1. SILS Complications Dan Geisler, MD, FACS, FASCRS

2. 2 Disclosures  CovidienConsultant

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7. 7 V A R I A B L E S

8. 8 TROCARS SURGEONS STEPS SEQUENCE INSTRUMENTS POSITIONING

9. 9 Challenges of Laparoscopic Colorectal Surgery  Multiple Quadrants  Multiple Vessels  Small Bowel Positioning  Bowel Transection  Bowel Anastomosis

10. 10 Challenges of Laparoscopic Colorectal Surgery  Time Consuming  Technically Challenging  Technical Ability  Advanced Technology  Capable Assistants

11. 11 Strategy to Combat Time Constraints of Laparoscopic Colorectal Surgery  break operation into directly productive vs. nonproductive actions  standardize  standardize approach to improve efficiency gravity  retraction performed by gravity  keep repositioning to a minimum 3 Trocar Technique

12. 12 SILS Colectomy  Advantages simplified method need only a camera operator safe and efficient reproducible

13. 13 “Problems” with M.I.S.

14. 14 “Problems” with M.I.S.  Problems with SILS

15. 15 Laparoscopic CRS  Improved cosmesis  Decreased pain  Decreased recovery

16. 16 “Problems” with M.I.S.  Decreased ability to complain of pain Improvement in maximum pain score on POD1 & POD2 (p<0.05) Shorter LOS Papaconstantinou & Thomas SILS

17. 17 “Problems” with M.I.S.  Decreased ability to complain of pain  Inability to “show off” a big scar SILSSILS

18. 18 “Problems” with M.I.S.  Decreased ability to complain of pain  Inability to “show off” a big scar SILSSILS

19. 19 “Problems” with M.I.S.  Decreased ability to complain of pain  Inability to “show off” a big scar  Having to return to work earlier

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21. 21 Laparoscopic Colectomy  Less blood loss  Quicker recovery to normal function  Better margins of resection  Better visualization Mesorectal excision Decrease incidence of autonomic nerve injury More precise surgical procedure  Less wound related problems Infection Dehiscence Incisional hernia  Minimally invasive procedure Advantages

22. 22 SILS Colorectal Surgery

23. 23 SILS Colectomy  N = 99  Age = 9 – 93  30 with previous abdominal operations  BMI = 26 (15 – 39)

24. 24 SILS Colectomy  N = 99 Diagnosis  UC: 46Neoplasia: 17  Crohn’s: 10Diverticulitis: 10  FAP: 2Other: 14

25. 25 SILS Colectomy N = 99  OR Time:105 minutes (13 – 245)  Incision Length:3.7 cm (1.2 – 7.8)  LN Harvest*:44

26. 26 SILS Colectomy N = 99 Ports  87SILS  12Additional Ports 1:9 2:1 3:2

27. 27 Complications? Wound Complications  Infections Similar Easy to deal with  Hernias? Too early to tell Access technique?

28. 28 Hernia  Variable rates of occurrence  Dependent on location  Avoidable?  Tissue necrosis?

29. 29 Hernia  Variable rates of occurrence  Dependent on location  Avoidable?  Tissue necrosis?  WE DON’T KNOW!!!!!

30. 30 Difficulties?  5 mm endoeye  SKILLED camera operator  Camera, then instruments Not both at the same time  Splenic flexure

31. 31 Difficulties? Port  SILS (Covidien) Atraumatic Simplistic Easy to use  Triport, Ethicon, Gelpoint

32. 32 SILS Colorectal  Benefits over conventional laparoscopy  Drawbacks over conventional laparoscopy  Incidence of hernia formation?

33. 33 Summary Single port laparoscopy in colorectal surgery  Minimize abdominal trauma  May utilize a natural body orifice or scar such as the Umbilicus  Potential decrease in morbidity  Certainly superior cosmesis  “NOTES” Natural Orifice Transluminal Endoscopic Surgery”……..experimental  SPL seems to be a practical clinical step towards NOTES

34. 34 Summary Single port laparoscopy in colorectal surgery  Minimize abdominal trauma  May utilize a natural orifice or scar such as the Umbilicus  Potential decrease in morbidity  Certainly superior cosmesis  “NOTES” Natural Orifice Transluminal Endoscopic Surgery”……..experimental  SPL seems to be a practical clinical step towards NOTES A BRIDGE TO THE FUTURE!!!