Are practicing surgeons and community hospitals able to acquire the skills and instrumentation and offer patients alternative procedures to NOTES during the early developmental phase of the translumenal procedures? Does SPA have a much stronger potential to be safely learned by experienced laparoscopic surgeons? Do advanced laparoscopic procedures being performed via SPA using traditional laparoscopic instruments, keeping costs competitive with costs for traditional MIS?
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SLS members attending the AsianAmerican MultiSpecialty Summit III in Honolulu were treated to an excellent and diverse program of scientific as well as cultural presentations. We learned about endoscopic breast surgery in India, multiple approaches to laparoscopic colon surgery (including robotic), complex laparoscopic surgery for endometriosis, the varied surgical presentations of tuberculosis, robot-assisted laparoscopic aortoiliac surgery, and complex advanced laparoscopic surgery through a single 18-mm umbilical incision.
Dr. Paul Curcillo and his colleagues from Drexel University presented their multidisciplinary experience with single-port access (SPA) laparoscopic surgery, also known as single-incision laparoscopy (SIL). Laparoscopic gallbladder, foregut, and gynecologic procedures were described in detail. Other current applications include urologic, colorectal, hernia, and spleen surgery.
The multidisciplinary applications of SPA are expanding, and the potential significance of the technique is yet to be recognized. Safety and efficacy studies of SPA are underway in many institutions. The technique has potential incremental advantages over traditional MIS for cosmesis, wound infection, postoperative pain (especially in upper abdominal surgery), and recuperation. Specialized disposable and reusable instruments are being produced to facilitate SPA, but no major capital investments are required. Many advanced laparoscopic procedures are being performed via SPA using traditional laparoscopic instruments, thus keeping costs competitive with costs for traditional MIS. Traditional laparoscopic 2-handed dissection, ablation, and suturing techniques are utilized, so surgeon training in SPA should be much less painful than the transition from open surgery to traditional laparoscopic surgery in the early 1990s was. Most procedures are currently being carried out using a 5-mm camera trocar and two 5-mm working trocars, all introduced through one peri-umbilical incision. A flexible, radially dilating, 3- or 4-channel port could certainly be envisioned for the near future.
Much attention is being paid to totally incision-free, natural orifice translumenal endoscopic surgery (NOTES). This surgery, presently experimental, has the potential for more significant improvement in cosmesis, skin infections, hernias, postoperative pain, and recuperation. NOTES must be distinguished from fully endolumenal, natural orifice surgery (NOS), such as cystoscopic, colonoscopic, transanal, and endoscopic procedures carried out within a hollow structure. NOTES technology, by contrast, is designed to produce an opening in an unrelated organ which must be safely and reliably repaired at the end of the procedure. In NOTES, a highly specialized, sophisticated instrument is passed through an incision in the stomach, vagina, bladder, or colon to access the peritoneal cavity, thus upgrading the potential severity of complications as a result of the entry process. Animal studies are underway in many institutions evaluating the risks of transluminal entry of this kind and attempting to develop the optimal endoscopic closure technique… as well as the ideal endoscopic vehicle and effector instruments. As of July, 2008, seven clinical papers have been published describing experience with 10 peritoneoscopies… 3 appendectomies…, 1 cholecystectomy… and 1 repair of a dislodged PEG tube… four cholecystectomies… and two hybrid studies of one cholecystectomy with two 3 mm umbilical trocars… and three cholecystectomies with a 5mm left upper quadrant trocar… It is widely recognized that substantial technological development and years of experience in dedicated centers will be needed to evaluate and perfect NOTES technology… As the instrumentation evolves, safety and efficacy studies will be needed followed by extensive outcome studies comparing NOTES results with results for traditional MIS.
In the meantime, SPA has a much stronger potential to be safely learned by experienced laparoscopic surgeons and may offer some advantages over traditional MIS with comparable cost. Practicing surgeons and community hospitals that are so inclined should be able to acquire the skills and instrumentation and offer patients this alternative to NOTES during the early developmental phase of the translumenal procedures. SPA may serve as a bridge, a transition, an adjunctive safety procedure, or ultimately an alternative to NOTES. Comparative outcome studies among all of these techniques will be critically important.
SLS is indeed fortunate to have hosted the first presentation of single-port access surgery at a national meeting, delivered by Dr. Curcillo at the SLS Cyber Café during the San Francisco meeting in 2007. The first scientific paper presentations were performed by Dr. Curcillo and his colleagues at the AsianAmerican MultiSpecialty Summit in February. They have submitted 4 papers for the SLS Meeting and EndoExpo in Chicago this September discussing SPA hysterectomy and oophorectomy, SPA colon resection, their first 100 SPA cholecystectomies, and 1-year follow-up for their early cohort of SPA cholecystectomies. Dr. Dan Geisler will also be presenting Single-Port Laparoscopic Colectomy in Chicago.
William E. Kelley, Jr., MD, President of the Society of Laparoendoscopic Surgeons, is the Director of General Surgery for the Minimally Invasive Surgery Center of Virginia. He is in private practice with The Richmond Surgical Group in Richmond, Virginia, and serves on the clinical faculty at the Medical College of Virginia. Dr. Kelley serves on the editorial board of JSLS. He has contributed over one hundred-fifty papers and presentations in the fields of surgical oncology, minimally invasive surgery, image guided breast surgery, and robot-assisted surgery, and textbook chapters in laparoscopic antireflux, colon and spleen surgery.