Single-incision laparoscopic colectomy has been demonstrated to be a safe and feasible minimally invasive surgical modality for colon resections. In addition to the perceived cosmetic benefits, this technique is associated with reduced postoperative pain, the potential for quicker recovery, and shorter length of stay [7
]. Moreover, the SILC technique eliminates the use of peripheral ports potentially reducing the risk for port-site bleeding, hernia, infection, and tumor recurrence. Several case series have evaluated outcomes following SILC; however, only a few have compared SILC to other well-established minimally invasive techniques. To date, there are two randomized controlled trials (RCTs) comparing SILC to CLC for the management of colon cancer. The first study by Huscher et al. assessed outcomes of 16 patients on each arm [17
], whereas the second study by Poon et al. evaluates outcomes of 25 patients on each arm [11
]. In addition, a large retrospective study by Champagne et al. reported outcomes following SILC and CLC in a cohort of 165 patients on each arm [10
]. This report consisted of a multicenter, multiple-surgeon study, with the potential for confounding secondary to different postoperative pathways and management. In the present study, we retrospectively evaluated outcomes of 50 patients following SILC for the management of colon cancer and compared outcomes to one of two well-established minimally invasive surgical approaches, HALC and CLC. The present study represents a single-institution experience, which minimizes confounding factors such as surgeon experience and variations among institutions.
In the present study, we found that the OT was nearly identical in both groups. Similarly, Champagne et al. [10
] reported near equal OT in both arms. Huscher et al. and Poon et al. reported longer OT for SILC as compared to CLC by 18 and 31 minutes, respectively; however, the differences did not reach statistical significance [11
]. Single-incision laparoscopic colectomy presents some technical challenges resulting from the coaxial instrumentation alignment including a reduced the visual field, increased internal and external instrument clashing, and diminished range of motion. Accordingly, one may anticipate an increased OT during SILC. We believe that, as experience is gained, many of the SILC limitations may be overcome by technical modifications such as the utilization of different length instrumentation, the “hand-over-fist” maneuver with the resulting triangulation of tissues, and the utilization of an inferior-to-superior approach for right hemicolectomy [15
]. These adjustments result in the reduction of the procedure length, thus equalizing the OT of SILC to that of other minimally invasive techniques. Furthermore, we believe that by eliminating peripheral ports, SILC provides a platform to streamline the steps of the procedure and to reduce extraneous maneuvers throughout.
Conversion to laparotomy during minimally invasive colorectal surgery has been reported to be as high as 29%, and it has been associated with slow recovery and high postoperative morbidity [1
]. In our series, one case required conversion to open surgery and occurred in the MIS group and was due to difficult dissection and exposure in the setting of a large, bulky tumor. In the SILC group, although there were no conversions to open surgery, five cases required conversion to HALC. Despite the challenges of the SILC approach, our conversion rate to laparotomy is low, which is consistent with other SILC studies [10
]. In challenging SILC cases, a minimally invasive platform may be maintained by the placement of additional ports or conversion to HALC [8
]. The HALC technique has become our preferred modality for conversion, as it is readily available requiring only an extension of the incision. Furthermore, it offers the advantages of an enhanced exposure, blunt digital dissection, and the confidence provided by the hand-assistance, which is particularly beneficial early in the learning curve. Additionally, the HALC approach results in outcomes similar to those of other MIS techniques and improved as compared to open surgery and thus the patients attain the benefits of a minimally invasive platform and the enhanced recovery measures.
In our practice, we now favor the single-incision approach as the MIS option for the majority of colon resections. Although morbid obesity may be a factor predicting conversion, it is not an absolute contraindication of SILC [8
]. We have found, however, that for those with a BMI of 35 or greater, the SILC approach is less ideal and the benefits to the patient may not outweigh the technical challenges of the procedure.
Reported data typically shows that the SILC approach results in nearly identical or shorter LOS, as compared to CLC [10
]. In the present study, the mean LOS in the SILC group was slightly longer than that of the MIS group; yet this difference was not statistically significant. This difference may be attributed to an overall low number of cases, and thus a sampling error. Furthermore, we are comparing a relatively new procedure comprising the initial surgeons' experience to techniques in which we had performed over one hundred cases.
In this series, the overall complication rate was 12% and was similar between the SILC and MIS groups. In the SILC group, the most common complication was wound infection (n
= 2), followed by anastomotic leak (n
= 1), para-anastomotic abscess (n
= 1), prolonged postoperative ileus (n
= 1), stroke (n
= 1), and respiratory failure (n
= 1). The patient with the anastomotic leak required reintervention during the same hospital stay whereas the patient with the abscess required readmission, and was successfully treated with percutaneous drainage and systemic antibiotic therapy. In the MIS group the most common complication was anastomotic leak (n
= 2), followed by wound infection (n
= 1), pelvic abscess (n
= 1), and respiratory failure (n
= 1). One patient with anastomotic leak was reoperated during the same hospital stay and the other case was readmitted for reintervention. The pelvic abscess required readmission and was managed with percutaneous drainage. These similar results between SILC and CLC with regard to postoperative complications are consistent with the reported literature [10
The pathological evaluation demonstrated that all MIS techniques result in oncologically sound outcomes. In all cases the specimen had tumor-free proximal and distal margins. There was a slight, nonsignificant, difference in the median number of lymph nodes harvested between the SILC and MIS groups, 19.5 and 17, respectively. This was in accordance with current colorectal cancer guidelines [19
]. In order to accomplish suitable oncological outcomes during minimally invasive colectomy, some technical considerations have to be taken into account. We perform a technique in which the neoplastic lesion is not manipulated during the procedure, thus eliminating the potential for intraperitoneal tumor seeding. The high ligation of vascular pedicles is also performed so as to maximize lymph node extraction, in addition to the utilization of a wound protector for specimen extraction in order to eliminate tumor seeding at the extraction site.
The main limitation of this study was relatively small sample size and is limited to short-term followup. We matched the SILC cases to a series of HALC and CLC cases to overcome the small sample size, which may negatively affect comparisons. Moreover, the SILC procedures represent the initial experience of the surgeons with the single-incision platform, whereas the MIS group consisted of procedures performed after hundreds of cases of HALC and CLC. Although this would have resulted in poor SILC outcomes, this learning curve discrepancy did not compromise the results following the SILC technique, which compared similarly to the MIS group.
Single-incision laparoscopic surgery is a safe and efficacious alternative MIS approach for the management of colonic malignancies when performed by an experienced surgeon. This technique results in similar short-term operative and oncological outcomes when compared to well-established laparoscopic approaches such as conventional multiport and hand-assisted laparoscopic surgery.