J Gastrointest Surg (2009) 13:159–162 DOI 10.1007/s11605-008-0737-y
Transumbilical Gelport Access Technique for Performing Single Incision Laparoscopic Surgery (SILS) Aziz M. Merchant & Michael W. Cook & Brent C. White & S. Scott Davis & John F. Sweeney & Edward Lin
Received: 1 September 2008 / Accepted: 14 October 2008 / Published online: 30 October 2008 # 2008 The Society for Surgery of the Alimentary Tract
Abstract Introduction Single incision laparoscopic surgery (SILS) is an area of active research within general surgery. Discussion A number of procedures, including cholecystectomy, appendectomy, urologic procedures, adrenalectomy, and bariatric procedures, are currently being performed with this methodology. There is, as yet, no standard published technique for single-port access to the peritoneal cavity for SILS. We describe, herein, an access technique utilizing existing instrumentation including a Gelport and wound retractor that is reliable and easy. This technique has been used successfully at our institution for a number of single incision laparoscopic procedures. Keywords Single incision laparoscopic surgery . Gelport . Single-port access
Introduction Single incision laparoscopic surgery (SILS), also known as laparoendoscopic single-site surgery or single-port access surgery, is an area of active investigation for abdominal surgery. A number of advantages have been proposed including cosmesis (scarless abdominal surgery performed through an umbilical incision), less incisional pain, and the ability to convert to standard multiport laparoscopic surgery if needed. Single incision cholecystectomy1 has been described by Piskun et al., as early as 1999 with the insertion of two trocars through the umbilical incision and additional stay sutures to stabilize the gallbladder. In addition, a number of recent reports of single-incision The authors have no financial relationships with any of the device companies mentioned in this manuscript. A. M. Merchant : M. W. Cook : B. C. White : S. S. Davis : J. F. Sweeney : E. Lin (*) Emory Endosurgery Unit, Department of Surgery, Emory University, 1364 Clifton Road, Suite H-127, Atlanta, GA 30322, USA e-mail:
[email protected]
donor nephrectomies2,3 and other urologic applications4,5 have been described, as well as single incision sleeve gastrectomies for morbid obesity.6 The primary disadvantages of SILS are the restricted degrees of freedom of movement, the number of ports that that can be used, and the proximity of the instruments to each other during the operation—all of which increase the complexity and technical challenges of the operation. Many of these difficulties can be related to the technique of port placement and utilization during single incision laparoscopic surgery. A number of methods have been described for port access to perform SILS, including multiple fascial punctures through one skin incision, the use of additional transabdominal sutures to stabilize the target organ, and use of novel port access devices such as the Unix-XTM (Pnavel Systems, Brooklyn, NY, USA)7 and R-portTM (Advanced Surgical Concepts, Wicklow, Ireland).3 To further overcome the technical challenges for SILS, different instruments that provide angulations and small profile trocars are being developed. We describe our method of establishing single-port access for SILS that has reduced some of the technical challenges of performing SILS cholecystectomies. Our method involves the use of existing instrumentation, including a wound protector and the Gelport (Applied Medical, Rancho Santa Margarita, CA, USA). In addition, the use of the Gelport allows introduction of three to five
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ports for operation, with minimal “clashing” of ports and instruments during the procedures.
Surgical Technique After induction of general anesthesia and prepping and draping the patient, we first prepare the Gelport device to minimize leakage of pneumoperitoneum during the procedure. This is accomplished by layering several sheets of Ioban (3M, St. Paul, MN, USA) on the undersurface of the Gelport and cutting them to appropriate circular dimension (Fig. 1). A 1-cm umbilical skin incision is made and carried down to the peritoneum. The Gelport's double-ring wound retractor (Alexis®, Applied Medical, Rancho Santa Margarita, CA, USA) is inserted through the incision, which stretches the fascial diameter to 1.5 cm (Fig. 2). A 5- or 10-mm trocar is inserted through the Gelport centrally, and the Gelport with trocar is latched on to the wound retractor ring. It is easier to insert the first trocar through the Gelport, prior to securing the Gelport to the wound protector. Pneumoperitoneum is established and a 10-mm 30° videoscope inserted. Two 5mm operating ports are inserted in 2- and 8-o'clock positions, with the videoscope port as the center. Graspers and dissectors are inserted through these accessory ports as needed to assist in the gallbladder dissection (Fig. 3). This system allows the insertion of an additional 5-mm trocar anytime during the operation, as well as the insertion of an instrument directly through the Gelport without the use of a trocar. The videoscope can also be placed through the other ports for different viewing perspectives and not be permanently fixed in the center. The Gelport system essentially creates trocar positions with “flexible fulcrums” that allow combined motions in linear, radial, and translational planes (Fig. 4). A cholecystectomy is then performed in standard fashion. The gallbladder is extracted from the abdomen Figure 1 a, b A large Ioban is used multiple times to coat the undersurface of the Gelport device. This helps prevent leakage of pneumoperitoneum throughout the case, as additional trocars are punctured through.
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through the single incision, and the wound retractor allows the extraction to be achieved easily as the fascial diameter is already enlarged. The single fascial incision is closed, followed by skin closure (Fig. 5). In summary, a transumbilical fascial incision 1 to 1.5 cm in length is made, and a wound protector is inserted. A Gelport is then snapped on to the wound protector. Pneumoperitoneum is sealed within this Gelport/wound protector system. Videoscopes and instruments are inserted through trocars placed through the Gelport, traveling through the protected fascial wound and into the abdomen.
Comment SILS has been performed since the late 1990s for a wide variety of surgical procedures. As early as 1998, a single incision laparoscopic appendectomy8 was described, in which the appendix was mobilized laparoscopically and the appendectomy was performed extracorporeally through the single umbilical incision. This was followed by reports in the urologic literature of single incision surgery for various procedures.2,3 Recently, we and others have performed single incision laparoscopic colorectal surgery,7 adrenalectomy,4,5 and cholecystectomy.1,9 In addition, bariatric procedures such as laparoscopic sleeve gastrectomies and gastric band placements have been performed using the SILS method.6 Single-port thoracoscopic procedures for evacuation of empyema had also been described.10 Critics of SILS cite the lack of data regarding patient benefit over standard open or multiport laparoscopic techniques. The potential need for advanced instrumentation may translate into increased costs as well. In addition, the lack of triangulation, pneumoperitoneum leaks, and instrument “clashing” have been described as real disadvantages of this procedure, thereby increasing difficulty.
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a
b
Figure 2 After the fascia is incised, an Alexis® wound retractor is inserted. The wound retractor allows stretching of the fascial incision to about 1.5 cm and for easy access with instruments into the abdominal cavity.
There is no standard technique for trocar placement in SILS. The first reports of laparoscopic cholecystectomy, from 1999,1 and current reports9 used multiple fascial punctures from a single umbilical skin incision to insert multiple ports for operation. The development of skin flaps circumferentially to accommodate the subcutaneous ports is necessary with the multiple fascial puncture technique. The theoretical disadvantages of this technique include the
Figure 3 The Ioban-sealed Gelport is snapped on with the first trocar pre-inserted. After insufflation, the central trocar of the “flexible fulcrum” can be a 5- or 10-mm videoscope, with the operating ports started off in a 2- and 8-o'clock position.
Figure 4 a Initial trocar placements, one in each quadrant of the Gelport surface. b The “flexible fulcrum” allows movement in linear, radial, and translational planes.
potential weakening of fascia by intentionally creating a “Swiss cheese” defect. Furthermore, seroma formation after skin flap elevation is a common occurrence. Other reports include the use of specialized newly developed umbilical port entry systems, such as Unix-XTM 7 and R-portTM 3 for
Figure 5 This figure illustrates the size of the incision used and appearance after closure of the umbilical wound.
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access. The above methods also result in placement of ports that are too close to each other for effective hand movements. In addition, the use of “suture slings” to aid in retraction and exposure of the target organ, such as in appendectomy11 or cholecystectomy,9 has been described. This requires additional punctures through the abdominal wall to establish the sling. Our Gelport technique overcomes some of the disadvantages of current techniques. We use one transumbilical incision with a wound retractor/protector that increases the size of the incision. The Gelport and wound protector are ubiquitous devices that are commonly employed for handassisted abdominal surgeries. In addition, the Gelport provides a “flexible fulcrum” for insertion and manipulation of a videoscope and up to three or four 5-mm trocars with minimal clashing of instruments, while minimizing the loss of degrees of freedom for operation. In our practice, we generally avoid the use of additional puncture wounds for suture slings, as there is enough access to provide the appropriate retraction of the target organ. Lastly, the Gelport technique readily maintains the pneumoperitoneum. Our current experience with the SILS Gelport access system includes 21 cholecystectomies. In addition, we have performed laparoscopic hemicolectomies, a laparoscopic adjustable gastric band placement, a laparoscopic sleeve gastrectomy, and laparoscopic esophagectomy. Our longest follow-up is approximately 6 months. The major complaint from patients is pain from the umbilical wound site. At follow-up, there have been no wound complications such as surgical site infections or hernias. Our cholecystectomy and gastric band patients have all left on the same day of surgery with minimal narcotic requirement. Operative times for SILS cholecystectomy have ranged from 45 to 90 min. Two cases were performed for acute cholecystitis, one of them requiring the addition of an accessory port in the right upper quadrant for dissection. SILS cholecystectomy performed for acute cholecystitis proved to be slightly more challenging, requiring longer operative times. In summary, we provide an alternative access system using a commonly used Gelport device with a flexible fulcrum to
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allow single-port access surgery to be performed. According to our experience, wide variety of laparoscopic procedures, patient populations, and disease processes are amenable to this approach. We believe that this type of port access is one way to lessen the technical difficulties of performing SILS and therefore broaden its applicability to other procedures.
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