Use of a multi-instrument access device in abdominoperineal resections

Abstract

BACKGROUND:

Laparoscopic colorectal surgery results in less post-operative pain, faster recovery, shorter length of stay and reduced morbidity compared with open procedures. Less or minimally invasive techniques have been developed to further minimise surgical trauma and to decrease the size and number of incisions. This study describes the safety and feasibility of using an umbilical multi-instrument access (MIA) port (Olympus TriPort+) device with the placement of just one 12-mm suprapubic trocar in laparoscopic (double-port) abdominoperineal resections (APRs) in rectal cancer patients.

PATIENTS AND METHODS:

The study included 20 patients undergoing double-port APRs for rectal cancer between June 2011 and August 2013. Preoperative data were gathered in a prospective database, and post-operative data were collected retrospectively.

RESULTS:

The 20 patients (30% female) had a median age of 67 years (range 46-80 years), and their median body mass index (BMI) was 26 kg/m² (range 20-31 kg/m²). An additional third trocar was placed in 2 patients. No laparoscopic procedures were converted to an open procedure. Median operating time was 195 min (range 115-306 min). A radical resection (R0 resection) was achieved in all patients, with a median of 14 lymph nodes harvested. Median length of stay was 8 days (range 5-43 days).

CONCLUSION:

Laparoscopic APR using a MIA trocar is a feasible and safe procedure. A MIA port might be of benefit as an extra option in the toolbox of the laparoscopic surgeon to further minimise surgical trauma.

INTRODUCTION

Colorectal cancer is one of the leading causes of cancer-related deaths in the world, recently showing an increase in incidence due to the increase and the aging of the world population.[1,2] The only curative treatment for rectal cancer is a curative resection of the segment bearing the malignant tumour and its mesorectum. In most institutions, neoadjuvant radiotherapy (RT) has become the standard protocol for most patients with rectal cancer.[3,4] The outcomes for oncologic resection margins, number of lymph nodes harvested and the long-term outcomes are similar for laparoscopic and conventional oncologic resections of colorectal cancer.[5,6,7,8]

Laparoscopic resections of colorectal cancer have several benefits compared with conventional open surgical treatment, including less post-operative pain, faster recovery, shorter hospital stay and reduced morbidity.[7,9,10,11,12,13] Further elaborations of this minimally invasive technique have been developed to further minimise surgical trauma. Less surgical trauma results in less post-operative pain, faster recovery and a better cosmetic result.

Single-port laparoscopy (SPL) and the use of multi-instrument access (MIA) devices seem promising innovations in minimally invasive surgery. Nowadays, the single-port technique is used not only in benign disease but also in malignant resections.[14] In this study we describe the results of the first 20 patients who underwent an abdominoperineal resection (APR) in which a MIA port was used.

PATIENTS AND METHODS

Patient selection

SPL and the use of MIA devices were introduced in 2010 in the Jeroen Bosch Hospital. The study included patients with a pathologist-confirmed malignant tumour undergoing an APR procedure using a MIA device between June 2011 and August 2013. Patient characteristics were gathered in a prospective database, and surgical outcomes and post-operative results were collected retrospectively from medical files.

Patient workup

After rectal malignancy was diagnosed, all patients were discussed by a multidisciplinary team that included surgeons, oncologists, gastrointestinal specialists, radiologists, radiotherapists and pathologists. All patients were treated according to Dutch evidence-based guidelines for colorectal cancer treatment. These guidelines prescribe the routine preoperative application of RT for all stages except cT1 N0, regardless of the distance between the tumour and the anal verge. Short-course radiotherapy (SCRT) of five sessions at 5 Gy with a short interval to surgery is the standard preoperative treatment. In case of cT4 tumours, an expected positive circumferential resection margin, or cN2 tumour, long-course chemoradiotherapy (CRT) is preferred.[4] In our study, after consultation, each patient and the attending surgeon together chose the use of the MIA port in the APR procedure. The patients gave verbal informed consent, knowing the risks of the procedure and about the use of this new technique. Informed consent was noted in the medical report.

Surgical technique

All patients received a fluid diet the day before surgery and were administered three doses of 15 mL of Prunacolon (Takeda Nederland bv, s-Hertogenbosch, the Netherlands). Two experienced laparoscopic surgeons (at least 50 laparoscopic APR procedures and more than 30 benign SPL procedures) and a dedicated operating team operated on all patients. The patients received an epidural catheter for analgesia before entering the operating theater. Prophylactic intravenous antibiotics, consisting of cefuroxime (Zinacef, GlaxoSmithKline, s-Hertogenbosch, the Netherlands; 1500 mg) and metronidazole (Flagyl, Baxter, s-Hertogenbosch, the Netherlands; 500 mg), were administered. Patients were placed under general anaesthesia for the operation. The patients were positioned on their back for the abdominal phase of the operation and were turned around on to the abdomen for the perineal phase (Miles position).

The TriPort+ (Olympus Corporation, Shinjuku Monolith, 3-1 Nishi-Shinjuku 2-chome, Shinjuku-ku, Tokyo 163-0914, Japan) was introduced transumbilically, and a 14 mmHg pneumoperitoneum was created. After inspection of the abdomen, a standard second 12-mm trocar was placed suprapubically to optimise the procedure in the pelvis. This second trocar was routinely placed in all APR procedures.

The surgical procedure is otherwise identical to the standard laparoscopic APR performed with multiple incisions. Briefly, the lateral fold of the descending colon is pushed downwards and the splenic flexure is only mobilised on indication. The complete total mesorectal excision is performed with sharp dissection by diathermia starting posteriorly and dissecting ventrally of the rectum until, ideally, the sphincter complex is reached. The lateral folds of the rectum are taken down using sealing devices. In contrast to the placing of the trocars, the perineal phase does not differ between the double-port and conventional laparoscopic procedures. The specimen is removed through the perineum after a stapling device is used to transect the rectosigmoid.

A colostoma is placed in the lower left quadrant unless this is technically not possible. The transumbilical and suprapubic incisions are closed with resorbable sutures.

Post-operative care and follow-up

The patients were treated according to an enhanced recovery-after-surgery protocol post-operatively.[15,16,17] All patients received standardised analgesics by an epidural catheter with bupivacaine, with or without sufentanil, and received paracetamol (1000 mg, 4 times daily) and opiates, if necessary. They received anti-emetics (metoclopramide) and laxatives (lactulose or Movicolon, Norgine, Harefield, UK). Patients were motivated to eat, drink and mobilise as soon as possible.

The patients were discharged according the enhanced recovery-after-surgery protocol.[17] All patients were seen in the outpatient clinic 2 weeks after discharge by the first attending surgeon. After this post-operative visit, patients were routinely seen as specified by the Dutch guidelines for rectal cancer.

Outcome measures

Preoperative data included age, sex, body mass index (BMI), comorbidity, American Society of Anesthesiologists (ASA) Physical Status Classification, TNM stadium and distance to the anal verge. Perioperative data included operating time (defined as time from first skin incision to completion of closure), need for extra ports, conversion to open procedure, and perioperative complications. Post-operative data included the following: Hospital length of stay, including the day before the operation and the day of operation; complications (during hospitalisation); reoperation; admission to the intensive care unit (ICU); readmission to the hospital (within 30 days after discharge); and mortality rate.

Statistical analysis

All data were collected in a computerised database and statistically analysed using SPSS 19.0 software (IBM Corp, Armonk, NY, USA). Means, medians and percentages were calculated using frequency calculations.

RESULTS

Patient characteristics

Between June 2011 and August 2013, 20 patients with a malignant tumour in the rectum underwent an APR using a MIA device in the Jeroen Bosch Medical Center. In 17 patients, a carcinoma was histologically proven preoperatively. In 3 patients, no carcinoma was found in the biopsy specimens, but dysplasia was seen and a malignant tumour was highly suspected. The patients had a median age of 67 years (range 46-80 years), 6 patients (30%) were women, and the median BMI was 26 kg/m² (range 20-31 kg/m²). Six patients (30%) were classified as ASA 1 and 14 (70%) as ASA 2. All patients underwent neoadjuvant RT, comprising SCRT in 9 patients or CRT in 11 patients. Two patients were preoperatively diagnosed with liver metastases and were planned for metastasectomy after recovery from the APR procedure. The median distance of the tumour to the anal verge was 4 cm (range 1-10 cm). Baseline characteristics are reported in Table 1, including preoperative TNM stadia.

Table 1.

Patient characteristics

Perioperative results

The median operating time was 195 min (range 115-306 MIN). One (5%) perioperative surgical complication occurred, involving an injury to the urethra caused by adhesions between the tumour and the prostate. A urologist repaired the injury during the same session through the perineal incision, and the patient was treated with a catheter for 3 weeks post-operatively.

The TriPort was placed transumbilically in all patients except for 1 patient, who was being planned for a low anterior resection and in whom the the TriPort was placed at the site of the stoma. In this patient, however, the tumour was preoperatively found too distal, and an APR was performed. An extra (third) trocar was placed in 2 patients (10%). No APRs were converted to open procedure [Table 2].

Table 2.

Perioperative data

Post-operative results

Three patients (15.8%) experienced a post-operative complication (Clavien-Dindo grades 1-2: n = 2; Clavien-Dindo grade 3: n = 1). One patient (5.3%) developed a perineal wound infection and severe pneumonia with respiratory insufficiency, leading to admission to the ICU for 19 days. The patient was intubated and treated with antibiotics; a tracheostomy tube was placed later because of a bilateral paralysis of the vocal cords and periods of apnoea. The patient was discharged from the hospital 43 days post-operatively. An ileus in a second patient was treated conservatively with lactulose, Colex Klysma (Tramedico bv, 's-Hertogenbosch, the Netherlands) and total parenteral nutrition. A third patient developed a genitourinary tract infection and pneumonia, which was treated with intravenous antibiotics and resolved quickly. The median hospital length of stay was 8 days (range 5-43 days). Two patients (10%) were readmitted to the hospital 16 days and 24 days after discharge: One because of a perineal wound infection and the other because of an ileus. The first patient was discharged 9 days after readmission. The second patient underwent a reoperation 25 days after his initial surgery because of an obstructive ileus. An adhesiolysis was performed, and 15 cm of the ileum was resected; an anastomosis was made. No 30-day mortality was seen. During a median follow-up of 14 months (range 2-33 months), no incisional hernias were seen; however, two parastomal hernias were reported [Table 3].

Table 3.

Post-operative data

Oncologic outcomes

A radical resection was achieved in all patients. In 3 patients (15%) with a pathologist-confirmed malignant tumour preoperatively, no residual malignant cells were found by pathology (complete response). In 12 patients, a circumferential resection margin of more than 10 mm was seen. All other resection margins were between 2 mm and 7 mm. No irradical resections were observed. The median number of harvested lymph nodes was 14 (range 3-22).

The pathologic outcomes of this study are presented in Table 4.

Table 4.

Pathologic outcome

DISCUSSION

This study demonstrates that the use of MIA port in APR with routine placement of a second trocar (double port) can be a safe and feasible procedure. No procedures were converted, and a radical resection was achieved in all patients.

The available literature places more emphasis on post-operative complications after laparoscopic APR and less on intraoperative complications. The data in this study correlate with reported data about laparoscopic APR procedures. Intraoperative complications and conversions were described in, respectively, 5.4% and 3.7% of 520 patients, of whom 190 were treated using laparoscopic APR.[18] Operating times varied between 202 min and 290 min for conventional laparoscopic APR.[18,19,20] Major complications (including reoperation) of 0-6.3% and minor complications of approximately 30% are reported.[18,19] Very few studies have been performed on single-port or double-port APR. Operating times between 139 min and 318 min are reported.[14,21,22] The authors of a retrospective analysis of 257 patients stated that single-port surgery is a safe procedure in colorectal cancer patients, although it has to be mentioned that only four of these 257 procedures were an APR procedure.[14]

Particularly in APR, the use of MIA ports and SPL could be especially valuable due to the fact that the specimen is removed through the perineal incision, whereas other colorectal procedures need an additional incision through the abdominal wall for specimen removal. Therefore, SPL APR could be performed scar-free in the future if the single-port device is placed in the left lower quadrant, at the place of the stoma, and no additional trocar is needed. In this study group, only in 1 patient was the single-port placed at the site of the stoma; in all other patients the port was placed transumbilically. This median position of the MIA port seemed less challenging compared to the left flank position due to better exposure of the arteria mesenterica inferior. Besides, laparoscopic surgeons are used to this position.

Although single-port or double-port surgery might have cosmetic and functional benefits, the principal aim of surgical oncology, i.e., radical resection (R0 resection), should remain the leading goal. Radical resection was achieved in all patients, and the median number of harvested lymph nodes was 14, comparable to traditional laparoscopic and open results.[13]

In the literature, the use of bulkier MIA ports is associated with increased hernia rates, probably due to the larger incision through the umbilicus compared with conventional laparoscopic techniques.[23,24] After a follow-up of median 14 months, no trocar hernias were observed in this study. Agaba et al. published a retrospective study of 211 patients who underwent a single-port procedure, and they describe an incidence of 2.9% for port-site hernias[23] compared to 1.7% after conventional laparoscopic surgery.[25]

The limitations of this descriptive case series include, first, the small study population. Second, the choice of whether to perform a double-port APR was made by the attending surgeon and the patient, and thus selection bias could be an issue. Finally, the learning curve was not accounted for in this study. In general, a learning curve of 10-36 procedures is common for experienced laparoscopic surgeons to master SPL techniques.[26,27,28,29,30] As mentioned earlier, little is known concerning single-port or double-port APR. No studies reported to date mention the learning curve for a minimally invasive APR procedure.

CONCLUSION

In conclusion, the use of a MIA device is a safe and feasible new option in APR. Although MIA devices seems to be a practical new tool in the laparoscopic surgeon's toolbox, future research should compare conventional laparoscopy and single-port or double-port laparoscopy, not only comparing perioperative and post-operative surgical data, such as operating time, complications and length of stay, but also post-operative pain, cosmetic result, herniation rates, costs and quality of life.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.