Single Port Access (SPA) Gastric Band Placement

by Erica R. Podolsky, MD, Wade Naziri, MD, and Paul G. Curcillo II, MD

Drs. Podolsky and Curcillo are from Drexel University College of Medicine, Department of Surgery, Philadelphia, Pennsylvania, and Dr. Naziri is from Southern Surgical Associates, PA, Greenville, North Carolina.

Objective. The single port access (SPA) technique was introduced in 2007 as an alternative means to enter the abdominal cavity for laparoscopic procedures.[1] We present a series of patients who underwent gastric band placement using this access technique.
Design/Setting/Participants. Nineteen obese patients underwent placement of SPA gastric band by a single surgeon.
Results. All bands were placed successfully, leaving the port in the initial access incision. No operative or postoperative complications were encountered.

Conclusions. We present a series of successful gastric band placement using the SPA technique. This technique is an alternative to standard multiport insertion, and offers an enhanced cosmetic result and the possibility of decreased morbidity by reducing incision number. The end result is a right lateral abdominal incision accommodating the port.

Introduction
Obesity has become an international medical epidemic. Associated morbidities require additional medical attention and expense. Weight loss surgery has gained popularity and acceptance, proving to be useful in assisting weight loss and ameliorating comorbidities.[2,3] Over the last decade, laparoscopic surgery has become the method of choice. Shorter length of stay, lower costs, and decreased complications have been demonstrated, offering an advantage over open procedures.[4] Single port laparoscopic procedures were developed to possibly further exploit these benefits and to provide a more ergonomic operation and better cosmetic result. After FDA approval of the gastric band seven years ago and previous success in Europe, restrictive operations gained acceptance in the US.[5,6]

Since May 2007, the single port access (SPA) technique has been applied to a variety of laparoscopic procedures.[1,7] We now demonstrate its applicability in weight loss surgery. The SPA technique further expands on the benefits of minimally invasive surgery in the obese, offering less incisions and, therefore, possibly reducing concerns of multiple wound infections and multiple incisional hernias.

The SPA technique provides an alternative approach to insertion of the gastric band. Using this method, the entire procedure is performed via an incision that is ultimately used as the port access site, leaving the rest of the abdomen incision-free. We applied this technique to a series of obese patients undergoing placement of the gastric band.

Methods
Nineteen patients underwent placement of a gastric band using the SPA technique to gain entrance to the abdominal cavity. Each patient was positioned on the operating room table in supine position with the abdomen prepped and draped. A 4.5cm transverse incision was made in the right upper quadrant. Once the fascia was exposed, moderate skin and soft tissue flaps were raised off the fascia. A clear 15mm trocar was then inserted under direct visualization in the most medial area of the incision through the rectus abdominus (Visiport, Ethicon Endo-Surgery, Cincinnati, Ohio). Two very low-profile 5mm trocars were then inserted laterally within the same incision but through separate fascial openings (Figure 1A). One 5mm trocar was placed inferiorly in the middle and the other superior and lateral, forming a triangular arrangement of trocars within a single incision (Figure 1B). A 30-degree, extended length bronchoscope (Karl Storz, Tuttlingen, Germany) was used for optimal visualization through the 15mm trocar. A small, subxyphoid incision was made to accommodate a liver retractor (Nathanson Retractor) without a trocar to retract large livers. The stomach was dissected using hook cautery along the lesser curvature up to the gastroesophageal junction. After visualization and dissection to the angle of His, left crus, and then right crus, the band was wrapped and secured in place with interrupted sutures (Figure 2 and Figure 3). The trocars and retractor were withdrawn and the catheter portion of the band was secured to the port. The port was secured into position within the initial incision. Finally, the incision was approximated, leaving the abdomen with a single port site incision (Figure 4).

Results
Nineteen patients underwent successful placement of gastric band using the SPA entry technique. The average BMI was 42 and average weight was 259 pounds. All port access sites were placed within the initial operative incision on the right lateral abdominal wall. No operative or postoperative complications have been observed in these patients. Operative times ranged between 40 to 70 minutes. All bands are performed as same day discharges from the hospital with the option to stay overnight if the patient lives over an hour away from the hospital. No patients required extended stays. No incisional wounds or wound separations have occurred. All patients who have had follow-up visits have experienced weight loss. Follow-up times vary, making it difficult to give an average over a specific time course. Table 1

Discussion
SPA surgery provides a novel alternative to adjustable gastric band placement. The entire operation can be easily performed through one small incision.[8] This procedure can also be easily taught.[9] SPA placement and removal of a gastric band was developed on a porcine model and it has now been subsequently applied in clinical practice as a viable alternative to multiple port surgeries.
For this procedure, the incision is made in the right upper quadrant instead of the umbilicus. This position is optimal as the incision will ultimately become the site of the port reservoir. This places the port site away from the waistline (i.e. the beltline), increasing long-term patient comfort. Because the incision becomes the final port site, it can be 4.5cm. In other SPA procedures, we have maintained the incisions less than 2cm in total length. However, since the port site incision will ultimately be larger than 2cm in the bariatric patient, using the full length from the beginning allows for more distance between trocars. This results in two benefits. First, the further distance, albeit minimal, enhances the “independence of movement” of each individual trocar. In addition, the larger working area allows for a larger “triangulation of placement” of the trocars to approach the procedure intra-abdominally. This step reintroduces triangulation in the abdominal wall approach and virtually eliminates the need to modify operative technique with the introduction of articulating or roticulating instruments. Use of the extended bronchoscope is an option we found aids in reducing external interference of the hand pieces of the instruments and the camera head. Liver retraction can be a challenge in laparoscopic operations of the gastroesophageal junction. For the majority of our SPA gastroenterological procedures, we utilize a third instrument through the same incision without a trocar or an intra-abdominal hepatic sling10 for retraction of the liver. In our SPA weight reduction procedures, the subxyphoid retractor provides static retraction, eliminating the need for another retracting instrument to be placed within the incision. This retractor provides wider, more stable retraction of the liver necessary for the band placement.

Conclusion
Adoption of any new technique or equipment should be done with caution. Currently, the SPA technique employs all standard instrumentation. Since the development of SPA surgery in May 2007, there has been a rush to apply novel technology to this new space in minimal access surgery. Articulating instrumentation, single port access devices, and novel retraction methods are being advocated at our scientific meetings and in operating suites. Although these instruments may appear to fulfill a need initially, they may require a learning curve and certainly can add to the costs of standard laparoscopic approaches. In addition, the majority of these devices are disposable, which will have an impact on our environment as well. We advocate a stepwise and methodical approach to SPA surgery for all procedures, including cholecystectomy and gastric restrictive device placement. Moving one port site/instrument at a time to the SPA access site allows for an easy transition to SPA surgery.

This population of patients may require a selection bias. Large livers may obscure adequate exposure. Thick abdominal walls create a fulcrum effect with laparoscopic instruments. Caution must be used as there are many anatomic pitfalls.

Single port access surgery can be successfully applied in this population of patients with standard instrumentation. This approach follows the same dissection techniques without the increased cost of new instrumentation or access devices. It is early in its development and clearly needs to be continually evaluated. Large series will be necessary to determine if there are truly any benefits other than cosmetics to this approach. This also implies that we need to maintain the utmost attention to safety and costs as we move forward, as the benefit may not warrant any deviation from current standards.

References
1.    Podolsky ER, Rottman SJ, Curcillo PG. Single Port Access (SPATM Surgery); Initial Application to Gastric and Gallbladder Surgery. Society of Laparoendoscopic Surgeons: Asian American Summit III; Honolulu, Hawaii; February 6-9, 2008.
2.    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004; 292:1724.
3.    Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547.
4.    Nguyen NT, Hinojosa M, et al. Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers. Dept. of Surgery, University of California, Irvine Medical Center, Orange, California. March, 2007.
5.    Weiner R, Blanco-Engert R, Weiner S, et al. Outcome after laparoscopic adjustable gastric banding – 8 years experience. Obes Surg. 2003;13(3):427–423.
6.    Phillips E, Ponce J. Safety and effectiveness of Realize adjustable gastric band: 3-year prospective study in the United States. Surg Obes Relat Dis. 2009 Jan 18. [Epub ahead of print]
7.    Curcillo PG. High Dexterity Instrumentation in Laparoscopic Surgery. SAGES, Las Vegas, Nevada, 2006.
8.    Curcillo PG, Podolsky ER, Rottman SJ. Single Port Access (SPA) Surgery – Initial Experience of a New Approach Across Surgical Specialties – World Congress of Endoscopic Surgery (WCES) September 2008, Yokahama, Japan.
9.    Wu A, Podolsky ER, Rottman SJ, Curcillo PG. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Scientific Session: Single Port Access (SPATM Surgery) Cholecystectomy – Initial Validation of a Single Incision Approach, Philadelphia, Pennsylvania; April 9-12, 2008.
10.    Curcillo PG, Podolsky ER, Rottman SJ. Single Port Access (SPA) Surgery Hepatic Sling. World Congress of Endoscopic Surgery (WCES) September 2008, Yokahama, Japan.

Tags: Single Port Access, Surgical Perspective

Category: Case Series, Past Articles