dr anish nagpal laparoscopic and gastrosurgeon anya gastro surgicentre ahmedabad
TRANSCRIPT
Single IncisionLaparoscopic Surgery
Dr Anish NagpalLaparoscopic and Gastrosurgeon
Anya Gastro SurgicentreAhmedabad
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
ScarLESS 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 infectionsHernia formationAdhesions areAdditional 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 ScarLESS Surgery Etc……..
Rationale or Principles
Less Is MoreLessen the trauma of AccessLessen the residual scarGive 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
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
TurkeyDept. of Pediatric SurgeryAppendicectomy2005
Procedures performed
• Adrenalectomy• Appendectomy• Nephrectomy (partialpp y and donor)• Cholecystectomy• Gastrectomy• Prostatectomy • Pyeloplasty• Gastrostomy• Intestinal • Splenectomystoma• Varicelectomy• Hemicolectomy (right)yChamberlain 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
higherincidence of umbilical herniasNavarra 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 andhernia formation have NOT been
reported.• No Prospective Randomized Trials
yetreported (limited enthusiasm to carry
out)
Equipment - Ports
Options 3 Low profile 5mm ports SILS Port or similar
SILSTM 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
5mm 30 degree scope most commonly used Improvements: Variable angulation telescope - EndoChameleon (0
–120 degree) Light produced by super bright LED bulbs at the
headof the telescope Light source enteringback of camera head(Reduces extra-abdominalclashing)
LAPAROSCOPIC SURGERY- MULTIPORT
Difficult but possible minor trauma Moderate Pain, passes in
short term MoreChances 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 innovativedevices available• Feasibility established, outcomes are
not• Patients deserve transparency with
respectto 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)