Single-Incision Laparoscopic Surgery: A Hope or Hype

Introduction

Surgery is considered one of the oldest procedures for curing diseases. Since ancient times, several scholars have developed different instruments and techniques for performing surgeries. The goal of such developments is to reduce the complexities associated with surgical procedures. The biggest stigma associated with gastrointestinal surgeries is a large incision, longer healing time, blood loss, and surgical scar formation. The goal of introducing the laparoscopic technique in gastrointestinal surgeries is to reduce the hospitalization duration, small scar tissue, better healing, better visualization, and precise surgery.

What Is Laparoscopic Surgery?

Laparoscopic surgery is one of the most beneficial surgical procedures of modern times. In 1980, the first laparoscopic surgery was performed by Semm. However, the development of this surgical procedure can be traced back to much earlier days. The development of modern laparoscopic techniques draws its inspiration from endoscopic techniques. On the basis of several discoveries of the eighteenth century, Johann Mikulicz-Radecki and Joseph Leiter developed the first rigid gastroscope to visualize inside the abdomen. The utilization of laparoscopy as a diagnostic tool was first described by Georg Kelling in 1901. In 1944, the first minor surgical procedure through laparoscopy was done by Palmer in the year 1944. The subsequent development of cold light technology and optical technology by Harold Hopkins paved the way for modern laparoscopic surgery.

In this procedure, the operator can visualize the abdomen without making a large incision. This is a type of minimally invasive procedure done in the abdomen and pelvic areas. At first, one small incision is made over the abdomen to insert a cannula. With the help of the cannula, carbon dioxide gas is passed through the abdominal cavity. This gas separates the internal organs from the cavity wall. It also provides a better view through the laparoscope and helps prevent injuries. After inflating the abdomen, a laparoscope is inserted into the abdominal cavity for visualization. Several other incisions are also made over the abdomen, the size ranging from one to two centimeters. These incisions are used to insert several other instruments inside the abdominal cavity to perform surgery.

Laparoscopic procedures are used for the purpose of the following diseases:

1. Appendicitis (inflammation of the appendix) is treated by appendectomy.

2. Cholecystitis ( inflammation of the gallbladder).

3. Cholecystectomy ( removal of the gallbladder) for the treatment of gallstones.

4. Hernia (formation of a sac in the abdominal cavity).

5. Infection of the spleen, which is treated by splenectomy.

6. Endometriosis (growth of the uterine tissues in the other parts of the body).

What Is Single-Incision Laparoscopic Surgery?

Single-incision laparoscopic surgery is also known as a scarless surgical procedure. The single-incision procedure was first performed in the year of 1969 for tubal ligation (a surgical procedure done in women for the prevention of pregnancy). The first use of a single incision procedure in a major gastrointestinal procedure was seen in 1992. Appendectomy was done in 25 patients using this technique by D’Alessio. Later on, Navarra et al. performed laparoscopic cholecystectomies using this technique in 1997. The other names of this procedure are single-access surgery (SAS), transumbilical endoscopic surgery (TUES), single portal access (SPA), and single-access video endoscopic surgery ( SAVES).

Procedure: The first step of the procedure is to give an incision. In general, a 6-centimeter-long incision is given. Different locations are preferred according to the nature and the site of the surgery for incision purposes. These sites are:

1. An omega-shaped incision is given on the upper half of the umbilicus.

2. A transumbilical incision is given the upper inside edge of the belly button.

3. In some cases, incision is given in the medial to the pubic hairline.

4. In some cases, an incision can also be given just above the umbilicus or over the umbilicus.

In the first method after giving the incision the abdomen is inflated with the help of the carbon dioxide. After this, a port is placed over the area of the incision. This port-like device serves as an entry point for the laparoscope and several other instruments as they have multiple holes for inserting instruments.

In the second method, no port-like device is used for inserting the instruments. In this technique, a Veress needle is used to pass carbon dioxide gas inside the abdomen. After this, a single trocar is inserted with a rubber band typer device present on it. This trocar contains a powerful video camera and light source with it. After this, two additional trocars are inserted from the lateral side of the central trocar. These two trocars are held together with a rubber band-like device and help in various surgical procedures.

The first procedure is more advantageous than the second one as commercially available ports can be fitted to the incision site tightly, and this prevents carbon dioxide leakage. Additionally, changing trocars while performing the surgery will be much easier. On the contrary, such ports are expensive, which makes the cost of surgery much costlier.

At the end of the surgical procedure, instruments are taken out, and gas is released. After this, suturing is done.

• Ports Used in Surgery: Commercially, three different types of ports are used in this type of surgery. These ports are:
• SILS Port: This is the most commonly used port used in single-incision laparoscopic surgery. This is made up of blue foam-like material with three ports. The diameter of these ports is five millimeters and twelve millimeters.

• GEL Port: Such ports have a gel seal cap and retractor. Alexis retractor helps to retract the tissue in an atraumatic way and protects the underlying structures.

• TriPort And QuadPort: These types of ports require a larger incision. In general, an incision of 2.5 centimeters to 6.5 centimeters is needed in this case. Three to four instruments can be inserted through these ports.

• AnchorPort: These types of ports are made up of an integrated elastomeric, stretchable cannula system. This system gets elongated and adopted according to the abdominal thickness of the patient.

What Are the Clinical Implications?

Single-incision laparoscopic surgery has a few advantages over the traditional laparoscopic procedure. That is why, this is used in procedures like colectomy, appendectomy, splenectomy, gastric bypass surgery, and hernia operations. These advantages are:

1. Very small scar size which is esthetic and causes less postoperative problems.

2. Postoperative pain is less.

3. Less duration of hospitalization and chances of bleeding chances are less.

4. The chances of postoperative infection are very less.

But in the earlier days, doctors faced several problems with this type of procedure. These problems are:

1. Clashing of the instruments.

2. Accessibility problem.

3. Interference and deflection of the light source.

Such problems are overcome by the use of curved instruments, flexible-tip endoscopes, and back channel lighting in the laparoscope.

Conclusions

Laparoscopic surgery is a popular surgical procedure nowadays. This procedure reduces surgical complications and post-operative complications. The single-incision laparoscopic technique is a newer addition to this field. In this procedure, a single incision is made for surgical purposes. Small and single scar tissue, better infection con