Single-incision laparoscopic surgery

Abstract

This issue of JMAS is dedicated to a variant of the well-established multiport minimal access surgery, the advent of which in the mid-1980s revolutionised surgical practice and care beyond the dreams of its pioneers. As illustrated in Figure 1, the adoption of the MAS approach drastically reduced the traumatic insult to the patient not just by minimizing the access trauma inherent to traditional open surgery but equally important, though often overlooked, by safeguarding the internal environment of the patients’ organs (the milieu intérieur described by the great physiologist, Claude Bernard). It is, nowadays, equated with homeostasis such that the gastrointestinal tract is no longer exposed to the operating room air with the attendant dual risk of desiccation and absorption off endotoxin present in the operating room air by the peritoneal and serosal lining. The benefits that have been accrued as a result of the widespread adoption of the MAS approach are well-established but beyond the scope of this editorial except to emphasize that the MAS approach is now the gold standard for many common and advanced operations across the surgical specialties.Figure 1: Schematic representation of the reduction in trauma of access to the patients as a consequence of the adoption of MAS and variant MAS approaches.NOTES VS. SILS In recent years, two variants of the MAS approach have been introduced in the quest for further abrogation of the traumatic insult to the patient, thereby further reducing the postoperative pain and visible external scars [Figure 1]: natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) also referred to, regrettably by a variety of eponymous and unscientific names. In essence, there is at the moment an apparent conflict between these two variant MAS approaches which appears to extend beyond the surgical profession to industry in respect of the underpinning technologies: flexible and rigid optics/instrumentation. As usual in medical science, the truth lies somewhere between these opposing and entrenched views. The situation is clarified to some extent if one addresses the matter objectively and in scientific terms. Thus all the various NOTES interventions can and should be classed in scientific terms as: Hollow-visceral transperitoneal (HVT): transgastric, transoesophageal, transcolonic, trans vesical – access to the peritoneal cavity by planned perforation of a hollow viscus. Squamous conduit intraperitoneal (SCI): transvaginal, transanal – direct access to the peritoneal cavity These two categorise of the NOTES approach are, from the surgical perspective, fundamentally different one from the other in three respects. Thus, whereas HVT imposes a new operating paradigm and requires new interventional flexible technologies which is still in development, it introduces an extra layer of risk (intentional perforation of an intraperitoneal hollow organ), which SCI does not. Thirdly, SCI is performed with existing laparoscopic instrumentation and rigid optics. In many respects, the transvaginal approach approximates to vaginal SILS and the transanal approach (still in its infancy) is a logical extension of transanal endoscopic microsurgery pioneered by G Buess. This may well explain the very limited reported cases with no large series by the HVT in contrast to the substantive series of laparoscopic cholecystectomy (LC) by the SCI (transvaginal) approach. Even so to date, the transvaginal approach has been overshadowed by abdominal SILS. SINGLE-INCISION LAPAROSCOPIC SURGERY The concept of SILS is not new and has to be attributed to the late Dr. Raimund Wittmoser, the father of modern thoracoscopic surgery of the autonomic nervous system [Figure 2]. R Wittmoser used a single-intercostal incision through which he inserted a multifunctional port which contained all the instruments including the optic [Figure 2] for all his operations on the sympathetic and parasympathetic he perf