Single Incision Colectomy: the Reality of Adoption Into Practice

Deborah Nagle, MD, Vitaliy Poylin, MD, Steven Tizio, MD. Beth Israel Deaconess Medical Center

Introduction: Single incision or reduced port surgery is a newer development in colon and rectal surgery but is technically demanding. Our aim is to evaluate the uptake of single incision colectomy in a colon and rectal surgery practice focused on minimally invasive surgery.
Methods: Retrospective review of a prospectively collected, IRB approved database. Data from 60 consecutive, planned single incision colorectal surgical cases from September 2008 to September 2011 are reported.
Results: Sixty (N=60) patients underwent SIL colorectal surgery by two surgeons at our institution. Cases included: small bowel resection (N=4), appendectomy/partial cecectomy (N=9), ileocectomy and right colectomy (N=27), sigmoid or left colectomy (n=7), transverse colectomy (N=2), total abdominal colectomy (N=4), takedown of Hartman’s pouch (N=1), sigmoid colostomy (N=1) and a J-pouch (N=5). There were 40 female patients and 20 male patients. Mean age was 57.2 years (21-86 yrs). Mean BMI was 25.2 (range 18 to 41.8), but the average selected patient BMI per year dropped slightly from 25.7 to 25.4 to 24.1. Of the planned SILC cases, (85%) were successfully completed by single port technique. Six (10%) cases were completed by reduced port technique and three (5 %) were converted to open laparotomy. The converted cases all had previous abdominal surgery. The mean operative time for all SIL colorectal cases was 140 min (range 39-313 min), clearly varying with case complexity. Case times were comparable to our multiport cases. Case times did not decrease significantly after the learning curve was achieved. Residents of Postgraduate Year 5 and 6 participated in most all cases but essentially only the PGY6 physicians were able to operate rather than assist. The median length of stay for all SIL colorectal cases was 3.98 days (range 0-29). However, 22% (13/60) of patients were discharged on the first postoperative day, and 50% of patients were discharged within 2 days of surgery. There were 3 significant complications (5 %), including one death after hospital discharge (1.6%).
Conclusions: Single incision colorectal surgery is feasible, with acceptable complication rates and operative times. However, barriers to uptake include: technical complexity, decreased resident case participation, obese patients and previous abdominal surgery. Shorter hospital length of stay may compensate for some of these factors.  Over time, our practice pattern migrated to use single incision laparoscopic colectomy for right sided cases, patients with BMI under 30 and younger females. With evolving selection parameters, our reduced port case volume actually decreased, rather than increased, on a yearly basis. Further study and trials will help to identify the optimal patients for this technique.

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