Int J Gastrointest Interv 2019; 8(1): 35-40  https://doi.org/10.18528/ijgii180038
Suprapubic single-incision laparoscopic right colectomy with complete mesocolic excision, lateral-to-medial approach and intracorporeal anastomoses
Giovanni Dapri* , Kelly Ann Bobb, Ernesto Jesús Barzola Navarro, Angel Arabadzhiev
Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium
*Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, 322, Rue Haute, 1000 Brussels, Belgium. E-mail address:giovanni@dapri.net(G. Dapri). ORCID: https://orcid.org/0000-0001-7982-283X
Received: October 5, 2018; Revised: November 25, 2018; Accepted: November 25, 2018; Published online: January 31, 2019.
© Society of Gastrointestinal Intervention. All rights reserved.

cc This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Background

Single-incision laparoscopic right colectomy (SILRC) has been reported in 2008, and since that time an increased number of reports appeared in literature. Currently, it remains popular between the centers with achieved experience. Adoption of suprapubic access, instead of umbilical or other access-sites, allows to enhance the final cosmetic outcomes, together with the realization of complete mesocolic excision (CME) and intra-corporeal anastomosis (ICA).

Methods

Between January 2016 and August 2018, 20 patients (10 females, 10 males) were submitted to suprapubic single-incision laparoscopic right colectomy (SSILRC) for adenocarcinoma. Mean age was 74 years and mean body mass index was 24 kg/m2. Sixteen patients have already been submitted to open abdominal surgery.

Results

Mean total operative time was 233.9 minutes and mean laparoscopic time was 199.4 minutes. Mean time for ICA was 34 minutes. Mean blood loss was 279.5 mL. One additional 5-mm trocar was necessary in 1 patient (5.0%). Mean length scar was 60.5 cm. Mean hospital stay was 7.8 days. A minimal use of pain killers was registered postoperatively. Mean number of lymph nodes retrieved was 24.5. Early complications were one suprapubic abscess and one suprapubic hematoma. No late complications, including suprapubic incisional hernia, were achieved.

Conclusion

Since the specimen has to be removed from the abdomen after conventional laparoscopic right colectomy, the suprapubic access can be an option. SSILRC allows to join the surgical procedure, the specimen’s removal and the enhanced cosmetic results through the same access. Other advantages are the CME, the ICA, the reduced postoperative pain, and the decreased incisional hernia’s rate.

Keywords: Complete mesocolic excision, Intracorporeal anastomosis, Right colectomy, Single-incision
Introduction

Conventional laparoscopic right colectomy (CLRC) has been described since 1990,1,2 and single-incision laparoscopic right colectomy (SILRC) has been reported in 2008.3 Since that time, an increased experience to perform single-incision laparoscopy appeared in literature. Currently, this technique remains popular between the centers with achieved experience in single-incision and reduced port laparoscopic surgery (RPLS),4 whereas it remains an option for selected patients in other centers. Adoption of suprapubic access, instead of umbilical or other access-sites, allows to enhance the final cosmetic outcomes because the access-site remains under the bikini line.5 Hence suprapubic single-incision laparoscopic right colectomy (SSILRC) can be performed6 and it allows to add advantages like:

  • - the removal of small, medium and large specimens

  • - the realization of a complete mesocolic excision (CME) with good exposure, because the surgeon operates between the patient’s legs, and along the axis of the superior mesenteric vein (SMV) and superior mesenteric artery (SMA)

  • - to perform an easier intracorporeal anastomosis (ICA), under visual control and without tension of the mesocolon/mesentery

  • - the reduced postoperative pain

  • - the reduced incisional hernia’s rate.

Methods

Between January 2016 and August 2018, 20 patients (10 females, 10 males) were submitted to SSILRC. Informed consent was obtained from all the patients. Mean age was 74 years (range, 45–94 years). Mean body mass index was 24 kg/m2 (range, 18.3–30.9 kg/m2). Seven patients presented a caecum adenocarcinoma, 8 patients a right colic adenocarcinoma and 5 patients a hepatic flexure adenocarcinoma. In the previous history, 16 patients have already been submitted to open abdominal surgery, like appendectomy (9), inguinal hernia repair (3), prostatectomy (4), and gynecologic surgery (2). Preoperative work-up included hematological and biochemical laboratory evaluations, tumor markers, colonoscopy with biopsy, and thoraco-abdominal computed tomography scan. No patient received preoperative colon preparation. A urinary catheter was inserted after general anesthesia and removed in the first postoperative day. One gram of paracetamol was added at the end of the procedure. Postoperatively, 1 g of paracetamol was administered to patients who reported a World Health Organization visual analogue scale (VAS) pain score between 1 and 3. Patients with a VAS score between 4 and 8 received 100 mg of tramadol, and those with a VAS score between 9 and 10 received 1 mg of piritamide. Deep-vein thrombosis prophylaxis was given to all patients. Upon discharge, 1 g paracetamol or 50 mg tramadol perorally were prescribed only if needed. Office visits were scheduled at 10 days, 1 and 3, 6, 12 months after the procedure, and later after 6 and 12 months.

Total operative time was calculated between the skin incision and the end of the rectus abdominis muscle fascia closure. Laparoscopic time was calculated between the beginning of the instruments’ movements and the specimen’s extraction after the end of the ileocolic ICA. The ICA was fashioned following different methods: completely handsewn side-to-side, end-to-end, side-to-end, end-to-side, and linear mechanical side-to-side, side-to-end.

Technique

The patient is placed in a supine position, with the arms alongside the body and the legs apart. The surgeon stands between the patient’s legs, and the camera assistant to the patient’s left. The scrub-nurse stands to the patient’s left and to the camera assistant’s right. The video monitor is placed in front of the surgeon and camera assistant (Fig. 1). A 3.5-cm transverse skin incision is made in the midline, 1 cm above the pubic symphysis (Fig. 2). The underlying fascia is divided in a transverse fashion for 1.5 cm, until to expose the rectus abdominis muscle. A purse-string suture using polydioxanon (PDS) 1 is placed in the fascia. The peritoneal sheet is entered through the midline by a 1 cm incision, and a new purse-string suture using polyglactin (Vicryl) 1 is placed. An 11-mm trocar (or a 12-mm non-reusable trocar) is inserted into the both purse-string pursestring sutures for a 10-mm, 30° scope, and the pneumoperitoneum is created. A reusable DAPRI 6-mm flexible trocar (Karl Storz-Endoskope, Tuttlingen, Germany) (Fig. 3) is inserted at 9 o’clock position in the respect of the patient’s head, outside the purse-string sutures, for the insertion of the DAPRI reusable bicurved grasping forceps (Karl Storz-Endoskope) (Fig. 4A). Another reusable DAPRI 6-mm flexible trocar is inserted at 3 o’clock position in the respect of the patient’s head, outside the purse-string sutures, for the insertion of the other DAPRI reusable monocurved instruments, like the grasping forceps (Fig. 4B), the coagulating hook (Fig. 4C), the bipolar forceps and scissors (Fig. 4D, 4E), the dissecting forceps (Fig. 4F), the scissors (Fig. 4G), the needle holder (Fig. 4H), and the straight 5-mm clip applier. The abdominal cavity is explorated to rule out the presence of peritoneal metastases, superficial hepatic lesions and free ascites. The operative room table is placed initially in a moderate Trendelenburg position with left-sided tilt. The caecum and the last bowel loop are identified, moving some bowel loops to the right quadrants of the abdomen with the bicurved grasping forceps and the monocurved grasping forceps. The last bowel loop is grasped by the bicurved grasping forceps, and the mesentery is separated from the peritoneal sheet using the monocurved coagulating hook. The ileo-caecal valve is freed from the parietal peritoneal sheet, and the right mesocolon is dissected using a lateral-to-medial approach. This dissection is carried superiorly, respecting the Gerota’s fascia, until the 2nd and the 3rd portion of the duodenum are idientified. For the mesocolic dissection, the operative room table is positioned without any Trendelenburg and tilt. Surgeon is able to create optimal triangulation, which allows to work without crossing hands or clashing instruments’ tips (Fig. 5). The ileo-cecal vessels are exposed at their root centrally and dissected using the monocurved dissecting forceps. These vessels are individually clipped at their root, using a 5-mm straight clip applier, and divided with the monocurved scissors. As well, the right colic vessels (if present), and the right branch of the middle colic vessels are individually clipped at their root centrally, and divided (Fig. 6). For the hepatic flexure tumors, the right gastro-epiploic vessels followed by the dissection of the greater omentum within 10 cm of the tumor is further performed. For the mobilization of the hepatic flexure, the patient is placed in a reversed Trendelenburg position with left-sided tilt. The hepatic flexure attachments are dissected using a lateral-to-medial approach. The portion of the omentum attached to the proximal transverse colon is also dissected. For the anastomosis, the operative room table is placed in Trendelenburg position with right-sided tilt. The 11-mm trocar is replaced by a reusable 13-mm trocar (if the 12-mm non-reusable trocar is inserted at the beginning, this replacement is not needed), in order to accomodate an articulating linear stapler. The 10-mm scope is switched into a 5-mm, 30°, long scope, which is inserted into the 6-mm flexible trocar at 3 o’clock position (Fig. 7A). The small bowel is divided by a firing of linear stapler, and the proximal transverse colon is divided by two firings of linear stapler (Fig. 7B).

Different types of ileocolic ICA can be performed.

  • Completely handsewn side-to-side (Fig. 8A), end-to-end (Fig. 8B), side-to-end (Fig. 8C), end-to-side (Fig. 8D): The 13-mm trocar is replaced by the 11-mm trocar, together with the changement of the scope into 10-mm. The extremity of the small bowel and transverse colon are placed close each other’s. A PDS 2/0 running suture (posterior wall of the anastomosis) with preformed knot at one extremity, is used to join together both viscera. Surgeon continues to work without conflict of the hands or instruments’ tips. A new PDS 2/0 running suture (anterior wall of the anastomosis), with preformed knot at one extremity, is started at the superior corner of the anastomosis. After have passed the first bite, both viscera are opened by the monocurved coagulating hook. Then, the posterior running suture is used to reinforce the inferior corner of the anastomosis, going for some bites on the anterior layer. Finally, the two running sutures are joined together at the inferior part of the anterior layer of the anastomosis.

  • Linear mechanical side-to-side (Fig. 8E), side-to-end (Fig. 8F): The ileum and the transverse colon are opened for one cm by the monocurved coagulating hook, and the anastomosis is fashioned following the different orientation of both viscera. An articulating linear stapler is inserted and fired. The 13-mm trocar is replaced by the 11-mm trocar, together with the scope changement into 10-mm. The enterocolotomy is closed by two converging PDS 2/0 running sutures (with preformed knot at one extremity).

At the end of the ileocolic ICA, the mesenteric window (formed by the right mesocolon and the small bowel mesentery) is closed by a PDS 2/0 running suture (a preformed knot at its extremity is useful to gain operative time).

The operative room table is positioned without any Trendelenburg and tilt. No drain is left in the abdominal cavity. The specimen is kept by the bicurved grasping forceps, which is retrieved following its curves at 45° in the respect of the abdominal wall. Both purse-string sutures are retrieved together with the three trocars. The three trocars openings on the rectus abdominis muscle fascia are joined together, and a plastic wall protection is inserted into the peritoneal cavity at the access-site. The specimen is removed through the suprapubic incision (Fig. 9). This latter is enlarged considering the specimen’s size. The peritoneal sheet and the rectus abdominis muscle fascia are meticulously and separately closed by converging absorbable running sutures (Fig. 10). The cutaneous scar is joined by intradermic sutures.

Results

Mean total operative time was 233.9 minutes (range, 149–307 minutes). Mean laparoscopic time was 199.4 minutes (range, 120–265 minutes). Mean time for ICA was 34 minutes (range, 20–51 minutes). A handsewn anastomosis was performed in 17 patients and a linear mechanical in 3 patients. Between the handsewn anastomoses, 5 side-to-side, 6 end-to-end, 4 side-to-end, and 2 end-to-side have been created; between the linear mechanical anastomoses, 2 side-to-side, and 1 side-to-end have been performed. Mean blood loss was 279.5 mL (range, 10–1,200 mL).

Perioperative complications were a difficult access opening in 2 patients, and an intraabdominal bleeding in 4 patients.

One additional 5-mm trocar was necessary to be inserted in 1 patient (5.0%) to obtain a good exposure due to visceral obesity.

Mean length scar was 60.5 cm (range, 40–100 cm). In 3 patients, the initial scar length had to be enlarged at the time of the specimen’s extraction due to the size of the tumor.

Mean hospital stay was 7.8 days (range, 4–16 days). Postoperative complications were registered in 5 patients: an intraabdominal collection in 2 patients, an anastomotic fistula in 1 patient, and an intestinal ileus in 2 patients.

Mean VAS score at 6 hours was 5.9, at 18 hours was 4.7, at 30 and 42 hours was 2.4, at 54 and 66 hours was 2.1, and at 78 hours was 2.2. Postoperatively, only 6 patients required pain killers; two for 1 day, one for 2 days, one for 3 days, one for 5 days and one for 7 days.

TNM stage is reported in the Table 1 and a mean number of 24.5 (range, 12–48) lymph nodes retrieved were registered.

At clinical consultation of 10 days, one patient presented a suprapubic abscess and another one a suprapubic hematoma. At successive clinical consultations no late complications, including suprapubic incisional hernia, were achieved.

Discussion

The rationale of SSILRC finds its origin on the necessity to remove the specimen from the abdomen at the end of the CLRC. Different options can be adopted for specimen’s removal at the end of CLRC: (1) enlargement of one of the trocars used, (2) new access-site in the abdomen (like the suprapubic area), and (3) opening of the vagina in centers with experience in natural orifice transluminal endoscopic surgery.

The main difference between SSILRC and transumbilical SILRC is the enhanced cosmetic outcomes because the suprapubic scar remains under the bikini line and it can be cosmetically acceptable. It allows the extraction of the different specimen’s size and, if the scar has to be enlarged like it was in 3 patients reported, the cosmetics are not compromised.

Since the surgeon operates between the patient’s legs and in the axis of the SMV and SMA, CME can be easier performed than with the surgeon’s positioning on the left side of the patient. The suprapubic access allows a better exposure of the SMV and SMA in their posterior side, increasing the CME feasibility. In this series a 24.5 mean number of lymph nodes has been achieved. This data confirms the greater number of total lymph nodes’ removal compared with the non-CME.7

The technique reported shows the feasibility of different ileocolic ICA, which can be adopted considering the natural positioning of the viscera after sectioning or the clinical patient’s conditions, like the intestinal occlusion due to a tumor. In this latter situation, the completely handsewn end-to-end anastomosis is preferred because the small bowel is dilated and presents a similar diameter to the transverse colon. Then, ICA are performed under visual control, with the visceral opening control and with the intraluminal bleeding prevention. Furthermore, differently from the extracorporeal anastomosis, any tension of the mesocolon and the mesentery appears present duirng ICA.

The transverse incision is significantly less postoperative pain than the vertical incision,8,9 and the patients treated by SSILRC confirm this data in the postoperative course and after the discharge from the hospital. Transumbilical SILRC achieves more use of pain killers because, at the time of the specimen’s retrieval, the access-site has to be enlarged on the midline, increasing the postoperative pain like it appears after a median laparotomy.10

The original idea to perform the cesarean section through a transverse opening instead of a median incision to reduce the incidence of postoperative incisional hernia11 is confirmed in this study where the suprapubic access is adopted.

On the other hand, some important aspects not in favor of this technique have to be considered. The surgeon’s learning curve is one of the crucial point which influences the duration of the procedure and the rate of conversion to CLRC or to open surgery. It is not exactly clear how many procedures by single-incision have to be performed by the surgeon before to be familiar with this technique, but surely the cumulative experience in SILRC and overall the general experience in CLRC are fundamental. As well, in front of a perioperative complication, the necessity to insert other trocars or to convert to open surgery depends from the surgeon’s experience performing SILRC and in general CLRC. In the experience reported here, there was no necessity to insert a trocar to control perioperative complications, but in one patient a 5-mm trocar was required to obtain a correct operative field’s exposure due to the presence of a massive visceral obesity. Hence, the patients’ selection, especially at the beginning of the experience, is needed to allow the surgeon to finish the procedure without addition of any supplementary trocar or conversion to open surgery.12

In the experience reported, 8 patients were submitted to a previous surgery at the suprapubic area (inguinal hernia repair, prostatectomy, gynecologic surgery). This aspect can complicate the opening of the peritoneal cavity to insert the first trocar and to create the pneumoperitoneum, like it appeared in one of the patients treated. Moreover, the urinary catheter has to be inserted in all SSILRCs at the time of the patient’s positioning on the operative table, to avoid iatrogenic bladder perforation.

Finally, since there are no previewed instruments in the abdomen for the assistants, any help can be provided to obtain a good exposure and therefore some tricks have to be discovered, like the continue change of the operative table positioning, the placement of temporary percutaneous sutures or the insertion in the abdomen of some devices to retract the organs.

In conclusion, since the specimen has to be removed from the abdomen after CLRC, the suprapubic access can be considered an option. SSILRC allows to join the realization of the surgical procedure, the specimen’s removal and the enhanced cosmetic results through the same access. Other considerable advantages of the reported technique are the CME, the ICA, the reduced postoperative pain, and the decreased incisional hernia’s rate.

Conflicts of Interest

G.D. keeps the patent license for the reusable flexible trocar and reusable curved instruments manufactured by Karl Storz-Endoskope, Tuttlingen, Germany. That had no influence in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The other authors have nothing to disclose.

Acknowledgments

The author keeps the copyright of these figures: Figs. 1, 2, 5, 710.

Figures
Fig. 1. Patient’s and team’s positioning.
Fig. 2. Suprapubic incision and access-site.
Fig. 3. Reusable flexible trocar according to DAPRI (Karl Storz-Endoskope).
Fig. 4. Reusable curved instruments according to DAPRI (Karl Storz-Endoskope): bicurved grasping forceps (A), monocurved grasping forceps (B), monocurved coagulating hook (C), monocurved bipolar forceps and scissors (D, E), monocurved dissecting forceps (F), monocurved scissors (G), monocurved needle holder (H).
Fig. 5. Surgeon’s ergonomy and optimal intracorporeal triangulation.
Fig. 6. Complete mesocolic excision with denudation of the superior mesenteric artery and vein.
Fig. 7. Insertion of 5-mm long scope and articulating linear stapler, for small bowel (A) and transverse colon (B) sectioning.
Fig. 8. Ileocolic intracorporeal anastomoses: completely handsewn side-to-side (A), completely handsewn end-to-end (B), completely handsewn side-to-end (C), completely handsewn end-to-side (D), linear mechanical side-to-side (E), linear mechanical side-to-end (F).
Fig. 9. Specimen’s removal through the suprapubic access.
Fig. 10. Final suprapubic scar.
Tables

Table 1

TNM Stage and Number of Nodes Retrieved

TNM stage No. of nodes (positive/total)
pT3N0 0/12
pT3N2b 15/34
pT4aN2b 8/44
pT3N2b 19/25
pT1N0 0/21
pTisN0 0/26
pT3N1a 1/23
pT3N0 0/22
pT3N1b 3/48
pT3N0 0/29
pT3N1b 2/28
pT3N0 0/16
pTisN0 0/13
pT3N2a 6/33
pT3N2b 7/27
pT3N0 0/27
pT3N0 0/26
pT3N0 0/13
pTisN0 0/12
pTisN0 0/12
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