Early Experience of Single-Port Laparoscopic Anterior Resection for Colon Cancer

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(1)대한내시경복강경외과학회지 Vol. 14. No. 2, 2011. □원 저□. 단일공 복강경 전방절제술의 초기경험 가톨릭대학교 대전성모병원 외과. 김우연ㆍ최병조ㆍ이관주ㆍ김세준ㆍ김정구ㆍ이동호ㆍ이상철. Early Experience of Single-Port Laparoscopic Anterior Resection for Colon Cancer Woo-Yeon Kim, M.D., Byung-Jo Choi, M.D., Kwan-Ju Lee, M.D., Say-June Kim, M.D., Jeong-Goo Kim, M.D., Dong-Ho Lee, M.D., Sang-Chul Lee, M.D. Department of Surgery, Daejeon St. Mary’s Hospital, The Catholic University of Korea, Daejeon, Korea. Purpose: Single-port laparoscopic surgery (SPLS) has recently emerged as a method to improve the morbidity and cosmetic benefit of conventional laparoscopic surgery. We describe our experience of SPLS for an anterior resection (AR). The results of a prospective series of single-port laparoscopic anterior resection procedures are presented. Methods: Anterior resections were performed on 16 cases using a single-port laparoscopic technique between March 2009 and March 2010. The surgical and oncologic outcomes were recorded on a prospective database. Results: Sixteen (8 women) unselected patients (eight males, eight females), aged 43∼82 years (median 66.5 years), underwent a SPLS anterior resection for sigmoid colon cancers (median 16 cm above AV, range 13∼27). All patients were alive at 30 days. The surgery time ranged from 150∼415 min (median 242 min) and the median wound incision length. was 2.4 cm (range 1.5∼4.0 cm). The median hospital stay was 7.5 days. Pathological reports from the resected specimens revealed adenocarcinoma in 15 patients and mucinous carcinoma in one. There was one case of an anastomotic leak that required reanastomosis. The median number of lymph nodes harvested was 27.5 (range 10∼56). Conclusion: SPLS is a possible approach to an anterior resection with the potential for minimal access. A SPLS anterior resection is feasible and safe when performed by an experienced laparoscopic surgeon and team. On the other hand, the technique and oncologic safety warrants further prospective randomized studies. 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Key words: Single-port laparoscopic surgery (SPLS), Minimally invasive surgery, Colon cancer 중심단어: 단일공 복강경 수술, 최소침습 수술, 대장암. incision for completion of the procedure. There are also inherent risks of visceral and epigastric vessel injuries at port introduction and development of port-site incisional hernias. Single-port laparoscopic surgery (SPLS) may potentially diminish these complications and offer improved cosmesis. While many reports on the use of SPLS have been published, few reports have addressed SPLS in oncology. The present study presents 16 cases of anterior resection (AR) performed on sigmoid colon cancer and descending colon cancer patients, describes our experience with SPLS AR, and analyzes the short-term surgical results.. INTRODUCTION Laparoscopic colorectal surgery for both benign and malignant diseases is increasingly popular due to better perioperative recovery. The first laparoscopic colectomy was 1 reported almost two decades ago. Laparoscopic colectomy has been an alternative method to open colectomy ever since. This is reflected by advantages that include shorter median hospital stay, reduced use of parenteral narcotics and oral analgesics, reduced morbidity, faster return of bowel function, and better 2-5 Most importantly, oncologic outcomes are as cosmesis. 6 effective compared to those of conventional open surgery. 7 Long-term cancer outcome is equivalent. Despite its ameliorating effects, conventional laparoscopic colectomy still requires three-to-four additional abdominal incisions besides umbilical. MATERIALS AND METHODS Prospectively collected data from patients who underwent SPLS AR due to sigmoid colon cancer in the Department of Surgery, Daejeon St. Mary's Hospital, the Catholic University of Korea, between March, 2009 and March, 2010 were retrospectively reviewed. During this period, SPLS AR was performed for 16 unselected cases with malignant pathologies.. ※ 통신저자：이상철, 대전시 중구 대흥동 520-2 우편번호：301-723 가톨릭대학교 대전성모병원 외과 Tel：042-220-9114, Fax：042-252-6807 E-mail：[email protected]. 56.

(2) 김우연 외 6인: Early Experience of Single-Port Laparoscopic Anterior Resection for Colon Cancer. 57. Fig. 1. Single ports. (A) Home-made port made by combination of a wound retractor and surgical glove. (B) Commercially ready- made port (OCTO Port, Dalim, Korea).. 1) Surgical technique. Fig. 2. Intracorporeal dissection with the same range and procedures as that of conventional laparoscopic surgery.. This study was approved by the hospital`s institutional review board (DC09FZZZ0045). We enrolled patients with AR since AR was thought to be the easiest to deal with and because those cases were most numerous. Inclusion criterion was patients available for conventional AR. Exclusion criteria were patients with underlying severe medical diseases and tumors larger than 10 cm on radiologic imaging (which can make it difficult for the specimen to be obtained). Operations were conducted by one surgeon (Professor Sang-Chul Lee), who had previously performed 104 conventional AR procedures. Patients were specifically sorted with respect to age, gender, 2 body mass index (BMI, kg/m ), American Society of Anesthesiologists (ASA) score, surgical indication, intraoperative and postoperative morbidity (within 30 days from surgery), operative time, estimated blood loss, length of incision, conversion rate and length of hospital stay, and oncologic features, including size of the tumor, proximal and distal free resection margin, number of harvested lymph nodes, and pathologic TNM stage.. Patients were placed in the lithotomy position under general anesthesia with antibiotic prophylaxis. The peritoneal cavity was accessed by the open method and carbon dioxide was insufflated to maintain the intraperitoneal pressure of 10∼12 mmHg. The incision sites were mostly umbilicus. Vertical incision 1.5∼4.0 cm in length (median 2.4 cm) was usually made depending on respective tumor size. These were performed using a hand-made glove port or commercially ready-made single ports (OCTO port, Dalim, Korea) (Fig. 1). In our series of single-port surgery, three trocars - two 12 mm (Xcel, Ethicon, USA) and one 5 mm (threaded cannulas and seals 5 mm; Applied Medical, USA) - were employed for the glove port formation. For the SPLS AR, a medial-to-lateral mesenteric dissection was performed upward from the pelvic promontory to the low pancreatic border with ligation of the inferior mesenteric artery and vein with hemolocks. Lateral dissection was continued following the fusion fascia of Toldt to the colon proper with verification of the left ureter and gonadal vessels (Fig. 2). Downward dissection was continued to 5 cm distal from the lesion following the mesorectal fascia with preservation for the hypogastric nerves. On completion of mobilization, distal bowel transection was performed intracorporeally after distal cytocidal washout (Fig. 3). Then, then specimen was removed through the umbilicus, and a purse-string suture was extracorporeally applied in the proximal stump using Auto-purse string clamp (Fig. 4). The proximal stump and anvil head were connected, and placed in abdominal cavity through the umbilicus. A circular stapler (28 or 31 mm, DST series PCEEA, autosuture; Covidien, Norwalk, CT, USA) was introduced through the anus. The previously purse-string sutured proximal stump capped the anvil and was fired up, intracorporeally (Fig. 5). After the anastomosis, an air leakage test was performed. A Jackson-Pratt drain was inserted into the Douglas pouch..

(3) 58 대한내시경복강경외과학회지 제14권 제2호 2011 Table 1. Patients’ demographics Patients (n=16). Fig. 3. Distal resection by Endo-GIA application.. Fig. 4. Proximal stump maturation before returning into abdominal cavity.. Mean age (years) Gender Male Female Median BMI (range) ASA grade I II III IV Surgical indication Descending colon adenoca Sigmois colon adenoca Sigmois colon mucinous ca. 66.5 (43∼82) 8 8 23.2 (19.3∼31.7) 5 8 2 1 1 14 1. Fig. 6. Abdominal views of postoperative and 2 weeks after the operation. (A) Post-operative abdominal view. (B) 2 weeks after the operation view.. RESULTS. Fig. 5. End-to-end intracorporeal anastomosis using EEA via anus.. Sixteen anterior resection procedures were performed by the SPLS technique between March 2009 and March 2010. There were 16 elective resection and all operations were completed by the SPLS procedure. There were no conversions to open surgery or switching to conventional laparoscopic surgery. The patients included eight men and eight women of sigmoid colon cancers (median 16 cm above AV, range 13∼27); their median (range) age was 66.5 years (range 43∼82 years) and BMI 23.2 2 2 kg/m (range 19.3∼31.7 kg/m ) and a median ASA score of 2 (range 1∼4) (Table 1). A skin incision of 2.4 cm (range 1.5∼4 cm) was necessary for the operation (Fig. 6). The median operating time was 242 min (range 150∼415 min). No intraoperative complications were encountered. Patients typically started on a soft diet on.

(4) 김우연 외 6인: Early Experience of Single-Port Laparoscopic Anterior Resection for Colon Cancer. Table 2. Perioperative outcomes. 59. Table 4. Oncologic outcomes Patients (n=16). Length of skin incisions (cm), median (range) Operative time (min), median (range) Conversion rate (%) Switching to conventional laparoscopy Conversion to open surgery Start of Soft diet (day), median (range) Postoperative hospital stay (days), median (range). 2.4 (1.5∼4) 242 (105∼415) 0 (0) 0 0 3 (1∼6) 7.5 (4∼16). Patients (n=16) Tumor size (cm), median (range) Safety margins (cm), median (range) Proximal cut margin Distal cut margin Lymph node harvest, median (range) TNM stage I II III IV. 5 (1.2∼10) 13 (7∼23.2) 6.8 (4∼12) 27.5 (10∼56) 4 2 10 0. Table 3. Surgical complications Patients (n=16) Perioperative complication (%) Anastomotic leakage Intra-abdominal abscess Ileus Cardiovascular disease Wound infection. 1 (6.25) 1 0 0 0 0. post-operative day 3 (range 1∼6). The median length of hospital stay was 7.5 days (range 4∼16 days) (Table 2). All patients were alive and well at 30 days. One patient, a 73-year-old woman, had an anastomotic leakage that required reanastomosis (Table 3). The pathological specimens were reviewed. The average length of specimen was 24.5 cm (range 17∼37 cm) and the median tumor size in the major axis was 5 cm (range 1.2∼10 cm). Proximal and distal cut margins from the tumor revealed 13 cm (range 7∼23.2 cm) and 6.8 cm (range 4∼12 cm), respectively. Pathological findings were adenocarcinoma in 15 patients and mucinous carcinoma in one patient. Fifteen tumors were in the sigmoid colon and one was in the descending colon. AJCC stage of the tumors was stage 1 in four patients, stage 2 in two patients, and stage 3 in 10 patients. There were no stage 4 tumors. The median number of lymph node harvest was 27 (range 10∼56) (Table 4).. DISCUSSION The available literature on SPLS suggests that it is a promising alternative to conventional laparoscopic surgery. 8 Since the first reports on SPLS in 1997 for cholecystectomy 9 and appendectomy, the applications have been varied, including in urology, adrenalectomy, bariatric procedures, and. hernia repairs. SPLS, however, has not been embraced as rapidly for colectomies due to complexities required in laparoscopic colectomies. This is largely due to the multiple stages involved in a laparoscopic colectomy, such as colon mobilization, vascular transection, and anastomosis. To perform SPLS, the operator should have extensive laparoscopic surgery skill based on many conventional laparoscopic surgeries. Unlike a laparoscopic cholecystectomy or appendectomy, which involves only surgery in a single abdominal quadrant, SPLS often requires operating in a multitude of different abdominal quadrants such as the flanks for mobilization, hypochondria for flexures, and pelvis for a TME. In addition, the need for adequate oncologic margins and the creation of tension-free 10 anastomosis is paramount in all colectomies. To overcome those limitations, our operation team applied the pivoting system. By just a simple rotation of operative instruments with the simultaneous involvement of a camera, we could access other quadrants. Actually, our team succeeded 16 cases of single-port laparoscopic AR perfectly without additional incision or port insertion. The reasons for these successes are abundant laparoscopic experience and the operator's pivoting centered on the umbilicus, which overcame the aforementioned limitations. With this simple convenient and beneficial action, in comparison with robotic surgery and conventional laparoscopic surgery, SPLS can reserve additional trocar insertion and may reduce the possibility of complications related with incisions for trocars (Fig. 7). The operation time varied considerably. At first, inferior mesenteric artery bleeding control required a lot of time. With experience, the time was markedly shortened. Supposedly, patients` BMI also influenced the reduction of operation time. In fact, except one case (415 minute), the variation of OP time in this study was 150∼285 minute. Extraordinarily long time was spent for finding a lost gauze which was used during.

(5) 60 대한내시경복강경외과학회지 제14권 제2호 2011. Fig. 7. Pivoting permits operation in multiquadrants without additional incision for trocar application.. intraperitoneal procedure in that patient. One patient who had anastomosis leakage and experienced reoperation. We performed that primary closure with the single-port approach and the patient was recovered and discharged without any problem. It has been rationalized that the reduction on the number of ports decreases the morbidity of visceral or vascular injuries during port introduction, and also reduces postoperative wound pain and the risk of incisional hernia. The result is improved cosmesis and overall patient satisfaction. This series showed that the SPLS technique can achieve satisfactory oncological mobilization and resection, allowing the surgeon to perform a standard intracorporeal colo-rectal anastomosis via only a small periumbilical incision.. CONCLUSION In our experience, SPLS for AR is safe and effective with reproducible oncologic results. SPLS can be a suitable alternative to conventional laparoscopic surgery. More experience with SPLS and prospective trials are needed to validate it as a more favorable alternative to conventional laparoscopic colectomy. We expect that our SPLS for AR can reduce pain, promote faster recovery, and lower operation cost.. REFERENCES 1) Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc. Endosc 1991;1:144-150. 2) Lacy AM, García-Valdecasas JC, Delgado S, Castells A, Taurá P, Piqué JM, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 2002;359:2224-2229. 3) The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-2059. 4) Jayne DG, Guillou PJ, Thorpe H, UK MRC CLASICC Trial Group. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 2007;25:3061-3068. 5) Buunen M, Veldkamp R, Hop WC, Colon Cancer Laparoscopic or Open Resection Study Group et al. Survival after laparoscopic surgery versus open surgery for colon cancer; longterm outcome of a randomised clinical trial. Lancet Oncol 2009;10:44-52. 6) Abraham NS, Young JM, Solomon MJ. Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer. Br J Surg 2004;91:1111-1124. 7) Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer HJ. Long-term results of laparoscopic colorectal cnacer resection. Cochrane Database Syst Rev 2008;16:CD003432. 8) Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incision outside the umbilicus. J Laparoendosc Adv Surg Tech A 1999;9:361-364. 9) Esposito C. One-trocar appendectomy in paediatric surgery. Surg Endosc 1998;12:177-178. 10) Min-Hoe Chew. Evaluation of current devices in single-incision laparoscopic colorectal surgery: preliminary experience in 32 consecutive cases. World J Surg 2011;35:873-880..

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