JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Full Report
Volume 00, Number 00, 2017
ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2017.0341

Hybrid Single-Incision Laparoscopic Colon Cancer

Surgery Using One Additional 5 mm Trocar
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* *
Hyung Ook Kim, MD, PhD, Dae Jin Choi, MD, Donghyoun Lee, MD, Sung Ryol Lee, MD,
Kyung Uk Jung, MD, Hungdai Kim, MD, PhD, and Ho-Kyung Chun, MD, PhD

Abstract

Background: Single-incision laparoscopic surgery (SILS) is a feasible and safe procedure for colorectal cancer.
However, SILS has some technical limitations such as collision between instruments and inadequate coun-
tertraction. We present a hybrid single-incision laparoscopic surgery (hybrid SILS) technique for colon cancer
that involves use of one additional 5 mm trocar.
Methods: Hybrid SILS for colon cancer was attempted in 70 consecutive patients by a single surgeon between
August 2014 and July 2016 at Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine.
Using prospectively collected data, an observational study was performed on an intention-to-treat basis.
Results: Hybrid SILS was technically completed in 66 patients, with a failure rate of 5.7% (4/70). One patient
was converted to open surgery for para-aortic lymph node dissection. Another was converted to open surgery
due to severe peritoneal adhesion. An additional trocar was inserted for adhesiolysis in the other two cases.
Median lengths of proximal and distal margins were 12.8 cm (interquartile range [IQR], 10.0–18.6), and 8.2
cm (IQR, 5.5–18.3), respectively. Median total number of lymph nodes harvested was 24 (IQR, 18–33).
Overall rate of postoperative morbidity was 12.9%, but there were no Clavien-Dindo grade III or IV
complications. There was no postoperative mortality or reoperation. Median postoperative hospital stay was 6
days (IQR, 5–7). Conclusions: Hybrid SILS using one additional 5 mm trocar is a safe and effective minimally
invasive surgical technique for colon cancer. Experienced laparoscopic surgeons can perform hybrid SILS
without a learning curve based on the formulaic surgical techniques presented in this article.

Keywords: colon cancer, single-incision laparoscopic surgery, colectomy

Introduction crowding in a small single incision, typically through the

umbilicus. Inadequate countertraction due to conflict
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between instruments can also make it difficult to dissect the

S ingle-incision laparoscopic surgery (SILS) for colo-rectal
cancer has been shown to be a feasible and safe procedure for
experienced laparoscopic surgeons.1,2 Sys-temic review with
pooled analyses of SILS in colorectal cancer or benign disease
revealed that length of hospital stay was shorter in the SILS
group than the conventional multiport laparoscopic surgery
(CMLS) group.3–5 Other reported ben-efits of SILS, such as
decreased intraoperative blood loss, quicker bowel function
recovery, and better cosmesis, remain
to be objectively proved.
SILS has some technical limitations, namely collision be-
tween laparoscopic instruments and the camera scope due to
tissue in an anatomically accurate manner.
Reduced port laparoscopic surgery (RPLS) is a surgical
technique that uses fewer and or smaller trocars than those
used in CMLS. RPLS includes SILS and SILS plus one ad-
ditional port. RPLS using one additional port can retain the
advantages of minimally invasive surgery while minimizing
6,7
the limitations of SILS in colorectal surgery. SILS plus one
additional port has been used to prevent conversion to CMLS
or open surgery, but few of these studies have reported
8,9
formulaic surgical techniques. Insertion of an additional 5
mm trocar at the beginning of surgery into the right lower

Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
*These authors contributed equally to this work.
Podium presentation at the meeting of the 16th Asia Pacific Federation of Coloproctology and 5th Eurasian Colorectal Technologies
Association, Seoul, Korea, March 29 to April 1, 2017.

1
 2 KIM ET AL.

quadrant for right or left colectomy and anterior resection

is a new concept. If necessary, an additional 5 mm trocar
site could be used for a drain.
In this study, we present our surgical technique, which
we call hybrid single-incision laparoscopic surgery (hybrid
SILS), which has the following criteria: (1) transumbilical
single incision; (2) only one additional trocar; and (3)
trocar no larger than 5 mm.
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Materials and Methods

This study involved 91 consecutive colon cancer surgeries
performed by a single surgeon between August 2014 and July
2016 at Kangbuk Samsung Hospital, Sungkyunkwan Uni-
versity School of Medicine, Seoul, Korea. Rectal cancer
surgery was excluded from this study, but low anterior re-
sections performed for rectosigmoid junction cancer to resect
distally 5 cm or more beyond tumor were included in this
study. The study was approved by the Ethics Committee at our
institution (KBSMC 2016-01-007). All surgeries in-cluded in
this study were performed by an experienced sur-geon who
had completed over 400 cases of laparoscopic colorectal
cancer surgery. During the study period, open surgery was
performed in 21 patients (23.1%); 5 because of combined
surgery, 12 because of an emergency operation performed for
perforation or obstruction, and 4 due to a tumor larger than 10
cm or direct invasion. Altogether, 70 patients (76.9%)
underwent hybrid SILS for colon cancer during the study
period. Using prospectively collected data, an obser-vational
study was performed on an intention-to-treat basis.
Surgical procedure
After general anesthesia, all patients were placed in the
modified lithotomy position. Hybrid SILS was performed with
a platform using a hand-made glove port. This platform was
made using one nonpowdered surgical glove (6.5† size), two
12 mm trocars, and a commercially available wound protector
(Alexis wound protector/retractor, small; Applied Medical,
Rancho Santa Margarita, CA) (Fig. 1). A right-hand glove was
used for left colectomy or anterior resection, and a left-hand
glove was used for right colectomy.
First, a 3–4 cm longitudinal transumbilical incision was
created, reflecting the patient’s body shape and tumor size.
After the wound protector was inserted into the incision, a
hand-made glove port was connected to the wound
protector, and they were rolled up together. In cases of left
colectomy or anterior resection, the platform using a right-
hand glove was aligned to the axis directed to the right
anterior superior iliac spine. For right colectomy, the
platform using the left-hand glove was aligned to the axis
directed to the left anterior superior iliac spine (Fig. 2).
These alignments were per-formed to minimize collisions
between laparoscopic instru-ments and the camera scope.
An additional 5 mm trocar was inserted into the right lower
quadrant in all cases of right or left colectomy and anterior
resection (Fig. 2). In all cases, a 10 mm flexible type scope
and standard laparoscopic straight instruments were used.
Colectomy and anterior resection were performed ac-
cording to the surgical strategy of complete mesocolic exci-
sion (CME) and D3 lymph node dissection for T1–T4 or
resectable metastatic colon cancer (Fig. 3). In some cases, D2
FIG. 1. The hand-made glove port consists of one non-
powdered surgical glove (6.5† size), two 12 mm trocars,
and a commercially available wound protector.
resection was performed for T1 cancer confirmed after co-
lonoscopic resection.
Right colectomy
Right hemicolectomy was started using an inferior ap-
proach, with peritoneal dissection between the mesoileum and
the retroperitoneum with the patient in the Trendelenburg
position with the right tilted upward. After continuous dis-
section from bottom to top through the anatomical plane along
the Toldt’s fascia, ileocolic vessels, right colic vessels, and the
right branches of the middle colic vessels were ligated at their
origins. The origins of the middle colic vessels were ligated in
cases of extended right hemicolectomy. CME was completed,
and the patient was then positioned in the reverse
Trendelenburg position for takedown of the hepatic flexure
and transverse colon from the parietal peritoneum. After right
hemicolectomy, extracorporeal end-to-side anastomosis was
performed using circular and linear staplers.
Left colectomy and anterior resection
The patient was placed in the Trendelenburg position with the left
tilted upward. Using conventional laparoscopic techniques, the origin
of the inferior mesenteric artery (IMA) was exposed, skeletonized,
and then ligated. Medial to lateral dissection was continued from
medial to lateral through the anatomical plane along the Toldt ’s
fascia. The inferior mes-enteric vein was also ligated at the
origin, below the inferior border of the pancreas, in case
splenic flexure mobilization had to be performed. In distal
sigmoid or rectosigmoid junction cancer cases, distal
resection was performed at least 5 cm be-yond the tumor.
Anastomosis was performed intracorporeally using a
conventional double-stapling technique. In some cases,
the root of the left colic artery was ligated after IMA lymph
 HYBRID SINGLE-INCISION SURGERY 3
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FIG. 2. When setting up hybrid single-incision laparoscopic surgery (hybrid SILS), alignment of the glove port is
important to reduce collisions. Left colectomy and anterior resection using a right-hand glove (A, C), right colectomy
using a left-hand glove (B), view from outside during right colectomy (D). , camera trocar; 1 , surgeon’s right hand; 2 ,
surgeon’s left hand.

node dissection in the splenic flexure or proximal descending discharged from hospital to home after they were tolerable
cancer, followed by anastomosis on a case-by-case basis. in regular diet and experienced normal bowel movement.
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Perioperative management Result

Patients scheduled to undergo left colectomy or ante-rior resection Patient characteristics

preoperatively received standard mechanical bowel preparation with
4 L polyethylene glycol (Colyte F; Taejoon Pharm, Inc., Seoul,
Korea). Right colectomy was per-formed after minimal bowel
preparation using 250 mL Magcorol solution (Taejoon Pharm, Inc.,
Seoul, Korea). A urinary catheter was inserted in the operation room
following general anesthesia. All anesthetic procedures were
performed in a routine manner. Intravenous patient-controlled
analgesia was postoperatively used for pain relief according to patient
preference. After full recovery from general anesthesia, all patients
were allowed a clear fluid diet. On the first postoperative day, patients
received a liquid diet, which was then advanced as tolerated. The
urinary catheter was removed at 6 am on the first postoperative day,
after which all patients were encouraged to ambulate. Patients were
In total, 70 patients with a mean age of 66.8 – 12.1 years
were analyzed. Clinical data, including gender, body mass
index, American Society of Anesthesiologists (ASA) score,
history of previous major abdominal surgery, and tumor lo-
cation, are show in Table 1. Intention-to-treat analysis was
performed. Categorical data are presented as percentage
and quantitative data as mean – standard deviation or
median value with interquartile range (IQR).
Perioperative outcomes
The most common type of surgery was anterior resection
(32, 45.7%). Hybrid SILS failed for technical reasons in 4
patients (5.7%). One patient was converted to open surgery
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FIG. 3. Ileocolic vessels at their origins (A); right colic vessels and right branches of the middle colic vessels are ligated
at their roots in right hemicolectomy, the origins of the middle colic vessels are ligated in cases of extended right hemi-
colectomy (B); IMA at the origin of the IMA (C); IMV at the origin, below the inferior border of the pancreas (D). GT,
gastrocolic trunk; ICA, ileocolic artery; ICV, ileocolic vein; IMA, inferior mesenteric artery; IMV, inferior mesenteric
vein; MC, midcolic vessels; RC, right colic vein; SMV, superior mesenteric vein.

for para-aortic lymph node dissection after confirmation of required during the surgeries. Mean operation time was
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para-aortic lymph node metastases by intraoperative frozen 152.0 – 37.0 minutes (Table 2).
sectioning. Severe peritoneal adhesion resulted in conversion Mean tumor size was 4.0 – 2.5 cm. Median lengths of
of hybrid SILS to open surgery in one case and necessitated proximal and distal margins were 12.8 cm (IQR, 10.0–18.6)
the use of additional trocars in two cases. Intraoperative blood and 8.2 cm (IQR, 5.5–18.3), respectively. Total number of
loss was less than 50 mL in 80.0% of cases and more than 100
mL in just 5.7% of cases. No transfusions were
Table 2. Perioperative Outcomes
No. of patients
Table 1. Clinical Characteristics of the Patients (n = 70)

No. of Type of surgery (%)

patients Right hemicolectomy 25 (35.7)
(n = 70) Segmental resection 2 (2.9)
Left hemicolectomy 2 (2.9)
Age (years) 66.8 – 12.1 Anterior resection 32 (45.7)
Gender (male/female) 45/25 Low anterior resection 7 (10.0)
ASA score (%) Subtotal colectomy 2 (2.9%)
1 20(28.6) Technical failure (%) 4 (5.7)
2 37(52.9) Open conversion 2
3 13(18.6) Additional trocar insertion 2
4 0(0) Estimated blood loss (%)
History of previous abdominal surgery (%) 14(20.0) <50 mL 56 (80.0)
Tumor location (%) 50–100 mL 10 (14.3)
Right colon or proximal transverse colon 25(35.7) >100 mL 4 (5.7)
Left colon or distal transverse colon 3(4.3) Transfusion during operation 0 (0)
Sigmoid colon 35(50.0) Operation time (minutes) 152.0 – 37.0
Rectosigmoid junction 7(10.0) Mean
Median 150 (128.75–170)
Values are presented as n (%) and mean value – standard
deviation. Values are presented as n (%), mean value – standard deviation,
ASA, American Society of Anesthesiologists. or median value (interquartile range).
HYBRID SINGLE-INCISION SURGERY 5
 Table 3. Pathologic Results SILS might be overestimated, because SILS is generally
performed by experienced laparoscopic surgeons. Further-
No. of patients (n = 70) more, the possible advantages of SILS might be due to bias in
12
Tumor size (cm) 4.0 – 2.5 patient selection criteria and reporting by SILS enthusiasts.
Proximal margin (cm) 12.8 (10.0–18.6) RCTs of single-incision laparoscopic colectomy (SILC) did
13,14
Distal margin (cm) 8.2 (5.5–18.3) not find SILC to be superior to CMLS. However, a RCT
Harvested lymph nodes (n) 24 (18–33) that enrolled only a selected group of patients with small
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a
Pathologic stage tumors and good operative risk showed that SILC was as-
I 20 (30.3) sociated with less postoperative pain and shorter hospital
II 20 (30.3) 15
stay than CMLS.
III 14 (21.2) We conceived of hybrid SILS to overcome the technical
IV 12 (18.2) limitations of SILS. In the present case series, a platform with
Values are presented as n (%), mean value – standard deviation, a glove and two 12 mm trocars was used. The feasibility of a
or median value (interquartile range). glove port for abdominal surgery, mainly cholecystectomy,
a 16
The 7th edition of the American Joint Committee on Cancer was first demonstrated in 2010. A glove port can minimize
Manual.
conflicts between the camera scope and instruments com-
pared with other commercially available SILS platforms. A
lymph nodes harvested was median 24 (IQR, 18–33) and 6.5† surgical glove is sufficiently flexible to separate the
mean 27.1 – 13.9. Pathologic stage was evenly distributed trocars for full movement with the camera scope or laparo-
(Table 3). scopic instruments inserted. Furthermore, only two trocars are
Overall rate of postoperative morbidity was 12.9%. No inserted into the SILS platform in hybrid SILS, mini-mizing
Clavien–Dindo grade III or IV complications were observed. crowding in the small single incision. These features allow a
There was no surgical site infection, postoperative mortality, shift from RPLS using three ports to hybrid SILS. Based on
or reoperation within 30 days after surgery. There was no our experience, hybrid SILS is technically very similar to
incisional hernia during the study period. During the follow-up RPLS using three ports. Experienced laparoscopic surgeons
period, 22 months after surgery, an incisional hernia oc-curred who can perform colon cancer surgery using only three ports
in a 75-year-old male patient who had suffered from chronic can shift to hybrid SILS without a learning curve.
kidney disease. Median postoperative hospital stay was 6 days In our hospital, CME with D3 lymph node dissection is
(IQR, 5–7) (Table 4). routinely performed in most curative colectomy and anterior
resections. D2 resection is performed only for pathologically
Discussion confirmed T1 cancer. Although there is limited evidence that
CME with D3 lymph node dissection leads to longer disease-
SILS is frequently compared with CMLS and has been free survival than D2 or less dissection, CME is associated
found to be feasible to perform, with several advantages with a larger number of lymph nodes harvested, an important
1,3,4,8–11
compared with CMLS. Reduction in hospital stay 17
quality marker of oncologic outcome. Hybrid SILS could
and less blood loss are commonly reported advantages of
10,11 provide a safe laparoscopic surgical field to complete CME
SILS over CMLS. However, most reports have re- with D3 lymph node dissection. In this study, median total
commended performing larger, multicentered, randomized
number of lymph nodes harvested was 24 (IQR, 18–33); fewer
controlled trials (RCTs) to confirm the benefits of SILS and to
3,4,10,11 than 12 lymph nodes were harvested in only two pa-tients,
clarify risks and disadvantages of SILS. SILS obvi-
both of whom had undergone D2 resection for T1 cancer. With
ously has more technical limitations than CMLS such as regard to the surgical strategy of CME and D3 lymph node
collision between laparoscopic instruments and the camera
dissection for colon cancer, well designed pro-spective RCTs
scope due to crowding in a small single incision. In addition to
are needed to conclude whether this strategy affords better
these technical limitations, the safety and advantages of
long-term oncologic outcomes than other strategies. Under
these circumferences, hybrid SILS could maximize the
Table 4. Postoperative Recovery possible benefits of SILS by minimizing technical limitations.
No. of patients
We excluded patients who underwent low anterior resec-
(n = 70)
tion using the hybrid SILS technique for rectal cancer. Low
Postoperative complications (%) 9 (12.9) anterior resections performed for rectosigmoid junction cancer
Ileus 6 (8.6) to resect distally 5 cm or more beyond tumor were included in
Bleeding, intraluminal 1 (1.4) this study, since upper or midrectum could be vertically
Pneumonia/atelectasis 2 (2.9) transected through an umbilical single incision without
Reoperation within 30 days of surgery 0 (0) excessive efforts and complications. However, when using
30-day postoperative mortality 0 (0) SILS for rectal cancer, it is technically difficult to vertically
Bowel function recovery (hours) transect the distal rectum through the umbilical single incision,
Time to first flatus 62.0 (48.0–72.5) even when using an articulating linear stapler. In particular, a
Time to first bowel movement 87.0 (72.0–103.3) narrow pelvis and/or lower rectal cancer ne-cessitate
Time to tolerance of regular diet 66.0 (48.0–90.0)
replacement of the 5 mm trocar in the right lower quadrant to a
Postoperative hospital stay (days) 6.0 (5.0–7.0)
12 mm trocar for insertion of a linear stapler. This is a
Values are presented as n (%) and median value (interquartile violation of the criteria for hybrid SILS. The next challenge is
range). how to vertically transect the distal rectum
 6 KIM ET AL.
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FIG. 4. Immediate postoperative wound and drain (A) in a patient (65-year-old female) who underwent anterior resection
with splenic flexure mobilization. A 3 cm longitudinal transumbilical incision for a hand-made glove port (B).
through an umbilical single incision without excessive
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efforts and complications. Advancements in laparoscopic
staplers or changes in surgical techniques would make it
2,18
feasible to perform distal rectal transection using SILS.
Hybrid SILS is one of the RPLS with insertion of an ad-
ditional 5 mm trocar during SILS. In previous reports of SILS
plus one additional port, the additional port appeared to have
been inserted during SILS to prevent conversion into CMLS
8,9
or open surgery. However, insertion of an additional 5 mm
trocar at the beginning of surgery into the right lower quad-
rant for right or left colectomy and anterior resection is a new
concept. If necessary, an additional 5 mm trocar site could be
used for a drain. Among the studies of SILS, a few have
1,2,8,9,14,19
mentioned use of a postoperative drain in SILS.
Drains are usually inserted through the umbilical single in-
cision site in SILS, but in cases using an additional trocar,
9
the drain was inserted in the additional trocar site. In a
Korean multicenter study of SILS, a drain was inserted in
65.4% of cases, and the most frequent site was the
1
umbilical incision. If the decision is made to leave a drain,
the right lower quadrant, an additional 5 mm trocar site,
might be a proper site for the drain in cases of right
colectomy or anterior re-section, which were the great part
of colon cancer surgery. Insertion of a drain into the
additional trocar site in RPLS (SILS plus one) indicates
that an umbilical incision is not the correct route for a
8,9
drain. Further studies would be needed to define the
necessity and route of surgical site drains in SILS/RPLS.
Median postoperative hospital stay was 6 days (IQR, 5–
7) in this study. Korean patients are usually discharged
from hospital to home after they are tolerable in regular
diet and experience normal bowel movement, since all
people living legally in Korea are automatically enrolled in
the national health insurance and total medical cost in the
hospital is low. Therefore, total hospital stay in Korea
would be longer than in other countries.
In conclusion, one additional 5 mm trocar makes it easy
to perform colon cancer surgery safely and effectively.
Furthermore, this trocar site can be reused as the site for a
postoperative drain (Fig. 4). Using the formulaic surgical
technique presented in this study, experienced laparoscopic
surgeons can perform hybrid SILS for colon cancer without
a learning curve.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Hyung Ook Kim, MD, PhD
Department of Surgery
Kangbuk Samsung Hospital
Sungkyunkwan University School of Medicine
29, Saemunan-ro
Jongno-gu
Seoul 03181
South Korea
E-mail: ho115.kim@samsung.com