1. Single-incision Laparoscopic Surgery An initial experience from Tung Wah Hospital Dr. Michael CO Division of Hepatobiliary Surgery Department of Surgery University of Hong Kong Tung Wah Hospital

2. Introduction Laparoscopic surgery –Gold standard of treatment of many major abdominal operations –Less morbidity and hasten post-operative recovery –Minimally invasive surgery (MIS)

3. 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

4. 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)

5. 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.

6. Instruments Tri-port system -One 10 mm camera port -Two 5 mm instrument ports

7. 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.

8. 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 report Romanelli 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

9. 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)

10. Types of operation

11. 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

12. Conversion Rate

13. 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

14. 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

15. 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

16. Post-op complications Cholecystectomy group –1 had retained cystic duct stone –Overall complication rate 3.1% (n = 1)

17. Limitations of our case series Relatively small sample size Not a comparative trial All cases were elective Only one patient had malignant condition

18. Co M et al.Roberts KE et al. 1 Additional ports9.3% (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 stay1.6 days (Range 0-6)0.3 days (Range 0-2) Complication rate 3.1% (1/32)5.4% (3/56) Mean blood loss25 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)

19. 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

20. SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY

29. SINGLE PORT LAPAROSCOPIC MARSUPIALISATION OF LIVER CYST

38. Special thanks to my supervisors Dr. W. K. Yuen Dr. W. K. Ip Dr. K. Y. Wong