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Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Comment on: Single incision laparoscopic bariatric surgery: a systematic review Single port laparoscopic surgery (SPLS) is a rapidly evolving, minimally invasive surgical approach. It offers an attractive blend that combines the familiarity of multiport laparoscopic surgery with the cosmetic appeal of natural orifice translumenal endoscopic surgery. The approach has been applied to a variety of surgical procedures, including appendectomy, cholecystectomy, colectomy, and, more recently, bariatric surgery. The approach is particularly attractive for the placement of an adjustable gastric band, which requires an incision large enough to insert the band and the port, and for the sleeve gastrectomy to allow retrieval of the gastric specimen. However, the true advantage of SPLS over conventional laparoscopic surgery has been a topic of debate. Moreno-Sanz C et al. are to be congratulated for this well-written review of the literature on the use of the single incision laparoscopic approach in bariatric surgery [1]. They present the current literature as several articles have been published since the latest review on the same topic [2]. It highlights the advantages and disadvantages of SILBS without over emphasizing either. However, as this is a new technique, an in-depth description of controversial technical aspects such as access, type of instruments, laparoscope, and liver retraction would have been helpful. As with any new technique, we should not compromise the outcome for the approach. Efficacy in terms of weight loss and improved co-morbidities should be similar to that of the conventional laparoscopic approach. There is no statistical significant difference in morbidity or mortality between the 2 approaches. However, it must be noted that these published outcomes are mainly from experts in the field. Since our group and others introduced this approach to bariatric surgery, we realize that this approach requires special skills to overcome its associated technical challenges [3–6]. The limitations of the SPLS technique stem from its divergent nature and include lost triangulation, inadequate liver retraction, and instrument conflict. Through the introduction of flexible instruments, the lost triangulation can be adequately restored because the
deflecting tips converge onto the target organ. Also, multichannel single ports have helped reduce extracorporeal conflict of instruments, thus providing a wider range of motion without sacrificing the pneumoperitoneum. Morbid obesity initially was considered a contraindication, but soon it became an indication for the SPLS approach. We have found that to be particularly useful for a selected group of patients, especially women with a short distance between the xiphoid process and umbilicus. We do not compromise the outcome for this technique, so we do not hesitate to add extra-umbilical trocars if we encounter a technical difficulty. For this reason, we like the term “reduced port laparoscopy”. Regarding cosmesis, even morbidly obese patients, who are predominantly young females, are concerned about an improved body image and self-esteem. Standardization of reduced port laparoscopic bariatric surgery is needed to speed adoption, reduce intraoperative complications, and improve the efficiency and safety of the approach. Single-port laparoscopy employs a 1.5 3-cm incision at the umbilicus for the placement of a single working port. There is a concern that the longer incision created by single port laparoscopy (SPL) compared with multiport laparoscopy may increase the incidence of trocar-site hernias, particularly in bariatric patients. Our results and others have shown that SPL bariatric surgery has a low rate of trocarsite hernia comparable with that of multiport laparoscopic approach [2,7]. The most important finding of this review is that it shows that SPLS is as safe as the conventional laparoscopic bariatric approach when performed in a proper environment (i.e., selected patients, expert bariatric surgeons) despite only 1 randomized controlled trial. We hope that these reports might help propel a more widespread adoption of the single-incision approach in the field of bariatric surgery [1,2]. High-quality, prospective, randomized studies comparing multiport laparoscopic bariatric surgeries with their SPLS counterparts in large numbers of patients with long-term follow-up are needed to confirm these results.
http://dx.doi.org/10.1016/j.soard.2014.01.004 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 Q5 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
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A. A. Saber / Surgery for Obesity and Related Diseases ] (2014) 00–00
111 Q6 Disclosures 112 ■■■ 113 114 115 Q1 Alan A. Saber, M.D., F.A.C.S., F.A.S.M.B.S. 116 Weill Cornell Medical College 117 Q3 The Brooklyn Hospital Center 118 119 References 120 [1] Moreno-Sanz C, Morandeira-Rivas A, Sedano-Vizcaino C, Tenías121 Burillo JM, Román-Ortíz C, Muñoz de la Espada JB. Single-incision 122 laparoscopic bariatric surgery. A systematic review. Surg Obes Relat 123 Dis. Epub 2013 Dec 4. 124 [2] Saber AA, El-Ghazaly TH, Dewoolkar AV. Laparoscopic bariatric 125 surgery: a comprehensive review. Surg Obes Relat Dis 2010;6:575–82.
[3] Nguyen NT, Slone J, Reavis K. Comparison study of conventional laparoscopic gastric banding versus laparoendoscopic single site gastric banding. Surg Obes Relat Dis 2010;6:503–7. [4] Saber AA, El-Ghazaly TH, Dewoolkar AV, Slayton SA. Singleincision laparoscopic sleeve gastrectomy versus conventional multiport laparoscopic sleeve gastrectomy: technical considerations and strategic modifications. Surg Obes Relat Dis 2010;6:658–64. [5] Saber AA, El-Ghazaly TH, Minnick DB. Single port access transumbilical laparoscopic Roux-en-Y gastric bypass using the SILS port: first reported case. Surg Innov 2009;16:343–7. [6] Huang CK, Lo CH, Houng JY, Chen YS, Lee PH. Surgical results of single-incision transumbilical laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2012;8:201–7. [7] Lee DY, Rehmani SS, Guend H, et al. The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy. Surg Endosc 2013;27: 1287–9.
126 127 128 129 130 131 132 133 134 135 136 137 138 139 140
Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Comment on: Single incision laparoscopic bariatric surgery: a systematic review Single port laparoscopic surgery (SPLS) is a rapidly evolving, minimally invasive surgical approach. It offers an attractive blend that combines the familiarity of multiport laparoscopic surgery with the cosmetic appeal of natural orifice translumenal endoscopic surgery. The approach has been applied to a variety of surgical procedures, including appendectomy, cholecystectomy, colectomy, and, more recently, bariatric surgery. The approach is particularly attractive for the placement of an adjustable gastric band, which requires an incision large enough to insert the band and the port, and for the sleeve gastrectomy to allow retrieval of the gastric specimen. However, the true advantage of SPLS over conventional laparoscopic surgery has been a topic of debate. Moreno-Sanz C et al. are to be congratulated for this well-written review of the literature on the use of the single incision laparoscopic approach in bariatric surgery [1]. They present the current literature as several articles have been published since the latest review on the same topic [2]. It highlights the advantages and disadvantages of SILBS without over emphasizing either. However, as this is a new technique, an in-depth description of controversial technical aspects such as access, type of instruments, laparoscope, and liver retraction would have been helpful. As with any new technique, we should not compromise the outcome for the approach. Efficacy in terms of weight loss and improved co-morbidities should be similar to that of the conventional laparoscopic approach. There is no statistical significant difference in morbidity or mortality between the 2 approaches. However, it must be noted that these published outcomes are mainly from experts in the field. Since our group and others introduced this approach to bariatric surgery, we realize that this approach requires special skills to overcome its associated technical challenges [3–6]. The limitations of the SPLS technique stem from its divergent nature and include lost triangulation, inadequate liver retraction, and instrument conflict. Through the introduction of flexible instruments, the lost triangulation can be adequately restored because the
deflecting tips converge onto the target organ. Also, multichannel single ports have helped reduce extracorporeal conflict of instruments, thus providing a wider range of motion without sacrificing the pneumoperitoneum. Morbid obesity initially was considered a contraindication, but soon it became an indication for the SPLS approach. We have found that to be particularly useful for a selected group of patients, especially women with a short distance between the xiphoid process and umbilicus. We do not compromise the outcome for this technique, so we do not hesitate to add extra-umbilical trocars if we encounter a technical difficulty. For this reason, we like the term “reduced port laparoscopy”. Regarding cosmesis, even morbidly obese patients, who are predominantly young females, are concerned about an improved body image and self-esteem. Standardization of reduced port laparoscopic bariatric surgery is needed to speed adoption, reduce intraoperative complications, and improve the efficiency and safety of the approach. Single-port laparoscopy employs a 1.5 3-cm incision at the umbilicus for the placement of a single working port. There is a concern that the longer incision created by single port laparoscopy (SPL) compared with multiport laparoscopy may increase the incidence of trocar-site hernias, particularly in bariatric patients. Our results and others have shown that SPL bariatric surgery has a low rate of trocarsite hernia comparable with that of multiport laparoscopic approach [2,7]. The most important finding of this review is that it shows that SPLS is as safe as the conventional laparoscopic bariatric approach when performed in a proper environment (i.e., selected patients, expert bariatric surgeons) despite only 1 randomized controlled trial. We hope that these reports might help propel a more widespread adoption of the single-incision approach in the field of bariatric surgery [1,2]. High-quality, prospective, randomized studies comparing multiport laparoscopic bariatric surgeries with their SPLS counterparts in large numbers of patients with long-term follow-up are needed to confirm these results.
http://dx.doi.org/10.1016/j.soard.2014.01.004 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 Q5 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
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A. A. Saber / Surgery for Obesity and Related Diseases ] (2014) 00–00
111 Q6 Disclosures 112 ■■■ 113 114 115 Q1 Alan A. Saber, M.D., F.A.C.S., F.A.S.M.B.S. 116 Weill Cornell Medical College 117 Q3 The Brooklyn Hospital Center 118 119 References 120 [1] Moreno-Sanz C, Morandeira-Rivas A, Sedano-Vizcaino C, Tenías121 Burillo JM, Román-Ortíz C, Muñoz de la Espada JB. Single-incision 122 laparoscopic bariatric surgery. A systematic review. Surg Obes Relat 123 Dis. Epub 2013 Dec 4. 124 [2] Saber AA, El-Ghazaly TH, Dewoolkar AV. Laparoscopic bariatric 125 surgery: a comprehensive review. Surg Obes Relat Dis 2010;6:575–82.
[3] Nguyen NT, Slone J, Reavis K. Comparison study of conventional laparoscopic gastric banding versus laparoendoscopic single site gastric banding. Surg Obes Relat Dis 2010;6:503–7. [4] Saber AA, El-Ghazaly TH, Dewoolkar AV, Slayton SA. Singleincision laparoscopic sleeve gastrectomy versus conventional multiport laparoscopic sleeve gastrectomy: technical considerations and strategic modifications. Surg Obes Relat Dis 2010;6:658–64. [5] Saber AA, El-Ghazaly TH, Minnick DB. Single port access transumbilical laparoscopic Roux-en-Y gastric bypass using the SILS port: first reported case. Surg Innov 2009;16:343–7. [6] Huang CK, Lo CH, Houng JY, Chen YS, Lee PH. Surgical results of single-incision transumbilical laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2012;8:201–7. [7] Lee DY, Rehmani SS, Guend H, et al. The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy. Surg Endosc 2013;27: 1287–9.
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