SALS or Single Access Laparoscopic surgery is a surgical procedure that is designed to reduce the stress and complications associated with traditional multiple incision laparoscopic surgery. Single Access Laparoscopic surgery involves only a single incision on the body through which instruments are inserted to perform a wide range of procedures (Rosati et al., 2010). Over the years there have been significant improvements in the procedure and today it is known by different names such as Single Port Access, Single Incision Laparoscopic Surgery and Laparoendoscopic Single Site Surgery (Katkhouda, 2010). Single access or single incision surgery was first mentioned in the year 1969 in medical literature on gynaecology and the technique was first used in surgery in 1992 by Pelosi et al. as a procedure for laparoscopic appendectomy in young children (Wheeless, 1969); (Pelosi & Pelosi, 1992). Since its introduction, the technique has evolved considerably but the debate surrounding its suitability or efficacy over the conventional laparoscopic surgery is yet to be settled. As more and more benefits of single access surgery are realized it became even more imperative that the debate on its suitability over the traditional methods is brought to a logical conclusion at the earliest.
Single access/incision laparoscopic surgery timeline:
As already mentioned, the technique was first reported in the field of gynaecology in the year 1969 in a study carried out by C. Wheeless. The author described the use of a procedure called single incision laparoscopic surgery tubal ligation on a cohort of 4000 patients with amazing postoperative success. The technique involved the creation of a small 5 millimetre port through which instruments were inserted to perform the procedure. After the procedure the recovery rate of the patients were relatively fast and there has hardly any scar visible from outside (Wheeless, 1969). Following the success of the technique it became a standard procedure for carrying out sterilization in females in the United States. The first use of the single incision laparoscopic surgical procedure in general surgery was reported in 1992 when researchers used to technique to carry out appendectomy in children. Another group of researchers in the same year used the technique to perform appendectomy in children where the umbilicus was used as a port of entry to extract the appendix (D'Alessio, Piro, Tadini & Beretta, 2002). This study was carried out on a cohort of 166 patients out of which only a fraction underwent full open surgery while around nineteen percent required more surgical trocars to complete the procedure. The results showed good promise for the single incision laparoscopic surgical procedure because the patients who received it were out of the hospital in just 35 minutes and returned to normal routine in a week compared to 10 days for those who required additional surgical trocars (D'Alessio, Piro, Tadini & Beretta, 2002). Today, single incision laparoscopic surgery has become routine for procedures such as cholecystectomy but it was used for the first time in 1997 in the UK (Navarra, Pozza, Occhionorelli, Carcoforo & Donini, 1997). The surgeons created two small 10 millimeter ports connected by a layer of skin and the gallbladder was removed through the opening created by incising the connecting skin layer. This was followed by another procedure in 1999 when surgeons created the port through the umbilicus (PISKUN & RAJPAL, 1999).
Advantages of Single Access Surgery: Hype of reality?
In the present time a very wide range of operations are performed using single incision laparoscopic surgery as shown in table 1 below but there isn't much credible scientific data to suggest if the procedure is better that the general laparoscopic techniques. As a matter of fact, apart from the more superficial cosmetic advantages single incision laparoscopic surgery does not seem to offer anything extra when compared with traditional laparoscopic procedures. Some researchers have even expressed reservations that single incision laparoscopic surgery can be more painful compared to the traditional procedures because of the large port size on the abdominal wall and that there is greater risk of hernia in the follow up months (Romanelli, Roshek, Lynn & Earle, 2009). A review of the literature indicates that there are not many randomized trials that compared single incision laparoscopic surgery with traditional laparoscopic procedures. Marks et al (2010) carried out a randomized study where they compared 4-port Laparoscopic Cholecystectomy to single incision laparoscopic surgery and found that the latter is slightly safer and had few cosmetic advantages. Similarly, Tsimoyiannis et al. (2010) carried out a randomized trial where they compared the pain scores of single trans-umbilical incision laparoscopic cholecystectomy and classic laparoscopic cholecystectomy and observed that the former left virtually no scar on the skin surface and the post-operative pain was substantially less in the first 24 hours after the operation. Another randomized trial carried out in 2008 stated that single incision laparoscopic surgery had longer operating periods compared to traditional laparoscopic procedures and there was no difference between the two regarding medical costs or pain thresholds. The study further stated that the chance of herniation was actually greater with single incision laparoscopic surgery. However it needs to be noted that there has been significant improvements in the instruments used in single incision laparoscopic surgery since the time of that study (Navarra, La Malfa, Bartolotta & Currò, 2008). A study carried out by Marks et al (2010) stated that single incision laparoscopic surgery had few cosmetic advantages over traditional laparoscopic methods but when the cohort members were asked what procedure would they prefer if they had to be operated again, 68% indicated that they will opt for single incision laparoscopic surgery. This is an encouraging inclination towards the single incision procedure but the researchers mentioned that the cohort comprised of just 20 individuals and for the results to be statistically significant, the size should have been at least 200. One more study tried to understand if the single incision procedure can lead to appreciable saving of operation theatre costs or any other medical costs to the patients when compared to traditional laparoscopic procedures and learned that there is absolutely no difference between the two procedures when seen in context of these aspects (Love, Durham, Meara, Mays & Bower, 2010).
Single access/incision laparoscopic surgery is still emerging and has been embraced by many hospitals across the globe for its good results. A wide range of studies carried out until now even though does not show any major benefits of the procedure, it must be understood that the technique has great promise. Given the rate of progress seen in the field of medical technology today, it is only a matter of time before single access/incision laparoscopic surgery becomes the preferred procedure for every operating surgeon. At this stage what is really necessary are more in-depth and lengthy randomized trials that follow the progress of the patients after single access/incision laparoscopic surgery for longer periods. Insights gained from such studies will help researchers to determine if the single access procedures are really the interventions of the future that will not leave any scars on the body (Richstone & Kavoussi, 2009).
At this stage the only advantages of single access/incision laparoscopic surgery over traditional laparoscopic procedures is purely cosmetic. The single access technique does not offer any other advantages over the traditional methods in terms of cost-saving or reduced post-operational pain. As already mentioned earlier, more exhaustive randomized trials may help in determining additional advantages of single access methods over the traditional methods in future but as of now the best way to gain maximum benefit from the procedure is through selection of the most suitable patients for the same. None the less, it is encouraging to know that interest on single access/incision laparoscopic surgery is growing every day and many centres around the globe are offering courses on the subject. A major reason behind this could be the broader realization among the medical fraternity that single access/incision laparoscopic surgery could be just the right technique to progress to from the traditional multiple incision laparoscopic surgery. Just like any other forms of laparoscopic surgery, single access/incision laparoscopic surgery can lead to serious complications if performed without sufficient training and at this stage the modalities of the most appropriate or specific training in this regard still needs to be worked out. Single access/incision laparoscopic surgery is definitely not a hype but what is prudent at this stage is to give maximum effort to shorten the learning curve.
D'Alessio, A., Piro, E., Tadini, B., & Beretta, F. (2002). One-Trocar Transumbilical Laparoscopic-Assisted Appendectomy in Children: Our Experience. European Journal Of Pediatric Surgery ,12(1), 24-27. http://dx.doi.org/10.1055/s-2002-25096
Katkhouda, N. (2010). Advanced laparoscopic surgery . Berlin: Springer.
Love, K., Durham, C., Meara, M., Mays, A., & Bower, C. (2010). Single-incision laparoscopic cholecystectomy: a cost comparison. Surgical Endoscopy , 25(5), 1553-1558. http://dx.doi.org/10.1007/s00464-010-1433-z
Navarra, G., La Malfa, G., Bartolotta, G., & Currò, G. (2008). The invisible cholecystectomy: a different way. Surgical Endoscopy , 22(9), 2103-2103. http://dx.doi.org/10.1007/s00464-008-9960-6
Navarra, G., Pozza, E., Occhionorelli, S., Carcoforo, P., & Donini, I. (1997). One-wound laparoscopic cholecystectomy. British Journal Of Surgery , 84(5), 695-695. http://dx.doi.org/10.1002/bjs.1800840536
Pelosi, M., & Pelosi, M. (1992). Laparoscopic appendectomy using a single umbilical puncture (minilaparoscopy). J Reprod Med. , 37(7), 588-94.
Phillips, M., Marks, J., Roberts, K., Tacchino, R., Onders, R., & DeNoto, G. et al. (2011). Intermediate results of a prospective randomized controlled trial of traditional four-port laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy. Surgical Endoscopy , 26(5), 1296-1303. http://dx.doi.org/10.1007/s00464-011-2028-z
PISKUN, G., & RAJPAL, S. (1999). Transumbilical Laparoscopic Cholecystectomy Utilizes No Incisions Outside the Umbilicus. Journal Of Laparoendoscopic & Advanced Surgical Techniques ,9(4), 361-364. http://dx.doi.org/10.1089/lap.1999.9.361
Richstone, L., & Kavoussi, L. (2009). Editorial Comment. Urology, 74(4), 812. http://dx.doi.org/10.1016/j.urology.2009.04.029
Romanelli, J., Roshek, T., Lynn, D., & Earle, D. (2009). Single-port laparoscopic cholecystectomy: initial experience. Surgical Endoscopy, 24(6), 1374-1379. http://dx.doi.org/10.1007/s00464-009-0781-z
Rosati, M., Bosev, D., Thiella, R., Capobianco, F., Bracale, U., & Azioni, G. (2010). Single port laparoscopically assisted hysterectomy with the TriPort system. A case report and review of the literature. Ann Ital Chir. , 81(3), 221-5. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21090561
Tsimoyiannis, E., Tsimogiannis, K., Pappas-Gogos, G., Farantos, C., Benetatos, N., Mavridou, P., & Manataki, A. (2010). Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surgical Endoscopy , 24(8), 1842-1848. http://dx.doi.org/10.1007/s00464-010-0887-3
Wheeless, C. (1969). A rapid, inexpensive and effective method of surgical sterilization by laparoscopy. J Reprod Med. , 3(5):65–9.(5), 65–9.