Single-Incision Laparoscopic Surgery

Educational Objectives

Educational Objectives

The goal of this program is to improve surgical outcomes through the appropriate use of minimally invasive techniques. After hearing and assimilating this program, the clinician will be better able to evaluate the evidence comparing single-incision laparoscopy (SILS) to standard laparoscopy.

Summary

Background: SILS (or laparoendoscopic single-site surgery [LESS]) performed through umbilicus with small single incisions; interest in single-incision surgery increased in patients and physicians; platforms for SILS procedures useful (although not required) and increase versatility; innovations being developed to make laparoscopic surgery easier for surgeons

Potential benefits of SILS: include decreased pain, lower morbidity due to decreased number of trocar sites, faster recovery times, fewer wound complications, decreased herniation due to trocars, and lower costs due to shorter hospitalizations; study — no decrease in inflammatory factors seen after SILS, compared to conventional laparoscopic surgery (large difference between laparoscopy and conventional open surgery); skilled surgeons performing SILS capable of working through adhesions caused by previous open surgeries (patients able to avoid additional scarring); Food and Drug Administration produced white paper requesting that surgeons decrease injuries due to trocars; injuries uncommon but significant when they occur

Difficulties with SILS: can include triangulation and visualization; potential exists for development of hernias and prolonged operative times; study — patients with SILS had longer operative times; pain same or less; procedure considered equivalent to general surgery

Appendectomy: excellent starter operation for SILS; appendectomy study — patients found SILS satisfactory; SILS procedure averaged 5 min longer, compared to standard 3-port laparoscopy

Cholecystectomy: 600,000 performed per year; carries risk for trocar injuries; procedure challenging for single-port surgeon; careful selection of patients required; set-up key to success; comparative studies — show that cholecystectomy with SILS appears safe; pain reported as increased in some studies, and decreased in others; cosmetic scores higher; scores for quality of life higher or same; technique — placement of stitch not required, but may be used to gain view of typical 4-point laparoscopic cholecystectomy; puppeteering gallbladder with stitch through fundus of gallbladder commonly done; passing stitch through infundibulum of gallbladder allows down and out traction; possible to use other grasper to push gallbladder up and over; operation should look and feel same as traditional 4-port cholecystectomy; lifting gallbladder off liver possibly difficult, but appropriate techniques available; learning curve for SILS laparoscopic cholecystectomy 52 cases in speaker’s institution

Inguinal hernias: herniorrhaphy study — mortality and multiple injuries noted in laparoscopic surgery arm; all injuries (to bladder, bowel, and iliac arteries and veins) due to trocars; SILS approach does not use trocar for totally extraperitoneal (TEP) inguinal technique (SILS can also be used for transabdominal preperitoneal [TAPP] technique); TEP SILS herniorrhaphy study — SILS found to be safe and effective; surgical times longer; patients may have more or less pain, compared to standard laparoscopy (improved satisfaction reported); learning curve for SILS procedure short because surgeons who perform standard laparoscopic herniorrhaphy already have required skill; procedure — begins with introduction of balloon dissector through umbilicus down to anterior rectus fascia; incision on fascia made as low as possible to position lip of SILS port below arcuate line; operation should look and feel as typical TEP repair for inguinal hernia; speaker prefers laparoscopic kittner for dissection; camera in single port allows surgeon to visualize placement of mesh

Colon resection: colectomy study — newer data show that adoption of laparoscopic colectomy ≈50%; comparison study — shows SILS and standard laparoscopic techniques equally effective; decreased pain noted with SILS procedure early after surgery; cosmetic scores and (in some studies) length of stay improved in SILS, compared with standard laparoscopic colectomy; starting at flexures good approach for SILS colectomy; learning curve short for surgeons already performing laparoscopic colectomies

Laparoscopic Nissen fundoplication: poor procedure for SILS (speaker’s conversion rate 40%; SILS did not shorten operative time; did not improve with experience); technically difficult steps can be accomplished; however, collaboration with technology such as flexible instrumentation, natural orifice translumenal endoscopic surgery (NOTES), or robotics may improve performance of procedure

Other SILS procedures: repair of paraesophageal hernia; Heller myotomy; distal pancreatectomy; minor liver resection; radiofrequency ablation (RFA); repair of Morgagni hernia

Increased postoperative pain: possibly due to method of closing (fascia, followed by soft tissue, then skin) at umbilicus; improved method — closure of fascia, followed by deep dermal sutures (if needed); vacuum dressing then created by applying bacitracin, gauze, and transparent film dressing (eg, Bioclusive, Tegaderm, TELFA), followed by removal of air from film dressing (prevents torque on skin, with outcome of decreased pain)

Readings

Suggested Reading

Ayav A et al: Early results of one-year robotic surgery using the Da Vinci system to perform advanced laparoscopic procedures. J Gastrointes Surg 8:720, 2004; Champagne BJ et al: Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg 255:66, 2012; Fitzgibbons RJ Jr et al: Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial. Ann Surg 221:3, 1995; Fox J et al: Laparoscopic Colectomy for the treatment of cancer has been widely adopted in the United States. Dis Colon Rectum 55:501, 2012; Fuller J et al: Laparoscopic trocar injuries: a report from a U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) Systematic Technology Assessment of Medical Products (STAMP) Committee. Food and Drug Administration.http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm197339.htm. Finalized November 7, 2003. Updated November 20, 2012. Accessed December 18, 2012; Jin LX et al: Robotic surgery claims on United States hospital websites. J Healthc Qual 33:48, 2011; Marks J et al: Prospective randomized controlled trial of traditional laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy: Report of preliminary data. Am J Surg 201:369, 2011; Papaconstantinou HT et al: Single-incision laparoscopic right colectomy: a case-matched comparison with standard laparoscopic and hand-assisted laparoscopic techniques. J Am Coll Surg 213:72, 2011; Prashanth PR et al: Single-incision laparoscopic surgery-current status and controversies. J Minim Access Surg 7:6, 2011; Pryor AD et al: Single-port cholecystectomy with the TransEnterix SPIDER: simple and safe. Surg Endosc 24:917, 2010; St. Peter SD et al: Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial. Ann Surg 254:586, 2011; Tran H: Safety and efficacy of single incision laparoscopic surgery for total extraperitoneal inguinal hernia repair. JSLS 15:47, 2011; Wolthuis AM et al: Outcomes for case-matched single-port colectomy are comparable with conventional laparoscopic colectomy. Colorectal Dis 14:634, 2012

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Buckley was recorded at Surgical Innovations: Expanding Surgical Frontiers, held June 1-2, 2012, in Austin/Bastrop TX, and sponsored by the Scott & White Department of Surgery. For information about upcoming CME activities from Scott & White Healthcare, please visit healthcare-professionals.sw.org. The Audio-Digest Foundation thanks the speakers and sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS600302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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