D3 lymph node dissection with versus without left colic artery preservation in single-incision laparoscopic surgery for sigmoid and rectosigmoid cancer: A propensity score-matched analysis.

PURPOSE: In surgery for colorectal cancer, dissection of the lymph nodes and fatty tissue around the root of the inferior mesenteric artery is important from an oncologic point of view. However, it is debatable whether it is better to preserve or remove the left colic artery (LCA). This study aimed to compare D3 lymphadenectomy with versus without LCA preservation in single-incision laparoscopic surgery for sigmoid and rectosigmoid cancer. METHODS: A total of 1138 patients underwent surgery for colorectal cancer between April 2011 and December 2018 at Fukui Prefectural Hospital. This propensity score-matched retrospective study analyzed the data of 163 patients: 42 patients with LCA preservation (group A) and 129 without LCA preservation (group B). Clinical and oncological outcomes were compared between the two groups. RESULTS: There were no significant differences between groups A and B in patient characteristics, surgical outcomes, including the 5-year overall survival rate (75% vs. 64.2%, hazard ratio [HR] 1.34, 95% confidence interval [CI] 0.37-4.30), 5-year disease-free survival rate (85.7% vs. 85.7%, HR 0.99, 95% CI 0.24-4.22), and 5-year cancer-specific survival rate (92.8% vs. 89.3%, HR 1.50, 95% CI 0.25-11.4). CONCLUSION: There were no significant differences in the short- and long-term outcomes of patients who underwent single-incision laparoscopic surgery with D3 lymphadenectomy with versus without LCA preservation. This suggests that LCA preservation is safe and feasible in single-incision laparoscopic surgery for sigmoid and rectosigmoid colon cancer.

Single-incision or Single-incision Plus One-Port Laparoscopic Surgery for Colorectal Cancer.

BACKGROUND: Single-incision laparoscopic surgery (SILS) and single-incision plus one-port laparoscopic surgery (SILS+1) for colorectal cancer are considered to require long operative times, experienced surgeons, and advanced surgical techniques. However, these procedures are advantageous because they require both fewer ports and fewer surgeons. PATIENTS AND METHODS: In the SILS procedure for colon cancer, a Lap Protector™ (LP; Hakkou Shoji, Japan) is inserted through a 2.5 cm transumbilical incision. Next, an EZ-Access (Hakkou Shoji, Japan) is mounted onto the LP, and three ports are made in the EZ-Access. In SILS+1 for rectal cancer, we use an extra incision in the lower quadrant for drainage from the beginning of the operation. Data from 849 patients who underwent elective surgery with SILS or SILS+1 for colorectal cancer were reviewed. RESULTS: In 808 patients who underwent a reduced-port procedure for colorectal cancer, the mean incision length was 2.91 cm. The average operative time was 198.2 minutes, and average intra-operative blood loss was 25.6 mL. Complications with a Clavien-Dindo classification of II or greater occurred in 63 patients (7.2%). Among 654 stage I-III colorectal cancer patients, 69 (10.6%) experienced postoperative relapse during the follow-up period of 42 months. CONCLUSIONS: Our cumulative findings support the use of SILS or SILS+1 in patients with colorectal cancer. The long-term oncologic outcomes make them acceptable technical alternatives to conventional multiport laparoscopic colectomy. Further trials are still needed to fully document the non-cosmetic benefits.

Single-port laparoscopic colectomy in elderly patients with colon cancer: A propensity score-matched comparison with younger patients.

INTRODUCTION: This study aims to evaluate the safety and feasibility of single-port laparoscopic colectomy (SPLC) in elderly patients with colon cancer. METHODS: During the study period, 344 patients underwent SPLC in our hospital. Among them, 87 patients were aged 80 years and older, and 257 patients were younger than 80 years. After 1:1 propensity-score matching, 87 elderly patients were compared with 87 young patients. RESULTS: Short-term clinical outcomes after SPLC were equivalent between the two groups, although the elderly group had a higher ASA score and more postoperative complications. The 5-year overall survival rates were 64.6% in the elderly group and 66.8% in control group. The 5-year cancer-specific survival rates were 78.0% in the elderly group and 70.9% in control group. There were no significant differences between the groups. CONCLUSION: Our results indicated that SPLC is technically feasible for operative teams that have adequately standardized the procedure, and it is oncologically safe in elderly patients with colon cancer.

Long-term oncological outcomes of single-port laparoscopic surgery for colon cancer.

BACKGROUND: We retrospectively reviewed our consecutive experience from the introduction of single-port laparoscopic surgery (SPS) for colon cancer, and its 5-year oncological outcomes are evaluated. METHODS: A total of 288 patients (140 males) with a mean age of 71.5 years were treated with the single-port laparoscopic colectomy for stage I, II and III colon cancers. Exclusion criteria of SPS were patients with unresolved bowel obstruction, T4b tumour, tumour perforation and severe medical illness. RESULTS: In 20 patients (6.9%), we inserted an extra port mainly to transect the rectum. The median follow-up period was 52 months. The 5-year relapse-free survival rates in stage I, II and III patients were 95.8%, 80.2% and 61.6%, respectively. The 5-year overall survival rates for stage I, II and III patients were 97.4%, 85.3% and 72.9%, respectively. The 5-year cancer-specific survival rates in patients diagnosed pathologically T1, T2, T3 and T4 were 100%, 100%, 92.1% and 73.9%, respectively. CONCLUSIONS: SPS colectomy can be applied to the treatment of colon cancer with good long-term oncological outcomes. However, we should pay more attention when we treat the pathologically diagnosed T4 tumours.

Single-Incision Laparoscopic Colectomy for Colon Cancer: Experiences with 308 Consecutive Cases.

Single-incision laparoscopic surgery (SILS) has been developed with the aim to further reduce the invasiveness of conventional laparoscopy. Our experiences with more than 300 consecutive patients with SILS for colon cancer are reviewed, and its outcomes are evaluated to determine the midterm clinical and oncologic safety of SILS for colon cancer in a community hospital. A single surgeon's consecutive experience of SILS for colon cancer is presented. Three hundred and eight patients were treated with the SILS procedure for colon cancer between December 2010 and March 2015. Data were analyzed according to intention to treat. Of these 308 patients, 19 (6.2%) were converted to laparotomy. Intraoperative injury occurred in five patients. Postoperative complications occurred in 19 patients (6.2%). The 2-year relapse-free survival rates of patients with Stage I, Stage II, and Stage III were 97.8, 92.2, and 80.4 per cent, respectively, and the 2-year overall survival rates of patients with Stage I, Stage II, Stage III, and Stage IV were 100, 95.7, 93.0, and 74.4 per cent, respectively. Our initial experiences showed that SILS colectomy for cancer can be performed safely and with good short-term oncologic outcomes by a skilled surgeon.

Short-Term Clinical and Oncological Outcomes after Single-Incision Plus One Port Laparoscopic Anterior Resection for Rectal Cancer.

AIM: In the past, we developed and reported single-incision plus one port laparoscopic anterior resection (SILS + 1-AR) of the rectum. In this study, we reviewed our experiences with 141 consecutive patients admitted in a community hospital for undergoing SILS + 1-AR for rectal cancer and evaluated the short-term clinical and oncological outcomes. METHODS: A lap protector (LP) was inserted through a 2.5 cm transumbilical incision; an EZ-access was mounted to the LP and three 5-mm ports were placed. A 12-mm port was inserted in the right lower quadrant. RESULTS: One hundred thirty-six patients (96.5%) completed their treatment with SILA+1-AR. The number of tumor locations in the rectosigmoid, rectum area above the peritoneal reflection (Ra), and rectum area below the peritoneal reflection (Rb) were 44, 63, and 29 respectively. Six (5.6%) tumor recurrences or metastasis occurred in 107 patients with stages I-III disease with a median follow-up of 30 months. One patient with a positive surgical margin rejected additional resection of the positive margin and died of recurrent disease. CONCLUSION: Our initial experiences suggested that SILS + 1-AR is a feasible and a safe treatment option for rectal cancer patients treated by experienced surgeons specialized in SILS. However, further studies are needed to demonstrate the advantages of this procedure compared to the benefits of conventional laparoscopic AR.

The Use of the EndoGrab™ Port-Free Endocavity Retractor in Single-Incision Laparoscopic Right Hemicolectomy.

The EndoGrab™ Port-Free Endocavity Retractor is an internally anchored retracting device that enables surgeons to reduce not only the number of ports and incisions but also the number of assistant surgeons. Our institution performs single-incision laparoscopic colectomy (SILC) as a routine procedure. Forty-nine patients underwent a single-incision laparoscopic right hemicolectomy. In this procedure, we use this retractor to the mesenteric tissue, including the ileocolic vessels and the mesentery of the transverse colon, and overcame the technical problems related to SILC and showed excellent short-term outcomes. To perform SILC safely while maintaining the minimal invasiveness and the quality, the use of this retractor is essential, especially in difficult situations, such as an unfavorable visual field when performing a lymph node dissection around the middle colic vessels in right hemicolectomy.

Single-Incision Laparoscopic Colectomy: A Case Match Study for Stage IV Colon Cancer.

BACKGROUND: Utilization of single-incision laparoscopic surgery for the management of colon cancer has increased; however, the feasibility of single-incision laparoscopic colectomy (SILC) for patients with stage IV colon cancer (ST4) has not been well examined. METHODS: Fifty-four patients with ST4 could be identified who electively underwent single-incision laparoscopic surgery. In a matched pairs design, 54 patients were then chosen out of a collective of 275 patients undergoing single-incision laparoscopic surgery for stages 0-III colon cancer (ST0-3). Short-term clinical outcomes were assessed, and the overall survival status in ST4 patients was assessed. RESULTS: The mean length of skin incision was 2.85 cm, and the median operating time and estimated blood loss were 156.1 min and 50.5 g respectively. The mean number of harvested lymph nodes was 20.7. All differences between short-time outcomes were not significant in both groups. The postoperative complication rate was significantly higher and postoperative hospital stay was significantly longer in ST4 patients. The 1-year overall survival rate was 78.5% in ST4 patients. In patients with complication, only postoperative stay was significantly prolonged compared with patients without complication. CONCLUSIONS: Our study indicated mid-term oncological and clinical safety of SILC for patients with ST4.

Single-incision laparoscopic surgery for colorectal cancer.

AIM: To determine the effect of single-incision laparoscopic colectomy (SILC) for colorectal cancer on short-term clinical and oncological outcomes by comparison with multiport conventional laparoscopic colectomy (CLC). METHODS: A systematic review was performed using MEDLINE for the time period of 2008 to December 2014 to retrieve all relevant literature. The search terms were "laparoscopy", "single incision", "single port", "single site", "SILS", "LESS" and "colorectal cancer". Publications were included if they were randomized controlled trials, case-matched controlled studies, or comparative studies, in which patients underwent single-incision (SILS or LESS) laparoscopic colorectal surgery. Studies were excluded if they were non-comparative, or not including surgery involving the colon or rectum. A total of 15 studies with 589 patients who underwent SILC for colorectal cancer were selected. RESULTS: No significant differences between the groups were noted in terms of mortality or morbidity. The benefit of the SILC approach included reduction in conversion rate to laparotomy, but there were no significant differences in other short-term clinical outcomes between the groups. Satisfactory oncological surgical quality was also demonstrated for SILC for the treatment of colorectal cancer with a similar average lymph node harvest and proximal and distal resection margin length as multiport CLC. CONCLUSION: SILC can be performed safely with similar short-term clinical and oncological outcomes as multiport CLC.

Single incision laparoscopic surgery for multiple colorectal cancers.

INTRODUCTION: The aim of this study was to evaluate short-term outcomes of single-incision surgery with two segmental colorectal resections and anastomoses for multiple synchronous colorectal cancers. METHODS: Ten patients with multiple colorectal cancers underwent two synchronous segmental colorectal resections and anastomoses. The methodology of the procedures, operative results, and postoperative outcomes were evaluated. RESULTS: The median operative time was 270 min (range, 146-427 min), and the median blood loss was 70 mL (range, 10-260 mL). No conversions to open surgery or intraoperative complications occurred. Four cases needed additional ports, and one case required a diverting stoma. CONCLUSION: SILS with two segmental colorectal resections and anastomoses was safely performed in all cases without severe postoperative complications. This procedure seems to be a feasible option for resecting multiple synchronous colorectal cancers.

Single-incision laparoscopic surgery for colon cancer in patient with situs inversus totalis: report of a case.

A preliminary experience with single-incision laparoscopic colectomy for colon cancer with situs inversus totalis (SIT) is reported. An 87-year-old man was admitted because of a fecal occult blood. A colonoscopy revealed cecal cancer. An air-barium and a computed tomography contrast enema showed the right-sided descending colon and the left-sided ascending colon and cecum. The surgical procedures were as follows: First, a Lap protector was inserted through a 2.5-cm transumbilical incision. Three 5-mm ports were placed in the Lap protector. We successfully performed ileocolectomy with lymph node dissection by using a single-incision laparoscopic approach without any technical problems. The operative time was 125 min, and blood loss was negligible. Postoperative follow-up did not reveal any umbilical wound complications and recurrences.

A New Laparoscopic Rectal Transection Method via Umbilical Incision Using Endo GIA™ Radial Reload.

We have developed a new laparoscopic rectal transection method via umbilical incision using Endo GIA™ Radial Reload with a Tri-Staple™ Technology (RR) (Covidien, New Haven, CT) stapler. A 65-year-old woman with a rectal carcinoid tumor underwent a laparoscopic low anterior resection. We successfully performed a rectal transection via umbilical incision using this stapler. The postoperative course was uneventful. The possibility of a rectal transection via umbilical incision was demonstrated in the current case. However, further studies are needed to confirm the safety and feasibility of this procedure.

Single-incision laparoscopic surgery for stage IV colon cancer.

AIM: : The safety and efficacy of single-incision laparoscopic resections for patients with stage IV colorectal cancer have not been examined explicitly. This article describes our experience with single-incision laparoscopic procedures for patients with stage IV colorectal cancer. METHODS: Seventy-seven patients who underwent single-incision laparoscopic colectomy between August 2010 and January 2012 were investigated retrospectively. Eleven patients were in clinical stage IV (ST4 group) and were compared with 66 patients in clinical stages 0 to III (control group). RESULTS: There were no differences in the intraoperative and the postoperative complications, the 30-day mortality rate, the number of the lymph nodes harvested, and the duration of postoperative hospital stay between the 2 groups. CONCLUSIONS: Our initial experiences suggested that single-incision laparoscopic colectomy is feasible for stage IV colon cancer patients. This is a good start comparing the outcomes of single-incision colectomy in stage IV patients with open and traditional laparoscopic colectomy.

Laparoscopic surgery for the ascending colon cancer associated with malrotation of the midgut.

Malrotation of the midgut is a congenital anomaly of the gastrointestinal tract that usually presents in neonates. Moreover, synchronous colon cancer has rarely been reported. In the present article, we report a preliminary experience with laparoscopic approach for intestinal malrotation with early colon cancer in a 68-year-old woman who presented with bloody stools. Colonoscopy revealed a lateral spreading tumor of the ascending colon. An air-barium contrast enema showed that the entire colon lay within the left hemiabdomen. A computed tomography revealed the superior mesenteric vein rotation sign. At surgery, a condition of malrotation of the midgut was observed: the third and the fourth part of the duodenum descended vertically without Treitz's ligament, and the small bowel and colon were located in the right and left side of the abdominal cavity, respectively. We mobilized the terminal ileum and the right colon with laparoscopic approach. A 3-cm abdominal incision was made via the umbilicus. Right colectomy with lymph node dissection was achieved following extracorporealization. Pathological examination revealed well-differentiated tubular adenocarcinoma without nodal involvement. The patient had an uneventful postoperative course. Laparoscopic surgery for colon cancer associated with malrotation of the midgut is feasible and a promising method because of its less invasiveness and its adaptability to the malrotation without extending the skin incision.

The transverse colon cancer with the reversed rotation of the midgut treated with single incision laparoscopic colectomy.

BACKGROUND: Reversed rotation of the midgut is a rare type of intestinal malrotation. Moreover, synchronous colon cancer has rarely been reported. Preliminary experience with single-incision laparoscopic colectomy (SILC) for colon cancer with reversed rotation of the midgut is reported. CASE: An 82-year-old woman was admitted because of a fecal occult blood. A colonoscopy revealed transverse colon cancer. An air-barium contrast enema showed the right-sided sigmoid colon and the left-sided cecum. A computed tomography revealed that the duodenum and the transverse colon were situated at the ventral side of the superior mesenteric artery, and a preoperative diagnosis of suspicion of reversed rotation of the midgut was made. SURGICAL PROCEDURES: First, a lap protector was inserted through a 4.0 cm transumbilical incision. Four 5 mm ports were placed in the lap protector. On the observation of laparoscopy, the cecum and the ascending colon were not fixed with the retroperitoneum and situated on the left, and the sigmoid colon was situated on the right. We successfully mobilized the transverse colon using a single-incision laparoscopic approach. Resection was achieved following extracorporealization, and the anastomosis was performed extracorporeally using staplers. The patient was discharged on the thirteenth postoperative day. Postoperative follow-up did not reveal any umbilical wound complications. CONCLUSION: SILC for colon cancer associated with malrotation of the midgut is feasible and a promising alternative method because of its less invasiveness and its adaptability to the malrotation without extending the skin incision.

Single-incision laparoscopic ileo-cecal resection for appendiceal mucocele.

Mucocele of the appendix is a rare lesion which denotes a distension of the lumen due to accumulation of mucoid substance, and a possible rupture of the mucocele may result in the clinical condition of pseudomyxoma peritonei. Therefore, the laparoscopic approach for this disease is still controversial because improper handling may cause inadvertent rupture. We present a successfully treated case with the single-incision laparoscopic approach. An 88-year-old man was diagnosed with the mucocele of the appendix, and we decided to perform the single incision laparoscopic ileocecal resection. First, a lap protector was inserted through a 3.0 cm transumbilical incision. Three 5 mm ports were placed in EZ access mounted on the lap protector. On the observation of laparoscopy, a retrocecal appendix was found. We successfully mobilized the right colon and transected the ileum using an endoscopic linear stapler. The right colon with appendix was carefully extracted through the umbilical incision. Resection and anastomosis were achieved following extracorporealization. The appendix was measured 7 cm in length and 3 cm in diameter; a final histopathological diagnosis was mucocele caused by mucinous cystadenoma. This is, to our knowledge, the first case of a single-incision laparoscopic ileocecal resection for mucocele of the appendix described in the indexed literature.

Single incision laparoscopic right colectomy using the techniques of open surgery through the small incision.

To perform single-incision laparoscopic colectomy (SILC) safely while maintaining the minimal invasiveness of SILC and the quality of the lymph node dissection, we have used hybrid single-incision laparoscopic colectomy (H-SILC). Preliminary experience with H-SILC in advanced colon cancer is reported. First, a multi-flap gate was inserted through a 4.0 cm transumbilical incision, and three 5 mm ports were placed in the converter sheet. The procedures were much the same as in usual laparoscopic colectomy excluding a lateral to medial approach. The initial identification or exposure of the ileocolic vessels was performed through a small incision, and lymphadenectomy was mainly achieved using laparoscopic technique. In the course of laparoscopic procedures, whenever we felt stress, we used the techniques of open surgery through the small incision. The procedure was completed successfully without any perioperative complication and no need to extend the skin incision. The operative time was 191 min. Postoperative follow-up did not reveal any umbilical wound complication or any recurrence. Our experience indicates H-SILC is safe and feasible for selected patients with colon cancer with improved cosmesis.

Concurrent single-incision laparoscopic right hemicolectomy and sigmoidectomy for synchronous carcinoma: report of a case.

Synchronous colorectal tumors that require surgical treatments are rare. Preliminary experience with concurrent single-incision laparoscopic right hemicolectomy and sigmoidectomy for synchronous carcinoma is reported. A 61-year-old woman presented to our department for the close examination of a bloody stool. Colonoscopy revealed two masses in the right-sided transverse colon and sigmoid colon and another slightly elevated lesion in the transverse colon, and all biopsies from these three lesions demonstrated adenocarcinoma. Under the diagnosis of transverse colon cancers and sigmoid colon cancer, we performed simultaneous single-incision laparoscopic sigmoidectomy and right hemicolectomy. First, a lap protector was inserted through a 2.5 cm transumbilical incision. Three 5 mm ports were placed in the lap protector. We successfully performed sigmoidectomy and right hemicolectomy with lymph node dissection. The patient was discharged on the thirteenth postoperative day. Postoperative follow-up did not reveal any umbilical wound complications. SILS should be the treatment of choice for concurrent laparoscopic surgery for also the other diseases.

the outcome of single-incision laparoscopic right colectomy for colon carcinoma in the elderly.

PURPOSE: Surgeons are increasingly being faced with the problem of treating elderly colon cancer patients. The purpose of this study was to elucidate the feasibility of single-incision laparoscopic surgery for these patients. METHODS: Among 34 right colon cancer patients treated with single-incision laparoscopic surgery procedure between August 2010 and September 2011, 9 (26.5%) were aged 80 or over. The results of treatment in this elderly group were compared retrospectively with those in 10 younger colon cancer patients (age, 59 to 67 y; control group, 29.5%). RESULTS: The sex distribution, body mass index, and the tumor location were similar between the groups. The elderly had a higher incidence of preoperative risk factors (77.7% vs. 40.0%; P=0.17). However, operative time and estimated blood loss were similar and postoperative complications had not occurred in both groups. CONCLUSIONS: We believe that single-incision laparoscopic colectomy can be carried out safely in elderly patients with colon cancer.

Hybrid single-incision laparoscopic sigmoidectomy: the effective use of small incision.

AIM: Single-incision laparoscopic colectomy (SILC) often requires steeper Trendelenburg positioning to displace or keep the small intestine away from the operative site. We have developed hybrid SILC in which we make a transumbilical incision to extract the specimen first and utilize a multiflap gate (MFG). METHODS: MFG was inserted through a 4.0-cm transumbilical incision, and a surgical towel was inserted via MFG and displaced the small intestine away from the operative site. Three 5-mm ports were placed in the converter sheet. Almost all the operative procedures were the same as usual laparoscopic sigmoidectomy. In the course of laparoscopic procedures, whenever we felt stress, we used the techniques of open surgery via MFG. RESULTS: In 3 patients, the procedure was successfully completed without any complications. CONCLUSIONS: Our procedure can be easily performed, which enables surgeons to achieve SILC safe and easy compared with conventional technique.