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

Introduction

• Laparoscopic surgery– Gold standard of treatment of many major

abdominal operations– Less morbidity and hasten post-operative

recovery– Minimally invasive surgery (MIS)

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

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)

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.

Instruments

Tri-port system

- One 10 mm camera port

- Two 5 mm instrument ports

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.

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

• 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)

Types of operation

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

Conversion Rate

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

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

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

Post-op complications

• Cholecystectomy group– 1 had retained cystic duct stone– Overall complication rate 3.1% (n = 1)

Limitations of our case series

• Relatively small sample size

• Not a comparative trial

• All cases were elective

• Only one patient had malignant condition

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)

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

SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY

SINGLE PORT LAPAROSCOPIC MARSUPIALISATION OF LIVER CYST

Special thanks to my supervisors

Dr. W. K. YuenDr. W. K. Ip

Dr. K. Y. Wong