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244
B.R. Davis
pressure may alleviate some of these changes, but short of
gasless laparoscopy, there is little a surgeon can do to prevent
these changes. Therefore, communication between the anesthesia team and the surgeons is critical to prevent untoward
outcomes. Limiting the time spent in extreme positions and
with pneumoperitoneum is an important consideration during laparoscopy on patients with hemodynamic and respiratory compromise. The maintenance of pneumoperitoneum
relies on an adequate seal between the trocars or hand port
and the abdominal wall. In instances where pneumoperitoneum cannot be maintained, the operative surgeon should
assess for ongoing CO
losses through any of the incisions.
2
Increasing the fl ow rate on the insuffl ator and selecting the
largest trocar for gas delivery will help mitigate this problem.
When attempts to seal a leaking trocar fail, sutures can be
placed in the fascia or skin, or alternatively the trocar can
be upsized. The use of trocars with a balloon tip that infl ate
below the fascia (Kii Advanced Fixation, Applied Medical,
Rancho Santa Margarita, CA) can prove benefi cial as a
means to create a better seal.
Summary
Knowledge of the pitfalls and technical challenges that await
surgeons attempting to perform laparoscopic colorectal procedures will allow for better success and fewer conversions
throughout the learning curve. Trocar insertions can be made
more diffi cult by thick abdominal walls and previous surgery, and a variety of safe methods are available to establish
the initial port. Bowel injury either from excessive traction or
dissection will happen, and it will be an advantage for you to
have laparoscopic suturing skills. This will also facilitate the
management of serosal and thermal injuries. Bleeding is
an expected problem, and a decision will need to be
made quickly as to the best method of management. An
ENDOLOOP
®
will generally be successful if the proximal
side can be controlled. Anastomotic leaks are generally
related to tension and ischemia, and techniques to assess the
blood supply and to lengthen the conduit will mitigate some
of these factors. Exposure is a critical component to success
which can be threatened in the obese patient or when adhesions prevent the free movement of the small bowel and
omentum.
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Part IV
New Horizons
Single-Incision Laparoscopic Approaches to Colorectal Disease
Virgilio George
22
K e y P o i n t s
• Single-incision laparoscopy is safe and feasible in major
colorectal surgery.
• The learning curve is quite short and almost nonexistent
for those already skilled in conventional laparoscopic surgery and, more specifi cally, right hemicolectomy.
• Using different length instruments and a 30-degree 5-mm
camera will aid in avoiding extracorporeal instrumentation collisions.
• A right-angled light cord adapter is a must.
• Do not sacrifi ce safety and adequacy of an operation for a
limited approach.
Introduction
New surgical techniques are constantly being developed
around the world. Yet, some interventions never gain traction,
while others become an important part of a surgeon’s skill
set. Single-port laparoscopy is one approach that has steadily
gained popularity across various surgical disciplines, including colorectal surgery, and is a frequent topic of discussion
and investigation. It would appear that single-port laparoscopy will remain a part of surgical therapy for some time.
As the fi eld of single-port laparoscopy grows, the trend in
publications changes with it. To date, there have been a number of studies within the general, urologic, and gynecologic
surgery literature looking at the feasibility and safety of the
single-port laparoscopic approach to various operations [ 1 – 7 ].
Electronic supplementary material: Supplementary material is available
in the online version of this chapter at
Videos can also be accessed at
videos/978-1-4939-1580-4
V. George , M.D. (*)
Associate Professor of Surgery, Indiana University School
of Medicine, Department of Surgery , Richard L. Roudebush VA
Medical, Center , 545 Barnhill Dr., #500 ,
Indianapolis , IN 46202 , USA
vigeorge@iupui.edu
e-mail:
.
10.1007/978-1-4939-1581-1_22 .
http://www.springerimages.com/
Although the technique may vary, it would appear that nearly
any surgery that can be done laparoscopically can also be
done using a single-port approach [ 8 ].
Colon and rectal surgery is no stranger to this trend and in
recent years has seen a vast increase in publications about the
use of single-port laparoscopy [
the largest series of single-port laparoscopic right hemicolectomies to date and has since had a growing experience with more
complex procedures using a single-port approach [ 11 ].
It is important to keep in mind that when learning any new
procedure, there is a learning curve that each person must
complete in order to become profi cient. Single-port surgery
is no different. Although the steps of a colectomy may be
well engrained and the point of achieving competency using
a laparoscopic approach is long past, bringing in the singleport dimension adds a degree of diffi culty to the mix. There
has been some data addressing the learning curve for singleport laparoscopy [ 12 – 14 ]. However, there have been no spe-
cifi c studies examining the learning curve for performing
single-port laparoscopic colorectal procedures, specifi cally.
In this chapter we will address the technical aspects of
single- port surgery for various colorectal operations and
highlight tips to hopefully make this approach much easier,
no matter where you are on your learning curve.
9 , 10 ]. Our group has published
Indications
Laparoscopic surgery has been shown to have multiple
advantages when compared to open surgery: decreased morbidity, decreased pain, faster recovery, and shorter hospital
stay [ 15 , 16 ], as well as equivalent oncological results seen
in the COST and MRC CLASICC trial [ 17 – 20 ]. Single-
incision laparoscopic surgery (SILS) uses only one incision
in the abdominal wall, allowing all operative work to be done
in the same opening, but this does not change the fundamental tenants of laparoscopic surgery: proper exposure, triangulation, and the use of instruments and devices tailored for
in-line viewing.
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_22, © Springer Science+Business Media New York 2015
249
250
V. George
During the past years, numerous reports of SILS procedures have been published showing the feasibility of this
approach for even complex colon and rectal procedures [
To date, all types of colorectal procedures have been performed through single-port laparoscopy, from a minimally
invasive stoma to a total proctocolectomy and ileoanal pouch.
It is not a result of a “landmark” randomized, prospective
study but rather through experience that single-site outcomes
have been shown to be equivalent to multiple-site laparoscopy
and open laparotomy from all perspectives. In many cases, this
approach has become the preferred technique for surgeons.
The most common single-site procedures will be reviewed
here, including right colectomy, sigmoid colectomy, and
total abdominal proctocolectomy with J pouch.
10 ].
Preoperative Planning
Whether you are performing a procedure through an open,
laparoscopic or single-incision laparoscopic approach, a
good history and physical examination is mandatory. In addition, appropriate patients should have a complete blood
count, chemistry, and carcinoembryonic antigen (CEA) levels as indicated by their comorbidities and disease process.
Additional assessment for staging and localization of a tumor
includes CT scan and colonoscopy to confi rm the exact location and mark the lesion with India ink. While still controversial, a bowel preparation typically follows the preference of
the individual institution and surgeon. In my institution, we
do not routinely prescribe bowel prep for right colectomies
and use oral laxative for the other colectomies. Also, intravenous antibiotics are used perioperatively for all patients.
Appropriate patient selection cannot be overemphasized.
During my initial experience, I selected patients with a low
body mass index (BMI). In addition, I avoided patients with
previous surgeries, due to the time-consuming lysis of adhesions, as well as patients with large tumors that can be diffi cult to handle.
As my experience has grown, I now use single-incision
laparoscopy for all my right colectomies as well as those undergoing a total abdominal colectomy with J pouch. Regar ding
BMI or previous surgery, I perform single-site laparoscopic
resection in selective cases for sigmoid and left colectomy
when the cosmetic results are important to the patient.
platform. At present, the most popular are the following six
systems including:
1. The platform most commonly used is the SILS port
(Covidien, Inc. Norwalk, CT), which is made from an
elastic polymer. It is hourglass-shaped and can be
deployed through a 2-cm fascial incision. It contains four
openings: one for insuffl ation via a right-angled tube and
three that can accommodate trocars 5–15 mm in size.
2. The GelPOINT
Margarita, CA) port uses a wound protector that is also
very helpful for retraction, accommodating multiple trocars 5–12 mm. This platform allows for laparoscopic surgery by providing a fl exible, airtight position for multiple
trocars and multiple positions that allows an easy triangulation and less collision. It’s large enough to allow bowel
exteriorization for extracorporeal resection and anastomosis using standard instrumentation. By offering an
increased range of motion and maximum retraction and
exposure, the GelPOINT platform provides the utmost
versatility and access for a wide range of abdominal and
transanal procedures.
3. The TriPort ® (Advanced Surgical, Co. Wicklow, Ireland)
has three channels, allowing up to one 12-mm and two
5-mm instruments.
4. The QuadPort (Advanced Surgical) has four lumens, permitting up to one 15-mm, two 10-mm, and one 5-mm
instruments.
5. The Uni-X single-port laparoscopic device (Pnavel
Systems Morganville, NJ) is a system designed to allow
the simultaneous use of three 5-mm laparoscopic instruments through a single fascial incision. It requires fascial
fi xation sutures and curved laparoscopic instruments.
The Uni-X system seems to be used primarily in urology
procedures [ 4 , 21 – 23 ]. Initial technical notes are provided
by Remzi et al. [ 10 ].
6. Ethicon Endo-Surgery SSL Access System (Ethicon,
Cincinnati, OH) consists of two 5-mm seals and a larger
15-mm seal in a low-profi le design. Unique to the device
is the 360-degree rotation of the seal cap that enables
quick reorientation of instruments during procedures and
reduces the need for instrument exchanges.
®
(Applied Medical, Rancho Santa
Right Hemicolectomy (Video 22.1 )
Single-Incision Port Types and Port Placement
Multiple access devices have been developed and are
constantly changing in an attempt to improve this developing technique of minimally invasive single-port surgery.
Among them is the recent addition of a robotic single-port
Operative Technique
After anesthesia is induced, a Foley catheter and orogastric
tube are placed. Then the patient is positioned supine on the
table; the left arm is padded and tucked. Some kind of
restraint device (beanbag or chest and leg straps) needs to be
used to prevent the patient from falling from the table during
position manipulation.
22 Single-Incision Laparoscopic Approaches to Colorectal Disease
251
Fig. 22.1 Port placement for single-incision right colectomy. Note the left colectomy can be in the umbilicus or in the Pfannenstiel position
The patient is prepped and draped in standard fashion.
The surgeon and assistants are located on the left side of the
patient. Visual monitors, as many as are needed, are positioned on the opposite side of the surgeon, which allows
comfort and good visualization (Fig. 22.1 ).
The operative technique starts with placement of the
SILS™ port device placed in the umbilicus using an open
technique. This provides an added degree of safety against
inadvertent intra-abdominal injury [ 24 ], as well as a cos-
metic benefi t by hiding the future scar. A vertical incision is
made in the fascia large enough to accommodate the singleport trocar (~2 to 3 cm; Fig. 22.2 ). A fascial opening bigger
than the device will cause loss of insuffl ation during extreme
movement of the instrumentation and can add time and frustration to the procedure and the surgeon.
Our preference is to use standard laparoscopic instrumentation (i.e . , straight) including the scope. This decreases the
Fig. 22.2 Single-port and umbilical incision. Notice the small incision
to accommodate the port to reduce air leaks
learning curve and allows the surgeon to perform the procedure with tools to which they are accustomed (Video 22.2 ).
A standard 5-mm 30° laparoscope of bariatric length is then
inserted (or rarely a 30° 10-mm laparoscope), followed by
two 5-mm working ports with non-articulating instruments:
(1) atraumatic bowel grasper and (2) an energy device with
multifunctional capability such as the ENSEAL ® (Ethicon
Endo-Surgery, Inc, Cincinnati, OH) (Fig.
22.3 ).
I prefer to orient the trocar with the gas port aimed toward
the patient’s feet, helping to keep triangulation on the 5-mm
port, as well as using the top of the triangle for the camera
port (Fig.
22.4 ).
The abdominal cavity is explored for adhesions, and
most importantly when performing the surgery for colon
252
V. George
cancer, the peritoneum and liver must be inspected for metastatic disease. The patient is then positioned in
Trendelenburg position and left side down. The omentum is
grasped and placed on top of the transverse colon. My common approach is to begin medial-to-lateral dissection where
the vascular pedicle is ligated before the mobilization of
the colon or the tumor. I prefer to maintain the “no touch”
technique and adhere to standard oncological principles
[
25 ] with gentle traction on the cecum. The ileocolic pedi-
cle is then elevated; the small bowel is positioned on the
left side of the abdominal cavity, allowing visualization of
the base of the mesentery. The peritoneum underlying the
ileocolic pedicle and the base of the mesentery are opened
(Fig. 22.5 ) using laparoscopic scissors or an energy device
of the surgeon’s preference in order to dissect the colon off
its retroperitoneal attachments and the duodenum in a
medial-to-lateral fashion. Careful retroperitoneal dissection continues until the duodenum is completely identifi ed
and the head of the pancreas is seen. Once this is complete,
a mesenteric window is created and the ileocolic vessels are
divided using an energy device.
After the division of the vascular pedicle, this space is
developed in cephalad direction, above the duodenum,
between the fi rst portion of the duodenum and the transverse
mesocolon. Identifi cation of the right branch of the middle
colic vein and artery must happen while dissecting at the origin (Fig. 22.6 ). Then this can be ligated using an energy
device. The mesenteric of the transverse colon is then divided
to encircle a distal portion of the colon for the creation of the
ileocolic anastomosis. The patient is then positioned into
reverse Trendelenburg; the omentum is grasped and divided
to be included in the en bloc resection from its attachments
to the transverse colon. Next, the hepatic fl exure and the
lateral attachments are taken down from superior to inferior
(Fig. 22.7 ). Careful dissection should be used when
approaching the lateral attachment in the right lower quad-
rant to minimize the risk of ureteral injury. After confi rming
the completed mobilization and division of the mesentery of
the terminal ileum, the cecum is grasped with a locking
instrument to help during extraction (Fig.
22.8 ). The fascial
incisions are enlarged as necessary to exteriorize the specimen for division and anastomosis. The use of a wound
protector is recommended to prevent contamination of the
wound, tumor seeding, and helping with the exposure. The
colon is then exteriorized, ensuring you maintain proper orientation of the specimen (Fig.
22.9 ). The previously selected
area of the transverse colon and the terminal ileum is divided
and the anastomosis is created according to surgeon’s preference in either side-to-side or end-to-side fashion with
staplers.
After inspecting the anastomosis intracorporeally, I do
not routinely close the mesenteric defect. Then the fascia is
Fig. 22.3 Instruments: 30-degree camera, energy device, bariatric
length, and atraumatic bowel grasper. Different lengths will help
decrease the extracorporeal collision
Fig. 22.4 ( a ) A vertical incision is made in the fascia large enough to accommodate the single-port trocar even in obese patients. ( b ) Diagram
indicating the orientation of the port to allow triangulation of the instruments with the gas line port toward the patient’s fee t
22 Single-Incision Laparoscopic Approaches to Colorectal Disease
253
Fig. 22.5 The ileocolic pedicle is elevated to allow tension to help
open the peritoneum underlying the ileocolic pedicle. This is extended
to the base of the mesentery
Fig. 22.7 Takedown of hepatic fl exure and the lateral attachments in a
superior-to-inferior fashion
Fig. 22.6 Right branch of the middle colic artery and vein. Notice that
division of the ileocolic pedicle decreases the visualization of the
duodenum
closed in either a running or fi gure-of-eight fashion
(Fig. 22.10 ).
Single-Port Left Colectomy
The indications for the SILS left colectomy are the same as
the open colectomy or laparoscopy. Advantages of the SILS
approach depend on the surgeon’s experience and the search
for alternative operative techniques as well as better cosmetic and highest patient satisfaction results [ 26 – 28 ]. Similar
to a right colectomy, there is not an absolute contraindication
for the use of single-port laparoscopy, as long as procedure
meets the safe surgery criteria. Also, if needed, an additional
trocar can be added for camera access or retraction.
Fig. 22.8 After complete mobilization and division of the mesentery
of the ileum, the cecum is grasped with a locking instrument to help
during extraction
Surgical Procedure
The patient’s preoperative evaluation is the same as previously described in this chapter including mechanical bowel
preparation and intravenous pre-op antibiotics. After induction of the anesthesia, the patient is placed in lithotomy position with arms tucked to the sides and protected. Special
attention is focused to secure the patient to the anesthesia
table to prevent falling or moving during extreme table position changes. The routine use of the left ureteral stent for left
colectomy may prevent any injury [ 29 ], though more likely
may allow recognition of any intraoperative injury, as well as
early identifi cation of the ureter itself to help expedite the
procedure.
254
V. George
Fig. 22.9 Extraction of the colon with a cecal tumor through the
wound protector. Notice the ileocolic pedicle seen at the tip of the
instrument
Fig. 22.10 Final incision after single-incision right colectomy
Port at the Umbilicus
The surgeon and the operative assistant are positioned on the
right side of the patient if the single-port trocar is placed in
the umbilicus. The surgeon may also need to stand between
the legs of the patient and the assistant on the right of the
patient when the alternative port placement of a suprapubic
location is used. This suprapubic port site hides the scar and
can also be used for colon specimen extraction. The suprapubic location is also over the rectal-sigmoid junction, allowing
for direct vision, division of the rectum, and performing the
anastomosis.
Fig. 22.11 The peritoneum is opened between the inferior mesenteric
vein and inferior mesenteric artery; the longer the incision, the better
the exposure of the retroperitoneum will be
An open technique is used to make a 3-cm abdominal wall
incision to accommodate the SILS port. After entering the
peritoneal cavity and achieving adequate insuffl ation, exploration of the abdominal cavity for adhesions and metastatic
disease should be performed if colon cancer is a preoperative
diagnosis. If the indication is cancer, then specifi c identifi cation of the location of the tumor should be the next step.
Ideally a previous, preoperative colonoscopy with intraluminal colon marking with ink identifi es anatomic location or, if
necessary, intraoperative colonoscopy with CO 2 to ensure the
location. Both colonoscopy techniques are superior to intraoperative manual palpation with instruments.
The patient is positioned in Trendelenburg, and the right
side of table is lower than the left. This uses gravity retraction to position the bowel on the right side of the abdomen.
Placement of the omentum on top/caudal to the transverse
colon allows for identifi cation of the transverse colon and
localization of the middle colic vessels and the inferior mesenteric vein (IMV) at the level of the ligament of Treitz.
After scoring the mesentery along the medial aspect of the
left colon from the inferior mesenteric artery (IMA) to the
IMV, the surgeon may use a medial-to-lateral dissection
approach with ureteral stents in place.
Surgeons may alternate between the next two steps. First,
with the SILS trocar in the umbilicus, the area between the
IMV and IMA can be easily accessed using a monopolar
scissor. The peritoneum is opened; the longer the incision,
the better the exposure of the retroperitoneum (Fig.
22.11 ).
The retroperitoneal dissection is started under the descending
mesocolon, which helps retraction by elevating the mesocolon with a sweeping movement up and down. This allows
the embryological plane to be identifi ed and bluntly separated. This dissection should be bloodless (Fig.
22.12 a,b).
22 Single-Incision Laparoscopic Approaches to Colorectal Disease
Fig. 22.12 Retroperitoneal dissection. Notice the elevation of the mesocolon with left arm and bloodless plane ( a ) before IMA division and ( b )
after IMA division
255
Fig. 22.13 Retroperitoneal dissection without division of the inferior
mesenteric vein. This dissection is lateral and superior, with identifi cation of the inferior border of the pancreas
With elevation of the IMV and continued dissection of the
retroperitoneum above Gerota’s fascia, you need to identify
the inferior border of the pancreas. Dissection continues all
the way to the lateral colon attachments with hand-over- hand
instrument exchanges (Fig.
22.13 ).
Caudal dissection is continued to visually encircle the
IMA and identify the left ureter. Once this is performed,
the dissection space around the IMA exposes the origin of the
artery and sweeps the nerves around the IMA-aorta junction to prevent injury to the sympathetic and parasympathetic nerve plexus. Division of the IMA can be done
according to the surgeon’s preference using an energy
device, stapler, or clip ligation (Fig. 22.14 ). Dissecting the
IMV without division facilitates the medial dissection of
the splenic fl exure and the lesser sac. Early division of the
IMV will allow the heavy, fl oppy mesentery to fall on top of
Fig. 22.14 Division of the IMA using an energy device. Notice the
in-line view and the triangulation with the crossover instruments
the camera and often create the need for an extra instrument
to retract the mesentery. The extended dissection of the retroperitoneum will make the dissection on the lateral left
colon attachments easier.
The next step involves opening the avascular area on top
of the pancreas to enter the lesser sac. Identifi cation of the
posterior wall of the stomach helps confi rm the correct location (Fig. 22.15 ). Continued use of the energy device helps
to divide the colon mesenteric attachments to the inferior
border of the pancreas until the left lateral attachment to the
abdominal wall is reached.
Attention is now turned to the lateral attachments of the
colon, starting with gentle retraction of the sigmoid medially.
This will expose the lateral attachments at the level of the
pelvic brim (Fig. 22.16a,b ). Using the monopolar scissors
will facilitate this step. After an opening is created in the