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SILS in bariatric surgery

SILS safe and feasible but controlled trials needed

SILS does have some potential benefits include less postoperative pain, improved cosmesis and patient satisfaction
Randomised trials involving larger patient series with a longer follow-up and larger cohort studies and/or systematic reviews will be necessary to assess the extent of the benefits and limitations of SILS in bariatric surgery

Laparoscopic single-incision gastric bypass is feasible, safe and reproducible technique used as an access to complex surgeries like gastric bypass in carefully selected patients, according to researchers from Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, and the Cleveland Clinic, Bariatric and Metabolic Institute, Cleveland, OH, USA. Their paper, ‘Laparoscopic single-incision gastric bypass: initial experience, technique and short-term outcomes’, was published in the Annals of Surgical Innovation and Research.

The authors write that single incision laparoscopic surgery (SILS) has questionable benefits when compared to laparoscopic bariatric surgery and is still under evaluation for its utility in the field of bariatric surgery. In theory, SILS should results in better cosmesis, potential less postoperative pain and shorter hospital , but the evidence in limited.

As a result, the study authors evaluated the short term outcomes and efficacy of SILS Roux-en-Y gastric bypass (RYGB) in a selected group of patients in a single centre. From March 2012 to January 2013, a total of fourteen patients underwent SILS RYGB using a single vertical 2.5–3cm intra-umbilical incision, three-ports placed trans-fascially, and a liver suspension technique in Cleveland Clinic’s Bariatric & Metabolic Institute, in Cleveland. Patient selection, short-term outcomes and technical issues were retrospectively viewed in this study.

The most prevalent preoperative co-morbidities in this selected group of patients included hypertension in eight patients (57%), hyperlipidaemia in six (43%), obstructive sleep apnoea in three (21%), hypothyroidism three (21%) and type 2 diabetes in two (14%).

SILS procedure

One 12mm trocar with Optiview technology (Ethicon), two 5mm port (Covidien), a 5mm 45-degree angled camera, regular inline graspers, Endo-Stitch (Covidien) suturing devices and when possible, we utilize a cordless ultrasonic dissection device (Sonicision, Covidien) with a long shaft. Powered articulating staplers (Ethicon) with a linear load of 60mm white, blue or green cartridges are used depending on transected tissue thickness.

A vertical 2–3.5cm skin incision is made starting slightly off and in the cusp of the umbilicus, proceeding towards the upper umbilical edge, exceeding it as needed. A 2–3cm space underneath the subcutaneous fat and over the abdominal fascia is dissected for port placement. Pneumoperitoneum (12–15mmHg) is created with the use of a veress needle inserted through the lower-middle part of the exposed fascia. A 12mm Optiview trocar is then inserted, centrally and slightly to the lower-middle part of the exposed fascia, under direct visualisation with a zero degree laparoscope. Next, a triangle with approximately 2cm sides is created by blindly inserting two 5mm ports laterally and superior to the 12mm port towards the subcutaneous pocket (Figure 1).

Figure 1: Port placement for single incision laparoscopic gastric bypass

Internal retraction is applied with a 2.0 silk stitch (30cm) on a straight cutting needle (Keith) which is passed through the mid-upper abdomen 5–7cm below the xiphoid process if the left lobe of the liver is found to be relatively small. The suture is picked up with non-toothed graspers and passed through the left lobe of the liver, about 5–7 cm medially from its edge. Then, it is passed back out proximal to the first insertion (through the abdominal wall) and gently pulled up to retract the liver. Needle insertion sites are monitored for any bleeding, bile leakage or laceration (Figure 2).

Figure 2: Technique of liver retraction with a stitch passed through the left lobe of liver

The alternative method utilizes the EndoLift Port-Free Retractor (Virtual Ports, Israel). It is comprised of a telescopic stainless steel bar positioned underneath the left liver lobe and two articulated clips on either end of the bar used to grasp and anchor it to the intra-abdominal wall (Figure 3).

Figure 3: Technique of liver retraction with EndoLift device

The operation starts with the creation of the jejuno-jejunal side-to-side stapled anastomosis, with a standard 50cm biliopancreatic limb and 150cm Roux limb. The authors state that their preferred site is the far upper-left of the peritoneal cavity and the placement of stay sutures is necessary. The closing of the resulting common enterotomy site with a stapler is difficult due to poor retraction. Therefore, they close the enterotomy site with the Endo-Stitch using a nonabsorbable suture.

The gastric pouch is created with the operative table in the steep reverse Trendelenburg position. They tend to create longer tubular shaped pouches to facilitate a low-tension anastomosis. A stitch is passed through the tip of the Roux limb to approximate it to the horizontal portion of the pouch. A 2cm gastro-jejunal hand-sewn anastomosis is created in a two-layer fashion using absorbable suture applied with the Endo-Stitch. Sewing with the Endo-Stitch is difficult in this cranial position with only one grasper to guide the stitch and no counter-traction. They state that it is important to pass the gastroscope prior to completion of the anastomosis to avoid strictures and to control bleeding. An air-leak test is always performed using a gastroscope.

Outcomes

A total of 14 morbid obese patients (12 women and two men; mean age, 46 years) has SILS with a mean operative time of 196 (range 131–265) min. Mean weight at surgery was 113 (range 91–135) kg. One patient required placement of one additional port (7%). No conversions to conventional laparoscopic surgery (CLS) or open surgery was needed. The estimated blood loss was 40 (range 20–100) ml. In terms of pain control, the frequency of patient controlled analgesia had a mean use of 21 times in postoperative day 0 (POD), 37 times in POD1 and 13 times in POD2. Pain score (assessed by visual analogue scale) had a median score of 6.9 in POD0, 5.2 In POD1 and 3.8 in POD2. Weight loss was approximately 7.25lb (±4.5) after first postoperative visit, 28.9lb (±11.86) after one month and 45.4lb (±15.4) after four months. No patients required re-operation or readmission during the 90 days after surgery.

“Appropriate surgical candidate selection is very important to the success of single incision bariatric surgery…In our study patients with BMI>50, a thick abdominal wall and tall stature were not considered for SILS,” the authors note. “Also patients with scars from open surgery were not offered SILS due to questionable cosmetic benefits and expected adhesions. “

Single incision is feasible, safe and reproducible technique used as an access to complex surgeries like gastric bypass in carefully selected patients. Results in short-term outcomes are comparable to those observed in literature. Some potential benefits include less postoperative pain, improved cosmesis, and patient satisfaction. Randomized trials involving larger patient series with a longer follow-up and larger cohort studies and/or systematic reviews will be necessary to assess the extent of the benefits and limitations of SILS in bariatric surgery.

Overall, the authors concluded that SILS does have some potential benefits include less postoperative pain, improved cosmesis and patient satisfaction, nevertheless, the stated that: “Randomised trials involving larger patient series with a longer follow-up and larger cohort studies and/or systematic reviews will be necessary to assess the extent of the benefits and limitations of SILS in bariatric surgery.”

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