Abstract

We performed a retrospective review of non-overweight (body mass index ≤ 25 kg/m2) patients scheduled to undergo a curative resection of locally advanced colon cancer via a transverse mini-incision (n = 62) or a longitudinal mini-incision (skin incision ≤7 cm, n = 62), with the latter group of patients randomly selected as historical controls matched with the former group according to tumor location. Extension of the transverse mini-incision wound was necessary in 3 patients (5%). Both groups were largely equivalent in terms of demographic, clinicopathological, and surgical factors and frequency of postoperative complications. Postoperative analgesic was significantly less (P = 0.04) and postoperative length of the hospital stay was significantly shorter (P < 0.01) in the transverse mini-incision group. Concerning a mini-incision approach for locally advanced colonic cancer, a transverse incision seems to be advantageous with regard to minimal invasiveness and early recovery compared with a longitudinal incision.

As a useful alternative to laparoscopic-assisted surgery, we have performed a longitudinal mini-incision (skin incision, <7 cm) for the resection of locally advanced colonic cancer in non-overweight (body mass index <25.0 kg/m2) patients since 2000 and have demonstrated satisfactory outcomes in terms of technical feasibility and safety, minimal invasiveness, and oncological safety.15  The “longitudinal short” or “transverse” incision has been proposed as part of an enhanced recovery after surgery (ERAS) clinical care protocol,6  which was developed firstly and mainly for open colectomies. The use of such incision types is considered to reduce postoperative pain, leading to a more rapid return of patient mobility. However, a “transverse mini-incision” has rarely been evaluated, probably because many surgeons likely believe a curative colectomy via such an incision type would be difficult to perform. In April 2009, we began using a “transverse mini-incision” for the curative resection of locally advanced colonic cancer as an alternative approach to the previously used “longitudinal mini-incision.” We herein report the results of a comparison between “transverse mini-incision” and “longitudinal mini-incision” for the resection of locally advanced colonic cancer in terms of technical feasibility and safety as well as minimal invasiveness.

Patients and Methods

This study was approved by the local ethics committee of Saitama Medical Center, Saitama medical University.

Patients

Data for 62 patients with locally advanced colonic cancer who were scheduled to undergo curative resection via a transverse mini-incision ≤7 cm (transverse mini-incision group) between April 2009 and March 2013 were evaluated retrospectively. In addition, 62 patients with locally advanced colonic cancer who were scheduled to undergo curative resection via a longitudinal (transrectus or midline) mini-incision (≤7 cm, longitudinal mini-incision group) between September 2002 and March 2009 were randomly selected as a control group and were matched with the patients in the transverse mini-incision group according to the tumor location. Patients with peritoneal carcinomatosis at the time of laparotomy were excluded.

Indications for transverse mini-incision

The inclusion and exclusion criteria for a transverse mini-incision were the same as for a longitudinal mini-incision performed prior to the introduction of the transverse mini-incision15 : the inclusion criteria were a body mass index ≤25.0 kg/m2, and a tumor size ≤7 cm, while the exclusion criteria were suspected severe adhesive formation after major abdominal surgery as determined by a computed tomography scan, and tumors invading the adjacent organs. Tumors located within 10 cm orally or anally from the splenic flexure were also excluded since such tumors are resected using laparoscopically assisted procedures at our institution.

Surgical techniques via transverse mini-incision

To standardize the surgical techniques of either transverse mini-incision or longitudinal mini-incision, board-certified surgeons of the Japan Society of Surgery and/or the Japan Society of Coloproctology managed all the surgical techniques as an operating surgeon or a supervisor. Thus, senior residents were occasionally an operating surgeon under the supervision of the board certificated surgeons (data not shown), similarly in conventional open curative colectomy. Drs. HI or JS was the operating surgeon or supervisor in the transverse mini-incision group, while Drs. HI, MY, or HN was the operating surgeon or supervisor in the longitudinal mini-incision group.

All the surgical procedures via the transverse mini-incision were the same as those via the longitudinal mini-incision reported elsewhere,15  except for the method of exposing the abdominal cavity. Each patient was positioned supine. A transverse incision ≤7 cm was placed in principle in the right lower abdomen for cecal or ascending colon cancers, in the lower abdomen for descending colon or sigmoid colon cancers, and in the epigastrium for transverse colon cancers (Fig. 1A). Following the skin incision, the anterior sheath of the rectus abdominis and the peritoneum were also incised transversely, without splitting the rectus muscle. A wound retractor (Alexis, medium size; Applied Medical, Rancho Santa Margarita, CA) was placed against the edge of the wound with the rectus muscle retracted laterally (Fig. 1B). If necessary, 1 to 4 gauze swabs were placed intraperitoneally to retract the small bowel and omentum away from the operative field. We did not use any specific instruments to obtain surgical field. Instead, an assistant slid the wound into position utilizing conventional retractors. Bowel resection along with mesocolic excision and high ligation of the regional vessels (D3-level lymph node dissection according to the Japanese guidelines7,8) was performed using a medial to lateral approach (Figs. 1C, 1D). All anastomoses were stapled extracorporeally.

Fig. 1

(A) Schema showing transverse mini-incision according to the tumor site: (a) right-sided colon, (b) mid-transverse colon, and (c) left-sided colon. (B) Right-sided colon retracted through the wound. (C) Photograph showing a wound retractor attached to the edge of the transverse mini-incision in a patient with ascending colon cancer. (D) Exposed superior mesenteric vein and superior mesenteric artery during standard lymph node dissection for the ascending colon. The ileocolic artery being ligated just prior to dissection.

Fig. 1

(A) Schema showing transverse mini-incision according to the tumor site: (a) right-sided colon, (b) mid-transverse colon, and (c) left-sided colon. (B) Right-sided colon retracted through the wound. (C) Photograph showing a wound retractor attached to the edge of the transverse mini-incision in a patient with ascending colon cancer. (D) Exposed superior mesenteric vein and superior mesenteric artery during standard lymph node dissection for the ascending colon. The ileocolic artery being ligated just prior to dissection.

Perioperative care

The perioperative care was almost similar between the two groups, even though the types of mechanical bowel preparation (use of polyethylene glycol or sennoside, or no bowel preparation) and the doses of intravenous antimicrobial prophylaxis with second-generation cephalosporins (single or multiple) differed according to the study period. In patients in whom an epidural anesthesia was given intraoperatively, the anesthesia was continued for 48 hours postoperatively. All the patients were given patient-controlled analgesia (PCA) postoperatively until no longer needed and oral fluid and diet were given as tolerated. None of the patients were given oral painkillers. Patients were discharged when they were fully mobile with minimal pain, could tolerate a full diet and experience normal bowel function, and were willing to go home.

Factors evaluated

Data for both groups were collected prospectively and were recorded on the patients' medical charts. Demographic, clinicopathological, and surgical factors, as well as postoperative complications and parameters related to postoperative recovery, were compared between the two groups.

Statistical analysis

A statistical software package (StatFlex version 7.0; Artec, Osaka, Japan) running on a personal computer was used to conduct the analysis. Continuous data were expressed as the median and range and were compared using the Mann-Whitney test. Categorical data were compared using the χ2  test or Fisher exact probability test where appropriate. All P values of less than 0.05 were denoted to be statistically significant. Since this study was performed on an intention-to-treat basis, patients with a failed mini-incision approach were included in the analysis.

Results

The site of tumor location was the cecum in 11 patients, the ascending colon in 24 patients, the transverse colon in 9 patients, the descending colon in 1 patient, and the sigmoid colon in 17 patients. Table 1 shows a comparison of the demographic, clinicopathological, and surgical parameters between the two groups. Age (P = 0.92), sex (P > 0.99), BMI (P = 0.53), types of surgery (P = 0.60), maximal tumor diameter (P = 0.36), pathological stage according to the 7th edition of the TNM classification (P = 0.13), and estimated blood loss (P = 0.12) did not differ significantly between the two groups. The median number of lymph nodes harvested tended to be larger in the transverse mini-incision group (21 versus 18, P = 0.12). Duration of surgery tended to be longer in the transverse mini-incision group (130 min versus 120 min, P = 0.07). Concerning the success rate of the mini-incision, 3 patients (5%) in the transverse mini-incision group required extension of the wound up to 9 cm in length because of poor visualization of the surgical field, while 2 patients in the longitudinal mini-incision group required extension of the wound up to 15 cm because of poor visualization in one and severe intra-abdominal adhesions in one. The success rate of the mini-incision did not differ between the 2 groups (95% versus 97%, P > 0.99). Table 2 shows a comparison of the postoperative complications. One patient in the transverse mini-incision group underwent a second laparotomy for re-anastomosis as a result of stricture, while 1 patient in the longitudinal mini-incision group underwent a re-laparotomy because of intra-abdominal bleeding. The frequency of postoperative complications did not differ between the 2 groups (11% versus 8%, P = 0.76). Concerning various parameters related to postoperative recovery, the time to first passage of flatus (P = 0.18) and the time to first passage of stool (P = 0.19) did not significantly differ between the 2 groups. Postoperative analgesic use (pentazocine, 15 mg, intramuscularly) was significantly less in the transverse mini-incision group (P = 0.04), even though the use of epidural anesthesia tended to be less in the transverse mini-incision group (P = 0.09). Postoperative length of the hospital stay was significantly shorter (P < 0.01) in the transverse mini-incision group than in the longitudinal mini-incision group (Table 3).

Table 1

Comparison of demographics, clinicopathological and surgical factors between patients with transverse and those with longitudinal mini-incision

Comparison of demographics, clinicopathological and surgical factors between patients with transverse and those with longitudinal mini-incision
Comparison of demographics, clinicopathological and surgical factors between patients with transverse and those with longitudinal mini-incision
Table 2

Postoperative complications between patients with transverse and those with longitudinal mini-incision

Postoperative complications between patients with transverse and those with longitudinal mini-incision
Postoperative complications between patients with transverse and those with longitudinal mini-incision
Table 3

Comparison of parameters related to postoperative recovery

Comparison of parameters related to postoperative recovery
Comparison of parameters related to postoperative recovery

Discussion

This study has shown that the transverse mini-incision was equivalent to a longitudinal mini-incision in terms of technical feasibility and safety as well as postoperative complications, although 3 patients required extension of the wound and 1 patient required a second laparotomy for re-anastomosis in the transverse mini-incision group. The duration of surgery tended to be significantly longer in the transverse mini-incision group, but the difference between the 2 groups (median value, 10 minutes) seems to be of little significance in clinical practice. The number of lymph nodes harvested did not significantly differ between the 2 groups and the median number of lymph nodes seems to be oncologically satisfactory9,10  in both groups. A longer follow-up period is needed to confirm the oncological safety of a transverse mini-incision approach, but we have already demonstrated that a longitudinal mini-incision had a similar oncological outcome, compared with a conventional open procedure. Thus, this approach seems to be acceptable if surgeons are familiar with a longitudinal mini-incision.15,1115  There may be a criticism regarding surgeons' experiences on the 2 study periods of different procedures. All the procedures throughout the 2 study periods were exclusively managed by the board-certified surgeons. In addition, surgical procedures related to colorectal surgery were standardized well in Japan according to the spread of the clinical guidelines7  for the management of colorectal cancer. Thus, we believe that there might be little difference in surgeons' experiences in the 2 study periods.

More importantly, we should note that a transverse mini-incision resulted in less postoperative pain and a shorter hospital stay in agreement with numerous previous reports. Although this study was retrospective in nature, the preoperative care was similar throughout the study period except for the perioperative bowel preparation and antimicrobial prophylaxis, suggesting a minimal bias in perioperative care between the 2 groups.

The possible mechanisms explaining the lesser pain after a transverse mini-incision are 2-fold. First, our approach could potentially avoid cutaneous somatic nerve injuries. In addition, our approach did not divide the rectus abdominis muscle and retracted it laterally, also avoiding relevant nerve injuries. Second, compared with a longitudinal incision, a transverse incision might decrease the tension on the wound itself as demonstrated in human16  and animal studies17 , leading to less pain.

Two systematic reviews or meta-analyses18,19  combining several studies comparing “long longitudinal incisions” and “long transverse incisions” for gastrointestinal and abdominal aortic surgeries demonstrated that postoperative pulmonary complications were fewer, short- and long-term wound complications were fewer, and postoperative pain was lesser in the “long transverse incision” group.

Regarding colorectal surgery, to the best of our knowledge, 3 retrospective studies have compared transverse incision and midline incision, regardless of the length of the incision and with no clear definition for a mini-incision. Stipa et al20 compared “transverse mini-incisions (n = 28)” and “midline incisions (n = 17)” for the curative resection of the right-sided colonic cancer. They reported that the recovery of postoperative bowel function tended to be faster and the postoperative hospital stay was significantly shorter in the “transverse mini-incision” group, though the actual lengths of the incision in both groups were not reported. Donati et al21 compared a “limited transverse incision” (median length, 10 cm; n = 62) and a “traditional midline incision” (median length, 20 cm, n = 61) for the resection of right-sided colonic cancer and concluded that the “limited transverse incision” had a significantly shorter operative time, earlier recovery of bowel motility, earlier oral intake, and shorter postoperative stay. Kam et al22 compared a “transverse mini-incision” (median length, 13.5 cm; n = 140) and a “midline incision” (median length, 20 cm; n = 140) for the resection of left-side colonic cancer and concluded that a “transverse min-incision” had significantly shorter operating time, an earlier postoperative recovery, less pain, and a shorter postoperative stay. In addition to these 3 reports, Theodosopoulos et al23 compared the results of right hemicolectomies for colonic cancer between a subcostal incision (median length, 10 cm; n = 113), and midline incision (median length, 12 cm; n = 100) and concluded that a subcostal incision, which might be a modification of a transverse incision, could achieve the same standards of tumor resection and surgical field accessibility as the midline approach, while reducing the time to postoperative recovery. Concerning a prospective randomized study, only 1 study24  has compared right hemicolectomies between a transverse incision group (n = 14) and a midline incision group (n = 14), but the study did not demonstrate any important difference between the 2 groups because of the insufficient number of cases.

The advantages of mini-incisions include a lower cost, faster completion of the procedure, reduced bulkiness of equipment, less manpower, and the possibility of exploring the entire peritoneal cavity without a loss of tactile sensation,15,1115  compared with laparoscopic-assisted approach. We do not deny the utility of a laparoscopic-assisted approach, but a retrospective study,25  comparing the effects of laparoscopic-assisted colectomies (average midline skin incision, 7.7 cm, n = 13) and open colectomies through a right transverse skin incision (average length, 10.3 cm, n = 20) for right-sided colon cancer, showed no significant differences between the 2 groups with regard to short-term surgical outcomes and oncological parameters, with longer operative time in the laparoscopic-assisted group.

This retrospective observational study with a small number of patients compared, possibly for the first time, a “transverse mini-incision” and a “longitudinal min-incision” for the resection of locally advanced colonic cancer with the same maximal incision (≤7cm) in both groups, which was shorter than those in previous reports describing “mini-incisions.” In addition, the tumor site was matched between the 2 groups; thus, this study seems to be more credible than previously reported studies comparing incision methods (transverse or longitudinal) and patients' outcomes, although a prospective randomized study with a larger series is needed to conclude the superiority of either type of mini-incision.

This study excluded patients with a BMI >25kg/m2, since we felt that a curative colectomy would be difficult to perform in overweight or obese patients. We previously reported that our “longitudinal mini-incision” would be suitable for most patients with colonic cancer in East Asian countries, since the incidence of overweight (BMI > 25.0 kg/m2) or morbidly obese patients (BMI > 30.0 kg/m2) in East Asian countries is lower than that in Western countries.26  Thus, we should note that the merits of a “transverse mini-incision” also might be restricted to select patients, similar to the situation for “longitudinal mini-incision.”

In conclusion, our preliminary case-match retrospective study demonstrated that a “transverse mini-incision” is similar to a “longitudinal mini-incision” in terms of technical feasibility and safety as well as postoperative morbidity for the surgical treatment of nonoverweight patients with locally advanced colonic cancer. In addition, some postoperative recovery-related parameters seemed to be more favorable in the “transverse mini-incision” group.

Acknowledgments

The authors would like to thank Professor Tomoyuki Kawada, Nippon Medical School, for his assistance with the statistical analysis.

The authors have no conflict of interest to disclose.

References

References
1
Ishida
H
,
Nakada
H
,
Yokoyama
M
,
Hayashi
Y
,
Ohsawa
T
,
Inokuma
S
et al
.
Minilaparotomy approach for colonic cancer: initial experience of 54 cases
.
Surg Endosc
2005
;
19
(
3
):
316
320
2
Ishida
H
,
Ishiguro
T
,
Ohsawa
T
,
Okada
N
,
Yokoyama
M
,
Kumamoto
K
et al
.
Curative colectomy via minilaparotomy approach without utilizing specific instruments
.
Tech Coloproctol
2010
;
14
(
2
):
153
159
3
Ishida
H
,
Ishiguro
T
,
Ohsawa
T
,
Okada
N
,
Kumamoto
K
,
Ishibashi
K
et al
.
Oncologic outcome of stages II/III colon cancer treated via minilaparotomy
.
Int Surg
2011
;
96
(
2
):
127
134
4
Ishida
H
,
Ishiguro
T
,
Ishibashi
K
,
Ohsawa
T
,
Okada
N
,
Kumamoto
K
et al
.
Curative resection of transverse colon cancer via minilaparotomy
.
Int Surg
2011
;
96
(
1
):
6
12
5
Ishida
H
,
Ishiguro
T
,
Ishibashi
K
,
Ohsawa
T
,
Kuwabara
K
,
Okada
N
et al
.
Impact of prior abdominal surgery on curative resection of colon cancer via minilaparotomy
.
Surg Today
2011
;
41
(
3
):
369
376
6
Fearon
KC
,
Ljungqvist
O
,
von Meyenfeldt
M
,
Revhaug
A
,
Dejong
CH
,
Lassen
K
et al
.
Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection
.
Clin Nutr
2005
;
24
(
3
):
466
477
7
Japanese Society for Cancer of the Colon and Rectum
.
JSCCR Guidelines 2005 for the Treatment of Colorectal Cancer
.
Tokyo, Japan
:
Kanehara & Co
.
Ltd, 2005
8
Ishiguro
M
,
Watanabe
T
,
Kotake
K
,
Sugihara
K
.
Japanese Society for Cancer of the Colon and Rectum Guidelines 2010 for the treatment of colorectal cancer: comparison with western guidelines
.
Colorect Cancer
2013
;
2
(
2
):
179
190
9
Swanson
RS
,
Compton
CC
,
Stewart
AK
,
Bland
KI
.
The prognosis of T3N0 colon cancer is dependent on the number of lymph node examined
.
Ann Surg Oncol
2003
;
10
(
1
):
65
71
10
Chang
GI
,
Rodriguez-Bigas
MA
,
Skibber
JM
,
Moyer
VA
.
Lymph node evaluation and survival after curative resection of colon cancer. Systematic review
.
J Natl Cancer Inst
2007
;
99
(
6
):
433
441
11
Nakagoe
T
,
Sawai
T
,
Tsuji
T
,
Ayabe
H
.
Use of minilaparotomy in the treatment of colonic cancer
.
Br J Surg
2001
;
88
(
6
):
831
836
12
Nakagoe
T
,
Sawai
T
,
Tsuji
T
,
Jibiki
M
,
Nanashima
A
,
Yamaguchi
H
,
et al
.
Colectomy for colon cancer via a 7-cm minilaparotomy
.
Surg Today
2001
;
31
(
12
):
1113
1115
13
Takegami
K
,
Kawaguchi
Y
,
Nakayama
H
,
Kubota
Y
,
Nagawa
H
.
Minilaparotomy approach to colon cancer
.
Surg Today
2003
;
33
(
6
):
414
420
14
Ishikawa
M
,
Nishioka
M
,
Nanaki
N
,
Miyauchi
T
,
Kashiwagi
Y
,
Miki
H
.
Colorectal resection by a minilaparotomy approach vs. conventional operation for colon cancer. Results of a prospective randomized trial
.
Hepatogastroenterol
2007
;
54
(
79
):
1970
1975
15
Hsu
TC
.
Feasibility of colectomy with mini-incision
.
Am J Surg
2005
;
190
(
1
):
48
50
16
Nishihara
G
,
Prudden
JF
.
A quantitative relationship of wound tensile strength to length
.
Surg Gynecol Obstet
1958
;
107
(
3
):
305
310
17
Nilsson
T
.
The relative rate of wound healing in longitudinal and transverse laparotomy incisions. Animal experiments
.
Acta Chir Scand
1982
;
148
(
3
):
251
256
18
Grantcharov
TP
,
Rosenberg
J
.
Vertical compared with transverse incisions in abdominal surgery
.
Eur J Surg
2001
;
167
(
4
):
260
267
19
Brown
SR
,
Goodfellow
PB
.
Transverse verses midline incisions for abdominal surgery
.
Cochrane Database Syst Rev
2005
;
19
(
4
):
CD005199
20
Stipa
F
,
Barreca
M
,
Lucandri
G
,
Fernades
E
,
Mercantini
P
,
Meli
L
,
Ziparo
V
.
Transverse minilaparotomy as an access route in right colon disease: a valid alternative to midline laparotomy
.
Chir Ital
2000
;
52
(
1
):
91
96
21
Donati
D
,
Brown
SR
,
Eu
KW
,
Ho
YH
,
Seow-Choen
F
.
Comparison between midline incision and limited right skin crease incision for right-sided colonic cancers
.
Tech Coloproctol
2002
;
6
(
1
):
1
4
22
Kam
MH
,
Seow-Choen
F
,
Peng
XH
,
Eu
KW
,
Tang
CL
,
Heah
SM
et al
.
Minilaparotomy left iliac fossa skin crease incision vs. midline incision for left-sided colorectal cancer
.
Tech Coloproctol
2004
;
8
(
2
):
85
88
23
Theodosopoulos
T
,
Yiallourou
AI
,
Dafnios
N
,
Polymeneas
G
,
Papaconstantinou
I
,
Staikou
C
et al
.
Right Kocher's incision: a feasible and effective incision for right hemicolectomy: a retrospective study
.
World J Surg Oncol
2012
;
10
:
101
24
Brown
SR
,
Goodfellow
PJ
,
Adam
IJ
,
Shorthouse
AJ
.
A randomized controlled trial of transverse skin crease vs. vertical midline incision for right hemicolectomy
.
Tech Coloproctol
2004
;
8
(
1
):
15
18
25
Lohsiriwat
V
,
Lohsiriwat
D
,
Boonnuch
W
,
Chinswangwatanakul
V
,
Akaraviputh
T
,
Methasade
A
et al
.
Comparison between midline and right transverse incision in right hemicolectomy for right-sided colon cancer: a retrospective study
.
J Med Assoc Thai
2009
;
92
(
8
):
1003
1008
26
WHO expert consultation
.
Appropriate body-mass index for Asian population and its implications for policy and intervention strategies
.
Lancet
2004
;
363
(
9403
):
157
163