Sils

The Queen Elizabeth Hospital

Single Incision LAPAROSCOPIC SURGERY

(SILS) COLORECTAL Resection

Nick Rieger

Assoc Professor

University of Adelaide


SILS• Urology

• Renal transplant

• Cholecystectomy

• Gastric band surgery

• Colectomy


SILS


SILS Colectomy and literature• 2 recorded cases

• Remzi FH, Kirat HT, Kaouk JH, Geisler DP. Single-port laparoscopy in colorectal surgery. Colorectal Dis. 2008 Oct;10(8):823-6. Epub 2008 Aug 5.

• Bucher P, Pugin F, Morel P. Single port access laparoscopic right hemicolectomy. Int J Colorectal Dis. 2008 Oct;23(10):1013-6. Epub 2008 Jul


Colectomy ?? HOW• Open Incision

• Laparoscopic assisted

• Laparoscopic Hand assisted

• Total laparoscopic

• SILS

• Endoscopic submucosal excision

• NOTES ??

• Robotic ??


SILS Colectomy


Case Experience: Dr Rieger• 7 cases from 28/11/2008 until 10/3/2009


Patient Age BMI Tumour Path Nodes

1 83 23 Caecum T1N0 0/10

2 63 21.5 Splenic T3N0 0/12

3 76 23 Caecum Benign (5 cm)

26

4 69 24 Ileal

Liver 2nd

carcinoid 3/16

5 74 22 Caecum T2N0 0/10

6 73 25 Caecum T2N1 1/7

7 60 28 Ascend Benign (2 cm)

21


Patient Op Time

Stay Complication

1 100 4 Nil

2 75 4 Nil

3 90 4 Nil

4 75 6 Nil

5 115 11 bacteraemia

6 80 4 Nil

7 88 5 Nil


SILS. Why Bother?• Cosmesis

• Smaller single incision (2.5-4.5 cm)

• Length of stay ???

• Less risk hernia

• Less risk tumour implantation

• Stepping stone to NOTES


SILS: Indications• Benign neoplasm of colon

• Carcinoma of colon (small)

• Tumour size less than incision (2.5cm)

• Thin patient


SILS: Ideal Indications• Right sided pathology proximal to the hepatic

flexure

• Left sided pathology distal to the mid-transverse colon and proximal to the sigmoid colon.

• Small bowel pathology


SILS: Disadvantages• 2 operating ports

• Instrument clash

• Loss of tissue triangulation

• Learning curve of flexible instrumentation

• No 90 degree staplers for transection rectum


Ink Impalpable Lesions


Operative Considerations• Table

• Anaesthesia

• Trocars

• Instruments

• Anastomosis

• Oncologic principles


SILS : Trocars1 X 5-12mm Bluntport Plus (Covidien,)

2 X 5mm Dexide Threaded Trocar (Covidien)


SILS : Instruments• 30 degree 10 mm camera

• Roticulator Endo Mini-Shears 5mm (Covidien)

• Straight non-disposable atraumatic bowel grasper.

• Alexis® Wound retractor; small. (Applied Medical)

• Ligasure Advance (Covidien)

• Vicryl endoloop (Ethicon)

• DST GIA 80 – 3.8mm stapler and cartridge reload. (Covidien)


SILS: Anastomosis


SILS: Oncologic principles


Port site hernia


SILS: Post Operative Care• DVT prophylaxis

• Opiate Analgesia (PCA or S/C)

• Oral analgesia

• Mobilise Day 1

• Urine catheter out early (24 hours)

• Early introduction of fluids (first 24 hours) and diet (second 24 hours if fluids tolerated)

• IVT out once fluids tolerated


Conclusions• SILS colon resection is feasible.

• Can be achieved with the same or reduced cost as standard laparoscopic resection.

• Very specific indications

Sils

Health & Medicine

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