North Bristol NHS Trust, Frenchay Hospital, Bristol, BS16 1LE, UK.
Surg Endosc. 2011 Mar;25(3):835-40. doi: 10.1007/s00464-010-1275-8. Epub 2010 Aug 24.
Fast-track surgery accelerates recovery, reduces morbidity, and shortens hospital stay. However, the benefits of laparoscopic versus open surgery remain unproven within a fast-track program. Case reports of laparoendoscopic single-site (LESS) colectomies are appearing with claims of cosmetic advantage and decreased parietal trauma. This report describes the largest case series of LESS colorectal surgery and its effects on recovery.
In this series, 20 consecutive unselected patients underwent LESS colorectal surgery including right hemicolectomy (n = 3), extended right hemicolectomy, high anterior resection (n = 2), low anterior resection involving total mesorectal excision (TME; n = 3), ileocolic anastomosis (n = 2, including 1 redo surgery), colectomy and ileorectal anastomosis (n = 4, including 1 with ventral mesh rectopexy), panproctocolectomy (n = 2), proctocolectomy and ileoanal pouch (n = 2) and an abdominoperineal excision of rectum. Single-port conventional instrumentation and transversus abdominus plane (TAP) block analgesia were used. The indications included cancer (n = 8), Crohn's disease (n = 4), ulcerative colitis (n = 3) complicated diverticulosis (n = 2), and slow-transit constipation (n = 3). Eight of the patients had undergone previous surgery.
Most of the cases (90%) were managed successfully using the LESS technique and conventional instrumentation. Two operations (10%) were converted to standard laparoscopy, due to insufficient theater time and an unstable port. The operative time ranged from 45 to 240 min (median, 110 min). A normal diet was tolerated within 6 h by 7 patients and in 12 to 16 h (overnight) by 11 patients. Complications included anastomotic bleed (n = 1), ileus (n = 2), acute renal failure secondary to hyperphosphatemia and hypocalcemia (n = 1), urine retention (n = 1), and wound infection (n = 1). The median hospital stay was 46 h (range, 7-384 h). Eight patients were discharged within 24 h. There was one readmission (5%).
Laparoendoscopic single-site colorectal resection using conventional instrumentation is feasible and safe when performed by an experienced team. The LESS approach may have advantages in terms of minimal pain, cosmesis, lower costs, and faster recovery. A randomized trial is required to confirm whether LESS offers a true patient benefit over standard laparoscopic resection.
快速通道手术可加速康复、降低发病率并缩短住院时间。然而，腹腔镜与开腹手术在快速通道方案中的优势仍未得到证实。腹腔镜经脐单孔（LESS）结直肠切除术的病例报告陆续出现，其具有美容优势和减少壁层创伤的说法。本报告描述了 LESS 结直肠手术的最大病例系列及其对康复的影响。
在本系列中，连续 20 例未经选择的患者接受 LESS 结直肠手术，包括右半结肠切除术（n=3）、扩大右半结肠切除术、高位前切除术（n=2）、低位前切除术包括全直肠系膜切除术（TME；n=3）、回肠结肠吻合术（n=2，包括 1 例再次手术）、结肠切除术和回肠直肠吻合术（n=4，包括 1 例带有腹侧网片直肠固定术）、全结肠直肠切除术（n=2）、直肠结肠切除术和回肠肛管吻合术（n=2）和直肠经腹会阴切除术。使用单端口常规器械和腹横肌平面（TAP）阻滞镇痛。适应证包括癌症（n=8）、克罗恩病（n=4）、溃疡性结肠炎（n=3）合并憩室病（n=2）和慢传输性便秘（n=3）。其中 8 例患者曾接受过手术。
大多数病例（90%）成功地使用 LESS 技术和常规器械进行了治疗。由于手术室时间不足和端口不稳定，有 2 例手术（10%）转为标准腹腔镜手术。手术时间为 45 至 240 分钟（中位数为 110 分钟）。7 例患者在 6 小时内可耐受正常饮食，11 例患者在 12 至 16 小时（过夜）内可耐受正常饮食。并发症包括吻合口出血（n=1）、肠梗阻（n=2）、继发于高磷血症和低钙血症的急性肾功能衰竭（n=1）、尿潴留（n=1）和伤口感染（n=1）。中位住院时间为 46 小时（范围 7-384 小时）。8 例患者在 24 小时内出院。有 1 例再入院（5%）。
当由经验丰富的团队进行操作时，使用常规器械进行腹腔镜经脐单孔结直肠切除术是可行且安全的。LESS 方法在疼痛最小化、美容效果、降低成本和更快康复方面可能具有优势。需要进行随机试验来确认 LESS 是否为患者带来了优于标准腹腔镜切除的真正获益。
