Goutaro Katsuno

Background The aim of this study was to reveal the short-term and long-term outcomes of single-incision laparoscopic colorectal resection (SILC) compared with multi-incision laparoscopic colorectal resection (MILC) for colorectal cancer using propensity score matching analysis. Methods The study group included 235 patients who underwent SILC and 730 patients who underwent MILC for colorectal cancer between April 2009 and September 2014. The propensity score matching for age, gender, body mass index, tumor location (right-sided colon/sigmoid colon/upper rectum), lymph node dissection (D1/D2/D3), pathologic T (≤T3) stage and TNM (0–I/II/III) stage produced 107 matched pairs. The exclusion criteria for SILC were as follows: (1) tumors located at the transverse, descending colon or lower rectum, (2) stage IV tumors, synchronous or previous malignancies, (3) locally advanced tumors >T4, (4) acute obstructions or previous major abdominal surgery and (5) obese patients: BMI > 30. Results No significant differences were observed in operating time, bleeding volumes, starting time of liquid diet and length of hospital stay between the SILC and MILC groups. However, the SILC group showed less analgesic requirements (1.1 vs. 1.9 times; p = 0.0006) and shorter length of incision (2.7 vs. 4.3 cm; p = 0.0000) compared to MILC group. The overall rate of postoperative complications was similar in both groups (2.8 vs. 3.7 %, p = 0.70). The 5-year overall survival rate of SILC and MILC was 100 and 95 % (p = 0.125) and 5-year disease-free survival rates in stages 0–III were 97 and 94 % (p = 0.189), 100 and 92 % in stage II and 90 and 85 % in stage III, respectively. Conclusions This study suggests that SILC for colorectal cancer is a safe and feasible option with better cosmetic results and less pain in strictly selected patients. SILC can also produce good oncological results with similar postoperative outcomes to MILC.

Introduction: It is often technically difficult to cut the lower rectum with an endoscopic linear stapler in single‐incision laparoscopic colorectal resections (SILC) because some surgical devices are inserted through the same access platform. If the rectum is cut incorrectly, it may cause anastomotic leakage. We recently applied natural orifice specimen extraction (NOSE) using the prolapsing technique to overcome this technical difficulty in SILC procedures in selected patients.Materials and Surgical Technique: The access platform is placed in the small umbilical incision area. SILC is performed using a surgical technique similar to the conventional laparoscopic medial‐to‐lateral approach. The proximal part of the tumor site is transected with laparoscopic staplers. Then, the tumor lesion and bowel are pulled out of the body through the anus by means of inversion. Next, the distal side of the bowel is cut with a stapler and the rectal stump is reinforced with sutures under direct vision. The distal side of the bowel is then pushed back into the body. NOSE with prolapsing technique is then complete. After that, the anvil is attached to the proximal part of the bowel at the umbilical incision site, and intracorporeal anastomosis is performed.Discussion: NOSE with prolapsing technique was applied in 14 SILC procedures for colorectal cancer patients. All procedures were successful, and there were no anastomotic leakages in the series. This technique enabled us to perform pure SILC safely without affecting cosmesis, even in cases where we needed to cut the lower rectum.

Transumbilical single-port surgery has been developed with the aim to further reduce the invasiveness of conventional laparoscopy. This study aimed to report our experience with 31 patients who were treated with transumbilical single-incision laparoscopic colectomy for colon cancer. This is a retrospective review of prospectively gathered data. This study was conducted at the Department of Surgery of Juntendo University Urayasu Hospital between April 2009 and April 2010. Data were obtained from a prospectively maintained single-institution laparoscopic colon cancer database. Thirty-one consecutively selected patients (mean BMI, 22.5 ± 2.3) were evaluated. All patients underwent single-incision laparoscopic colectomy for colon cancer. Two different approaches were used for single-incision laparoscopic colectomy: the trocar insertion method and the SILS port method. The trocar insertion method was adopted in 22 of 31 patients, and the SILS port method was used in 9 patients. The main measures of outcomes were intraoperative findings, postoperative course, and oncological outcomes. The most common procedure was sigmoid colon resection performed in 12 of 31 (39%) patients. The mean skin incision was 2.72 ± 0.79 (range, 3-5) cm. The operating time ranged from 101 to 263 (mean, 156 ± 45) minutes. The volume of bleeding ranged from 5 to 60 (mean, 27 ± 19) mL. No intraoperative complications were observed in this series. Postoperatively, there was no mortality. Wound infection was observed in 1 patient. The number of harvested lymph nodes was 18 ± 2.1, and the mean tumor-free resection margin was 11 ± 4.8 cm. Our experience indicates that single-incision laparoscopic colectomy is feasible for selected patients with colon cancer.

The ForceTriad™ generator has been recently developed. This new electrosurgical generator would demonstrate improved quality and efficiency in blood vessel sealing. To compare currently available 10-mm laparoscopic electrosurgical devices with the LigaSure™ Vessel Sealing System and ForceTriad generator (Valleylab, Inc., a division of Tyco Healthcare) for use in vessel sealing. Blood vessels of various types and diameters were harvested from alive four pigs using three instruments: LigaSure Atlas™ with LigaSure Vessel Sealing Generator (LSAt), LigaSure Atlas with ForceTriad Generator (LSAtFT), and Endoclip™ II (Autosuture, USSC; a division of Tyco Healthcare). A total of 100 arteries were processed by removal of fatty and connective tissue from the adventitia before sealing. An additional set of specimens was sealed and histopathologically analyzed after being stained with hematoxylin and eosin. The mean burst pressure was significantly higher with LSAtFT compared to LSAt (P < 0.01). The sealing process was significantly shorter with LSAtFT (P < 0.05). With regard to the degree of thermal injury, adventitial collagen denaturation and proximal thermal injury to the smooth muscle in the media of the vessel wall were less common with LSAtFT; however, the numbers were too small for statistical analysis. Both the LSAt and LSAtFT secured all vessel sizes to well above physiologic levels. The LSAtFT could be used more confidently in vessels up to 7 mm. Our findings indicate that LSAtFT could be a safer and more efficient instrument for advanced laparoscopic surgery.