Oncologic long-term outcome of single-incision laparoscopic surgery (SILS) for colorectal cancer.

PURPOSE: Single-incision laparoscopic surgery (SILS) has been introduced as a less invasive alternative to multi-port laparoscopic surgery (MLS). MLS is widely accepted for the treatment of colorectal cancer, but there remains minimal evidence for the use of SILS. Thus, we compared both short- and long-term outcomes of SILS and open surgery (OS) in matched cohorts of colorectal cancer patients. METHODS: Some 910 patients had colorectal resections for cancer between 2006 and 2013, and 134 of them were operated on using SILS. Eighty of these SILS patients were compared to a cohort of patients who had open surgery that were matching in tumour stage and location, type of resection, sex, age and ASA Score. Disease-free survival at 5 years (5y-DFS) was the primary endpoint; morbidity and hospitalization were secondary parameters. The role of surgical training in SILS was also investigated. RESULTS: Clavien Dindo ≥ IIIb complications occurred in 13.8% in both groups. 5y-DSF were 82% after SILS and 70% after OS (p = 0.11). Local recurrence after rectal cancer tended to be lower after SILS (0/43 (SILS) vs. 4/35 (OS), p = 0.117). Length of stay was significantly shorter after SILS (10 vs. 14 days, p = 0.0004). The rate of operations performed by surgical residents was equivalent in both groups (44/80 (SILS) vs. 46/80 (OS), p = 0.75). CONCLUSION: The data demonstrates that SILS results in similar long-term oncological outcomes when compared to open surgery as well as morbidity rates. The hospital stay in the SILS group was shorter. SILS can also be incorporated in surgical training programmes.

Single-Incision Laparoscopic versus Open Sigmoidectomy for Diverticular Disease: A Disease-Stratified Matched-Pair Analysis.

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a variant of laparoscopic surgery, especially for diverticular disease (DD), but there are very little data comparing SILS to standard surgical procedures for DD, and most studies on DD surgery do not declare the disease stage. We compared SILS to open sigmoidectomy for DD in a stage-stratified matched-pair analysis to validate the significance of SILS. METHODS: All patients with SILS or conventional sigmoidectomy for diverticulitis of a single visceral surgery department were subject to a matched-pair analysis stratified by age, sex, body mass index, previous abdominal surgery, and the stage of DD. RESULTS: Fifty-five pairs were included. In total, 84/110 (76%) had complicated stages of DD. ASA stages were higher in the laparotomy group; the proportion of elective operations was similar (SILS 78%, open: 71%). In the SILS group, length of hospital stay (LoS; 10.2 vs. 16.7 days) and duration of intensive or intermediate care (IMC; 1.8 vs. 3.7 days) were shorter, blood transfusions were reduced (0.1 vs. 0.4 units) and less patients received opioids postoperatively (75 vs. 98%). The day of first defecation, stoma rate, and rates of morbidity and mortality were similar. CONCLUSIONS: SILS equals open sigmoidectomy regarding complications with advantages regarding pain, LoS, IMC/intensive care unit treatment, and blood transfusion.

Single-Incision Multiport/Single Port Laparoscopic Abdominal Surgery (SILAP): A Prospective Multicenter Observational Quality Study.

BACKGROUND: Increasing experience with minimally invasive surgery and the development of new instruments has resulted in a tendency toward reducing the number of abdominal skin incisions. Retrospective and randomized prospective studies could show the feasibility of single-incision surgery without any increased risk to the patient. However, large prospective multicenter observational datasets do not currently exist. OBJECTIVE: This prospective multicenter observational quality study will provide a relevant dataset reflecting the feasibility and safety of single-incision surgery. This study focuses on external validity, clinical relevance, and the patients' perspective. Accordingly, the single-incision multiport/single port laparoscopic abdominal surgery (SILAP) study will supplement the existing evidence, which does not currently allow evidence-based surgical decision making. METHODS: The SILAP study is an international prospective multicenter observational quality study. Mortality, morbidity, complications during surgery, complications postoperatively, patient characteristics, and technical aspects will be monitored. We expect more than 100 surgical centers to participate with 5000 patients with abdominal single-incision surgery during the study period. RESULTS: Funding was obtained in 2012. Enrollment began on January 01, 2013, and will be completed on December 31, 2018. As of January 2016, 2119 patients have been included, 106 German centers are registered, and 27 centers are very active (>5 patients per year). CONCLUSIONS: This prospective multicenter observational quality study will provide a relevant dataset reflecting the feasibility and safety of single-incision surgery. An international enlargement and recruitment of centers outside of Germany is meaningful. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00004594; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004594 (Archived by WebCite at http://www.webcitation.org/6jK6ZVyUs).

Single-port laparoscopic resection for diverticular disease: experiences with more than 300 consecutive patients.

BACKGROUND: Single-port laparoscopic surgery (SILS) is a new minimally invasive technique, which has been developed to minimize the surgical access trauma. For colorectal resection, the access trauma can be limited to the one incision, which is needed for specimen extraction anyways, but dissection might be more demanding than in multiport laparoscopic surgery. The aim of this study was to evaluate the usefulness of SILS for the treatment of diverticular disease of the sigmoid colon. METHODS: Between July 2009 and December 2013, a total of 329 consecutive patients with intended SILS sigmoid colectomy for complicated or frequently recurring diverticulitis were studied. Clinical data were collected in a prospective database. Telephone follow-ups were performed to evaluate long-term morbidity and quality of life. RESULTS: Of the 329 patients (139 male) with intended SILS sigmoid colectomy, 309 were successfully operated on in SILS technique, while 20 (6.1%) were converted to open surgery. The mean duration of surgery was 153.5 (65-434) min. Total morbidity rate was 18.3%. Anastomotic leakage was the most serious complication occurring in 13 patients (leak rate 4%) with one consecutive death (mortality rate 0.3%). Quality of life had significantly improved 6 months after surgery in comparison with the preoperative value. At a mean follow-up of 18.6 months, 16 patients (4.9%) had incisional hernia and one patient had recurrent diverticulitis. CONCLUSION: In spite of almost 5% incisional hernia 6 months after surgery, single-incision sigmoid colectomy for diverticulitis is feasible and save and is therefore an alternative to multiport laparoscopic surgery. Further trials are necessary to evaluate its benefits over multiport laparoscopic surgery.

Single-incision laparoscopic surgery for diverticulitis in overweight patients.

AIM: Single-incision laparoscopic surgery (SILS) has been introduced as a new technique for the treatment of various colorectal diseases. Recurrent or complicated diverticulitis of the sigmoid colon is a frequent indication for minimally invasive sigmoid colectomy. The aim of this study was to investigate the impact of obesity on the outcome of SILS sigmoid colectomy. METHODS: From September 2009 to October 2014, data from 377 patients who had intended SILS sigmoid colectomy for diverticulitis at our institution were collected in a prospective database. The patients were categorized in the following subgroups: group 1 (normal weight, body mass index (BMI) < 25 kg/m(2)), group 2 (overweight, BMI 25-29.9 kg/m(2)), group 3 (obesity, BMI 30-34.9 kg/m(2)), and group 4 (morbid obesity, BMI > 35 kg/m(2)). RESULTS: The groups were equivalent for sex, age, status of diverticulitis, the presence of acute inflammation in the specimen, and the percentage of teaching operations, but the percentage of patients with accompanying diseases was significantly more frequent in groups 2, 3, and 4 (p = 0.04, 0.008, and 0.018, respectively). As compared to group 1, the conversion rate was significantly increased in groups 2 and 4 (2.3 vs. 9.3% (p = 0.013) and 2.3 vs. 12.5% (p = 0.017), respectively). The duration of surgery, hospitalization, and morbidity did not differ between the four groups. CONCLUSION: Up to a body mass index of 35 kg/m(2), increased body weight does not significantly reduce the feasibility and outcome of single-incision laparoscopic surgery for diverticulitis.

Single-incision laparoscopic surgery for colorectal malignancy--results of a matched-pair comparison to conventional surgery.

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a new minimally invasive technique which has frequently been applied for treatment of benign colorectal diseases. However, there is still little experience with this technique for the treatment of colorectal cancer. METHODS: Sixty-eight patients with SILS resections for colon (n = 25) or rectal cancer (n = 43) were compared to a group of conventionally operated patients who were matched for surgical procedure, tumor stage and tumor location, and the use of preoperative radiochemotherapy. RESULTS: Both groups were comparable for lymph node harvest, specimen length, and the duration of surgery. No significant differences were observed for the number of positive circumferential resection margins, or the distance of the tumor to both the aboral or lateral resection margin, but two positive resection margins were only present after SILS and not after conventional surgery. Hospitalization tended to be shorter after SILS (p = 0.097). Overall, morbidity was equivalent between the two groups, with a difference for colon cancer where it was significantly lower after SILS as compared to open surgery (p = 0.025) mainly due to a lower rate of wound complications. CONCLUSION: SILS might be an acceptable alternative to open surgery for the treatment of colon cancer. For rectal cancer, no apparent benefit could be documented. As no sufficient data on the oncologic quality are available, single-incision laparoscopic surgery can yet not be recommended for the treatment of rectal cancer out of clinical trials.

Conventional mesh repair of a giant iatrogenic bilateral diaphragmatic hernia with an enterothorax.

PURPOSE: Diaphragmatic hernias (DHs) are divided into congenital and acquired hernias, most of which are congenital. Among acquired DHs, up to 80% are left-sided, only a few iatrogenic DHs have been reported, and bilateral hernias are extremely rare. For diagnostic reasons, many DHs are overlooked by ultrasonography or X-ray and are only recognized at a later stage when complications occur. METHODS: In 2009, we performed three partial diaphragm replacements in our clinic for repairing DHs using a PERMACOL™ implant. RESULTS: As all patients had uneventful postoperative courses and the clinical outcomes were very good, we present one special case of a 65-year-old male with a giant iatrogenic bilateral DH with an enterothorax. CONCLUSION: We see a good indication for diaphragm replacements by using a PERMACOL™ implant for fixing especially DHs with huge hernial gaps and in cases with fragile tissue.

Long-term outcome of laparoscopic ileocecal resection for Crohn's disease before the era of biologics.

BACKGROUND: Crohn's disease (CD) of the terminal ileum not responding to standard medical treatment is more and more treated with biologics instead of surgery. In order to get more information on the results of surgery, we analyzed the outcome of laparoscopic ileocecal resection (LICR) performed before the widespread use of these drugs. METHODS: Chart reviews and telephone follow-ups were performed on 119 patients treated with laparoscopic ileocecal resection for CD. Follow-ups were performed at a median of 58 (17-124) and 113(69-164) months. Symptomatic restenosis requiring surgery or endoscopic dilatation was the primary endpoint. We further analyzed risk factors of recurrence. RESULTS: Of the 119 patients initially treated, 18 required surgery (n = 14) or endoscopic dilatation (n = 4). The calculated rates of re-intervention were 10 und 17.5 % at 5 and 10 years, respectively. Ninety percent of the patients had a Crohn-specific medication treatment at the time of surgery, but only 51.4 und 46.9 % at FU 1 und 2, respectively. Smoking increased the risk of recurrence (OR 3.7, P = 0.011). CONCLUSION: The data demonstrate excellent long-term results of LICR for CD of the terminal ileum. Surgery should be considered as a first choice treatment in many patients with ileocecal CD not responding to conventional treatment.

Single-incision laparoscopic surgery: outcomes from 224 colonic resections performed at a single center using SILS.

BACKGROUND: Compared with single-incision laparoscopy, multiport laparoscopy is associated with greater risk of postoperative wound pain, infection, incisional hernias, and suboptimal cosmetic outcomes. The feasibility of minimally invasive single-incision laparoscopic surgery (SILS) for colorectal procedures is well-established, but outcome data remain limited. METHODS: Patients with benign diverticular disease, Crohn's disease, or ulcerative colitis admitted to Klinikum Leverkusen, Germany, for colonic resection between July 2009 and March 2011 (n = 224) underwent single-incision laparoscopic surgery using the SILS port system. Surgeons had ≥7 years' experience in laparoscopic colon surgery but no SILS experience. Patient demographic and clinical data were collected prospectively. Pain was evaluated by using a visual analog scale (0-10). Data were analyzed by using the SPSS PASW Statistics 18 database. RESULTS: The majority of patients underwent sigmoid colectomy with high anterior resection (AR) or left hemicolectomy (n = 150) for diverticulitis. Our conversion rate to open surgery was 6.3 %, half in patients undergoing sigmoid colectomy with high AR or left hemicolectomy, 95 % of whom had diverticulitis. Mean operating time was 166 ± 74 (range, 40-441) min in the overall population, with shorter times for single-port transanal tumor resection (SPTTR; 89 ± 51 min; range, 40-153 min) and longer times for proctocolectomy (325 min; range, 110-441 min). Mean hospital stay was approximately 10 days, longer after abdominoperineal rectal resection or proctocolectomy (12-16 days). Most complications occurred following sigmoid colectomy with high AR or left hemicolectomy [19/25 (76 %) of early and 4/5 (80 %) of late complications, respectively]. Pain was <4 on a scale of 0-10 in all cases on postoperative day 1, and typically decreased during the next 2 days. CONCLUSIONS: Our findings support the feasibility and tolerability of colorectal surgery, conducted by experienced laparoscopic surgeons without specific training in use of the SILS port.

Current status of single-incision laparoscopic surgery: European experts' views.

Recent advances in minimally invasive surgery have centered on reducing the number of incisions required, which has led to the development of the single-incision laparoscopic technique. A panel of European single-incision laparoscopy experts met to discuss the current status of, and the future expectations for, the technique. The experts reached agreement on a number of statements and recommendations, which will support surgeons in adopting the technique. The panel agreed that the single-incision technique may offer a number of benefits to patients; however, further clinical data need to be published to confirm its value. An ideal training route for surgeons who are adopting the technique was agreed upon, as was the need for a single, large clinical registry of data.

Single-incision laparoscopic surgery: a promising approach to sigmoidectomy for diverticular disease.

BACKGROUND: Laparoscopic sigmoidectomy has become the standard procedure in elective surgery for recurrent diverticular disease. To realize further benefits of this minimal invasive procedure and to offer less postoperative pain, shorter recovery time, reduced complications, and improved cosmetic results, attempts are being made to minimize the number of necessary skin incisions for trocar positioning. One method is to use only one port for laparoscopic access to perform diverticular-related elective sigmoidectomies. METHODS: Between 7 July and 4 August 2009, 10 consecutive patients were referred for partial left colon resection due to multiple episodes of diverticulitis. In all cases, access to the abdomen was achieved through a 2- to 2.5-cm single incision via the umbilicus followed by insertion of the single-incision laparoscopic surgery (SILS™) port system. Outcomes such as change in the procedural method, operative time, postoperative complications, and length of stay were recorded. RESULTS: Of the 10 consecutive sigmoidectomies, 9 were performed successfully with the SILS™ procedure using only one incision in the umbilicus. No mortalities or major complications were noted. The median operating time was 120 min, and the median postoperative hospital stay was 7 days. CONCLUSION: As an alternative to the standard laparoscopic procedure, single-incision laparoscopic sigmoidectomy via the umbilicus is technically feasible and effective. This attractive procedure aims to increase the patient's comfort further after abdominal surgery.

Modified ileocecal interposition. The final sphincter-saving solution after failed salvage surgery for anastomotic complications of low anterior resection.

INTRODUCTION: Reversal of low Hartmann's procedures can be a challenging operation. We report on the successful treatment of patients who have already had prior salvage surgery for complications of a low colorectal anastomosis presenting with active fistulas from the rectal remnant. METHODS: An ileocolic segment was mobilized with the neurovascular pedicle of the ileocolic artery and turned counterclockwise into the pelvis. The fistulas were cured and a hand-sutured colo-anal anastomosis was performed at the level of the dentate line. Almost the entire length of the remnant colon was preserved. RESULTS: There was no morbidity. The functional outcome was good or reasonable and the subjective satisfaction with the outcome was very high. CONCLUSION: We conclude that an ileocolic segment is an excellent substitute for reversal of low Hartmann's procedures even in patients in whom prior salvage surgery has failed. As the functional outcome is slightly inferior to other alternatives for rectal replacement, its use should be restricted to patients with complex local situations or in whom alternative reconstructions would result in significant loss of bowel length.