In the lead up to Barcelona 2014, Dr Marat Khaikin from Chaim Sheba Medical Center, Tel-Hashomer in Israel, who is giving the keynote lecture 'SILS - where are we?', spoke with us about SILS.

Photo of Marat KhaikinThe potential advantages of moving from multi-port laparoscopic surgery to single incision laparoscopic surgery (SILS) is to reduce the number of ports and thereby:

  • minimise wound related complications,
  • decrease post-operative pain,
  • shorten hospital stay,
  • improve cosmesis,
  • improve cost effectiveness,
  • offer faster recovery; and
  • potentially fewer adhesions so in the long-term it is expected the procedure will result in less complications (such as small bowel obstruction).

“Studies have shown that the short-term outcomes from single port laparoscopic colectomy are comparable to multi-port laparoscopic colectomy with regards to oncologically adequate resection, operative time, complication rate, conversion rate, and mortality,” said Dr Khaikin. “So in effect the additional costs of the device can be justified by potentially shorter recovery time, earlier ambulation, decreased incision-related complications such as incisional hernias. There are some conflicting reports in the literature, so we do require bigger multi-institutional randomized controlled studies and more long-term data.”

He added that the literature shows that single port laparoscopic colectomy is feasible and safe, even if it is a technically challenging procedure. He acknowledges that most studies included highly-selected patients (low-risk, non-obese) who had small tumors and were operated on by very experienced laparoscopic colorectal surgeons, so there was some bias.

In addition, Dr Khaikin said that there is evidence that SILS significantly minimizes blood loss during laparoscopic colectomy. With regards to pain, there is conflicting evidence with some papers suggesting decreased pain for the first 48hrs post-op compared with traditional laparoscopy. SILS may also provide patients benefits reducing time to GI recovery.

“Most studies show that hospital stay following single port laparoscopic colectomy is significantly shorter compared with traditional laparoscopy, as well as reporting better cosmesis,” he added.

According to Dr Khaikin, there are patient and surgical factors to take into consideration when performing SILS. For example, whether the patient has had multiple previous laparotomies, although he adds that this is a relative contra-indication and there are no absolute contra-indications for SILS (other than the contra-indications for traditional laparoscopy).

An important surgical consideration is surgical experience and he recommends that SILS should be performed by highly-experienced surgeons, as he would expect less experienced surgeons to have an ‘extended learning curve’.
With regards to the literature he stated that there are two studies from the United States: the first reported a significant reduction in operative time and hospital stay after the first ten right hemicolectomy cases; the second paper reported the same reduction but after 30-36 right hemicolectomy procedures.

“From my own experience, I think the learning curve for experienced surgeons performing a single-port laparoscopic colorectal surgery is probably around 15-20 cases, but it depends on the surgeon and the procedure,” he said.

Dr Kaikin stated that one improvement that is required during the SILS procedure is improved triangulation, the basic principle of laparoscopy. He explained that due to the nature of the SILS the instruments and the surgeon’s hands are very close making triangulation very difficult.

“We are now trying to get intracorporeal triangulation and some companies are producing articulating instruments. There is also a need to improve traction and counter-traction so we can anchor the colon to the wall from the inside, and there are some devices (mechanical, magnetic etc.) available that can assist the surgeon in this respect,” he added.

“One of the current controversies regarding SILS is the absence of long-term data regarding clinical outcomes (incisional hernias and adhesive small bowel obstuctions rates), cost-effectiveness, and oncological outcomes, so we need to collect more long-term data to make an adequate comparison to multi-port laparoscopic colectomies” he concluded. “However, in the short-term for use in highly-selected patients and performed by an experienced surgeon, I believe that SILS offers several advantages to the patients.”

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