INTRODUCTION

With the marriage of surgery and technology, applications of laparoscopic surgery/minimal access surgery are increasing exponentially. Over the last few years, Single Incision Laparoscopic Surgery (SILS), also known as Scarless Laporoscopic Surgery or Minimally Invasive Surgery has become popular, for good reason - this surgery has the advantage of not leaving behind any visible scars since the incision is made within the umbilicus and heals without any noticeable scars. Perhaps blood loss, pain and recovery time associated is also less as procedure performed is from 1 incision rather than 3 or 4 incisions.

Laparoscopic Surgery:

4 Cuts

Conventional Surgery:

1 Large Cut

SILS Surgery:

1 Small Cut

WHAT IS SINGLE INCISION LAPAROSCOPIC SURGERY (SILS)

Single Incision Laparoscopic Surgery an advanced minimally invasive surgical procedure in which the surgeon operates almost exclusively through a single small cut in the umbilicus using instruments which can be inserted through a straight port and, once inside, can be roticulated to get appropriate angulation.

HISTORY

The advent of SILS was in the field of gynecology. Wheeless reported on the first 4000 cases of SILS tubal ligation in 1969. The procedure was done using an offset eyepiece and a 5-mm working port to introduce instruments to perform the procedure. They reported that healing was “so satisfactory that no scar was grossly visible.” Since then, SILS tubal ligation has become the standard of care for elective female sterilization. The first application of SILS in general surgery was a SILS appendectomy by Pelosi in 1992 in 25 patients. That same year, D'Alessio described a technique for appendectomy in pediatric patients in which a special port was used at the umbilicus to allow the surgeon to bring the appendix out through the umbilicus to perform an extracorporeal appendectomy. 

HOW IS SILS PERFORMED?

SILS is accomplished through a single 20 mm incision in the navel (umbilicus or belly button), or through only a 11 mm incision in the navel, minimizing the scarring and incisional pain associated with the multiple points of entry used during traditional laparoscopic surgery.

 

Specialized equipment for SILS surgery falls into two broad categories; access ports and hand instruments. There are a number of different access ports, including GelPOINT system from Applied Medical, the SILS device from Covidien, the TriPort+, TriPort15 and QuadPort+ a from Advanced Surgical Concepts and the Uni-X from Pnavel. Hand instruments come in three configurations - standard, articulating, and pre-bent rigid. Standard hand instruments are rigid in design and were developed over the last 30 years for use in laparoscopy. Articulation is designed to overcome one of the challenges inherent in SILS, decreased triangulation of instrument. A number of factors influence a surgeon's decision to use standard or articulating hand instruments, including which access port they use, their own surgical skills and cost as articulating instruments are significantly more expensive than standard instruments. SILS is enhanced by the use of specialized medical devices such as the SILS Multiple Instrument Access Port manufactured by Covidien and Laparo-Angle Articulating Instruments made by Cambridge Endoscopic Devices, Inc. The flexible port that can be fitted through a small incision in the navel to allow surgeons to use up to three laparoscopic devices simultaneously. Certain articulating instruments can be inserted through such specialized ports, providing surgeons with maneuverability and access to the target tissue from a single access point. However single port laparoscopic appendicectomy has also been performed using a single standard 10 mm "Y" shaped operating telescope having a 5 mm instruments channel also.

 

Although awareness of single-port surgery is high amongst surgeons, the use of specialised instruments through such limited access requires considerable skill and training. This operative training and experience is currently limited and some negative perceptions regarding increased operating time and complications with this type of surgery remain. One recent study suggests future uptake relies strongly on the availability of evidence, training, instrumentation and reduced costs.

WHY CHOOSE SILS SURGERY?

  • Lessen the trauma of access

  • Lessen the residual surgical scar

  • Ability to convert to standard lap surgery or open surgery when the need arises without compromise to patient safety

ADVANTAGES OF SILS SURGERY

  • Less post operative pain (1 instead of 4 cuts)

  • Less wound-related complications (1 instead of 4 cuts)

  • Faster recovery

  • Early return to work

  • Better cosmetic result – No visible scar like in multiport surgery or open surgery