SILS Complications

Dan Geisler, MD, FACS, FASCRS

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Disclosures

Covidien Consultant

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V A R I A B L E S

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V A R I A B L E S

TROCARS

SURGEONS STEPS

SEQUENCE

INSTRUMENTS

POSITIONING

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Challenges of Laparoscopic Colorectal Surgery

Multiple QuadrantsMultiple VesselsSmall Bowel PositioningBowel TransectionBowel Anastomosis

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Challenges of Laparoscopic Colorectal Surgery

Time ConsumingTechnically ChallengingTechnical AbilityAdvanced TechnologyCapable Assistants

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Strategy to Combat Time Constraints of Laparoscopic Colorectal Surgery

break operation into directly productive vs. nonproductive actions

standardizestandardize approach to improve efficiency retraction performed by gravitygravitykeep repositioning to a minimum

3 Trocar Technique

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SILS Colectomy

Advantages• simplified method• need only a camera operator• safe and efficient• reproducible

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“Problems” with M.I.S.

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“Problems” with M.I.S.

Problems with SILS

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Laparoscopic CRSImproved cosmesis

Decreased pain

Decreased recovery

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“Problems” with M.I.S.

Decreased ability to complain of pain

• Improvement in maximum pain score

on POD1 & POD2 (p<0.05)

• Shorter LOS

Papaconstantinou & Thomas

SILS

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“Problems” with M.I.S.Decreased ability to complain of pain

Inability to “show off” a big scar

SILS

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“Problems” with M.I.S.Decreased ability to complain of pain

Inability to “show off” a big scar

SILS

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“Problems” with M.I.S.Decreased ability to complain of pain

Inability to “show off” a big scar

Having to return to work earlier

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Laparoscopic Colectomy Less blood loss Quicker recovery to normal function Better margins of resection Better visualization

• Mesorectal excision• Decrease incidence of autonomic nerve injury• More precise surgical procedure

Less wound related problems• Infection • Dehiscence • Incisional hernia

Minimally invasive procedure

Advantages

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SILS Colorectal

Surgery

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SILS Colectomy N = 99 Age = 9 – 93 30 with previous abdominal operations BMI = 26 (15 – 39)

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SILS Colectomy N = 99

Diagnosis UC: 46 Neoplasia: 17 Crohn’s: 10 Diverticulitis: 10 FAP: 2 Other: 14

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SILS ColectomyN = 99 OR Time: 105 minutes (13 – 245) Incision Length: 3.7 cm (1.2 – 7.8)

LN Harvest*: 44

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SILS ColectomyN = 99

Ports 87 SILS 12 Additional Ports

• 1: 9

• 2: 1

• 3: 2

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Complications?

Wound Complications Infections

• Similar

• Easy to deal with

Hernias? • Too early to tell

• Access technique?

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HerniaVariable rates of occurrenceDependent on locationAvoidable?Tissue necrosis?

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HerniaVariable rates of occurrenceDependent on locationAvoidable?Tissue necrosis?

WE DON’T KNOW!!!!!

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Difficulties?

5 mm endoeye SKILLED camera operator Camera, then instruments

• Not both at the same time

Splenic flexure

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Difficulties?

Port SILS (Covidien)

• Atraumatic

• Simplistic

• Easy to use

Triport, Ethicon, Gelpoint

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SILS Colorectal Benefits over conventional laparoscopy

Drawbacks over conventional laparoscopy

Incidence of hernia formation?

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SummarySingle port laparoscopy in colorectal surgery Minimize abdominal trauma May utilize a natural body orifice or scar such as the

Umbilicus Potential decrease in morbidity Certainly superior cosmesis

“NOTES” Natural Orifice Transluminal Endoscopic Surgery”……..experimental

SPL seems to be a practical clinical step towards NOTES

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SummarySingle port laparoscopy in colorectal surgery Minimize abdominal trauma May utilize a natural orifice or scar such as the Umbilicus Potential decrease in morbidity Certainly superior cosmesis

“NOTES” Natural Orifice Transluminal Endoscopic Surgery”……..experimental

SPL seems to be a practical clinical step towards NOTES

A BRIDGE TO THE FUTURE!!!