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Figure 8.1 ASC TriPort (Olympus, Japan) installed inside the umbilicus
for LESS colectomy. (Courtesy of Mr Tony Dixon, consultant surgeon, UK.)
needed (Nissen procedure), with possibility of increased
postoperative pain.
Comparative studies between conventional laparoscopy
and single - access surgery are in publishing process, and
prospective randomized studies are needed to establish the
role of these new access techniques. Although higher rates
of wound infection, hernias, and possibly biliary complications could be expected, due to the learning curve for the
new technique, they were not higher than for formal
laparoscopy.
Available i nstruments for s ingle - p ort
s urgery
TriPort and QuadPort (Olympus)
The ASC TriPort ™ (Advanced Surgical Concepts, Wicklow,
Ireland) (Figure 8.1 ), also known as the R - port, is a device
designed to be deployed through a single incision, typically
at the umbilicus [21] . It requires a fascial incision approximately 1.5 – 2 cm long. A sheath is placed through the fascial
opening, and the peritoneal surface of this sheath has a self expanding ring, allowing the TriPort to remain inside the
peritoneum. Because the sheath is adjustable in size, the
outer component of the port can be placed snugly against
the skin regardless of the abdominal wall thickness. The
TriPort is introduced into the abdomen through the fascial
defect via an introducer device. The outer component of the
TriPort has three ports: two 5 mm ports and one 12 mm port.
To maintain pneumoperitoneum, the ports contain the same
gelatin material as the GelPort (Advanced Surgical Concepts) used for hand - assisted laparoscopic surgery (HALS).
Instruments require lubrication to pass through the ports
without unnecessary drag. Iodine solution works well
because it lubricates but does not coat the laparoscope with
Figure 8.2 Loading the ring of the ASC TriPort inside the blunt
introducer. (Courtesy of Mr Tony Dixon, consultant surgeon, UK.)
material such as a viscous lubricant that obscures the view.
In addition, the TriPort contains an insuffl ation port, allowing regulated gas insuffl ation without the additional need
for a Veress needle.
Insertion entails folding the ring of the TriPort and loading
it into the blunt introducer (Figure 8.2 ). This is then passed
through a 2 cm incision, into the peritoneal cavity (Figure
8.3 ). The introducer is then removed and the sleeve is pulled
up until the inner ring is snug with the peritoneal surface
of the anterior abdominal wall (Figure 8.4 ). The outer ring
of the device is pushed down so that it lies on the skin and
the sleeve is pulled up and removed (Figure 8.5 ).
SILS ™ - Single - i ncision Laparoscopic Surgery
Covidien, Inc. (Norwalk, CT) is currently marketing a single incision laparoscopic surgery (SILS ™ ) procedure kit; reticulating disposable instruments packaged together with a
SILS ™ access device, the SILS ™ port (Figure 8.6 ). The
device, made from an elastic polymer, is slightly hourglass
shaped and can be deployed through a 2 cm fascial incision.
It contains four openings: one for insuffl ation via a right angled tube and three that can accommodate trocars
5 – 12 mm in size. The compressibility of the elastic polymer
allows for the access ports to expand and form - fi t the space
in which it resides as well as the ports passed through the
working channels.
For colectomy, the Covidien SILS ™ port is inserted into
the peritoneal cavity placed within a small Alexis wound
protector (the latter is used for specimen extraction). We
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CHAPTER 8 Single-port Surgery
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Figure 8.3 Introducing the device inside the abdominal cavity through a
2 cm umbilical incision. (Courtesy of Mr Tony Dixon, consultant surgeon,
UK.)
Figure 8.4 The sleeve is pulled up after the introducer is removed.
(Courtesy of Mr Tony Dixon, consultant surgeon, UK.)
Figure 8.5 The outer ring is pushed down and the excess sleeve is cut
and removed. (Courtesy of Mr Tony Dixon, consultant surgeon, UK.)
Figure 8.6 SILS ™ port (Covidien, New Haven, USA) inserted inside
umbilical scar.
have found that placing the three individual plastic ports
within the SILS ™ device before insuffl ation prevents blood
droplets from being blown into the port, which would otherwise have a negative impact on the image.
Fundamental to the success of any laparoscopic surgery is
the ability to obtain good, safe, operative views with the
laparoscope. We rely on a combination of 5 mm and 10 mm
30 ° laparoscopes. The 10 mm scopes, some of which have a
fl exible EndoEYE ™ tip, (Olympus KeyMed, Southend - on Sea, UK), allow for greater light transmission and provide
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Figure 8.7 Axial connection of the light source and the optic. (Courtesy
of Mr Tony Dixon, consultant surgeon, UK.)
Figure 8.8 Cambridge Endo instrument for single access surgery
( www.cambridgeendo.com ). Courtesy of Mr Tony Dixon, consultant
surgeon, UK.)
the best images. However, when a stapler or other 12 mm
instrument is required, we switch to a 5 mm scope (accepting that the image will not be optimum). Some companies
promote longer length (bariatric) scopes with offset light
cables which center the camera away from the operating
hands and generalized instrument clutter. One of the problems of longer laparoscopes is that light transmission is
reduced, which has a negative effect on image quality. While
not absolutely essential, a 5 mm end - on light source video laparoscope (Olympus) with a malleable end (Figure 8.7 )
further reduces clutter of light leads and potential for instrument collision. A fi nal consideration is the need to invest in
high quality laparoscopes, new light cables, and high defi nition camera systems; less than perfect optics makes this
approach potentially dangerous as accurate image interpretation is fundamental to the success of this type of surgery.
Cambridge Endo Instruments
Conventional laparoscopic surgery is based around the
concept of triangulation of instruments and the laparoscope.
The successful SILS technique, as described in the literature
[8 – 13] , is based on this same assertion and to facilitate its
achievement articulating, or “ pre - bent, ” instrumentation has
been developed (Cambridge Endo) (Figure 8.8 ). These are
introduced via a fi xed and stable platform, i.e. a large caliber
trocar or alternatively small, adjacently placed trocars. Their
articulating tips offer seven degrees of freedom of motion.
These 5 mm diameter instruments map the motion of the
hand holding the instrument in the same proportion. The
axial rotation knob and tip orientation locking mechanism
can be controlled with one hand, rendering precise control
of the instrument tip. The movement of the tip is in tandem
with movement of the surgeon ’ s palm. When turning
the axial rotation knob, the tip turns 360 ° around its axis at
any angle; therefore, instrument articulation allows intra corporeal triangulation of parallel instruments.
There is much debate about whether the use of straight
or curved instruments in SILS is preferable. We have found
that using fi xed curved or rotating instruments merely overcomplicates the technique and adds yet another thought
process and challenge for the surgeon. These instruments
are not intuitive to use.
Spider s ystem
An interesting alternative single - port device has been developed recently, but only experimental data is available [22] .
The Single - Port Instrument Delivery Extended Research
(SPIDER) system developed by TransEnterix, Inc. (Research
Triangle Park, NC) is a sterile and disposable device and is
used to facilitate the movements of multiple instruments
during laparoscopic surgical procedures, performing variable
functions. After an open cutdown incision, the multichannel
cannula is inserted through a small abdominal incision. The
channels are deployed allowing special laparoscopic instruments to pass through each channel into the abdomen to
perform laparoscopic surgery.
Ethicon Endo - Surgery (Cincinatti, OH) produced SSL, a
disposable system that has already reached the market. Non disposable single - access devices are already produced by
many companies, including Karl Storz (Germany) and EDLO
(Porto Alegre, Brazil).
Cholecystectomy
Single - incision cholecystectomy is the most frequently performed LESS procedure in recent literature. Large series
of single - incision cholecystectomy have been published,
showing good short - term results [23] . Ongoing, still unpublished, prospective randomized studies may demonstrate
differences between the single - incision procedures and
standard therapy.
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Surgical t echnique
Technique 1: Separate f ascial o rifi ces, o ne
c utaneous i ncision (Video 8.1)
This technique has the advantage of obtaining single - incision
surgery using readily available straight laparoscopic instruments. However, the use of steerable or angled instruments
facilitates the technique in comparison to those with a
straight shaft, and may avoid use of accessory trocars or
conversion to formal laparoscopic surgery.
The patient is positioned in prone position with reverse
Trendelenburg angulation, and their right side is also tilted
up. Using an open Hasson technique, a 2.5 cm incision is
made through the umbilicus with dissection down to the
linea alba. A 1 cm incision is made in the fascia and the
peritoneum opened under direct vision. After placement of
fascial stay sutures, a 10 mm or 5 mm blunt trocar is introduced into the abdomen. Establishment of a pneumoperitoneum using carbon dioxide to an intra - abdominal pressure
of 12 mmHg is achieved. A 30 ° 10 mm or 5 mm laparoscope
is inserted through the trocar and a full diagnostic laparoscopy performed. Two 5 mm trocars are then inserted through
separate areas of fascia in the midline within the same
umbilical skin incision under direct vision; in some cases it
is possible to use one or two 10 mm trocars (Figure 8.9 ). The
operator stays at the left side of the patient with the camera
holder to the patient ’ s right side. If necessary, insertion of
retraction sutures can be applied to the infundibulum
through a transparietal straight needle, allowing for
improved visualization of Calot ’ s triangle. The left 5 mm
trocar is initially used to allow gallbladder retraction using
a grasper (Figure 8.10 ). Dissection of gallbladder structures
is achieved in the standard fashion using a Maryland grasper
in the right hand to manipulate the gallbladder, and an
alligator grasper in the left hand for retracting the gallbladder fundus. Once the cystic artery and duct are exposed,
they are clipped separately using a 5 mm clip and divided
(Figure 8.11 ). In cases when only 5 mm trocars are used,
mostly ligations are performed by external tied knots of non absorbable sutures. The gallbladder is then dissected free
from the liver bed using diathermy and a combination of
repositioning the traction grasper for better exposure. Prior
to complete removal of the gallbladder from the liver bed,
hemostasis is achieved. Following complete dissection of the
gallbladder, it is removed through the umbilical incision
with or without the use of a bag (Figure 8.12 ). To allow
this, the two or three separate incisions in the umbilical
fascia occasionally have to be combined into a single larger
Figure 8.10 Retraction of the gallbladder fundus by the left 5 mm
trocar.
Figure 8.9 Introduction of three trocars inside the umbilical incision by
three separate fascial wounds.
Figure 8.11 After dissection of the Calot ’ s triangle, 5 mm clips are used
to close the cystic duct and artery.
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Figure 8.12 Umbilical extraction of the gallbladder.
incision. Closure of the aponeurosis is performed with a
standard method, and umbilical skin is sutured for the best
cosmetic effect (Figure 8.13 ).
Technique 2: Insertion of a s ingle - p ort d evice
(Video 8.2)
The insertion of a manufactured device instead of laparoscopic trocars is always performed through an open incision
(Hasson technique) and the port inserted under direct vision.
Depending on the characteristics of the device, a larger
or smaller incision is necessary for introduction. Holding
sutures are placed to allow exposure of the incision, and the
port is gently inserted.
Appendectomy
In 1998, Esposito [5] reported a technique for performing
one - trocar appendectomy in a series of pediatric patients. In
this report, an operating telescope was used with a grasper
passing through it to exteriorize the appendix so that an
“ open ” appendectomy could be performed. More recent
reports of laparoscopic appendectomy with a single trocar
in the pediatric population were published in 2001 by
D ’ Alessio et al. [24] , and Palanivelu reported his early experience of transumbilical appendectomy using fl exible endoscope [25] .
Upper g astrointestinal and b ariatric
s urgery (Video 8.3)
Laparoscopic Nissen fundoplication, although a tricky procedure to perform, has also been described using various
adapted techniques through a single incision [26] .
Figure 8.13 Cosmetic aspect after single - access umbilical
cholecystectomy.
Simpler procedures for bariatric surgery, such as adjustable gastric banding, have been described recently [27] , and
single access was suggested for more advanced bariatric
techniques, including sleeve gastrectomy and gastric
bypass. Conventional laparoscopic Roux - en - Y gastric bypass
(LRYGB) is the gold standard for bariatric surgery. One
drawback of the laparoscopic technique is that it requires
fi ve to seven abdominal incisions to facilitate placement of
the multiple trocars used during the procedure and there is
often a poor cosmetic result. The surgical results and patient
satisfaction of single - incision transumbilical LRYGB to treat
morbid obesity were assessed in a study by Huang et al. with
50 morbidly obese patients [28] . The authors described a
novel intraoperative liver traction method with a “ liver suspension tape ” that was specifi cally designed for single incision LRYGB. Compared to fi ve - port surgery, there were
no intraoperative complications, wound healing was excellent, and there was almost no abdominal scarring. Single incision surgical time was longer than that with formal
LRYGB, and no difference in comorbidity was found in both
groups. They reported greater patient satisfaction with the
single - incision technique. Marchesini et al. reported the
fi rst case series on single - incision LRYGB and sleeve gastrectomy (Figures 8.14 – 8.16 ) in Latin America with good results
and no conversions [29] . The pioneers ’ experience suggests
that advanced procedures such as Roux - en - Y gastric bypass
and sleeve gastrectomy can be successfully achieved via a
single umbilical incision, a method that provides acceptable
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Figure 8.14 Installation of umbilical port for single - incision sleeve
gastrectomy. (Courtesy J.C. Marchesini, Curitiba, Brazil.)
Figure 8.15 Positioning and instrumentation for single - incision sleeve
gastrectomy. (Courtesy J.C. Marchesini, Curitiba, Brazil.)
operative time and good recovery and eliminates abdominal
scarring.
Splenectomy (Video 8.4)
Laparoscopic splenectomy (LS) performed by a single access
represents a technical challenge, because of diffi cult exposure, large vessels, and presence of hematologic diseases.
However, single access was applied recently for this procedure, with low complication and conversion rates.
Figure 8.16 Intraoperative stapling aspect of sleeve gastrectomy.
(Courtesy J.C. Marchesini, Curitiba, Brazil.)
Figure 8.17 LESS splenectomy through umbilical access: external
aspect.
The technique described by Targarona et al. was applied
successfully in 17 patients, mostly for immune thrombocytopenic purpura (ITP) [30] , and similar experience was also
presented by other authors [15 – 19,31] . The patient is placed
in the standard right decubitus position for LS, with the table
fl exed at the fl ank. The transumbilical approach is indicated
for thin patients and in cases of splenic cyst and for enlarged
spleens a left 2 cm subcostal incision is placed at a point
between the subcostal margin and the umbilicus in the midclavicular line. Single - access splenectomy can be performed
either using multiple trocars in one skin incision or through
a multiple - port device (Figures 8.17 – 8.20 ).
The technique used for splenic dissection is similar to that
used in standard LS. After an explorative laparoscopy has
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Figure 8.18 Intraoperative view of hilar control using external tied
knots for LESS splenectomy.
Figure 8.19 Umbilical extraction of enlarged spleen without
morcellation.
Figure 8.20 External aspect of umbilical wound after LESS splenectomy.
aspect of the splenic hilum. The posterior spleno - renal
attachments are freed. Sometimes, especially if the umbilical
approach is used and there are some diffi culties with the
more posterior and upper part of the upper splenic pole, a
3 mm instrument can be introduced through the left fl ank.
Once the spleen is completely mobile, the fl exible scope is
removed and the intra - abdominal visual device is changed
to a 5 mm scope. A stapler with a 6 cm white cartridge
(Echelon, Ethicon Endo - Surgery) is inserted through a
12 mm trocar/port and advanced to the splenic fossa and
applied several times to sever the splenic hilum. Once the
spleen is completely free, a large endobag is inserted, pulled
to the umbilical incision, and the spleen is retrieved intact
or morcellated (Figure 8.19 ).
Single - s ite a drenalectomy
ruled out the possible existence of accessory spleens, a 5 mm
curved grasper normally used for transanal endoscopic
microsurgery (TEM) (Richard Wolff, Vernon Hills, IL, USA)
is placed through the left channel of the single port. The
slightly curved end of this instrument fi ts into the fl exible
trocar or through a port of the mutichannel device, and it
is suffi ciently curved to work intra - abdominally without
causing instruments to clash. A 5 mm Harmonic scalpel
(Harmonic Ace, Ethicon Endo - Surgery, Cincinnati, OH,
USA) is then introduced through the right channel. Using
this approach, it is possible to mobilize the splenic colon
fl exure and to reach the lower pole of the spleen. The next
step is to gain access to the retrogastric pouch and to divide
the short gastric vessels at the upper pole of the spleen,
enabling ligation of the splenic artery. The instruments are
then moved to the posterior aspect of the spleen and the
table is tilted to the left to obtain exposure to the posterior
88
Castellucci et al. performed single - site adrenalectomy in
2008 through three separate fascial trocars inserted in a 2 cm
incision [20] . Desai et al. reported single - port adrenalectomy, and Yuge et al. their experience with partial adrenalectomy [32,33] . A higher mean operative time was found
in these early cases, due to several reasons. The distance
from the port to the tissue in the transumbilical approach is
longer than in the laparoscopic technique, and the transumbilical approach is performed in a more tangential direction.
Moreover, retracting must be frequently regrasped as
approaching the target tissue in a straightforward manner is
diffi cult by the transumbilical approach. Bent instruments
can be used to overcome these diffi culties; however, there
is still room for improvement in device research. Walz et al.
published a study comparing retroperitoneal single - port
adrenalectomy with matched cases of the same procedure
performed by a three - trocar technique, with 47 patients in
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each arm. They found longer operative times, less use of
analgesia, and shorter hospital stay for the single - port group
[34] . As adrenalectomy is usually a very direct procedure
regarding positioning of the patient and instruments, often
with small specimens and simpler vascular dissection, it is
very suitable for transabdominal or retroperitoneal single access surgery.
Single - p ort l aparoscopic c olorectal s urgery
In recent years we have witnessed the proliferation of laparoscopic surgery and with this, a continuous evolution of
techniques and procedures. It has soared in popularity both
among patients and surgeons and has produced a huge
market for medical devices companies, designing a variety
of gadgets that make minimal - access surgery possible. The
overall aim is to minimize parietal trauma and thus postoperative pain, resulting in a shorter recovery and reduced
length of hospital stay. In addition, there are benefi ts of
improved cosmesis, which remain important to some
patients.
Colorectal laparoscopic surgery has been shown to be safe
in large randomized trials such as CLASICC [35] and COST
[36] , and is associated with better short - term outcomes than
open surgery, without producing a negative effect on long term cancer survival. That said, it has still not become the
standard of care but merely an acceptable alternative. In
addition, the widespread dissemination of the complex skills
required has being challenging. Although less invasive than
open surgery, it still requires several incisions for port placement as well as an extraction site. Each of these is painful,
impacts on the fi nal cosmetic appearance, and has the
potential for bleeding, inter - fascial hematoma formation,
visceral injury, and incisional hernia development.
A potential alternative to conventional laparoscopic
surgery and to NOTES is LESS or SILS ™ . This technique uses
one multilumen port, usually sited through the umbilicus,
and umbilical specimen extraction. Not only is it less invasive, it also spares the healthy structures, e.g., the vagina
and rectum, used as extraction sites in NOTES and thus
avoids collateral morbidity. As a result, it deserves further
consideration and evaluation. Besides the described techniques in this chapter, single - port surgery has been used in
right hemicolectomy [37 – 39] and sigmoidectomy [39 – 41] ,
and total colectomy with ileo - rectal anastomosis for familial
adenomatous polyposis (FAP) [42] and cancer [43] have
been described recently.
SILS was fi rst introduced in the late 1990s for appendectomy and cholecystectomy but due to issues of instrumentation, a diffi cult learning curve, and peer group pressure
(from the surgical community) it did not gain acceptance.
However, over the last three years there has been a remarkable turnaround, particularly in urology. Remzi performed
the fi rst SILS colectomy at the Cleveland clinic in July 2008
[44] ; a right hemicolectomy undertaken through a 3.5 cm
incision. The fi rst case series came out of Australia the
following year [45] : seven resections for cancer using
traditional laparoscopic instruments via a single umbilical
incision. The average incision length was 3.1 cm, the length
of stay was 5.4 days, and the average lymph node harvest
was 15, data that falls into line with that reported following
traditional laparoscopic colectomy with the added benefi t of
a smaller scar [46] .
Spurred on by these early successes, SILS restorative proctocolectomy has been recently reported for both ulcerative
colitis [47] and FAP [48] , with the added benefi t of a shortened hospital stay. Some would consider that these two
disease processes lend themselves to this particular approach,
as patients are young and have benign disease. However,
three - or four - port laparoscopic restorative proctocolectomy
is technically challenging and time consuming itself [49] ,
without the additional challenges afforded by SILS.
The experience from the literature with SILS colectomy
suggests that this is a safe and viable approach, and in the
case of malignancy, allows for the performance of adequate
cancer resection. However, the reports are limited by follow up beyond hospital discharge and lack of long - term clinical
and cancer outcome. Case selection is another factor, with
most reports only including patients with a BMI below
25 kg/m
2
.
This technique involves the use of a multichannel access
system that allows the simultaneous passage of two 5 mm
and one 12 mm instrument with ports for gas insuffl ation
and plume extraction. There is also a larger quad - port available for an additional 12 mm instrument. In our colorectal
experience we most frequently use the ASC TriPort ™
(Olympus KeyMed) pictured in Figure 8.1 , or the Covidien
SILS ™ port (Figure 8.6 ) .
Our experience would suggest that the skill mix required
for successful SILS colectomy is different from conventional
laparoscopy. In particular, traction and counter - traction as
traditionally applied to laparoscopic surgery is not possible
with SILS. This therefore requires the surgeon to use instruments without triangulation and to perform hand maneuvers that are not usually recommended in conventional
laparoscopy; optimal instrument utility in SILS demands
that the operating surgeon make greater use of their non dominant hand and have the ability to “ cross - over ” hands.
These maneuvers negate the perceived need for curved
instruments. It is also mandatory to have an expertise in
directing, using, and interpreting the image produced by a
30 ° laparoscope in whatever direction one sees it. SILS
colectomy is thus not necessarily a progression of current
laparoscopic technique but is rather a modifi cation or an
adaptation of another approach.
That said, we – like others [42] – were very surprised at
the ease and speed at which we were able to perform what
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amounted to complex colorectal interventions, including
low rectal division and intra - corporeal suturing. In order to
ease the adaptation from laparoscopic to SILS surgery, the
surgeon must be experienced in performing pragmatic
three - port complex laparoscopic colorectal resections, while
not relying on an assistant to provide traction. Gravity and
natural tissue planes provide counter - traction to a highly
active non - dominant hand and a relatively “ still ” operating dominant hand using an energy source or scissors. Perhaps
one of the most surprising fi ndings was the ease of mobilization of both fl exures and the transverse colon, probably all
a function of the centrally placed port at the umbilicus. In
our experience we did not fi nd it necessary to use transparietal sutures to provide retraction, nor did we use articulating instruments. We consider it important to keep the
laparoscope in a relatively fi xed position just inside the
abdominal cavity – if it is too far in it will restrict the operating instrumentation. It is also necessary to periodically rotate
the port, cross hands, and to swap over operating hands.
Rotating instrumentation at fi rst hand may seem essential,
but in our opinion, this is not the case and simply adds a
further unwanted dimension to an already complicated
thought process.
The single port is most frequently positioned at the umbilicus; however, this can be adapted to suit the operation or
patient body habitus. We also insert it at the proposed ileostomy site, for example in proctocolectomies and low anterior resections, or in the left - iliac fossa when performing an
abdomino - perineal excision of rectum. The resection technique is comparable to that of conventional laparoscopic
surgery. Dissection is pragmatic and requires the use of a
combination of cranial to caudal and lateral to medial dissection (and vice versa). Named vessels are divided at their
origin using either Harmonic (Ethicon Endo - Surgery, Bracknel, UK), ATW45 endostapler (Ethicon Endo - Surgery,
Bracknell, UK), or where appropriate 5 mm Hem - o - Loc clips
(Telefl ex Medical, High Wycombe, UK). We mobilize the
splenic fl exure in all left - sided resections.
In proctocolectomies we utilize close mesenteric division
with greater omentum preservation, followed by a rectal
total mesorectal excision (TME). In panproctocolectomy
cases the specimen is delivered via an inter - sphincteric
pelvic dissection. For restorative proctocolectomies the gut
tube is divided at the pelvic fl oor within the puborectalis
sling using two anterior - posterior fi rings of the ATG45
(Ethicon Endo - Surgery, Bracknel, UK). The formation of an
ileal pouch - anal anastomosis requires the extra - corporeal
construction of 20 cm J pouches after removal of the specimen through the SILS site. The port is removed from the
Alexis wound retractor (if using SILS ™ port) to allow specimen extraction and placement of a purse string/circular
staplergun head before being replaced to allow restoration
of bowel continuity (Figures 8.21 and 8.22 ). In FAP patients
we deliver the specimen transanally following a rectal
mucosectomy and the pouch anal anastomosis is then constructed by hand, the pouch having being pulled down into
the pelvis using transanal forceps. Great care is taken to
ensure no twisting of the small bowel mesentery and a
diverting loop ileostomy created at the SILS port site. We
have also carried out single - port (SILS) restorative proctectomy after both open and laparoscopic sub - total colectomy
after fi rst mobilizing the end stoma (SILS port placement).
Figure 8.21 External view of transumbilical extraction, SILS colectomy.
(Courtesy of Mr Tony Dixon, consultant surgeon, UK.)
90
Figure 8.22 Transumbilical extraction, SILS colectomy. (Courtesy of Mr
Tony Dixon, consultant surgeon, UK.)
Peri - operative management consists of multimodal anal-
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gesia (oral morphine, diclofenac, and intravenous paracetamol) augmented by bilateral transversus abdominals plane
(TAP) blocks. Patients are allowed fl uids and diet as tolerated
and early mobilization is encouraged. Discharge is determined by the junior doctors ’ and ward nurses ’ assessment
of “ fi tness to be discharged. ” To facilitate prompt discharge,
we begin stoma education (where indicated) pre - operatively
with a visit from a stoma nurse to the patient at home; they
are also seen a minimum of two times while in hospital to
expedite training, and follow - up care is provided in the community by stoma nurse visits.
Within our unit our experience of SILS colorectal resections extends to around 150 patients, including 60 anterior
resections and 10 restorative proctocolectomies. We also
employ the technique for Hartmann ’ s reversal and selected
cases of abdominoperineal excision of rectum [50] . Similarly, we have used the SILS technique for numerous indications, including cancer, complicated diverticular disease,
ulcerative colitis, and Crohn ’ s disease (including re - dos)
[51] . The cohort of cancer patients we have performed SILS
for includes all Dukes ’ stages A – D and all tumor stages T
T
. The median number of lymph nodes obtained in our
4b
specimens is 17 (range 10 – 36) and all had R
resection
o
–
1
margins; SILS should not compromise the oncological
outcome of surgery.
For SILS to be economically viable, particularly in a
government - based health service such as the UK ’ s NHS or
in a commercial organization, it not only needs to reduce
length of hospital stay, but also must not extend operative
time signifi cantly, as the extra expense in theatre hours may
in some cases negate any fi nancial benefi t of earlier discharge. Our median operative times for SILS resections are
comparable to those of our laparoscopic practice [52] . Data
for our fi rst 100 SILS colorectal procedures includes a
median of 65 minutes for anterior resection (37 – 180 min),
subtotal colectomy 152 minutes (58195 min), right hemicolectomy 55 minutes (17 – 110 min), and TME (low anterior
resection) 115 minutes (55 – 280 min). These times demonstrate that for an experienced laparoscopic surgeon, SILS
need not prolong procedures unnecessarily. For this approach
to work it is important that the entire theatre team, scrub
staff, anesthetists, etc. are all comfortable with the SILS
approach and the set - up and maintenance of the SILS equipment. The additional benefi t in terms of improved cosmesis
by reduced scarring can be most signifi cant (Figure 8.23 ).
We have been able to complete 95% of attempted procedures with the SILS technique. Conversions to conventional
laparoscopic surgery were due to the SILS port splitting, diffi culty mobilizing the rectum in a panproctocolectomy, and
time constraints with a heavily booked theatre list. One
patient was converted to open due to bleeding from the
inferior mesenteric artery. The technique has particularly
lent itself to performing medial to lateral dissection in seg-
CHAPTER 8 Single-port Surgery
Figure 8.23 Final cosmetic aspect of single - incision colectomy.
(Courtesy of Mr Tony Dixon, consultant surgeon, UK.)
mental resections in patients with signifi cant abdominal
aortic aneurysms, where a conventional laparoscopic
approach (traversing the aneurysm) would have been
impossible.
Although laparoscopic colorectal resectional surgery can
ameliorate recovery compared to open surgery, there
remains little objective evidence of major benefi t within an
effective fast - track program [53] . This may be due in part to
laparoscopic colorectal surgery requiring three to six transparietal ports and an extraction site, each of which causes
pain, muscle spasm, bruising, and hematoma formation
postoperatively. Through the concept of NOTES, which aims
at avoiding any scars at the body surface area, surgeons are
attempting to decrease parietal trauma, reduce convalescence, and improve the overall cosmetic appearance. Recent
surveys have shown that 56% of patients would favor
NOTES cholecystectomy, unless the risks drastically exceeded
those of a conventional approach [54] . Procedure - related
risks, pain, and recovery time were considered more important than cosmesis, cost, length of hospital stay, and anesthesia type in the choice of approach. Patients were less willing
to accept NOTES as risks and costs increased and as surgeon
experience and availability decreased. The same group evaluated its acceptance among surgeons; 72% expressed interest in NOTES training, and 44% would like to introduce
NOTES cholecystectomy into their practices [55] .
Single - port or SILS surgery in the hands of an experienced
laparoscopic surgeon allows for all the common complex
colorectal operations to be performed entirely through the
patient ’ s umbilicus or chosen stoma site [50] . In doing so, it
enables an essentially scarless and a relatively less painful
procedure with the potential for an impressively quick
recovery and almost certain psychological benefi t. In our
fi rst 100 SILS colorectal resections the median length of stay
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