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