Intervention Protocol

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Single-incision versus standard multi-incision laparoscopic colectomy in patients with malignant or benign colonic disease

  1. Anne Catharina Brockhaus1,2,*,
  2. Stefan Sauerland3,
  3. Stefan Saad4

Editorial Group: Cochrane Colorectal Cancer Group

Published Online: 26 AUG 2013

DOI: 10.1002/14651858.CD010717


How to Cite

Brockhaus AC, Sauerland S, Saad S. Single-incision versus standard multi-incision laparoscopic colectomy in patients with malignant or benign colonic disease (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD010717. DOI: 10.1002/14651858.CD010717.

Author Information

  1. 1

    Institute for Quality and Efficiency in Health Care (IQWiG), Department of Medical Biometry, Cologne, Germany

  2. 2

    University of Cologne, Institute for Health Economics and Clinical Epidemiology, Cologne, Germany

  3. 3

    University of Witten/Herdecke, Institute for Research in Operative Medicine (IFOM), Cologne, Germany

  4. 4

    Acedemic Hospital University Cologne, Dept. of General, Abdominal, Vascular and Thoracic Surgery, Cologne, Germany

*Anne Catharina Brockhaus, catharina.brockhaus@iqwig.de.

Publication History

  1. Publication Status: New
  2. Published Online: 26 AUG 2013

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. What's new
  8. History
  9. Contributions of authors
  10. Declarations of interest
 

Description of the condition

Both benign and malignant diseases may necessitate colonic resection. The most common reasons for colonic resection are colon cancer and diverticulitis. Colon cancer is the fourth most frequent malignancy worldwide, with an expected incidence of 1.23 million and a mortality rate of more than 609,000 people in 2008 (GLOBOCAN 2008). The complete removal of the affected part of the intestine including the tumour, the affected lymph nodes and a safety area around the tumour is the therapy of choice (Weitz 2005). Diverticulitis, as the most frequent benign cause for colectomy, affects the sigmoid colon in the majority of cases. Its incidence is rising (Etzioni 2009; Kang 2003), and many patients undergo sigmoid resection, sometimes on an emergency basis. Resection of additional tissue or organs, such as lymphadenectomy in colon cancer, is usually not necessary when colonic resection is performed for benign disease,

 

Description of the intervention

Colonic resection (or colectomy) is one of the most common operations in general surgery. In 2011, a total of 97,000 partial or total colectomies were performed in Germany, which results in an annual rate of about 120 operations per 100,000 population. Over 90% of all colonic resections are partial colectomies, which includes segmental resection, ileocolectomy, cecectomy, right hemicolectomy, transverse colectomy, left hemicolectomy, and sigmoidectomy.

Laparoscopic colonic surgery was introduced in 1991 (Jacobs 1991) and gained acceptance based on evidence from clinical studies (Braga 2011; Lacy 2002; Lacy 2008; Nelson 2004), meta-analysis (Bonjer 2007) and Cochrane Reviews (Kuhry 2008; Schwenk 2008) over the years. It has been shown that laparoscopic surgery is a safe technique with many advantages for patients compared to open surgery, such as shorter hospital stay through improved convalescence, fewer wound infections, and less pain and fatigue.

Single-incision laparoscopic surgery (SILS) is a further development of laparoscopic surgery, which uses only one incision in the navel. This new technique was first applied for colectomy in 2008 (Bucher 2008; Remzi 2008). All the required instruments are inserted through this incision of 2 to 3 cm in length. Many surgeons perform SILS with specially-designed curved or articulated instruments, whereas conventional laparoscopic surgery is routinely performed using rigid instruments.

In laparoscopic multi-port colectomy, an additional incision (e.g. a low Pfannenstiel or midline incision) is necessary in most cases to facilitate specimen removal from the peritoneal cavity. In SILS colectomy, an additional incision is usually not required, because the specimen can be removed through the umbilical port site (with or without lengthening the incision). Alternatively, the resected part of the bowel can also be removed through the anus (Saad 2010). Anaesthesia and perioperative care are also the same for both techniques.

 

How the intervention might work

Laparoscopic surgery offers many advantages and the insult to the body is less severe compared to the open surgery, but there are still three to five incisions necessary through which the instruments are inserted. With each incision the risk of wound infection rises. For cosmetic reasons, it is desirable to obviate visible incisions, but SILS colectomy may also reduce wound pain, allow for quicker healing and have lower complication rates.

 

Why it is important to do this review

The number of surgeons who practice SILS is increasing rapidly, and the medical device industry has a strong thrust towards increasing the use of SILS, although this new technology is still in its infancy. Early case reports (Chow 2011; Leroy 2009) and series (Chambers 2011; Katsuno 2011; Law 2010; Palanivelu 2012; Paranjape 2012; Ramos-Valadez 2011; Vestweber 2012) have shown its feasibility and safety, and a number of comparative studies (Champagne 2011; Chen 2011; Delaney 2011; Papaconstantinou 2011; Ross 2011; Waters 2010) have recently been published. Nevertheless there are still unanswered questions regarding the efficacy and safety of this new technique. Therefore it is important to assess the efficacy and safety of SILS by preparing this systematic review.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. What's new
  8. History
  9. Contributions of authors
  10. Declarations of interest

To assess the effects of single-incision laparoscopic colectomy compared to conventional multi-port laparoscopic colectomy, using the current evidence provided by randomised controlled trials.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. What's new
  8. History
  9. Contributions of authors
  10. Declarations of interest
 

Criteria for considering studies for this review

 

Types of studies

Randomised controlled trials (RCTs).

 

Types of participants

Adult patients, in whom elective colectomy is indicated because of either malignant or benign disease.

We will exclude studies on children, because the relationship between patient size and instrument size is different in children. Furthermore, the indications for colectomy in children and the outcomes assessed in children are likely to differ from those in adults.

Because rectal surgery is technically more demanding and the advantages of the laparoscopic over the open approach are less clear than for colon surgery, we will restrict the current review to colonic resection.

 

Types of interventions

Single incision laparoscopic surgery (SILS) colectomy versus conventional multi-port laparoscopic colectomy.

 

Types of outcome measures

 

Primary outcomes

The review will look at two primary outcomes:

  • Local complications, including both intraoperative and postoperative events (rates)
  • Mortality at longest available follow-up (rates or hazard ratio)

When the data allow, we will also present the results for specific outcome subcategories, such as complications of higher severity or specific type (e.g. wound infection or incisional hernia).

 

Secondary outcomes

The secondary outcomes to be assessed in the review are listed in chronological order:

  • Conversion rate to laparoscopic (more than 1 port site), hand-assisted laparoscopic, or open surgery (rates)
  • Estimated blood loss (ml)
  • Operative time (minutes)
  • Number of patients with R0 resection, tumour-free resection margins, or both (rates)
  • Number of lymph nodes harvested (means)
  • Postoperative pain intensity (as measured on visual analogue scale, numerical rating scale or other valid instruments)
  • General complications (rates)
  • Resumption of bowel function (days)
  • Length of hospital stay (days)
  • Quality of life or fatigue (means, as measured on valid instruments)
  • Cosmetic result (means)
  • Disease-free survival (rates or hazard ratio)

 

Search methods for identification of studies

 

Electronic searches

We will conduct a comprehensive literature search to identify all published and unpublished randomised controlled trials with no language restriction.
Single-incision laparoscopic surgery (SILS) was first applied for colectomy in 2008 (Bucher 2008; Remzi 2008). We will search the following electronic databases to identify potentially-relevant studies from 2008 and onward:

  • Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) (latest issue) (for search strategy see Appendix 1);
  • MEDLINE (Ovid), 2008 to date (for search strategy see Appendix 2);
  • EMBASE (Ovid), 2008 to date (for search strategy see Appendix 3);
  • Clinical trials registries (WHO International Clinical Trials Registry Platform and ClinicalTrials.gov).

 

Searching other resources

We will handsearch abstracts from the following society meetings from 2008 to date: European Association for Endoscopy Surgery (EAES), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), American Society of Colon and Rectal Surgeons (ASCRS) and Society for Surgery of the Alimentary Tract (SSAT). In addition, the reference lists of retrieved studies will be checked.

 

Data collection and analysis

 

Selection of studies

Anne Catharina Brockhaus (ACB) and Elke Hausner (EH) will screen the results of the search strategy for potentially-relevant trials, and retrieve the full articles for all potentially-relevant trials. They will independently assess each of the trials for inclusion in the review. We will contact the original authors to retrieve the missing data. We will resolve any disagreements by discussion, with referral to a third author Stefan Sauerland (STS) if necessary. We will exclude potentially-relevant studies that do not meet the inclusion criteria and state the reason.

 

Data extraction and management

ACB and STS will independently extract data on study characteristics, including methods, participants, interventions, outcomes and results for the prespecified outcomes of interest. We will resolve any disagreements through discussion or by referring to a third author. If data from the trial reports are insufficient or missing, we will contact the authors for additional information.

Both data extraction and 'Risk of bias' assessment will be documented using a pre-designed proforma.

 

Assessment of risk of bias in included studies

ACB and STS will independently assess the risk of bias using the criteria described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Disagreements will be solved through discussion. We will present the results of our risk of bias assessment in a table and with a risk of bias summary figure. We will examine the following sources of bias :

Random sequence generation

  • Low risk of bias (The investigators describe a random component in the sequence generation process, i.e. computer generated random numbers)
  • Uncertain risk of bias (There was insufficient information to assess whether the method used was adequate)
  • High risk of bias (The investigators describe a non-random (or quasi-randomised) component in the sequence generation process)

Allocation concealment

  • Low risk of bias (Participants and investigators could not foresee assignment, i.e. because of central allocation)
  • Uncertain risk of bias (There was insufficient information to assess whether the method used was adequate)
  • High risk of bias (Participants or investigators could foresee assignments, i.e. because of alternation, unconcealed procedure)

Blinding of participants and personnel

  • Low risk of bias (Blinding of participants and personnel, or incomplete blinding, but the review authors judge that the outcome is not likely to be influenced by lack of blinding i.e. mortality)
  • Uncertain risk of bias (There was insufficient information to assess whether the blinding was adequately done)
  • High risk of bias (No or incomplete blinding and the outcome is likely to be influenced by lack of blinding)

Blinding of outcome assessment

  • Low risk of bias (Blinding of outcome assessment, no blinding, but the review authors judge that the outcome measurement is not likely to be influenced by lack of blinding i.e. mortality)
  • Uncertain risk of bias (There was insufficient information to assess whether the blinding was adequately done)
  • High risk of bias (No or incomplete blinding and the outcome measurement is likely to be influenced by lack of blinding)

Incomplete outcome data

  • Low risk of bias (No missing outcome data, stated reasons for missing outcome unlikely to be related to true outcome or imputed missing data using appropriate methods)
  • Uncertain risk of bias (There was insufficient information to make a decision)
  • High risk of bias (Reason for missing data likely to be related to true outcome, potentially inappropriate application of simple imputation, substantially missing patients in one of the treatment groups compared to the randomised group)

Selective outcome reporting

  • Low risk of bias (All of the study's pre-specified outcomes have been reported, which could be verified by the study protocol or becomes clear in the published reports)
  • Uncertain risk of bias (There was insufficient information to permit judgement)
  • High risk of bias (Not all of the study's pre-specified outcomes have been reported or not pre-specified measurements, analysis, methods or subsets of the data are reported)

Other bias

  • Low risk of bias (The study appears to be free of other sources of bias)
  • Uncertain risk of bias (There was insufficient information to permit judgement)
  • High risk of bias (There is at least one important risk of bias)

 

Measures of treatment effect

We will use Review Manager 5 to analyse the data. We expect to identify both dichotomous data and continuous data. As the effect measure for the dichotomous data we will use the risk ratio (RR) with 95% confidence intervals (CI). Continuous outcome data will, wherever possible, be expressed as mean differences with 95% CI. In case of different reported scales, we will use the standardised mean difference (SMD) with 95% CI for continuous outcomes. In the case of time to event data, the primary effect measure will be the hazard ratio (HR) with 95% CI.

 

Unit of analysis issues

As colectomy does not lend itself to study in cross-over trials, individual patients will be used as the unit of analysis.

 

Dealing with missing data

We will contact authors of trials to obtain any missing data. If there are still missing data despite our efforts to obtain them from the authors or estimate them from other statistics, we will try to decide whether this data are missing at random. If this is the case, we will only analyse the available data. If this is not the case, replacement of missing data will be performed. Continuous outcomes data will be replaced by the median or mean (depending on the anticipated outcome distribution) of the available information. Sensitivity analysis will be performed to estimate the impact of the chosen replacement method.

 

Assessment of heterogeneity

We will conduct tests for heterogeneity using a Chi2 test with significance being set at P value < 0.05, but due to the low power of this test we will examine every case with a P value < 0.2 for potential heterogeneity in its forest plot. In the case of heterogeneity we will not pool the results but try to explain the heterogeneity by subgroup and sensitivity analysis.

As additional information and quantification of heterogeneity we will also use the I2 as described in the Cochrane Handbook (Deeks 2011). It is defined as the proprotion of total heterogeneity that exceeds what would be expected due to chance. It depends on the strength of evidence for heterogeneity and the number of studies included, in other words on the Chi2 test and the degrees of freedom.

 

Assessment of reporting biases

We will assess potential publication bias using the funnel plot.

 

Data synthesis

If meta-analysis is possible, we will use the random-effects method (DerSimonian 1986).

 

Subgroup analysis and investigation of heterogeneity

We intend to explore the following potential sources of heterogeneity using subgroup analyses:

  1. type of disease (malignant vs. benign)
  2. study quality (good vs. lower quality (unclear allocation concealment and/or lack of blinded outcome assessment)
  3. surgeon's expertise as reported and analysed within the primary studies (with vs. without learning curve)

 

Sensitivity analysis

We will explore reasons for heterogeneity in the studies and, if necessary, use sensitivity analyses to examine the effects of excluding study subgroups. These exclusions might be:

  1. studies with lower quality
  2. type of disease (if necessary, we will regard malignant and benign disease separately)

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. What's new
  8. History
  9. Contributions of authors
  10. Declarations of interest

CCCG TSC for developing the Search strategy

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. What's new
  8. History
  9. Contributions of authors
  10. Declarations of interest
 

Appendix 1. Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) search strategy

#1 MeSH descriptor: [Colectomy] explode all trees
#2 MeSH descriptor: [Diverticulitis, Colonic] explode all trees and with qualifiers: [Surgery - SU]
#3 MeSH descriptor: [Colonic Neoplasms] explode all trees and with qualifiers: [Surgery - SU]
#4 MeSH descriptor: [Colorectal Neoplasms] explode all trees and with qualifiers: [Surgery - SU]
#5 MeSH descriptor: [Colonic Polyps] explode all trees and with qualifiers: [Surgery - SU]
#6 MeSH descriptor: [Intestinal Diseases] explode all trees
#7 MeSH descriptor: [Colorectal Surgery] explode all trees
#8 (colectom* or hemicolectom* or sigmoidectom* or ileocolectom* or cecectom*):ti,ab,kw
#9 (colon* or colorect* or intestin* or bowel* or diverticul* or polyp*) near/3 (resection* or surger* or operation*):ti,ab,kw
#10 (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9)
#11 MeSH descriptor: [Laparoscopy] explode all trees
#12 MeSH descriptor: [Surgical Procedures, Minimally Invasive] explode all trees
#13 (laparoscop* or minimal* invasiv* or keyhole* or bandaid):ti,ab,kw
#14 (#11 or #12 or #13)
#15 (incision* or single-incision* or site* or single-site or port* or multiport* or access* or SILS*):ti,ab,kw
#16 (#10 and #14 and #15) from 2008

 

Appendix 2. MEDLINE (Ovid) search strategy

1. exp Colectomy/
2. exp Diverticulitis, Colonic/su [Surgery]
3. exp Colonic Neoplasms/su [Surgery]
4. exp Colorectal Neoplasms/su [Surgery]
5. exp Colonic Polyps/su [Surgery]
6. exp Intestinal Diseases/su [Surgery]
7. exp Colorectal Surgery/
8. (colectom* or hemicolectom* or sigmoidectom* or ileocolectom* or cecectom*).mp.
9. ((colon* or colorect* or intestin* or bowel* or diverticul* or polyp*) adj3 (resection* or surger* or operation*)).mp.
10. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11. exp Laparoscopy/
12. exp Surgical Procedures, Minimally Invasive/
13. (laparoscop* or minimal* invasiv* or keyhole* or bandaid).mp.
14. 11 or 12 or 13
15. (incision* or single-incision* or site* or single-site or port* or multiport* or access* or SILS*).mp.
16. 10 and 14 and 15
17. randomized controlled trial.pt.
18. controlled clinical trial.pt.
19. randomized.ab.
20. placebo.ab.
21. clinical trial.sh.
22. randomly.ab.
23. trial.ti.
24. 17 or 18 or 19 or 20 or 21 or 22 or 23
25. humans.sh.
26. 24 and 25
27. 16 and 26
28. limit 27 to yr="2008 -Current"

 

Appendix 3. EMBASE (Ovid) search strategy

1. exp colon resection/
2. exp colorectal surgery/
3. exp colon cancer/su [Surgery]
4. exp colorectal cancer/su [Surgery]
5. exp colon diverticulosis/su [Surgery]
6. exp colon polyp/su [Surgery]
7. exp colon disease/su [Surgery]
8. (colectom* or hemicolectom* or sigmoidectom* or ileocolectom* or cecectom*).mp.
9. ((colon* or colorect* or intestin* or bowel* or diverticul* or polyp*) adj3 (resection* or surger* or operation*)).mp.
10. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11. exp laparoscopy/
12. exp minimally invasive surgery/
13. (laparoscop* or minimal* invasiv* or keyhole* or bandaid).mp.
14. 11 or 12 or 13
15. exp incision/
16. (incision* or single-incision* or site* or single-site or port* or multiport* or access* or SILS*).mp.
17. 15 or 16
18. 10 and 14 and 17
19. CROSSOVER PROCEDURE.sh.
20. DOUBLE-BLIND PROCEDURE.sh.
21. SINGLE-BLIND PROCEDURE.sh.
22. (crossover* or cross over*).ti,ab.
23. placebo*.ti,ab.
24. (doubl* adj blind*).ti,ab.
25. allocat*.ti,ab.
26. trial.ti.
27. RANDOMIZED CONTROLLED TRIAL.sh.
28. random*.ti,ab.
29. 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28
30. (exp animal/ or exp invertebrate/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans or man or men or wom?n).ti.)
31. 29 not 30
32. 18 and 31
33. limit 32 to yr="2008 -Current"

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. What's new
  8. History
  9. Contributions of authors
  10. Declarations of interest


DateEventDescription

20 June 2013Amended3rd draft: reply to reviewers' comments and new search strategy



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. What's new
  8. History
  9. Contributions of authors
  10. Declarations of interest

Protocol first published: Issue 8, 2013


DateEventDescription

16 May 2013Amended2nd draft: reply to reviewers' comments

17 April 2013Amendedsearch strategy



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. What's new
  8. History
  9. Contributions of authors
  10. Declarations of interest

STS conceived the idea for this review. ACB and STS drafted this protocol, and Stefan Saad commented on all surgical content.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. What's new
  8. History
  9. Contributions of authors
  10. Declarations of interest

The authors declare that they have no competing interests.

References

Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Acknowledgements
  7. Appendices
  8. What's new
  9. History
  10. Contributions of authors
  11. Declarations of interest
  12. Additional references
Bonjer 2007
  • Bonjer HJ, Hop WCJ, Nelson H, Sargent DJ, Lacy AM, Castells A, et al. Laparoscopically assisted vs open colectomy for colon cancer. Archives of Surgery 2007;142:298-303.
Braga 2011
  • Braga M, Pecorelli N, Frasson M, Vignali A, Zuliani W, Carlo VD. Long-term outcomes after laparoscopic colectomy. World Journal of Gastrointestinal Oncology 2011;3(3):43-8.
Bucher 2008
Chambers 2011
Champagne 2011
  • Champagne BJ, Lee EC, Leblanc F, Stein SL, Delaney CP. Single-incision vs straight laparoscopic segmental colectomy: a case-controlled study. Diseases of the Colon & Rectum 2011;54(2):183-6.
Chen 2011
  • Chen WT-L, Chang S-C, Chiang H-C, Lo W-Y, Jeng L-B, Wu C, et al. Single-incision laparoscopic versus conventional laparoscopic right hemicolectomy: a comparison of short-term surgical results. Surgical Endoscopy 2011;25(6):1887-92.
Chow 2011
Deeks 2011
  • Deeks JJ, Higgins JPT, Altman DG (editors). Chapter 9: Analysing data and undertaking meta-analyses. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011.
Delaney 2011
  • Champagne BJ, Lee EC, Leblanc F, Stein SL, Delaney CP. Single-incision vs straight laparoscopic segmental colectomy: a case-controlled study. Diseases of the Colon & Rectum 2011;54(2):183-6.
DerSimonian 1986
Etzioni 2009
  • Etzioni DA, Mack TM, Beart RW Jr, Kaiser AM. Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Annals of Surgery 2009;249(2):210-7. [PUBMED: 19212172]
GLOBOCAN 2008
  • International Agency for Research on Cancer. Country Fast Stat [online]. GLOBOCAN 2008.
Higgins 2011
  • Higgins JPT, Altman DG, Sterne JAC (editors). Chapter 8: Assessing risk of bias in included studies. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011.
Jacobs 1991
  • Jacobs M, Verdeja JC, Goldstein HS. Minimally Invasive colon resection (laparoscopic colectomy). Surgical Laparoscopy & Endoscopy 1991;1:144-50.
Kang 2003
Katsuno 2011
  • Katsuno G, Fukunaga M, Nagakari K, Yoshikawa S, Ouchi M, Hirasaki Y. Single-incision laparoscopic colectomy for colon cancer: early experience with 31 cases. Diseases of the Colon & Rectum 2011;54(6):705-10.
Kuhry 2008
  • Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer J. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database of Systematic Reviews 2012, Issue 5. [DOI: 10.1002/14651858.CD003432.pub2]
Lacy 2002
  • Lacy AM, García-Valdecasas JC, Delgado S, Castells A, Taurá P, Piqué JM, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. The Lancet 2002;359(9325):2224-9.
Lacy 2008
  • Lacy AM, Delgado S, Castells A, Prins HA, Arroyo V, Ibarzabal A, et al. The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Annals of Surgery 2008;248(1):1-7.
Law 2010
Leroy 2009
  • Leroy J, Cahill RA, Asakuma M, Dallemagne B, Marescaux J. Single-access laparoscopic sigmoidectomy as definitive surgical management of prior diverticulitis in a human patient. Archives of Surgery 2009;144(2):173-9.
Nelson 2004
  • Nelson H, Sargent DJ, Wieand HS, Fleshman J, Anvari M, Stryker SJ. A comparison of laparoscopically assisted and open colectomy for colon cancer. New England Journal of Medicine 2004;350:2050-9.
Palanivelu 2012
  • Palanivelu C, Vij A, Rajapandian S, Palanivelu P, Parthasarathi R, Vaithiswaran V, et al. Single incision laparoscopic colorectal resection: our experience. Journal of Minimal Access Surgery 2012;8(4):134-9.
Papaconstantinou 2011
  • Papaconstantinou HT, Thomas JS. Single-incision laparoscopic colectomy for cancer: assessment of oncologic resection and short-term outcomes in a case-matched comparison with standard laparoscopy. Surgery 2011;150(4):820-7.
Paranjape 2012
  • Paranjape C, Ojo OJ, Carne D, Guyton D. Single-incision laparoscopic total colectomy. Journal of the Society of Laparoendoscopic Surgeons 2012;16:27-32.
Ramos-Valadez 2011
  • Ramos-Valadez DI, Patel CB, Ragupathi M, Bokhari MB, Pickron TB, Haas EM. Single-incision laparoscopic colectomy: outcomes of an emerging minimally invasive technique. International Journal of Colorectal Disease 2011;26(6):761-7.
Remzi 2008
Ross 2011
  • Ross H, Steele S, Whiteford M, Lee S, Albert M, Mutch M, et al. Early multi-institution experience with single-incision laparoscopic colectomy. Diseases of the Colon and Rectum 2011;54(2):187-92. [PUBMED: 21228667]
Saad 2010
  • Saad S, Hosogi H. Natural orifice specimen extraction for avoiding laparotomy in laparoscopic left colon resections: a new approach using the McCartney tube and the tilt top anvil technique. Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 2010;20(8):689-92.
Schwenk 2008
  • Schwenk W, Haase O, Neudecker JJ, Müller JM. Short term benefits for laparoscopic colorectal resection. Cochrane Database of Systematic Reviews 2008, Issue 4. [DOI: 10.1002/14651858.CD003145.pub2]
Vestweber 2012
  • Vestweber B, Galetin T, Lammerting K, Paul C, Giehl J, Straub E, et al. Single-incision laparoscopic surgery: outcomes from 224 colonic resections performed at a single center using SILS. Surgical Endoscopy 2012;27(2):434-42. [DOI: 10.1007/s00464-012-2454-6]
Waters 2010
  • Waters JA, Guzman MJ, Fajardo AD, Selzer DJ, Wiebke EA, Robb BW, et al. Single-port laparoscopic right hemicolectomy: a safe alternative to conventional laparoscopy. Disease of the Colon & Rectum 2010;53(11):1467-72.
Weitz 2005