Single Incision Laparoscopic Surgery-An Overview and Current Status

doi:10.4236/ss.2012.310100

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Surgical Science, 2012, 3, 503-505

http://dx.doi.org/10.4236/ss.2012.310100 Published Online October 2012 (http://www.SciRP.org/journal/ss)

Single Incision Laparoscopic Surgery—An Overview

and Current Status

Amit Goel

Army College of Medical Sciences, New Delhi, India

Email: [email protected]

Received August 15, 2012; revised September 30, 2012; accepted October 9, 2012

ABSTRACT

Single incision laproscopic surgery is an alternative to conventional multiport laproscopy. Natural orifice transluminal

endoscopic surgery term coined by a Consortium in 2005 remains a research technique with few clinical cases. Single

incision surgery offers advantage of better cosmesis, reduced incisions, lesser hernias, decreased pain and infections.

Long learning curves and cost of instrumentation are the difficulties encountered in its propagation. Single incision la-

proscopic surgery is an evolving technique for advanced laproscopic centers. This article outlines the overview of de-

vices and instruments and the techniques, feasibility of single in cision laproscopic surgery.

Keywords: Notes; Sils; Ports; Endoscopy; Laparoscopy

1. Introduction

Conventional multiport minimal access surgery has been

established as gold standard for many abdominal surgical

procedures. In its endeavor to reduce scarring and trauma,

surgeon and instrument industry combined their ingenuity

to promote two new approaches for laparoscopic surgery,

Natural orifice transluminal endoscopic surgery (NOTES)

and Single incision laparoscopic surgery. NOTES leaves

no scar but requires entry into peritoneal cavity with use

of flexible endoscopes by perforation of a hollow viscus

the stomach, oesophagus, colon and bladder whereas

SILS requires a single port of entry with multiple articu-

lating instruments introduced through that port with op-

tics to perform various abdominal procedures which were

earlier performed by multiple ports in conventional la-

proscopic surg ery.

2. Material and Methods

It requires various types of endoscopes, instrumentation

and techniques. Single incision laparoscopic surgery

performs these procedures as multiport through one inci-

sion at umbilicus. A vast variety of hand instruments

have evolved which are curved, coaxial and articulating

having greater degree of freedom. NOTES interventions

can be classified as “hollow visceral transperitoneal”

which may be transgastric, transoesophageal, transcolo-

nic, transvesical access to peritoneal cavity by planned

perforation of a hollow viscus. The second approach

“squamous conduit intraperitoneal” is transvaginal or a

transanal-direct access to the peritoneal cavity. Hollow

visceral transperitoneal requires interventional flexible

technologies. Squamous conduit intraperitoneal is per-

formed with existing laparoscopic instrumentation with

rigid optics. Concept of SILS is attributed to Dr. Raimund

Wittmoser, the father of modern thoracoscopic surgery.

Many instrument companies have produced single in-

cision laparoscopic surgery port. Vast majority of these

are disposable with exception of two reusable SILS ports

namely X-PORT (STORZ TUTTILINGEN GERMANY)

and ENDOCONE designed and developed at Institute of

medical science and technology in Dundee in association

with Storz. ENDOCONE has a detachable bulk which

contains six lateral valved inlets that allow the insertion

of large instruments including staplers. The surgeon is

able to use three instruments and an optic at any one time

during the course of operation. The instrumentation for

SILS has improved with development of proximally de-

viated curved coaxial articulating instruments. Intracor-

poreal suturing is greatly facilitated with introduction of

5 mm hand held surgical manipulators with six degree of

freedom. SILS procedure has been used for wide range

of laparoscopic operations like colorectal resections,

bariatric operations, nephrectomies, cholecystectomy and

splenectomy.

3. Discussion

The first description of procedure to be known as natural

orifice transluminal endoscopic surgery is credited to

Kallo et al. in 2000 where they demonstrated the feasibil-

ity of peroral transgastric endoscopic approach to perito-

neal cavity [1]. Gettman and colleagues in 2002 reported

A. GOEL

504

series of transvaginal porcine nephrectomies [2]. Rao and

Reddy reported the f irst human cases of NOTES in 2004

with transgastric appendicectomy [3]. In July 2005, there

was meeting of American Society of Gastrointestinal

Endoscopy (ASGE) and Society of American Gastroin-

testinal and Endoscopic Surgeons. The deliberations of

this group called Natural Orifice Surg ery Consortium for

Assessment and Research (NOSCAR group) was pub-

lished as a white paper of ASGE/SAGES group on

NOTES [4]. Pure NOTES is that which is only per-

formed through natural orifices like transgastric, transe-

sophageal, transcolonic and transvescical routes. NO-

SCAR group emphasized the need for institutional re-

view for doing any human cases. Rend evous NOTES has

been used to describe an approach where more than one

portal of entry is used [5]. Robotic NOTES is new de-

velopment using Da Vinci surgical robot (INTUITIVE

SURGICAL, SUNNYVALE, CA) in animals to perform

reconstructive surgery [6].

Gastrointestinal endoscopists are most familiar with

transgastric route. The primary difficulty is tedious ori-

entation after retroflexing the scope for cholecystectomy

and upper abdominal procedures [7]. Vaginal routes have

had most success as closure of vagina is easy and possi-

ble with rigid laproscopic instruments. The act of causing

perforation to viscus may be detrimental if closure of the

hollow viscus is insecure.

Single incision laproscopic surgery for cholecystec-

tomy was described by Navarre et al. in 1997 and later

Piskin et al. in 1999 [8]. The first cases of single port

access device in form of prototype of R-Port was done by

Rao et al. and reported to world congress endourology in

2007 [9]. The R-Port was single gel interphase th at could

be perforated to get the instruments inside the abdomen.

This led to development of triports and quad ports avail-

able today. The articulating instruments could be intro-

duced through these ports for better angulation and tri-

angulation. A multidisciplinary consortium of surgeons

met at Cleveland clinic in July 2008 suggested stan-

dardization for reporting these surgeries [10]. Since the

introduction of single port access in 2007 hundreds of

cases have been performed. The only randomized study

conducted between SILS and laparoscopic surgery showed

improvement in pain scales in SILS [11].

The Vinci robot system has been used with some suc-

cess in single incision laproscopic surgery enabling three

dimensional visualization thereby reducing the technical

challenges posed by single site surgery [12].

Large series of SILS had been report ed by R e was et al.

in 2009 comprising of hundred cases with conversion in

13% and no complication using SILS port [13]. White in

2009 published 6% conversion and 4% complications in

his series of 100 cases [14]. Er bella in 2010 reported 100

cases with 2% conversion using similar technique [15].

Curcillo in 2010, had a conversion rate of 8.7% in 297

cases [16]. Antonio et al. reported a meta-analysis of 29

studies of 1166 patients undergoing SILS for cholecys-

tectomy with conversion in 0.4% cases [17].

Only 3 SILS laproscopic colorectal surgeries have been

reported. Leroy et al. reported SILS colorectal surgery

with no conversions [18]. Larger series of SILS spleenec-

tomy has been published by Targorona et al. In his series

of 8 cases, conversion was required in 2 cases, the blood

loss was <100 ml and the spleen weight < 500 g. It offered

better cosmesis, fewer complications, enhanced patient

recovery but evidence was scarce [19].

Lee et al. described single port access laproscopic as-

sisted vaginal hysterectomy in 4 cases and concluded that

it was safe and effective [20]. Langebrekke and Ovistad

described total laproscopic hysterectomy through single

port as a better cosmetic alternative to conventional la-

proscopi c hysterect omy [21].

4. Conclusion

Single port surgery has left its mark in Minimal Access

Surgery. All initial studies showed it to be feasible, rea-

sonably safe and cosmetically better than standard lapro-

scopy. Experienced laproscopic skills are needed to ac-

complish safe single port surgery. The cost factor of the

access devices and instrumentation is significantly more.

Even with the best SILS instrumentation currently avail-

able the SILS approach imposes restriction on instrument

manipulation, retraction and limits triangulation. It re-

quires training and should be practiced in centers per-

forming advanced laproscopic surgery. The advantages

of single access surgery are better cosmesis, less bleeding,

reduced infection and herniations. The existing evidence

suggests that SILS is similar to standard laparoscopic

surgery in terms of complication rates, completion rates

and post-operative pain scores. Sils procedure has better

cosmesis and decreased pain but cost is a limiting factor.

Sils procedure should be practiced at advanced laparo-

scopic and minimal access centres and requires training

for surgeon and proper instrumentation.

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