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SILS V SILS + 1: a Case Matched Comparison for Pelvic Colorectal Surgery
Reena Tahilramani*1, 2, Deborah Keller1, Juan R. Flores1, Sergio Ibarra1, Madhu Ragupathi1, Jean-Paul J. Lefave1, 2, T Bartley Pickron1, 2, Eric M. Haas1, 2
1Colorectal Surgical Associates, Houston, TX; 2Surgery, University of Texas Medical School at Houston, Houston, TX
Background: Single-incision laparoscopic surgery is safe and feasible for benign and malignant colorectal diseases. The modality offers improved cosmesis, less tissue trauma, perioperative pain and narcotics use, port-site related complications, and, possibly, shorter length of stay. However, this approach has technical limitations when operating in the pelvis. To address these limitations, we developed an innovative approach using a single Pfannenstiel incision for pelvis access with one additional umbilical port. Our goal was to compare outcomes for Single Incision Laparoscopic Surgery versus Single Incision Laparoscopic Surgery with one additional port in a case matched series of pelvic colorectal surgery.
Methods: Review of a prospectively maintained database identified patients who underwent an elective anterior rectosigmoidectomy (AR) or low anterior resection (LAR) through a reduced port laparoscopic approach from 2009-2014. Cases were stratified by approach: SILS versus SILS with one additional port (SILS+1), then matched 1:2 on age, gender, body mass index (BMI), and comorbidity. Demographic, perioperative, and postoperative outcome variables were evaluated. The main outcome measures were operative time, conversion rate, length of stay, complication, morbidity, and mortality rates.
Results: 132 reduced port AR/LAR patients were evaluated- 44 SILS and 88 SILS+1. The groups were similar in age, gender, BMI, and ASA class. The primary diagnosis in both cohorts was diverticulitis (90.9% SILS, 87.5% SILS+1), and main procedure performed an anterior rectosigmoidectomy (86.4% SILS, 88.2% SILS+1). Significantly more SILS+1 patients had previous abdominal surgery (p=0.01). The operative time was significantly shorter in SILS+1 (mean 166.6 [SD 48.4] vs. 178.0 [SD70.0], p=0.03). The conversion rate to multiport or open surgery was also significantly lower with SILS + 1 compared to SILS (1.1% vs. 11.4%, p=0.02). Postoperatively, the length of stay across the groups was similar. SILS trended towards higher complication and readmission rates (NS). There were no unplanned reoperations or mortality in either group.
Conclusions: SILS+1 facilitates pelvic surgery, with shorter operative times and lower conversion rates. The additional port allowed greater visualization and mobility, lowering the length of stay, readmission and complication rates. While greater experience and controlled trials are needed, SILS+1 may be the ideal approach for minimally invasive pelvic colorectal surgery.
Case Matched Pelvic Series
| Value | SILS (n=44) | SILS+1(n=88) | p-Value | | Diagnosis (n, %) | | Diverticulitis | 40 (90.9%) | 77 (87.5%) | | | Rectal Cancer | 4 (9.1%) | 11 (12.5%) | | | Procedure (n, %) | | Anterior Rectosigmoidectomy | 38 (86.4%) | 78 (88.6%) | | | Low Anterior Resection | 6 (13.6%) | 10 (11.4%) | | | Gender (n, %) | 1.00 | | Female | 22 (50%) | 44 (50%) | | | Male | 22 (50%) | 44 (50%) | | | Mean Age (years, SD) | 56.14 (12.83) | 57.16 (10.98) | 0.63 | | Mean Body Mass Index (kg/m2, SD) | 26.57 (4.36) | 27.63(4.50) | 0.42 | | Median ASA Class (Range) | 2 (Range 2-3) | 2 (Range 2-4) | 0.46 | | Previous Abdominal Surgery? (n, %) | 25 (56.8%) | 62 (70.5%) | 0.01* | | Mean Operative Time (min, SD) | 178.0 (70.0) | 166.6 (48.4) | 0.05* | | Conversion Rate (n, %) | 5 (11.4%) | 1 (1.1%) | 0.02* | | Intraoperative Complications (n, %) | 1 (2.3%) | 1 (1.1%) | 1.00 | | Mean Length of Stay (days, SD) | 3.45 (1.00) | 3.56 (1.49) | 0.45 | | Complications? (n, %) | 2 (4.5%) | - | 0.11 | | Readmission (30 day) (n, %) | 1 (2.3%) | - | 0.33 |
ASA- American Society of Anesthesiologists; SD- Standard Deviation; 30-day Outcomes Analyzed; *- Statistically Significant
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