1. Single Site Umbilical Laparoscopic Surgery (SSULS)
George W. Holcomb, III, M.D., MBA
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas City, MO

2. Open Surgery Laparoscopic Surgery Less discomfort
Reduced hospitalization
Faster return to routine activities
Cosmesis

3. SSULS Open Surgery Laparoscopic Surgery NOTES
Cosmesis, but less risky c/w NOTES
Open Surgery
Laparoscopic Surgery
NOTES
Cosmesis, but risks

4. All use umbilicus as single site.
Acronyms
SILS (TM) - Single Incision Laparoscopic Surgery
SPA (TM) - Single Port Access
SSULS - Single Site Umbilical Laparoscopic Surgery (CMH)
SIPES – Single Incision Pediatric Endosurgery (CH-A)
All use umbilicus as single site.

5. Umbilical Portals (U.S.)
SILS Port
(Covidien)
Tri - Port
(Olympus)

6. Umbilical Portals (U.S.)

7. SSULS Appendectomy

8. What Else Is Different?
Instruments are in-line and parallel to each other
Ideally, instruments/telescope should be different lengths

9. What Else Is Different?
Assistant/camera holder stands next to or behind the surgeon

10. What Else Is Different?
Harder to operate

11. What Operations Are Being Done Using This SSULS Approach?
Appendectomy
Cholecystectomy
Splenectomy
Ileocecectomy
Pyloromyotomy (CH-A)
Fundoplication (CH-A)
Others

12. SSULS Appendectomy

13. SSULS Appendectomy
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14. Postoperative Appearance

15. SSULS Cholecystectomy
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16. SSULS Splenectomy
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17. SSULS Splenectomy

18. SSULS Ileocecectomy Intracorporeal dissection/mobilization
Extracorporeal resection/anastomosis

19. CMH Experience 142 SSULS procedures: Appendectomy (103)
Cholecystectomy (24)
Splenectomy (2)
Cholecystectomy/splenectomy (1)
Ileocecectomy (8)
CAPS, 2010 19

20. Cholecystectomy/splenectomy
Results
Procedure
Additional ports
Mean Op time (min)
Mean LOS (days)
Complications
Appendectomy (103) 10
34+/-16 1 6
Cholecystectomy (24) 2
73+/-28
1.5
Splenectomy
(2)
90+/- 6
Cholecystectomy/splenectomy
(1)
116
Ileocecectomy
(8)
86+/-22 5
CAPS, 2010

21. SIPES CH - ALABAMA Appendectomy - 130 Pyloromyotomy - 32
Cholecystectomy - 32
Fundoplication - 6
Pull-through - 4
204
Pediatr Surg Int 2010

22. Conclusion
These series show that single site surgery is feasible, and appears to be associated with acceptable operating times 22

23. Conclusion Disadvantages
Compromised degrees of freedom and triangulation
Visualization limited by inline field of view and motion of instruments
More difficult for the surgeon
Skeptical caution before embracing this approach as the next step in the evolution of minimally invasive surgery

24. Questions Do the benefits outweigh the risks? What are the benefits?
Is there improved cosmesis?
Prospective evidence needed
We are enrolling in 3 SSULS PRT’s
Appendectomy, Cholecystectomy, Splenectomy
Validated scar assessment tool
Questions still need to be answered
Validated scar assessment tool at 6 wks and 6 months post op to see if the pts perceives the benefit

25. Prospective Randomized Trials
Power 10 Outcome Analysis Variable
SSULS Appendectomy 360 (324) Infection
SSULS Cholecystectomy 60 (44) Operative time
SSULS Splenectomy 30 ( 5) Operative time

26. Other Variables Being Collected
Pain
Cost (hospital charges)
Cosmesis (Validated Scar Assessment Tool)