Scarless Surgery? Understanding Laparoscopy

Colon removal through one small, hidden incision
3d image of colon

When laparoscopy was new in the 1990s, many colorectal surgeons thought it was a bad idea. It was never going to apply to colon surgery. This minimally invasive technique was good for gallbladder surgery, but for colon surgery, we thought it was not worth the time or the effort. The surgery was difficult to perform and the surgical tools were primitive.

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Even when I was in my training as short as five years ago, the common way to remove the colon was at least through a 10-inch incision, which could be up to a 15-inch incision depending on the size of the patient.

However, as surgeons’ laparoscopic skills improved over time, it became clear that a minimally invasive technique such as laparoscopy could tackle more than a gallbladder or an appendix. Incisions got smaller, operating room times dropped and instruments got better. Surgeons started doing laparoscopic colon removal surgery until it became commonplace.

Warning: The video is graphic. Viewer discretion is advised.

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This traditional laparoscopy leaves four to six incisions in the person’s abdomen. A special rod connected to a video camera is inserted through a small incision in the person’s abdomen. Then, three to five additional small incisions are made and used as “ports” in which to insert instruments to remove the colon.

But we could do better. As this method proved successful, colon removal with one single incision, called “single-port proctocolectomy,” became a game changer for patients. During the procedure, first performed at Cleveland Clinic, a special port is placed over the patient’s belly button, allowing for attachment to a camera and instruments for removing the colon all through one incision. We remove a person’s entire large intestine and rectum (which make up the colon) and leave only one coin-sized scar hidden in a person’s belly button.

One of the unique facets of colon surgery, which is not true of every specialty, is that the surgeon must remove the colon intact. This means that we always need a 2- to 3-cm incision to get the colon out. Three centimeters is plenty of room to put two instruments and a camera and remove a colon with no added incisions. The goal is to make the hole exactly big enough to get the colon out.

With this single-incision technique, I remove one to two colons weekly, using patients’ ileostomy sites for the incision. It’s an amazing procedure, just getting rid of the colon, getting rid of what is making people sick turns them around very quickly. With this technique, we help patients with colon cancer, Crohn’s disease, ulcerative colitis, diverticulitis or constipation when doctors advise that the colon be surgically removed.

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Potential benefits of single-port proctocolectomy include minimal or no scarring, shorter hospital stays, faster recovery and reduced pain for patients. This procedure has been thought to possibly improve female fertility after surgery by minimizing scar tissue in the abdomen.

Particularly for young people, I think there’s a real benefit to not having incisions all over your abdomen cosmetically. While we still need randomized studies to prove a benefit, surgeons who are good at it are doing so because they believe that the results are at least equal to laparoscopy. I think it’s the future of colon and rectal surgery as we keep moving forward.

The instrumentation is becoming so advanced that we may see a day when surgeons are able to operate inside the colon and rectum, which would mean no incisions for patients. I welcome this innovation and look forward to the day when even single-port surgery is considered too invasive because of new, better techniques.

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