1. Single Incision Bariatric Surgery Ninh T. Nguyen, MD, FACS University of California, Irvine Medical Center, Orange, CA

2. Disclosures CovidienGrant/speaker GoreSpeaker SurgiquestConsultant ReshapeResearch EthiconSpeaker

3. Rationale for Single Incision Bariatric Band – need a 3.5 cm incision to place subQ port Sleeve – need to remove gastric specimen Bypass – no role

4. Acronym Single Port Access (SPA) Natural Orifice Transumbilical Surgery (NOTUS) Single Incision Laparoscopic Surgery (SILS) Single Laparoscopic Incision Transabdominal (SLIT) surgery Laparosendoscopic Single Site Surgery (LESS) Strategic Laparoscopy for Improved Cosmesis (SLIC)

5. Philosophy of SLIC Strategic use of anatomic sites that will minimize visible postoperative scars - Umbilicus - Suprapubic region Not new philosophy (plastic, ENT, GYN) Still laparoscopy (maintain triangulation)

6. Evolution of Single Incision Sleeve Gastrectomy “Happy Medium” SILSLESSSLICSILS Hybrid

7. Balanced Strategy to Single Incision Bariatric Surgery Improved cosmesis - Technical difficulty -Compromising safety -Prolong OR time

8. Conventional vs SLIC Sleeve

9. Hurdles from Laparoscopy to SILS Lack triangulation Use of 5 mm scope “Fighting” of instrumentation

10. Evolution of SILS to SLIC Better triangulation Less “fighting” of instrumentation

11. NOTUS Cholecystectomy

12. NOTUS Appendectomy NOTUS Cecectomy.mpg

13. SLIC Gastric Banding

14. Laparoscopic vs. Single Incision Gastric Band →

15. Single Incision Gastric Band Lap Band SLIT band realize.mpg

16. Evolution of Single Incision Gastric Banding Single incision (4-4.5 cm) between umbilicus and xyphoid process Transition to single incision (3.2 cm) and three 5 mm trocars within umbilicus

17. Trocar Position for SLIC Gastric Banding Lap band SLIT realize fast.wmv

18. Laparoscopic vs. SLIC Gastric Banding Characteristics CharacteristicsLaparoscopy (n=23) SLIC (n=23) Female : Male17 : 6 Age (years)50 ±947 ±10 Preop weight (lbs)252 ±39248 ±32 Mean BMI (kg/m 2 )40 ±4 (range, 35-49)39 ±4 (range, 35-48) *p<0.05, two-sample t tests

19. Laparoscopic vs. SLIC Gastric Banding Outcomes OutcomesLaparoscopy (n=23) SLIC (n=23) Conversion to Laparoscopy (%)013 OR time (min)66 ±2165 ±20 Blood loss (ml)22 ±2114 ±5 Hospital stay (days)1.4 ±0.91.1 ±0.5 Early Complications (%)00 Late Complications (%)00

20. SLIC Gastric Banding

21. 21 | SLIC Sleeve Gastrectomy

22. Evolution of Single Incision Sleeve Gastrectomy “Happy Medium” SILSLESSSLICSILS Hybrid

23. Evolution of SLIC Sleeve Gastrectomy X

24. SLIC Sleeve

25. Laparoscopic vs. SILS Sleeve Characteristics CharacteristicsLaparoscopy (n=24) SLIC (n=26) Female : Male16 : 817 : 9 Age (years)47 ± 1144 ± 11 Mean BMI (kg/m 2 )47 ± 7*42 ± 4 *p<0.05, two-sample t tests

26. Laparoscopic vs. SILS Sleeve OutcomesLaparoscopy (n=24) SLIC (n=26) Conversion to Laparoscopy (%)---3.8% OR time (min)78 ±2684 ±24 Blood loss (ml)23 ± 1430 ± 21 Mean hospital stay (days)1.4 ± 0.61.8 ±0.7 Intraoperative complications (%)0%7.7% Major Complications (%)0% Minor Complications (%)8.3%7.7%

27. Relative Contraindications of SLIC BMI > 50 Need to perform other procedures (hiatal hernia repair) Hx of prior bariatric or gastric surgery

28. SLIC Sleeve Gastrectomy

30. Conclusions In a selected group of patient, SLIC bariatric operations are feasible Safe – no major complications Reproducible – low conversion rate to laparoscopy Outcomes - comparable between SLIC vs. laparoscopic sleeve & band without prolonging the operative time Cost – comparable with utilization of mostly conventional trocars, instrument, and scope

31. Single Incision Bariatric Surgery Ninh T. Nguyen, MD, FACS University of California, Irvine Medical Center, Orange, CA

32. Strategic Laparoscopy for Improved Cosmesis (SLIC) – Bariatric Surgery Ninh T. Nguyen, MD, FACS University of California, Irvine Medical Center, Orange, CA

33. We’re Making Progress Come on! It can‘t go wrong every time...

34. Philosophy of SLIC Transition most or all laparoscopic trocars to strategic location that minimize operative scar - Umbilicus - Suprapubic region One visible 5 mm incision

35. SLIC Cholecystectomy

36. Spectrum of Invasiveness OpenLaparoscopicSingle Incision