|Year : 2018 | Volume
| Issue : 1 | Page : 27-32
Comparison of single-port and conventional laparoscopic abdominoperineal resection
Nikolaj Nerup, Steffen Rosenstock, Orhan Bulut
Department of Surgical Gastroenterology, Copenhagen University Hospital Hvidovre, Kettegaards allé 30, DK-2650 Hvidovre, Denmark
|Date of Submission||06-Mar-2017|
|Date of Acceptance||17-May-2017|
|Date of Web Publication||11-Dec-2017|
Dr. Nikolaj Nerup
Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet
Source of Support: None, Conflict of Interest: None
Background: Within the last two decades, surgical treatment of colorectal cancer has changed dramatically from large abdominal incisions to minimal access surgery. In the recent years, single port (SP) surgery has spawned from conventional laparoscopic surgery. The purpose of this study was to compare conventional with SP laparoscopic abdominoperineal resection (LAPR) for rectal cancer.
Patients and Methods: This was a single-center non-randomised retrospective comparative study of prospectively collected data on 53 patients who underwent abdominoperineal resection for low rectal cancer; 41 with conventional laparoscopy and 12 with SP surgery.
Results: Patients' characteristics were in general comparable, but patients in the conventional laparoscopy-group had a significantly higher American Society of Anesthesiologists-score. The operative time was slightly shorter in the conventional laparoscopy-group, but no differences were found in oncological margins of the resected specimen, in length of stay or readmission rate.
Conclusions: SP LAPR appeared to be safe and feasible in selected patients. Adequate oncologic resections can be performed with acceptable morbidity and mortality. Larger randomised controlled trials with longer follow-up are needed to determine the beneficial role of this new procedure.
Keywords: Colorectal surgery, minimal invasive surgery, rectal neoplasms, retrospective study, safety
|How to cite this article:|
Nerup N, Rosenstock S, Bulut O. Comparison of single-port and conventional laparoscopic abdominoperineal resection. J Min Access Surg 2018;14:27-32
| ¤ Introduction|| |
Within the last two decades, surgical strategies for the treatment of colorectal cancer have changed dramatically from major abdominal incisions to less invasive techniques in combination with fast track perioperative regimens. When the laparoscopic approach was introduced in colorectal surgery, evidence of its superiority to open surgery was non-existing. Today an increasing number of studies documents the benefits of minimal invasive surgery in colorectal cancer, and laparoscopy are considered the golden standard in many countries. Laparoscopic colorectal resections is associated with; less bleeding, reduced post-operative pain, less post-operative ileus, earlier return to normal daily activity and shorter hospital stay compared to open surgery.,
Now even less invasive procedures are under development; Single port (SP) laparoscopic surgery SP (SPLS), trans-anal endoscopic surgery, natural orifice transluminal endoscopic surgery (NOTES), and robotic laparoscopic surgery. NOTES leave a scar less abdomen, but there is high risk of complications and patient-related discomforts when entering the abdomen through, for example, the vagina. Robotic colorectal laparoscopic surgery is evolving and overcoming some of the technical difficulties regarding ergonomics in the narrow pelvis, but the costs per procedure is still very high. With time, hybrids of the procedures may be introduced and robotic SP surgery is an obvious opportunity.
SP colon resections have been reported since 2008, and feasibility and safety for various SP procedures has been assessed in several large case series and some comparative studies.,, Most series, however, have included heterogeneous groups of both benign and malignant diseases, and different operative procedures have been assessed. The majority of comparative studies of SP colorectal surgery have mainly focused on colonic disease. Reports on separate SP rectal resection, on the other hand, are still very few. Currently, initial experiences with SP abdominoperineal resection (SPAPR) have only been reported in a few papers.,,,
The aim of the present study was to compare the outcome of SPAPR and laparoscopic abdominoperineal resection (LAPR), to investigate the safety and feasibility of this new approach in the treatment of low rectal cancer.
| ¤ Patients and Methods|| |
This was a single-center, retrospective, non-randomised, comparative study of prospective collected data on patients who underwent abdominoperineal resection for low rectal cancer between August 2009 and May 2012. The departmental review board approved the study. Patients referred to our institution for surgical treatment of low rectal cancer were evaluated for SPAPR or LAPR.
Rectal tumours were staged according to national guidelines. The pre-operative work-up included targetted biopsy from the rectal lesion, proctoscopy with a rigid rectoscope, colonoscopy, computed tomography (CT) with intravenous contrast and magnetic resonance imaging (MRI) of the rectum. Tumours were considered low rectal cancers if located <5 cm from the anal verge (AV) on examination with a rigid rectoscope. All patients were discussed at a multidisciplinary colorectal cancer team meeting before and after surgery.
The following variables were assessed in the study: (1) Demography; age, gender, body mass index (BMI), and American Society of Anesthesiologists (ASA) score. (2) Tumour characteristics on pre-operative MRI; tumour size, regional lymph node involvement, metastases (TNM stage), distance from the AV, and circumferential resection margins (CRM). (3) Perioperative data; operative procedure, operating time, blood loss and conversion to conventional laparascopic surgery (LAPR), hand-assisted laparoscopy or open surgery. (4) Histopathology reports; TNM stage, quality of specimen, number of harvested lymph nodes, length of specimen, circumferential resection margin (CRM), distal resection margin (DRM), and tumour size. (5) Post-operative data; short-term complications, length of hospital stay (LOS), readmissions, 30-day overall mortality, and follow-up.
Patients with CT or MRI evidenced tumour infiltration into adjacent organs and T4 obstructive cancers was not considered for SPAPR due to the foreseen limited space in a narrow pelvis. Tumour size, BMI, and the anatomical shape of the patient played a substantial role in patient selection for SPAPR. All patients were informed about the possible risks of SP and understood that they were having a non-standard procedure. Informed written consent was obtained. Patients were also informed about the conventional LAPR approach and that additional incisions and/or conversion to open surgery may be needed as warranted during the SPAPR procedure. Stoma sites were marked preoperatively. A phosphate enema was given prior to surgery. All procedures were performed by the same surgical team with a considerable experience in advanced laparoscopic colorectal surgery. Oncological surveillance and follow-up after surgery was done according to Danish Colorectal Cancer Group guidelines.
The SPAPR and LAPR techniques have previously been described in detail. In short, the SPAPR was commenced with 2.5 cm skin and fascia incision to access the abdominal cavity. The perineal part of the operation was done with the patient in the prone position and included removal of the tip of the coccyx together with the specimen ad modum Holm et al. according to departmental guidelines. The specimen was retrieved through the perineal incision. No drains were used. Intraabdominal smoke formation was drained through an intravenous cannula working as a separate venting channel inserted at the suprapubic site. Conversion from SPAPR to LAPR, hand-assisted laparoscopy, or laparotomy was considered conversion.
Five port sites were used for the LAPR. Standard dissection was medial-to-lateral. Conversion to open procedure was defined as an extension of the abdominal incision more than needed for extracting the sigmoid ostomy. Patients who received pre-operative chemo-radiotherapy underwent surgery 6–8 weeks after completion of treatment. The low pelvic dissection in LAPR was done posteriorly and then anteriorly, and finally with lateral dissection. The remaining part of the deep pelvic dissection was done through a perineal approach.
A standardised perioperative care protocol was used for both patient groups. The patients were discharged when fully ambulatory. Whenever necessary, some patients were sent to recovery facilities for colostomy training.
Data were analysed on an intention-to-treat basis. Statistical analyses were performed using the statistical software (SPSS version 19; SPSS INC. Chicago, IL, USA). Student's t-test was used for normally distributed continuous variables, and χ2 tests were used for non-parametric data. We considered a P < 0.05 statistically significant. Proportions are given as percentages with 95% confidence intervals (95%). All values are presented as median with interquartile ranges and upper-lower ranges.
| ¤ Results|| |
Fifty-three patients underwent APR for low rectal cancer, 41 patients with LAPR and 12 with SPAPR. Patient characteristics were in general comparable but patients in the LAPR-group had a significantly higher ASA-score. No significant differences were seen in BMI, age, gender, tumour site, pre-operative chemo radiotherapy, or rate of earlier abdominal surgery between LAPR and SPAPR patients. LAPR patients group had more advanced clinical staging than the SPAPR patients [Table 1].
The operative time was significantly shorter in the LAPR group. There were no significant differences in intraoperative estimated blood loss, median LOS, or re-admissions between the two groups. Two patients in the LAPR group needed conversion to open surgery because of an unexpectedly bulky tumour in one case and fixation of the tumour to the pelvic wall in the second case [Table 2]. Intraoperative complications occurred in four patients in the LAPR group, three were inadvertent rectal perforation. One urethral lesion and one bladder perforation were repaired immediately. There were no intraoperative complications in the SP group. There was no operative mortality. Superficial perineal wound infection/dehiscence and urinary tract problems were the most common complications in both groups. Three cases with deep perineal wound infections in the LAPR group were treated by vacuum assisted closure. Reoperations were performed in five patients (2%) in the LAPR group. These included two stoma revisions, repair of a small bowel perforation (n = 1), and secondary suture of early port-site dehiscence (n = 1). There were no reoperations in the SPAPR group [Table 3].
The oncological clearance in terms of harvested number of lymph nodes, tumor size, and length of the specimen was comparable between the two groups [Table 4]. Free margins were achieved in all patients. Macroscopically incomplete resected specimens were recorded in one patient (8.3%) after SP surgery and in 15 (36.6%) after LAPR. Final pathological examination with TNM staging showed no difference between the groups (P = 0.86).
Two patients (4.9%) in the LAPR group died during hospital stay. One patient had a missed small bowel perforation, and never recovered because of extensive co-morbidity. The other patient underwent a reoperation 13 days after the primary operation because of intestinal obstruction and later on abdominal wall dehiscence. He suffered from mitral stenosis, and developed progressive respiratory insufficiency and died 30 days after the primary operation. No patients in the SPAPR group died during hospital admission. Two patients, however, died after discharge, 14 and 19 days after the primary surgical procedure after otherwise successful operation and uncomplicated post-operative care. Autopsy was unfortunately not performed. In the follow-up period (1–18 months), no additional deaths was found in the SPAPR-group. In the follow-up period (1–42 months), additional seven deaths was found in the LAPR-group, given a total mortality of 9 (22%). Of the nine deceased patients 4 (44%) had disseminated cancer, 2 (22%) died under admission as described, and one from pulmonary edema (11%). The remaining 2 (22%) died in their own home of unknown cause, and no autopsy was performed.
In the LAPR-group, two patients (4.9%) had metastases to the liver; one of these underwent resection of the metastasis. Three patients had lung metastases (7.3%) one of these received surgical treatment. One patient (2.5%) had a metastasis to an inguinal lymph node. One (2.5%) had tumor ingrowth to the bladder and 1 (2.5%) to the vertebral column and spinal cord. Fourteen (34%) patients received post-operative chemotherapy. In the SPAPR-group, four patients had metastases to the lungs, two patients (2.7%) received surgical treatment and two patients (2.7%) received chemotherapy.
| ¤ Discussion|| |
The present study indicates that SPAPR is safe and feasible in selected patients with low rectal cancer, with adequate oncological resection margins and acceptable morbidity and mortality rates compared to the conventional laparoscopic approach. The operative time was longer in the SP group, but we believe that the procedure time will shorten in time, as studies shows that the operating time correlates to the number of performed procedures, suggesting that procedure time may decrease after a learning curve has been passed.
The literature addressing SP rectal surgery is very limited. Unfortunately, many studies include a mixture of different SP-procedures; high and low anterior resection, Hartman's operation, and APR, which make it hard to conclude anything regarding the APR alone.,, A similar but slightly reverse technique was investigated in a series of twenty patients with T1-T3 tumours in the lower rectum. In this series, the procedure was initiated with the cylindrical abdominoperineal dissection from the perineum to the peritoneal reflection. The dissected rectum was then wrapped in sterile gloves and placed in the abdomen. The SP access procedure was undertaken through the colostomy site and a sigmoid colostomy made. There were no conversions, no rectal perforation and sufficient oncological margins, as in our data. The operating time was 138.55 min (±9.32), which is shorter than seen in this study. This difference could be explained by a predominance of relative small T1 tumours where as our SP-operated patients had larger tumours. Mean LOS was shorter 4.25 days (±0.97) compared to our median 7 days (7–9). No severe morbidity or mortality was found in the 24 week of follow-up.
A meta-analysis of 15 comparative studies of SP versus multiport laparoscopic colectomy indicated that SP-operated patients had shorter hospital-stays, less estimated perioperative blood loss, and a larger lymph node harvest, with no significant difference in operating time or complications. Our study of abdominoperineal rectal resection could, however, not document these differences. Another meta-analysis of 15 non-randomised comparative studies including more than a thousand colorectal SP procedures concludes that single-port laparoscopic colorectal surgery is as feasible and safe as conventional laparoscopy. Bearing this in mind, single incisions could be preferable to 4 or even 5 incisions, particularly if minimising the abdominal wall trauma is beneficial to the patient. Reduction in post-operative pain, earlier patient recovery, lower risk of incisional hernia and port site bleeding and not negligible, improved cosmetic results are other potential advantages of SPLS, although not yet been proven in controlled randomised trials. However, SPLS is associated with several technical disadvantages, such as handling the instruments in parallel with the vision of the laparoscope and not from different angles as in conventional laparoscopic surgery. This is, especially challenging in colorectal surgery where the surgical field is not limited to one abdominal quadrant, as in cholecystectomy or appendectomy.
An international multicenter registry, European Consensus of SP Expertise in Colorectal Treatment (ESCPECT), has been established in order to evaluate the general safety and feasibility of SP procedures in colorectal surgery. They recently published a retrospective study with 30 days follow-up of 1769 patients who underwent SPLS for colorectal benign and malign disease. Conversion was needed in 4.2% of procedures, and was related to male patients, ASA-score over 1, and procedures involving the rectum. Data from the present study is included in the ESCPECT publication but, interestingly, we did not find any conversions in the present study. The overall 30-day mortality was 0.5%. Post-operative complications were found in 12.7% of patients and related to male sex, ASA-score, and rectal procedures. The ESCPECT will continue to register data on SPLS procedures to provide data for the evaluation of safety and feasibility. However, the authors still state that large randomised trials are needed to allow any conclusions.
There are several limitations to our study. The small number of highly selected patients and the non-randomised nature of the study are obvious sources of bias. The groups were rather comparable, but the conventional laparoscopic group had a significantly higher ASA-score. Both groups had relatively low BMI, but this reflects the population, and no patients were excluded due to high BMI. The follow-up period is relatively short. It is unknown if a longer follow-up would change long-term outcomes.
| ¤ Conclusions|| |
SPAPR appeared to be safe and feasible in highly selected patients with rectal tumours limited to the rectal wall when performed by very experienced laparoscopic colorectal surgeons. Adequate oncologic resections can be performed with acceptable morbidity and mortality in SPAPR. Larger randomised controlled trials with longer follow-up are needed to determine the beneficial role of this new procedure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]