Thursday, May 10, 2012

Single-incision laparoscopic surgery: What are the indications?

My answer is “None.”

There is no compelling reason to perform single-incision laparoscopic surgery (SILS).

Take cholecystectomy, for example. The three 5 mm incisions in the upper abdomen done for standard laparoscopic cholecystectomy are nearly painless and, after a few months, almost always become invisible. The umbilical incision is larger and does cause pain, but the incision for SILS is generally 50% larger than that of standard laparoscopic cholecystectomy and likely to be just as painful if not more so.

For appendectomy, the same reasoning applies regarding the two 5 mm incisions and the umbilical incision. Not only is the umbilical SILS incision larger, one recent paper reports that it results in more postoperative pain too.

The ergonomics of SILS leave a lot to be desired as well. Since the instruments enter the abdomen so close to each other, it is difficult to triangulate them. Obtaining the critical view of the structures in Calot’s triangle is more difficult. It certainly is hard to imagine that SILS is safer for the patient.

There has not been one study convincingly showing superiority of SILS over conventional surgery for any outcome. It will be a challenge to show that compared with multiple-port surgery, SILS shortens length of stay, decreases pain or even has a better cosmetic result after six months.

Small pilot studies of robotic SILS are surfacing. The robotic method offers the possibility that triangulation is slightly improved. But increased costs and longer operative times negate that minor technical gain. What’s more, triangulation is even better with 4-port surgery.

I propose the following:

If SILS had been invented first, papers extolling the safety, ease and comfort of multiple-port surgery would be appearing and everyone would be jumping on the bandwagon to offer it to patients as a better procedure.

Feel free to comment. And don’t ask me if I’ve done a SILS case. The answer should be obvious.

For a more extensive review of single-port vs.standard laparoscopic cholecystectomy, read this paper. Thanks to @anblog84 for sending it to me via Twitter.

Note: This blog appeared yesterday on General Surgery News.


RegionsTrauma said...

Maybe the surgeon trying to invent SILS for the appendix should have put the incision at McBurney's point first and had the appendix pop out at them before trying to make things more complicated. Could have done away with the scope altogether and rediscovered the open appy.

Skeptical Scalpel said...

Good point. The next step may be "hand-assisted" appendectomy.

Anonymous said...

If you have been a surgeon for 40 years then it makes sense that you see no benefit. SILS is not for the average general surgeon to be attempting.

Skeptical Scalpel said...


Are you implying that because I've been a surgeon for 40 years I must be average? Or do you think I am incapable of learning the technique? You're wrong on both counts.

If SILS catches on, and it probably will, I guarantee there will be more CBD injuries, even if you "above average" surgeons are doing them.

Anonymous said...

There are more CBD injuries with lap cholecystectomies than with open cholecystectomies (double incidence), yet the standard of care is laparoscopic.

Skeptical Scalpel said...

Physicians, patients and society in general have accepted the trade-off of more CBD injuries for the substantial gain in patient comfort and return to work for laparoscopic vs. open cholecystectomy.

No such gain has been or will be shown with SILS laparoscopic surgery.

And thanks for admitting that there will be more CBD injuries with SILS.

Ask any lay person whether he would trade 3 5 mm scars for a CBD injury.

Peter said...

This type of surgery reminds me of robotic surgery. If a doctor told me something was minimally invasive my question would be does that been minimally effective? As a patient I would want to see some real evidence if given the options. On another note I was wondering as a surgeon what you thought of NOTES (natural orifice translumenal endoscopic surgery).

Skeptical Scalpel said...

I don't think much of NOTES. I'd blog about it but haven't seen many recent papers about it.

Rob said...

If the goal is to be less invasive, maybe look into an all 5mm approach. There is now a 5mm pouch and hassan on the market.

Skeptical Scalpel said...

Rob, that might work except not many gallbladders are going to come out through a 5 mm incision.

Rob said...

That's what I thought, but about 70% of the time the gall bladder can come out without extending the incision, especially cases of billiary diskenesia and sludge. Of course larger stones will require extending the incision, but at least the patient gets the chance to have a smaller umbilical incision to start. Here is a study I ready about it
Love this forum!

Skeptical Scalpel said...

No way that 70% of GBs come out through a 5 mm incision. That reference you cite is from 8 years ago. There must be a reason that the technique didn't catch on. It's not practical.

Anonymous said...

They open or decompress the gallbladder prior to taking it out in the all 5mm approach.

As for SILS, there may not be much of a benefit in cholecystectomies and appendectomies, but I have done inguinal hernias and colon resections this way and have seen excellent results.

Skeptical Scalpel said...

I don't care how much you decompress the gallbladder, it's very difficult to remove any GB through a 5 mm incision. See my post on minimally invasive cholecystectomy via the penis. I's number 3 on my all time most viewed posts above and to your right.

Hernias would work because there is no specimen. Colon resections maybe, but the specimen can be quite large too.

Trevor said...

I believe you are correct in some regards, but in others you are possibly tarring all single port devices and surgeries with the same brush. Yes there are devices on the market which are creating 25-30mm incisions - but there are also devices which create a single incision the exact same size as a 12mm trocar (Which is needed anyway to get the Gallbladder out). I believe some manufacturers acted irresponsibly in the beginning - handing out bad ports and simply saying "here you go doc, do single port surgery" and because these ports were being pushed by large corporations, the less well known devices were negatively included under the SILS umbrella, and therefore branded with the same issues.
If you give a surgeon a port and just send him off, it is going to be extremely difficult, if not impossible to perform a procedure safely - but if you provide him with the necessary components, i.e. a good port, a good technique, the right instrumentation and adequate training, I guarantee that with a few cases under his belt, he can do that procedure through the same Umbilical incision as you already use, with the exact same critical view (better with a flexible scope), as safely, and in the same time as a standard four port procedure. There is some very good work being done, and over the next few months it will be clear what single port surgery can be when all the necessary components are in place. We are still in the early stages of single port surgery, so I believe we should keep an open mind, take small, safe steps and hopefully evolve laparoscopic surgery a little more.
For these reasons I propose: If single port surgery had been invented first, introduced with a reproducible and teachable technique, the right instrumentation and some ground rules, people would consider adding extra 3 punctures as unnecessary and almost cruel

Skeptical Scalpel said...

Trevor, thanks for the detailed and thoughtful comments. I guess time will tell regarding single-port procedures. If I needed my gallbladder removed right now, I would prefer the 4-port operation. I wonder what most surgeons would say?

Shankarabarathi said...
This comment has been removed by a blog administrator.
itmaiden said...

Thank you to the link to the paper discussing the single-port vs.standard laparoscopic cholecystectomy. I have been looking for this information.

Skeptical Scalpel said...

If you are considering a single-port cholecystectomy, make sure you find a surgeon who has a lot of experience. It might not be easy to find because data are not public. Make sure you ask about hernia rates. Hernias appear to be more common after single-incision cholecystectomy.

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