Single-Incision Laparoscopic Sigmoidectomy

Abstract

Introduction: Laparoscopic surgery has been accepted to be safe and efficacious for the management of colorectal cancer.1,2 The superiority of laparoscopy over open surgery in terms of reduced postoperative pain, shorter hospital stay, early return of bowel activity, and cosmesis has been documented as advantageous in various studies.3,4 In an attempt to reduce the potential complications such as port site bleeding, hernia, infection, and improved cosmesis, minimally invasive colorectal surgery is trending toward single-incision laparoscopic surgery. Bucher et al.5 and Remzi et al.6 described the first single-incision laparoscopic colectomy (SILC) in 2008. But SILC has disadvantages of prolonged operative time, limited applicability, and long learning curve.7 We successfully report the technique of single-incision laparoscopic sigmoidectomy (SILS) for a case of sigmoid colon cancer. Materials and Methods: A 62-year-old man was diagnosed with sigmoid colon adenocarcinoma in the routine screening colonoscopy in June 2013. On clinical examination, bilateral hernioplasty scars were present. His body mass index was 22.7 kg/cm2 and carcinoembryonic antigen (CEA) was 0.62 ng/mL. Colonoscopy showed encircling mass in the sigmoid colon (27–31 cm above anal verge). CT (abdomen+pelvis) showed sigmoid colon cancer stage cT2N0M0. PET CT showed fludeoxyglucose (FDG) avid malignant tumor in sigmoid colon. OCTOTM port (Dalim surginet), model 504V2-A and Olympus camera size–10 mm, LTF type VH with Deflectable Tip were used. Operative Technique: Patient's position was supine with legs abducted and minimally elevated. A 3-cm vertical incision was made through the umbilicus, and the OCTO port was inserted. The pressure was set at 11 mm Hg. SILS was performed from medial to lateral approach. Tumor was identified. Distal margin of 10 cm was marked with the help of black silk. Mesenteric dissection was done with monopolar cautery along the embryological fusion plane. Inferior mesenteric artery (IMA) was identified, dissected, clipped, and cut near the origin. Inferior mesenteric vein (IMV) was also identified, dissected, and severed. Lateral mobilization of sigmoid and descending colon was done to achieve adequate length. Sigmoid colon of 10 cm distal to the tumor was denuded. Laparoscopic bulldog was applied above the distal transection site, and the distal colorectum was irrigated through the anus. Distal colon was transected with Endo GIA stapler. Tumor was exteriorized through the OCTO port. Colon was transected 10 cm proximal to the tumor. Anvil of directional stapling technology end to end anastomosis ( DST EEA) stapler was fixed at the proximal cut end. Colon was reposited back into the abdominal cavity through the OCTO port. DST EEA stapler was inserted through anus. DST EEA trocar was introduced through the distal stump. Anvil was joined to the cartridge fork of the stapler. Stapler was then slowly approximated. Approximation was checked circumferentially for proper. Proximal colon was checked to avoid torsion. Stapler was fired and slowly withdrawn through the anus. End-to-end colo-colo anastomosis using double stapling technique was accomplished. Operative time was 4 hours and 40 minutes, the estimated blood loss was 100 mL, and the length of stay was 6 days. Pathological staging was pT3N0Mx. The postoperative recovery of patient was uneventful. Conclusion: In patients with small tumor, SILS is technically feasible and safe oncological procedure with short-term results similar to conventional laparoscopic colectomy (CLC). No competing financial interests exist. Runtime of video: 9 mins 6 secs