Transcript The Idea behind SILS!! - obesity treatment ahmedabad

Dr Anish Nagpal
Laparoscopic and Gastrosurgeon
Anya Gastro Surgicentre
Ahmedabad
www.obesityclinic.in
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Laparoscopic surgery through the umbilicus
with a single incision
Advanced minimally invasive procedure in
which the surgeon operates thru a single
incsion :mostly tthru the umbilicsu
More Surgery with LESS or No Incision
ScarLESS Surgery
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As a bridge b/n NOTES and Lap. Surgery
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Natural Orifice Trans Endoscopic Surgery
Access to the abdominal cavity is required for
diagnostic and therapeutic endeavors for a variety of
medical and surgical diseases.
Historically, abdominal access has required a formal
laparotomy to provide adequate exposure.
Natural orifice transluminal endoscopic surgery
(NOTES) is an emerging experimental alternative to
conventional surgery that eliminates abdominal
incisions and incision-related complications by
combining endoscopic and laparoscopic techniques to
diagnose and treat abdominal pathology.
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Innovative surgical endoscopists
Innovative Medical endoscopists
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Surgical site infections
Hernia formation
Adhesions are
Additional prospective benefits derived from
an incisionless technique are minimization of
anesthesia and analgesia and lowered patient
apprehension to elective surgeries
From Germany,
Seifert described the first documented case of
NOTES
 in 2000, in which a posterior gastrotomy was
created
 with an endoscopic needle-knife, enabling
retroperitoneal
 passage of the endoscope to perform a
pancreatic
 necrosectomy in 3 patients too ill to tolerate
formal
 debridement
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Drs Reddy and Rao from India further
validated the
feasibility of NOTES by performing a NOTES
appendectomy
in a human.40
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Several inherent technical challenges to
NOTES exist, including creating a
viscerotomy, manipulating intraabdominal
organs, and safely closing the viscerotomy.
the physiologic effects of orificial
contaminates may be catastrophic
LESS- Laparo Endoscopic Single Site Surgery
SPA- Single Port Access
NOTUS- Natural Orifice Trans Umbilical Surgery
TUES- Trans Umbilical Endoscopic Surgery
SIMPLE- Single Incision Multi Port
Laparoendoscopic Surgery
 ScarLESS Surgery
 Etc……..
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Less Is More
Lessen the trauma of Access
Lessen the residual scar
Give the patient max. cosmetic benefit
• Reduced surgical site infection
• Reduced visible scarring
• Reduction in pain & analgesics
• Quicker recovery time
• Reduction in hernias, adhesions
• Advantages in the morbidly obese
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Laparoscopy can be
dated to over 100 years
ago when George
Kelling from Dresden,
Germany introduced a
cystoscope into the
peritoneal cavity of a
living dog and
insufflated air to
enhance the view.
SILS was described as early as 1992 by Pelosi who
performed a single-puncture laparoscopic
appendectomy
 In 1997 Navarra et al. performed a laparoscopic
cholecystectomy via two transumbilical trocars and
three transabdominal gallbladder stay sutures
 Refinement of equipment and technique have
recently brought SILS into the mainstream.
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Turkey
Dept. of Pediatric Surgery
Appendicectomy
2005
• Adrenalectomy
• Appendectomy
• Nephrectomy (partial
pp y and donor)
• Cholecystectomy
• Gastrectomy
• Prostatectomy • Pyeloplasty
• Gastrostomy
• Intestinal • Splenectomy
stoma
• Varicelectomy
• Hemicolectomy (right)
y
Chamberlain et al. J Gastrointest Surg 2009.
• Unpublished data suggests no significant
cosmetic advantage, cost-effectiveness, or
pain postoperatively between single incision
surgery and standard LC.
• Longer OR time and suspected higher
incidence of umbilical hernias
Navarra G et al. Surg Endoc 2008.
• Objective reporting of postoperative data
such as cosmetic result, pain scores, length
of stay, return to work, hematoma and
hernia formation have NOT been reported.
• No Prospective Randomized Trials yet
reported (limited enthusiasm to carry out)
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Options
3 Low profile 5mm ports
SILS Port or similar
Reticulating graspers with variable angulation
of the forward 1/3
Various tips
Grasper
Dissector
Scissors
5mm 30 degree scope most commonly used
Improvements:
Variable angulation telescope - EndoChameleon (0 –
120 degree)
Light produced by super bright LED bulbs at the head
of the telescope
Light source entering
back of camera head
(Reduces extra-abdominal
clashing)
LAPAROSCOPIC SURGERYMULTIPORT
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Difficult but possible
minor trauma
Moderate Pain, passes in short
term
MoreChances of Skin Infection
LOS- few days
4–5 small scars, less visible; good
effect
Patient quite satisfied of his look
SILS
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Cumbersome, no specialists in
this area
Low, minimal trauma to the
tissues
Minimal Pain
Lack of skin incisions—rare cases
of infection
LOS -A few days
No scars—perfect effect
Patient very satisfied of his look
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Cost
Learning curve
Data
Questions that need to be answered by well
constructed large series
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Equivalent safety?
Additional advantages over accepted laparoscopy
other than cosmesis?
Optimal technique?
Cost?
• Variety of techniques and innovative
devices available
• Feasibility established, outcomes are not
• Patients deserve transparency with respect
to innovative surgical procedures
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The possibility of performing truly scarless,
safe, more effective, and at the same time
less painful and minimally invasive surgery is
so tempting for doctors and, what is actually
more important, for patients that it will
encourage the medical world to make every
effort to make this dream come true.
Is SILS for Real?
(we’ll see)