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Single Site Umbilical Laparoscopic Surgery (SSULS)

Single Site Umbilical Laparoscopic Surgery (SSULS). George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO. Open Surgery. Laparoscopic Surgery Less discomfort Reduced hospitalization Faster return to routine activities Cosmesis. SSULS

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Single Site Umbilical Laparoscopic Surgery (SSULS)

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  1. Single Site Umbilical Laparoscopic Surgery(SSULS) George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO

  2. Open Surgery • Laparoscopic Surgery • Less discomfort • Reduced hospitalization • Faster return to routine activities • Cosmesis

  3. SSULS • Cosmesis, but less risky c/w NOTES • NOTES • Cosmesis, but risks Open Surgery Laparoscopic Surgery

  4. Acronyms • SILS(TM) - Single Incision Laparoscopic Surgery • SPA (TM) - Single Port Access • SSULS - Single Site Umbilical Laparoscopic Surgery (CMH) • SIPES – Single Incision Pediatric Endosurgery (CH-A) All use umbilicus as single site.

  5. Umbilical Portals (U.S.) Tri - Port (Olympus) SILS Port (Covidien)

  6. Umbilical Portals (U.S.)

  7. Instruments are in-line and parallel to each other What Else Is Different? Ideally, instruments/telescope should be different lengths

  8. What Else Is Different? Assistant/camera holder stands next to or behind the surgeon

  9. What Else Is Different? Harder to operate

  10. Appendectomy Cholecystectomy Splenectomy Ileocecectomy Pyloromyotomy (CH-A) Fundoplication (CH-A) Others What Operations Are Being Done Using This SSULS Approach?

  11. SSULS Appendectomy

  12. SSULS Appendectomy

  13. SSULS Appendectomy Please use this link if you experience problems viewing the video above.

  14. Postoperative Appearance

  15. SSULS Cholecystectomy Please use this link if you experience problems viewing the video above.

  16. SSULS Splenectomy Please use this link if you experience problems viewing the video above.

  17. SSULS Splenectomy

  18. SSULS Ileocecectomy • Intracorporeal dissection/mobilization • Extracorporeal resection/anastomosis

  19. Single-Incision Laparoscopic Surgery in Children: Initial Single-Center Experience 142 SSULS procedures: • Appendectomy (103) • Cholecystectomy (24) • Splenectomy (2) • Cholecystectomy/splenectomy (1) • Ileocecectomy (8) J PediatrSurg 46:904-907, 2011

  20. Results J PediatrSurg 46:904-907, 2011

  21. SIPESCH - ALABAMA Appendectomy - 130 Pyloromyotomy - 32 Cholecystectomy - 32 Fundoplication - 6 Pull-through - 4 204 Pediatr Surg Int 2010

  22. Conclusion These series show that single site surgery is feasible, and appears to be associated with acceptable operating times

  23. Disadvantages • Compromised degrees of freedom and triangulation • Visualization limited by inline field of view and motion of instruments • More difficult for the surgeon

  24. Questions • Do the benefits outweigh the risks? • What are the benefits? • Is there improved cosmesis? • Prospective evidence needed • We are enrolling in 3 SSULS PRT’s • Appendectomy, Cholecystectomy, Splenectomy • Validated scar assessment tool

  25. Prospective Randomized Trials Power10 Outcome AnalysisVariable SSULS Appendectomy 360 (360) Infection SSULS Cholecystectomy 60 (60) Operative time SSULS Splenectomy 30 ( 7) Operative time

  26. Other Variables Being Collected • Pain • Cost (hospital charges) • Cosmesis (Validated Scar Assessment Tool)

  27. Aug 2009 – Nov 2010 • Non-perforated appendicitis • 360 pts – 180 each arm • No difference in patient characteristics at time of operation

  28. SSULS vs 3-Port Lap.Appendectomy Table 1- Patient Characteristics at Operation Ann Surg 254: 586-590, 2011

  29. SSULS vs 3-Port Lap.Appendectomy Table 2 - Operative Data Ann Surg 254: 586-590, 2011

  30. SSULS vs 3-Port Lap.Appendectomy Table 3 - Outcome Data *Hospital charges minus the stapler charges. Ann Surg 254: 586-590, 2011

  31. SSULS vs 3-Port Lap.Appendectomy Table 4 - Convalescence After Hospital Discharge Ann Surg 254: 586-590, 2011

  32. Summary • No difference in infectious complications: wound infx, intra-abd abscess • mean operating time for SSULS – 5 min ? clinical relevance (but leads to hospital charges) • doses analgesics (p = .04) for SSULS • Cosmetic advantage for SSULS – We’ll see. Ann Surg 254:586-590, 2011

  33. Does Body Habitus Make a Difference? IPEG 2012

  34. Outcomes for 3-Port Based on Body Habitus IPEG 2012

  35. Outcomes for Single Incision Based on Body Habitus IPEG 2012

  36. Outcome Comparison for Normal Weight IPEG 2012

  37. Outcome Comparison for Overweight IPEG 2012

  38. Outcome Comparison for Obese IPEG 2012

  39. Conclusions • Obesity increases operating time, postoperative length of stay, doses of narcotics, and hospital charges c/w single site lap appendectomy • Obesity has no impact in 3 port appendectomy • Clinically significant increase in wound infection in overweight and obese patient undergoing single site lap appendectomy • We do not recommend single site laparoscopic appendectomy in obese patients IPEG 2012

  40. SSULS vs 4-Port Lap. Cholecystectomy Table 1 – Patient Characteristics at Operation APSA 2012

  41. SSULS vs 4-Port Lap. Cholecystectomy Table 2 – Operative Data Table 3 – Outcome Data APSA 2012

  42. SSULS vs 4-Port Lap. Cholecystectomy Table 4 – Convalescence After Discharge APSA 2012

  43. QUESTIONS www.cmhclinicaltrials.comwww.cmhmis.com

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