1. SILS George Fielding NYU School of Medicine New York George Fielding NYU School of Medicine New York

2. SILS What’s been done? Pretty much everything  Appendicitis  Lap Chole  Fundoplication  Total Gastrectomy for cancer  Colectomy  Splenectomy  Gynaecology  Urology Pretty much everything  Appendicitis  Lap Chole  Fundoplication  Total Gastrectomy for cancer  Colectomy  Splenectomy  Gynaecology  Urology

3. SILS What’s been done? Bariatrics  Lap band  Bypass  Sleeve Bariatrics  Lap band  Bypass  Sleeve

4. SILS What’s been done? Bariatrics  Obes Surg. 2008 Nov;18(11):1492-4. Epub 2008 Aug 10.Single- laparoscopic incision transabdominal surgery sleeve gastrectomy.Reavis KM, Hinojosa MW, Smith BR, Nguyen NT. Obes Surg.Reavis KMHinojosa MW Smith BRNguyen NT Bariatrics  Obes Surg. 2008 Nov;18(11):1492-4. Epub 2008 Aug 10.Single- laparoscopic incision transabdominal surgery sleeve gastrectomy.Reavis KM, Hinojosa MW, Smith BR, Nguyen NT. Obes Surg.Reavis KMHinojosa MW Smith BRNguyen NT

5. SILS What’s been done?  Transumbilical 2-site laparoscopic Roux- en-Y gastric bypass: initial results of 100 cases and comparison with traditional laparoscopic technique. Lee Wj etal TaiwanLee Wj  BMI 43 kg/m(2) (range 32-61),  OT 144 minutes (range 95-160)  The 2-site LRYGB group had a significantly longer operating time and more blood loss than the traditional LRYGB group but less pain and better cosmesis.  Transumbilical 2-site laparoscopic Roux- en-Y gastric bypass: initial results of 100 cases and comparison with traditional laparoscopic technique. Lee Wj etal TaiwanLee Wj  BMI 43 kg/m(2) (range 32-61),  OT 144 minutes (range 95-160)  The 2-site LRYGB group had a significantly longer operating time and more blood loss than the traditional LRYGB group but less pain and better cosmesis.

6. SILS Why Bother? Pain? Cosmesis? Because you can? Pain? Cosmesis? Because you can?

7. SILS Why Bother?  Cosmesis has never been an issue in bariatrics  More patients with lower BMI, more interested in cosmesis  After weight loss, we’ve underestimated the privacy issues implied by the scars  Especially for younger female patients  Cosmesis has never been an issue in bariatrics  More patients with lower BMI, more interested in cosmesis  After weight loss, we’ve underestimated the privacy issues implied by the scars  Especially for younger female patients

8. SILS Why Bother?  Hiding the main scar, and possibly adding a tiny scar for the Nathanson, allows band patients to go to the beach, wear more revealing clothes and go on dates without having to explain all the scars  Keloid scarring is very troublesome for some patients, especially African Americans  Hiding the main scar, and possibly adding a tiny scar for the Nathanson, allows band patients to go to the beach, wear more revealing clothes and go on dates without having to explain all the scars  Keloid scarring is very troublesome for some patients, especially African Americans

9. SILS Why Bother? Pain?  Am Surg 2010 Dec;76 1328-32. Saber etal  December 2008 to September 2009 n = 27  15 SILS 12 Normal bands  The overall pain score significantly less in SILS group P 0.012.  Operating time significantly less in the multiport group P 0.000.  Differences in immediate postoperative pain scores, analgesia, and the overall length of hospital stay were found to be statistically insignificant.  Am Surg 2010 Dec;76 1328-32. Saber etal  December 2008 to September 2009 n = 27  15 SILS 12 Normal bands  The overall pain score significantly less in SILS group P 0.012.  Operating time significantly less in the multiport group P 0.000.  Differences in immediate postoperative pain scores, analgesia, and the overall length of hospital stay were found to be statistically insignificant.

10. SILS Why Bother? Pain?  Prasad etal J Min Access Surg 2011 7:24-7.  No significant difference in the pain score between the CLS and SILS  Operative time significantly lower in the CLS group (28 versus 67 minutes).  The second half of SILS group had a significantly lower pain score compared to the first half  Prasad etal J Min Access Surg 2011 7:24-7.  No significant difference in the pain score between the CLS and SILS  Operative time significantly lower in the CLS group (28 versus 67 minutes).  The second half of SILS group had a significantly lower pain score compared to the first half

11. SILS Why Bother?  Patient demand  Market share  To be honest, there’s been minimal patient demand  It’s fun to do this for people, as part of the overall care of the patient  Patient demand  Market share  To be honest, there’s been minimal patient demand  It’s fun to do this for people, as part of the overall care of the patient

12. Techniques  Single upper abdo incision - to me this wastes the whole premise of doing it  I use an infra-umbilical incision  Learn to operate with hands almost in parallel - minimal triangulation  Single upper abdo incision - to me this wastes the whole premise of doing it  I use an infra-umbilical incision  Learn to operate with hands almost in parallel - minimal triangulation

13. Techniques  The major decision is whether to use a 5 mm or a 10mm scope  It depends how good your scopes are  I currently use a 12 mm port, place the band through the fascial incision, then put the port in  Crowding is magnified if you don’t use a Nathanson, and need another port for liver retraction.  The major decision is whether to use a 5 mm or a 10mm scope  It depends how good your scopes are  I currently use a 12 mm port, place the band through the fascial incision, then put the port in  Crowding is magnified if you don’t use a Nathanson, and need another port for liver retraction.

14. Techniques  For fundoplication I use a 10 scope in a 12mm port and 2 5mm ports  For Gastric bypass I do all the dissection using a 10mm scope, then switch to a 5mm scope to use the stapler  For fundoplication I use a 10 scope in a 12mm port and 2 5mm ports  For Gastric bypass I do all the dissection using a 10mm scope, then switch to a 5mm scope to use the stapler

15. Techniques  Try to use a scope with an end attatchment to reduce clashing. We use Stryker  Some use flexible scopes. I’ve found no advantage  Try to use a scope with an end attatchment to reduce clashing. We use Stryker  Some use flexible scopes. I’ve found no advantage

16. Techniques  It’s all about best use of the space at the umbilicus, as you have to operate with minimal triangulation  Offset port lengths really help  Put the ports at the very lateral ends of the wound. A small curved wound will stretch out flat.  A curved dissector is essential to go safely behind the esophagus.The Real Hand was best. The Ethicon band passer is a reasonable alternative  It’s all about best use of the space at the umbilicus, as you have to operate with minimal triangulation  Offset port lengths really help  Put the ports at the very lateral ends of the wound. A small curved wound will stretch out flat.  A curved dissector is essential to go safely behind the esophagus.The Real Hand was best. The Ethicon band passer is a reasonable alternative

17. SILS Lap Band Techniques Use both Allergan and Realize bands About a 3: 1 ratio Both work great Allergan easier to pass tubing and lock in this technique The long tag on the Realize helps with retraction to expose the upper pouch Use both Allergan and Realize bands About a 3: 1 ratio Both work great Allergan easier to pass tubing and lock in this technique The long tag on the Realize helps with retraction to expose the upper pouch

18. Techniques Mesh fixation of the Allergan port, Use a small disc of Marlex mesh sutured to the back of the port, and just lay the port on the deep fascia at the right hand end of the wound Use applicator for Realize port  Minimal dissection of a pouch for the port  Must get down to fascia Mesh fixation of the Allergan port, Use a small disc of Marlex mesh sutured to the back of the port, and just lay the port on the deep fascia at the right hand end of the wound Use applicator for Realize port  Minimal dissection of a pouch for the port  Must get down to fascia

19. Instrumentation  12 mm Applied port  5mm extra long Applied port  1 or 2 hubless Covidien 5 mm ports  1 Novare Real Hand dissector  Standard long lap band instruments  12 mm Applied port  5mm extra long Applied port  1 or 2 hubless Covidien 5 mm ports  1 Novare Real Hand dissector  Standard long lap band instruments

20. Technique  Peri-umbilical incision  Insert 12 mm port through root of umbilicus  2 - 5’s, offset lengths  Nathanson liver retractor or retractor via umbilicus  Look for and repair any hiatal hernias  Crossed hand dissection technique  Use standard long needle driver and grasper to suture  Peri-umbilical incision  Insert 12 mm port through root of umbilicus  2 - 5’s, offset lengths  Nathanson liver retractor or retractor via umbilicus  Look for and repair any hiatal hernias  Crossed hand dissection technique  Use standard long needle driver and grasper to suture

34. Results SILS bands NYU  November 2008- November 2010  N=756  67% Female  Age 39 yrs (14-82)  Wt 265 lbs (165 – 484)  BMI 42 ( 28-67)  November 2008- November 2010  N=756  67% Female  Age 39 yrs (14-82)  Wt 265 lbs (165 – 484)  BMI 42 ( 28-67)

35. Operating time  N=756  Time 46 mins (12-179)  Converted to standard technique 0  Extra port for omental retraction 12  Hiatal Hernia repair 403  Longer in males long torsos  N=756  Time 46 mins (12-179)  Converted to standard technique 0  Extra port for omental retraction 12  Hiatal Hernia repair 403  Longer in males long torsos

36. Results SILS bands NYU Hospital stay Hospital stay all within 24 hrs, except 5 patients In - hospital complications Small bowel injury – laparotomy, recovery Band obstruction – band removal and replacement Port infection- port removed

37. Results SILS bands NYU Death  Female, presented to outside hospital day 4  Eventually laparotomy – perf ’ d esophago- gastric junction anterior  Peritionitis, death Death  Female, presented to outside hospital day 4  Eventually laparotomy – perf ’ d esophago- gastric junction anterior  Peritionitis, death

38. Results SILS bands NYU  Complications Port flip131.72% Band slippage111.46% Port site complication 81.06% Port leak50.66%

39. Results SILS bands NYU Weight loss  1 yr 44%  2 yr 59% Weight loss  1 yr 44%  2 yr 59%

41. Plans for the future  Use for all females to BMI 60  Males to Bmi 50  Except super tall males  Patients love it  Use for all females to BMI 60  Males to Bmi 50  Except super tall males  Patients love it

42. So what’s the future of SILS  It’s here to stay  It’s fun to do  It’s definitely more difficult, and harder to teach  It’ll never replace standard laparoscopy in the mainstream  It’s being driven by industry, with special SILS ports.  I don’t think you need them  It’s here to stay  It’s fun to do  It’s definitely more difficult, and harder to teach  It’ll never replace standard laparoscopy in the mainstream  It’s being driven by industry, with special SILS ports.  I don’t think you need them