Single-incision Access Research Articles

Comparison between the Flapless Surgical Approach and a Novel Single Incision Access in Terms of Recovery Time and Comfort after Extraction of Impacted Inferior Third Molars: A Randomised, Blinded, Split-Mouth Controlled Clinical Trial

The recent attention to quality of life and oral health care procedures reflects a renewed 'patient-based' approach to dealing with non-life-threatening conditions. In the current study, we proposed a novel surgical approach to the extraction of impacted inferior third molars (iMs3) through a randomised, blinded, split-mouth controlled clinical trial following the CONSORT guidelines. The novel surgical procedure, hereinafter referred to as single incision access (SIA), will be compared with our previously described flapless surgical approach (FSA). The predictor variable was the novel SIA approach, involving access through a single incision without removal of soft tissue, on the impacted iMs3. The primary endpoint was the acceleration of the iMs3 extraction healing time. The secondary endpoints were the incidences of pain and oedema as well as gum health (pocket probing depth and attached gingiva). The study was carried out on 84 teeth of 42 patients with both iMs3 impacted. The cohort was composed of 42% Caucasian males and 58% Caucasian females, aged 23.8 ± 7.9 (17-49) years. We observed faster recovery/wound-healing on the SIA side (33.6 ± 4.3 days) than at the FSA side (42.1 ± 5.4 days; p < 0.05). The FSA approach confirmed the evidence previously detected concerning early post-surgery improvement in terms of attached gingiva and reduced oedema and pain, with respect to the traditional envelope flap. The novel SIA approach follows the early positive post-surgery FSA results.

Extraction of impacted inferior third molars: A randomised, split-mouth controlled study to compare the flapless surgical approach and a novel single incision access

Extraction of impacted inferior third molars: A randomised, split-mouth controlled study to compare the flapless surgical approach and a novel single incision access

Outcomes from different minimally invasive approaches for infected necrotizing pancreatitis.

Infected necrotizing pancreatitis (INP), the leading cause of mortality in the late phase of acute pancreatitis, nearly always requires intervention. In recent years minimal invasive surgery is becoming more and more popular for the management of INP, but few studies compared different minimally invasive strategies. The objective of this observation study was to evaluate the safety and effectiveness with several minimal invasive treatment.We retrospectively reviewed cases of percutaneous catheter drainage (PCD), minimal access retroperitoneal pancreatic necrosectomy (MARPN), small incision pancreatic necrosectom (SIPN), single-incision access port retroperitoneoscopic debridement (SIAPRD) for INP between January 2013 and October 2018. Data were analyzed for the primary endpoints as well as secondary endpoints.Eighty-one patients with INP were treated by minimally invasive procedures including PCD (n = 32), MARPN (n = 18), SIPN (n = 16), and SIAPRD (n = 15). Overall mortality was greatest after PCD 34% (MARPN 11% vs SIPN 6% vs SIRLD6%). Problems after initial surgery were ongoing sepsis (PCD 56% vs MARPN 50% vs SIPN 31% vs SIAPRD13%; P < .05). There was a significant difference in number of interventions (median, 6 vs 5 vs 3 vs 2; P < .05). Time from onset of symptoms to recovery was less for SIAPRD than for PCD, MARPN, or SIPN (median, 45 vs 102 vs 80 vs 67 days; P < .05).SIAPRD remedy evidently improved outcomes, including systemic inflammatory response syndrome, number of interventions, length of hospital stay and overall cost. It is technically feasible, safe, and effective for INP, in contrast to others, and can achieve the best clinical results with the least cost. Furthermore, relevant multicentre randomized controlled trials are eager to prove these findings.

Future of uniportal video-assisted thoracoscopic surgery-emerging technology.

Uniportal VATS poses unique difficulties to the surgeon, mainly as a consequence of operating through a small single incision. The instruments in uniportal VATS have limited movement through the small incision. In addition, the approach to the surgical operating site is unidirectional, which may restrict vision and retraction, and unavoidably suffers from instrument fencing. Recent thoracoscopic technology in the form of a wide variable angled lens has to some extent improved these shortcomings. The development of an extendable flexible thoracoscope and wireless steerable endoscope (WSE) systems can further improve the visualization for surgery and reduce or even remove fencing between endoscope and instruments. New single incision access platforms both derived from Natural orifice transluminal endoscopic surgery (NOTES) and robotic surgery approaches are on the horizon. These may allow uniportal VATS to be performed through an even smaller ultra-minimally invasive incision, with improved vision, more freedom of movement of the instruments and greater precision. However, a number of problems remain to be resolved, including provision of a stable platform and payload, applied force limitations and equipment sterilization. Advances in uniportal VATS major lung resection techniques have not only challenged the surgeon to acquire new skills and knowledge, but at the same time have rekindled the collaborative spirit between industry and clinician in developing novel equipment and technology to push the boundaries of minimally invasive surgery. These technological improvements and innovations may improve operating efficiency and safety during uniportal VATS surgery.

TAMIS for rectal tumors: advancements of a new approach.

TAMIS allows transanal excision of rectal lesions by the means of a single-incision access port and traditional laparoscopic instruments. This technique represents a promising treatment of rectal neoplasms since it guarantees precise dissection and reproducible approaches. From May 2010 to September 2015, we performed excisions of rectal lesions in 55 patients using a SILS port. The pre-operative diagnosis was 26 tumours, 26 low and high grade displasias and 3 other benign neoplasias. 11 patients had a neoadjuvant treatment. Pneumorectum was established at a pressure of 15-20mmHg CO2 with continuous insufflation, and ordinary laparoscopic instruments were used to perform full thickness resection of rectal neoplasm with a conventional 5-mm 30° laparoscopic camera. The average operative time was 78min. Postoperative recovery was uneventful in 53 cases: in one case a Hartmann procedure was necessary at two postoperative days due to an intraoperative intraperitoneal perforation; in another case, a diverting colostomy was required at the five postoperative days due to an intraoperative perforation of the vaginal wall. Unclear resection margins were detected in sixpatients: thereafter five patients underwent radical surgery; the other patient was unfit for radical surgery, but is actually alive and well. Patients were discharged after a median of 3days. Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for low rectal tumors. The feasibility of TAMIS also for malignant lesions treated in a neoadjuvant setting could be cautiously evaluated in the future.

Single port VATS: recent developments in Asia.

Single port video-assisted thoracic surgery (VATS) is the most recent evolution in minimally invasive thoracic surgery. With increasing global popularity, the single port VATS approach has been adopted by experienced thoracic surgeons in many Asian countries. From initial experience of single port VATS lobectomy to the more complex sleeve resection procedures now forming part of daily practice in some Asia institutes, the region has been the proving ground for single port VATS approaches' feasibility and safety. In addition, certain technical refinements in single port VATS lung resection and lymph node dissection have also sprung from Asia. Novel equipment designed to facilitate single port VATS allowing further reduce access trauma are being realized by the partnership between surgeons and the industries. Advanced thoracoscopes and staplers that are narrower and more maneuverable are particularly important in the smaller habitus of patients from Asia. These and similar new generation equipment are being applied to single port VATS in novel ways. As dedicated thoracic surgeons in the region continue to striving for excellence, innovative ideas in single incision access including subxiphoid and embryonic natural-orifice transluminal endoscopic surgery (e-NOTES) have been explored. Adjunct techniques and technology used in association with single port VATS such as non-intubated surgery, hybrid operating room image guidance and electromagnetic navigational bronchoscopy are all in rapid development in Asia.

Prospective randomized comparison of single-incision laparoscopic cholecystectomy with new facilitating maneuver vs. conventional four-port laparoscopic cholecystectomy.

We aimed to investigate the technical feasibility of single-incision laparoscopic cholecystectomy (SILC) with our new facilitative maneuver and to compare it with the gold standard four-port laparoscopic cholecystectomy (LC). Operation time, cosmetic score and incisional hernia rates between LC (n=20) and SILC-1 (first 20 consecutive operations with the new technique) and 2 (subsequent 20 operations with the new technique) were compared. The median operation time for LC, SILC-1 and SILC-2 were; 35 min (12-75), 47.5 min (30-70), and 30 min (12-80), respectively (p=0.005). The operation duration was similar in LC and SILC-2 (p=0.277) groups. Wound seroma rate was higher in SILC-1 (45%) and SILC-2 (30%) groups than LC (5%) group (p=0.010). Cosmetic score was similar between all the groups. Hernia rates were 15.8% and 5.3% in the SILC-1 and SILC-2 groups, respectively, while there was no hernia in the LC group. SILC with new facilitating maneuver is comparable with classical four-port laparoscopic cholecystectomy in terms of ease, operation time, reproducibility and safety. Besides these advantages, the single-incision access technique must be optimized to provide comparable wound complication and postoperative hernia rates before being recommended to patients.

Laparoscopic Intragastric Surgery for Early Gastric Cancer and Gastrointestinal Stromal Tumors

T1a gastric cancer and gastrointestinal stromal tumors (GIST) often require extensive resection despite their favorable tumor biology. This holds especially true for lesions located at the gastroesophageal junction. In this video we will demonstrate an oncologically sound technique of laparoscopic intragastric surgery that allows for safe and effective tumor resection. The first patient has a T1a gastric adenocarcinoma with no adverse features at the gastroesophageal junction. The tumor is resected with multiple cuffed ports placed directly into the stomach. The specimen is removed via the mouth. The next video shows the use of multi-port access to resect a 6cm GIST at the cardia. An endoloop is used to provide safe manipulation with minimal handling of the GIST itself. The third patient has a small 1.5cm GIST, and a single incision access device is used for stapled removal of this tumor located at the gastroesophageal junction. The video shows safe and feasible techniques for intragastric surgery to remove early gastric cancer and GIST. We demonstrate the use of multiple ports and single access, as well as stapling inside the stomach. The technique of intragastric laparoscopic surgery allows for safe removal of T1a gastric cancer too extensive for endoscopic resection. At this point, gastric adenocarcinomas of <4-5cm, with no submucosal, lymphatic, or vascular invasion or ulceration and no suspicion for lymph node metastasis should undergo this treatment. Excellent visualization, the ability to perform full-thickness resection and manage perforations make this new technique an excellent treatment option for early gastric cancer and GIST.

Safety of single-incision cholecystectomy

I read with interest the systematic review by Arezzo et al. [1], and congratulate the authors for their valuable efforts to perform a timely meta-analysis on the role of single-incision access for cholecystectomy. As the title of their article indicated, the review aimed to assess the ‘‘safety’’ of this new approach. Cholecystectomy is regarded as safe because it avoids bile duct injuries, which remain a surgical risk in laparoscopy. A recent review [2] that included all published studies (not only randomized trials, as in the Arezzo et al. review) showed that singleincision cholecystectomy can be associated with an increased risk of bile duct injury and was it gave a clear word of caution. In contrast, the review by Arezzo et al. found no increased risk with the single-incision approach. However, I fear that because of the number of patients included the studies reviewed (n = 996), the authors cannot assert with a high level of confidence that single-incision access is really safe. Because bile duct injuries are a relatively uncommon event, it has been calculated that many thousands of patients (depending on the considered rate of the event) should be included in any trial or metaanalysis evaluating the risk of bile duct injury [3]. Hence, while this article is a systematic review of randomized trials, it absolutely does not demonstrate (as it has been presented in the title) the safety of the single-incision approach to cholecystectomy. In the lack of proven safety (due to the lack of power) or superiority in terms of postoperative outcomes [2, 4], one cannot consider single-incision surgery as evidence-based. Only future properly sized randomized controlled trials will demonstrate (or not) that this approach is really safe and will become the preferred approach for cholecystectomy in daily practice.

A Case of a Jejunal Ectopic Pancreas Presenting as Obscure Gastrointestinal Bleeding

A jejunal ectopic pancreas, where pancreatic tissue is found outside of the usual anatomical location, is a rare submucosal tumor that may cause obscure gastrointestinal (GI) bleeding. After initial negative endoscopic evaluation of the obscure GI bleeding, including colonoscopy and/or upper endoscopy, it is reasonable to proceed with further evaluation of the small bowel. Diagnostic options for the evaluation of the small bowel may include capsule endoscopy, push enteroscopy, or barium contrast small bowel studies. Here, we report a case of obscure GI bleeding caused by a jejunal ectopic pancreas, diagnosed through capsule endoscopy and barium contrast small bowel studies, which was treated successfully with single incision access laparoscopy.

Single-Incision Laparoscopic Sigmoid Resection

Initially described in 2008, single-incision laparoscopic colectomy has evolved into a safe and feasible surgical approach. Noted advantages include elimination of trocar-site incisions and improved cosmesis. Additional benefits including reduced abdominal wall trauma, diminished pain, and shorter length of hospitalization have been proposed. Following utilization in over 150 colectomies, we present a standardized approach and describe our technique for single-incision laparoscopic sigmoid resection through a single-port access device. A 2.5-cm umbilical incision is used for insertion of the single-incision access device. A 30° 5-mm camera with a right-angle light cord adaptor and 2 bowel graspers are inserted through the access device. Exploration and lysis of adhesions are performed before placing the patient in a steep Trendelenburg position with 20° left-sided elevation. Dissection commences in a medial-to-lateral fashion, developing the presacral avascular plane while ensuring nerve preservation. The retroperitoneal plane is established from the sacral promontory to the lateral peritoneal reflection. After identification of the left ureter and isolation of the vascular pedicle, the inferior mesenteric artery is isolated and ligated. The lateral attachments of the left colon and rectosigmoid are then divided, followed by additional pelvic dissection along the presacral avascular plane. The mesentery of the distal resection margin is divided before transection of the corresponding bowel using a stapling device. The bowel is then extracted and resected at the site of the single-incision access device. An intracorporeal primary end-to-end anastomosis is fashioned. We present a dynamic article with video illustrating a standardized medial-to-lateral approach for single-incision laparoscopic sigmoid resection. The technique effectively avoids the use of multiple trocar sites, maintains basic oncologic principles of resection, and affords the benefits of minimally invasive surgery.

Single-Incision Laparoscopic Appendectomy Using a Wound Retractor and Surgical Glove

Abstract Introduction: Single-incision laparoscopic surgery has become increasingly popular in children. The expense incurred from using commercial single-incision access devices for commonly perfo...

Performance curve of basic skills in single-incision laparoscopy versus conventional laparoscopy: Is it really more difficult for the novice?

BackgroundSingle-incision laparoscopy is a step forward toward nearly scarless surgery. Concern has been raised that single-incision laparoscopy is technically more challenging than conventional laparoscopy. This study researched the performance curves of novice trainees for single-incision laparoscopy (SILS) versus conventional laparoscopy for performing two basic tasks on a box trainer.MethodsIn this study, 20 novice participants performed two tasks (peg transfer and a dissection task) on a standard box trainer. All the participants practiced each task 11 times and were randomized in two groups. The first group performed the tasks on a box trainer through three incisions. The second group used a single-incision access with the same box trainer. The assessment scores for errors and time were recorded. The 2nd, 8th, and 11th runs of both tasks in both settings were assessed to objectify the gain in basic laparoscopic skills.ResultsThe performance curves for both groups improved significantly in terms of both time and errors in performing the two tasks [P < 0.01, analysis of variance (ANOVA)]. For the first task, no significant difference in time between the two groups was observed at the top of the performance curve (mean, 212 ± 64 vs. 182 ± 48 s), but the SILS group performed with fewer errors (1.3 ± 1.5 vs. 2.7 ± 2.11). However, the difference was not significant (P = 0.10). The dissection task was performed faster in the SILS group (mean, 205 ± 78 vs. 243 ± 40 s; P = 0, 18) with fewer errors (0.7 ± 1.05 vs. 1.9 ± 2.1; P = 0. 12), but the difference was not significant.ConclusionThis study showed a significant improvement in basic skills for both the SILS and conventional laparoscopy settings after 11 repetitions. These data suggest that box training shows no significant difference between conventional laparoscopic and single-incision laparoscopic settings in terms of error or time in performing basic tasks at a low complexity level for the novice. These data also show significant improvement in basic skills over a relatively short period.

Incisionless Laparoscopic Total Proctocolectomy with Ileal J-Pouch Anal Anastomosis

Minimally invasive surgery continues to evolve. Recent innovations have included single-incision access, robotic technology, and natural orifice dissection and/or specimen extraction. Many argue that there is minimal patient benefit to these advanced techniques. We report 39 patients undergoing laparoscopic ileal J-pouch anal anastomosis surgery, 17 of whom did not have a separate specimen extraction incision (Group 1). The specimen for this group was extracted through the circular incision made for the ileostomy; the pouch was constructed extracorporeally and returned to the abdomen through the stoma site. For the remaining 22 patients, a suprapubic Pfannenstiel incision was made (Group 2). No hand-assistance was used for either group. Group 1 showed a 45-minute reduction in operative time, a 1-day reduction in hospital stay, and a reduction in complications. Although these differences are modest, it shows that minimally invasive surgery is an evolving process. Small modifications may translate into significant advantages.

Transcervical videoscopic esophageal dissection during two-field minimally invasive esophagectomy: early patient experience

Transhiatal (two-field) esophagectomy reduces cardiopulmonary complications by avoiding thoracic access, but requires blind mediastinal dissection. The authors developed a minimally invasive esophagectomy (MIE) technique applying single-incision laparoscopy technology to better visualize the thoracic esophageal dissection. This is performed using laparoscopy and simultaneous transcervical videoscopic esophageal dissection (TVED). Our aim is to demonstrate feasibility of two-field MIE with TVED and improve recovery in high-risk patients. We performed a retrospective cohort study of eight patients who underwent two-field MIE with TVED over 10 months. The majority were male (N = 6) with mean age of 63 ± 12 years. Mean body mass index (BMI) was 30.2 ± 5.1 kg/m(2). Indications for operation were: high-grade dysplasia (N = 2), adenocarcinoma (N = 6) with one receiving neoadjuvant chemoradiation. Using the Charlson comorbidity index, three patients were low risk and five were high risk. TVED was performed with a modified single-incision access device across the left neck. The mediastinal esophagus was dissected distally and circumferentially with simultaneous transabdominal laparoscopy for gastric conduit creation and distal esophageal dissection. Mean operative time was 292 min (range 194-375 min). Three obese patients required temporary abdominal desufflation to avoid extrinsic mediastinal compression. Mean estimated blood loss was 119 mL (range 25-400 mL). A median of 23 lymph nodes (range 13-29) was harvested. Median intensive care unit (ICU) stay was 1 day (range 1-5 days), and median overall stay was 7 days (range 5-16 days). The three low-risk patients had no major complications. Three of five high-risk patients had major complications, including two cervical anastomotic leaks. Major complications were seen in three of four obese patients (BMI >30 kg/m(2)). There were no mortalities. The TVED approach may avoid the morbidity of transthoracic esophageal dissection by improving esophageal visualization. Complications with TVED appear to correlate with obesity and comorbidities. Although TVED appears feasible, a larger experience is required.

Da Vinci robotic single‐incision cholecystectomy and hepatectomy using single‐channel GelPort access

Minimally invasive surgery including laparoscopic and robotic surgery was recently approved for clinical use in hepatobiliary surgery. The purpose of this article is to evaluate the feasibility and technical aspects of robotic single incision for hepatobiliary surgery using the GelPort laparoscopic system in a preliminary animal study. We performed eight robotic single-incision laparoscopic surgery (SILS) procedures, including four cholecystectomies and four lateral segmentectomy of the liver, in a porcine study using the da Vinci S-HD Surgical System. A single-channel GelPort access was placed through a 2.5-cm single incision for robotic access. A 12-mm camera port, two 8-mm ports for the robotic arms and one 5-mm port for the patient-side assistant were inserted. A Mini Loop Retractor was applied to retract the fundus of the gallbladder. The EndoWrist dissector and grasping forceps was introduced to fine-dissect Calot's triangle. The instruments were crossed to avoid "sword fighting" and clashing of instruments in the abdomen. The cystic duct was divided after double ligation and the gallbladder was removed. Hepatic transection was performed with bipolar Harmonic shears and LigaSure for vascular pedicles. All robotic SILS procedures were completed (8/8, 100%). The cholecystectomies and hepatectomies were safely performed in average operating times of 70min (±15) and 60min (±20), respectively, with minimal blood loss. There were no conversions, re-interventions or extension of the skin incision. Robotic hepatobiliary SILS is technically feasible and safe using GelPort as a single-incision access platform. Robotic SILS is becoming established and is enormously advantageous to the patient.

Single-incision laparoscopic colectomy: a novel approach through a Pfannenstiel incision

Single-incision laparoscopic colectomy is evolving as a safe and feasible approach for the management of various diseases of the colon and rectum. The modality affords completion of "scarless" surgery through a transumbilical incision; however, this approach is associated with several limitations when performing colorectal procedures involving the pelvis. Collinear alignment of the camera and instruments through a single umbilical incision results in restricted visualization, inadequate dissection and mobilization, and the potential for inadvertent injury. We have developed an innovative approach utilizing a Pfannenstiel incision for single-incision access to the pelvis. Single-incision laparoscopic colon resection was performed using a single-access device placed through a mini-Pfannenstiel incision. Three consecutive patients underwent single-incision laparoscopic anterior rectosigmoid resection for recurrent diverticulitis through a 4-cm Pfannenstiel incision. The procedures were performed at 150, 180, and 195 min with an estimated blood loss of 50, 150, and 75 mL, respectively. The resected specimen lengths were 10.5, 20.2, and 15.0 cm, respectively. There were no conversions to multi-port laparoscopic or open surgery. The length of hospital stay was 4 days for patients 1 and 2, and 3 days for patient 3. There were no major complications or readmissions during postoperative follow-up. Single-incision laparoscopic anterior rectosigmoid resection for diverticulitis can be performed successfully through a Pfannenstiel incision. This approach facilitates direct visualization and access for rectal and pelvic dissection while maintaining adequate exposure to the left colon and splenic flexure during the procedure.

Pediatric single port transumbilical nephrectomy and nephroureterectomy

ObjectiveTo present seven cases of single incision laparoscopic nephrectomy and nephroureterectomy in children as a recent videoscopic innovation.Patients and methodsSeven children with nonfunctioning kidneys, three with multicystic dysplastic kidneys, two with end-stage renal nephropathy due to vesicoureteral reflux, and two with giant hydronephrosis were qualified to nephrectomy or nephroureterectomy. The surgery was performed transperitoneally using single incision access laparoscopy. The operative time was in the range of 50-90 min.ResultsThere were no intraoperative or postoperative complications. The patients were discharged on the third postoperative day. The incision scars were hidden inside the umbilicus.ConclusionsNephrectomy or nephroureterectomy using a single transumbilical port in children is a feasible and efficacious technique. The advantages are shortened convalescence, excellent cosmetic results, and reduction of potential wounds complications. However, clear indication of single site laparoscopic procedures in children remains to be clarified.

Single-incision laparoscopic myomectomy

Laparoscopic myomectomy is a minimally invasive surgical option for the treatment of uterine leiomyomas. Single-incision laparoscopy is a relatively new concept that has potential in gynaecological surgery although the technical challenges of single-incision access have limited the widespread use of the technique. The use of intracorporeal suturing is a significant component of the learning curve for laparoscopic myomectomy and presents an even greater challenge with single-incision laparoscopic myomectomy. This article describes a surgeon’s approach to single-incision laparoscopic myomectomy.

Our ideas for introduction of single-port surgery

Single-port surgery, which is also called single-incision laparoscopic surgery (SILS), laparoscopic single-site surgery, or single-port access surgery, has been performed in several countries. However, it has not been widely adopted throughout the world because there still remain some challenging problems to be solved, in terms of safety and technology, and the majority of devices specific to SILS are under development and have not been approved by the Japanese Pharmaceutical Affairs Law. Herein, we introduce single-incision access using existing surgical devices that will give us the opportunity to adopt SILS to our hospital.