Introduction

Laparoscopic surgery is associated with fewer postoperative complications, decreased length of stay, faster return of gut function, and reduced surgical site infection over open approach in patients undergoing colorectal surgery [1–3]. Despite these advantages, surgeons have tried to decrease the number of ports used during conventional laparoscopy in order to achieve better cosmesis, less pain, and fewer risk of development of hernia. Therefore, natural orifice transluminal endoscopic surgery (NOTES) [4, 5] and single-port laparoscopic surgery (SPLS) [6–13] have drawn attention and been used in patients with urologic and surgical pathologies. Although NOTES offers scarless surgery, it is associated with steep learning curve, and extraction sites are major concerns compared to SPLS in which incision used to access the abdomen can be concealed in the umbilicus. Case reports including patients with colonic polyp and diverticulitis reported that SPLS is feasible and safe for colonic procedures [12, 13]. However, these reports included short-term results following SPLS. Herein, we report a patient with 1-year follow-up in whom a sigmoid colectomy performed for sigmoid cancer through a single-port technique.

Methods

SPLS through a 3-cm umbilical incision was performed on a patient with a diagnosis of sigmoid cancer using an R-port™ System (Advanced Surgical Concepts Ltd., Wicklow, Ireland) with specially designed curved laparoscopic instrumentation (Fig. 1). Data was obtained from our prospectively maintained Institutional Review Board approved laparoscopy and cancer databases. Patient was 54-year-old female with a body mass index of 25.8 kg/m2. Preoperatively, a circumferential malign tumor in the sigmoid colon was detected during colonoscopy. A CT scan did not show any metastasis. Therefore, patient was elected for a sigmoid resection.

Fig. 1
figure 1

A 5-mm straight camera and two 5-mm specially designed curved instruments were used via an R-port™ System

Full size image

Patient had a bowel preparation prior to surgery. After anesthesia induction, patient was placed into Lloyd-Davis position. A small 3-cm incision was made vertical through the umbilicus, and an R-port™ single-port device was used to access the abdominal cavity. A 5-mm straight camera and two 5-mm specially designed curved instruments, a LigaSure device™ (Covidien Ltd., Norwalk, Connecticut, USA) and a grasper, were introduced via a multichannel port system. High ligation of the inferior mesenteric artery right below the pancreas was done using a LigaSure device. Subsequently, medial-to-lateral dissection was performed; left colon and splenic flexure were mobilized. An EndoGIA (Auto Suture, United States Surgical Corporation, Norwalk, Conn.) was fired twice from the 10-mm port of the R-port™ to come across the level of the upper rectum safely. The 3-cm incision in the umbilicus was used to extract the specimen after application of an Alexis O™ wound protector/retractor (Applied Medical, Rancho Santa Margarita, CA). The proximal resection was done with a TA-60 (Auto Suture, United States Surgical Corporation, Norwalk, Conn.). The anvil of a 31-mm circular stapler was placed outside the abdomen. An intracorporeal anastomosis was made with the circular stapler inserted through anus under direct vision. Hemostasis was obtained. Sigmoidoscopy was performed and showed no leak. The 3-cm incision was closed with a in a figure-of-eight fashion. Skin was closed with a subcuticular fashion (Fig. 2). No intraoperative complication was recorded. Patient tolerated the procedure well.

Fig. 2
figure 2

Wound in the umbilicus at the end of the operation

Full size image

Results

The total operative time was 198 min with 300 ml blood loss. Length of hospital stay was 3 days. Patients had no intraoperative or postoperative complications. Total length of specimen was 16 cm (Fig. 3). Surgical pathology report showed a 5 cm × 2.5 cm × 2.5 cm circumferential lesion, pT3 moderately differentiated invasive colonic cancer. Resected specimen had adequate surgical margins (10 and 5.5 cm). No regional lymph node metastasis was found among 14 lymph nodes examined. Figure 4 shows the completely healed scar at postoperative day 30. Patient did not receive adjuvant chemotherapy after surgery. CEA was tested every 3 months after surgery and was found within normal range. Colonoscopy performed 1 year after surgery showed that there was no neoplasm or polyp identified. Abdomen and pelvis CT also found no evidence of abdominal wall defect, recurrence or metastatic disease.

Fig. 3
figure 3

Surgical specimen

Full size image
Fig. 4
figure 4

Incision site at postoperative day 30

Full size image

Discussion

Laparoscopic surgery is associated with less pain, better cosmesis, and fewer risk of wound complications compared to open surgery [1–3]. Recently, SPLS has drawn attention for its potential advantages over conventional laparoscopy. It has been first used in general surgery and urology [6–11]. Subsequently, SPLS for colonic polyp by us [12] and diverticulitis [13] was reported. Although good short-term outcomes have been reported after SPLS for colorectal conditions, its feasibility and benefits for colorectal cancer have remained unknown. Herein, we report a patient with 1-year follow-up in whom a sigmoid colectomy performed for sigmoid cancer using SPLS.

Common laparoscopic procedures can be performed using single-port via umbilicus, and if necessary, additional ports can be added during the procedure. Although multiport laparoscopic skills are paramount for a safe SPLS and flexible instruments used have a learning curve, SPLS seems to be practical compared to NOTES. Also, current development of instruments used for SPLS helps optimize their range of motion and reduce the challenges of SPLS to move toward more complicated procedures. In addition, traction, counter traction, and tilting of the table to reverse trandelenburg and toward the right side to the patient help perform the task with two instruments only.

The patient in this report had a circumferential malign tumor in the sigmoid colon with no distant metastasis. The patient had no preoperative, intraoperative or postoperative morbidity. SPLS was able to be performed with sufficient margins and number of lymph nodes with respect to oncologic principle. Acceptable blood loss was recorded, and the total time for procedure was comparable to conventional laparoscopic procedures [14]. We present this case 1 year after the surgery was performed in order to evaluate oncologic results with a longer follow-up. The fact that colonoscopy and abdominopelvic CT scan performed 1 year after SPLS procedure found no recurrence or metastatic lesion showed that SPLS is promising for colorectal cancer patients.

In conclusion, SPLS seems to be a good technique in patients with colorectal cancer in terms of complications and oncologic outcomes after 1-year follow-up. However, we advise using this technique in selected colorectal cancer cases with a prospective data gathering and consenting until attainment of proficiency in SPLS.