Single-incision Laparoscopic Sleeve Gastrectomy

| February 11, 2011

by Koji Park, MD; John Afthinos, MD; James McGinty, MD;
Ninan Koshy, MD; and Julio Teixeira, MD

Financial Disclosure: Dr. Teixeira is a consultant for Allergan, Inc. and Covidien.

Author Affiliation: Dr. Teixeira is from St. Luke’s-Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, New York, New York.

Abstract
Objective: Laparoscopic sleeve gastrectomy is commonly performed through multiple ports. The quest to minimize surgical trauma has led to the development of single-port laparoscopy, which has been shown to be a safe, less invasive method of performing a variety of abdominal surgeries. In this article, we describe the history, technical considerations, and our outcomes for single-incision laparoscopic surgery for sleeve gastrectomy for morbid obesity. Design: Twenty-one patients undergoing elective single-incision laparoscopic sleeve gastrectomy were compared to a demographically similar contemporaneous cohort of nine patients who underwent standard multiple-port laparoscopic sleeve gastrectomy. Data was prospectively collected and retrospectively analyzed. Setting: Academic affiliate of university hospital. Participants: 21 patients underwent single-incision laparoscopic sleeve gastrectomy. Nine patients underwent multiple port sleeve gastrectomy. Measurements: Data collected included operative time, narcotic consumption, duration of patient controlled analgesia device, subjective pain scores, and length of stay. Results: The mean operative time for single-incision laparoscopic surgery was 122 minutes versus 92 minutes for multiple-port surgery (p=0.023). There was no significant difference between the two groups in terms of total narcotic consumption (p=0.873), duration of patient controlled analgesia device use (p=0.564), subjective pain scores at 1, 12, and 24 postoperative hours (p=0.104, 0.531, 0.520), or length of stay (p=0.538). Conclusion: Single-incision laparoscopic surgery sleeve gastrectomy is safe and feasible for selected patients. No significant differences between the two groups were seen in any of the postoperative parameters. Through use of new techniques facilitated by novel technology, we can reestablish fundamental tenets of multiple-port laparoscopy in order to safely perform sleeve gastrectomy through a single port.

Introduction
Surgery remains the only effective treatment for obesity that has been proven to have durable, long-term success.[1–4] While laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures, laparoscopic sleeve gastrectomy (SG) has been gaining considerable popularity since its introduction as a stand-alone operation for the treatment of obesity.[5]

Due to its technical simplicity, laparoscopic SG was initially performed in high-risk patients as a first-stage operation to induce significant weight loss prior to completing a more complex and definitive bariatric procedure in the future, such as a RYGB or biliopancreatic diversion(BD).[6–22] Recently, studies have demonstrated that SG alone can lead to significant weight loss and improvement of various medical comorbidities, including diabetes mellitus, hypertension, and hypercholesterolemia.[23–28] These surprising results have convinced many surgeons to perform this procedure as the definitive bariatric operation in selected patients. Until recently, laparoscopic SG was classified as an investigational procedure by insurance companies. In the past year, however, as a result of the compelling clinical benefits associated with SG, several major insurance providers have started to cover the operation as a primary bariatric procedure. This policy change will likely further popularize SG among bariatric surgeons.The rising popularity of single-stage SG has been paralleled by growing interest in single-incision laparoscopic surgery (SILS). These developments are fortuitous in their timing, as SG seems particularly well suited for a SILS approach.

Since the advent of natural orifice transluminal endoscopic surgery (NOTES), there has been increasing interest in developing alternative access techniques for laparoscopic surgery that may be less invasive. NOTES has the potential to provide numerous clinical benefits, including the elimination of most wound-related morbidity, minimizing exposure to anesthetic agents, reducing postoperative pain, and leaving no visible external scar.[28–31] However, several obstacles have limited its popularity in the United States.32 NOTES has been criticized as being an overly technically challenging procedure, and procedure-specific instruments have not been adequately developed to facilitate new ergonomic challenges. Furthermore, the safety of viscerotomy closure techniques has been called into question. Unfortunately, the envisioned benefits of NOTES are still limited by current technical shortcomings. While instrumentation and techniques continue to evolve in order to close the gap between concept and reality in NOTES, SILS has been developed in parallel as a practical and conceptual stepping-stone between standard multiport laparoscopy and NOTES. Interestingly, SILS appears to be growing in popularity despite the fact that few studies have demonstrated the clinical advantages of this technique.[36–38] Patient demand, industry support, and market forces have nudged SILS closer toward widespread acceptance before adequate evidence-based investigations have been performed.

The concept of SILS has been questioned as it seems to violate basic tenets of multiple-port laparoscopy. A single, central point of access restricts instruments to in-line, parallel movements. Without widely spaced access ports, triangulation is difficult to achieve, and attempts to establish traction and countertraction are compromised. Complex laparoscopic tasks, such as intracorporeal suturing, are made even more difficult by limited range of motion. Furthermore, a relatively long incision must be made to facilitate the insertion of multiple instruments. Despite these technical limitations, SILS has been described as a safe and effective alternative method of performing many operations, including appendectomy, cholecystectomy, colectomy, Nissen fundoplication, and adjustable gastric band placement.[36–54] Saber et al[55] first described the use of SILS for SG. Since then, other authors have described their experience with SILS for SG in small case series.[56–58]

From a technical perspective, SILS seems to be a reasonable alternative approach in performing SG. Compared to other bariatric operations, SG is a technically simple procedure that does not rely on complex laparoscopic tasks. A direct line of access leads from the central port to the gastroesophageal junction, minimizing the need for widely spaced access ports in order to establish adequate working angles. Also, a larger incision is necessary, even in standard multiple-port laparoscopic SG, in order to extract the large, bulky specimen.

Operative Technique
Our approach for SILS SG is a purely single-incision technique, not requiring the use of any additional trocars or percutaneous puncture sites for retraction devices. The umbilical incision can be approached one of two ways. The first is via a vertical incision contained within the umbilicus itself. The skin is then detached from the underlying fascia for the length of the incision. The congenital defect present under the umbilical stalk is used to elevate the linea alba with a Kelly clamp. A vertical incision is made and the peritoneal cavity is entered. The second method involves a single 2.5cm curvilinear incision made at the superior aspect of the umbilicus. Dissection is achieved on an approximately 3cm[2] area superior to the umbilicus. The umbilical stalk and midline fascia 3cm cephalad are grasped with Kocher clamps and the resultant fascial ridge is incised, gaining peritoneal access.

A soft SILS Port (Covidien, Norwalk, Connecticut) is introduced into the peritoneal cavity with its three 5mm low-profile ports. A flexible-tip 5mm laparoscope, LFT-VP (Olympus, Center Valley, Pennsylvania) is used for visualization. A traditional 5mm port can then be introduced through the same skin incision, but through a different fascial defect to accommodate a self-retaining liver retractor (Nathanson Liver Retractor, Cook Medical, Bloomington, Indiana); however, our technique has now evolved to exclude the use of the liver retractor. We now routinely use the shaft of a flexible grasper to retract the liver anterolaterally, while it is being used to grasp the stomach. A distance of 4 to 5cm cephalad from the vein of Mayo is measured on the greater curvature of the stomach. At this point along the greater curvature, a Ligasure (Covidien) device is used to divide the greater omentum from the stomach, including the short gastric arteries, until the angle of His is reached. The stomach is retracted anterolaterally and any posterior attachments are divided. Once the greater curvature of the stomach is completely mobile, a 32Fr bougie is advanced under direct vision along the lesser curvature. At this point, a 4.8mm linear cutting stapler with buttress material (endoGIA Duet TRS, Covidien) is used to divide the greater curvature against the bougie, taking care not to narrow the stomach at the incisura. Hemostasis is achieved with clips or 2-0 polyester sutures as needed. The staple line may be oversewn if its integrity is questionable. A flexible endoscope can be used to inspect the staple line intraluminally, and an air leak test is performed with the staple line submerged under saline irrigation. The excised portion of the stomach is placed in a specimen bag and removed through the umbilical incision. The fascia is closed with interrupted 0-vicryl sutures.

Authors’ Experience with SILS Sleeve Gastrectomy
From March 2008 through August 2010, we performed a total of 30 elective SGs, 21 of which were performed via SILS. All operations were performed by the same surgeon. The patients were selected for body mass index (BMI), medical comorbidities, type of obesity (android vs. gynecoid), and liver size. Exclusion criteria included prior open upper abdominal surgery, ventral hernia repair with mesh, and a liver greater than 20cm in size.
We performed SILS for SG in 20 women and in one man. The mean age was 48 years (range 22–59 years). The mean BMI was 48kg/m[2] (range 37–59kg/m[2]). We compared this group with a demographically equivalent contemporaneous cohort who had undergone standard multiple-port surgery for SG. In this group, we included eight patients (7 women and 1 man). The mean age was 47 years (range 25–62 years). The mean BMI was 48kg/m[2] (range 36–67 kg/m[2]). The patients in the two groups were similar in medical comorbidities and surgical history. Statistical analysis was performed with an unpaired t-test. P-value less than 0.05 was considered to be statistically significant.

The mean operative time for SILS was 122 minutes versus 92 minutes for multiple-port surgery (p=0.023). However, the mean operative time for the last 10 patients undergoing SILS was 108 minutes, which was not significantly longer than the multiple port group (p=0.190).

Total narcotic use in milligrams of dilaudid via patient-controlled analgesia (PCA) was 5.4mg for SILS versus 5.8mg for multiple-port surgery (p=0.873). The duration of PCA use was 43.6 hours for SILS versus 40.5 hours for multiple-port surgery (p=0.564). Subjective pain scores at 1, 12, and 24 postoperative hours for SILS were 4, 1, and 1, respectively; pain scores at 1, 12, and 24 postoperative hours for multiple-port surgery were 6, 1, and 1, respectively (p=0.104, 0.531, 0.520). The mean hospital length of stay was 58.8 hours for SILS versus 64.1 hours for multiple-port surgery (p=0.538). No statistically significant differences were seen in any of the postoperative parameters.

Although sufficient time has not yet passed to allow for thorough long-term follow up, our preliminary postoperative data at six months demonstrate no statistically significant difference in weight loss between the two groups. Six patients in the SILS group and six patients in the multiple-port group returned for follow up. At six months, the mean BMI in the SILS group was 37.9kg/m[2] versus 39.3kg/m[2] in the multiple-port group (p=0.750). The percent of excess body weight lost was 34.6 percent in the SILS group and 37.8 percent in the multiple-port group (p=0.600).

One patient in the SILS group required conversion to multiple-port surgery due to inadvertent transection of the nasogastric tube with a linear cutting stapler. The nasogastric tube was retrieved and the staple line was revised. The patient was discharged home in a timely fashion without any further complications. One patient in the SILS group was readmitted on the Postoperative Day 5 with a pulmonary embolus. The duration of this patient’s operation was 164 minutes. The patient underwent placement of an inferior vena cava (IVC) filter and was discharged home on low-molecular weight heparin. This patient was later diagnosed with an underlying hypercoaguable state.

One patient in the multiport group was considered a statistical outlier and excluded from grouped analysis. This patient was superobese (BMI=80kg/m[2]) with severe Pickwickian syndrome. While admitted to the medical service for respiratory failure, the patient acutely decompensated on the ward, requiring emergent open tracheostomy and prolonged mechanical ventilation. After being medically stabilized, he immediately underwent a laparoscopic SG in order to urgently induce weight loss, accelerate chest wall unloading, and expedite weaning from the ventilator. Postoperatively, this patient lost 40kg, was liberated from the ventilator, and was successfully discharged home.

Overcoming Technical Challenges Associated with SILS Sleeve Gastrectomy
SILS poses unique technical challenges. By advancing instruments through a single central point of access at the umbilicus, the surgeon is confronted with several obstacles that need to be addressed. Without widely spaced access sites, instruments are positioned adjacent and parallel to each other and ergonomic freedom is considerably limited by the crowded working space. The field of view is narrowed by the laparoscope’s limited range of motion. Instruments within the abdomen are confined to in-line movements, and triangulation is difficult to achieve in order to perform standard laparoscopic tasks.

These formidable technical hurdles are overcome by employing novel techniques facilitated by new technology. Low-profile ports allow the surgeon to reclaim valuable external working real estate. Ergonomics are further optimized through the use of a flexible-tip laparoscope, which permits the camera to be held away from the working cylinder. Triangulation and working angles are re-established by the use of flexible laparoscopic instruments, which are critical in allowing us to expose and safely divide the short gastric vessels (Figure 1 and Figure 2). We strategically alter camera and instrument placement through the SILS port in order to gain access to different planes of movement. For example, we can place the camera through the SILS port at the six o’clock position and the dissecting instruments at 10 and two o’clock in order to move our instruments along the vertical plane (Figure 3A). In order to move our instruments along the horizontal plane, we can then move the camera to the nine o’clock position and our instruments to the one and five o’clock positions (Figure 3B). Although we are operating through a single, central point of access, with the application of these techniques we are able to perform the identical intracorporeal maneuvers as those utilized in traditional multiple-port SG.

The single-incision approach is particularly well suited for SG. Overall, the operation is a technically simple procedure. A straight line of access leads directly from the SILS port to the gastroesophageal junction, minimizing the need for widely spaced ports in order to achieve adequate working angles. The key steps of the operation consist of mobilizing and dividing the stomach, which require mostly in-line movements and do not rely heavily on triangulation of instruments. Also, complex intracorporeal suturing is not routinely required in order to complete this procedure. Lastly, some may argue that a bigger incision may be associated with a greater incidence of wound-related complications. However, a relatively long incision is required for the extraction of a large, bulky specimen, thus justifying the use of a 1.5 to 2cm incision for the placement of the SILS port. Due to the need for a long incision, even in a multiple port approach, we do not feel that SILS would increase the risk of wound-related morbidity. In our limited, short-term follow up, we have not encountered any wound-related complications following SILS SG, including wound infections or hernias.

Beyond these technical aspects specific to SG, a single-incision approach is ideal for bariatric surgery in general, due to issues regarding scarring. Bariatric patients are often concerned with body image and cosmesis, and there is a strong demand to minimize scarring for aesthetic reasons.[59] Also, by discreetly hiding a single incision in the umbilicus, a patient’s external appearance no longer reveals their operative history to the public, and enables patients to maintain a degree of privacy not otherwise possible.

Evolution of our Operative Technique
As our experience with laparo-endoscopic single-site (LESS) surgery for SG has grown, we have successfully decreased our operative time. The mean operative time of our first 11 cases was 135 minutes; the mean operative time of our last 10 cases was 108 minutes. We have also found ways to refine our operative approach.

Various liver retraction techniques have been described. Surgeons have tried using sutures and penrose drains to suspend the liver in order to avoid occupying a SILS port site or requiring an extra trocar. Our experience began with the use of a self-retaining liver retractor placed through an additional 5mm trocar in a separate fascial puncture site within the same central skin incision. However, we have discovered that in most cases the liver can be retracted with the shaft of the flexible grasper, thus eliminating the need for an additional fascial puncture.

We typically use a 32F bougie in order to calibrate the size of our gastric pouch. However, we find that using an endoscope instead of a bougie can offer several advantages. The endoscope allows intraluminal visualization to examine the integrity of the staple line, confirm hemostasis, and evaluate the intraluminal shape of the pouch. Furthermore, it permits the surgeon to perform the air-leak test without having to blindly exchange the bougie for an orogastric tube.

We have learned that a patient’s body habitus can present specific challenges to the LESS surgery approach. The distance from the umbilicus to the xiphoid greater than 30cm can make the operation exceedingly difficult to perform, due to difficulty in reaching the gastroesophageal junction with laparoscopic instruments. In patients who present such challenging anatomy, the umbilicus may not be the ideal site to position the SILS port. In one such case, we performed a SG on a patient who had previously failed to lose adequate weight following LAGB. Due to the great distance from the umbilicus to xiphoid, we elected to place to SILS port in the right epigastric paramedian position of the band port site, thus ensuring that our laparoscopic instruments could comfortably reach the gastroesphageal junction.

Conclusion
SILS SG in selected patients seems to be safe, feasible, and reproducible. Potential benefits of this approach include improved cosmesis, less postoperative pain, and improved patient satisfaction. It remains to be seen if SILS can be widely applied to the majority of patients who are candidates for SG. In our studies, we excluded patients who had central obesity and hepatomegaly, as both of these are contributing factors that can impair access to the abdominal cavity and exposure. Future studies must be performed to clarify the ideal patient population for the single-incision approach.

Although our study is the largest series of SILS for SG published to date, our relatively modest sample size may have prohibited detection of any significant differences in short-term outcomes. Further investigation with a large prospective, randomized trial with longer follow up may be necessary in order to clarify differences in various outcome measures between LESS surgery and multiple-port surgery.

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