In the past 2 years, a total of 34 articles and two systematic reviews on single-access laparoscopic colorectal surgery have been published [1]. The article by Kanakala et al. [2] adds to the existing literature a series of 40 single-port colorectal resections with results that compare favourably with those of multiport laparoscopic surgery at the same institution. Its main clinical messages are single-port laparoscopy is safe in selected cases and cosmesis is the advantage of this technique compared with standard laparoscopic colorectal surgery. Although this might seem a minimalist message, it is important in the sense that it emphasizes that in colorectal surgery we are approaching the optimal outcome. If we exclude rectal surgery, morbidity and mortality of elective colon resections are minimal, long-term results are good or excellent, and as a consequence, the surgeons can concentrate on reducing abdominal wall trauma and improving cosmesis. Nevertheless, in the mind of the average surgeon, two questions arise: is it wise to propose a more complex and manually demanding surgical technique only to achieve a cosmetic improvement? Are 40 non-randomized, retrospective, selected cases sufficient to define the safety of a technique? Furthermore, is it logical to propose a consistent change in the laparoscopic approach when laparoscopic surgery for colorectal diseases represents at present less than 30 % of colorectal surgery in the Western countries and its role in colorectal cancer, the most common indication, has only recently been proven to be efficacious in the long term? At present, is it not more crucial to improve the clinical application and encourage the use of standard colorectal laparoscopic surgery rather than modifying this recently established technique? There is hardly any field of surgery where technical improvements are pushed forward so forcefully as in the field of endoscopic surgery. This progressive modification of established practice may even appear initially to be an undesirable change when addressing a problem or clinical condition and may only later and retrospectively prove to be an improvement [3]. Although numberless concerns may rise, I believe that single-port colorectal surgery should be carefully tested in clinical practice and that the concepts underlying this technique will undoubtedly be of help in reducing trauma to the body while maintaining the excellence of clinical outcome. Without any doubt, prospectively designed randomized clinical trials showing that there is indeed a difference without a significant compromise of safety should be awaited before there is a wide diffusion of these techniques, but in discussing pros and cons of single-port colorectal surgery, we agree with Margo’s statement that ‘innovation through deviation from standard practice is an important means of improving surgical care and needs to be encouraged even if results may not always turn out as expected’ [4].
Invited comment on Kanakala et al: Comparative study of safety and outcomes of single-port access versus conventional laparoscopic colorectal surgery
MORINO, Mario
2012-01-01
Abstract
In the past 2 years, a total of 34 articles and two systematic reviews on single-access laparoscopic colorectal surgery have been published [1]. The article by Kanakala et al. [2] adds to the existing literature a series of 40 single-port colorectal resections with results that compare favourably with those of multiport laparoscopic surgery at the same institution. Its main clinical messages are single-port laparoscopy is safe in selected cases and cosmesis is the advantage of this technique compared with standard laparoscopic colorectal surgery. Although this might seem a minimalist message, it is important in the sense that it emphasizes that in colorectal surgery we are approaching the optimal outcome. If we exclude rectal surgery, morbidity and mortality of elective colon resections are minimal, long-term results are good or excellent, and as a consequence, the surgeons can concentrate on reducing abdominal wall trauma and improving cosmesis. Nevertheless, in the mind of the average surgeon, two questions arise: is it wise to propose a more complex and manually demanding surgical technique only to achieve a cosmetic improvement? Are 40 non-randomized, retrospective, selected cases sufficient to define the safety of a technique? Furthermore, is it logical to propose a consistent change in the laparoscopic approach when laparoscopic surgery for colorectal diseases represents at present less than 30 % of colorectal surgery in the Western countries and its role in colorectal cancer, the most common indication, has only recently been proven to be efficacious in the long term? At present, is it not more crucial to improve the clinical application and encourage the use of standard colorectal laparoscopic surgery rather than modifying this recently established technique? There is hardly any field of surgery where technical improvements are pushed forward so forcefully as in the field of endoscopic surgery. This progressive modification of established practice may even appear initially to be an undesirable change when addressing a problem or clinical condition and may only later and retrospectively prove to be an improvement [3]. Although numberless concerns may rise, I believe that single-port colorectal surgery should be carefully tested in clinical practice and that the concepts underlying this technique will undoubtedly be of help in reducing trauma to the body while maintaining the excellence of clinical outcome. Without any doubt, prospectively designed randomized clinical trials showing that there is indeed a difference without a significant compromise of safety should be awaited before there is a wide diffusion of these techniques, but in discussing pros and cons of single-port colorectal surgery, we agree with Margo’s statement that ‘innovation through deviation from standard practice is an important means of improving surgical care and needs to be encouraged even if results may not always turn out as expected’ [4].
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