Single IncisionLaparoscopic Surgery

Dr Anish NagpalLaparoscopic and Gastrosurgeon

Anya Gastro SurgicentreAhmedabad

www.obesityclinic.in

What is SILS?

Laparoscopic surgery through the umbilicus with a single incision

Advanced minimally invasive procedure in which the surgeon operates thru a single incsion :mostly tthru the umbilicsu

More Surgery with LESS or No Incision

ScarLESS Surgery

The Idea behind SILS!!

As a bridge b/n NOTES and Lap. Surgery

NOTES

Natural Orifice Trans Endoscopic Surgery Access to the abdominal cavity is required for

diagnostic and therapeutic endeavors for a variety of medical and surgical diseases.

Historically, abdominal access has required a formal laparotomy to provide adequate exposure.

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology.

Innovative surgical endoscopists Innovative Medical endoscopists

Surgical site infectionsHernia formationAdhesions areAdditional prospective benefits

derived from an incisionless technique are minimization of anesthesia and analgesia and lowered patient apprehension to elective surgeries

From Germany, Seifert described the first documented case of

NOTES in 2000, in which a posterior gastrotomy was

created with an endoscopic needle-knife, enabling

retroperitoneal passage of the endoscope to perform a

pancreatic necrosectomy in 3 patients too ill to tolerate

formal debridement

Drs Reddy and Rao from India further validated the

feasibility of NOTES by performing a NOTES appendectomy

in a human.40

Several inherent technical challenges to NOTES exist, including creating a viscerotomy, manipulating intraabdominal organs, and safely closing the viscerotomy.

the physiologic effects of orificial contaminates may be catastrophic

Acronyms

LESS- Laparo Endoscopic Single Site Surgery

SPA- Single Port Access NOTUS- Natural Orifice Trans Umbilical

Surgery TUES- Trans Umbilical Endoscopic Surgery SIMPLE- Single Incision Multi Port

Laparoendoscopic Surgery ScarLESS Surgery Etc……..

Rationale or Principles

Less Is MoreLessen the trauma of AccessLessen the residual scarGive the patient max. cosmetic

benefit

Alleged SILS Benefits

• Reduced surgical site infection• Reduced visible scarring• Reduction in pain & analgesics• Quicker recovery time• Reduction in hernias, adhesions• Advantages in the morbidly obese

History

Laparoscopy can be dated to over 100 years ago when George Kelling from Dresden, Germany introduced a cystoscope into the peritoneal cavity of a living dog and insufflated air to enhance the view.

History of SILS

SILS was described as early as 1992 by Pelosi who performed a single-puncture laparoscopic appendectomy

In 1997 Navarra et al. performed a laparoscopic cholecystectomy via two transumbilical trocars and three transabdominal gallbladder stay sutures

Refinement of equipment and technique have recently brought SILS into the mainstream.

Documented SILS - First

TurkeyDept. of Pediatric SurgeryAppendicectomy2005

Procedures performed

• Adrenalectomy• Appendectomy• Nephrectomy (partialpp y and donor)• Cholecystectomy• Gastrectomy• Prostatectomy • Pyeloplasty• Gastrostomy• Intestinal • Splenectomystoma• Varicelectomy• Hemicolectomy (right)yChamberlain et al. J Gastrointest Surg 2009.

Preliminary outcomes

• Unpublished data suggests no significant

cosmetic advantage, cost-effectiveness, or

pain postoperatively between single incision

surgery and standard LC.• Longer OR time and suspected

higherincidence of umbilical herniasNavarra G et al. Surg Endoc 2008.

We have yet to learn…

• Objective reporting of postoperative data

such as cosmetic result, pain scores, length

of stay, return to work, hematoma andhernia formation have NOT been

reported.• No Prospective Randomized Trials

yetreported (limited enthusiasm to carry

out)

Equipment - Ports

Options 3 Low profile 5mm ports SILS Port or similar

SILSTM Port - Covidien

Ethicon SPA

Equipment - Graspers

Reticulating graspers with variable angulation of the forward 1/3

Various tips Grasper Dissector Scissors

Articulating Instruments

Bent Instruments

Equipment - Telescope

5mm 30 degree scope most commonly used Improvements: Variable angulation telescope - EndoChameleon (0

–120 degree) Light produced by super bright LED bulbs at the

headof the telescope Light source enteringback of camera head(Reduces extra-abdominalclashing)

LAPAROSCOPIC SURGERY- MULTIPORT

Difficult but possible minor trauma Moderate Pain, passes in

short term MoreChances of Skin

Infection LOS- few days 4–5 small scars, less

visible; good effect Patient quite satisfied of

his look

SILS

Cumbersome, no specialists in this area

Low, minimal trauma to the tissues

Minimal Pain Lack of skin incisions—rare

cases of infection LOS -A few days No scars—perfect effect Patient very satisfied of his

look

Problems with SILS

Challenges

Cost Learning curve Data Questions that need to be answered by

well constructed large series

Equivalent safety? Additional advantages over accepted

laparoscopy other than cosmesis? Optimal technique? Cost?

Single Port Summary

• Variety of techniques and innovativedevices available• Feasibility established, outcomes are

not• Patients deserve transparency with

respectto innovative surgical procedures

The possibility of performing truly scarless, safe, more effective, and at the same time less painful and minimally invasive surgery is so tempting for doctors and, what is actually more important, for patients that it will encourage the medical world to make every effort to make this dream come true.

Is SILS for Real?(we’ll see)