CHICAGO (EGMN) – Single-incision laparoscopy is a safe approach for right colectomy and reduces both length of stay and early postoperative pain, compared with established laparoscopic techniques, according to Dr. Harry T. Papaconstantinou.
“I had one patient ask if he could do sit-ups the day after surgery,” the physician said. “These patients were actually asking me to go home.”
Although single-incision laparoscopy (SIL) is gaining momentum as an advance in laparoscopic colectomy, direct comparisons of outcomes between SIL and established techniques are lacking.
Dr. Papaconstantinou and his colleagues at Scott & White Memorial Hospital in Temple, Texas, compared their first 29 SIL right colectomy cases to an equivalent number of standard laparoscopic (LAP) and hand-assisted laparoscopic (HAL) cases matched for age, sex, body mass index (BMI), American Society of Anesthesiologists score, and pathology.
Operating time was similar for SIL, LAP, and HAL (128.8 min. vs. 128.3 min. vs. 116.2 min., respectively), as was estimated blood loss (60 mL, 90 mL, and 71 mL), Dr. Papaconstantinou reported at the annual meeting of the Western Surgical Association.
Although the mean incision length was similar for the SIL and LAP groups (4.5 cm and 5.1 cm), both had significantly shorter incisions than the HAL patients at 7.2 cm (P less than .001).
“Our operating times are a little longer and incision length larger, but I don’t think it should dissuade an experienced laparoscopist from doing a colectomy single incision,” he said.
One SIL patient (3.4%) was converted to the HAL technique, and four conversions occurred in both the LAP group (two to HAL and two to open surgery) and HAL group (four to open surgery).
The median length of stay was 1 day shorter at 3 days in the SIL group, compared with 4 days for both the LAP and HAL groups (P less than .05), said Dr. Papaconstantinou, chief of colon and rectal surgery at Scott & White Memorial Hospital.
Maximum pain scores on a 10-point visual analog scale were significantly higher in the LAP and HAL groups than in the SIL group on postoperative day 1 (6.0 vs. 6.0 vs. 4.7, respectively) and on post-op day 2 (5.1 vs. 5.0 vs. 3.8); however, pain at the time of discharge was similar among the LAP, HAL, and SIL groups (1.6 vs. 1.4 vs. 1.0).
Four SIL patients were readmitted, compared with two in the LAP group and three in the HAL group. The reasons for SIL readmissions included one anastomotic leak, one presumed ileus that resolved after a bowel movement, and two cases of nonocclusive portal vein thrombus that were treated with anticoagulation. These patients had other risk factors for venous thrombosis including a BMI greater than 30 kg/m2 and visceral malignancy. No patients in any of the groups died.
Dr. Papaconstantinou acknowledged having initial concerns about impaired visualization and triangulation during the technically demanding surgery, but said that SIL is safe and feasible, even in obese patients. He said he routinely extends the incision to reduce traction on the mesenteric vessels in larger patients, and has found that curved instruments actually hinder, rather than facilitate, the operation.
“One of the things that is critical is a flexible-tip 5-mm camera because it allows you to move the camera driver away from the surgeon’s hands,” he said. “Then you can actually come in at an angle, so you get a side view rather than an on-axis view [of the operative field].”
Using instruments of variable length (standard and bariatric length), and maintaining the instrument handles in a different orientation and plane, also avoids collision.
Invited discussant Dr. Alessandro Fichera, with the University of Chicago Medical Center, said, “There is no doubt in my mind that single-incision laparoscopy is here to stay and that it provides advantages that go way beyond cosmesis, including decreased postoperative pain, narcotic use, and length of stay.”
He said that the retrospective nature of the study may introduce a selection bias, and asked who the authors would recommend as candidates for SIL.
“I’ve done all comers, including those with a BMI greater than 40 [kg/m2],” said Dr. Papaconstantinou. Patients in the study had an average age of about 60 years, 55% were women, the average BMI was about 30 kg/m2, and one-third had a history of previous abdominal surgery. Cases included 15 with adenocarcinomas, 12 with polyps, and 2 with Crohn’s disease.
Dr. Papaconstantinou reported receiving honorarium from Covidien for speaking and teaching activities.
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芝加哥(EGMN)—— 与现有的腹腔镜技术相比，单切口腹腔镜手术为右侧结肠切除提供了一种更加安全的途径，并减少住院时程和早期术后疼痛。
单切口腹腔镜手术(SIL)推动了腹腔镜结肠切除术的发展，但缺乏SIL和现有技术之间预后效果的比较。德克萨斯州坦普尔市斯哥特及怀特纪念医院的研究者在按照年龄、性别和体重指数(BMI)及美国麻醉学家学会病理评分进行匹配后，对29例SIL患者和同等数量的标准腹腔镜术(LAP)、手辅助腹腔镜术(HAL)效果进行了比较。这些患者的平均年龄为60岁，55%的为女性，平均BMI为30 kg/m2，1/3的患者有腹部手术史。其中，15例患有腺癌，12例患鼻息肉，2例患节段性回肠炎。
研究发现，SIL、LAP和HAL的手术时间较为接近，分别为128.8、128.3和116.2 min，近似失血量分别为60、90和71ml。尽管SIL和LAP手术组的平均切口长度较为近似(分别为4.5cm和5.1cm)，但均明显短于HAL手术组的7.2cm，P<0.001。尽管手术时间稍微长了一些，而且切口大了点，但是这并不会阻碍经验丰富的腹腔镜医师实施这种单切口切除术。
1例SIL术患者和LAP组有4例患者(2例换为HAL术，另2例换为开放术)改用HAL术，HAL组有4例患者改为开放术。SIL手术组的平均住院时间为3天，比LAP和HAL组的平均住院4天缩短1天(P<0.05)。在术后第1天，LAP组和HAL组视觉模糊评分(visual analog scale,十分制)均显著高于SIL组，分别为6.0、6.0和4.7分，第二天时分别为5.1、5.0和3.8分。不过在出院时该评分较为接近，分别为1.6、1.4和1.0分。4例SIL患者再次入院，而LAP和HAL组则有2例和3例。SIL手术组的这4例再入院原因包括：1例吻合口漏，1例肠梗阻，2例为抗凝治疗导致的非封闭的门静脉血栓。这些患者存在其他风险因素，包括BMI>30 kg/m2和内脏恶性肿瘤。无患者死亡。
研究者表示，所有的患者都可以做这一手术，包括那些BMI>40kg/m2的患者。芝加哥医学中心的特邀评论员称，这种单切口腹腔镜手术将广泛被采用，提供一种除了美观以外的优势，包括术后疼痛减轻，麻醉剂使用减少和住院时间缩短。不过这项回顾性研究可能引入了选择偏倚。
研究者称收到了Covidien公司的演讲费和教学活动酬金。
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