Colorectal resections are common surgical procedures worldwide. Laparoscopic colorectal surgery is technically feasible for a considerable number of patients under elective conditions. Several short- and long-term benefits of the laparoscopic approach to colorectal resection (less pain, less morbidity, improved reconvalescence, and better quality of life) have been proposed [5, 8–10, 12, 14–16, 25, 27–30, 32].

Recently, laparoscopy has been characterized by increasing development of smaller laparoscopes, trocars, and operative instruments to minimize nerve and muscle damage and to optimize aesthetic results. As a consequence, minilaparoscopy has been used gradually for the treatment of several pathologies including inguinal hernia, appendectomy, and cholecystectomy [1–4, 7, 11, 13, 17–22, 23, 26, 31]. However, the feasibility of the minilaparoscopic technique is not completely clear. On one hand, the major benefit of the minilaparoscopy still is controversial compared with its “major sister,” laparoscopy, and it appears to be more expensive [2, 3, 11, 21].

Considerable confusion also exists regarding terminology. “Minilaparoscopy,” “microlaparoscopy,” “microendoscopic surgery,” “needlescopic surgery,” and “microinvasive surgery” all are often used synonyms for minilaparoscopy [11]. We prefer to use the general term mini-endoscopic surgery for any procedure that uses endoscopic instruments and optics 5 mm in diameter or smaller, but with the honest specification of which instrument’s diameter is the predominant one.

Over the past 5 years, our institutions have routinely started with minilaparoscopy in treating various abdominal pathologies such as appendectomy, spermatic vein legations, diagnostic and inguinal hernia repair (instrument diameter, 3 mm), and cholecystectomy (instrument diameter, 5 mm). Since then, we have worked together to share in the experience of minilaparoscopy.

This study aimed to evaluate retrospectively patients over the past 5 years who underwent minilaparoscopic colon resection, focusing attention on feasibility of the technique (defined as the ratio of successful to total attempts) as the primary end point of the investigation . The secondary end point was the incidence of minilaparoscopic colon resection–related complications. Minor complications were defined as those that did not influence the length of the postoperative hospital stay, whereas major complications were defined as those leading to mortality, those requiring conversion to “classical” laparoscopy/open surgery or reintervention, and those leading to prolongation of the hospital stay.

Materials and methods

Between 1 January 2001 and 31 December 2006, a total 3,088 patients underwent scheduled and urgent laparoscopic procedures at the Nuovo Regina Margherita Hospital in Rome (a regional medical center) and at Civil Hospital in Vittorio Veneto (TV) (a community hospital). Of these patients, 517 (16.7%) underwent scheduled laparoscopic colorectal surgery, 161 (31.1%) of whom were approached with mini-instruments. Because minilaparoscopic surgery was not performed by all the surgeons of our staff, patients were treated by minilaparoscopy or “regular” laparoscopy, depending on whether the first field had a well-trained surgical team, and not randomly allocated to either treatment. As a result, our series may reflect a selection bias in favor of minilaparoscopy.

Irrespective of the chosen approach, all the patients underwent the same preoperative workup, and all had elective surgery. The minilaparoscopic group consisted of 74 men and 87 women with a median age of 66.8 years (range, 41–78 years). Patients with a history of previous colorectal surgery or, in the case of cancer, an already known distal metastasis were not included the minilaparoscopic group. The surgical procedures and outcomes are detailed in Table 1.

Table 1 Minilaparoscopy colon resection: types of procedures performed and outcomes
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Technical aspects

The surgical techniques used were similar to those described by other authors in all the principal phases and according to the standard laparoscopic procedures for colon resection (right and left sides) [8, 9]. In all cases, a mechanical bowel preparation was completed. The patients were administered parenteral antibiotics and subcutaneous heparin preoperatively, and the bladder was catheterized.

For left-side colon resection (Fig. 1), four trocars (five if needed) and general anesthesia plus local anesthetic injected at the port sites were always used, as well as a 30° viewing laparoscope and no disposable instruments. The first 5-mm trocar normally was inserted 2 cm above the umbilicus (Veress technique) for the optic. The second 5-mm trocar was placed superiorly almost 3 cm and laterally at least 8 cm at the right side of first trocar for all the operative instruments. The third 5-mm trocar was positioned opposite the previous one in the right iliac fossa in an imaginary equilateral triangle with the first two trocars for all the instruments needed plus the clips applicator. This trocar was exchanged for a 10- to 12-mm trocar when stapler insertion was needed. The fourth 5-mm trocar was placed at the left transverse umbilical line, as laterally as possible, for the handler’s instruments. If needed, a fifth 3-mm trocar was place according to the anatomic surgical situation.

Fig. 1
figure 1

Trocar placement for left-side resection

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For the third trocar, we normally used the VersaStep trocar (Tyco Healthcare, Norwalk, CT, USA), which can be changed in diameter easily, leaving the sleeve in situ. For all the other trocars, we normally used the Endopath dilating tip trocar (Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA). Specimen extraction and proximal bowel division were performed through a Pfannenstiel small muscle-splitting incision.

For the conventional approach, the position of the trocars was the same, but the trocars all were 10-mm trocars except trocars 4 and 5, which were 5-mm trocars. The optic was a 30° instrument with a diameter of 10 mm to match the diameter of the clips applied.

For right-side resection, all the trocars and instruments were 5 mm in size (Fig. 2). The first trocar, for the 30° optic, was inserted as previously described. Trocars 2 and 3 were inserted in the manner described earlier and used for all the instruments needed. Trocars 4 and 5 (possibly a 3-mm trocar), if needed, were placed in the epigastrium and above the pubis.

Fig. 2
figure 2

Trocar placement for right-side resection

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All the anastomoses performed after a right-side resection were fashioned extracorporeally through a midline incision above the umbilicus. With the conventional approach, the positions of the trocars were the same. All the trocars were 10-mm except the trocars 3 and 4, which were 5 mm. The optic was a 30° instrument 10 mm in diameter to match the clips applied. In both groups, the peritoneum and fascia usually were closed at the 10-mm trocar site insertion group with a continuous absorbable suture.

With the patient’s informed consent, all procedures initially were attempted minilaparoscopically. Any case that could not be completed minilaparoscopically was considered a conversion. The operative time was measured from the first skin incision to the application of the dressing. The time to discharge was measured from the date of surgery. The patients usually were started on clear liquids the first postoperative day, and their diet was advanced as tolerated. The time of a full diet was defined as the first day that the patient tolerated a solid meal.

Results

No postoperative deaths were reported. The mean operative time was 155.56 ± 31.2 min in the minilaparoscopic group and 125 ± 28.2 min in the conventional group. Interestingly, the minilaparoscopy cases in the last year of the study showed a reduction of almost 15 min in the operation time. No conversion to conventional laparoscopy was reported in the former group. Eight cases (4.9%) were converted to laparotomy in the minilaparoscopic group (4 cases involving a tumor mass too large to handle and 4 cases involving a local inflammatory situation and not considered safe for continuation of the laparoscopic approach).

In the conventional group, five cases were converted to an open approach (2 cases involving a tumor mass too large to handle laparoscopically, 1 case involving an iatrogenic lesion of an iliac artery, and 2 cases involving inflammatory local changes). Five cases of major morbidity (3.1%) were registered in the minilaparoscopic group (3 cases of anastomotic leakage treated with a temporary ileostomy, 1 case of a prolonged ileus treated medically, and 1 case of respiratory failure).

In the classical laparoscopic group, the major morbidity rate was 3.3% (12 cases) and included seven cases of anastomotic leakage, all managed with an ileostomy; two cases of bleeding, both managed initially by laparoscopy then completed with laparotomy, and three cases of cardiopulmonary morbidity.

According to our policy, ileostomy is performed during surgery only when there is suspicion of possible anastomotic “failure” (mechanical reason secondary to a poorly created stapler anastomosis or “weak” tissue secondary to inflammatory or radiotherapy). In eight minilaparoscopic cases (4.9%) and 19 classic laparoscopic cases ((5.3%), an ileostomy was considered necessary for the aforementioned reasons.

The global median postoperative length of hospital stay was 6 days (range, 4–15 days), without any statistical difference between right- and left-side resections in the two groups. All the patients resumed oral intake within the first 72 h and passed air within a mean of 4 ± 2.6 days. Minor morbidity occurred in 19 minilaparoscopic cases (11.8%), all managed with medical therapy, and in 35 classical laparoscopic cases (9.8%).

Discussion

The “natural” evolution of laparoscopy involves robotic development (to enhance precision and easy performance of any surgical step) and the use of miniaturized instruments (to reduce the greater invasive approach). The first appears not to be reproducible in every hospital situation (due the problem of costs/benefits), whereas the second appears to be applicable and feasible almost everywhere [11, 20, 22, 24].

Every surgical technique proposed to the surgical world must be easy, feasible, and reproducible in every situation, with possibly no related morbidity/mortality, an acceptable cost–benefit ratio, and good patient perception. This is especially true if the current surgical technique for the management of the pathology is the overall accepted gold standard treatment.

Since 2000, we have decided to perform several procedures (appendectomy, hernia repair, spermatic vein legation for varicoceles) routinely using miniaturized instruments, ensuring the supervision of a competent laparoscopic surgeon. The idea of using a minilaparoscopic approach for the aforementioned diseases resulted from the need to handle and remove huge specimens, which would need larger trocars and incisions. The problem with a laparoscopic colon resection results from this need to handle and remove huge specimens.

We therefore decided to standardize our technique for scheduled procedures using trocars with a diameter of 5 mm, with all instruments and optics of the same diameter. Only for the last step of the left-side procedure do we exchange a 5-mm trocar for a 10- to 12-mm trocar to introduce the stapler. Since our decision, 161 patients admitted for a colorectal pathology have been treated with the aforementioned standardized technique by all members of our surgical team. In this report, we analyze the advantages of this experience in terms of its indications, morbidity, mortality, and socioeconomic impact, comparing it with the conventional laparoscopic approach.

Indications

The indications for a minilaparoscopic approach to colon diseases equal those for laparoscopy [5, 6, 10, 25]. To be a competitive proposal, a technique must be easy to perform, feasible, and reproducible in every situation by everyone everywhere. The operative mean time for the minilaparoscopic procedure should be “statistically” equal to that for the conventional approach, as reported in the literature.

Ease of performance means that the technique does not require many changes of instruments, optics, or the like. All such maneuvers could result in an unsafe increase in the complexity and difficulty of the surgery, a waste of time, and above all, contamination of the operative field. As already stated, only at the end of the left-side procedures do we need to exchange one trocar for a larger one to introduce the stapler.

In terms of reproducibility, we have used the minilaparoscopic approach to colorectal pathologies with good and comparable results at two different institutions. The surgeons on our team were already skilled in minilaparoscopy and did not need to “rewrite” their own learning curve.

Instruments

We have already used, with good results, the 3-mm optic, whose resolution is different from that of 5- or 10-mm optics in depth of visual field. Also, the resolution and quality of images are preserved routinely in appendectomy, hernia repair, and varicocele surgical therapy [7, 26]. For these procedures, the lesser depth and laterality of the visual field can easily be overcame by bringing the optic nearest to the operating theater. However, this cannot be applied in laparoscopic colon resection. The 5-mm optic is equal to the 10-mm optic in terms of image quality and, as stated earlier, there is no need to change it during the procedure.

With respect to the instruments, all the tools (e.g., scissors, dissector, needleholder, pickup, hook, clips, Harmonic Scalpel) are available in the 5-mm size. They are the same as those everyone is using for all conventional laparoscopic procedures. Their operative surface and handling are right for all the steps of the operation for all kinds of specimens.

Conversion

In our series, the rate of conversion to an open approach was comparable with that for classical laparoscopy. Generally speaking, conversion in laparoscopy should never be regarded as a defeat. Even when forced to convert the procedure, a surgeon may choose the most appropriate incision for treatment of the patient [9].

Morbidity and mortality

The results of our experience show the feasibility of minilaparoscopic colon resection with acceptable morbidity and no mortality. The rates are comparable or equal to those reported for the classical laparoscopic approach. However, these favorable results may be a consequence of patient selection. Overall, the results of our experience lack randomization. Nevertheless, this study aimed only to evaluate retrospectively the feasibility of the technique, which we already have shown for other pathologies approached minilaparoscopically.

Above all, the results we achieved appear promising for future prospective randomized studies. The expectation with the use of this technique is that of no type of morbidity will be found related to the size of trocar access [22].

Hospital stay

Hospital stay after minilaparoscopic colon resection is the same as that after the classical procedure. It cannot be said with certainty that the pain experienced with a colon resection is mainly due to the size of the trocars. We believe the pain is more likely related to the “degree” of the disease, the length of the surgery procedures (and as a consequence, the experience of the surgeon), and the individual patient’s medical history (related pathology) and “reactivity.” Surely, trocar size may play a role in possible trocar-related complications (e.g., herniation), including pain. In fact, the area of the wound for a 10-mm trocar is four times that for a 5-mm trocar. Although the wound area may not be directly proportional to the extent of tissue damage, there is no doubt that a smaller trocar causes less tissue damage [1, 18, 19, 31].

In addition, with removal of a large trocar (10 or 12 mm in size) after a long operation, all clinicians have observed a hole passing through the abdomen wall that allows them to see the inside! This is due to a sort of alignment of the traumatized tissues. For this reason, for left resection, trocars 3 to 5 are replaced only at the last step of the procedure by the 12-mm trocars for insertion of the stapler into the abdomen.

Costs

The advantage of minilaparoscopic colon resection consists not only of better cosmesis (with an unquestionably positive patient perception of surgery), but also of a decrease in operative trauma [1, 18, 19, 31]. The latter may result in a reduced incidence of incisional hernias and possibly complications (hemorrhages) related to the trocar site of insertion. Furthermore, the instruments used are the same as those used for conventional laparoscopy, with no costs added.

The surgeon

A well-trained and experienced surgeon working together with a well-trained team is a necessary requirement for minilaparoscopic colorectal surgery, as it is for the classical laparoscopic approach. To offer patients the same chance of cure at our institutions, minilaparoscopic colorectal surgery is performed only when a well-trained minilaparoscopic surgeon is on duty. We maintain that minilaparoscopic experience and background should be part of the professional update of every laparoscopic surgeon, in both large and small medical centers. The outcome depends more on surgeons possessing advanced laparoscopic skills (patience and perseverance are important too!) and adhering to accepted oncologic surgical principles in the case of malignancy than on the size or location of the health care institution.

Conclusions

On the basis of our initial experience (although limited by its retrospective nature), we can conclude that minilaparoscopic colorectal surgery is feasible, effective, and easy to perform (without any increase in technical difficulties) in experienced hands. In terms of operative time, postoperative morbidity, and hospital stay, minilaparoscopic colon surgery provides acceptable results comparable with those reported for classical laparoscopy [1, 4, 7, 18, 19].

“Smaller is not always the better,” someone could say [2, 3]. However, most of the advantages with laparoscopic surgery rely on the minimal access required. As a consequence, the benefits of this technique will be greater as the access becomes smaller. Sparing patients a wider skin incision at the trocar site may reduce postoperative pain, increase prompt recovery of gastrointestinal functions, shorten the hospital stay, help contain health care costs, and improve cosmesis [7, 22, 26].

The desire of every surgeon to operate with respect for the body integrity of the patient may be attainable with minilaparoscopy. We therefore conclude that in a proper setting, minilaparoscopic colon surgery can be part of the laparoscopic colon practice in every hospital situation, provided a group of skilled and motivated surgeons is actively participating in the project. On these grounds, further studies, especially prospective randomized and controlled trials, need to be conduced to confirm these early encouraging results.