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Initial experience in children using conventional laparoscopic instruments in single-incision laparoscopic surgery
Journal of Pediatric Surgery (2010) 45, 2381–2385
www.elsevier.com/locate/jpedsurg
Initial experience in children using conventional laparoscopic instruments in single-incision laparoscopic surgery☆ Yuk Him Tam ⁎, Kim Hung Lee, Jennifer Dart Yin Sihoe, Kin Wai Chan, Sing Tak Cheung, Kristine Kit Yi Pang Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China Received 7 August 2010; accepted 12 August 2010
Key words: Single-incision laparoscopic surgery; Conventional instruments; Children
Abstract Background: Single-incision laparoscopic surgery (SILS) has been successfully performed in children using 5-mm reticulating instruments. There are, however, few reports investigating the use of conventional instruments in SILS in the pediatric population. Methods: We conducted a retrospective review of all consecutive children who underwent SILS from October 2009 to January 2010, with the procedure being solely performed by conventional 3- and 5-mm instruments through a standard access technique. Results: A total of 19 SILS procedures were successfully performed in children aged 3 to 15 years. They included appendectomy (n = 10), nephrectomy (n = 1), combined cholecystectomy and splenectomy (n = 2), cholecystectomy (n = 1), high ligation for varicocele (n = 2), excision of Meckel diverticulum (n = 1), and staged orchidopexy and exploration for impalpable testis (n = 2). There was one conversion to conventional laparoscopic surgery, and that occurred in our first case of splenectomy. All the patients had smooth recovery from surgery without complications. Conclusions: Using conventional instruments in SILS is technically feasible in children from simple to complex procedures and may have the potential to popularize this approach by eliminating the mandatory demand for specially designed instruments. © 2010 Elsevier Inc. All rights reserved.
Minimally invasive surgery has been widely recognized as a sound alternative to open surgery with multiple advantages. To strive for further decrease in surgical trauma, single-incision laparoscopic surgery (SILS) is currently ☆ The study was solely supported by the Department of Surgery, The Chinese University of Hong Kong. No external funding was received. ⁎ Corresponding author. Tel.: +852 26322953; fax: +852 26377974. E-mail address: [email protected] (Y.H. Tam).
0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.08.036
under active investigation. With the recent availability of reticulating instruments, SILS has been rapidly adapted into practices; and various procedures have been successfully performed in adult and pediatric populations using these special instruments [1-8]. There are, however, still some recent reports describing the use of conventional laparoscopic instruments in SILS [9-11]. We herby report our early experience with SILS in children using solely conventional laparoscopic instruments.
2382
Y.H. Tam et al.
1. Methods 1.1. Patients Over a 3-month period from October 2009 to January 2010, 19 consecutive children with mean age of 10.1 years (range, 3-15) and mean body weight of 34.2 kg (range, 13-53) who underwent SILS using conventional laparoscopic instruments were reviewed. A retrospective study was performed on the types of procedures, the operation details, and intraoperative complications. Postoperative courses and outcomes at early follow-up were also analyzed. The successful procedures included appendectomy (n = 10), nephrectomy (n = 1), combined cholecystectomy and splenectomy (n = 2), cholecystectomy (n = 1), high ligation for varicocele (n = 2), excision of Meckel diverticulum (n = 1), and staged orchidopexy and exploration for impalpable testis (n = 2). Among the 10 patients who underwent appendectomy, 2 had perforated appendicitis. The youngest patient was a 3-year-old boy with body weight of 13 kg who underwent right nephrectomy for nonfunctioning multicystic dysplastic kidney. The study was approved by the joint ethical committee of our university and the hospital.
1.2. Standard access technique We have recently reported our technique of singleincision laparoscopic appendectomy [12]. A slight modification was used for upper abdominal surgery. A hemicircumferential incision was made along the lower half of the umbilical ring from the 3- to the 9-o'clock position and was deepened to the fascia. The infraumbilical subcutaneous fat was mobilized from the fascia caudally until a fascial surface with a radial distance of around 1 to 1.5 cm from the umbilical stalk was created. Depending on the type of the procedures, one of the following combinations of ports was used : (a) 5 mm × 2 + 3 mm, (b) 5 mm + 3 mm × 2, and (c) 5 mm × 3 (Table 1). The 3 ports were placed over the fascial surface in a triangular configuration. A 5-mm port was placed by open method at midline inferior to the umbilical stalk for the telescope. For lower abdominal surgical procedures, the first working port was placed lateral to the
Table 1
camera port on the right side, whereas the second one was inferolateral to the camera port on the left side. For upper abdominal procedures, the camera port was placed more inferiorly at the midline, whereas the 2 working ports were placed superolaterally to the camera port on both sides at the superior ends of the wound.
1.3. Maneuverability with uncrossed and crossed instruments We used standard 3- and 5-mm straight instruments including graspers, scissors, and hook electrocautery and a 5-mm vessel sealing device (LigaSure; Valleylab, Boulder, CO). Both 0° and 30° lens were used in our patients. Spacing the 2 working ports farthest away within the limits of the skin incision provided adequate extracorporeal working space and triangulation at the abdominal fascia to accomplish with 2 uncrossed instruments most of the steps in those procedures that focused at a relatively small operating field such as appendectomy and cholecystectomy (Fig. 1). Crossing 2 straight instruments would increase both intra- and extracorporeal working space and was required in more complex procedures. Taking our right nephrectomy as an example, the 3-mm grasper on the surgeon's left hand retracted the ascending colon medially while the 3-mm hook on the right hand crossed the grasper to incise the lateral peritoneal reflection. After the ureter was divided, the grasper on the surgeon's right hand retracted the kidney anterolaterally while the vessel sealing device on the left hand crossed the grasper to coagulate and divide the renal pedicle (Fig. 2).
1.4. Specific points about different procedures For appendectomy, the mesoappendix was divided by 5-mm hook electrocautery or a vessel sealing device.
Combinations of ports used in different procedures
Combinations of ports
Types of procedures
Two 5 mm and one 3 mm
Appendectomy, high ligation of varicocele, cholecystectomy, excision of Meckel diverticulum Combined cholecystectomy and splenectomy Nephrectomy, staged orchidopexy and exploration for intraabdominal testis
Three 5 mm One 5 mm and two 3 mm
Fig. 1 Uncrossed instruments during appendectomy. Threemillimeter grasper on the surgeon's left hand retracted the appendix superiorly while endoloop was applied by the surgeon's right hand.
Initial experience in using conventional instruments in SILS
2383 tive complications—such as significant bleeding that required blood transfusion, or injury to intraabdominal organs—were encountered. Narcotic analgesic to control postoperative pain was required only in those patients who had undergone splenectomy. All the patients recovered smoothly from the surgical procedures without complications such as intraabdominal collections or prolonged ileus. Early postoperative follow-up at 2 weeks after surgery did not reveal any wound complications such as seroma or infection. At a mean follow-up of 16 weeks, none of the patients returned with procedure-related complications; and no access site hernia has been noted in our patients.
Fig. 2 External view of the ports (telescope at the 5-mm port and working instruments at the two 3-mm ports) in nephrectomy. Note the wide extracorporeal working space when the two 3-mm ports and instrument were actually crossing each other intracorporeally.
Endoloops were placed at the appendiceal base with the suture on specimen side being uncut. The appendix was extracted through the wound connecting the two 5-mm port sites while the wound was tunneled with a specimen retrieval bag for protection [12]. For cholecystectomy, 1 to 2 transabdominal stay sutures were placed to the gallbladder for cephalad retraction. Cholecystectomy was then performed in standard fashion with mostly uncrossed instruments. Splenectomy and nephrectomy required crossedinstrument maneuvers in most of the procedures. In the nephrectomy, we switched to a 3-mm laparoscope to save the only 5-mm port for the vessel sealing device when dividing the renal pedicle. The kidney was extracted through the wound connecting the 5- and one of the 3-mm port sites. The splenic pedicle and attachments were divided by the vessel sealing device. The spleen was retrieved by a 15-mm endobag (Endocath II; Tyco Healthcare, North Haven, CT) that was inserted through the wound incorporating two 5-mm port sites. Meckel diverticulum was delivered through the wound connecting two 5-mm port sites, and excision and anastomosis were done extracorporeally.
3. Discussion Our standard access technique has reproduced consistently successful outcomes in both upper and lower abdominal surgery. The scar can be very well concealed along the skin fold of lower umbilical ring, and the original umbilical configuration can be retained (Fig. 3). We have found the fascial surface at the infraumbilical area to be a convenient and reliable place for multiple port insertion, whether it was for upper or lower abdominal surgery. By approximating the subcutaneous fat properly to close any dead space, we believe the risk of seroma formation following wound closure would not be substantial. Seroma formation at the umbilical wound following SILS has been reported [9]. Concern has been raised about this potential complication following the mobilization of umbilical skin flaps [10]. Our technique does not create any umbilical skin flaps, as only the infraumbilical subcutaneous tissue is mobilized caudally along the fascia. Further studies are required to compare the risk of seroma between different access techniques. Triangular arrangement with the 2 working ports spaced farthest away within the limits of the skin incision maximizes the extracorporeal working space and allows adequate
2. Results The only conversion to conventional laparoscopic surgery happened in our first attempted case of combined cholecystectomy and splenectomy. Cholecystectomy was successfully performed by SILS, whereas we needed to place 2 additional extraumbilical 5-mm ports to complete the splenectomy. There was no conversion to open surgery in this series. The mean operative time for appendectomy was 84 minutes (55-110 minutes), whereas the nephrectomy took 120 minutes and the 2 combined cholecystectomy and splenectomy took 300 and 320 minutes, respectively. Of all the successful procedures, no intraopera-
Fig. 3 Infraumbilical wound healed with an inconspicuous scar at 2 weeks after SILS. Note the retention of the original configuration of the umbilicus.
2384 freedom of movement for uncrossed straight instruments to perform those procedures in a relatively focused operating field such as appendectomy, cholecystectomy, and high ligation for varicocele. Using ports of different lengths or adjusting the extracorporeal lengths of the ports further facilitates uncrossed instrumental maneuverability by minimizing collisions at the back ends. Complex procedures require more instrumental maneuverability and extracorporeal working space than the inline, uncrossed instruments can provide. The technique of crossing 2 reticulating instruments has been described to perform various SILS procedures [1,4]. However, the counterintuitive nature of this maneuver requires surgeons' retraining to acquire the skills and may have steep learning curve. Others have advocated using one reticulating instrument and one straight instrument to ease the dissection [2,8]. We found that crossing 2 straight instruments had no significant difference from the conventional laparoscopic skills. The grasper provided the retractions while the energy source crossed the grasper below or above, depending on the situation, to coagulate vessels and divide tissues. The surgeon, however, may need to control the energy source with the nondominant hand, and the instruments may need to be switched between the hands at different steps of the procedure. In the few reports retrospectively comparing SILS with a cohort of its conventional laparoscopic counterpart, either no difference or a trend of more wound pain was noted in the SILS group [5,9,13], contrary to the proposed benefits of SILS. Blinman [14] has recently reported the mathematical estimation of wound tension and suggested that the tension created from a single wound was higher than the total tension of multiple wounds of equal total length. The author raised doubt about the claim that SILS creates a less morbid wound. We postulate that the musculofascial tissues contribute more than the skin to wound tension. If our assumption is correct, the number and the size of each of the fascial defects in SILS would be the primary factors to determine the true invasiveness of SILS and the postoperative wound pain. We suggest that surgeons be more cautious about the creation of fascial defects when performing SILS. We connected 2 fascial incisions only in those procedures that required specimen retrieval. The size of the enlarged fascial defect was similar to that we created in conventional laparoscopic surgery, while leaving only one additional 3- or 5-mm fascial incision in SILS as compared with 2 to 3 in conventional laparoscopic procedures. Mandatory demand for 5-mm reticulating instruments in SILS may require a 5-mm trocar puncture that should otherwise be 3 mm in standard laparoscopic procedure. We closed each fascial incision separately, including 3-mm defects that we do not close in conventional laparoscopic procedures, given that extra caution is deserved in any new technique at the developmental stage. Whether the close proximity of multiple fascial defects, although each was small, would lead to more access site hernias remains to be seen.
Y.H. Tam et al. Podolsky and Curcillo [15] have recently reported their 2-year experience with more than 100 SILS procedures, and one of their major technical refinements was the transition from special reticulating instruments to conventional straight instruments. The authors reported shorter operative time in their cholecystectomies after the transition to all straight instruments. By revising the thought of many that costly special instruments are strictly required for SILS, our results should be encouraging to those who have yet to start performing SILS because of resources concern and unavailability of special instruments. Any development of new surgical techniques would only be meaningful if they are widely accepted and applicable to large case volume. Costs and availability of new instruments, the need for surgeons' retraining and steepness of the learning curve, and the efficacy and safety are all important factors that determine the acceptance of a new technique. To date, the evidence about SILS in children does not tell anything more than technical feasibility. We hope our initial experience with the conventional straight instruments might promote the interest in performing and investigating SILS in children. With more input from the experiences of colleagues around the world, the feasibility and safety of adopting SILS into routine pediatric practice as well as its benefits, if any, over conventional laparoscopic surgery can be determined.
References [1] Tacchino R, Greco F, Matera D. Single incision laparoscopic cholecystectomy: surgery without a visible scar. Surg Endosc 2009;23:896-9. [2] Roberts KE, Solomon D, Duffy AJ, et al. Single-incision laparoscopic cholecystectomy: a surgeon's experience with 56 consecutive cases and a review of the literature. J Gastrointest Surg 2010;14(3): 506-10. [3] Stolzenburg JU, Kallidonis P, Hellawell G, et al. Technique of laparoscopic-endoscopic single-site surgery radical nephrectomy. Eur Urol 2009;56(4):644-50. [4] Saber AA, Elgamal MH, El-Ghazaly TH, et al. Simple technique for single incision transumbilical laparoscopic appendectomy. Int J Surg 2010;8(2):128-30. [5] Tracy CR, Raman JD, Bagrodia A, et al. Perioperative outcomes in patients undergoing conventional laparoscopic versus laparoendoscopic single-site pyeloplasty. Urology 2009;74(5): 1029-34. [6] Ponsky TA, Diluciano J, Chwals W, et al. Early experience with single-port laparoscopic surgery in children. J Laparoendosc Adv Surg Tech 2009;19:551-3. [7] Dutta S. Early experience with single incision laparoscopic surgery: eliminating the scar from abdominal operations. J Pediatr Surg 2009;44:1741-5. [8] Bayazit Y, Aridogan IA, Abat D, et al. Pediatric transumbilical laparoendoscopic single-site nephroureterectomy: initial report. Urology 2009;74(5):1116-9. [9] Philipp SR, Miedema BW, Thaler K. Single-incision laparoscopic cholecystectomy using conventional instruments: early experience in comparison with the gold standard. J Am Coll Surg 2009;209(5): 632-7.
Initial experience in using conventional instruments in SILS [10] Merchant AM, Cook MW, White BC, et al. Transumbilical Gelport access technique for performing single incision laparoscopic surgery (SILS). J Gastrointest Surg 2009;13:159-62. [11] Muensterer OJ, Adibe OO, Harmon CM, et al. Single-incision laparoscopic pyloromyotomy: initial experience. Surg Endosc 2010;24:1589-93. [12] Tam YH, Lee KH, Sihoe JD, et al. A surgeon-friendly technique to perform single incision laparoscopic appendectomy intracorporeally in
2385 children with conventional laparoscopic instruments. J Laparoendosc Adv Surg Tech 2010;20:577-80. [13] Hodgett SE, Hernandez JM, Morton CA, et al. Laparoendoscopic single site (LESS) cholescystectomy. J Gastrointest Surg 2009;13:188-92. [14] Blinman T. Incisions do not simply sum. Surg Endosc 2010;24: 1746-51. [15] Podolsky ER, Curcillo II PG. Single port access (SPA) surgery—a 24-month experience. J Gastrointest Surg 2010;14:759-67.
www.elsevier.com/locate/jpedsurg
Initial experience in children using conventional laparoscopic instruments in single-incision laparoscopic surgery☆ Yuk Him Tam ⁎, Kim Hung Lee, Jennifer Dart Yin Sihoe, Kin Wai Chan, Sing Tak Cheung, Kristine Kit Yi Pang Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China Received 7 August 2010; accepted 12 August 2010
Key words: Single-incision laparoscopic surgery; Conventional instruments; Children
Abstract Background: Single-incision laparoscopic surgery (SILS) has been successfully performed in children using 5-mm reticulating instruments. There are, however, few reports investigating the use of conventional instruments in SILS in the pediatric population. Methods: We conducted a retrospective review of all consecutive children who underwent SILS from October 2009 to January 2010, with the procedure being solely performed by conventional 3- and 5-mm instruments through a standard access technique. Results: A total of 19 SILS procedures were successfully performed in children aged 3 to 15 years. They included appendectomy (n = 10), nephrectomy (n = 1), combined cholecystectomy and splenectomy (n = 2), cholecystectomy (n = 1), high ligation for varicocele (n = 2), excision of Meckel diverticulum (n = 1), and staged orchidopexy and exploration for impalpable testis (n = 2). There was one conversion to conventional laparoscopic surgery, and that occurred in our first case of splenectomy. All the patients had smooth recovery from surgery without complications. Conclusions: Using conventional instruments in SILS is technically feasible in children from simple to complex procedures and may have the potential to popularize this approach by eliminating the mandatory demand for specially designed instruments. © 2010 Elsevier Inc. All rights reserved.
Minimally invasive surgery has been widely recognized as a sound alternative to open surgery with multiple advantages. To strive for further decrease in surgical trauma, single-incision laparoscopic surgery (SILS) is currently ☆ The study was solely supported by the Department of Surgery, The Chinese University of Hong Kong. No external funding was received. ⁎ Corresponding author. Tel.: +852 26322953; fax: +852 26377974. E-mail address: [email protected] (Y.H. Tam).
0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.08.036
under active investigation. With the recent availability of reticulating instruments, SILS has been rapidly adapted into practices; and various procedures have been successfully performed in adult and pediatric populations using these special instruments [1-8]. There are, however, still some recent reports describing the use of conventional laparoscopic instruments in SILS [9-11]. We herby report our early experience with SILS in children using solely conventional laparoscopic instruments.
2382
Y.H. Tam et al.
1. Methods 1.1. Patients Over a 3-month period from October 2009 to January 2010, 19 consecutive children with mean age of 10.1 years (range, 3-15) and mean body weight of 34.2 kg (range, 13-53) who underwent SILS using conventional laparoscopic instruments were reviewed. A retrospective study was performed on the types of procedures, the operation details, and intraoperative complications. Postoperative courses and outcomes at early follow-up were also analyzed. The successful procedures included appendectomy (n = 10), nephrectomy (n = 1), combined cholecystectomy and splenectomy (n = 2), cholecystectomy (n = 1), high ligation for varicocele (n = 2), excision of Meckel diverticulum (n = 1), and staged orchidopexy and exploration for impalpable testis (n = 2). Among the 10 patients who underwent appendectomy, 2 had perforated appendicitis. The youngest patient was a 3-year-old boy with body weight of 13 kg who underwent right nephrectomy for nonfunctioning multicystic dysplastic kidney. The study was approved by the joint ethical committee of our university and the hospital.
1.2. Standard access technique We have recently reported our technique of singleincision laparoscopic appendectomy [12]. A slight modification was used for upper abdominal surgery. A hemicircumferential incision was made along the lower half of the umbilical ring from the 3- to the 9-o'clock position and was deepened to the fascia. The infraumbilical subcutaneous fat was mobilized from the fascia caudally until a fascial surface with a radial distance of around 1 to 1.5 cm from the umbilical stalk was created. Depending on the type of the procedures, one of the following combinations of ports was used : (a) 5 mm × 2 + 3 mm, (b) 5 mm + 3 mm × 2, and (c) 5 mm × 3 (Table 1). The 3 ports were placed over the fascial surface in a triangular configuration. A 5-mm port was placed by open method at midline inferior to the umbilical stalk for the telescope. For lower abdominal surgical procedures, the first working port was placed lateral to the
Table 1
camera port on the right side, whereas the second one was inferolateral to the camera port on the left side. For upper abdominal procedures, the camera port was placed more inferiorly at the midline, whereas the 2 working ports were placed superolaterally to the camera port on both sides at the superior ends of the wound.
1.3. Maneuverability with uncrossed and crossed instruments We used standard 3- and 5-mm straight instruments including graspers, scissors, and hook electrocautery and a 5-mm vessel sealing device (LigaSure; Valleylab, Boulder, CO). Both 0° and 30° lens were used in our patients. Spacing the 2 working ports farthest away within the limits of the skin incision provided adequate extracorporeal working space and triangulation at the abdominal fascia to accomplish with 2 uncrossed instruments most of the steps in those procedures that focused at a relatively small operating field such as appendectomy and cholecystectomy (Fig. 1). Crossing 2 straight instruments would increase both intra- and extracorporeal working space and was required in more complex procedures. Taking our right nephrectomy as an example, the 3-mm grasper on the surgeon's left hand retracted the ascending colon medially while the 3-mm hook on the right hand crossed the grasper to incise the lateral peritoneal reflection. After the ureter was divided, the grasper on the surgeon's right hand retracted the kidney anterolaterally while the vessel sealing device on the left hand crossed the grasper to coagulate and divide the renal pedicle (Fig. 2).
1.4. Specific points about different procedures For appendectomy, the mesoappendix was divided by 5-mm hook electrocautery or a vessel sealing device.
Combinations of ports used in different procedures
Combinations of ports
Types of procedures
Two 5 mm and one 3 mm
Appendectomy, high ligation of varicocele, cholecystectomy, excision of Meckel diverticulum Combined cholecystectomy and splenectomy Nephrectomy, staged orchidopexy and exploration for intraabdominal testis
Three 5 mm One 5 mm and two 3 mm
Fig. 1 Uncrossed instruments during appendectomy. Threemillimeter grasper on the surgeon's left hand retracted the appendix superiorly while endoloop was applied by the surgeon's right hand.
Initial experience in using conventional instruments in SILS
2383 tive complications—such as significant bleeding that required blood transfusion, or injury to intraabdominal organs—were encountered. Narcotic analgesic to control postoperative pain was required only in those patients who had undergone splenectomy. All the patients recovered smoothly from the surgical procedures without complications such as intraabdominal collections or prolonged ileus. Early postoperative follow-up at 2 weeks after surgery did not reveal any wound complications such as seroma or infection. At a mean follow-up of 16 weeks, none of the patients returned with procedure-related complications; and no access site hernia has been noted in our patients.
Fig. 2 External view of the ports (telescope at the 5-mm port and working instruments at the two 3-mm ports) in nephrectomy. Note the wide extracorporeal working space when the two 3-mm ports and instrument were actually crossing each other intracorporeally.
Endoloops were placed at the appendiceal base with the suture on specimen side being uncut. The appendix was extracted through the wound connecting the two 5-mm port sites while the wound was tunneled with a specimen retrieval bag for protection [12]. For cholecystectomy, 1 to 2 transabdominal stay sutures were placed to the gallbladder for cephalad retraction. Cholecystectomy was then performed in standard fashion with mostly uncrossed instruments. Splenectomy and nephrectomy required crossedinstrument maneuvers in most of the procedures. In the nephrectomy, we switched to a 3-mm laparoscope to save the only 5-mm port for the vessel sealing device when dividing the renal pedicle. The kidney was extracted through the wound connecting the 5- and one of the 3-mm port sites. The splenic pedicle and attachments were divided by the vessel sealing device. The spleen was retrieved by a 15-mm endobag (Endocath II; Tyco Healthcare, North Haven, CT) that was inserted through the wound incorporating two 5-mm port sites. Meckel diverticulum was delivered through the wound connecting two 5-mm port sites, and excision and anastomosis were done extracorporeally.
3. Discussion Our standard access technique has reproduced consistently successful outcomes in both upper and lower abdominal surgery. The scar can be very well concealed along the skin fold of lower umbilical ring, and the original umbilical configuration can be retained (Fig. 3). We have found the fascial surface at the infraumbilical area to be a convenient and reliable place for multiple port insertion, whether it was for upper or lower abdominal surgery. By approximating the subcutaneous fat properly to close any dead space, we believe the risk of seroma formation following wound closure would not be substantial. Seroma formation at the umbilical wound following SILS has been reported [9]. Concern has been raised about this potential complication following the mobilization of umbilical skin flaps [10]. Our technique does not create any umbilical skin flaps, as only the infraumbilical subcutaneous tissue is mobilized caudally along the fascia. Further studies are required to compare the risk of seroma between different access techniques. Triangular arrangement with the 2 working ports spaced farthest away within the limits of the skin incision maximizes the extracorporeal working space and allows adequate
2. Results The only conversion to conventional laparoscopic surgery happened in our first attempted case of combined cholecystectomy and splenectomy. Cholecystectomy was successfully performed by SILS, whereas we needed to place 2 additional extraumbilical 5-mm ports to complete the splenectomy. There was no conversion to open surgery in this series. The mean operative time for appendectomy was 84 minutes (55-110 minutes), whereas the nephrectomy took 120 minutes and the 2 combined cholecystectomy and splenectomy took 300 and 320 minutes, respectively. Of all the successful procedures, no intraopera-
Fig. 3 Infraumbilical wound healed with an inconspicuous scar at 2 weeks after SILS. Note the retention of the original configuration of the umbilicus.
2384 freedom of movement for uncrossed straight instruments to perform those procedures in a relatively focused operating field such as appendectomy, cholecystectomy, and high ligation for varicocele. Using ports of different lengths or adjusting the extracorporeal lengths of the ports further facilitates uncrossed instrumental maneuverability by minimizing collisions at the back ends. Complex procedures require more instrumental maneuverability and extracorporeal working space than the inline, uncrossed instruments can provide. The technique of crossing 2 reticulating instruments has been described to perform various SILS procedures [1,4]. However, the counterintuitive nature of this maneuver requires surgeons' retraining to acquire the skills and may have steep learning curve. Others have advocated using one reticulating instrument and one straight instrument to ease the dissection [2,8]. We found that crossing 2 straight instruments had no significant difference from the conventional laparoscopic skills. The grasper provided the retractions while the energy source crossed the grasper below or above, depending on the situation, to coagulate vessels and divide tissues. The surgeon, however, may need to control the energy source with the nondominant hand, and the instruments may need to be switched between the hands at different steps of the procedure. In the few reports retrospectively comparing SILS with a cohort of its conventional laparoscopic counterpart, either no difference or a trend of more wound pain was noted in the SILS group [5,9,13], contrary to the proposed benefits of SILS. Blinman [14] has recently reported the mathematical estimation of wound tension and suggested that the tension created from a single wound was higher than the total tension of multiple wounds of equal total length. The author raised doubt about the claim that SILS creates a less morbid wound. We postulate that the musculofascial tissues contribute more than the skin to wound tension. If our assumption is correct, the number and the size of each of the fascial defects in SILS would be the primary factors to determine the true invasiveness of SILS and the postoperative wound pain. We suggest that surgeons be more cautious about the creation of fascial defects when performing SILS. We connected 2 fascial incisions only in those procedures that required specimen retrieval. The size of the enlarged fascial defect was similar to that we created in conventional laparoscopic surgery, while leaving only one additional 3- or 5-mm fascial incision in SILS as compared with 2 to 3 in conventional laparoscopic procedures. Mandatory demand for 5-mm reticulating instruments in SILS may require a 5-mm trocar puncture that should otherwise be 3 mm in standard laparoscopic procedure. We closed each fascial incision separately, including 3-mm defects that we do not close in conventional laparoscopic procedures, given that extra caution is deserved in any new technique at the developmental stage. Whether the close proximity of multiple fascial defects, although each was small, would lead to more access site hernias remains to be seen.
Y.H. Tam et al. Podolsky and Curcillo [15] have recently reported their 2-year experience with more than 100 SILS procedures, and one of their major technical refinements was the transition from special reticulating instruments to conventional straight instruments. The authors reported shorter operative time in their cholecystectomies after the transition to all straight instruments. By revising the thought of many that costly special instruments are strictly required for SILS, our results should be encouraging to those who have yet to start performing SILS because of resources concern and unavailability of special instruments. Any development of new surgical techniques would only be meaningful if they are widely accepted and applicable to large case volume. Costs and availability of new instruments, the need for surgeons' retraining and steepness of the learning curve, and the efficacy and safety are all important factors that determine the acceptance of a new technique. To date, the evidence about SILS in children does not tell anything more than technical feasibility. We hope our initial experience with the conventional straight instruments might promote the interest in performing and investigating SILS in children. With more input from the experiences of colleagues around the world, the feasibility and safety of adopting SILS into routine pediatric practice as well as its benefits, if any, over conventional laparoscopic surgery can be determined.
References [1] Tacchino R, Greco F, Matera D. Single incision laparoscopic cholecystectomy: surgery without a visible scar. Surg Endosc 2009;23:896-9. [2] Roberts KE, Solomon D, Duffy AJ, et al. Single-incision laparoscopic cholecystectomy: a surgeon's experience with 56 consecutive cases and a review of the literature. J Gastrointest Surg 2010;14(3): 506-10. [3] Stolzenburg JU, Kallidonis P, Hellawell G, et al. Technique of laparoscopic-endoscopic single-site surgery radical nephrectomy. Eur Urol 2009;56(4):644-50. [4] Saber AA, Elgamal MH, El-Ghazaly TH, et al. Simple technique for single incision transumbilical laparoscopic appendectomy. Int J Surg 2010;8(2):128-30. [5] Tracy CR, Raman JD, Bagrodia A, et al. Perioperative outcomes in patients undergoing conventional laparoscopic versus laparoendoscopic single-site pyeloplasty. Urology 2009;74(5): 1029-34. [6] Ponsky TA, Diluciano J, Chwals W, et al. Early experience with single-port laparoscopic surgery in children. J Laparoendosc Adv Surg Tech 2009;19:551-3. [7] Dutta S. Early experience with single incision laparoscopic surgery: eliminating the scar from abdominal operations. J Pediatr Surg 2009;44:1741-5. [8] Bayazit Y, Aridogan IA, Abat D, et al. Pediatric transumbilical laparoendoscopic single-site nephroureterectomy: initial report. Urology 2009;74(5):1116-9. [9] Philipp SR, Miedema BW, Thaler K. Single-incision laparoscopic cholecystectomy using conventional instruments: early experience in comparison with the gold standard. J Am Coll Surg 2009;209(5): 632-7.
Initial experience in using conventional instruments in SILS [10] Merchant AM, Cook MW, White BC, et al. Transumbilical Gelport access technique for performing single incision laparoscopic surgery (SILS). J Gastrointest Surg 2009;13:159-62. [11] Muensterer OJ, Adibe OO, Harmon CM, et al. Single-incision laparoscopic pyloromyotomy: initial experience. Surg Endosc 2010;24:1589-93. [12] Tam YH, Lee KH, Sihoe JD, et al. A surgeon-friendly technique to perform single incision laparoscopic appendectomy intracorporeally in
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