Medical Articles

Single Incision Laparoscopic Surgery

---

Overview

• Overview
• History
• Technique
• Discussion and Data
• Questions
• Biologicals

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.

• In 1985 German surgeon Eric Muhe applied the technique of laparoscopy to remove a gallbladder using a modified laparoscope
• In 1987 Phillipe Mouret performed the first video-laparoscopic cholecystectomy.

Rationale

• Progress from open surgery “Big surgeons making big incisions” to minimal access surgery has been driven by two principles
  • Lessen tthe ttrauma off access
  • Lessen tthe resiiduall scar
• “These are Exciting times to be a Surgeon” Lord Lister more than 100 years ago

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.

The Acronyms

• SPA - Single Port Access
• NOTUS - Natural Orifice Trans Umbilical Surgery
• TUES - Trans Umbilical Endoscopic Surgery
• OPUS - One Port Umbilicus Surgery
• SPL - Single Port Laparoscopic .....
• SIMPLE - Single-incision multiport laparoendoscopic

……with more to come as equipment makers dream up names to trademark!

Overview

• Requirementts
  • Surgeon
  • Assistant
• Equipment
  • Ports
  • Graspers
  • Telescope
  • Clips
• Procedure
  • Steps
  • Pitfalls
  • Tips

Surgeon

• Advanced laparoscopic skills
• Accurate cordination between surgeon and camera holder – constant team
• Limited range of motion and clashing of instrumentation – Patience
• Counterintuitive movements

Equipment - Ports

• Options
  • 3 Low profile 5mm ports
  • SILS Port or similar

Equipment - Graspers

• Reticulating graspers with variable angulation of the forward 1/3
  • Various tips
  • Grasper
  • Dissector
  • Scissors

Equipment - Telescope

• 5mm 30 degree scope most commonly used
• Improvements:
  • Variable angulation telescope - EndoChamelleon (0 – 120 degree)
  • Light produced by super bright LED bulbs at the head of the telescope
  • Light source entering back of camera head (Reduces extra-abdominal clashing)

Equipment – Clip applicator

• 5mm applicator produces 10mm equivalent clips (18 titanium clips per disposable device)

SILS Procedures

• Recognised
  • Cholecystectomy
  • Appendisectomy
• Less common
  • Splenectomy
  • Right Hemicolectomy
  • Salpingo-oopherectomy
  • Prostatectomy
  • Nephrectomy
  • Adrenalectomy
  • Others

Steps – SILS Cholecystectomy

• Five steps -
  • Umbilical port placement
  • Gallbladder retraction
  • Dissection and division of structures
  • Gallbladder retrieval
  • Closure of umbilicus

Umbilical port placement

• Infiltrate with local
• Evert umbilicus

• Incise umbilicus
• Dissect into abdomen

• Place 3 low profile ports or
• Place SILS port

Gallbladder retraction

• Suture fundus to abdominal wall
• 2/0 Nylon on straight needle
• Through and through abdominal wall

Dissection and division

• Expose Calot’s triangle by retracting gallblader using reticulating grasper
• Disect using reticulating disector
• Clip using 5mm applicator
• Divide structures using reticulating scisors

Gallbladder retrieval

• Replace one 5mm port with a 10mm port
• Keep gallbladder tethered to the abdominal wall.
• Place retrieval pouch under GB and remove holding suture allowing it to drop into the pouch

Closure of umbilical wound

• Close sheath
• Reconstruct umbilicus with subcutucular Monocryl
• Pack umbilicus with gauze to maintain shape under dressing.

Technique - Tips

• Assistant
  • Experienced laparoscopic surgeon with patience
• Patient
  • Not with acute cholecystitis
  • Low BMI
• Ports
  • Least bulky – Shape to fit

Discussion and data

• Proposed advantages over routine laparoscopic surgery
  • Improved cosmesis
  • Decreased post operative pain
  • Equivalent complication profile
  • Earlier return to work

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 techniique?
    • Cost?