SILS Colectomy: a technique of great promise

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Single-incision 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


Abstract

Aims: Single 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 were immunosupressed.

Results: Umbilical, 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.

 

Introduction

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 patients16.   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 .

 

Methods

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 proctocolectomy-ileoanal pouch.  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.

ASC-Triports (Advanced 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.

 

Results.

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.


Discussion

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 water-soluble gel.

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 approach.

 

References

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 Acknowledgement

We are grateful to Olympus KeyMed who provided the Triports, the EndoEye 5mm video-laparoscope and the 10mm deflectable tip HDlaparoscope.

 

 


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