Grace Montenegro, MD, Joseph Frenkel, MD, Margaret Shields, Gerald Marks, MD, John Marks, MD. Lankenau Medical Center.
Single port (SP) colorectal surgery has been characterized as a gimmick with limited applicability in regards to procedure, disease and patient characteristics. Although theoretically attractive for patients, there is question if SP procedures can safely be performed and if it offers any disadvantages or advantages to multiport (MP) laparoscopic colorectal surgeries. We hypothesize that SP is at least equivalent to MP surgery, and can be a safe alternative. Moreover, we intend to examine SP for the full spectrum of colorectal procedures.
Case-matched retrospective analysis of a prospectively maintained database of a single colorectal surgeon to compare perioperative outcomes in single port vs. multiport laparoscopic surgery (SP/MP) for total (5/5), right (24/24) and left (51/51) colectomy, stoma (3/3), and TME (12/12) surgery was performed. Case-match (SP/MP) included preoperative diagnosis, disease location, procedure, BMI (25.6/26.2kg/m2; 17.2-38.7), age (60/60, 19-88 yo), gender (53/53 women), history of previous abdominal operation (50/47%) and pelvic radiation (12/12%). Perioperative outcomes, morbidity, mortality, local recurrence and 5-year survival for cancer patients were analyzed. Subset analysis was performed for surgery type. Statistically significant differences were identified using Student’s t-Test.
Case match of 159 SP cases with 1617 MP found 95 matches for analysis (SP/MP). Preoperative diagnoses included diverticulitis (46/46), cancer (27/27), polyps (14/14), ulcerative colitis (3/3), colonic inertia (2/2), rectal prolapse (2/2) and volvulus (1/1). There was lower mean EBL in SP (109/177cc, p=0.03) but no difference in transfusion requirement (0/1). Decreased OR time for SP left colectomy (206/244min, p=0.01) with a trend to shorter for SP found in all procedures (217/249min, p=0.05). 99% SP and 98% MP had no intra-operative complications. Complications included enterotomy (0/1), lost needle (1/0) and presacral bleeding (0/1). Conversion to open was equivalent (0/1), with 6.3% of SP requiring additional ports. Mean largest incision was smaller for SP (3.1/5.2cm, p=0.01). There were no differences in specimen length (27.9/31.3cm, p=0.42). Overall LN harvest for SP compared to MP did not show a difference. There were no differences in return of bowel function (flatus (POD 2/2) and bowel movements (POD 3/3)) or length of hospital stay (POD 4/4). There were no differences in perioperative morbidity (12/17%, p=0.55) such as anastomotic leak (1/1) or delayed morbidity such as wound infection (1/0) or incisional hernia (0/1). There were no mortalities. There was no difference in local recurrence, distant metastasis or overall 5-year survival (cancer patients only) between SP and MP.
Single port is a safe alternative to multiport laparoscopic colorectal surgery across the full array of procedures, in equivalent patients. This study demonstrates SP has less blood loss, smaller incisions and is quicker in left colectomy, and trends to quicker across all procedures. Conversion and morbidity rates are equivalent to MP, without compromise in quality of surgical technique. No differences in discharge criteria were shown. While proper training is essential, concerns regarding the inability to use SP laparoscopic colorectal surgery safely are unfounded. These issues will require further study as SP laparoscopic colorectal surgery is practiced more widely.