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Single-port laparoscopic colectomy is safe and feasible in patients with previous abdominal surgery Mitsuyoshi Tei, M.D., Ph.D.*, Masaki Wakasugi, M.D., Takeshi Omori, M.D., Ph.D., Shigeyuki Ueshima, M.D., Masayuki Tori, M.D., Ph.D., Hiroki Akamatsu, M.D., Ph.D. Department of Surgery, Osaka Police Hospital, 10-31, Kitayama-cho, Tennoji-ku, Osaka City, Osaka 543-0035, Japan KEYWORDS: Single-incision laparoscopic surgery; Single-port surgery; Colorectal disease; Previous abdominal surgery
Abstract BACKGROUND: The aim of this study was to assess the impact of previous abdominal surgery (PAS) on single-port laparoscopic colectomy (SPLC). METHODS: We studied 429 consecutive patients who underwent SPLC in our department from May 2009 to December 2013. Patients were divided into 2 groups: those with PAS (PAS group) and those with NPAS (NPAS group). Operative parameters and outcomes were analyzed between the 2 groups retrospectively. RESULTS: SPLC was performed in 152 PAS patients and 277 NPAS patients. Eight patients in the PAS group and 6 patients in the NPAS group were converted to multiport laparoscopic colectomy (5.3% vs 2.2%, respectively; P 5 .077). Three patients in the PAS group and 2 patients in the NPAS group had inadvertent enterotomy (2.0% vs .7%, respectively; P 5 .352). No patients were converted to open surgery. There were no significant differences between the 2 groups in terms of blood loss, operative time, and postoperative outcomes. CONCLUSION: Our experience has demonstrated the safety and feasibility of SPLC in patients with PAS. Ó 2014 Elsevier Inc. All rights reserved.
Previous abdominal surgery (PAS) leads to the formation of adhesions. Adhesions are considered to be associated with an increased risk of intestinal obstruction and prolonged operative times. Some studies have repor ted no
There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs. The authors declare no conflicts of interest. * Corresponding author. Tel.: 181-6-6771-6051; fax: 181-6-6775-2838. E-mail address: [email protected] Manuscript received March 10, 2014; revised manuscript May 12, 2014 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.06.015
significant differences in short-term surgical outcomes when evaluating the impact of PAS on laparoscopic colectomy.1–4On the other hand, PAS has been associated with a significantly higher conversion rate, a higher rate of inadvertent enterotomy, and a higher incidence of postoperative bowel obstructions, compared with no previous abdominal surgery (NPAS).5–7 It is controversial whether PAS is associated with the increase of risk in laparoscopic colectomy. Single-port laparoscopic colectomy (SPLC) was first described in 2008.8 The benefits of SPLC include better
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cosmetic outcomes, less postoperative pain, faster postoperative recovery, and earlier discharge from the hospital compared with multiport laparoscopic colectomy (MPLC).9,10 Most reports have concluded that SPLC was feasible and safe for colorectal disease.11–19 In our department, the first case of SPLC for benign disease was carried out in May 2009 and the indication was expanded to include advanced colorectal cancer regardless of the history of PAS. Currently, SPLC is considered a reasonable alternative approach for colorectal disease in our department. There is no report evaluating the impact of PAS on SPLC currently. In this study, we aimed to assess the impact of PAS on SPLC in terms of the short-term surgical results, analyzing these data in a large number of patients over several years.
Postoperative complications were classified according to the Clavien–Dindo classification.21 As listed in Table 1, other disease consisted of inflammatory tumors and lipomas. Operative mortality was defined as death on the same day of admission or within 30 days of surgery. All patients were followed for at least 30 days after surgery. Operative parameters and outcomes were analyzed between the PAS and NPAS groups retrospectively.
Methods Patient profiles Consecutive patients who underwent SPLC for colorectal disease from the cecum to the rectosigmoid colon in our department between May 2009 and December 2013 were included in this study. Cases of obstruction or perforation that required emergent operation were excluded. Before January 2010, SPLC was performed for benign disease and early colon cancer only, but the indication was expanded later to include advanced colorectal cancer regardless of the history of PAS. Data for age, sex, and preoperative evaluation were obtained from the medical records. Of the patients who had adhesions, the following grading system was used to define severity: mild: filmy thickness, avascular; moderate: moderate thickness, limited vascularity; severe: dense thickness, well vascularized.20
Table 1
Surgical technique A single intra-umbilical incision 2.5- to 3-cm long was made. We typically used EZ Access (Hakko Co. Ltd, Nagano, Japan) on the Lap Protector (Hakko Co. Ltd) for the insertion of two 5-mm trocars and one 12-mm trocar for a right colectomy, and one 5-mm trocar and two 12mm trocars for a left colectomy, sigmoidectomy, or rectal resection. A flexible laparoscope 10 mm in diameter and standard straight laparoscopic instruments were used. Every procedure was performed using an Ultracision Harmonic scalpel (Ethicon, Somerville, NJ). For a right colectomy, the right colon was mobilized using the medial-to-lateral approach and the ileocolic or the middle colic trunk was isolated and divided by laparoscopic clips. After the mobilization of the right colon and lymph node dissection, the terminal ileum and distal right colon were divided. An extracorporeal functional end-to-end anastomosis was then created. For a left colectomy, sigmoidectomy, and rectal resection, the left colon was mobilized using the medial-to-lateral approach, and the middle colic trunk or the inferior mesenteric pedicle was isolated and divided by laparoscopic clips. The sigmoid colon or upper rectum was divided laparoscopically with staplers. An end-to-end anastomosis was performed with the trans-anal insertion of a circular stapler.
Patients’ profiles PAS group (n 5 152)
Age (years) Sex Male Female BMI ASA score 1 or 2 R3 Performance status 0 or 1 R2 Diagnosis Cancer Benign polyp Other disease*
71 (37–93)
NPAS group (n 5 277) 69 (36–94)
66 (43.4) 86 (56.6) 22.4 (15.5–32.2)
150 (54.2) 127 (45.8) 22.0 (12.5–34.9)
123 (80.9) 29 (19.1)
232 (83.8) 45 (16.2)
140 (92.1) 12 (7.9)
260 (93.9) 17 (6.1)
146 (96.1) 5 (3.3) 1 (.6)
264 (95.3) 11 (4.0) 2 (.7)
P value .023 .033
.786 .457
.488
.935
Data are expressed as number of patients (percentages). ASA score 5 American Society of Anesthesiology score; BMI 5 body mass index; NPAS 5 no previous abdominal surgery; PAS 5 previous abdominal surgery. *Inflammatory tumors and lipomas.
M. Tei et al. Table 2 group
SPLC in patients with PAS
3
Details of previous abdominal surgery in the PAS PAS group (n 5 152)
Number of previous abdominal surgeries 1 1. Type of procedure Appendectomy Hysterectomy Other gynecologic surgery Cholecystectomy* Colorectal surgery† Gastroduodenal surgery‡ Urologic surgeryx Aortic aneurysm Small bowel surgery Other abdominal surgery Type of incision Median Upper median Lower median Right lower abdomen Right subcostal Upper and lower median incision Median and right lower abdomen Upper median and right lower abdomen Lower median and right lower abdomen Several small incisions (laparoscopic surgery)
134 (88.2) 18 (11.8) 67 (44.1) 24 (15.8) 24 (15.8) 20 (13.2) 10 (6.6) 9 (5.9) 5 (3.3) 10 (6.6) 4 (2.6) 2 (1.3) 10 15 45 58 2 3 2 3 5 9
PAS 5 previous abdominal surgery. *10 open and 10 laparoscopic surgeries. † 4 open and 6 laparoscopic surgeries. ‡ 3 open and 6 laparoscopic surgeries. x 4 open and 1 laparoscopic surgeries.
Drains were not used except in cases of rectal resection. All skin incisions were closed with absorbable sutures.
Statistical methods Continuous data are expressed as median (range), unless specifically noted. Preoperative and operative factors were analyzed retrospectively. Statistical analyses were performed with the use of JMP 9.0 software (SAS Institute, Inc., Cary, NC). All group data were reported as median values. Differences in age, body mass index), operative time, blood loss, and number of harvested lymph nodes were analyzed using the Mann–Whitney U test. Other factors were analyzed by Fisher’s exact probability test. Statistical significance was established at P value less than .05.
Results We analyzed data from 429 patients (152 with PAS and 277 with NPAS) who underwent SPLC in our department from May 2009 to December 2013. Table 1 lists the profiles of the patients analyzed in both groups. The proportion of female patients and the patient age were in the PAS group were significantly greater in the PAS group than in the NPAS group (56.6% vs 45.8%, P 5 .033; 71 vs 69 years, P 5 .023). There were no significant differences between the 2 groups in terms of body mass index, American Society of Anesthesiology score, performance status, and preoperative diagnosis (Table 1). Table 2 summarizes the details of previous abdominal surgery in the PAS group, of which 134 patients (88.2%) had undergone 1 PAS and 18 patients (11.2%) had undergone more than 1 PAS. Appendectomy was the most common operative procedure (n 5 67, 44.1%), which was performed by a right lower quadrant or pararectal incision. All hysterectomies and other gynecologic surgeries were performed by a lower median incision. As for cholecystectomy, 10 patients had undergone open laparotomy (8 patients, upper median incision; 2 patients, right subcostal incision) and 10 patients had undergone laparoscopic surgery. As for colectomy, 4 patients had undergone open surgery by a median incision and 6 patients had undergone laparoscopic surgery. As for gastroduodenal surgery, 3 patients had undergone open surgery by an upper median incision and 6 patients had undergone laparoscopic surgery. As for urologic surgery, 4 patients had undergone open surgery by a lower median incision and 1 patient had undergone laparoscopic surgery. Aortic aneurysm repair, small bowel surgery, and other abdominal surgeries were performed by median incision. Nine patients had undergone laparoscopic surgery and the other patients had undergone open surgery (Table 2). Table 3 summarizes the operative factors of the PAS and NPAS groups. The most common operative procedure was right colectomy. Rectal resection was performed in 29 PAS patients and 72 NPAS patients. Adhesions were diagnosed in 116 patients in the PAS group and 81 patients in the NPAS group (76.3% vs 29.2%, respectively; P , .001). There was a significant difference between the PAS and NPAS groups in terms of adhesion severity grade (P , .001). In PAS patients with severe adhesions, the source was considered to be inflammation because of a primary advanced tumor in 1 patient and postoperative adhesions in 21 patients. On the other hand, in the NPAS patients with severe adhesions, the source was considered to be inflammation because of a primary advanced tumor (n 5 2), related to previous treatment for gynecologic disease (n 5 3), diverticulitis (n 5 2), appendicitis (n 5 4), or chronic cholecystitis (n 5 4), or unknown (n 5 3). The conversion rate was 5.3% (8/152 patients) in the PAS group and 2.2% (6/277) in the NPAS group, respectively (P 5 .077). The reasons for conversion in the PAS group were bulky tumor in 2 patients (adhesion severity grade:
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4 Table 3
Comparison of operative factors
Operative procedure Right colectomy Transverse colectomy Left colectomy Sigmoidectomy Rectal resection Operative time (minutes) Blood loss (mL) Number of harvested lymph nodes Adhesion severity grade None Mild Moderate Severe Intraoperative complication Inadvertent enterotomy Conversion to MPLC Conversion to open surgery
PAS group (n 5 152)
NPAS group (n 5 277)
59 10 8 46 29 169 0 22
(38.8) (6.6) (5.3) (30.3) (19.1) (81–340) (0–1,500) (1–84)
93 15 9 88 72 182 0 26
(33.6) (5.4) (3.2) (31.8) (26.0) (90–480) (0–630) (3–109)
(23.7) (37.5) (24.3) (14.5) (2.6) (2.0) (5.3)
196 45 18 18 2 2 6 0
(70.8) (16.2) (6.5) (6.5) (.7) (.7) (2.2)
P value .398
36 57 37 22 4 3 8 0
.907 .592 .016 ,.001
.107 .352 .077 d
Data are expressed as number (percentage). MPLC 5 multiport laparoscopic surgery; NPAS 5 no previous abdominal surgery; PAS 5 previous abdominal surgery.
none), severe obesity in 2 patients (adhesion severity grade: mild), intraoperative bleeding in 1 patient (adhesion severity grade: mild), and moderate adhesion in 3 patients. The reasons for conversion in the NPAS group were tumor directly invading the bladder wall in 2 patients (adhesion severity grade: none), bulky tumor in 2 patients (adhesion severity grade: none), and severe adhesion in 2 patients. All 14 patients underwent conventional MPLC. None of the patients was converted to open surgery. The rate of inadvertent enterotomy was 2.0% (3/ 152 patients; adhesion severity grade: none, n 5 1 and moderate, n 5 2) in the PAS group and .7% (2/277 patients; adhesion severity grade: none, n 5 1 and moderate, n 5 1) in the NPAS group (P 5 .352). There were significantly fewer harvested lymph nodes in the PAS group than in the NPAS group (22 vs 26, respectively; P 5 .016). There were no significant differences between the 2 groups in terms of operative procedure, operative
Table 4
time, blood loss, conversion rate, and intraoperative complication (Table 3). Table 4 depicts the postoperative complications that occurred in each group. Bleeding occurred in 3 patients in the PAS group and 4 patients in the NPAS group. Anastomotic leakage occurred in 3 patients in the PAS group and 9 patients in the NPAS group. Abdominal abscess was diagnosed in 10 patients in the PAS group and 9 patients in the NPAS group. Wound infection was diagnosed in 11 patients in the PAS group and 21 patients in the NPAS group. Bowel obstruction was diagnosed in 3 patients in the PAS group and 10 patients in the NPAS group. More than one complication was observed in 34 patients. There were no significant differences between the 2 groups in terms of postoperative complications. The median length of hospital stay was similar in both groups (8 days). Perioperative death was recorded in 1 patient in the PAS group because of pneumonia (Table 4).
Postoperative complications
Complication
PAS group (n 5 152)
NPAS group (n 5 277)
P value
Bleeding Anastomotic leakage Wound infection Abdominal abscess Cardiac or pulmonary disease Bowel obstruction Perioperative death Length of hospital stay (days)
3 3 11 10 2 3 1 8
4 9 21 9 4 10 0 8
.702 .396 1.000 .140 1.000 .557 .354 .992
(2.0) (2.0) (7.2) (6.6) (1.3) (2.0) (.7) (4–70)
NPAS 5 no previous abdominal surgery; PAS 5 previous abdominal surgery.
(1.4) (3.2) (7.6) (3.2) (1.4) (3.6) (.0) (6–110)
M. Tei et al.
SPLC in patients with PAS
Comments Based on our experience, we consider SPLC superior to MPLC in terms of better skin cosmesis. We showed that there were no significant differences between the PAS and NPAS groups in terms of blood loss and operative time. SPLC was performed successfully in 94.7% of the patients in the PAS group and 97.8% of the patients in the NPAS group. Three patients in the PAS group and 2 patients in the NPAS group had inadvertent enterotomy (2.0% vs .7%, respectively; P 5 .152), but underwent the operation completely, converting not to open laparotomy but to MPLC. One of the conversions in the PAS group was because of intraoperative bleeding. Some studies have reported that the conversion rate from SPLC to MPLC or open surgery ranged from 0% to 36.4%,11,14–16,18 and PAS has been associated with a significantly higher conversion rate.5–7 Our results with SPLC had high reliability in terms of intraoperative complications and a successful completion rate regardless of the history of PAS. Adhesions were diagnosed in 116 patients in the PAS group and 81 patients in the NPAS group (76.3% vs 29.2%, respectively; P , .001), and there was a significant difference between the PAS and NPAS groups in terms of adhesion severity grade (P , .001). However, there was no significant difference in terms of conversion rate between the 2 groups (5.3% vs 2.2%, respectively; P 5 .077). In this study, 6 patients in the PAS group were converted to MPLC, because of mild adhesions (n 5 3) and moderate adhesion (n 5 3). Two patients in the NPAS group had converted to MPLC, because of severe adhesions. Other patients in the PAS group (n 5 2) and the NPAS group (n 5 4) had no adhesions and were converted because of bulky tumor or tumor directly invading another organ. Adhesion severity grade was not correlated with the conversion to MPLC (P 5 .249, data not shown). However, the conversion rate by tumor factors (bulky or invasion) was 25.0% (2/8) in the PAS group and 66.7% (4/6) in the NPAS group. We conducted that it was difficult to evaluate the correlation of adhesion and conversion in this study. We showed that there were no significant differences between the 2 groups in terms of postoperative complications. Fourteen patients with conversion to MPLC, including 1 patient with intraoperative bleeding and 5 patients with inadvertent enterotomy, had no postoperative complications. Wound infection was diagnosed in 11 patients in the PAS group and 21 patients in the NPAS group (7.2% vs 7.6%, respectively; P 5 1.000). Bowel obstruction occurred in 3 patients in the PAS group and 10 patients in the NPAS group (2.0% vs 3.6%, respectively; P 5 .557). The incidence of complications in this study was lower compared with other reports of MPLC with PAS,5,7 but higher compared with other reports of SPLC.18,19 Even minor complications that might have little or no influence on postoperative hospital stay or mortality were counted. We concluded that the rate of complications is within an acceptable range.
5 Maintaining the surgical oncologic outcome is the most important factor for the treatment of cancer. High vascular ligation and a nontouch technique were maintained for colorectal cancer in this series. No gross or microscopic positive resection margins were observed in this series. One patient in the NPAS group had an anastomotic recurrence 12 months after the operation. The median number of harvested lymph nodes was 22 in the PAS group and 26 in the NPAS group (P , .016), which exceeded that of other reports.9,16,17,19 In our experience, SPLC could be performed with a sufficient field for lymph node dissection and an adequate number of harvested lymph nodes regarding the oncologic aspect. The main limitations of this study were that it was carried out at a single institution and it was retrospective in nature. Furthermore, it was difficult to demonstrate the clinical impact of PAS in this study. We consider that SPLC in patients with PAS is safe and feasible.
Conclusion This is the first study that showed the safety and feasibility of SPLC in patients with PAS. We consider that PAS is not a contradiction to SPLC.
References 1. Hamel CT, Pikarsky AJ, Weiss E, et al. Do prior abdominal operations alter the outcome of laparoscopically assisted right hemicolectomy? Surg Endosc 2000;14:853–7. 2. Law WL, Lee YM, Chu KW. Previous abdominal operations do not affect the outcomes of laparoscopic colorectal surgery. Surg Endosc 2005;19:326–30. 3. Arteaga Gonza´lez I, Martı´n Malago´n A, Lo´pez-Tomassetti Ferna´ndez EM, et al. Impact of previous abdominal surgery on colorectal laparoscopy results: a comparative clinical study. Surg Laparosc Endosc Percutan Tech 2006;16:8–11. 4. Vignali A, Di Palo S, De Nardi P, et al. Impact of previous abdominal surgery on the outcome of laparoscopic colectomy: a case-matched control study. Tech Coloproctol 2007;11:241–6. 5. Franko J, O’Connell BG, Mehall JR, et al. The influence of prior abdominal operations on conversion and complication rates in laparoscopic colorectal surgery. JSLS 2006;10:169–75. 6. Yamamoto M, Okuda J, Tanaka K, et al. Effect of previous abdominal surgery on outcomes following laparoscopic colorectal surgery. Dis Colon Rectum 2013;56:336–42. 7. Offodile II AC, Lee SW, Yoo J, et al. Does prior abdominal surgery influence conversion rates and outcomes of laparoscopic right colectomy in patients with neoplasia? Dis Colon Rectum 2008;51: 1669–74. 8. Remzi FH, Kirat HT, Kaouk JH, et al. Single-port laparoscopy in colorectal surgery. Colorectal Dis 2008;10:823–6. 9. Papaconstantinou HT, Thomas JS. Single-incision laparoscopic colectomy for cancer: assessment of oncologic resection and short-term outcomes in a case-matched comparison with standard laparoscopy. Surgery 2011;150:820–7. 10. Gaujoux S, Maggiori L, Bretagnol F, et al. Safety, feasibility, and short-term outcomes of single port access colorectal surgery: a single institutional case-matched study. J Gastrointest Surg 2012;16: 629–34.
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11. Chen WT, Chang SC, Chiang HC, et al. Single-incision laparoscopic versus conventional laparoscopic right hemicolectomy: a comparison of short-term surgical results. Surg Endosc 2011;25:1887–92. 12. Bucher P, Pugin F, Morel P. Single-port access laparoscopic radical left colectomy in humans. Dis Colon Rectum 2009;52:1797–801. 13. Merchant AM, Lin E. Single-incision laparoscopic right hemicolectomy for a colon mass. Dis Colon Rectum 2009;52:1021–4. 14. Wolthuis AM, Penninckx F, Fieuws S, et al. Outcomes for casematched single-port colectomy are comparable with conventional laparoscopic colectomy. Colorectal Dis 2012;14:634–41. 15. Champagne BJ, Papaconstantinou HT, Parmar SS, et al. Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg 2012;255:66–9. 16. Huscher CG, Mingoli A, Sgarzini G, et al. Standard laparoscopic versus single-incision laparoscopic colectomy for cancer: early results of a randomized prospective study. Am J Surg 2012;204: 115–20.
17. Poon JT, Cheung CW, Fan JK, et al. Single-incision versus conventional laparoscopic colectomy for colonic neoplasm: a randomized, controlled trial. Surg Endosc 2012;26:2729–34. 18. Yun JA, Yun SH, Park YA, et al. Single-incision laparoscopic right colectomy compared with conventional laparoscopy for malignancy: assessment of perioperative and short-term oncologic outcomes. Surg Endosc 2013;27:2122–30. 19. Kwag SJ, Kim JG, Oh ST, et al. Single incision vs conventional laparoscopic anterior resection for sigmoid colon cancer: a case-matched study. Am J Surg 2013;206:320–5. 20. Becker JM, Dayton MT, Fazio VW, et al. Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study. J Am Coll Surg 1996;183:297–306. 21. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13.
Single-port laparoscopic colectomy is safe and feasible in patients with previous abdominal surgery Mitsuyoshi Tei, M.D., Ph.D.*, Masaki Wakasugi, M.D., Takeshi Omori, M.D., Ph.D., Shigeyuki Ueshima, M.D., Masayuki Tori, M.D., Ph.D., Hiroki Akamatsu, M.D., Ph.D. Department of Surgery, Osaka Police Hospital, 10-31, Kitayama-cho, Tennoji-ku, Osaka City, Osaka 543-0035, Japan KEYWORDS: Single-incision laparoscopic surgery; Single-port surgery; Colorectal disease; Previous abdominal surgery
Abstract BACKGROUND: The aim of this study was to assess the impact of previous abdominal surgery (PAS) on single-port laparoscopic colectomy (SPLC). METHODS: We studied 429 consecutive patients who underwent SPLC in our department from May 2009 to December 2013. Patients were divided into 2 groups: those with PAS (PAS group) and those with NPAS (NPAS group). Operative parameters and outcomes were analyzed between the 2 groups retrospectively. RESULTS: SPLC was performed in 152 PAS patients and 277 NPAS patients. Eight patients in the PAS group and 6 patients in the NPAS group were converted to multiport laparoscopic colectomy (5.3% vs 2.2%, respectively; P 5 .077). Three patients in the PAS group and 2 patients in the NPAS group had inadvertent enterotomy (2.0% vs .7%, respectively; P 5 .352). No patients were converted to open surgery. There were no significant differences between the 2 groups in terms of blood loss, operative time, and postoperative outcomes. CONCLUSION: Our experience has demonstrated the safety and feasibility of SPLC in patients with PAS. Ó 2014 Elsevier Inc. All rights reserved.
Previous abdominal surgery (PAS) leads to the formation of adhesions. Adhesions are considered to be associated with an increased risk of intestinal obstruction and prolonged operative times. Some studies have repor ted no
There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs. The authors declare no conflicts of interest. * Corresponding author. Tel.: 181-6-6771-6051; fax: 181-6-6775-2838. E-mail address: [email protected] Manuscript received March 10, 2014; revised manuscript May 12, 2014 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.06.015
significant differences in short-term surgical outcomes when evaluating the impact of PAS on laparoscopic colectomy.1–4On the other hand, PAS has been associated with a significantly higher conversion rate, a higher rate of inadvertent enterotomy, and a higher incidence of postoperative bowel obstructions, compared with no previous abdominal surgery (NPAS).5–7 It is controversial whether PAS is associated with the increase of risk in laparoscopic colectomy. Single-port laparoscopic colectomy (SPLC) was first described in 2008.8 The benefits of SPLC include better
2
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cosmetic outcomes, less postoperative pain, faster postoperative recovery, and earlier discharge from the hospital compared with multiport laparoscopic colectomy (MPLC).9,10 Most reports have concluded that SPLC was feasible and safe for colorectal disease.11–19 In our department, the first case of SPLC for benign disease was carried out in May 2009 and the indication was expanded to include advanced colorectal cancer regardless of the history of PAS. Currently, SPLC is considered a reasonable alternative approach for colorectal disease in our department. There is no report evaluating the impact of PAS on SPLC currently. In this study, we aimed to assess the impact of PAS on SPLC in terms of the short-term surgical results, analyzing these data in a large number of patients over several years.
Postoperative complications were classified according to the Clavien–Dindo classification.21 As listed in Table 1, other disease consisted of inflammatory tumors and lipomas. Operative mortality was defined as death on the same day of admission or within 30 days of surgery. All patients were followed for at least 30 days after surgery. Operative parameters and outcomes were analyzed between the PAS and NPAS groups retrospectively.
Methods Patient profiles Consecutive patients who underwent SPLC for colorectal disease from the cecum to the rectosigmoid colon in our department between May 2009 and December 2013 were included in this study. Cases of obstruction or perforation that required emergent operation were excluded. Before January 2010, SPLC was performed for benign disease and early colon cancer only, but the indication was expanded later to include advanced colorectal cancer regardless of the history of PAS. Data for age, sex, and preoperative evaluation were obtained from the medical records. Of the patients who had adhesions, the following grading system was used to define severity: mild: filmy thickness, avascular; moderate: moderate thickness, limited vascularity; severe: dense thickness, well vascularized.20
Table 1
Surgical technique A single intra-umbilical incision 2.5- to 3-cm long was made. We typically used EZ Access (Hakko Co. Ltd, Nagano, Japan) on the Lap Protector (Hakko Co. Ltd) for the insertion of two 5-mm trocars and one 12-mm trocar for a right colectomy, and one 5-mm trocar and two 12mm trocars for a left colectomy, sigmoidectomy, or rectal resection. A flexible laparoscope 10 mm in diameter and standard straight laparoscopic instruments were used. Every procedure was performed using an Ultracision Harmonic scalpel (Ethicon, Somerville, NJ). For a right colectomy, the right colon was mobilized using the medial-to-lateral approach and the ileocolic or the middle colic trunk was isolated and divided by laparoscopic clips. After the mobilization of the right colon and lymph node dissection, the terminal ileum and distal right colon were divided. An extracorporeal functional end-to-end anastomosis was then created. For a left colectomy, sigmoidectomy, and rectal resection, the left colon was mobilized using the medial-to-lateral approach, and the middle colic trunk or the inferior mesenteric pedicle was isolated and divided by laparoscopic clips. The sigmoid colon or upper rectum was divided laparoscopically with staplers. An end-to-end anastomosis was performed with the trans-anal insertion of a circular stapler.
Patients’ profiles PAS group (n 5 152)
Age (years) Sex Male Female BMI ASA score 1 or 2 R3 Performance status 0 or 1 R2 Diagnosis Cancer Benign polyp Other disease*
71 (37–93)
NPAS group (n 5 277) 69 (36–94)
66 (43.4) 86 (56.6) 22.4 (15.5–32.2)
150 (54.2) 127 (45.8) 22.0 (12.5–34.9)
123 (80.9) 29 (19.1)
232 (83.8) 45 (16.2)
140 (92.1) 12 (7.9)
260 (93.9) 17 (6.1)
146 (96.1) 5 (3.3) 1 (.6)
264 (95.3) 11 (4.0) 2 (.7)
P value .023 .033
.786 .457
.488
.935
Data are expressed as number of patients (percentages). ASA score 5 American Society of Anesthesiology score; BMI 5 body mass index; NPAS 5 no previous abdominal surgery; PAS 5 previous abdominal surgery. *Inflammatory tumors and lipomas.
M. Tei et al. Table 2 group
SPLC in patients with PAS
3
Details of previous abdominal surgery in the PAS PAS group (n 5 152)
Number of previous abdominal surgeries 1 1. Type of procedure Appendectomy Hysterectomy Other gynecologic surgery Cholecystectomy* Colorectal surgery† Gastroduodenal surgery‡ Urologic surgeryx Aortic aneurysm Small bowel surgery Other abdominal surgery Type of incision Median Upper median Lower median Right lower abdomen Right subcostal Upper and lower median incision Median and right lower abdomen Upper median and right lower abdomen Lower median and right lower abdomen Several small incisions (laparoscopic surgery)
134 (88.2) 18 (11.8) 67 (44.1) 24 (15.8) 24 (15.8) 20 (13.2) 10 (6.6) 9 (5.9) 5 (3.3) 10 (6.6) 4 (2.6) 2 (1.3) 10 15 45 58 2 3 2 3 5 9
PAS 5 previous abdominal surgery. *10 open and 10 laparoscopic surgeries. † 4 open and 6 laparoscopic surgeries. ‡ 3 open and 6 laparoscopic surgeries. x 4 open and 1 laparoscopic surgeries.
Drains were not used except in cases of rectal resection. All skin incisions were closed with absorbable sutures.
Statistical methods Continuous data are expressed as median (range), unless specifically noted. Preoperative and operative factors were analyzed retrospectively. Statistical analyses were performed with the use of JMP 9.0 software (SAS Institute, Inc., Cary, NC). All group data were reported as median values. Differences in age, body mass index), operative time, blood loss, and number of harvested lymph nodes were analyzed using the Mann–Whitney U test. Other factors were analyzed by Fisher’s exact probability test. Statistical significance was established at P value less than .05.
Results We analyzed data from 429 patients (152 with PAS and 277 with NPAS) who underwent SPLC in our department from May 2009 to December 2013. Table 1 lists the profiles of the patients analyzed in both groups. The proportion of female patients and the patient age were in the PAS group were significantly greater in the PAS group than in the NPAS group (56.6% vs 45.8%, P 5 .033; 71 vs 69 years, P 5 .023). There were no significant differences between the 2 groups in terms of body mass index, American Society of Anesthesiology score, performance status, and preoperative diagnosis (Table 1). Table 2 summarizes the details of previous abdominal surgery in the PAS group, of which 134 patients (88.2%) had undergone 1 PAS and 18 patients (11.2%) had undergone more than 1 PAS. Appendectomy was the most common operative procedure (n 5 67, 44.1%), which was performed by a right lower quadrant or pararectal incision. All hysterectomies and other gynecologic surgeries were performed by a lower median incision. As for cholecystectomy, 10 patients had undergone open laparotomy (8 patients, upper median incision; 2 patients, right subcostal incision) and 10 patients had undergone laparoscopic surgery. As for colectomy, 4 patients had undergone open surgery by a median incision and 6 patients had undergone laparoscopic surgery. As for gastroduodenal surgery, 3 patients had undergone open surgery by an upper median incision and 6 patients had undergone laparoscopic surgery. As for urologic surgery, 4 patients had undergone open surgery by a lower median incision and 1 patient had undergone laparoscopic surgery. Aortic aneurysm repair, small bowel surgery, and other abdominal surgeries were performed by median incision. Nine patients had undergone laparoscopic surgery and the other patients had undergone open surgery (Table 2). Table 3 summarizes the operative factors of the PAS and NPAS groups. The most common operative procedure was right colectomy. Rectal resection was performed in 29 PAS patients and 72 NPAS patients. Adhesions were diagnosed in 116 patients in the PAS group and 81 patients in the NPAS group (76.3% vs 29.2%, respectively; P , .001). There was a significant difference between the PAS and NPAS groups in terms of adhesion severity grade (P , .001). In PAS patients with severe adhesions, the source was considered to be inflammation because of a primary advanced tumor in 1 patient and postoperative adhesions in 21 patients. On the other hand, in the NPAS patients with severe adhesions, the source was considered to be inflammation because of a primary advanced tumor (n 5 2), related to previous treatment for gynecologic disease (n 5 3), diverticulitis (n 5 2), appendicitis (n 5 4), or chronic cholecystitis (n 5 4), or unknown (n 5 3). The conversion rate was 5.3% (8/152 patients) in the PAS group and 2.2% (6/277) in the NPAS group, respectively (P 5 .077). The reasons for conversion in the PAS group were bulky tumor in 2 patients (adhesion severity grade:
The American Journal of Surgery, Vol -, No -, - 2014
4 Table 3
Comparison of operative factors
Operative procedure Right colectomy Transverse colectomy Left colectomy Sigmoidectomy Rectal resection Operative time (minutes) Blood loss (mL) Number of harvested lymph nodes Adhesion severity grade None Mild Moderate Severe Intraoperative complication Inadvertent enterotomy Conversion to MPLC Conversion to open surgery
PAS group (n 5 152)
NPAS group (n 5 277)
59 10 8 46 29 169 0 22
(38.8) (6.6) (5.3) (30.3) (19.1) (81–340) (0–1,500) (1–84)
93 15 9 88 72 182 0 26
(33.6) (5.4) (3.2) (31.8) (26.0) (90–480) (0–630) (3–109)
(23.7) (37.5) (24.3) (14.5) (2.6) (2.0) (5.3)
196 45 18 18 2 2 6 0
(70.8) (16.2) (6.5) (6.5) (.7) (.7) (2.2)
P value .398
36 57 37 22 4 3 8 0
.907 .592 .016 ,.001
.107 .352 .077 d
Data are expressed as number (percentage). MPLC 5 multiport laparoscopic surgery; NPAS 5 no previous abdominal surgery; PAS 5 previous abdominal surgery.
none), severe obesity in 2 patients (adhesion severity grade: mild), intraoperative bleeding in 1 patient (adhesion severity grade: mild), and moderate adhesion in 3 patients. The reasons for conversion in the NPAS group were tumor directly invading the bladder wall in 2 patients (adhesion severity grade: none), bulky tumor in 2 patients (adhesion severity grade: none), and severe adhesion in 2 patients. All 14 patients underwent conventional MPLC. None of the patients was converted to open surgery. The rate of inadvertent enterotomy was 2.0% (3/ 152 patients; adhesion severity grade: none, n 5 1 and moderate, n 5 2) in the PAS group and .7% (2/277 patients; adhesion severity grade: none, n 5 1 and moderate, n 5 1) in the NPAS group (P 5 .352). There were significantly fewer harvested lymph nodes in the PAS group than in the NPAS group (22 vs 26, respectively; P 5 .016). There were no significant differences between the 2 groups in terms of operative procedure, operative
Table 4
time, blood loss, conversion rate, and intraoperative complication (Table 3). Table 4 depicts the postoperative complications that occurred in each group. Bleeding occurred in 3 patients in the PAS group and 4 patients in the NPAS group. Anastomotic leakage occurred in 3 patients in the PAS group and 9 patients in the NPAS group. Abdominal abscess was diagnosed in 10 patients in the PAS group and 9 patients in the NPAS group. Wound infection was diagnosed in 11 patients in the PAS group and 21 patients in the NPAS group. Bowel obstruction was diagnosed in 3 patients in the PAS group and 10 patients in the NPAS group. More than one complication was observed in 34 patients. There were no significant differences between the 2 groups in terms of postoperative complications. The median length of hospital stay was similar in both groups (8 days). Perioperative death was recorded in 1 patient in the PAS group because of pneumonia (Table 4).
Postoperative complications
Complication
PAS group (n 5 152)
NPAS group (n 5 277)
P value
Bleeding Anastomotic leakage Wound infection Abdominal abscess Cardiac or pulmonary disease Bowel obstruction Perioperative death Length of hospital stay (days)
3 3 11 10 2 3 1 8
4 9 21 9 4 10 0 8
.702 .396 1.000 .140 1.000 .557 .354 .992
(2.0) (2.0) (7.2) (6.6) (1.3) (2.0) (.7) (4–70)
NPAS 5 no previous abdominal surgery; PAS 5 previous abdominal surgery.
(1.4) (3.2) (7.6) (3.2) (1.4) (3.6) (.0) (6–110)
M. Tei et al.
SPLC in patients with PAS
Comments Based on our experience, we consider SPLC superior to MPLC in terms of better skin cosmesis. We showed that there were no significant differences between the PAS and NPAS groups in terms of blood loss and operative time. SPLC was performed successfully in 94.7% of the patients in the PAS group and 97.8% of the patients in the NPAS group. Three patients in the PAS group and 2 patients in the NPAS group had inadvertent enterotomy (2.0% vs .7%, respectively; P 5 .152), but underwent the operation completely, converting not to open laparotomy but to MPLC. One of the conversions in the PAS group was because of intraoperative bleeding. Some studies have reported that the conversion rate from SPLC to MPLC or open surgery ranged from 0% to 36.4%,11,14–16,18 and PAS has been associated with a significantly higher conversion rate.5–7 Our results with SPLC had high reliability in terms of intraoperative complications and a successful completion rate regardless of the history of PAS. Adhesions were diagnosed in 116 patients in the PAS group and 81 patients in the NPAS group (76.3% vs 29.2%, respectively; P , .001), and there was a significant difference between the PAS and NPAS groups in terms of adhesion severity grade (P , .001). However, there was no significant difference in terms of conversion rate between the 2 groups (5.3% vs 2.2%, respectively; P 5 .077). In this study, 6 patients in the PAS group were converted to MPLC, because of mild adhesions (n 5 3) and moderate adhesion (n 5 3). Two patients in the NPAS group had converted to MPLC, because of severe adhesions. Other patients in the PAS group (n 5 2) and the NPAS group (n 5 4) had no adhesions and were converted because of bulky tumor or tumor directly invading another organ. Adhesion severity grade was not correlated with the conversion to MPLC (P 5 .249, data not shown). However, the conversion rate by tumor factors (bulky or invasion) was 25.0% (2/8) in the PAS group and 66.7% (4/6) in the NPAS group. We conducted that it was difficult to evaluate the correlation of adhesion and conversion in this study. We showed that there were no significant differences between the 2 groups in terms of postoperative complications. Fourteen patients with conversion to MPLC, including 1 patient with intraoperative bleeding and 5 patients with inadvertent enterotomy, had no postoperative complications. Wound infection was diagnosed in 11 patients in the PAS group and 21 patients in the NPAS group (7.2% vs 7.6%, respectively; P 5 1.000). Bowel obstruction occurred in 3 patients in the PAS group and 10 patients in the NPAS group (2.0% vs 3.6%, respectively; P 5 .557). The incidence of complications in this study was lower compared with other reports of MPLC with PAS,5,7 but higher compared with other reports of SPLC.18,19 Even minor complications that might have little or no influence on postoperative hospital stay or mortality were counted. We concluded that the rate of complications is within an acceptable range.
5 Maintaining the surgical oncologic outcome is the most important factor for the treatment of cancer. High vascular ligation and a nontouch technique were maintained for colorectal cancer in this series. No gross or microscopic positive resection margins were observed in this series. One patient in the NPAS group had an anastomotic recurrence 12 months after the operation. The median number of harvested lymph nodes was 22 in the PAS group and 26 in the NPAS group (P , .016), which exceeded that of other reports.9,16,17,19 In our experience, SPLC could be performed with a sufficient field for lymph node dissection and an adequate number of harvested lymph nodes regarding the oncologic aspect. The main limitations of this study were that it was carried out at a single institution and it was retrospective in nature. Furthermore, it was difficult to demonstrate the clinical impact of PAS in this study. We consider that SPLC in patients with PAS is safe and feasible.
Conclusion This is the first study that showed the safety and feasibility of SPLC in patients with PAS. We consider that PAS is not a contradiction to SPLC.
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