sils george fielding nyu school of medicine new york george fielding nyu school of medicine new york
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SILSSILS
George FieldingNYU School of Medicine
New York
George FieldingNYU School of Medicine
New York
SILSWhat’s been done?
SILSWhat’s been done?
Pretty much everythingAppendicitisLap CholeFundoplicationTotal Gastrectomy for cancerColectomySplenectomyGynaecologyUrology
Pretty much everythingAppendicitisLap CholeFundoplicationTotal Gastrectomy for cancerColectomySplenectomyGynaecologyUrology
SILSWhat’s been done?
SILSWhat’s been done?
BariatricsLap bandBypassSleeve
BariatricsLap bandBypassSleeve
SILSWhat’s been done?
SILSWhat’s been done?
BariatricsObes Surg. 2008 Nov;18(11):1492-4.
Epub 2008 Aug 10.Single-laparoscopic incision transabdominal surgery sleeve gastrectomy.Reavis KM, Hinojosa MW, Smith BR, Nguyen NT.
BariatricsObes Surg. 2008 Nov;18(11):1492-4.
Epub 2008 Aug 10.Single-laparoscopic incision transabdominal surgery sleeve gastrectomy.Reavis KM, Hinojosa MW, Smith BR, Nguyen NT.
SILSWhat’s been done?
SILSWhat’s been done?
Transumbilical 2-site laparoscopic Roux-en-Y gastric bypass: initial results of 100 cases and comparison with traditional laparoscopic technique. Lee Wj etal Taiwan
BMI 43 kg/m(2) (range 32-61), OT 144 minutes (range 95-160)The 2-site LRYGB group had a significantly
longer operating time and more blood loss than the traditional LRYGB group but less pain and better cosmesis.
Transumbilical 2-site laparoscopic Roux-en-Y gastric bypass: initial results of 100 cases and comparison with traditional laparoscopic technique. Lee Wj etal Taiwan
BMI 43 kg/m(2) (range 32-61), OT 144 minutes (range 95-160)The 2-site LRYGB group had a significantly
longer operating time and more blood loss than the traditional LRYGB group but less pain and better cosmesis.
SILS Why Bother?SILS Why Bother?
Pain?Cosmesis?Because you can?
Pain?Cosmesis?Because you can?
SILS Why Bother?SILS Why Bother?
Cosmesis has never been an issue in bariatrics
More patients with lower BMI, more interested in cosmesis
After weight loss, we’ve underestimated the privacy issues implied by the scars
Especially for younger female patients
Cosmesis has never been an issue in bariatrics
More patients with lower BMI, more interested in cosmesis
After weight loss, we’ve underestimated the privacy issues implied by the scars
Especially for younger female patients
SILS Why Bother?SILS Why Bother?
Hiding the main scar, and possibly adding a tiny scar for the Nathanson, allows band patients to go to the beach, wear more revealing clothes and go on dates without having to explain all the scars
Keloid scarring is very troublesome for some patients, especially African Americans
Hiding the main scar, and possibly adding a tiny scar for the Nathanson, allows band patients to go to the beach, wear more revealing clothes and go on dates without having to explain all the scars
Keloid scarring is very troublesome for some patients, especially African Americans
SILS Why Bother?Pain?
SILS Why Bother?Pain?
Am Surg 2010 Dec;76 1328-32. Saber etalDecember 2008 to September 2009 n = 27 15 SILS 12 Normal bandsThe overall pain score significantly less in SILS
group P 0.012. Operating time significantly less in the multiport
group P 0.000. Differences in immediate postoperative pain
scores, analgesia, and the overall length of hospital stay were found to be statistically insignificant.
Am Surg 2010 Dec;76 1328-32. Saber etalDecember 2008 to September 2009 n = 27 15 SILS 12 Normal bandsThe overall pain score significantly less in SILS
group P 0.012. Operating time significantly less in the multiport
group P 0.000. Differences in immediate postoperative pain
scores, analgesia, and the overall length of hospital stay were found to be statistically insignificant.
SILS Why Bother?Pain?
SILS Why Bother?Pain?
Prasad etal J Min Access Surg 2011 7:24-7.
No significant difference in the pain score between the CLS and SILS
Operative time significantly lower in the CLS group (28 versus 67 minutes).
The second half of SILS group had a significantly lower pain score compared to the first half
Prasad etal J Min Access Surg 2011 7:24-7.
No significant difference in the pain score between the CLS and SILS
Operative time significantly lower in the CLS group (28 versus 67 minutes).
The second half of SILS group had a significantly lower pain score compared to the first half
SILS Why Bother?SILS Why Bother?
Patient demandMarket share
To be honest, there’s been minimal patient demand
It’s fun to do this for people, as part of the overall care of the patient
Patient demandMarket share
To be honest, there’s been minimal patient demand
It’s fun to do this for people, as part of the overall care of the patient
TechniquesTechniques
Single upper abdo incision - to me this wastes the whole premise of doing it
I use an infra-umbilical incision
Learn to operate with hands almost in parallel - minimal triangulation
Single upper abdo incision - to me this wastes the whole premise of doing it
I use an infra-umbilical incision
Learn to operate with hands almost in parallel - minimal triangulation
TechniquesTechniquesThe major decision is whether to use a 5 mm or a 10mm scope
It depends how good your scopes areI currently use a 12 mm port, place the band through the fascial incision, then put the port in
Crowding is magnified if you don’t use a Nathanson, and need another port for liver retraction.
The major decision is whether to use a 5 mm or a 10mm scope
It depends how good your scopes areI currently use a 12 mm port, place the band through the fascial incision, then put the port in
Crowding is magnified if you don’t use a Nathanson, and need another port for liver retraction.
TechniquesTechniques
For fundoplication I use a 10 scope in a 12mm port and 2 5mm ports
For Gastric bypass I do all the dissection using a 10mm scope, then switch to a 5mm scope to use the stapler
For fundoplication I use a 10 scope in a 12mm port and 2 5mm ports
For Gastric bypass I do all the dissection using a 10mm scope, then switch to a 5mm scope to use the stapler
TechniquesTechniques
Try to use a scope with an end attatchment to reduce clashing. We use Stryker
Some use flexible scopes. I’ve found no advantage
Try to use a scope with an end attatchment to reduce clashing. We use Stryker
Some use flexible scopes. I’ve found no advantage
TechniquesTechniques
It’s all about best use of the space at the umbilicus, as you have to operate with minimal triangulation
Offset port lengths really helpPut the ports at the very lateral ends of the wound. A small curved wound will stretch out flat.
A curved dissector is essential to go safely behind the esophagus.The Real Hand was best. The Ethicon band passer is a reasonable alternative
It’s all about best use of the space at the umbilicus, as you have to operate with minimal triangulation
Offset port lengths really helpPut the ports at the very lateral ends of the wound. A small curved wound will stretch out flat.
A curved dissector is essential to go safely behind the esophagus.The Real Hand was best. The Ethicon band passer is a reasonable alternative
SILS Lap Band Techniques
SILS Lap Band Techniques
Use both Allergan and Realize bandsAbout a 3: 1 ratioBoth work great Allergan easier to pass tubing and lock in this technique
The long tag on the Realize helps with retraction to expose the upper pouch
Use both Allergan and Realize bandsAbout a 3: 1 ratioBoth work great Allergan easier to pass tubing and lock in this technique
The long tag on the Realize helps with retraction to expose the upper pouch
TechniquesTechniques
Mesh fixation of the Allergan port, Use a small disc of Marlex mesh sutured to the back of the port, and just lay the port on the deep fascia at the right hand end of the wound
Use applicator for Realize port
Minimal dissection of a pouch for the port
Must get down to fascia
Mesh fixation of the Allergan port, Use a small disc of Marlex mesh sutured to the back of the port, and just lay the port on the deep fascia at the right hand end of the wound
Use applicator for Realize port
Minimal dissection of a pouch for the port
Must get down to fascia
InstrumentationInstrumentation
12 mm Applied port5mm extra long Applied port1 or 2 hubless Covidien 5 mm ports
1 Novare Real Hand dissectorStandard long lap band instruments
12 mm Applied port5mm extra long Applied port1 or 2 hubless Covidien 5 mm ports
1 Novare Real Hand dissectorStandard long lap band instruments
TechniqueTechnique
Peri-umbilical incisionInsert 12 mm port through root of umbilicus
2 - 5’s , offset lengths Nathanson liver retractor or retractor via umbilicus
Look for and repair any hiatal herniasCrossed hand dissection techniqueUse standard long needle driver and grasper to suture
Peri-umbilical incisionInsert 12 mm port through root of umbilicus
2 - 5’s , offset lengths Nathanson liver retractor or retractor via umbilicus
Look for and repair any hiatal herniasCrossed hand dissection techniqueUse standard long needle driver and grasper to suture
Results SILS bands NYUResults SILS bands NYU
November 2008- November 2010 N=75667% FemaleAge 39 yrs (14-82)Wt 265 lbs (165 – 484)BMI 42 ( 28-67)
November 2008- November 2010 N=75667% FemaleAge 39 yrs (14-82)Wt 265 lbs (165 – 484)BMI 42 ( 28-67)
Operating timeOperating time
N=756Time 46 mins (12-179)Converted to standard technique 0Extra port for omental retraction 12Hiatal Hernia repair 403
Longer in males long torsos
N=756Time 46 mins (12-179)Converted to standard technique 0Extra port for omental retraction 12Hiatal Hernia repair 403
Longer in males long torsos
Results SILS bands NYUResults SILS bands NYU
Hospital stay
Hospital stay all within 24 hrs, except 5 patients
In - hospital complications Small bowel injury – laparotomy, recovery Band obstruction – band removal and replacement Port infection- port removed
Results SILS bands NYUResults SILS bands NYU
DeathFemale, presented to outside hospital day 4Eventually laparotomy – perf’d esophago-
gastric junction anteriorPeritionitis, death
DeathFemale, presented to outside hospital day 4Eventually laparotomy – perf’d esophago-
gastric junction anteriorPeritionitis, death
Results SILS bands NYUResults SILS bands NYU
ComplicationsComplications
Port flip 13 1.72%
Band slippage 11 1.46%
Port site complication
8 1.06%
Port leak 5 0.66%
Results SILS bands NYUResults SILS bands NYU
Weight loss1 yr 44%2 yr 59%
Weight loss1 yr 44%2 yr 59%
Plans for the futurePlans for the future
Use for all females to BMI 60Males to Bmi 50
Except super tall males
Patients love it
Use for all females to BMI 60Males to Bmi 50
Except super tall males
Patients love it
So what’s the future of SILS
So what’s the future of SILS
It’s here to stayIt’s fun to doIt’s definitely more difficult, and harder to teach
It’ll never replace standard laparoscopy in the mainstream
It’s being driven by industry, with special SILS ports.
I don’t think you need them
It’s here to stayIt’s fun to doIt’s definitely more difficult, and harder to teach
It’ll never replace standard laparoscopy in the mainstream
It’s being driven by industry, with special SILS ports.
I don’t think you need them
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