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Single Site Umbilical Laparoscopic Surgery (SSULS) George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO Open Surgery Laparoscopic Surgery 1) Less discomfort 2) Reduced hospitalization 3) Faster return to routine activities 4) Cosmesis SSULS Cosmesis, but less risky c/w NOTES Open Surgery Laparoscopic Surgery NOTES • Cosmesis, but risks Acronyms • SILS • SPA (TM) (TM) - - Single Incision Laparoscopic Surgery Single Port Access • SSULS - Single Site Umbilical Laparoscopic Surgery (CMH) • SIPES – Single Incision Pediatric Endosurgery (CH-A) All use umbilicus as single site. Umbilical Portals (U.S.) SILS Port (Covidien) Tri - Port (Olympus) Umbilical Portals (U.S.) SSULS Appendectomy What Else Is Different? Instruments are in-line and parallel to each other Ideally, instruments/telescope should be different lengths What Else Is Different? Assistant/camera holder stands next to or behind the surgeon What Else Is Different? Harder to operate What Operations Are Being Done Using This SSULS Approach? • Appendectomy • Pyloromyotomy (CH-A) • Cholecystectomy • Fundoplication (CH-A) • Splenectomy • Others • Ileocecectomy SSULS Appendectomy SSULS Appendectomy Please use this link if you experience problems viewing the video above. Postoperative Appearance SSULS Cholecystectomy Please use this link if you experience problems viewing the video above. SSULS Splenectomy Please use this link if you experience problems viewing the video above. SSULS Splenectomy SSULS Ileocecectomy •Intracorporeal dissection/mobilization •Extracorporeal resection/anastomosis CMH Experience 142 SSULS procedures: • Appendectomy (103) • Cholecystectomy (24) • Splenectomy (2) • Cholecystectomy/splenectomy (1) • Ileocecectomy (8) CAPS, 2010 Results Procedure Additional ports Mean Op time (min) Mean LOS (days) Complications Appendectomy (103) 10 34+/-16 1 6 Cholecystectomy (24) 2 73+/-28 1.5 0 Splenectomy (2) 0 90+/- 6 1.5 0 Cholecystectomy /splenectomy (1) 0 116 1 0 Ileocecectomy (8) 0 86+/-22 5 0 CAPS, 2010 SIPES CH - ALABAMA Appendectomy - 130 Pyloromyotomy - 32 Cholecystectomy - 32 Fundoplication - 6 Pull-through - 4 204 Pediatr Surg Int 2010 Conclusion These series show that single site surgery is feasible, and appears to be associated with acceptable operating times Conclusion Disadvantages • Compromised degrees of freedom and triangulation • Visualization limited by inline field of view and motion of instruments • More difficult for the surgeon Questions • Do the benefits outweigh the risks? • What are the benefits? • Is there improved cosmesis? • Prospective evidence needed • We are enrolling in 3 SSULS PRT’s Appendectomy, Cholecystectomy, Splenectomy Validated scar assessment tool Prospective Randomized Trials SSULS Appendectomy Power Analysis 10 Outcome Variable 360 (324) Infection SSULS Cholecystectomy 60 (44) Operative time SSULS Splenectomy 30 ( 5) Operative time Other Variables Being Collected • Pain • Cost (hospital charges) • Cosmesis (Validated Scar Assessment Tool) www.centerforprospectiveclinicaltrials.com www.cmhmis.com