‘Single Plus One’ Technique for Rectosigmoid Resection of Benign and Malignant Disease

Madhu Ragupathi, MD, Javier Nieto, MD, Rodrigo Pedraza, MD, T Bartley Pickron, MD, Eric M Haas, MD, FACS, FASCRS

Colorectal Surgical Associates, Ltd, LLP / Minimally Invasive Colon and Rectal Surgery, Department of Surgery, The University of Texas Medical School / Michael E. DeBakey Department of Surgery, Baylor College of Medicine / Houston, TX

INTRODUCTION: Single-incision laparoscopic colectomy (SILC) has emerged as a safe and feasible approach for the surgical treatment of benign and malignant colorectal diseases. Although the approach averts the use of multiple port sites, certain limitations, such as inadequate visualization and insufficient exposure through an umbilical incision, may restrict its utilization for more complex procedures requiring rectosigmoid resection. As a result, we have developed a modified approach to overcome many of the technical challenges and avoid the high rate of ventral hernias associated with an umbilical extraction site. We present our experience with “Single Plus One” technique for anterior rectosigmoid resection.

METHODS AND PROCEDURES: Between June 2011 and July 2012, “single plus 1” anterior rectosigmoid resection was performed by one of two colorectal surgeons. Each procedure commenced with placement of a 5-mm umbilical optical port for initial laparoscopic exploration with a 5-mm 30° camera, followed by placement of a single-incision access device through a 4-cm Pfannenstiel incision (Figure 1a). Standard non-articulated laparoscopic instrumentation and an energy device were then introduced through three trocars on the port. A medial-to-lateral approach was performed with complete dissection in the retroperitoneal followed by division of the pedicle and lateral mobilization (Figure 1b). Splenic flexure takedown was performed as clinically indicated (Figure 1c). Transrectal division was performed intracorporeally and the bowel was extracted through the Pfannenstiel incision. A primary intracorporeal end-to-end stapled anastomosis was fashioned in each case. Demographic, intraoperative and postoperative data were collected and analyzed.

RESULTS: “Single plus one” technique was performed in 40 patients (42.5% male) with a mean age of 54.1±12.2 (range: 31-84) years, mean BMI 27.8±5.2 (range: 18.7-44.8) kg/m2, and median ASA of 2 (range 1-3). Twenty-six (65%) were overweight (BMI 25-29.9) or obese (BMI > 30) and 57.5% (n=23) had prior abdominal surgery with a mean of 1.7±0.9 (range: 1-3) procedures. Resection for benign disease was performed in 29 patients (72.5%), with the most common indication being diverticulitis (n=27). Eleven patients (27.5%) underwent resection for malignant disease (adenocarcinoma). There were no intraoperative complications or conversions to another approach. The mean operative time and estimated blood loss were 177.0±45.0 (range: 110-300) min and 80.0±87.9 (range: 20-500) ml, respectively. The mean initial incision length was 4.0±0.3 (range: 3.3-5.0) cm. Six patients (15%) required extension of the incision secondary to bulky disease. For malignant cases, mean lymph node extraction was 19.5±8.1 (range: 12-40) and all margins were negative. Three postoperative complications (7.5%) were encountered during hospitalization (ileus [n=2], rectal bleeding [n=1]). The mean length of hospital stay was 3.9±2.0 (range: 2-12) days. One patient (2.5%) was readmitted for abdominal pain and dehydration. There were no secondary surgical interventions.

CONCLUSIONS: “Single plus one” laparoscopic colectomy is an efficacious approach combining the advantages of single-incision and reduced port techniques to facilitate rectosigmoid resection. The approach optimizes visualization and exposure, limits instrument collisions, provides enhanced cosmesis, and reduces the risk for umbilical extraction site hernia. Comparative studies are warranted to further evaluate benefits and limitations of this approach.

Session: Poster Presentation

Program Number: P085

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