Right lower transverse incision versus vertical transumbilical incision for laparoscopic specimen extraction in patients with left-sided colorectal cancer: a comparative study of two mini-laparotomy techniques

Two hundred twelve consecutive patients with rectosigmoid and upper rectal cancer underwent laparoscopic resection between July 2010 and December 2014 and were registered prospectively into the database. Upper rectal cancer was defined as a tumor located above the anterior peritoneal reflection based on operative findings. Of the 212 patients, 29 were excluded for the following reasons: no anastomosis (n = 14), surgery for perforation or obstruction (n = 13), and laparoscopic resection with specimen extraction through the anus (n = 2). The data of the remaining 183 patients were analyzed.

All operations were performed by one colorectal surgeon with considerable experience in laparoscopic colorectal surgery (more than 1000 cases). Initially, a mini-laparotomy incision of about 4 cm was made at the right lower quadrant or vertical transumbilicus similar to the technique of single-incision laparoscopic colectomy. The incision length was decided according to tumor size. A right lower transverse incision was preferred if the tumors were located distally or a protective stoma was expected. After deployment of a wound protector (Alexis® wound retractor, Applied Medical, Rancho Santa Margarita, CA, USA) into the incision site, a surgical glove was installed. The surgical glove port was constructed by fixing two trocars (one 12-mm trocar and one 5-mm trocar) to the resected finger tip of the glove. A pneumoperitoneum was then established at a pressure of 10 to 12 mmHg. In all patients, a 0° 5-mm rigid laparoscope was used. A laparoscope was introduced through the surgical glove port, and additional trocars were inserted under laparoscopic vision. In patients who underwent laparoscopic surgery using a right lower transverse incision, a transumbilical 5-mm trocar was inserted for the laparoscopic camera, one 5-mm trocar was inserted for the operator’s use in the right midabdomen in the midclavicular line, and another 5-mm trocar was inserted for the assistant’s use in the left midabdomen lateral to the rectus muscle. In patients who underwent laparoscopic surgery using a transumbilical incision, one 12-mm trocar was inserted in the right lower abdomen and two 5-mm trocars were inserted, one in the right midabdomen in the midclavicular line and one in the left midabdomen lateral to the rectus muscle (Fig. 1). With the patients positioned in a slight Trendelenburg positioning with a right lateral tilt, laparoscopic electrocautery was used to score the peritoneum at the sacral promontory level, immediately dorsal to the pedicle of the inferior mesenteric artery. Next, the inferior mesenteric artery was ligated close to its origin while avoiding injury to the superior hypogastric nerve plexus. The inferior mesenteric vein was divided as close to the inferior border of the pancreas as possible. The dissection was discontinued when the left colon and retroperitoneum were separated, and all parts of colonic mesentery were transected intracorporeally using a vessel-sealing device. In patients with upper rectal cancer, a partial mesorectal excision was accomplished and the rectum was transected using one or two laparoscopic linear staplers. Following all laparoscopic procedures, the specimen was extracted through the initial right lower transverse or vertical transumbilical incision. Some patients underwent performance of a long right lower transverse incision to extract bulky specimens and create a stoma. In such cases, the appropriate stoma size was ensured by suturing this long abdominal incision. After extracorporeal transection of the proximal colon, intracorporeal anastomosis was usually performed with a circular stapler. Following this, four to six intracorporeal reinforcement sutures were performed in nearly all patients.

The 183 patients that underwent laparoscopic resection for rectosigmoid or upper rectal cancer were divided into two groups according to the specimen extraction site: right lower transverse incision group (RLT group, n = 61) or vertical transumbilical incision group (VTU group, n = 122). The clinical parameters analyzed included patient characteristics and perioperative outcomes, including operative time, intraoperative blood loss, numbers of lymph nodes examined, time to first flatus, postoperative pain scores, and postoperative length of hospital stay. Maximum pain was assessed on days 1 to 7 postoperatively using a visual analog scale, and the scores obtained were used to assess postoperative pain severity. The operative time was defined as the duration from performance of the first incision to completion of wound closure. The intraoperative blood loss volume was determined by subtracting the volume of instilled fluids from the volume of aspirated fluids. Diverting stomas were constructed at the surgeon’s discretion. Anastomotic leakage was considered present when a patient had fluid collection in the abdominopelvic cavity seen on imaging or by clinical symptoms (fever, leukocytosis, and purulent or fecal discharge from the drain) requiring operative or radiological intervention. Incisional hernia was defined as a palpable defect at the laparoscopic extraction or stoma site found on follow-up clinical examination. For patients that underwent diverting stoma, the development of an incisional hernia at the extraction site was evaluated after stoma closure. Parastomal hernia was defined as a palpable defect or bulge adjacent to a stoma. Wound infection was considered to be present when purulent discharge from a wound was observed or culture of the discharge was positive. Mortality was defined as death either during hospitalization or ≤30 days postoperatively. The ethics committee of Inje University Haeundae Paik Hospital approved the study protocol, and written informed consent was obtained from all patients before surgery.