Single Incision Laparoscopic Rectal Resection for Cancer: A Preliminary Study

Elie K Chouillard, MD PhD, Nelson Trelles, MD, Andrew Gumbs, MD FACS. On behalf of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS), Poissy, France

Aim: Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging concept in surgical ideology. Many variants have been described including « pure » NOTES, « Hybrid » NOTES, or even endoscopic surgery. Single Incision Laparoscopic Surgery (SILS) has been inspired by the potential advantages of NOTES including less abdominal wall complications, less postoperative pain, faster return to activity, and better cosmesis. This study analyzed the results of our preliminary experience with these new techniques in patients with rectal cancer.
Methods: All patients were prospectively included after a written informed consent. The Ethical Board of the Hospital approved the study. All patients with resectable rectal or low sigmoid cancer could be theoretically included. A single 25 to 35-mm diameter, umbilical incision was used. Three 5-mm ports were inserted through a special platform device.
Patients: From January 2009 to April 2011, SILS or NOTES (either hybrid or pure) was attempted in 31 patients. Preoperative radiochemotherapy was performed in 17 patients (54.8 %). Exclusion criteria comprised mainly prior open abdominal surgery, ASA III status, organ insufficiency, and hemostasis disorders.
Results: The success rate without conversion to laparotomy or additional port sites was 90.3 % (28 patients). Additional procedures included oophorectomy (4), hysterectomy (2), intraperitoneal chemohyperthermia (2), bladder resection (1), appendectomy (1), and atypical liver resection (1). 21 patients had rectal resection with sphincter preservation (coloanal anastomosis) and 10 patients had abdominoperineal resection. Mortality rate was nil. The overall morbidity rate (mainly minor complications) was 19.6 % (8 complications in 6 patients). Two patients (9.5 %) had leaks (including one diagnosed only radiologically 6 weeks later) and no reoperation occurred. One year survival rate is 96.8 %
Conclusions: SILS and NOTES procedures are safe and feasible in selected patients with rectal cancer. Advantages regarding postoperative pain and length of hospital stay could be demonstrated. However, larger scale studies are needed for further evidence-based analysis, especially regarding oncological outcome.

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