SILS Colectomy: a technique of great promise
laparoscopic surgery (SILS) for complex resectional colorectal surgery: a
technique offering great potential and not just cosmesis
WM Chambers, Monica Bicsak,
M Lamparelli, AR Dixon
SPIRE Bristol Hospital,
Durdham Down, Bristol, BS6 6UT
Key words: single incision
laparoscopic surgery (SILS), laparoscopic colorectal surgery, ERAS, NOTES
incision (or port) laparoscopic surgery (SILS) has emerged in an attempt to further
reduce morbidity and enhance the cosmetic benefits of conventional laparoscopic
surgery. The literature contains
two reports of SILS right hemicolectomies. We report our experience of SILS in colorectal surgery.
Methods: Seven consecutive,
unselected patients underwent SILS retro-caecal appendicectomy, right hemicolectomy,
extended right hemicolectomy, colectomy/ileo rectal anastomosis,
panproctocolectomy, anterior resection and restorative proctocolectomy/ileoanal
pouch using a single Tri-port (Advanced
Surgical Concepts, Bray, Ireland), conventional instrumentation and TAP
block analgesia. Three had undergone previous surgery, two had cancer and two
right and left iliac fossa SILS was feasible using conventional
instruments. Operative time ranged
between 23 - 195mins (median 48).
Four patients tolerated normal diet within 6hrs (12-16 hrs/overnight for
remainder). Only one patient
required postoperative enteral morphine (10mg x4). Discharge occurred between 8-90hrs (median 16hrs) of surgery. A secondary haemorrhage from the ileo rectal
anastomosis was managed conservatively.
Conclusion: SILS LCRS is
feasible and safe when performed by an experienced laparoscopic surgeon and
theatre team and may have advantages over conventional laparoscopic colorectal
surgery in terms of minimal pain, lower costs, faster recovery and cosmesis. A formal comparison is in progress.
Although it was in 1990 that Jacobs reported the first successful
laparoscopic right-hemicolectomy1 the uptake of laparoscopic
colorectal surgery (LCRS) has been painfully slow2; 8.2% of UK resections
are LCRS3 and only 18% of ACPGBI members have a laparoscopic
practice approaching 50%2. This poor uptake arose through concerns about oncological
safety4-6 as well the technically demanding learning curve7-9. Large randomized trials (CLASSIC10,COST11,
Barcelona12), Cochrane13 reviews and meta-analysis14
have concluded that LCRS is not only safe but is associated with better
short-term outcomes and without a negative effect on long-term cancer
survival. NICE updated its
guidance15 in-favor of NHS trusts and appropriately trained surgeons
offering LCRS as an alternative to conventional open surgery.
Whilst LCRS is by definition less invasive than open surgery, it
still requires several incisions for ports and an extraction site each of which
is painful, impacts on the final cosmetic appearance and has the potential for
bleeding, interfascial haematoma formation, internal organ injury, local nerve
irritation and incisional hernia development. Cosmesis is increasingly demanded by increasingly discerning
Natural Orrifice Transluminal Endoscopic Surgery (NOTES) e.g., trans-vaginal
cholecystectomy17 and nephrectomy (porcine model)18 is
evolving and is considered by its enthusiasts as being the next surgical
frontier. However, additional
ports are often required, particularly when using endoscopic staplers18. The procedures are also protracted and
require expensive specialized equipment and not least extensive training. NOTES colectomy as it stands
probably has no clinical application.
An alternative is single-incision or single port laparoscopic surgery
(SILS) using multi-lumen ports and flexible instrumentation that obviates the
need for triangulation, a fundamental component of conventional laparoscopic
surgery. More importantly from a
cost point of view, conventional laparoscopic instrumentation can be used as in
the first reported series of SILS; 53 retroperitoneal adrenalectomies19. SILS has been reported for
appendicectomy20, cholecystectomy21, nephrectomy22,
pyelopasty23 and most recently right hemicolectomy24,25 .
Seven unselected, consecutive patients (five women) aged 26-78yrs
(median 44yrs) underwent SILS surgery in March 2009 (table 1). Operations comprised: retro caecal
appendicectomy, right hemicolectomy, extended right hemicolectomy, colectomy/ileo
rectal anastomosis, panproctocolectomy, anterior resection and restorative
Three had undergone previous surgery: open nephro-uretectomy for Willm’s
tumour, extended left hemicolectomy for obstructed defecation/slow transit
constipation and laparoscopic high anterior resection for a Duke’s B
carcinoma. The two Colitics were
receiving (i) high dose prednisolone, azathioprin, cyclosporin (ii)
prednisolone and mycophenolate.
All received a preoperative phosphate enema and a carbohydrate drink. Each operation used a single ASC -
Tri-port (Advanced Surgical Concepts,
Bray, Ireland) and conventional instruments: Johan bowel grasper (Karl Storz, Slough, UK), Harmonic
Scalpel and linear/circular staplers (Ethicon
EndoSurgery, Bracknel, UK).
The two cancer resections followed conventional oncological principles
and techniques. Analgesia was by a
combination of pre-operative transversus abdominals plane (TAP block) analgesia,
short acting intra-operative opiods and post-operative intravenous paracetamol26.
The ASC-Triport (Advanced
Surgical Concepts, Bray, Ireland) is a multichannel access system that
allows the simultaneous passage of up to two 5mm and one 12mm laparoscopic
instruments with a separate port for gas insufflation. It is made up of two components, a
retractor and a valve. The
retractor consists of one internal ring, two external rings and a “doubled over
“ cylindrical plastic sleeve. The
valve is composed of a thermoplastic elastomer that will allow the passage of
lubricated laparoscopic instruments.
The Triport is deployed using a blunt introducer loaded with the
internal ring, passed through a 15mm incision into the peritoneal cavity. It is the incision that determines the
size of the instruments that can be used through the port. The plastic sleeve is then pulled
upwards to pull the internal ring up against the abdominal wall. The external ring is then pushed
against the abdominal wall. It is
the tension between these two rings that retracts the abdominal wall27.
Surgical Concepts, Bray, Ireland) were positioned as appropriate: umbilical
(4), proposed ileostomy site (2) and left-iliac fossa in the lateral aspect of previous
oblique scar (1). 300
laparoscopes were used throughout - 5mm EndoEye
video-laparoscope, (Olympus KeyMed,
Southend-on-Sea, UK) in four, 10mm conventional (1), 10mm flexible High
Definition EndoEye flexible tip (Olympus KeyMed, Southend-on-Sea, UK) and
5mm conventional (1). The channel
of the Johan grasper was used for flume extraction. Close mesenteric
dissection/division with greater ommentum preservation followed by a rectal TME
was used for the two proctocolectomies.
A TLC55 (Ethicon Endosurgery,
Bracknel, UK) was used to divide the terminal ileum in the
panproctocolectomy after removal of the Triport; the specimen was then
delivered via an inter-sphincteric pelvic dissection. An ATG45 (Ethicon Endosurgery, Bracknel, UK) - two anterior-posterior firings
was used in the IAP patient to divide the gut tube at the level of the pelvic
floor. A 20cm J pouch was
constructed extracorporeal after removal of the specimen through the port site.
A combination of cranial to caudal
and lateral to medial dissection (and visa versa) was employed in each of the
colectomies. Rectal division was
achieved using an ATG45 (Ethicon
EndoSurgery, Bracknel, UK).
The Triport was then removed to allow specimen extraction, placement of
a purse string/circular staple gun head before being replaced to allow restoration
of bowel continuity in the usual manner.
Named vessels were divided at the origins using an ATW45 endostapler (Ethicon Endosurgery, Bracknell, UK). The retrocaecal appendix required mobilization of the caecum
and ascending colon.
No extra-umbilical skin incisions or drains were used. Urinary catheters were removed in
theatre. Patients were encouraged
to mobilize and were offered a normal diet as the time of day of their surgery
dictated. A caudal anaesthetic was
administered to the pan-proctocolectomy patent prior to extubation.
All seven procedures were successfully completed without the need
for open conversion or any extra-port skin incision/auxiliary port insertion. All dissecting maneuvers were done
using regular instrumentation inserted through the Tri-port. No intra-operative complications
occurred. Operative time was
surprisingly quick (20-195mins); median 48mins. TAP blocks augmented by parenteral paracetamol were
sufficient for providing good post-operative analgesia in all but one patient
who required four single 10mg dose of enteric morphine. No patient complained of any shoulder
pain whilst his or her TAP blocks were working. The patient who had undergone the previous laparoscopic high
anterior resection commented - “the pain is a 10th of what it was
last time”, “I was ready to go to work by the third day”. Recovery was impressively quick with normal
diet tolerated at between 4-6hrs post procedures in four and 12, 14 and 16hrs (i.e.,
overnight) in the remaining patients.
The two colitics were changing her stoma appliances under supervision
within 18hrs of surgery. The
median hospital stay was very short at 16hrs (8-90hrs). A secondary bleed from the ileo-rectal
anastomosis was managed conservatively.
Single-port Tran umbilical laparoscopy (SILS) was first reported for
appendicectomy28 and cholecystectomy29 in 1999 and it was
only through the technical limitations of conventional instrumentation that it
failed to gain momentum. SILS has emerged
in an attempt to further enhance the cosmetic benefits and reduce the morbidity
of minimally invasive surgery.
Conventional laparoscopic surgery is based around the concept of
triangulation of instruments and laparoscope. Successful SILS as described in the literature to date is
based on this same assertion and its achievement has required the development
and use of either articulating or bent instrumentation introduced via a fixed
and stable platform (a large caliber trocar) or alternatively small, adjacently
placed trocars. Instrument
articulation allows intra-corporeal triangulation of parallel instruments. Unlike conventional laparoscopic
surgery, optimal instrument utilisation in SILS demands that the operating surgeon
makes greater use of their none dominant hand. SILS also makes it mandatory to have an expertise in
directing, using and interpreting the image produced by a 300 laparoscope. Whilst not essential, a 5mm end-on
light source reduces clutter and instrument collision. It is these differences and the
tendency for instrument collision that makes this technique inherently
difficult to learn and by definition, teach.
That said we were very surprised at the ease and speed at which we
were able to perform what amounted to complex laparoscopic interventions. This ease of adaption probably relates
to the experience of the senior author in performing pragmatic three-port in-line
dissection complex laparoscopic surgery with low traction rather than relying
on an assistant to provide traction.
Gravity and natural tissue planes providing counter traction to a highly
active none-dominant hand and a relatively “still” operating-dominant right hand
using an energy source. It
is totally unnecessary to use any trans-parietal sutures24 to
provide retraction. This coupled with exclusive use of a 300
laparoscope and a well taught “camera operator” who intuitively co-ordinates
himself or herself with the surgeon as well as providing positive encouragement. We consider it important to keep
the laparoscope in a relatively fixed position just inside the abdominal cavity
- if it is too far in it will restrict the operating instrumentation. In our limited experience our preferred
option was the 5mm video-laparoscope or the flexible 10mm high definition
scope. Nether the less, instrument
collision still remains a challenge.
It is also necessary to periodically rotate the Triport and swap operating hands to optimize the placement and use
of the instrumentation. It was
useful if the camera operator sat on the side opposite to the surgeon. The laparoscope was lubricated using
lens cleaning/anti fog solutions.
The operating instruments were lubricated using generous amounts of
Although this early limited experience of SILS is promising,
experienced laparoscopic skills are mandatory and essential for its safe and
effective completion. Evolving articulating
instrumentation which offer surgeons seven degrees of freedom all within the
control of one hand30 and the newer deflectable tip laparoscopes
advocated for SILS implementation requires considerable training and practice
and it is our view that for the former this is probably best gained by repeated
visits to an animal lab.
Single-port laparoscopic surgery in the hands of an experienced
laparoscopic surgeon allows for common complex colorectal operations to be
performed entirely through the patients umbilicus or chosen stoma site and in
doing so enables an essentially scarless and an almost painless procedure with
the potential for an impressively quick recovery and almost certain patient
psychological benefit. Unlike
other groups25, 31 we see no reason why SILS can’t be applied to
cancer resections provided that the surgeon carries out the exact same
dissection. For small
lesions/benign disease a transverse peri-umbilical incision is probably
appropriate. For larger sized tumours
we would continue to advocate a longitudinal umbilical incision that can be
extended as appropriate26.
The observation of a complete lack of shoulder tip pain when the TAP
blocks were working would suggest that it is referred pain form parietal injury/irritation
and not the widely held view that CO2 insufflation and diaphragmatic
irritation is responsible for its development. Tap blocks
could thus be used on the ward to treat “breakthrough” shoulder pain to reduce
the need for overnight admission and allow for higher rates of day case
laparoscopic cholecystectomy. We
are encouraged to increase our clinical experience and continued investigation
of this new and potentially fruitful technique. Future developments of four-port multiport single access
with facilities for flume extraction may facilitate/improve this single port
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We are grateful
to Olympus KeyMed who provided the Triports, the EndoEye 5mm video-laparoscope and the 10mm deflectable tip