Safety and Short-term Outcomes of a Single-Port Laparoscopic Approach to Colorectal Surgery

Recent literature has established that single-port laparoscopy (SPL) is a feasible alternative to the traditional multiport laparoscopic approach for colorectal surgery.^1-3 Multiport laparoscopy has been demonstrated to be safe for obese patients⁴; however, there is a lack of experience with and data on the use of SPL for obese patients. We hypothesize that safe and reasonable outcomes can be achieved when SPL is used before a right hemicolectomy for obese patients (ie, those patients with a body mass index [BMI] ≥30 [calculated as weight in kilograms divided by height in meters squared]).

This is a retrospective analysis of all patients who underwent SPL before a right hemicolectomy between July 2009 and June 2014 in a high-volume, academic, colorectal surgery practice at a single VA facility. During the study period, all right hemicolectomies at this facility were performed by 1 of 2 attending surgeons and were initially approached with SPL. The primary outcomes investigated are 30-day complications and oncologic resection parameters, including positive margin rate, number of lymph nodes harvested, and specimen length. Statistical analyses were performed to compare these outcomes between 2 groups of patients, obese and nonobese patients. This study was reviewed and approved by the Indiana University institutional review board and the VA Research and Development Committee. Because this was a restrospective study, we did not contact the patients; all data were obtained by reviewing the medical records and were deidentified.

A total of 118 patients who underwent SPL before a right hemicolectomy were included. There were 55 patients in the obese group (BMI ≥ 30) and 63 patients in the nonobese group (BMI < 30). The 2 groups did not differ significantly in age, American Society of Anesthesiologists classification, number of prior abdominal surgical procedures, or percentage of operations performed for cancer (Table 1). The mean duration of SPL was longer for obese patients (132 minutes) than for nonobese patients (107 minutes) (P < .001). There were no significant differences in the rate of conversion to open or multiport laparoscopy (P = .21), intraoperative blood loss (P = .24), or overall length of stay (P = .16) (Table 2).

There were 8 nonobese patients and 12 obese patients who had complications (P = .22). There was no significant difference in complications graded using the Clavien-Dindo classification (P = .27) or in anastomotic leak rate (ie, 1 obese patient and no nonobese patient experienced an anastomotic leak; P = .46). Four obese patients and no nonobese patient had a wound infection (P = .04). The mean specimen length was longer in the obese group than in the nonobese group (P = .04). With regard to oncologic resections, there was no difference in the mean number of lymph nodes harvested (P = .74) or in the rate of positive margins (P = .49) (Table 2).

Safety and short-term outcomes do not appear to be compromised by obesity when SPL is used before a right hemicolectomy. The statistically significant differences between the 2 groups of patients were a higher wound infection rate, a longer specimen length, and increased operative time in the obese group. Our finding of an increased wound infection rate in the obese group is consistent with the existing literature, and this, unfortunately, continues to be a pervasive problem for obese patients regardless of surgical approach.⁵

Single-port laparoscopy offers excellent cosmetic results and has been associated with better postoperative pain control.¹ These factors can have a significant positive effect on patient satisfaction, and as the emphasis on satisfaction continues to increase, SPL may be an advantageous approach when indicated. Our results indicate that a BMI of 30 or higher does not preclude a patient from undergoing SPL. However, our study does not further categorize the class of obesity, and it would be useful to evaluate the results of SPL in the morbidly obese and super obese populations. We also recognize that the power of our study is limited by the retrospective nature of the study, and therefore, our data collection is ongoing. In addition, further studies are needed regarding the longer-term outcomes of using SPL before colorectal surgery, including hernia rate, cost analyses, and patient satisfaction in all patient populations.

Corresponding Author: Virgilio V. George, MD, Department of Surgery, Richard L. Roudebush VA Medical Center, 1481 W 10th St, Indianapolis, IN 46202 (vigeorge@iupui.edu).

Published Online: September 16, 2015. doi:10.1001/jamasurg.2015.2409.

Author Contributions: Drs Danforth and George had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Danforth, Spera, Fajardo, George.

Acquisition, analysis, or interpretation of data: Danforth, Monn, Spera, George.

Drafting of the manuscript: Danforth, Fajardo, George.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Danforth, Monn, George.

Administrative, technical, or material support: Danforth.

Study supervision: Fajardo, George.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented at the 39th Annual Meeting of the Association of VA Surgeons; May 3, 2015; Miami Beach, Florida.