Learning lessons for the future: assessments of demand and benefit are required in addition to training in single incision laparoscopic surgery

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To the Editor, We would like to thank Dr. Rehman and colleagues for their comments on our recent review of surgical training for single incision laparoscopic surgery (SILS) [1]. We agree that the current evidence base for SILS remains inconclusive. Recent publications continue to offer partly contradictory findings regarding certain outcomes, such as reduced postoperative pain, a purported advantage of SILS due to the reduced number and length of incisions, compared with traditional multiport laparoscopy. Whereas one recent study has reported significant reductions for postoperative pain [2], others have found this to be equal [3–5]. Crucially, however, these studies confirm the safety and efficacy of SILS, with equivalence in terms of morbidity, error, and adverse events. However, to suggest that the establishment of formalized SILS training is premature is to ignore the realities of clinical practice. In the current era of patient choice, cosmesis plays a valid role in the selection of surgical techniques, with a recent systematic review demonstrating advantages for SILS in this area [6]. Whether or not SILS techniques provide objective advantages as measured by traditional surgical endpoints, the practice of SILS is rapidly expanding—indeed, a lack of training was one of the issues preventing further expansion identified in the survey Dr. Rehman cites. Our review highlights the fact that current training schemes for laparoscopic surgery do not prepare surgeons for the different demands of SILS surgery. Without specialized training, the resulting learning curve places patients at undue risk of injury, even in the hands of laparoscopic experts. Having experienced the massive increase in major complications, such as bile duct injuries with the advent of laparoscopic surgery several decades ago, the surgical profession must avoid making the same mistakes again. There is no doubt that further research into the potential advantages and disadvantages of new techniques, such as SILS is required, and the results of a number of ongoing randomized trials are eagerly awaited. However, with SILS already widely being offered to the public, it is imperative that its safe implementation and practice be assured through dedicated training, assessment, and accreditation.