CHICAGO – Single-incision laparoscopy is a safe approach for right colectomy and reduces both length of stay and early postoperative pain, compared with established laparoscopic techniques, according to Dr. Harry T. Papaconstantinou.
Dr. Harry T. Papaconstantinou
"I had one patient ask if he could do sit-ups the day after surgery," the physician said. "These patients were actually asking me to go home."
Although single-incision laparoscopy (SIL) is gaining momentum as an advance in laparoscopic colectomy, direct comparisons of outcomes between SIL and established techniques are lacking.
Dr. Papaconstantinou and his colleagues at Scott & White Memorial Hospital in Temple, Tex., compared their first 29 SIL right colectomy cases to an equivalent number of standard laparoscopic (LAP) and hand-assisted laparoscopic (HAL) cases matched for age, sex, body mass index (BMI), American Society of Anesthesiologists score, and pathology.
Operating time was similar for SIL, LAP, and HAL (128.8 min. vs. 128.3 min. vs. 116.2 min., respectively), as was estimated blood loss (60 mL, 90 mL, and 71 mL), Dr. Papaconstantinou reported at the annual meeting of the Western Surgical Association.
Although the mean incision length was similar for the SIL and LAP groups (4.5 cm and 5.1 cm), both had significantly shorter incisions than the HAL patients at 7.2 cm (P less than .001).
"Our operating times are a little longer and incision length larger, but I don’t think it should dissuade an experienced laparoscopist from doing a colectomy single incision," he said.
One SIL patient (3.4%) was converted to the HAL technique, and four conversions occurred in both the LAP group (two to HAL and two to open surgery) and HAL group (four to open surgery).
The median length of stay was 1 day shorter at 3 days in the SIL group, compared with 4 days for both the LAP and HAL groups (P less than .05), said Dr. Papaconstantinou, chief of colon and rectal surgery at Scott & White Memorial Hospital.
Maximum pain scores on a 10-point visual analog scale were significantly higher in the LAP and HAL groups than in the SIL group on postoperative day 1 (6.0 vs. 6.0 vs. 4.7, respectively) and on post-op day 2 (5.1 vs. 5.0 vs. 3.8); however, pain at the time of discharge was similar among the LAP, HAL, and SIL groups (1.6 vs. 1.4 vs. 1.0).
Four SIL patients were readmitted, compared with two in the LAP group and three in the HAL group. The reasons for SIL readmissions included one anastomotic leak, one presumed ileus that resolved after a bowel movement, and two cases of nonocclusive portal vein thrombus that were treated with anticoagulation. These patients had other risk factors for venous thrombosis including a BMI greater than 30 kg/m2 and visceral malignancy. No patients in any of the groups died.
Dr. Papaconstantinou acknowledged having initial concerns about impaired visualization and triangulation during the technically demanding surgery, but said that SIL is safe and feasible, even in obese patients. He said he routinely extends the incision to reduce traction on the mesenteric vessels in larger patients, and has found that curved instruments actually hinder, rather than facilitate, the operation.
"One of the things that is critical is a flexible-tip 5-mm camera because it allows you to move the camera driver away from the surgeon’s hands," he said. "Then you can actually come in at an angle, so you get a side view rather than an on-axis view [of the operative field]."
Using instruments of variable length (standard and bariatric length), and maintaining the instrument handles in a different orientation and plane, also avoids collision.
Invited discussant Dr. Alessandro Fichera, with the University of Chicago Medical Center, said, "There is no doubt in my mind that single-incision laparoscopy is here to stay and that it provides advantages that go way beyond cosmesis, including decreased postoperative pain, narcotic use, and length of stay."
He said that the retrospective nature of the study may introduce a selection bias, and asked who the authors would recommend as candidates for SIL.
"I’ve done all comers, including those with a BMI greater than 40 [kg/m2]," said Dr. Papaconstantinou. Patients in the study had an average age of about 60 years, 55% were women, the average BMI was about 30 kg/m2, and one-third had a history of previous abdominal surgery. Cases included 15 with adenocarcinomas, 12 with polyps, and 2 with Crohn’s disease.
Dr. Papaconstantinou reported receiving honoraria from Covidien for speaking and teaching activities.