Traditional laparoscopic colorectal resections can be performed effectively using a three-port technique

Abstract

Dear Editor, With the increasingly widespread use of laparoscopic surgery to treat colorectal diseases, many innovations have been made in attempts to develop the best technique. While the use of four or more ports has been routine in most laparoscopic colorectal resections, the drawbacks are the need for added manpower, consisting of the camera-person and another assistant to provide counter-traction, as well as costs and the unaesthetic effects of additional ports. Specimen extraction through an additional muscle-cutting incision may also result in increased postoperative pain and spoil the cosmetic results of laparoscopic surgery. We describe our technique of colorectal laparoscopy using only two ports and one camera port with extraction of specimen via the camera port. Between June 2008 and June 2009, we performed 49 colorectal resections using a three-port technique. This series includes 13 cases of segmental colectomy, 29 cases of anterior resection and 7 cases of total colectomy or total proctocolectomy. We recently published this technique of three-port laparoscopic ultra low anterior resection [1]. In applying the three-port technique to any resection, a sensible placement of the two manipulation ports is absolutely essential. Our manpower in the three-port laparoscopic procedure involved the operating surgeon, a nurse to hold the camera port and a scrub nurse who also held the uterine manipulator as the need arose. We utilized the umbilicus to remove the specimen in these cases, extending it to extract the specimen as needed. For left hemicolectomy and anterior resection or ultra low anterior resection, the first manipulation port (10/ 12 mm) was inserted medial to the right anterior superior iliac spine, and the second port (5 mm) was inserted in between the umbilical port and the first manipulation port (Fig. 1). The 5-mm port was used for tissue retraction and the 10/12-mm port was for the energy device as well as for insertion of staplers. In females, we used a Zumi 4.5TM (UA Medical Products Inc, Charlotte, NC, USA) uterine manipulator inserted via the vagina to manipulate the uterus when needed as this obviated the use of an additional port (Fig. 2). For right hemicolectomy, a 5-mm port a palms length below the umbilicus either in the midline or in the left iliac fossa and a 10/12-mm port to the left of the midline a palms length above the umbilicus were sufficient. In all cases, after dissection and sufficient mobilization, the umbilical port was removed and the wound lengthened only to the size needed for specimen extraction. After insertion of the stapler head in cases of left-sided colon cancer, the proximal colon was returned to the abdomen and the umbilical wound closed around the camera port for completion of the anastomosis after re-insufflation of the abdomen (Fig. 3). For right hemicolectomy and some cases of left hemicolectomy where the retained sigmoid colon was very long, the colon and tumor were exteriorized and transected and the anastomosis was performed extra-corporeally. We used either the Harmonic ACE (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) or the LigaSure Atlas (Tyco Healthcare UK Ltd, Gosport, UK) device for dissection and I. Seow-En K.-Y. Tan M. A. B. Mohd Daud F. Seow-Choen (&) Seow-Choen Colorectal Centre, #03-09 Mt Elizabeth Medical Centre, Singapore 228510, Singapore e-mail: seowchoen@colorectalcentre.com