Single Site Umbilical Laparoscopic Surgery (SSULS) George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO

Open Surgery Laparoscopic Surgery Less discomfort Reduced hospitalization Faster return to routine activities Cosmesis

SSULS Open Surgery Laparoscopic Surgery NOTES Cosmesis, but less risky c/w NOTES Open Surgery Laparoscopic Surgery NOTES Cosmesis, but risks

All use umbilicus as single site. Acronyms SILS (TM) - Single Incision Laparoscopic Surgery SPA (TM) - Single Port Access SSULS - Single Site Umbilical Laparoscopic Surgery (CMH) SIPES – Single Incision Pediatric Endosurgery (CH-A) All use umbilicus as single site.

Umbilical Portals (U.S.) SILS Port (Covidien) Tri - Port (Olympus)

Umbilical Portals (U.S.)

SSULS Appendectomy

What Else Is Different? Instruments are in-line and parallel to each other Ideally, instruments/telescope should be different lengths

What Else Is Different? Assistant/camera holder stands next to or behind the surgeon

What Else Is Different? Harder to operate

What Operations Are Being Done Using This SSULS Approach? Appendectomy Cholecystectomy Splenectomy Ileocecectomy Pyloromyotomy (CH-A) Fundoplication (CH-A) Others

SSULS Appendectomy

SSULS Appendectomy Please use this link if you experience problems viewing the video above.

Postoperative Appearance

SSULS Cholecystectomy Please use this link if you experience problems viewing the video above.

SSULS Splenectomy Please use this link if you experience problems viewing the video above.

SSULS Splenectomy

SSULS Ileocecectomy Intracorporeal dissection/mobilization Extracorporeal resection/anastomosis

CMH Experience 142 SSULS procedures: Appendectomy (103) Cholecystectomy (24) Splenectomy (2) Cholecystectomy/splenectomy (1) Ileocecectomy (8) CAPS, 2010 19

Cholecystectomy/splenectomy Results Procedure Additional ports Mean Op time (min) Mean LOS (days) Complications Appendectomy (103) 10 34+/-16 1 6 Cholecystectomy (24) 2 73+/-28 1.5 Splenectomy (2) 90+/- 6 Cholecystectomy/splenectomy (1) 116 Ileocecectomy (8) 86+/-22 5 CAPS, 2010

SIPES CH - ALABAMA Appendectomy - 130 Pyloromyotomy - 32 Cholecystectomy - 32 Fundoplication - 6 Pull-through - 4 204 Pediatr Surg Int 2010

Conclusion These series show that single site surgery is feasible, and appears to be associated with acceptable operating times 22

Conclusion Disadvantages Compromised degrees of freedom and triangulation Visualization limited by inline field of view and motion of instruments More difficult for the surgeon Skeptical caution before embracing this approach as the next step in the evolution of minimally invasive surgery

Questions Do the benefits outweigh the risks? What are the benefits? Is there improved cosmesis? Prospective evidence needed We are enrolling in 3 SSULS PRT’s Appendectomy, Cholecystectomy, Splenectomy Validated scar assessment tool Questions still need to be answered Validated scar assessment tool at 6 wks and 6 months post op to see if the pts perceives the benefit

Prospective Randomized Trials Power 10 Outcome Analysis Variable SSULS Appendectomy 360 (324) Infection SSULS Cholecystectomy 60 (44) Operative time SSULS Splenectomy 30 ( 5) Operative time

Other Variables Being Collected Pain Cost (hospital charges) Cosmesis (Validated Scar Assessment Tool)

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