1. No (Visible) Scar Colectomy Michael J Stamos, MD Professor and Chair Department of Surgery Univ. of California, Irvine

2. PHILOSOPHY of SINGLE PORT/ACCESS SURGERY Perform interventional laparoscopy through the umbilicus (No Scar) Perform interventional laparoscopy through the umbilicus (No Scar) Perform interventional laparoscopy with reduced number of laparoscopic incisions (goal of 1 incision) - Without increasing the size of the incision Perform interventional laparoscopy with reduced number of laparoscopic incisions (goal of 1 incision) - Without increasing the size of the incision Appropriate for: - Procedures requiring implantation of a device - Procedures requiring removal of a surgical specimen Appropriate for: - Procedures requiring implantation of a device - Procedures requiring removal of a surgical specimen

3. Revolution Transition from open surgery to multiport trans-abdominal surgery Transition from open surgery to multiport trans-abdominal surgery

4. Evolution Single site transabdominal surgery Single site transabdominal surgery LESS (Laparo Endoscopic Single Site Surgery) LESS (Laparo Endoscopic Single Site Surgery)

5. Revolution? Transition from open surgery to multiport trans-abdominal surgery Transition from open surgery to multiport trans-abdominal surgery Single site transabdominal surgery Single site transabdominal surgery LESS (Laparo Endoscopic Single Site Surgery) LESS (Laparo Endoscopic Single Site Surgery) Single port transoral/visceral surgery (NOTES) Single port transoral/visceral surgery (NOTES)

8. Advantages of LESS vs. NOTES Able to use many conventional rigid laparoscopic instruments Able to use many conventional rigid laparoscopic instruments Laparoscopic skill set Laparoscopic skill set Able to work on same organs approached via conventional laparoscopy Able to work on same organs approached via conventional laparoscopy Stepping stone for the next evolution Stepping stone for the next evolution

9. Balanced Strategy leads to Single Incision Surgery Improved cosmesis Technical difficulty & Compromising safety

10. Tools available Narrow-low profile trochars/multiport devices Narrow-low profile trochars/multiport devices Articulated camera Articulated camera Articulated grasper Articulated grasper Articulated dissector Articulated dissector Articulated L-hook Articulated L-hook Articulated scissors Articulated scissors Straight instruments Straight instruments

11. Principles to follow Triangulation of view with adequate exposure Triangulation of view with adequate exposure Open surgery Open surgery Single incision, angled arms, straight instruments Single incision, angled arms, straight instruments Laparoscopic surgery Laparoscopic surgery Multiple ports, straight camera and instruments Multiple ports, straight camera and instruments Single site laparoscopy Single site laparoscopy Single site, Articulated camera +/- instruments Single site, Articulated camera +/- instruments

12. Triangulation

13. NOTES vs. Single Site Surgery NOTES Require 1-port Require 1-port All Flexible equipment All Flexible equipment Potential Benefits - No abdominal scar Potential Benefits - No abdominal scar - Other ? Almost all are hybrid Almost all are hybrid Endoscopic skills Endoscopic skills Single Site Surgery Requires 1-port/site Requires 1-port/site Flexible/rigid equipment Flexible/rigid equipment Benefits - Minimal scar Benefits - Minimal scar - Other ? - Some hybrids Purely Laparoscopic skills Purely Laparoscopic skills

14. Appendectomy Umbilicus Target organ Camera Instrument Single-Incision Appendix

15. LESS Appendectomy Nguyen, Reavis, Hinojosa, Smith, Stamos, Surg Innov 2009

16. LESS Appendectomy Nguyen, Reavis, Hinojosa, Smith, Stamos, Surg Innov 2009

17. What about LESS Colectomy? Increased complexity w/trocars due to multi quadrant operation Increased complexity w/trocars due to multi quadrant operation Awkward/suboptimal location for “single site” at umbilicus Awkward/suboptimal location for “single site” at umbilicus Unfavorable cosmesis Unfavorable cosmesis Hernia risk Hernia risk Consider goal of single site (i.e. it’s all about cosmesis) Consider goal of single site (i.e. it’s all about cosmesis)

18. What about LESS Colectomy? No Visible Scar (NVIS) Colectomy No Visible Scar (NVIS) Colectomy Standard approach Standard approach Applicable to right and left/sigmoid colon Applicable to right and left/sigmoid colon 2 sites utilized 2 sites utilized Suprapubic incision below hair line(3-5 cm) Suprapubic incision below hair line(3-5 cm) 2 trocars(5 + 12 mm) or 2 trocars(5 + 12 mm) or Multiport device Multiport device Umbilicus is a “freebie” Umbilicus is a “freebie”

19. NVIS vs. Single Site Surgery NVIS Allows 2 ports/sites Allows 2 ports/sites Flexible/rigid equipment Flexible/rigid equipment Potential Benefits - Minimal/hidden scar Potential Benefits - Minimal/hidden scar - Other? Hybrid an option Hybrid an option Purely Laparoscopic skills Purely Laparoscopic skills Single Site Surgery Requires 1-port/site Requires 1-port/site Flexible/rigid equipment Flexible/rigid equipment Benefits - Minimal scar Benefits - Minimal scar - Other ? - Some hybrids Purely Laparoscopic skills Purely Laparoscopic skills

20. NVIS vs. Single Site Surgery NVIS No IRB issues No IRB issues Regain triangulation Regain triangulation Less expensive? Less expensive? Shorter OR time Shorter OR time Less device dependent Less device dependent Single Site Surgery IRB required? IRB required? Angled/articulated instruments/scope try to regain triangulation Angled/articulated instruments/scope try to regain triangulation

21. Standard Lap Sigmoidectomy/LAR

23. Standard Lap Right Colectomy

25. NVIS Approach

26. NVIS Sigmoid Colectomy Need long instruments(45 mm) Need long instruments(45 mm) Camera at umbilicus for medial lateral dissection and at suprapubic site for splenic flexure Camera at umbilicus for medial lateral dissection and at suprapubic site for splenic flexure Multiport device facilitates placement of anvil and subsequent anastomosis Multiport device facilitates placement of anvil and subsequent anastomosis

32. NVIS Right Colectomy Need long instruments(45 mm) Need long instruments(45 mm) Camera at suprapubic site for operation Camera at suprapubic site for operation Multiport device not needed Multiport device not needed Intracorporeal anastomotic technique required Intracorporeal anastomotic technique required

37. We’re Making Progress Come on! It can‘t go wrong every time...

38. Conclusions LESS or NVIS surgery can be used as a bridge to NOTES procedures or instead of NOTES LESS or NVIS surgery can be used as a bridge to NOTES procedures or instead of NOTES Enable surgeons to advance skill set while providing safety for our patients Enable surgeons to advance skill set while providing safety for our patients Unlike NOTES, there are no reimbursement issues Unlike NOTES, there are no reimbursement issues Can also be applied to advanced laparoscopic operations that are not amenable to NOTES technique Can also be applied to advanced laparoscopic operations that are not amenable to NOTES technique

39. What does the Future hold? Technologic advances will drive surgery toward less invasive options Technologic advances will drive surgery toward less invasive options Robotic single port Robotic single port Newer/improved robotics Newer/improved robotics Improved miniaturization Improved miniaturization

40. Conclusions Exciting time to be in surgery Exciting time to be in surgery Evolution from open to minimally invasive surgery to “minimalist” approaches Evolution from open to minimally invasive surgery to “minimalist” approaches Dual site allows use of current skill set and instrumentation (with more to come) Dual site allows use of current skill set and instrumentation (with more to come) Principles of surgical technique followed Principles of surgical technique followed Surgical evolution is a journey… Surgical evolution is a journey…

41. Minimize the footprint we leave behind

42. Thank you