Single-incision laparoscopic surgery: An overview

Abstract

Over the last two decades, conventional multi-port Minimal Access Surgery (MAS) has established itself as the gold standard for almost all abdominal surgical procedures. The procedure provides safety, ease, undisputed patient benefit at a cost acceptable to the healthcare system by surgeons from several specialties all over the world, in large hospitals as well as underprivileged rural areas. MAS has effectively addressed the patients’ right to less scarring, trauma (both of access and intra-abdominal manipulation), medication, pain, hospitalization, and early return to family and work. The only truth in surgery is change. Reducing scars and the insult of surgical trauma has become a vital end point of all surgical assessment and endeavour. In the pursuit of further reduction in scarring and the trauma of multi-port MAS, surgeons and the instrument industry have combined their ingenuity and expertise to promote two new approaches for MAS – Natural Orifice Trans-luminal Endoscopic Surgery (NOTES) and Single-Incision Laparoscopic Surgery (SILS). NOTES leaves no skin scars, but requires entry into the peritoneal cavity with the use of flexible endoscopes by perforation of a hollow viscus, the stomach oesophagus, colon, and bladder. It further necessitates a collage of various types of endoscopes, instrumentation, and techniques that are largely alien to surgeons, to many of whom making and maintaining for the duration of the procedure a viscus perforation may seem repugnant. Historically, surgery has always been performed by two hands of the surgeon working in synergy by hand contact in open surgery, which is now done by the long instruments in MAS. SILS performs the same procedure as multi-port MAS through only one incision at the umbilicus in the expectation of reducing scarring and surgical trauma. Hence, SILS could perhaps be accepted as the progression of multi-port MAS by surgeons, and could be more in consonance with their psyche and technology than NOTES. This is confirmed by the rapid spread of SILS worldwide in just two or three years. The number of surgeons who enthusiastically practice and advocate SILS is increasing rapidly, and the instrument industry has a strong thrust towards increasing the safety and evolving the technology for SILS. SILS has been performed in the full spectrum of all abdominal surgery, gallbladder, appendix, colon, spleen, adrenals, and kidney, with results reported comparable to multi-port MAS. Hence, this issue of Journal of Minimal Access Surgery (JMAS) will focus only on SILS. Having extolled the safety, comparable morbidity and good results of SILS, one needs to pause and evaluate SILS in its totality. The basis of safe and smooth multi-port MAS is the ability to secure perfect triangulation at the tips of the hand instruments, just like the hands of the surgeon during open surgery, which ensured that conventional MAS was accepted as the logical progression of open surgery. The design and complexity of several ports advocated, size and number of incisions at the umbilicus highlight just some of the complexities inherent to SILS. Safe and smooth MAS necessitates the triangulation of the hand instrument tips. With parallel trocars and telescope inserted just a few millimeters apart, it requires ingenuity of instrumentation and technique to achieve a degree of triangulation also slightly comparable with the perfect triangulation of multi-port surgery. A vast array of such hand instruments has evolved, all of which are curved coaxial instruments with outward deviation proximally, each generation of which gives greater ease of performance, yet becomes more complex and more expensive. The raison d’être of NOTES and SILS is less scarring, less surgical trauma. NOTES leaves no scars, while SILS leaves at least a 1.5-cm – 2-cm scar at the umbilicus. With a marked improvement in design, diversity, and durability of 3-mm hand instruments and 3-mm optics, the multi-port MAS is increasingly being perfo