Surgery, Gastroenterology and Oncology

ABSTRACT

Background: The small intestine is not fixed to the retroperitoneum, and lesions in the smallintestine can be resected through a very small skin incision, similar to laparoscopic surgery,if it is placed accurately. In 2010, we reported on small incisional surgery (SIS) for smallintestinal diseases, in which the skin incision was placed at the umbilicus based on anthropometricanalysis. However, the feasibility and usefulness of SIS for resection of smallintestinal lesions have not been elucidated.
Methods: From January 2015 to December 2018, seven consecutive patients diagnosedwith small intestinal tumors preoperatively underwent partial resection of the small intestinewith a 4-cm skin incision at the umbilicus, were retrospectively registered. After the partialresection of the small intestine extracorporeally, intestinal reconstruction was manuallyperformed by end-to-end anastomosis. Four of the patients had cancer, and three patientshad Meckel’s diverticulum with inflammation.
Results: The length of the skin incision was 4 cm in all patients. No patient required enlargementof the skin incision. The mean surgical time was 52.0 (43-58) min. The mean bloodloss was less than 5.0 ml. The mean postoperative hospital stay was 9.0 (8-10) days. Nopostoperative complications were encountered.
Conclusion: SIS with a 4-cm skin incision at the umbilicus for resection of small intestinal lesionsseems feasible and safe for non-obese patients, similar to single incision laparoscopic surgery.Key words: small incisional surgery, laparoscopic surgery, small intestinal disease.

INTRODUCTION

Recently, laparoscopic surgery has been performed for various diseases withsmaller surgical incisions instead of open surgery. However, the small intestine isnot fixed to the retroperitoneum, and lesions in the small intestine can beresected through a very small skin incision if it is placed accurately. In 2010, wereported on small incisional surgery (SIS) for small intestinal diseases, in whichan incision was placed at the umbilicus based on anthropometric analysis (1).

In this previous study, each visceral position (X cm, Y cm), measured by thecoordinate originating in relation to the umbilicus in all cases, was as follows:duodenojejunal flexure (1.3±1.3, 9.4±2.1) and ileocecal valve (-7.3±1.0, -2.8±1.7)(fig. 1).
The distance between the duodenojejunal flexure and ileocecal valve was approximately 15 cm. The length of the smallintestine was approximately 2,500 cm, and it waslocated between the two positions. When the incisionwas made at the umbilicus, almost the entire length ofthe small intestine, including the disease site, could bedelivered through the umbilical incision. However, thefeasibility and usefulness of SIS for the resection ofsmall intestinal lesions has not been elucidated.

METHODS

From January 2015 to December 2018, sevenconsecutive patients diagnosed with small intestinaltumors preoperatively underwent SIS with a 4-cm skinincision at the umbilicus at Kashiwa Hospital, JikeiUniversity, were retrospectively registered. Four of thepatients had cancer, and three patients had Meckel’sdiverticulum with inflammation (table 1).

The Ethics Committee for Biomedical Research of the JikeiInstitutional Review Board approved the protocol [30-431 (9452)], and all patients or their family membersprovided written informed consent to participate.

SURGICAL TECHNIQUE

First, a 4-cm incision with placement of a woundprotector was made at the umbilicus.






After the detection of the disease site in the small intestine underdirect vision, the small intestine, including the diseasesite, was delivered through the wound (fig. 2). Partialresection of the small intestine was performed extracorporeally,and intestinal reconstruction was manuallyperformed by end-to-end anastomosis. Finally, thelength of the skin incision immediately after removingwound protector was measured (fig. 3). Any drainagetubes for peritoneal drainage were not installed.

RESULTS

The length of the skin incision was 4 cm in allpatients. No patient required enlargement of the skinincision. The mean body mass index (BMI) was 22.9(21.6-23.4) kg/m2. Obese patients were not found inthem. The mean surgical time was 52.0 (43-58) min.The mean blood loss was less than 5.0 ml. The meanpostoperative hospital stay was 9.0 (8-10) days. No postoperative complications were encountered. Nopostoperative recurrence was identified more thanthree years after surgery in patients with small intestinalcancer.

DISCUSSION

In our previous study (1), the location of theduodenojejunal flexure and the ileocecal valve had fewanatomical variations. The duodenojejunal flexure wasanthropometrically located at approximately 9 cmcephalad from the umbilicus and approximately 1 cmleft side from the umbilicus. The ileocecal valve wasanthropometrically located approximately 7 cm rightfrom the umbilicus and 3 cm below the umbilicus.When the surgical incision was made at the umbilicus,almost the entire length of the small intestine, includingthe disease site, could be delivered through theumbilical incision without any laparoscopic assistance.
Recently, laparoscopic surgery has been performedfor various diseases with smaller incisions instead ofopen surgery. In laparoscopic colorectal surgery for colorectalcancer, mobilization of the digestive tract andlymphatic dissection have usually been performedintracorporeally (2-5). As laparoscopic mobilization ordissection of the small intestine is not needed for theintestine, which is not fixed to the retroperitoneum, SIScan be performed with a relatively small incisionwithout any laparoscopic assistance, which is similar tosingle incision laparoscopic surgery (SILS) (6,7). If thedisease site in the small intestine cannot be deliveredthrough the umbilical incision because the disease siteis located near the ileocolic valve, SILS should bemodified to mobilize from the cecum to the ascendingcolon to easily remove the disease site of the smallintestine (8-10).
As to the day of discharge, the mean postoperativehospital stay was 9.0 days. It seems that all patientswere physiologically ready to go home within 7 daysafter the operation. However, they wished to go homeon a Sunday/holiday or the day before. This is thereason why the period of hospitalization was extended.

CONCLUSION

In conclusion, SIS with a 4-cm skin incision at theumbilicus for resection of small intestinal lesions seemsfeasible and safe for non-obese patients, similar to SILS.

Ethics approval and consent to participate

The Ethics Committee for Biomedical Research ofthe Jikei Institutional Review Board approved the protocol[30-431 (9452)], and all patients or their family membersprovided written informed consent to participate.

Consent for publication

The written consent to publish images or otherpersonal or clinical details of participants was obtainedfrom the patient.

Competing interest

The authors declare no competing interests.

Funding: None.

REFERENCES

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