1. Single Incision Laparoscopic Surgery
Dr Anish Nagpal
Laparoscopic and Gastrosurgeon
Anya Gastro Surgicentre
Ahmedabad

2. What is SILS?
Laparoscopic surgery through the umbilicus with a single incision
Advanced minimally invasive procedure in which the surgeon operates thru a single incsion :mostly tthru the umbilicsu
More Surgery with LESS or No Incision
ScarLESS Surgery

3. The Idea behind SILS!!
As a bridge b/n NOTES and Lap. Surgery

4. NOTES Natural Orifice Trans Endoscopic Surgery
Access to the abdominal cavity is required for diagnostic and therapeutic endeavors for a variety of medical and surgical diseases.
Historically, abdominal access has required a formal laparotomy to provide adequate exposure.
Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology.

5. Innovative surgical endoscopists
Innovative Medical endoscopists

6. Surgical site infections
Hernia formation
Adhesions are
Additional prospective benefits derived from an incisionless technique are minimization of anesthesia and analgesia and lowered patient apprehension to elective surgeries

7. From Germany,
Seifert described the first documented case of NOTES
in 2000, in which a posterior gastrotomy was created
with an endoscopic needle-knife, enabling retroperitoneal
passage of the endoscope to perform a pancreatic
necrosectomy in 3 patients too ill to tolerate formal
debridement

8. Drs Reddy and Rao from India further validated the
feasibility of NOTES by performing a NOTES appendectomy
in a human.40

9. Several inherent technical challenges to NOTES exist, including creating a viscerotomy, manipulating intraabdominal organs, and safely closing the viscerotomy.
the physiologic effects of orificial contaminates may be catastrophic

10. Acronyms LESS- Laparo Endoscopic Single Site Surgery
SPA- Single Port Access
NOTUS- Natural Orifice Trans Umbilical Surgery
TUES- Trans Umbilical Endoscopic Surgery
SIMPLE- Single Incision Multi Port Laparoendoscopic Surgery
ScarLESS Surgery
Etc……..

11. Rationale or Principles
Less Is More
Lessen the trauma of Access
Lessen the residual scar
Give the patient max. cosmetic benefit

12. Alleged SILS Benefits • Reduced surgical site infection
• Reduced visible scarring
• Reduction in pain & analgesics
• Quicker recovery time
• Reduction in hernias, adhesions
• Advantages in the morbidly obese

13. History
Laparoscopy can be dated to over 100 years ago when George Kelling from Dresden, Germany introduced a cystoscope into the peritoneal cavity of a living dog and insufflated air to enhance the view.

14. History of SILS
SILS was described as early as 1992 by Pelosi who performed a single-puncture laparoscopic appendectomy
In 1997 Navarra et al. performed a laparoscopic cholecystectomy via two transumbilical trocars and three transabdominal gallbladder stay sutures
Refinement of equipment and technique have recently brought SILS into the mainstream.

15. Documented SILS - First
Turkey
Dept. of Pediatric Surgery
Appendicectomy
2005

16. Procedures performed
• Adrenalectomy • Appendectomy • Nephrectomy (partial pp y and donor) • Cholecystectomy • Gastrectomy • Prostatectomy • Pyeloplasty • Gastrostomy • Intestinal • Splenectomy stoma • Varicelectomy • Hemicolectomy (right) y Chamberlain et al. J Gastrointest Surg 2009.

17. Preliminary outcomes
• Unpublished data suggests no significant cosmetic advantage, cost-effectiveness, or pain postoperatively between single incision surgery and standard LC. • Longer OR time and suspected higher incidence of umbilical hernias Navarra G et al. Surg Endoc 2008.

18. We have yet to learn… • Objective reporting of postoperative data
such as cosmetic result, pain scores, length
of stay, return to work, hematoma and
hernia formation have NOT been reported.
• No Prospective Randomized Trials yet
reported (limited enthusiasm to carry out)

19. Equipment - Ports
Options
3 Low profile 5mm ports
SILS Port or similar

20. SILSTM Port - Covidien

22. Ethicon SPA

23. Equipment - Graspers
Reticulating graspers with variable angulation of the forward 1/3
Various tips
Grasper
Dissector
Scissors

24. Articulating Instruments

25. Bent Instruments

26. Equipment - Telescope
5mm 30 degree scope most commonly used Improvements: Variable angulation telescope - EndoChameleon (0 – 120 degree) Light produced by super bright LED bulbs at the head of the telescope Light source entering back of camera head (Reduces extra-abdominal clashing)

27. Laparoscopic Surgery- Multiport
SILS
Difficult but possible
minor trauma
Moderate Pain, passes in short term
MoreChances of Skin Infection
LOS- few days
4–5 small scars, less visible; good effect
Patient quite satisfied of his look
Cumbersome, no specialists in this area
Low, minimal trauma to the tissues
Minimal Pain
Lack of skin incisions—rare cases of infection
LOS -A few days
No scars—perfect effect
Patient very satisfied of his look

28. Problems with SILS

29. Challenges Cost Learning curve Data
Questions that need to be answered by well
constructed large series
Equivalent safety?
Additional advantages over accepted laparoscopy
other than cosmesis?
Optimal technique?
Cost?

30. Single Port Summary
• Variety of techniques and innovative devices available • Feasibility established, outcomes are not • Patients deserve transparency with respect to innovative surgical procedures

31. The possibility of performing truly scarless, safe, more effective, and at the same time less painful and minimally invasive surgery is so tempting for doctors and, what is actually more important, for patients that it will encourage the medical world to make every effort to make this dream come true.

32. Is SILS for Real?
(we’ll see)