Traditional laparoscopic right hemicolectomy (TLS) is more effective and less invasive than open right hemicolectomy. TLS could decrease postoperative pain, complication rates, adhesions, and incision hernia, and it could also enhance recovery.1 Meanwhile, laparoscopic trocar could cause severe trauma to the abdominal wall and peritoneum and result in hemorrhage and hernias at the port site.
However, all these complications may potentially be reduced by single-incision laparoscopic right hemicolectomy (SILS).2 Since the first case of SILS was reported in 2008, SILS has been widely used for right colon diseases.3 According to the previous meta-analyses about SLIS versus TLS, SILS had advantages in terms of efficacy and recovery.4,5 There are 2 meta-analyses that have focused on right hemicolectomy to compare SLIS with TLS. Vettoretto et al6 and Dong et al7 each published an article in 2013 and 2018, respectively. Vettoretto et al6 indicated that no statistical differences were observed between the 2 techniques. Dong et al7 discovered that SILS had a smaller incision, shorter hospital stay, and less blood loss than TLS.
However, we incorporated more studies with more patients and added more relevant figures. The aim of the meta-analysis was to systematically compare the advantages and disadvantages of 2 operative techniques and to obtain more accurate data.
We adhered to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) statement to perform this study. We systematically reviewed related studies as per the protocol including query strategy, inclusion and exclusion, evaluation, and statistical analysis.
We had systematically searched useful studies of PubMed, Medline, Embase, Cochrane Library, and Wanfang database from 2010 to 2018. The search terms included “single-incision,” “laparoscopy,” “single-port,” “SILS,” “single site,” “single-incision laparoscopic right hemicolectomy,” “traditional laparoscopic right hemicolectomy,” “colon cancer,” and “right colon diseases.” When necessary, manual searches of references from the articles were performed. We tried our best to get the most comprehensive information of the related articles, with summary, research, and application reviewed.
Inclusion and Exclusion Criteria
Studies were reviewed carefully according to the criteria of the Population, Intervention, Comparator, Outcomes, and Study design (PICOS). The details are as follows: Population: patients with right colon diseases (including tumor, inflammation, polyps, adenoma, Crohn disease, and other diseases that need surgery); Intervention: assessment of SILS or TLS; Comparator: clinical and pathologic outcome of the 2 techniques; Outcomes: clinical and long-term outcomes were expressed by standardized mean differences (SMD) with 95% confidence intervals (CIs) for continuous data and relative risks (odds ratios or RRs) with 95% CIs for dichotomous outcomes; Study design: randomized controlled trials (RCTs), retrospective comparative nonrandomized trials, prospective comparative nonrandomized trials, or comparative observational (cohort and case-control) studies except letters.
Types of Interventions and Outcomes of Interest
Laparoscopic surgery was performed through a small hole with special instruments. SILS had only 1 hole for port, whereas TLS always had ≥3 ports for surgery. We used the following outcomes to compare SILS and TLS: (1) operative outcomes including the surgical duration, the amount of bleeding (blood loss), the time of bowel movement, and the incision length; (2) recovery outcomes including postoperative complications, proximal surgical edge (PSE), the distal surgical edge (DSE), the lymph nodes’ dissection, readmission and hospital stay; and (3) midterm outcomes including local recurrence, metastasis, and mortality. In the subgroup analysis, we divided the patient group into malignant group and mixed group (mixed disease group including tumor, inflammation, polyps, adenoma, Crohn disease, and other disease) to further compare SILS and TLS in laparoscopic right hemicolectomy.
Data Extraction and Quality Control
The literature was searched according to the rules of the Newcastle-Ottawa Scale by 2 reviewers (G.H.Z. and H.T.W.) independently.8 The following data are shown in Table 1, including study characteristics (the first author, publication data, study area, study type and size, disease type) and patients’ baselines (age, sex, body mass index, and study quality). A third reviewer resolved all disagreements about the articles until a consensus was reached. We contacted the authors of the included studies with incomplete data, but did not get any additional information. For the continuous data with means and range, we did not use this type of data due to the inaccurate SD obtained by the online calculation formula.
We used Stata 11.0 to compare 2 groups by SMD with 95% CIs for continuous data and relative risks (ORs or RRs) with 95% CIs for dichotomous outcomes. The statistical heterogeneity was estimated by I2 statistic and χ2 test. When I2>50%, Begg test and funnel plot indicated publication bias; we used random-effects models. When I2<50%, the funnel plot and the Begg test showed no publication bias; the fixed-effects model was used. P<0.05 indicated statistically differences. Begg test and funnel plot were used to evaluate publication bias. Sensitivity analyses were conducted to decrease the impact of single study.
Among the 279 publications identified by our Internet search, 157 duplicated records were excluded. Full titles and abstracts were screened, and 88 studies were abandoned due to SILS, TLS, and right colon not being mentioned or due to insufficient data. Finally, 22 English research studies were included with 2218 patients with right colon diseases.9–30 Among the patients, 1038 (46.7%) patients underwent SILS, and 1180 (53.3%) patients underwent TLS. The malignant group contained 9 studies (1 multicenter data) with only malignant tumors, and mixed groups’ studies were composed of Crohn disease, adenoma, inflammatory, and other diseases (Table 1). There was no significant difference in the baseline characteristics of patients (age, sex, and body mass index). Data of operative outcomes and midterm outcomes are shown in Table 2. Data of recovery outcomes are shown in Table 3.
Quality Assessment Results
The qualities of nonrandomized controlled trials (NRCTs) were assessed with the Newcastle-Ottawa Scale from 3 aspects: patient selection, confirmation of exposure, and comparability of both groups. The study quality was low for 1<stars≤3, moderate for 4<stars≤6, and high for 7≤stars≤9. A total of 18 high-quality studies with suitable patient selection, appropriate confirmation of exposure, and comparability of both groups had achieved 7 to 8 scores, while other studies had moderated quality. The included NRCTs all had moderate or high quality, and the specific score is shown in Table 1. This study only included 3 prospective clinical trials without RCTs.
Operation Duration and Blood Loss
A total of 11 studies described the operation duration with complete data. SILS was associated with significantly less operation time than TLS in random-effects model (SMD: −0.35, 95% CI: −0.61 to −0.08, P<0.001; χ2=49.40, P<0.001, I2=79.8%, Figs. 1, 2A). Furthermore, 6 studies of malignant right colon diseases indicated the advantage of SILS in operative duration.
Depending on available data from 6 studies, SILS had less blood loss than TLS, without significant heterogeneity in the fixed-effects model (SMD: −0.23, 95% CI: −0.36 to −0.10; P<0.001; χ2=5.36, P=0.37, I2=6.6%, Fig. 2B). Both malignant and benign diseases confirmed this conclusion in subgroup analysis.
Incision Length and Conversion Rates
SILS had shorter incision length than TLS in random-effects model with high heterogeneity (SMD: −2.19, 95% CI: −3.66 to −0.71, P<0.001; χ2=316.1, P<0.001, I2=98.7%; Fig. 2C). Sixteen studies reported the conversion rates and showed that SILS had a similar conversion rate to TLS without statistical heterogeneity (RR: 1.24, 95% CI: 0.81-1.90, P=0.41; χ2=15.60, P=0.32, I2=3.9%, Fig. 2D).
Postoperative Complications and Lymph Node Dissection
Postoperative complications (RR: 0.88, 95% CI: 0.73-1.06, P=0.87; χ2=12.28, P=0.17, I2=0%, Fig. 3A) and lymph nodes dissection (SMD: −0.06, 95% CI: −0.17 to 0.04, P=0.24; χ2=14.53, P=0.10, I2=38.1%, Fig. 3B) of SILS and TLS also had the same result without huge heterogeneity.
PSE and DSE
PSE (SMD: −0.08, 95% CI: −0.20 to 0.05, P=0.24; χ2=0.59, P=0.96, I2=0%, Fig. 3C) and DSE (SMD: −0.08, 95% CI: −0.19 to 0.35, P=0.55; χ2=12.69, P=0.01, I2=68.5%, Fig. 3D) of SILS were similar to that of TLS.
Readmission and Hospital Stay
On the basis of fixed-effects model, 2 groups had no obvious difference of readmission (RR: 0.94, 95% CI: 0.35-2.53, P=0.90; χ2=1.63, P=0.65, I2=0%; Fig. 3E). Compared with the TLS group, the SILS group had a shorter hospital stay (SMD: −0.27, 95% CI: −0.37 to −0.16, P<0.001; χ2=9.17, P=0.42, I2=1.9%, Fig. 3F), especially for the treatment of malignant colon diseases, but this was not true for the mixed group.
Local Recurrence, Metastasis, and Mortality
Three studies provided data on local recurrence, with 4 studies mentioning distant metastasis and mortality. Local recurrence of SILS was similar with TLS (RR: 1.35, 95% CI: 0.48-3.80, P=0.28; χ2=1.53, P=2.5, I2=20%, Fig. 4A), metastasis (RR: 0.76, 95% CI: 0.28-2.12, P=0.69; χ2=1.45, P=0.60, I2=0%, Fig. 4B) or mortality (RR: 0.86, 95% CI: 0.22-3.37, P=0.85, χ2=0.81, P=0.83, I2=0%, Fig. 4C) without significant heterogeneity.
On the basis of similar baseline characteristics, Begg correlation test (complication, P=0.75; conversion, P=0.35) revealed no clear publication bias. Sensitivity analysis indicated good quality of researches would not impact the final results.
The incidence of right colon disease is getting higher. Minimally invasive surgery became more and more popular in colorectal surgery, and it could bring many benefits to patients. The emergence of advanced equipment and techniques had facilitated laparoscopic surgery. Laparoscopic right hemicolectomy is a common clinical surgical procedure, and it has replaced open surgery in many hospitals and become the gold standard of colorectal surgery for right colon diseases. The amplification of laparoscopy is helpful to clear the tiny metastatic lymph nodes around the superior mesenteric artery, and it could improve patient survival. Several meta-analyses demonstrated that SILS had some advantages in rectal and sigmoid cancer.31 Liu et al32 had indicated SILS had less defecation time, exhaust time, and hospital stay than TLS in sigmoid colon and rectal cancer.
Vettoretto and colleagues, Dong and colleagues had reported SILS was better than TLS in some data in laparoscopic right hemicolectomy. Vettoretto and colleagues published the first meta-analysis to compare SILS and TLS for right colon diseases, and analyzed some data to compare the 2 techniques. However, the meta-analysis only included 9 studies and indicated many negative results due to the short technique development time. Dong and colleagues included 17 studies and confirmed that SILS had some advantage in blood loss, skin incisions, and hospital stay. The study contained more disease types and patient cases, and it could be better for comparison between SILS and TLS for right colon diseases. However, the article did not compare the patient’s recurrence, metastasis, and other data. To further illustrate the advantages of SILS in laparoscopic right hemicolectomy, we included more studies to compare the outcomes between SILS and TLS in right colon diseases. We collected the evidence-based data to compare operative data, recovery, and midterm outcomes between SILS with TLS. Most of the included NRCTs (retrospective comparative NRCTs and prospective comparative NRCTs) were good quality, and the studies provided reliable outcomes.
We observed that SILS had shorter operation duration than TLS. The surgeries in every study were performed by surgical teams, and every study was published in English with reliable data. Because of the improvement of the device, SILS with 3D visual effect could make the cooperation of the operator and assistant become easier than TLS. With the popularity of laparoscopic surgery, patients also hoped that a smaller incision could solve more problems. The experience with SILS increased, and the operation time decreased. Park et al24 also indicated SILS had less operation time than TLS for right colon disease. In subgroup analysis, the malignant group also had a similar result. Because of the high incidence of malignant tumors and the complexity of the disease in the mixed group, the surgical procedure is not exactly the same as the malignant group, and the surgical time had some difference in the mixed group.
SILS had less blood loss than TLS, and both malignant and benign groups also supported this phenomenon. Blood loss might be affected by surgical skills, experience of surgeons, and patient differences among centers. SILS was easy to carry out and decrease subsidiary-injury and blood loss. SILS had shorter incision length than TLS, which could reduce the suture time. SILS with only 1 incision could avoid multiple incisions in the abdomen and correspondingly shorten the length of the incision. Because of the large specimen of the right colon, TLS needed to extend the umbilical incision to facilitate specimen removal. However, SILS, with only a long incision in the umbilicus, might be more convenient to remove specimens without enlarging the incision. However, TLS must use multiple incisions to complete the surgery, correspondingly increase the length of the incision, and prolong the healing time. This finding was similar to some clinical reports.33 SILS also had shorter hospital stay than TLS, and we speculated that short incision could cut down the recovery time of patients and reduce the length of hospital stay. The advantages of SILS were reflected through incision length, blood loss, operation duration, and hospital stay.34
SILS had similar results of conversion and complication as those of TLS. The main reasons of conversion included obesity, narrow pelvis, abdominal adhesion, vascular variation, abdominal fetal development, heavy mesentery, and so on.35 High conversion rate is due to abdominal adhesion, especially in patients with double or multiple operations. We suggested that doctors could choose suitable cases to make the single-port laparoscopic right hemicolectomy easy when carrying out the operation for the first time. Once the learning curve has been completed, single-port laparoscopic surgery becomes simple.36 The complication rate is the main contributor to surgical technique and operative time. SILS with a short incision length might reduce postoperative pain, promote early activities, and reduce the incidence of complications. Our study showed that SILS had a similar complication rate and maximal pain score as that of TLS, and more RCTs were needed to further reveal the clinical significance of SILS.
The heterogeneity of pathologic outcomes might be attributed to variation in surgical skills, and experience of surgeons, lymph node dissection, and proximal and DSE seemed to be the same. Because of the large scope of laparoscopic right hemicolectomy, it is easy to achieve a good negative surgical margin, and we believed that SILS could be promoted in many hospitals. Because of the short development time of SILS, lack of clinical data might impact the results of distal metastasis and produce bias. We expect more clinical research to further illuminate the relationship between the groups.37
In subgroup analysis, the malignant group was better than the mixed group in operative duration and hospital stay. Some reasons might contribute to the results. First, due to the high incidence of colorectal cancer, SILS for malignant tumor was classical. Mixed group was composed of inflammatory, Crohn disease, and other diseases, which could have had an impact on the outcome. Second, regional differences, surgeon’s skill differences, and medical development differences might also affect the result.
The results of this study might have several limitations. First, 22 studies only contained a modest number of patients, and the included studies without RCTs were not of the highest quality of evidence. Second, different population differences and different units’ variations could cause potential selection bias. Third, due to the short development time of SILS, few studies have reported long-term survival and metastasis between the 2 techniques. Fourth, mixed group contained other colonic diseases that could lead to more heterogeneity to affect the final results. Fifth, several papers only reported the extracorporeal anastomosis method, and other papers had no related reports. Different anastomosis method could cause bias and affect the results.
For an advance in equipment, the SILS port could hold more holes, which makes it easier to contain more forceps to accelerate the operation. The technique could be better for people’s health than the previous treatment. In the future, more RCT studies with clinical follow-up data will be available to compare the 2 surgical techniques.38 Our meta-analysis provided current information on the role of SILS compared with TLS. We applied a series of keywords to identify the studies by strict criteria, with high quality and Begg test to evaluate the publication bias. Our study focused on laparoscopic right hemicolectomy with compatible patients and minimized bias for a broad range of colorectal surgery.
Hence, this study compared the reliability and safety of the SILS and TLS in laparoscopic right hemicolectomy. SILS had shorter operation time, shorter hospital stay, shorter incision length, and less blood loss than TLS. Short operation time and low blood loss could reduce intraoperative risk and enhance patient safety. Short-term recovery and midterm outcomes were similar between SILS and TLS, such as lymph node, PSE, DSE, readmission, complication rate, and other factors. In the subgroup analysis, the malignant group was better than the mixed group with respect to operation duration and hospital stay. With the continuing development of professional technology, future evidence of improvement in long-term oncological outcomes might justify the advantages and disadvantages of SILS and TLS.
The authors thank the Department of General Surgery of Cancer Hospital of China Medical University and Liaoning Cancer Hospital & Institute for technical assistance.
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