Surgical Science, 2013, 4, 433-437
http://dx.doi.org/10.4236/ss.2013.410085 Published Online October 2013 (http://www.scirp.org/journal/ss)
Evaluation of the Sin gle-P ort Laparoscopic Right
Hemicolectomy Learning Curve*
Virgilio V. George#, Michael J. Guzman, Joshua A. Waters, Andrea L. Jester,
Don J. Selzer, Bruce W. Robb
Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
Received June 17, 2013; revised July 16, 2013; accepted July 24, 2013
Copyright © 2013 Virgilio V. George et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: The use of single-port laparoscopy has gained po pularity within recent years. Part of the appeal in learn-
ing this approach is that it draws heavily from concepts mastered through conventional laparoscopy. Various studies
have shown the efficacy and feasibility of the single-port laparoscopic approach, but there are few that examine the
learning curve in adop ting this new technique. Objective: Our goal was to better define the learning curve in perform-
ing a single-port laparoscopic right hemicolectomy. Design: A review of prospectively gathered operative data was
performed to analyze the results of single-port laparoscopic right hemicolectomies performed within our institution by
experienced laparo scopic surgeons. The first 100 cases were divided in to quintiles. Comparisons were made among the
cohorts regarding patient demographics, operative time, length of stay, conversions, and complications. Results: There
was no difference among quintiles with regard to age, sex, BMI, or ASA class. Operative time, conversions, length of
stay, and number of complications did not significantly vary among each group of patients. There was a significant dif-
ference in estimated blood loss and length of stay between the fifth cohort and the others due to one patient’s poor out-
come. Conclusions: The single-port laparoscopic right hemicolectomy learning curve for surgeons already skilled in
laparoscopy is short. Th ere are few differences in various outcome measures among groups at any stage in the learning
curve. The skills utilized to perform conventional laparoscopic colorectal surgery readily translate to the single-port
approach and result in proficiency from nearly the start.
Keywords: Single-Port; Laparoscopy; Learning Curv e; Colectomy
New surgical techniques are constantly being developed
around the world. Some interventions never gain traction,
while others become an important part of a surgeon’s
skill set. Single-port laparoscopy is one approach that has
steadily gained popularity across various surgical disci-
plines and is a frequent topic of investigation. It would
appear that single-port laparoscopy will remain a part of
surgical therapy for some time.
As the field of single-port laparoscopy grows, the
trend in publications changes with it. To date, there have
been a number of studies from the general, urologic, and
gynecologic surgery literature looking at the feasibility
and safety of the single-port laparoscopic approach to
various surgeries [1-5]. Although the technique may vary,
it would appear that nearly any surgery that can be done
laparoscopically can also be done using a single-port
Colon and rectal surgery is no stranger to this trend
and in recent years it has seen a vast increase in publica-
tions about the use of single-port laparoscopy. Our group
has published the largest series of single-port laparo-
scopic right hemicolectomies to d a te .
When learning any new procedure, there is a learning
curve that each person must complete in order to become
proficient. There has been some data addressing the
learning curve for single-port laparoscopic cholecystec-
tomy, gastric band placement, and nephrectomy [7-9].
However, there have been no studies looking at the
learning curve for performing any single-port laparo-
scopic colorectal surgeries. In this study, we aim to de-
fine the learning curve for single-port laparoscopic right
*Selected for podium presentation at the American Society of Colon
and Rectal Surgeons annual scientific meeting San Antonio, TX June
opyright © 2013 SciRes. SS
V. V. GEORGE ET AL.
2. Materials and Methods
2.1. Patient Selection
All study participants were selected based on the guide-
lines and regulations set by the Indiana University
School of Medicine Institutiona l Review Board.
This series represents a retrospective analysis of pro-
spectively gathered data from a consecutive series of
patients undergoing planned SPLRH in a single colorec-
tal surgery group between January 2008 and November
2010. The primary inclu sion criterion was planned sing le
port laparoscopic approach in the setting of a right
hemicolectomy. Patients were included in this series re-
gardless of operative indication, urgency of operation, or
ultimate approach (i.e. co nv ersion to open ) . Patients were
then divided into quintiles of twenty consecutive cases
for the purpose of statistical analysis.
2.2. Measurements and Endpoints Assessed
The data collected and analyzed in this series fall into
three groups: patient demographics, operative measure-
ments, and short term outcomes. Patient specific data
included: gender, age, body mass index (BMI), and
American Society of Anesthesiology (ASA) classifica-
tion as a surrogate of patient comorbidity. The operative
measurements used in our study were: operative time,
conversions to either multi-port laparoscopy or open
surgery, and the estimated blood loss (EBL). Short term
outcome measurements were total length of stay (LOS)
and number of complications. The different complica-
tions measured within our study included superficial
wound infection, abdominal abscess, anastomotic leak,
renal failure defined by increase in creatininegreater than
or equal to 1 mg/dL above baseline, post-o perative ileus,
post-operative bleeding (regardless of intervention), and
30 day mortality.
2.3. Operative Technique
The operative technique used by the surgeons within our
institution h as prev iously b een describ ed by W aters et al.
[6,10]. Briefly, a vertical incision was made in the fascia
large enough to accommodate the single-port trocar. A
standard 5-mm 30˚ laparoscope was then inserted (or
rarely a 10-mm laparoscope), followed by 25-mm work-
ing ports with non-articulating instruments. The ileocolic
pedicle was then elevated in order to dissect the colon off
its retroperitoneal attachments and duodenum in a medial
to lateral fashion. Once this was complete, the ileocolic
vessels were divided using an energy device. The hepatic
flexure and the lateral attachments were then tak en down
from superior to inferior. Fascial incisions were enlarged
as necessary to exteriorize the specimen for division and
anastomosis. After inspecting the anastomosis intracor-
poreally, the fascia was closed in either a running or fig-
ure-of-eight fas hi on.
2.4. Data Analysis and Presentation
All data was compiled, analyzed, and formatted into fig-
ures using GraphPad Prism (La Jolla, CA). Continuous
variables were compared using one-way analysis of vari-
ance (ANOVA). This data was described using means
with ranges where appropriate. Categorical data was
compared using a Chi-square test and presented as pro-
portions or number of instances where appropriate. Prob-
ability values less than or equal to 0.05 were considered
statistically significant. Data tables were made using Mi-
crosoft Word 2010 (Redmond, WA).
During our study period, a total of 100 patients under-
went SPLRH by our group of surgeons. The patient
demographics for all patients included in our study are
outlined in Table 1. As outlined in the table, there was
no statistical difference between quintiles with reg ards to
patient gender, age, ASA classification, or BMI. When
considering the entire study population, 61% were male,
the mean age was 64 years, the mean ASA class was 3,
and mean BMI was 28.
Operative measurements are described in Table 2.
Operative times are reported as mean time in minutes
with range, and mean time of operation throughout the
study period was 114 minutes with a range from 64 - 270
minutes. Conversion to either multi-port laparoscopy or
open was made at the discretion of each surgeon. Indica-
tions for conversion varied from failure to progress, dis-
covery of more invasive cancer than anticipated pre-
operatively, and inability to control bleeding. Estimated
blood loss is displayed in more detail in Figure 1. The
fifth quintile had a significantly higher mean blood loss
(228 mL) compared to the other groups. This quintile
contained one patient who was a particularly high outlier
in operative measures and short term outcomes.
Short term outcomes are displayed in Table 3. The
mean LOS for the entire population was 5.6 days with a
Table 1. Patient demographics.
group % maleAge (mean
1 - 20 55 65 (39 - 90) 3 (1 - 3) 28 (20 - 39)
21 - 40 65 65 (25 - 85) 3 (2 - 4) 27 (21 - 46)
41 - 60 55 67 (26 - 86) 3 (2 - 4) 26 (18 - 36)
61 - 80 70 64 (30 - 85) 3 (2 - 4) 29 (19 - 41)
81 - 10065 56 (28 - 83) 3 (2 - 4) 30 (18 - 43)
Copyright © 2013 SciRes. SS
V. V. GEORGE ET AL. 435
Table 2. Operative measures.
group Mean operative
time (min) Operative time
ranges (min) Conversions
1 - 20 109 71 - 212 1 open
21 - 40 119 83 - 194 2 lap, 1 open
41 - 60 108 64 - 177 1 open
61 - 80 112 67 - 190 0
81 - 100 127 86 - 270 1 open
Table 3. Short term outcomes.
group Mean length of
stay (days) Length of stay
range (days) Complications
1 - 20 6 2 - 24 4
21 - 40 4 2 - 11 3
41 - 60 5 2 - 10 1
61 - 80 5 2 - 26 3
81 - 100 7* 2 - 48 2
*p < 0.05.
Figure 1. Estimated blood loss (mean ± range) by 20 patient
cohorts. *Significantly different from other groups (p <
range from 2 - 48 days. Here again, the high outlier in the
fifth quintile made it significantly different from the
other groups. This patient had the longest stay out of the
entire population and eventually died due to multi-system
organ failure. When comparing the number of complica-
tions between each quintile, there was no difference be-
tween groups and overall rate of morbidity was 13%.
Single-port laparoscopy is becoming a popular option in
the field of colorectal surgery. However, because it is a
relatively new approach many surgeons do not have any
formal training in performing these operations. Those
who are taking it upon themselves to learn th is new tech-
nique do not yet know the number of cases it takes to
become proficient in safely performing a SPLRH, and
our study sought to evaluate the learning curve for this
operation. We have found that the learning curve is quite
short and almost non-existent fo r those already skilled in
conventional laparoscopic surgery and more specifically,
When examining the patients included in this study it
is important to note that our population is a fairly accu-
rate representation of a typical surgeon’s patient mix, as
we did not select out patients that are particularly slender,
young, or healthy. In fact, the average patient who un-
derwent SPLRH in our series was overweight (mean
BMI 28), older (mean age 64), and with significant co-
morbid conditions (mean ASA 3). This makes our results
easier to reproduce by the average colorectal surgeon in
Our group has been slowly expanding inclusion crite-
ria for those who are offered a SPLRH as experience
grows and currently any patient who would be an appro-
priate candidate for conventional laparoscopy is also
considered appropriate for the single-port approach, and
they are offered that option as well. It is likely that as th e
general public becomes more aware of single-port
laparoscopy the demand for it will increase based on its
potential benefits whether perceived or truly present.
With respect to operative times, we did not find any
significant change in the duration of operation between
quintiles. These times are also similar to those for per-
forming a conventional laparoscopic right hemicolec-
tomy. While this could mean that we have not yet started
the drastic improvement phase of the typical learning
curve, we think that is unlikely. All surgeons within our
group have significant experience with conventional
laparoscopy from formal fellowship training and years of
practice as attending surg eons. While it is possible that at
some point SPLRH could be performed faster than con-
ventional laparoscopy, our operative times are already
similar to other groups with right hemicolectomy . It
is likely that the skills already estab lished with multi-port
laparoscopic right hemicolectomy readily translate the
single-port approach. This may be due in part to our use
of standard laparoscopic instruments and cameras, which
eliminates the learning of new specialized and more
Conversions from the single-port approach to either a
multi-port approach or open technique did not change
significantly throughout our study period. Interestingly,
the only two conversions to conventional laparoscopy
took place within the second quintile by a single surgeon
who did so because of failure to progress within the op-
eration from difficult dissection. The conversions to open
surgery were done because of difficult dissection, where
it was believed that additional trocars would not signifi-
cantly improve the chance of completing the operation
laparoscopically and in the final instance, significant
Copyright © 2013 SciRes. SS
V. V. GEORGE ET AL.
bleeding was encountered that required direct visualiza-
tion for control. However, our overall conversion rate
was in line with other reported experiences . Addi-
tionally, we believe that conversion of the procedure
from a single-port approach should not be deemed a fail-
ure as much as it represents better judgment on the part
of the surgeon to change direction when the individual
scenario requires it.
Measurement of blood loss during an operation can be
interpreted in various ways. A large amount of blood loss
to one surgeon may mean that the surgery was particu-
larly difficult and that it may be expected that the patient
has a higher risk of having a post-operative complication,
but another surgeon may see that same blood loss and
interpret it as poor performance of the operating surgeon .
With that in mind, there was no diff erence in mean blood
loss across the quintiles until the final group. As previ-
ously mentioned, this was due to on e particular patien t in
that group who had a significant blood loss due to injury
to the middle colic vein. Interestingly, as the series went
on, there was an increase in the range of blood loss.
Our short term outcomes with regard to length of stay
and peri-operative morbidity did not change through the
progression of cases. Rather, both remained consistent
with other reported series of both single-port and multi-
port laparoscopic colectomies [10,12-14]. This suggests
that the key to determining patient recovery may not lie
within the approach between single or multi-port laparo-
scopy, and instead hinders on the nature of the operation
itself and/or inherent patient factors. Importantly, the use
of the single-port approach did not negatively impact the
rates of post-operative morbidity.
When examining the data presented here, it is impor-
tant to take into account a few limitations of this study.
These cases were performed by multiple surgeons in a
group. However, one surgeon either performed or as-
sisted in the majority of the cases ex amined in this series,
and all of our surgeons have similar training, experience
with colorectal surgery, and method to performing a
SPLRH, reducing the inter-surgeon variability. We did
look at the data from a single surgeon’s perspective but
did not find significant difference between his and the
rest of the group’s measures. Another limitation is that
the role of residents and fellows cannot be quantified
within the data. However, as would be expected, there is
a graded role of involvement over time with experience
by both the trainee and staff surgeon.
The introduction of new surgical techniques requires
completing a number of procedures before becoming
proficient. With the increasing presence of single-port
laparoscopy within surgical practice, it is important to
understand how long it takes a surgeon to become facile
with this evolving approach. Prior studies have already
examined the learning curve for various single-port
laparoscopic operations [7-9], and have concluded that
the learning curve is fairly short for those already ex-
perienced in their field. However, this is the first report
examining the learning curve with regards to colorectal
surgery. Whether this approach will become a part of an
average colorectal surgeon’s practice has yet to be de-
termined, and further investigations to understand its
potential long term benefits an d hazards are needed.
The learning curve for SPLRH is short for colorectal
surgeons who already experienced with conventional lap-
aroscopic operations. Surgeons who desire to start offer-
ing their patients a single-port approach to right hemi-
colectomy can do so without significant increase in op-
erative time, length of stay, or per-operative morbidity.
Surgeons will need to become facile with SPLRH to keep
up with patients’ increasing awareness and desire for this
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