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Sils Sils Presentation Transcript

  • Single Incision L APAROSCOPIC S URGERY (SILS) C OLORECTAL Resection Nick Rieger Assoc Professor University of Adelaide
  • SILS
    • Urology
    • Renal transplant
    • Cholecystectomy
    • Gastric band surgery
    • Colectomy
  • SILS View slide
  • SILS Colectomy and literature
    • 2 recorded cases
    • Remzi FH , Kirat HT , Kaouk JH , Geisler DP . Single-port laparoscopy in colorectal surgery. Colorectal Dis. 2008 Oct;10(8):823-6. Epub 2008 Aug 5.
    • Bucher P , Pugin F , Morel P . Single port access laparoscopic right hemicolectomy. Int J Colorectal Dis. 2008 Oct;23(10):1013-6. Epub 2008 Jul
    View slide
  • Colectomy ?? HOW
    • Open Incision
    • Laparoscopic assisted
    • Laparoscopic Hand assisted
    • Total laparoscopic
    • SILS
    • Endoscopic submucosal excision
    • NOTES ??
    • Robotic ??
  • SILS Colectomy
  • SILS Colectomy
  • Case Experience: Dr Rieger
    • 7 cases from 28/11/2008 until 10/3/2009
  • 0/10 T2N0 Caecum 22 74 5 1/7 T2N1 Caecum 25 73 6 21 Benign (2 cm) Ascend 28 60 7 3/16 carcinoid Ileal Liver 2nd 24 69 4 26 Benign (5 cm) Caecum 23 76 3 0/12 T3N0 Splenic 21.5 63 2 0/10 T1N0 Caecum 23 83 1 Nodes Path Tumour BMI Age Patient
  • bacteraemia 11 115 5 Nil 4 80 6 Nil 5 88 7 Nil 6 75 4 Nil 4 90 3 Nil 4 75 2 Nil 4 100 1 Complication Stay Op Time Patient
  • SILS. Why Bother?
    • Cosmesis
    • Smaller single incision (2.5-4.5 cm)
    • Length of stay ???
    • Less risk hernia
    • Less risk tumour implantation
    • Stepping stone to NOTES
  • SILS: Indications
    • Benign neoplasm of colon
    • Carcinoma of colon (small)
    • Tumour size less than incision (2.5cm)
    • Thin patient
  • SILS: Ideal Indications
    • Right sided pathology proximal to the hepatic flexure
    • Left sided pathology distal to the mid-transverse colon and proximal to the sigmoid colon.
    • Small bowel pathology
  • SILS: Disadvantages
    • 2 operating ports
    • Instrument clash
    • Loss of tissue triangulation
    • Learning curve of flexible instrumentation
    • No 90 degree staplers for transection rectum
  • Ink Impalpable Lesions
  • Operative Considerations
    • Table
    • Anaesthesia
    • Trocars
    • Instruments
    • Anastomosis
    • Oncologic principles
  • SILS : Trocars
    • 1 X 5-12mm Bluntport Plus (Covidien,)
    • 2 X 5mm Dexide Threaded Trocar (Covidien)
  • SILS : Instruments
    • 30 degree 10 mm camera
    • Roticulator Endo Mini-Shears 5mm (Covidien)
    • Straight non-disposable atraumatic bowel grasper.
    • Alexis® Wound retractor; small. (Applied Medical)
    • Ligasure Advance (Covidien)
    • Vicryl endoloop (Ethicon)
    • DST GIA 80 – 3.8mm stapler and cartridge reload. (Covidien)
  • SILS: Anastomosis
  • SILS: Oncologic principles
  • Port site hernia
  • SILS: Post Operative Care
    • DVT prophylaxis
    • Opiate Analgesia (PCA or S/C)
    • Oral analgesia
    • Mobilise Day 1
    • Urine catheter out early (24 hours)
    • Early introduction of fluids (first 24 hours) and diet (second 24 hours if fluids tolerated)
    • IVT out once fluids tolerated
  • Conclusions
    • SILS colon resection is feasible.
    • Can be achieved with the same or reduced cost as standard laparoscopic resection.
    • Very specific indications