Sils

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Sils

  1. 1. Single Incision L APAROSCOPIC S URGERY (SILS) C OLORECTAL Resection Nick Rieger Assoc Professor University of Adelaide
  2. 2. SILS <ul><li>Urology </li></ul><ul><li>Renal transplant </li></ul><ul><li>Cholecystectomy </li></ul><ul><li>Gastric band surgery </li></ul><ul><li>Colectomy </li></ul>
  3. 3. SILS
  4. 4. SILS Colectomy and literature <ul><li>2 recorded cases </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul>
  5. 5. Colectomy ?? HOW <ul><li>Open Incision </li></ul><ul><li>Laparoscopic assisted </li></ul><ul><li>Laparoscopic Hand assisted </li></ul><ul><li>Total laparoscopic </li></ul><ul><li>SILS </li></ul><ul><li>Endoscopic submucosal excision </li></ul><ul><li>NOTES ?? </li></ul><ul><li>Robotic ?? </li></ul>
  6. 6. SILS Colectomy
  7. 7. SILS Colectomy
  8. 8. Case Experience: Dr Rieger <ul><li>7 cases from 28/11/2008 until 10/3/2009 </li></ul>
  9. 9. 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
  10. 10. 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
  11. 11. SILS. Why Bother? <ul><li>Cosmesis </li></ul><ul><li>Smaller single incision (2.5-4.5 cm) </li></ul><ul><li>Length of stay ??? </li></ul><ul><li>Less risk hernia </li></ul><ul><li>Less risk tumour implantation </li></ul><ul><li>Stepping stone to NOTES </li></ul>
  12. 12. SILS: Indications <ul><li>Benign neoplasm of colon </li></ul><ul><li>Carcinoma of colon (small) </li></ul><ul><li>Tumour size less than incision (2.5cm) </li></ul><ul><li>Thin patient </li></ul>
  13. 13. SILS: Ideal Indications <ul><li>Right sided pathology proximal to the hepatic flexure </li></ul><ul><li>Left sided pathology distal to the mid-transverse colon and proximal to the sigmoid colon. </li></ul><ul><li>Small bowel pathology </li></ul>
  14. 14. SILS: Disadvantages <ul><li>2 operating ports </li></ul><ul><li>Instrument clash </li></ul><ul><li>Loss of tissue triangulation </li></ul><ul><li>Learning curve of flexible instrumentation </li></ul><ul><li>No 90 degree staplers for transection rectum </li></ul>
  15. 15. Ink Impalpable Lesions
  16. 16. Operative Considerations <ul><li>Table </li></ul><ul><li>Anaesthesia </li></ul><ul><li>Trocars </li></ul><ul><li>Instruments </li></ul><ul><li>Anastomosis </li></ul><ul><li>Oncologic principles </li></ul>
  17. 17. SILS : Trocars <ul><li>1 X 5-12mm Bluntport Plus (Covidien,) </li></ul><ul><li>2 X 5mm Dexide Threaded Trocar (Covidien) </li></ul>
  18. 18. SILS : Instruments <ul><li>30 degree 10 mm camera </li></ul><ul><li>Roticulator Endo Mini-Shears 5mm (Covidien) </li></ul><ul><li>Straight non-disposable atraumatic bowel grasper. </li></ul><ul><li>Alexis® Wound retractor; small. (Applied Medical) </li></ul><ul><li>Ligasure Advance (Covidien) </li></ul><ul><li>Vicryl endoloop (Ethicon) </li></ul><ul><li>DST GIA 80 – 3.8mm stapler and cartridge reload. (Covidien) </li></ul>
  19. 19. SILS: Anastomosis
  20. 20. SILS: Oncologic principles
  21. 21. Port site hernia
  22. 22. SILS: Post Operative Care <ul><li>DVT prophylaxis </li></ul><ul><li>Opiate Analgesia (PCA or S/C) </li></ul><ul><li>Oral analgesia </li></ul><ul><li>Mobilise Day 1 </li></ul><ul><li>Urine catheter out early (24 hours) </li></ul><ul><li>Early introduction of fluids (first 24 hours) and diet (second 24 hours if fluids tolerated) </li></ul><ul><li>IVT out once fluids tolerated </li></ul>
  23. 23. Conclusions <ul><li>SILS colon resection is feasible. </li></ul><ul><li>Can be achieved with the same or reduced cost as standard laparoscopic resection. </li></ul><ul><li>Very specific indications </li></ul>

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