Single Incision Laparoscopic Surgery Dr Anish Nagpal Laparoscopic

Single Incision Laparoscopic Surgery Dr Anish Nagpal Laparoscopic and Gastrosurgeon Anya Gastro Surgicentre Ahmedabad 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 Scar. LESS 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 infections Hernia formation Adhesions are Additional 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 Scar. LESS Surgery Etc……. .

Rationale or Principles Less Is More Lessen the trauma of Access Lessen the residual scar Give 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 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 Turkey Dept. of Pediatric Surgery Appendicectomy 2005

Procedures performed • Adrenalectomy • Appendectomy • Nephrectomy (partial pp y and donor) • Cholecystectomy • Gastrectomy • Prostatectomy • Pyeloplasty • Gastrostomy • Intestinal • Splenectomy stoma • Varicelectomy • Hemicolectomy (right) y Chamberlain 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 higher incidence of umbilical hernias Navarra 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 and hernia formation have NOT been reported. • No Prospective Randomized Trials yet reported (limited enthusiasm to carry out)

Equipment - Ports Options 3 Low profile 5 mm ports SILS Port or similar

TM SILS 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 5 mm 30 degree scope most commonly used Improvements: Variable angulation telescope - Endo. Chameleon (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)

LAPAROSCOPIC SURGERYMULTIPORT Difficult but possible minor trauma Moderate Pain, passes in short term More. Chances 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 innovative devices available • Feasibility established, outcomes are not • Patients deserve transparency with respect to 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)