Fig. 5.1
Olympus EndoEYE® Flex 3D Scope (Available online at http://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d)
Fig. 5.2
Example of laparoscopic camera with right-angle adaptor (From Stryker. Available online at: http://www.stryker.com/en-us/GSDAMRetirement/index.htmstellent/groups/public/documents/web_content/126633.pdf)
Curved laparoscopic instruments were introduced specifically to address the internal sword fighting with SILS cases. While they may avoid internal clashing, there are increased external collisions, and they cannot be passed through conventional trocars; thus, we do not recommend these tools. Articulating instruments, with a flexible tip that rotates 360° around the axis of the instrument, have been recommended to increase freedom of motion and overcome the lack of triangulation with straight instruments in SILS [27–29]. However, there is a loss of rigidity and tactile feedback with these tools that adds further technical difficulty to the case; thus, the editors do not recommend them for SILS. We feel standard, straight laparoscopic instruments with the tricks aforementioned are the most effective for SILS. The straight instruments offer rigidity and tactile feedback and can transmit applied force evenly for the operator. Instruments are generally 5 mm in width and available in standard (34–35 cm) and bariatric/extra-long (44–45 cm) shaft lengths. The extra-long/bariatric length instruments may be helpful to stagger the port lengths and diminish external clashing between the surgeon’s hand and assistant’s camera.
Given the ergonomic challenges and higher technical difficulty with SILS compared with conventional laparoscopy, an additional learning curve is needed for proficiency [20, 21, 23, 30]. Studies have evaluated this learning curve in specific procedures for recommendations on how many cases are needed to ascend it. For a right hemicolectomy, a surgeon with advanced laparoscopic skills can reach baseline operative times and complication rates in ten cases [31]. Analysis of outcomes and operative time for a surgeon trained in advanced laparoscopic techniques found they are optimized following 40 SILS right colectomies [32]. Comparing the learning curve for SILS head to head to conventional multiport laparoscopy using a moving average of operative time and cumulative sum (CUSUM) analysis for right hemicolectomy, Park et al. found the learning phase of SILS was completed after 31 cases, while only 25 cases were needed for multiport laparoscopy; the CUSUM analysis demonstrated to reach a steady state of complication-free performance; ten SILS cases were needed compared to two multiport cases [33]. Using a similar moving multidimensional analysis risk adjusted to evaluate low anterior resections for sigmoid colon cancer, Kim et al. found the cases required for proficiency (including operative time, hospital length of stay, and oncologic outcomes) with SILS were approximately 61–65 [34]. While these reports assess the learning curve in experienced laparoscopic surgeons, recent studies have shown SILS is safe and feasible in surgical training, with residents able to safely perform SILS colorectal resections with appropriate supervision [35].
Available Platforms
For SILS, there are several commercially produced platforms that are commonly used for access, as well as a homemade glove port that has been described. The most common ports are the GelPOINT® platform (Applied Medical, Rancho Santa Margarita, California, USA), the SILS™ Port (Covidien, Mansfield, Massachusetts, USA), and the TriPort or QuadPort (Olympus Medical, Center Valley, Pennsylvania, USA). The platforms all have the ability to introduce three or more working channels for instruments and a laparoscopic camera through a single port and single incision. The commercially available access devices are packaged with all essential trocars and parts and are compatible with all currently available laparoscopic instruments. Each platform has been proven effective for SILS, with individual benefits and drawbacks , so surgeon preference and availability can govern the access used.
With the GelPOINT® (Applied Medical, Rancho Santa Margarita, California, USA), Applied uses the successful same wound protector and cap design for SILS as for hand-assisted laparoscopic surgery (GelPort®) and transanal surgery (GelPOINT Path®) (Fig. 5.3). The sleeve is inserted into the abdominal cavity through a single fascial incision (usually ~ 4 cm) and then rolled down to create a secure seal. The desired trocars (5–12 mm) are introduced into the GelSeal® cap in a triangular fashion, and the cap is secured to the sleeve. Benefits of this port are that trocars can be repositioned or exchanged without affecting pneumoperitoneum and there is a smoke evacuator side port, which can aid visualization. In addition, the port has a low internal profile, and the sleeve is flexible, which helps to adapt to the patient’s specific body habitus and abdominal wall size. Plus, the wound protector helps facilitate specimen extraction and offers protection from tumor seeding in malignant cases [36, 37]. Drawbacks of this port are the larger, dome-shaped external profile on the abdominal wall and that it may lose pneumoperitoneum with extreme torque and allow trocars to slip [24, 25].
Fig. 5.3
Applied GelPOINT® Port (From http://www.appliedmedical.com/Products/GelPoint_Overview.aspx)
The SILS™ Port (Covidien, Mansfield, Massachusetts, USA) is constructed from pliable elastomeric foam that is inserted through a single 2–4 cm skin and fascial incision (Fig. 5.4). Benefits of this port are that it creates a seal with the skin to maintain pneumoperitoneum and allows the surgeon to interchange 5 mm and 12 mm ports with ease and readily remove and reinsert the port as needed. The drawbacks are that the port is limited to three trocars for the instrument and camera and there is no wound protector for specimen extraction, necessitating port removal and a separate wound protector inserted for specimen extraction. The port’s length is also fixed, which makes it prone to dislodgement if the fascial incision is too large and less ideal in obese or patients with a thick abdominal wall [24, 25].
Fig. 5.4
Covidien SILS® Port (From http://www.medtronic.com/covidien/products/trocars-access/sils-port)
The TriPort, TriPort15, and QuadPort (Olympus Medical, Center Valley, Pennsylvania, USA) are similar to the GelPOINT®, with three or four instrument channels, respectively, but a lower external profile (Fig. 5.5). The port is introduced through a single incision using the introducer from the kit with the distal ring attached. The distal ring and excess protector sleeve are then removed, the ring is tightened to the abdominal wall, and insufflation commences. Drawbacks to these ports are that the assembly, insertion, and extracorporealization of specimens are reported more difficult than other platforms and the gel is reportedly prone to damage and leaks [24, 25]. Thus, they are not commonly used as the GelPOINT and SILS ports .
If a commercially available SILS port is not available, the surgeon can construct a glove port (Fig. 5.6). Reports have described a sterile, non-latex size 6 glove secured to a small wound protector, with the glove’s fingers used for instruments and camera access as a cost-effective alternative to commercially available access platforms [38–41]. In addition to the cost advantage and simplicity of this port, the flexible finger extensions reduce the external trocar conflict routinely experienced during SILS. Drawbacks are a poor seal, with loss of pneumoperitoneum, and lack of rigidity provided from the finger ports [12, 38–41].
Fig. 5.6
Glove port (From Indian J Surg. 2011 Apr; 73(2): 142–145)
Conclusions
Single-incision laparoscopic colorectal surgery is safe and feasible for a wide variety of procedures, with added potential benefits of improved cosmesis, perioperative pain, and quality of life. There are multiple ports available for access, as well as ergonomic and technical challenges, which can be overcome with experience and special tips and tricks. These pearls help ascension up the learning curve, to facilitate safe training and implementation of SILS into practice.
