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Anastomotic leakage, cystic duct stump leakage and local tumour recurrence: ‘unhappy triad’ following single port access laparoscopic right colectomy for cancer

Dear Sir, Single port access (SPA) laparoscopic colectomy is a new technique that may offer superior cosmetic benefits compared with conventional laparoscopic surgery. Proponents of this new approach also emphasize the potential for reducing the risk of port-site incisional hernias. Various recent reports described the SPA technique for relatively complex procedures, such as right colectomy, sigmoid colectomy and gastrojejunostomy. All instruments are introduced through a single umbilical 3-cm incision. This approach, however, is technically challenging because of the combination of two major drawbacks: (i) a lack of triangulation; and (ii) the absence of off-axis vision. Most proponents of SPA concur to say that the technique is safe and only minor complications have been reported so far. Herein the clinical outcome is described of a patient with colon cancer who was operated on in our institution and who did not benefit from this approach. The patient was an 81-year-old woman who underwent an SPA right colectomy and cholecystectomy for colon cancer and cholelithiasis, according to a previously described technique [1]. Traction on the ascending colon was applied through transparietal stitches anchored to the colonic wall and then, in performing a medial-to-lateral approach, the ileocolic vessels were exposed with a suspending transparietal stitch anchored to the central vascular pedicle. A stapled extraperitoneal ileotransverse anastomosis was constructed with an Echelon Endopath 60 mm stapler (Ehticon Endo-Surgery, Spreitenbach, Switzerland). Retrograde cholecystectomy was performed and clips were applied to close the cystic duct stump and artery. Histopathological examination of the surgical specimen revealed a T4N0 mucinous colon adenocarcinoma. The duration of the procedure was 215 min. On postoperative day 4 the patient developed a pulmonary embolism and was transferred to the Intensive Care Unit. She eventually became septic with peritonitis and was taken back to the operating room on postoperative day 7. An emergency laparotomy showed a bile leak from the cystic duct stump and a leak from the ileocolic anastomosis with faecal peritonitis. The anastomosis was taken down and a terminal ileostomy was performed, with peritoneal lavage and ligature of the cystic duct. The patient was finally discharged on postoperative day 60. Six months later, the possibility of restoring intestinal continuity was discussed; unfortunately, a fluorodeoxyglucose-positron emission tomography (FDG-PET) CT scan revealed tumour recurrence [in the form of a 4 · 5cm hypermetabolic mass; standardized uptake value (SUV) = 7] in the pouch of Douglas. The patient died 18 months after the operation. SPA colectomy is a cosmetically attractive, commercially promising, but also a technically demanding approach developed by enthusiastic surgeons. In comparison with conventional laparoscopic surgery, it provides inferior vision of the operating field, inferior tissue retraction and a more difficult dissection. We propose that SPA should be critically evaluated in prospective, adequately designed randomized trials, in order to avoid repeating the mistakes that were made at the beginning of the laparoscopic colon cancer experience, back in the early 1990s [2]. There is little doubt that SPA surgery in general will continue to develop, taking advantage of newly designed surgical instruments and the patients’ demand for better cosmetic results. SPA colorectal surgery for benign diseases, such as Crohn’s disease or diverticulitis, is certainly an interesting alternative to conventional laparoscopic surgery, although the real benefits are as yet unproven. Many surgeons would concur that the cosmetic benefit of SPA is, at best, minimal and that it does not justify its application for colorectal malignancy outside research protocols. Our experience reported herein suggests that better cosmesis after colorectal surgery comes at a price and that this price may be too high for cancer patients.