In recent years advances in optics, instrumentation, and technical skill coupled with a desire to further minimize operative wounds has led to the proliferation of new highly sophisticated techniques. These newer modalities often challenge the traditional tenets of modern laparoscopy. Single-incision laparoscopic surgery (SILS) uses specialized access devices or multiple tightly spaced fascial incisions at the umbilicus to accomplish what has been traditionally done through multiple port sites. To accomplish an operation in such a limited space requires the laparoscopic surgeon to work in a cross-handed manner and employ specialized curved instruments. Robotic surgery removes the operating surgeon from the bedside and places him or her at a console where hand motions are translated electronically into actions. Natural-orifice transluminal endoscopic surgery (NOTES) uses advanced endoscopic techniques to traverse the upper or lower GI tract or vagina to reach the targeted surgical area. To date, a wide array of surgical procedures have been attempted using these advanced minimally invasive surgery techniques with varying degrees of success. Outcomes data to justify increased costs and OR times has lagged behind market demand in all three of these areas.
SINGLE-INCISION LAPAROSCOPIC SURGERY
SILS techniques have now been applied to a number of different procedures, but the most established application for this technique has been for cholecystectomy. SILS cholecystectomy is described in Chapter 33. The major advantage of this technique is improved appearances, resulting from a single scar that can often be hidden in the umbilicus (Figure 1).
The main disadvantage of the SILS approach lies in its technical challenges, which require some time to master. Whether performed through specialized trocars or multiple tightly spaced facial openings, traditional ergonomics is significantly compromised (Figures 2, 3). Operative times—initially quite long with SILS—decrease significantly after the first 10 cases are completed. Another disadvantage of SILS is the requirement for customized articulating instruments that allow the operating surgeon a sufficient degree of angulation from the target to complete the procedure. Postoperative pain following SILS cholecystectomy may be more of the same as standard laparoscopic surgery. Studies suggest that complication rates and outcomes are comparable to those for laparoscopic cholecystectomy, but the rate of incisional hernia appears to be greater after SILS access.
Choosing patients with modest body mass index and without extensive past surgical history is critical during initial SILS learning curve. Operative indications for specific procedures are the same for the traditional laparoscopic procedure. Expertise in traditional advanced laparoscopy and a low threshold for placement of additional trocars when patient safety requires it are prerequisites for safe SILS.