LETTER TO THE EDITOR Single Incision Laparoscopic Surgery for Colorectal Cancer To the Editor: e would like to congratulate Kim and coworkers1 on their study of singleport laparoscopic surgery (SPLS) in patients with colorectal cancer. In this retrospective analysis of 179 oncological laparoscopic procedures, perioperative parameters were thoroughly assessed in 73 single-port and 106 conventional laparoscopic resections, respectively. They found single-port colonic surgery feasible and safe in the largest published oncological series to date. On the basis of our personal experience of 1319 consecutive SPLS procedures, including 190 colorectal resections within the last 3 years, we would like to comment on 2 interesting points. Kim and coworkers observed an extremely low umbilical complication rate of 1.4% without any wound dehiscence in the SPLS group. It is important that this finding be balanced against the common fear of laparoscopic surgeons to increase the umbilical complication rate by lengthening the incision to more than 2 cm. A systematic review of more than 11,000 patients undergoing conventional laparoscopic gastrointestinal surgery found a trocar site hernia rate of 0.74% overall and 1.47% for colorectal surgery.2 The authors concluded that all facial defects 1 cm or more should be closed to prevent hernia formation. In this light, the advocated route of drainage placement through the umbilicus certainly prevents additional scarring; however, it might increase the risk for wound disruption or late herniation. In our experience, drainage of elective colonic anastomoses is no longer performed, as ample evidence in the literature does not support the use of drainages in routine colorectal surgery.3 Even in the present study, the authors speculate that specimen retrieval via the transumbilical route might “undermine the potential benefits of SPLS” by increasing the risk of wound complications and therefore chose the transanal path for specimen extraction in most cases. At our institution, we have assessed transumbilical, transanal, and transvaginal specimen retrieval paths for SPLS procedures. However, except for coloanal anastomosis, our routine extraction site remains the
W
Disclosure: The authors declare no conflicts of interest. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26101-e0017 DOI: 10.1097/SLA.0000000000000567
umbilicus. Of note, our series also included bulky specimen retrieval for gastric, liver, or pancreas SPLS resections, with an incisional length of up to 6 cm. We have prospectively assessed the umbilical complication rates in our SPLS cohort. Of 1003 patients with a minimal follow-up of 6 months, our wound infection and incisional hernia rate yielded at 0.9% and 1.4%, respectively. Because of this experience, we consider the umbilical route safe and appropriate, even for larger tumor retrieval. A second comment relates to the surprisingly high rate of blood transfusions in both the conventional laparoscopic (25.0%) and SPLS (12.3%) cohorts. Given the documented detrimental effect of intraoperative blood administration in patients with colon cancer,4 the 25% rate in the conventional laparoscopic cohort seems quite high for a minimal invasive approach, especially as this approach represents the well-established standard treatment arm. Matthias O. Biebl, MD Jan Schirnhofer, MD Helmut G. Weiss, MD, MSc Department of Surgery St. John of God Hospital Salzburg Salzburg, Austria [email protected]
REFERENCES 1. Kim SJ, Ryu GO, Choi BJ, et al. The short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer. Ann Surg. 2011; 254:933–940. 2. Owens M, Barry M, Janjua AZ, et al. A systematic review of laparoscopic port site hernia in gastrointestinal surgery. Surgery. 2011;9:218–224. 3. Merad F, Hay JM, Fingerhut A, et al. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. Surgery. 1999;125:529–535. 4. Koch M, Antolovic D, Reissfelder C, et al. Leucocyte-depleted blood transfusion is an independent predictor of surgical morbidity in patients undergoing elective colon cancer surgery—a singlecenter analysis of 531 patients. Ann Surg Oncol. 2011;18:1404–1411.
Reply:
W
e appreciate the interest shown by Helmut G. Weiss and colleagues in our article published in Annals of Surgery, and we gratefully read their sincere comments concerning our short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer.1
Disclosure: The authors have no conflicts of interest or financial ties to disclose. 10.1097/SLA.0000000000000568
Annals of Surgery r Volume 261, Number 1, January 2015
Reducing the soiling of the operation (OP) field during surgery definitely contributes to postoperative outcomes. It is especially important in surgery for lesions including cancer. Consequently, discussions about the no-touch technique have emerged.2 A clean finish in an OP field is crucial in reducing postoperative complications, including adhesion. Therefore, we performed a cleansing of the OP field via irrigation and application of an antiadhesion solution in most patients at the end of surgery. Thus, a relatively high proportion of patients needed postoperative drainage. The transumbilical method is routinely used for drainage, most commonly using the Jackson-Pratt (JP) drain (diameter ≤ 5 mm). The drain was placed through the narrow pathway between the stay sutures (with a 3– 5 mm interval) prepared at the beginning of surgery. Judging from our experiences, drains could be removed easily and there was no need for additional procedure such as suturing or stapling. In addition, the JP drain is a closed-suction drain that excludes the possibility of fluid oozing along the outer surface by containing it within the drain lumen, which can counteract the concerns of some surgeons about drain-induced wound soiling or increase in herniation. If the additional use of trocars can be reduced, no matter to what extent, it can directly contribute to reducing the risk of trocar site-associated complications.3 According to our experiences with SPLS so far, most specimen retrievals have been performed via the transumbilical route. Because an umbilical incision can be freely extended depending on the specimen size or condition, a minimal incision “tailored” to the need of each patient is possible, even though it can result in a considerably large incision. In some cases, to keep the diameter of the umbilical incision as small as possible, we perform an additional intracorporeal procedure as a recourse, in which thinner specimens are retrieved, mostly by dividing the adhesive bowel loops or omentum, within the scope of oncologic principles. The decision to apply the natural orifice specimen extraction (NOSE) method can be made depending on the relationship between the lesion size and the diameter of anal sphincter.4 We use this method only when the lesion is adequately small and the dilated diameter of anal sphincter is large enough to allow passage of the specimens including lesions. Even in cases of considerably large lesions, if the anal sphincter can be easily extended to allow their passage, the drainage can be performed by using the NOSE method; however, the transumbilical route should be chosen even in cases of small lesions if the anus is too small, or problems such as stenosis arise. By choosing the appropriate methods, the umbilical incision can be www.annalsofsurgery.com | e17
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Biebl and Weiss
reduced to 1.5 cm when applying the NOSE method. We use anal trocars when we remove specimens by using the NOSE method, whereby the transanal setting is implemented by choosing a metal cylindrical trocar of various diameters (3–6 cm) suitable for the individually different anal sphincter. An anal trocar functions as a conduit that protects the rectal wall and anal sphincter from excessive pressures likely to occur during specimen removal and facilitate specimen discharge. That intraoperative transfusion has a detrimental effect was previously demonstrated.5 Admittedly, our study was conducted during the period when intraoperative transfusion had been generally performed without paying much attention to its consequences. We were aware of this fact during the data collection for this study. It was an opportunity for us to introduce more stringent management and control of intraoperative blood loss or application of transfusion. We have been rigorously implementing this practice and since then, we have encountered only 2 of 100 cases of transfusion in colorectal resection in the most recent colorectal surgery cases. By way of reference, we would like
e18 | www.annalsofsurgery.com
Annals of Surgery r Volume 261, Number 1, January 2015
to point out that for the most part, surgery has currently been totally shifted to SPLS. Among the 1512 consecutive SPLS cases we have performed so far, 563 involved colorectal resections, excluding 612 cases of appendectomy. The application of SPLS is still controversial, and SPLS-associated procedures continue to undergo changes and developments. Specifically, in addition to its wellknown cosmetic excellence, several advantages of SPLS have been discovered, such as pivoting, spreading out dissection, and stomarelated surgery. At this juncture, to establish more solid evidence and broader application, large-scale multicenter prospective and randomized trials should be conducted. In addition, with the development of SPLS and the integration of various ideas, a trend of converging the content of laparoscopic surgery and the approach of NOSE has been observed. For instance, we have been maintaining a surgical system that has totally shifted to SPLS, with which we have experienced many new advantages, including clinically satisfactory results. On the basis of these experiences, a new paper is in preparation.
Say-June Kim, MD, PhD Byung-Jo Choi, MD Sang Chul Lee, MD, PhD Department of Surgery Daejeon St Mary’s Hospital The Catholic University of Korea Daejeon, Republic of Korea [email protected]
REFERENCES 1. Kim SJ, Ryu GO, Choi BJ, et al. The short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer. Ann Surg. 2011; 254:933–940. 2. Turnbull RB, Jr. Current concepts in cancer. Cancer of the GI tract: colon, rectum, anus. The notouch isolation technique of resection. JAMA. 1975; 231:1181–1182. 3. Choi GS, Park IJ, Kang BM, et al. A novel approach of robotic-assisted anterior resection with transanal or transvaginal retrieval of the specimen for colorectal cancer. Surg Endosc. 2009;23:2831–2835. 4. Karthik S, Augustine AJ, Shibumon MM, et al. Analysis of laparoscopic port site complications: a descriptive study. J Minim Access Surg. 2013;9:59– 64. 5. Merad F, Hay JM, Fingerhut A, et al. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. Surgery. 1999;125:529–535.
C 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
W
Disclosure: The authors declare no conflicts of interest. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26101-e0017 DOI: 10.1097/SLA.0000000000000567
umbilicus. Of note, our series also included bulky specimen retrieval for gastric, liver, or pancreas SPLS resections, with an incisional length of up to 6 cm. We have prospectively assessed the umbilical complication rates in our SPLS cohort. Of 1003 patients with a minimal follow-up of 6 months, our wound infection and incisional hernia rate yielded at 0.9% and 1.4%, respectively. Because of this experience, we consider the umbilical route safe and appropriate, even for larger tumor retrieval. A second comment relates to the surprisingly high rate of blood transfusions in both the conventional laparoscopic (25.0%) and SPLS (12.3%) cohorts. Given the documented detrimental effect of intraoperative blood administration in patients with colon cancer,4 the 25% rate in the conventional laparoscopic cohort seems quite high for a minimal invasive approach, especially as this approach represents the well-established standard treatment arm. Matthias O. Biebl, MD Jan Schirnhofer, MD Helmut G. Weiss, MD, MSc Department of Surgery St. John of God Hospital Salzburg Salzburg, Austria [email protected]
REFERENCES 1. Kim SJ, Ryu GO, Choi BJ, et al. The short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer. Ann Surg. 2011; 254:933–940. 2. Owens M, Barry M, Janjua AZ, et al. A systematic review of laparoscopic port site hernia in gastrointestinal surgery. Surgery. 2011;9:218–224. 3. Merad F, Hay JM, Fingerhut A, et al. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. Surgery. 1999;125:529–535. 4. Koch M, Antolovic D, Reissfelder C, et al. Leucocyte-depleted blood transfusion is an independent predictor of surgical morbidity in patients undergoing elective colon cancer surgery—a singlecenter analysis of 531 patients. Ann Surg Oncol. 2011;18:1404–1411.
Reply:
W
e appreciate the interest shown by Helmut G. Weiss and colleagues in our article published in Annals of Surgery, and we gratefully read their sincere comments concerning our short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer.1
Disclosure: The authors have no conflicts of interest or financial ties to disclose. 10.1097/SLA.0000000000000568
Annals of Surgery r Volume 261, Number 1, January 2015
Reducing the soiling of the operation (OP) field during surgery definitely contributes to postoperative outcomes. It is especially important in surgery for lesions including cancer. Consequently, discussions about the no-touch technique have emerged.2 A clean finish in an OP field is crucial in reducing postoperative complications, including adhesion. Therefore, we performed a cleansing of the OP field via irrigation and application of an antiadhesion solution in most patients at the end of surgery. Thus, a relatively high proportion of patients needed postoperative drainage. The transumbilical method is routinely used for drainage, most commonly using the Jackson-Pratt (JP) drain (diameter ≤ 5 mm). The drain was placed through the narrow pathway between the stay sutures (with a 3– 5 mm interval) prepared at the beginning of surgery. Judging from our experiences, drains could be removed easily and there was no need for additional procedure such as suturing or stapling. In addition, the JP drain is a closed-suction drain that excludes the possibility of fluid oozing along the outer surface by containing it within the drain lumen, which can counteract the concerns of some surgeons about drain-induced wound soiling or increase in herniation. If the additional use of trocars can be reduced, no matter to what extent, it can directly contribute to reducing the risk of trocar site-associated complications.3 According to our experiences with SPLS so far, most specimen retrievals have been performed via the transumbilical route. Because an umbilical incision can be freely extended depending on the specimen size or condition, a minimal incision “tailored” to the need of each patient is possible, even though it can result in a considerably large incision. In some cases, to keep the diameter of the umbilical incision as small as possible, we perform an additional intracorporeal procedure as a recourse, in which thinner specimens are retrieved, mostly by dividing the adhesive bowel loops or omentum, within the scope of oncologic principles. The decision to apply the natural orifice specimen extraction (NOSE) method can be made depending on the relationship between the lesion size and the diameter of anal sphincter.4 We use this method only when the lesion is adequately small and the dilated diameter of anal sphincter is large enough to allow passage of the specimens including lesions. Even in cases of considerably large lesions, if the anal sphincter can be easily extended to allow their passage, the drainage can be performed by using the NOSE method; however, the transumbilical route should be chosen even in cases of small lesions if the anus is too small, or problems such as stenosis arise. By choosing the appropriate methods, the umbilical incision can be www.annalsofsurgery.com | e17
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Biebl and Weiss
reduced to 1.5 cm when applying the NOSE method. We use anal trocars when we remove specimens by using the NOSE method, whereby the transanal setting is implemented by choosing a metal cylindrical trocar of various diameters (3–6 cm) suitable for the individually different anal sphincter. An anal trocar functions as a conduit that protects the rectal wall and anal sphincter from excessive pressures likely to occur during specimen removal and facilitate specimen discharge. That intraoperative transfusion has a detrimental effect was previously demonstrated.5 Admittedly, our study was conducted during the period when intraoperative transfusion had been generally performed without paying much attention to its consequences. We were aware of this fact during the data collection for this study. It was an opportunity for us to introduce more stringent management and control of intraoperative blood loss or application of transfusion. We have been rigorously implementing this practice and since then, we have encountered only 2 of 100 cases of transfusion in colorectal resection in the most recent colorectal surgery cases. By way of reference, we would like
e18 | www.annalsofsurgery.com
Annals of Surgery r Volume 261, Number 1, January 2015
to point out that for the most part, surgery has currently been totally shifted to SPLS. Among the 1512 consecutive SPLS cases we have performed so far, 563 involved colorectal resections, excluding 612 cases of appendectomy. The application of SPLS is still controversial, and SPLS-associated procedures continue to undergo changes and developments. Specifically, in addition to its wellknown cosmetic excellence, several advantages of SPLS have been discovered, such as pivoting, spreading out dissection, and stomarelated surgery. At this juncture, to establish more solid evidence and broader application, large-scale multicenter prospective and randomized trials should be conducted. In addition, with the development of SPLS and the integration of various ideas, a trend of converging the content of laparoscopic surgery and the approach of NOSE has been observed. For instance, we have been maintaining a surgical system that has totally shifted to SPLS, with which we have experienced many new advantages, including clinically satisfactory results. On the basis of these experiences, a new paper is in preparation.
Say-June Kim, MD, PhD Byung-Jo Choi, MD Sang Chul Lee, MD, PhD Department of Surgery Daejeon St Mary’s Hospital The Catholic University of Korea Daejeon, Republic of Korea [email protected]
REFERENCES 1. Kim SJ, Ryu GO, Choi BJ, et al. The short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer. Ann Surg. 2011; 254:933–940. 2. Turnbull RB, Jr. Current concepts in cancer. Cancer of the GI tract: colon, rectum, anus. The notouch isolation technique of resection. JAMA. 1975; 231:1181–1182. 3. Choi GS, Park IJ, Kang BM, et al. A novel approach of robotic-assisted anterior resection with transanal or transvaginal retrieval of the specimen for colorectal cancer. Surg Endosc. 2009;23:2831–2835. 4. Karthik S, Augustine AJ, Shibumon MM, et al. Analysis of laparoscopic port site complications: a descriptive study. J Minim Access Surg. 2013;9:59– 64. 5. Merad F, Hay JM, Fingerhut A, et al. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. Surgery. 1999;125:529–535.
C 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
