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Application of single-incision laparoscopic-assisted technique for the closure of end colostomy with intestinal shortening
https://doi.org/10.21203/rs.3.rs-2716267/v1
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Brief reports do not require abstract
Partial colectomy plus distal bowel closure and proximal colonic single-lumen stoma is a common choice for patients with colorectal trauma, perforation, or acute tumor obstruction [1].The majority of these patients have the need for colostomy closure. However, reduction of colostomy is challenging given the presence of abdominal adhesions and shortened colon. The laparoscopic technique has special advantages such as minor trauma, magnified field of view, and wide range of operation, thus it is increasingly used in colorectal surgery and has advantages in the dissection of abdominal adhesions [2, 3].These advantages are even more significant in single-incision laparoscopic surgery. In present study, we reported our preliminary experiences of closing end colostomy via single-incision laparoscopic-assisted technique.
Patients who received single-incision laparoscopic-assisted single-lumen colostomy closure during the May 1, 2020 to April 20, 2022 in the department of gastrointestinal surgery of the first affiliated hospital of South China University were retrospectively reviewed. The patient's perioperative data including gender, age, body mass index, stoma etiology, stoma site, operation time, intraoperative dissociated bowel range, intraoperative blood loss, perioperative blood transfusion, perioperative complications (pulmonary infection, anastomotic leak/fistula, bowel obstruction, intra-abdominal infection) and wound healing grade were collected and analyzed. Patient’s data collection was approved by the hospital ethics committee (ethical approval number: 2022ll0516001). All persons gave their informed consent prior to their inclusion in the study.
Surgical procedure:① Stoma closure;② Stoma dissociation; ③ Establishment of operating space;④Intra-abdominal space expansion; ⑤ dissociate the distal closed stump⑥ dissociate the intestine with stoma⑦ intestinal anastomosis. A typical intraoperative situation is illustrated in Fig. 1.
During the above period,5 patients with end colostomy and intestinal shortening were admitted to our department and received single-incision laparoscopic-assisted colostomy closure. There were 3 males and 2 females, aged 37–76 years. The length of resected bowel ranged from 20 to 42cm (Table 1).
Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | |
---|---|---|---|---|---|
gender | male | male | female | male | female |
Age (years) | 47 | 37 | 52 | 61 | 76 |
pathogeny | Traumatic perforation | Traumatic perforation | Infection of perforation | Infection of perforation | Obstruction of rectal cancer |
Length of colon removed by previous operation (cm) | 42 | 20 | 35 | 30 | 26 |
Site of previous stoma | left upper quadrant | left middle quadrant | left upper quadrant | left upper quadrant | left middle quadrant |
The grade of intraoperative adhesion was judged according to the modified American Society for Reproductive Medicine (ASRM) adhesion grading criteria (Supplementary Table 1), with 2, 3, 6 points in 3 different cases, and 5 points in other 2 cases. None of the patients needed a blood transfusion or conversion to open surgery, and the anastomosis method was end-to-end anastomosis with a circular stapler (Table 2).
Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | |
---|---|---|---|---|---|
Score of abdominal adhesion | 6 | 3 | 5 | 5 | 2 |
Free bowel range | Splenic flexure/hepatic flexure | Splenic flexure | Splenic flexure/hepatic flexure | Splenic flexure | Splenic flexure |
Operation time (min) | 320 | 165 | 260 | 225 | 190 |
Intraoperative blood loss (ml) | 120 | 50 | 100 | 80 | 20 |
Intraoperative blood transfusion | No | No | No | No | No |
Anastomosis Methods | Instruments - End to end | Instruments - End to end | Instruments - End to end | Instruments - End to end | Instruments - End to end |
Conversion to open surgery | No | No | No | No | No |
Note: Abdominal adhesion score: according to the modified ASRM adhesion grading standard. |
All 5 patients obtained satisfactory healing after the operation. In terms of postoperative complications, no patient had anastomotic leakage, fistula, bowel obstruction, or intra-abdominal infection complications, and only 1 patient developed pulmonary infection. Only 1 patient had grade B healing, the others had grade A healing (Table 3).
Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | |
---|---|---|---|---|---|
First exhaust time (days) | 3 | 2 | 4 | 2 | 2 |
First defecation time (days) | 3 | 3 | 6 | 4 | 3 |
First time out of bed activity (day) | 1 | 1 | 1 | 1 | 2 |
Pain index 3 days after surgery | 3 | 2 | 4 | 3 | 2 |
Length of stay (days) | 9 | 7 | 8 | 11 | 9 |
Lung infection | No | No | No | No | Yes |
Anastomotic leakage/fistula | No | No | No | No | No |
Postoperative bowel obstruction | No | No | No | No | No |
Intra-abdominal infection | No | No | No | No | No |
Wound healing grade | A | A | A | B | A |
Note: Pain index: A numerical assessment of pain on a scale from 0 to 10; Pulmonary infection: Postoperative chest CT showed pleural effusion; Intra-abdominal infection: the presence of pus drainage in the postoperative abdominal drainage tube, drainage culture indicating bacterial infection, or CT indicating intra-abdominal infection; Wound healing grade: Refer to the wound healing grade standard of Technical Guidelines for the Prevention and Control of Surgical Site Infection (Trial). |
All the patients in this report were successfully treated with single-incision laparoscopic operation. Our preliminary data indicated Intraoperative bleeding was controllable, and no patient needed blood transfusion. No patient had serious complications after operation. Except for 1 patient with grade B wound healing, other patients achieved grade A wound healing.
In this study, we found that all cases in this group had relatively long resected colon, and 80% (4/6) were perforated cases, resulting in a significant increase in the complexity of the operation. Secondly, the intra-abdominal adhesions were relatively serious in this group, with 60% (3/5) of the patients having an abdominal adhesion score higher than 5, which led to a significant increase in the difficulty of the laparoscopic surgery.
In summary, in centers with rich experience in gastrointestinal laparoscopic and single-port laparoscopic surgery, through scientific case selection and delicate operation, single-incision laparoscopic-assisted stoma closure is safe and effective for patients with end colostomy and intestinal shortening, especially for non-neoplastic patients. However, the number of cases in this study is still limited, and clinical studies with a larger sample size are needed to further determine its safety, and potential advantages or disadvantages compared with conventional open surgery.
Acknowledgements The authors wish to acknowledge Xu Yun-Hua for his contributions to data management and analysis.
Funding This work was supported by Natural Science Foundation of Hunan Province (2022JJ30538), Innovation Project of Hunan Provincial Science and Technology Department(2020SK51815) and Major project of Hunan Provincial Health Commission (20201919).
Conflict of Interest The authors declare that they have no competing interests
Authors’ Contributions Xiao-Feng Wu: Study concept and design, data collection, and manuscript writing/editing. Guang Fu: Study concept and design, data analysis, manuscript writing/ editing. Shuai Xiao: Study concept and design, data analysis, and manuscript writing/editing. All authors provided final approval of the version to be submitted.
Ethics approval Patient’s data collection was approved by the hospital ethics committee (ethical approval number: 2022ll0516001). All persons gave their informed consent prior to their inclusion in the study.
No competing interests reported.
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