One incision, multiple benefits

The last two decades have seen a steady, if cautious, progression from open colorectal surgery to less invasive approaches for both benign and malignant disease. Although technically more challenging, conventional laparoscopy has been shown to provide many patient benefits, including less postoperative pain, decreased narcotic use, shorter hospital stays and faster recovery. As important, several multicenter prospective trials demonstrated no difference in three-year recurrence or survival rates between open and laparoscopic approaches.

Over the last few years, increased experience with laparoscopy has led to the development of even less invasive techniques, most notably single-incision procedures, which use one port at either the umbilicus or the ileostomy site. Preliminary reports show that this approach offers further patient advantages, including improved cosmetic results.

Procedures and outcomes

In June 2009, Tonia M. Young-Fadok, M.D., chair of the Division of Colon and Rectal Surgery at Mayo Clinic in Arizona, performed one of the first single-incision total colectomies in the United States and the first at Mayo Clinic. The procedure involved removing the right, transverse, descending and sigmoid colon through a 1.2-inch (3-centimeter) incision around the umbilicus. The patient, a 32-year-old Arizona woman with attenuated familial adenomatous polyposis, recovered quickly without complications. She had one small umbilical scar.

Two months later, Dr. Young-Fadok performed one of the first single-incision proctocolectomy and ileal pouch-anal anastomosis procedures, removing the colon through the temporary ileostomy site. The patient was another young woman with familial adenomatous polyposis.

Since then, Dr. Young-Fadok has performed 60 single-port laparoscopic colectomies. Analysis of the data, now under way, shows that the procedure is associated with a reduction in pain and length of stay.

"We're seeing a statistically different hospital stay — about one day less than with laparoscopic-assisted colectomy," she says. "Other comparison studies have reported no difference in length of stay, but did find similar mean operating times. Although we haven't evaluated this fully yet, it's likely we save time closing incisions."

Maximum pain scores on a 10-point visual analog scale were significantly lower for single-incision colectomy on postoperative day one. Pain at the time of discharge was comparable with standard laparoscopy.

Other benefits are also similar to those seen with conventional laparoscopy, including a reduction in wound infections and intraabdominal adhesions. "Adhesions are one of the main causes of small bowel obstruction, so we expect to see a decrease in small bowel obstruction," she says.

Dr. Young-Fadok views single-incision colectomy as the next step in the effort to minimize physiologic trauma. But she cautions that the technique adds a significant layer of complexity and increases the already steep surgical learning curve. "It's important that this technology is evaluated by an experienced team, in a prospective manner, so that patients don't suffer complications from surgeons adopting single-port procedures without sufficient experience."

In the future: Enhanced recovery protocols

Despite its apparent advantages, Dr. Young-Fadok doesn't see single-access surgery as an endpoint. She notes the documented benefits of the enhanced recovery programs currently used in some European institutions and recently introduced in a few select centers in the United States, including Mayo Clinic.

Enhanced recovery is a combination of pre-, intra- and postoperative interventions proven to reduce surgical stress and organ dysfunction. Protocols include early eating, drinking and ambulation, preemptive pain management, and limited use of opioids and IV fluids.

A number of European studies have demonstrated that enhanced recovery programs result in fewer complications, reduced length of stay and significantly fewer readmissions — even in open procedures.

"So far, no one has combined all the enhanced recovery protocols with laparoscopic colectomy," Dr. Young-Fadok says. "That is our next goal."