single-incision laparoscopic surgery an initial experience from tung wah hospital dr. michael co...
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Single-incision Laparoscopic Surgery
An initial experience from Tung Wah Hospital
Dr. Michael CODivision of Hepatobiliary Surgery
Department of Surgery
University of Hong Kong
Tung Wah Hospital
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Introduction
• Laparoscopic surgery– Gold standard of treatment of many major
abdominal operations– Less morbidity and hasten post-operative
recovery– Minimally invasive surgery (MIS)
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Ways to minimize surgical trauma
• Needlescopic surgery– Reducing the size of the incisions– 2-3mm ports and instruments
• Single-incision laparoscopic surgery– Reducing the numbers of incision
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Single Incision Laparoscopic Surgery (SILS)
• Acronyms– Single Port Access (SPA) Surgery– Single Incision Laparoscopic Surgery (SILS)– Laparoscopic Endoscopic Single-port Surgery
(LESS)– Embryonic Natural Orifice Transumbilical
Endoscopic Surgery (E-NOTES)
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Applications
• First described in urologic operations Scarless single port transumbilical nephrectomy and pyeloplasty: first clinical report. Desai, Mihir M
et. al. BJU International. 101(1):83-88, January 2008
• Then being applied in general surgery– Cholecystectomy – Appendicectomy– Colectomy
Single-port laparoscopy in colorectal surgery. Remzi et. al. Colorectal Disease. 10(8):823-826, October 2008.
Single port acces (SPA) Surgery – Initial experience of a novel minimal access approach applied across surgical specialties. Surg Endosc 2008; 22: S172.
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Instruments
Tri-port system
- One 10 mm camera port
- Two 5 mm instrument ports
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Problems
• Crowded space for multiple instruments
• Lack of triangulation of instruments
• Lack of adequate organ retraction
• Learning curve for surgeon
• Limited evidence of benefits from literature
Initial experience with single-incision laparoscopic cholecystectomy.Carr AM, Bhavaraju, A Goza, J Wilson R. Am Surg. 2010 Jul;76(7):703-7.
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Lack of literature
• Only a numbers of case reports / case series
Transumbilical single-port laparoscopic cholecystectomy: a case report.
Guo Wei et al. CMJ, 2008, Vol 121. No. 23: 2463-2464
Single port laparoscopic cholecystectomy with the TriPort system: a case reportRomanelli JR et al. Surg Innov. 2008 Sep;15(3):223-8
Single Incision Laparoscopic Cholecystectomy: Is it more than a challenge? Ersin S et al. Surg Endosc 2010:24:68-71
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• Started to perform SILS since May 2009• First operation was laparoscopic
cholecystectomy• 44 operations performed (till July 2010)• 31 Female / 13 Male• Mean age 56.7 years old (Range 32-72)
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Types of operation
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Conversion to conventional laparoscopic surgery
• Cholecystectomy group– 1/32 need one extra port (3.1%)– 2/32 need three extra ports (6.2%)– None had conversion to open surgery
• Splenectomy group– 1/2 need two extra ports (50%)– None had conversion to open surgery
• Overall conversion rate– 4/44 (9%) had extra-ports
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Conversion Rate
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Operating Time• Cholecystectomy
– Mean 120 minutes (Range 33 to 299 minutes)
• Marsupialisation of liver cyst– Mean 125 minutes (Range 45 - 180 minutes)
• Splenectomy– Mean 129 minutes (Range 60 - 198 minutes)
• Wedge resection of small HCC– 135 minutes
• Indirect inguinal hernia repair– 60 minutes
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Length of stay• Cholecystectomy
– 1.6 days (Range 0-6 days)
• Liver cyst marsupialisation– 2.3 days (Range 1-3 days)
• Splenectomy– 1.5 days (Range 1-2 days)
• Wedge resection– 4 days
• Hernia repair– 1 day
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Mean Blood Loss• Cholecystectomy
– 25ml (Range 0-200ml)
• Liver cyst marsupialisation– 30ml (Range 0-100ml)
• Splenectomy– 35ml (Range 20-50ml)
• Wedge resection– 200ml
• Hernia repair– Minimal
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Post-op complications
• Cholecystectomy group– 1 had retained cystic duct stone– Overall complication rate 3.1% (n = 1)
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Limitations of our case series
• Relatively small sample size
• Not a comparative trial
• All cases were elective
• Only one patient had malignant condition
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Co M et al. Roberts KE et al. 1
Additional ports 9.3% (3/32) 1.7% (1/56)
Conversion to open surgery
0% 1.7% (1/56)
Mean operating time
120 mins (Range 33-299) 80 mins (Range 49-186)
Length of stay 1.6 days (Range 0-6) 0.3 days (Range 0-2)
Complication rate
3.1% (1/32) 5.4% (3/56)
Mean blood loss 25 ml (Range 0-200) N/A
1. Single-incision laparoscopic cholecystectomy: A surgeon's initial experience with 56 consecutive cases and a review of the literature Roberts KE, Solomon D, Duffy AJ, Bell RL J Gastrointest Surg. 2010 Mar;14(3)
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Conclusion
• Single-port surgery– Feasible procedure– Advances in technology will enable us to
perform SILS in difficult cases in the future– Need more evidence from literature
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Special thanks to my supervisors
Dr. W. K. YuenDr. W. K. Ip
Dr. K. Y. Wong
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