No (Visible) Scar Colectomy

Michael J Stamos, MDProfessor and Chair

Department of SurgeryUniv. of California, Irvine

PHILOSOPHY of PHILOSOPHY of SINGLE PORT/ACCESS SURGERYSINGLE 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 Perform interventional laparoscopy with reduced number of laparoscopic incisions (goal of 1 incision)laparoscopic incisions (goal of 1 incision)- Without increasing the size of the incision- Without increasing the size of the incision

Appropriate for:Appropriate for:- Procedures requiring implantation of a device - Procedures requiring implantation of a device - Procedures requiring removal of a surgical specimen- Procedures requiring removal of a surgical specimen

RevolutionRevolution

Transition from open surgery Transition from open surgery to multiport trans-abdominal to multiport trans-abdominal surgerysurgery

EvolutionEvolution

Transition from open surgery to Transition from open surgery to multiport trans-abdominal surgerymultiport trans-abdominal surgery

Single site transabdominal surgerySingle site transabdominal surgery LESS (Laparo Endoscopic Single LESS (Laparo Endoscopic Single

Site Surgery)Site Surgery)

Revolution?Revolution?

Transition from open surgery to Transition from open surgery to multiport trans-abdominal surgerymultiport trans-abdominal surgery

Single site transabdominal surgerySingle site transabdominal surgery LESS (Laparo Endoscopic Single Site LESS (Laparo Endoscopic Single Site

Surgery)Surgery) Single port transoral/visceral surgery Single port transoral/visceral surgery

(NOTES)(NOTES)

Advantages of LESS vs. Advantages of LESS vs. NOTESNOTES

Able to use many conventional rigid Able to use many conventional rigid laparoscopic instrumentslaparoscopic instruments

Laparoscopic skill setLaparoscopic skill set

Able to work on same organs approached via Able to work on same organs approached via conventional laparoscopyconventional laparoscopy

Stepping stone for the next evolutionStepping stone for the next evolution

Balanced Strategy leads to Balanced Strategy leads to Single Incision SurgerySingle Incision Surgery

Improved cosmesis

Technical difficulty &Compromising safety

Tools availableTools available

Narrow-low profile Narrow-low profile trochars/multiport trochars/multiport devicesdevices

Articulated cameraArticulated camera Articulated grasperArticulated grasper Articulated dissectorArticulated dissector Articulated L-hookArticulated L-hook Articulated scissorsArticulated scissors Straight instrumentsStraight instruments

Principles to followPrinciples to follow

Triangulation of view with adequate exposureTriangulation of view with adequate exposure

Open surgeryOpen surgery Single incision, angled arms, straight Single incision, angled arms, straight

instrumentsinstruments Laparoscopic surgeryLaparoscopic surgery

Multiple ports, straight camera and instrumentsMultiple ports, straight camera and instruments Single site laparoscopySingle site laparoscopy

Single site, Articulated camera +/- instrumentsSingle site, Articulated camera +/- instruments

TriangulationTriangulation

NOTES vs. Single Site SurgeryNOTES vs. Single Site Surgery

NOTESNOTES Require 1-portRequire 1-port All Flexible equipmentAll Flexible equipment Potential BenefitsPotential Benefits

- No abdominal scar- No abdominal scar

- Other ?- Other ? Almost all are hybridAlmost all are hybrid Endoscopic skillsEndoscopic skills

Single Site SurgerySingle Site Surgery Requires 1-port/siteRequires 1-port/site Flexible/rigid Flexible/rigid

equipmentequipment BenefitsBenefits

- Minimal scar- Minimal scar- Other ?Other ?

- Some hybridsSome hybrids Purely Laparoscopic Purely Laparoscopic

skillsskills

AppendectomyAppendectomy

UmbilicusTarget organCameraInstrument

Single-Incision Appendix

LESS AppendectomyLESS Appendectomy

Nguyen, Reavis , Hinojosa, Smith, Stamos, Surg Innov 2009

LESS AppendectomyLESS Appendectomy

Nguyen, Reavis , Hinojosa, Smith, Stamos, Surg Innov 2009

What about LESS Colectomy?What about LESS Colectomy?

Increased complexity w/trocars due to Increased complexity w/trocars due to multi quadrant operationmulti quadrant operation

Awkward/suboptimal location for Awkward/suboptimal location for “single site” at umbilicus“single site” at umbilicus

Unfavorable cosmesisUnfavorable cosmesis

Hernia riskHernia risk

Consider goal of single site (i.e. it’s all Consider goal of single site (i.e. it’s all about cosmesis)about cosmesis)

What about LESS Colectomy?What about LESS Colectomy? No Visible Scar (NVIS) ColectomyNo Visible Scar (NVIS) Colectomy

Standard approachStandard approach

Applicable to right and left/sigmoid colonApplicable to right and left/sigmoid colon

2 sites utilized2 sites utilized

Suprapubic incision below hair line(3-5 cm)Suprapubic incision below hair line(3-5 cm)

2 trocars(5 + 12 mm) or2 trocars(5 + 12 mm) or

Multiport deviceMultiport device

Umbilicus is a “freebie”Umbilicus is a “freebie”

NVIS vs. Single Site SurgeryNVIS vs. Single Site Surgery

NVISNVIS Allows 2 ports/sitesAllows 2 ports/sites Flexible/rigid equipmentFlexible/rigid equipment Potential BenefitsPotential Benefits

- Minimal/hidden scar- Minimal/hidden scar

- Other?- Other? Hybrid an optionHybrid an option Purely Laparoscopic skillsPurely Laparoscopic skills

Single Site SurgerySingle Site Surgery Requires 1-port/siteRequires 1-port/site Flexible/rigid Flexible/rigid

equipmentequipment BenefitsBenefits

- Minimal scar- Minimal scar- Other ?Other ?

- Some hybridsSome hybrids Purely Laparoscopic Purely Laparoscopic

skillsskills

NVIS vs. Single Site SurgeryNVIS vs. Single Site Surgery

NVISNVIS No IRB issuesNo IRB issues Regain triangulationRegain triangulation Less expensive?Less expensive?

Shorter OR timeShorter OR time Less device Less device

dependentdependent

Single Site SurgerySingle Site Surgery IRB required?IRB required? Angled/articulated Angled/articulated

instruments/scope instruments/scope try to regain try to regain triangulationtriangulation

Standard Lap Sigmoidectomy/LAR

Standard Lap Right Colectomy

NVIS Approach

NVIS Sigmoid ColectomyNVIS Sigmoid Colectomy

Need long instruments(45 mm)Need long instruments(45 mm) Camera at umbilicus for medial lateral Camera at umbilicus for medial lateral

dissection and at suprapubic site for dissection and at suprapubic site for splenic flexure splenic flexure

Multiport device facilitates placement Multiport device facilitates placement of anvil and subsequent anastomosisof anvil and subsequent anastomosis

NVIS Right ColectomyNVIS Right Colectomy

Need long instruments(45 mm)Need long instruments(45 mm) Camera at suprapubic site for Camera at suprapubic site for

operation operation Multiport device not neededMultiport device not needed Intracorporeal anastomotic technique Intracorporeal anastomotic technique

requiredrequired

We’re Making ProgressWe’re Making Progress

Come on! It can‘t go

wrong every time...

ConclusionsConclusions LESS or NVIS surgery can be used as a LESS or NVIS surgery can be used as a bridgebridge to to

NOTES procedures or NOTES procedures or instead ofinstead of NOTES NOTES

Enable surgeons to advance skill set while providing Enable surgeons to advance skill set while providing safety for our patientssafety for our patients

Unlike NOTES, there are no reimbursement issuesUnlike NOTES, there are no reimbursement issues

Can also be applied to advanced laparoscopic Can also be applied to advanced laparoscopic operations that are not amenable to NOTES techniqueoperations that are not amenable to NOTES technique

What does the Future hold?What does the Future hold?

Technologic advances will drive Technologic advances will drive surgery toward less invasive optionssurgery toward less invasive options Robotic single portRobotic single port Newer/improved roboticsNewer/improved robotics Improved miniaturizationImproved miniaturization

ConclusionsConclusions

Exciting time to be in surgeryExciting time to be in surgery

Evolution from open to minimally Evolution from open to minimally invasive surgery to “minimalist” invasive surgery to “minimalist” approachesapproaches

Dual site allows use of current skill set Dual site allows use of current skill set and instrumentation (with more to come)and instrumentation (with more to come)

Principles of surgical technique followedPrinciples of surgical technique followed

Surgical evolution is a journey…Surgical evolution is a journey…

Minimize the footprint we leave

behind

Thank youThank you