass size. After the peritoneum was entered, an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) was inserted. We used a custom-made glove port consisting of a surgical glove and three or four Separator access systems (Applied Medical) (Fig. 1). The patient was placed in a Trendelenburg position with the left side elevated. The surgeon and assistant holding the laparoscope stood beside the patient on his/her left side. An additional port was inserted in case when it was difficult to proceed with the operation for any reason. The 12-mm trocar was mainly used and it was generally located in the right suprapubic area, on the lateral side of right deep inferior epigastric vessels (Fig. 2). After getting sufficient distal margin, the rectum was divided using an Endo GIA Ultra Universal Stapler (Covidien, Mansfield, MA, USA). The bowel was extracted through the wound retractor, after removing the covering glove. In case of advanced tumours (T3 or 4), we covered the distal part of the rectum containing the tumour with a LapBag (Sejong Medical Co., Ltd., Paju, Korea) to prevent tumour seeding by extrusion while extracting. The incision was extended in cases where the tumour size or mesenteric thickness was not favourable for the initial one. After delivery of the specimen, anastomosis was made with a DST Series EEA 28 stapling device (Covidien). When the tumour location was very close to
the anus, the bowel was extracted through the anus and a hand-sewn coloanal anastomosis was made. Although splenic flexure take-down is not a routine procedure, it was performed in a large percentage of cases to achieve a tension-free anastomosis. We used common straight devices for conventional laparoscopy in all cases.
Statistics The data were analysed using SPSS software version 19.0 (IBM SPSS Statistics, Armonk, NY, USA). They were analysed using the Mann–Whitney non-parametric U-test, Chi-squared test or Fisher’s exact test and one-sample Student’s t-test. Results were considered statistically significant at P < 0.05.
Results Patient characteristics and operation-related parameters Ninety-six patients (59 men and 37 women) with median age of 57 years and a median body mass index (BMI) of 24.1 kg/m2 underwent SIL–LAR for the treatment of malignant or premalignant neoplastic disease during the study period (Table 1). The tumours were mainly located between the rectosigmoid junction (n = 30, 31%) and rectum (n = 65, 68%). Fifteen patients (16%) had a history of abdominal operations, and 24 (25%) received CCRT before surgery. Combined procedures were performed in 11 patients (12%). Incision for the main portal was made in the midline transumbilically in 59 patients (62%) and at the future ileostomy site in the other 37 patients (39%). In addition to these 37 patients with an initial plan of the diverting stoma, only one in the transumbilical approach group underwent protective ileostomy. Of all 96 cases of surgical operation, 28 (29%) ©©2014 2014 Royal Royal Australasian Australasian College of Surgeons
Single incision laparoscopic LAR
3 405
Fig. 2. Location of the additional port. (a) It is usually inserted in the right suprapubic area, on the lateral side of the right deep inferior epigastric vessels. (b) Final operative wound of single incision laparoscopic low anterior resection plus one additional port after completion of the procedure.
Table 1 Clinical characteristics and procedure-related parameters of the patients (n = 96) Age (years) Gender (M : F) BMI (kg/m2) ASA score (I : II : III) Tumour location (sigmoid colon : rectosigmoid junction : rectum) Previous abdominal operation (Yes : No) Preoperative chemoradiation (Yes : No) Combined procedure (Yes : No) Purpose (curative : palliative) Main portal approach (ileostomy site : transumbilical) Protective ileostomy† (Yes : No) Additional port (0:1:2) Conversion to open surgery Final size of incision‡ (cm) Anastomosis method (double stapling method : hand sewing) Level of anastomosis§ (≤3 cm : 3 cm < and ≤ 6 : 6 < cm) Duration of operation (min) Estimated blood loss (mL)
57 (range 28–77) 59:37 24.1 (range 18.3–31.6) 48:46:2 1:30:65 15:81 24:72 11:85 91:5 37:59 38:58 28:64:4 No 3.5 (range 2.0–6.0) 88:8 18:39:25 165 (range 93–357) 100 (range 20–700)
†Only one patient in the transumbilical approach group required protective ileostomy. ‡Data from one patient were missing. §Data from 14 patients were missing. ASA, American Society of Anesthesiologists; BMI, body mass index; F, Female; M, male.
were completed by the SIL technique. Sixty-four cases (67%) required one additional port and two more ports were needed in four other cases (4%). There was no need for open conversion. The median length of the final wound was 3.5 cm (range 2.0–6.0 cm). The median duration of the operation was 165 min (range 93–357 min) and the median estimated blood loss was 100 mL (range 20–700 mL).
Oncological resection and postoperative recovery Most tumours were adenocarcinomas (n = 94, 98%), except for one tubular adenoma with high-grade dysplasia and one carcinoids © Australasian College College of of Surgeons Surgeons © 2014 2014 Royal Australasian
Table 2 Parameters associated postoperative recovery (n = 96)
with
Tumour histology Carcinoid Tubular adenoma with high-grade dysplasia Adenocarcinoma (WD : MD : PD : MUC) Stage† (0 : I : II : III : IV) Tumour size (cm) Proximal resection margin (cm) Distal resection margin (cm) Circumferential resection margin‡ (negative : positive) Harvested lymph nodes Median time to first bowel movement (days) Median time to full diet (days) Median postoperative hospital stay (days) Complications (Yes : No) Leakage Bleeding Deep surgical site infection Postoperative ileus Chyle leakage Ileostomy prolapse Delirium Paroxysmal supraventricular tachycardia Urinary retention Complication grade by Clavien-Dindo classification ( I : II : III : IV) Readmission within 30 days (Yes : No)
oncologic
resection
and
1 1 94 (33:57:1:3) 4:30:13:41:6 3.0 (range 0.1–10.0) 11.0 (range 4.0–25.0) 3.5 (range 0.5–15.0) 89:4 15 (range 3–73) 2 (range 0–5) 3 (range 1–8) 7 (range 5–52) 19:77 6 1 1 5 1 1 1 1 2 5:5:5:4 3:93
†According to the AJCC7 stage, in cases of adenocarcinoma. ‡There were no pathology reports about the circumferential resection margin in three cases of rectosigmoid colon cancers. MD, moderately differentiated; MUC, mucinous; PD, poorly differentiated; WD, well differentiated.
(Table 2). The pathology stages of adenocarcinomas included stage 0 (n = 4, 4%), stage I (n = 30, 31%), stage II (n = 13, 14%), stage III (n = 41, 43%) and stage IV (n = 6, 6%). Of six patients with stage IV tumours, five underwent palliative resection for primary disease. Multifocal metastases were not controlled in these cases. All proximal and distal resection margins (DRMs) were negative and the
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Jung et al.
Table 3 Parameters related with additional port insertion Additional port
Tumour location Sigmoid colon : rectosigmoid junction : rectum Preoperative chemoradiation (Yes : No) Anastomosis level (cm)
P value
Yes (n = 68)
No (n = 28)
0:19:49
1:11:16
22:46
2:26
Single incision and reduced port laparoscopic low anterior resection for rectal cancer: initial experience in 96 cases Kyung Uk Jung,* Seong Hyeon Yun,† Yong Beom Cho,† Hee Cheol Kim,† Woo Yong Lee† and Ho-Kyung Chun* *Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea and †Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Key words colorectal neoplasms, laparoscopy, laparoscopic low anterior resection, reduced port surgery, single incision laparoscopic surgery. Correspondence Professor Seong Hyeon Yun, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea. Email: [email protected] K. U. Jung MD; S. H. Yun MD, PhD; Y. B. Cho MD, PhD; H. C. Kim MD, PhD; W. Y. Lee MD, PhD; H. K. Chun MD, PhD. This study was presented at the 20th International Congress of the European Association for Endoscopic Surgery, Brussels, Belgium in 2012. Accepted for publication 9 June 2014. doi: 10.1111/ans.12775
Abstract Background: Although a single incision laparoscopic (SIL) technique has been used increasingly in colorectal surgery, there are only a few reports on the clinical availability of this approach coupled with low anterior resection (SIL–LAR) for colorectal cancers. We report here 96 consecutive cases of SIL–LAR and reduced port LAR cases, of which the initial approach was SIL. Methods: This is a retrospective review of prospectively collected data of SIL–LAR cases performed by a single surgeon in Samsung Medical Center between June 2011 and June 2012. Results: Out of 96 cases, 28 were finished as ‘pure’ SIL–LAR. Sixty-four cases were performed with one additional port, and four needed two more ports. There was no open conversion. The median duration of operation was 165 min. Proximal and distal resection margins were negative in all cases. Circumferential resection margins were positive in four cases. The median duration of postoperative stay was 7 days and the complication rate was 20%. There were six cases of anastomosis leakage (6%). Conclusion: The SIL–LAR technique can be applied safely with the optional use of an additional port. One additional port in the right suprapubic area is useful for obtaining a secure distal division and a safe total mesorectal excision, especially in patients with lower lesions or history of neoadjuvant chemoradiation.
Introduction
Methods
The single incision laparoscopic (SIL) technique has been used increasingly in colorectal surgery. Up to 20 reports about SIL colectomy including a meta-analysis of >1000 colorectal procedures have concluded that ileocolic resection, right hemicolectomy and anterior resection via SIL was safe and feasible.1–4 However, there is little evidence for the clinical availability of SIL coupled with low anterior resection (SIL–LAR). Although there have been several studies reporting successful cases of SIL–LAR,5,6 there were too few patients to make any definite conclusion. Here, we have compiled our collective experience of patients with colorectal cancer treated with SIL–LAR for a year after its introduction at our institution. To examine the safety and effectiveness of this approach, we analysed the short-term outcomes of SIL–LAR and reduced port LAR of which the initial approach was SIL.
Patients and data collection
© Australasian College College of of Surgeons Surgeons © 2014 2014 Royal Australasian
The institutional review board of Samsung Medical Center approved this study. This series is a retrospective review of prospectively collected data regarding a consecutive series of patients with colorectal cancer undergoing planned SIL–LAR in Samsung Medical Center by a single surgeon between June 2011 and June 2012. Patients were included in this series regardless of final operative method when the initial approach was SIL–LAR. Because of the retrospective nature of the study, the selection criteria for SIL–LAR were not determined strictly and changed as time went by. In the early phase, we carefully selected patients with upper rectal cancers at a relatively early stage, without a history of neoadjuvant concurrent chemoradiation (CCRT). However, after several successful cases, the indication extended to that of conventional laparoscopy. ANZ J Surg (2014) ••–•• ANZ J Surg 86•• (2016) 403–407
2404
Jung et al.
Fig. 1. Custom-made glove port and mounting. (a) It usually comprised a powder-free left-hand surgical glove and three disposable trocars. (b) Unlike other ready-made ports for single incision laparoscopic surgery, the trocars of this custom-made glove port do not intrude into the skin incision. This can reduce the collision between instruments.
Surgical techniques The patient was placed in the lithotomy position. The skin incision was made in the midline transumbilically or at the future ileostomy site, which was marked preoperatively by a qualified enterostomal therapist. The surgeon decided whether to create a diverting ileostomy before making the incision, considering the location of the mass, preoperative treatment history and the patient’s general condition. The initial incision was about 2–4 cm long, reflecting the patient’s body shape and mass size. After the peritoneum was entered, an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) was inserted. We used a custom-made glove port consisting of a surgical glove and three or four Separator access systems (Applied Medical) (Fig. 1). The patient was placed in a Trendelenburg position with the left side elevated. The surgeon and assistant holding the laparoscope stood beside the patient on his/her left side. An additional port was inserted in case when it was difficult to proceed with the operation for any reason. The 12-mm trocar was mainly used and it was generally located in the right suprapubic area, on the lateral side of right deep inferior epigastric vessels (Fig. 2). After getting sufficient distal margin, the rectum was divided using an Endo GIA Ultra Universal Stapler (Covidien, Mansfield, MA, USA). The bowel was extracted through the wound retractor, after removing the covering glove. In case of advanced tumours (T3 or 4), we covered the distal part of the rectum containing the tumour with a LapBag (Sejong Medical Co., Ltd., Paju, Korea) to prevent tumour seeding by extrusion while extracting. The incision was extended in cases where the tumour size or mesenteric thickness was not favourable for the initial one. After delivery of the specimen, anastomosis was made with a DST Series EEA 28 stapling device (Covidien). When the tumour location was very close to
the anus, the bowel was extracted through the anus and a hand-sewn coloanal anastomosis was made. Although splenic flexure take-down is not a routine procedure, it was performed in a large percentage of cases to achieve a tension-free anastomosis. We used common straight devices for conventional laparoscopy in all cases.
Statistics The data were analysed using SPSS software version 19.0 (IBM SPSS Statistics, Armonk, NY, USA). They were analysed using the Mann–Whitney non-parametric U-test, Chi-squared test or Fisher’s exact test and one-sample Student’s t-test. Results were considered statistically significant at P < 0.05.
Results Patient characteristics and operation-related parameters Ninety-six patients (59 men and 37 women) with median age of 57 years and a median body mass index (BMI) of 24.1 kg/m2 underwent SIL–LAR for the treatment of malignant or premalignant neoplastic disease during the study period (Table 1). The tumours were mainly located between the rectosigmoid junction (n = 30, 31%) and rectum (n = 65, 68%). Fifteen patients (16%) had a history of abdominal operations, and 24 (25%) received CCRT before surgery. Combined procedures were performed in 11 patients (12%). Incision for the main portal was made in the midline transumbilically in 59 patients (62%) and at the future ileostomy site in the other 37 patients (39%). In addition to these 37 patients with an initial plan of the diverting stoma, only one in the transumbilical approach group underwent protective ileostomy. Of all 96 cases of surgical operation, 28 (29%) ©©2014 2014 Royal Royal Australasian Australasian College of Surgeons
Single incision laparoscopic LAR
3 405
Fig. 2. Location of the additional port. (a) It is usually inserted in the right suprapubic area, on the lateral side of the right deep inferior epigastric vessels. (b) Final operative wound of single incision laparoscopic low anterior resection plus one additional port after completion of the procedure.
Table 1 Clinical characteristics and procedure-related parameters of the patients (n = 96) Age (years) Gender (M : F) BMI (kg/m2) ASA score (I : II : III) Tumour location (sigmoid colon : rectosigmoid junction : rectum) Previous abdominal operation (Yes : No) Preoperative chemoradiation (Yes : No) Combined procedure (Yes : No) Purpose (curative : palliative) Main portal approach (ileostomy site : transumbilical) Protective ileostomy† (Yes : No) Additional port (0:1:2) Conversion to open surgery Final size of incision‡ (cm) Anastomosis method (double stapling method : hand sewing) Level of anastomosis§ (≤3 cm : 3 cm < and ≤ 6 : 6 < cm) Duration of operation (min) Estimated blood loss (mL)
57 (range 28–77) 59:37 24.1 (range 18.3–31.6) 48:46:2 1:30:65 15:81 24:72 11:85 91:5 37:59 38:58 28:64:4 No 3.5 (range 2.0–6.0) 88:8 18:39:25 165 (range 93–357) 100 (range 20–700)
†Only one patient in the transumbilical approach group required protective ileostomy. ‡Data from one patient were missing. §Data from 14 patients were missing. ASA, American Society of Anesthesiologists; BMI, body mass index; F, Female; M, male.
were completed by the SIL technique. Sixty-four cases (67%) required one additional port and two more ports were needed in four other cases (4%). There was no need for open conversion. The median length of the final wound was 3.5 cm (range 2.0–6.0 cm). The median duration of the operation was 165 min (range 93–357 min) and the median estimated blood loss was 100 mL (range 20–700 mL).
Oncological resection and postoperative recovery Most tumours were adenocarcinomas (n = 94, 98%), except for one tubular adenoma with high-grade dysplasia and one carcinoids © Australasian College College of of Surgeons Surgeons © 2014 2014 Royal Australasian
Table 2 Parameters associated postoperative recovery (n = 96)
with
Tumour histology Carcinoid Tubular adenoma with high-grade dysplasia Adenocarcinoma (WD : MD : PD : MUC) Stage† (0 : I : II : III : IV) Tumour size (cm) Proximal resection margin (cm) Distal resection margin (cm) Circumferential resection margin‡ (negative : positive) Harvested lymph nodes Median time to first bowel movement (days) Median time to full diet (days) Median postoperative hospital stay (days) Complications (Yes : No) Leakage Bleeding Deep surgical site infection Postoperative ileus Chyle leakage Ileostomy prolapse Delirium Paroxysmal supraventricular tachycardia Urinary retention Complication grade by Clavien-Dindo classification ( I : II : III : IV) Readmission within 30 days (Yes : No)
oncologic
resection
and
1 1 94 (33:57:1:3) 4:30:13:41:6 3.0 (range 0.1–10.0) 11.0 (range 4.0–25.0) 3.5 (range 0.5–15.0) 89:4 15 (range 3–73) 2 (range 0–5) 3 (range 1–8) 7 (range 5–52) 19:77 6 1 1 5 1 1 1 1 2 5:5:5:4 3:93
†According to the AJCC7 stage, in cases of adenocarcinoma. ‡There were no pathology reports about the circumferential resection margin in three cases of rectosigmoid colon cancers. MD, moderately differentiated; MUC, mucinous; PD, poorly differentiated; WD, well differentiated.
(Table 2). The pathology stages of adenocarcinomas included stage 0 (n = 4, 4%), stage I (n = 30, 31%), stage II (n = 13, 14%), stage III (n = 41, 43%) and stage IV (n = 6, 6%). Of six patients with stage IV tumours, five underwent palliative resection for primary disease. Multifocal metastases were not controlled in these cases. All proximal and distal resection margins (DRMs) were negative and the
4406
Jung et al.
Table 3 Parameters related with additional port insertion Additional port
Tumour location Sigmoid colon : rectosigmoid junction : rectum Preoperative chemoradiation (Yes : No) Anastomosis level (cm)
P value
Yes (n = 68)
No (n = 28)
0:19:49
1:11:16
22:46
2:26
