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SINGLE-INCISION LAPAROSCOPIC VERSUS CONVENTIONAL LAPAROSCOPIC RIGHT COLECTOMY: A META-ANALYSIS OF SHORT-TERM OUTCOMES
Boye Dong¹, Jiabao Lu¹, Yang Yang², Yixian Song², Wanglin Li^*1
1Department of Colorectal Surgery, Guangzhou First People’s Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China; ²Nanshan College, Guangzhou Medical University, Guangzhou, Guangdong, China

Background: Single-incision laparoscopic surgery has gained widespread attention because of its potential benefits such as smaller incisions and faster recovery. Many meta-analyses have compared single-incision laparoscopic surgery with conventional laparoscopic surgery for colorectal diseases, but only one (performed in 2013; including 9 studies, a total of 585 cases) focused on right colectomy. This updated meta-analysis, including more studies, was undertaken to compare single-incision laparoscopic right colectomy (SILRC) with conventional laparoscopic right colectomy (CLRC).
Methods: We searched PubMed, Embase, Web of Science and the Cochrane Library for studies compared SILRC with CLRC, and performed a meta-analysis. Egger's test was used to determine the presence of publication bias. The latest date that we done this search on was October 24, 2017.
Results: 17 studies (1 prospective study,16 retrospective studies) including a total of 1778 cases were identified. Age, gender, body mass index (BMI) and previous abdominal operation did not differ significantly. There were no significant differences in operative time, conversion, reoperation, perioperative complications, postoperative mortality and 30-days readmission. However, in studies including only malignant tumors, SILRC showed shorter operative time (weighted mean difference [WMD]: -28.72min; 95% confidence interval [CI], -43.63 to -13.80; p=0.0002; Egger's test: p=0.241) but higher conversion rate (odds ratio: 2.10; 95%CI, 1.13-3.89; p=0.02; Egger's test: p=0.235) than CLRC. Pathological outcomes were similar between the two groups, including lymph nodes harvested (WMD: 0.12; 95%CI, -1.58 to 1.83; p=0.89; Egger's test: p=0.261), proximal resection margin (WMD: -0.39cm; 95%CI, -1.10 to 0.32; p=0.28; Egger's test: p=0.086) and distal resection margin (WMD: 0.74cm; 95%CI, -1.09 to 2.58; p=0.43; Egger's test: p=0.171). Patients in SILRC group might benefit from less estimated blood loss (WMD: -15.67ml; 95%CI, -24.36 to -6.98; p=0.0004; Egger's test: p=0.635), less skin incisions (WMD: -1.56cm; 95%CI, -2.63 to -0.49; p=0.004; Egger's test: p=0.26) and shorter hospital stay (WMD: -0.73d; 95%CI, -1.04 to -0.41; p<0.00001; Egger's test: p=0.345).
Conclusion: SILRC offers a safe and efficient alternative to CLRC with less estimated blood loss, less skin incisions, and shorter hospital stay. Given the inherent limitations of included studies, future well-designed randomized controlled trials -- especially studies that focus on malignancy -- and long-term outcomes are awaited to confirm and update the findings.

Table 1: Characteristics of Included Studies

	Year	Country/Area	Type	Patients,n SILRC/CLRC	Indication	Matching	Quality score
Adair et al.	2010	United States	RP	17/17	i,ii,iii,viii	1,2,3,4	8
Waters et al.	2010	United States	R	16/27	i,iii,vi	1,2,3,4,7	7
Chen et al.	2011	Taiwan	RP	18/21	i,v	1,2,3,5,7	6
Papaconstantinou et al.	2011	United States	R	29/29	i,ii,iii	1,2,3,4,7	7
Lai et al.	2011	United Kingdom	RP	14/12	i,ii,vi	1,2,3,7	7
Curro et al.	2012	Italy	R	10/10	i	1,2,3,4,5,7	6
Egi et al.	2012	Japan	R	10/10	i,iv	1,2,3,4,8	6
Rijcken et al.	2012	Germany	R	20/20	ii	1,2,3,4,7	7
Chew et al.	2012	Singapore	R	40/104	i,iii,vi,vii	1,2,3,6,7	7
Velthuis et al.	2012	Netherlands	P	50/50	i,ii,iii,iv	1,2,3,4,7	8
Keshava et al.	2013	Australia	R	75/74	i,iv,vii	1,2,3	8
Rosati et al.	2013	Italy	R	50/50	i,iv	1,2,4	7
Yun et al.	2013	Korea	R	66/93	i	1,2,3,4,7,8	7
Park et al.	2015	Korea	R	35/29	i,iv	1,2,3,4,5,8	7
Chouillard et al.	2016	France, Kuwait, Lebanon, Italy	R	336/256	i	1,2,3,4,5,7	8
Suzuki et al.	2016	Japan	RP	35/35	i	1,2,3,4,7,8	7
Kim et al.	2017	Korea	R	40/80	i	1,2,3,4,6,7	7

SILRC=single-incision laparoscopic right colectomy. CLRC=conventional laparoscopic right colectomy. R=retrospective. P=prospective. RP=comparison between retrospective and prospective data collection. NA=data not available. Indication: i=malignancy; ii=Crohn's disease; iii=polyp; iv=adenoma; v=diverticulosis ; vi=carcinoid tumour; vii=inflammatory; viii=bascule. Matching: 1=age; 2=gender; 3=body mass index; 4=previous abdominal operation; 5=tumor size; 6=perioperative condition; 7=ASA(American society of anesthesiologists) score; 8=location of tumor.


Table 2: Results of Meta-analysis Comparing Single-incision Laparoscopic Right Colectomy (SILRC) Versus Conventional Laparoscopic Right Colectomy (CLRC)

	Studies,n	SILRC patients,n	CLRC patients,n	Total patients,n	OR/WMD [95%CI]	p value	Study heterogeneity
							Chi2	df	I2	p-value
Patient demographics
Age(year)	10	619	611	1230	-0.53 [-2.02, 0.96]	0.48	12.24	9	26%	0.2
Gender(male)	17	861	917	1778	0.85† [0.70, 1.03]	0.09	3.82	16	0%	1
Body mass index	8	559	551	1110	0.13 [-0.35, 0.61]	0.6	5.79	7	0%	0.56
Previous abdominal operation	14	754	810	1564	0.79† [0.62, 1.01]	0.06	5.33	12	0%	0.95
Operative outcomes
Operative time(min)
Malignancy	3	442	429	871	-28.72 [-43.63, -13.80]	0.0002	6.67	2	70%	0.04
Mix	6	157	226	383	-4.58 [-12.30, 3.13]	0.24	7.24	5	31%	0.2
Total	9	599	655	1254	-12.46 [-25.62, 0.69]	0.06	65.02	8	88%	<0.00001
Estimated blood loss(ml)	4	421	392	813	-15.67 [-24.36, -6.98]	0.0004	2.59	3	0%	0.46
Conversion
Malignancy	5	487	474	961	2.10† [1.13, 3.89]	0.02	5.13	3	42%	0.16
Mix	12	374	443	817	0.95† [0.47, 1.94]	0.9	8.2	8	2%	0.41
Total	17	861	917	1778	1.51† [0.96, 2.38]	0.08	16.11	12	26%	0.19
Conversion to open laparotomy	15	801	793	1594	0.61† [0.30, 1.26]	0.19	2.9	7	0%	0.89
Length of skin incisions(cm)	4	415	375	790	-1.56 [-2.63, -0.49]	0.004	145.63	3	98%	<0.00001
Pathological outcomes
Lymph nodes harvested	8	524	512	1036	0.12 [-1.58, 1.83]	0.89	12.25	7	43%	0.09
Proximal resection margin(cm)	4	476	457	933	-0.39 [-1.10, 0.32]	0.28	0.67	3	0%	0.88
Distal resection margin(cm)	4	476	457	933	0.74 [-1.09, 2.58]	0.43	9.79	3	69%	0.02
Perioperative complications	17	861	917	1778	0.91 [0.72, 1.16]	0.47	13.86	14	0%	0.46
Reoperation	7	197	203	400	0.91† [0.32, 2.54]	0.86	1.32	3	0%	0.72
Postoperative mortality	12	419	528	947	0.90† [0.29, 2.79]	0.85	1.83	5	0%	0.87
Length of hospital stay(day)	7	524	522	1046	-0.73 [-1.04, -0.41]	<0.00001	7.69	6	22%	0.26
30-Days readmission	6	200	300	500	0.83† [0.32, 2.17]	0.71	2.45	4	0%	0.65

OR=odds ratio. WMD=weighted mean difference. df=degrees of freedom. Malignancy: studies including only malignant tumors. Mix: studies including several colonic diseases.† Odds ratio.

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