Single Incision Laparoscopic Colorectal Surgery- Evolution after 750 Cases

Deborah S Keller, MS, MD1, Matt Schultzel, DO2, Irlna Tantchou, MD2, Juan R Flores-Gonzalez, MD1, Sergio Ibarra, MD1, David A Cardona, MD1, Eric M Haas, MD, FACS, FASCRS3. 3Colorectal Surgical Associates; Houston Methodist Hospital; University of Texas Medical Center at Houston, 1Colorectal Surgical Associates, 2University of Texas Medical Center at Houston

Background: With the drive towards less invasive colorectal surgery to optimize outcomes, there has been a growing interest in single incision laparoscopic surgery (SILS).  Safety and feasibility have been demonstrated, and advantages and applications continue to emerge. Widespread integration of SILS has lagged, partly due to the perceived technical difficulty, additional learning curve, and patient selection criteria. With experience, these can be addressed to realize the benefit of SILS. Our goal was to describe the clinical and financial outcomes in the largest series to date of colorectal SILS.

Methods: Review of a prospective departmental database was performed of a consecutive series of elective colorectal resections performed via a SILS approach at a single institution. Patient demographics, perioperative variables, postoperative outcomes and hospital costs were evaluated across time for overall outcomes and trends with SILS. The main outcome measures were the operative time, length of stay (LOS), and conversion, complication and readmission rates, and costs with SILS.

Results: Between 2009 and 2015, 2 surgeons performed 750 consecutive SILS colorectal cases. The mean age was 57.0 years(SD14.8), and BMI 28.8kg/m2(SD4.8). The main overall indications for surgery were colon cancer(26.5%) and diverticulitis(25.3%). Over time, there were sharp increases in use for rectal cancer(0%, 2009 to 16.9%, 2015) and inflammatory bowel disease(3.6%, 2009 to 20.3%, 2015). To facilitate pelvic cases, a SILS+1 adaptation was developed in 2012. The main overall procedure performed was a segmental resection(45.7%). The segmental rate remained stable during the study period, but rates of low anterior resections increased(0%, 2009 to 23.7%, 2015). The overall conversion rate was 5.7%, but decreased yearly(9.9%, 2009 to 3.4%, 2015). The mean operative time was 163.3 minutes(SD 67.9) for all resections, and increased over time with the change in case mix. The mean LOS for all patients was 3.8 days(SD 3.2). The overall rate of complications was 8.0%, readmissions was 4.3%, and unplanned reoperation 1.5%. Complications and readmissions increased with time, as more complex patients and procedures were performed; reoperations did not rise. The mean total costs were $16,819(SD $12,847), and remained stable.

Conclusions: In the largest single-institution experience of consecutive SILS colorectal patients, the ability to optimize results–without selection criteria-is seen. With experience, more complex patients and cases can approached in this fashion without impacting clinical or financial outcomes. Efforts should be aimed at improving training and utilization so that patients can benefit from this advanced MIS platform.

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