Single Incision Bariatric Surgery

Ninh T. Nguyen, MD, FACS

University of California, Irvine University of California, Irvine

Medical Center, Orange, CAMedical Center, Orange, CA

Disclosures

• Covidien Grant/speaker• Gore Speaker• Surgiquest Consultant• Reshape Research• Ethicon Speaker

Rationale for Single Incision Bariatric

• Band – need a 3.5 cm incision to place subQ port

• Sleeve – need to remove gastric specimen

• Bypass – no role

Acronym

• Single Port Access (SPA)

• Natural Orifice Transumbilical Surgery (NOTUS)

• Single Incision Laparoscopic Surgery (SILS)

• Single Laparoscopic Incision Transabdominal (SLIT) surgery

• Laparosendoscopic Single Site Surgery (LESS)

• Strategic Laparoscopy for Improved Cosmesis (SLIC)

Philosophy of SLIC

• Strategic use of anatomic sites that will minimize visible postoperative scars - Umbilicus- Suprapubic region

• Not new philosophy (plastic, ENT, GYN)

• Still laparoscopy (maintain triangulation)

Evolution of Single IncisionSleeve Gastrectomy

“Happy Medium”

SILS LESS SLICSILS Hybrid

Balanced Strategy to Single Incision Bariatric Surgery

Improved cosmesis

- Technical difficulty -Compromising safety-Prolong OR time

Conventional vs SLIC Sleeve

Hurdles from Laparoscopy to SILS

• Lack triangulation

• Use of 5 mm scope

• “Fighting” of instrumentation

Evolution of SILS to SLIC• Better triangulation

• Less “fighting” of instrumentation

NOTUS Cholecystectomy

NOTUS AppendectomyNOTUS Cecectomy.mpg

SLIC Gastric Banding

Laparoscopic vs. Single Incision Gastric Band

→

Single Incision Gastric BandLap Band SLIT band realize.mpg

Evolution of Single Incision Gastric Banding

• Single incision (4-4.5 cm) between umbilicus and xyphoid process

• Transition to single incision (3.2 cm) and three 5 mm trocars within umbilicus

Trocar Position for SLIC Gastric Banding

Lap band SLIT realize fast.wmv

Laparoscopic vs. SLIC Gastric Banding

Characteristics

Characteristics Laparoscopy(n=23)

SLIC(n=23)

Female : Male 17 : 6 17 : 6

Age (years) 50 ±9 47 ±10

Preop weight (lbs) 252 ±39 248 ±32

Mean BMI (kg/m2) 40 ±4 (range, 35-49) 39 ±4 (range, 35-48)

*p<0.05, two-sample t tests

Laparoscopic vs. SLIC Gastric Banding

Outcomes

Outcomes Laparoscopy(n=23)

SLIC(n=23)

Conversion to Laparoscopy (%) 0 13

OR time (min) 66 ±21 65 ±20

Blood loss (ml) 22 ±21 14 ±5

Hospital stay (days) 1.4 ±0.9 1.1 ±0.5

Early Complications (%) 0 0

Late Complications (%) 0 0

SLIC Gastric Banding

21 |

SLIC Sleeve Gastrectomy

Evolution of Single IncisionSleeve Gastrectomy

“Happy Medium”

SILS LESS SLICSILS Hybrid

Evolution of SLIC Sleeve Gastrectomy

X

SLIC Sleeve

Laparoscopic vs. SILS Sleeve

Characteristics

Characteristics Laparoscopy(n=24)

SLIC(n=26)

Female : Male 16 : 8 17 : 9

Age (years) 47 ± 11 44 ± 11

Mean BMI (kg/m2) 47 ± 7* 42 ± 4

*p<0.05, two-sample t tests

Laparoscopic vs. SILS Sleeve

Outcomes Laparoscopy(n=24)

SLIC(n=26)

Conversion to Laparoscopy (%) --- 3.8%

OR time (min) 78 ±26 84 ±24

Blood loss (ml) 23 ± 14 30 ± 21

Mean hospital stay (days) 1.4 ± 0.6 1.8 ±0.7

Intraoperative complications (%) 0% 7.7%

Major Complications (%) 0% 0%

Minor Complications (%) 8.3% 7.7%

Relative Contraindications of SLIC

• BMI > 50

• Need to perform other procedures (hiatal hernia repair)

• Hx of prior bariatric or gastric surgery

SLIC Sleeve Gastrectomy

SLIC Sleeve Gastrectomy

Conclusions• In a selected group of patient, SLIC bariatric operations are feasible

• Safe – no major complications

• Reproducible – low conversion rate to laparoscopy

• Outcomes - comparable between SLIC vs. laparoscopic sleeve & band without prolonging the operative time

• Cost – comparable with utilization of mostly conventional trocars, instrument, and scope

Single Incision Bariatric Surgery

Ninh T. Nguyen, MD, FACS

University of California, Irvine University of California, Irvine

Medical Center, Orange, CAMedical Center, Orange, CA

Strategic Laparoscopy for Improved Cosmesis (SLIC) – Bariatric Surgery

Ninh T. Nguyen, MD, FACS

University of California, Irvine University of California, Irvine

Medical Center, Orange, CAMedical Center, Orange, CA

We’re Making Progress

Come on! It can‘t go

wrong every time...

Philosophy of SLIC

• Transition most or all laparoscopic trocars to strategic location that minimize operative scar- Umbilicus- Suprapubic region

• One visible 5 mm incision

SLIC Cholecystectomy

Spectrum of Invasiveness

Open Laparoscopic Single Incision