From
Dr. Jeffrey Ponsky
Overview of Single Incision Surgery Tool Box and Technique: Jeffrey Ponsky, M.D.
With Dr. Jeffrey Ponsky
Chapter 1 of 5 · Fundamentals
Cosmetic benefits
Introduction and cosmetic benefits of single-port surgery
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Many single-port surgery instruments were originally developed in preparation for NOTES (natural orifice transluminal endoscopic surgery).
Laparoscopic incisions are hardly noticeable a month after surgery.
Single-port surgery may make it difficult in the ER or clinical care to determine what procedures patients have had done due to lack of visible scars.
There is no question that single-port laparoscopy has caught on and is this year's hot topic.
The speaker is not sure that single-port surgery results in less pain than standard laparoscopy.
The speaker is not sure that single-port surgery results in less morbidity than standard laparoscopy.
The speaker does not think single-port surgery is less expensive than standard laparoscopy.
Improved cosmetics is the whole selling point of single-port surgery, and patients want this, particularly in certain subsets of the population.
Right transverse incisions from pyloromyotomy are not very nice incisions when seen years later in older patients.
The speaker trained in an era when laparoscopy was performed with room air under local anesthesia with one eye to the scope.
Laparoscopy became much easier after the advent of the video camera adapted to the scope.
Single-site laparoscopic surgery is currently very difficult with surgeons banging into one another.
With modified trocars, instruments, and laparoscopes, single-site surgery will become easier, and techniques may improve in the future.
Traditional trocars placed through a single site move independently of one another (advantage), but their big heads bump into one another (disadvantage).
The Advanced Surgical multi-port trocar (now distributed by Olympus) now has a quad port with four ports instead of three and is very easy to use and effective.
The Advanced Surgical multi-port trocar used to leak out of the valves because the gel leaked, but this has been improved.
The SurgiQuest trocar has no valve and uses rapid flow of CO2 so that there is no loss of pneumoperitoneum and no smudging of the lens regardless of what is inserted.
The SurgiQuest trocar makes a little bit of noise in the operating room, which some people may not like.
Applied Medical's gel port allows insertion of multiple trocars wherever desired, a concept taken from hand-assist laparoscopy.
Covidien has developed a single-piece expandable port that is squeezed down small, popped in, and then expands, with the number of openings being modified from three to four.
The Covidien expandable ports wiggle around a little bit, allowing them to function somewhat like multiple independent devices.
Paul Kerchelow and his wife Stephanie King developed a technique using multiple low-profile Apple trocars for single-site surgery.
The Apple trocar technique involves raising a flap above the fascia, inserting the first trocar, then raising more tissue and inserting additional trocars.
With single-site surgery using the Apple trocar technique, you never see your additional trocars coming in, requiring extra caution.
The anchor port is small, distended, popped in, then released to lock in place, and these trocars could be used in many situations beyond single-site surgery.
Optical entry, used for a long time in standard laparoscopy, can be used in single-site surgery.
The low-profile Apple trocars used by Paul Kerchelow and Stephanie King are very small and allow movement in multiple directions when placed.
Many surgeons are very good at using rigid instruments for single-port surgery, and some are even good at crossing their hands, which is sometimes necessary.
Rigid instruments sometimes bang into the scope and into each other during single-port surgery.
Novare's real hand instruments allow maneuvering but are not necessarily intuitive and don't always work as expected, though they represent a great advancement.
Covidien has rigid rotating graspers, scissors, and other instruments that articulate and are very good for dissecting and retracting.
Curved instruments provide a new concept where the curved portion goes out of the visual field and back in, potentially obviating the need to cross instruments, and can be rotated around.
If curved instruments are not the right length, they get in the way and are frustrating because they work well at a particular focal length but not at others.
Two-millimeter minilap instruments for needlescopic surgery can be used for single-port surgery to add another port without taking up much space.
The EndoGrab device, developed by an Israeli company for NOTES, does not require a trocar and can be clipped to tissue (such as the gallbladder) and then to the parietal peritoneum to provide retraction.
The EndoGrab device could be used for regular laparoscopy, single-site surgery, or NOTES in the future.
Rigid laparoscopes get in the way during single-port surgery, leading to use of flexible-tip laparoscopes by companies like Olympus and Stryker.
Todd Ponsky found he was banging into himself with standard scopes and ports, so he used a 50-centimeter, 5-millimeter bronchoscope with a horizontal cord orientation to get the scope out of the way.
The bronchoscope approach got the scope out of the way but had inferior optics compared to chip cameras.
The TransEnterix system uses curved instruments that operate outside the visual field, and when used in the laboratory, it feels like doing regular laparoscopic surgery.
The TransEnterix system has cost implications.
Innovation is expensive, leading some to advocate for reusable instruments.
Storz is developing a multi-port single-site port with curved instruments of various shapes as a reusable option.
When the speaker used some Storz curved instruments in the lab, sometimes they worked and sometimes it was unclear where to place them.
The speaker does not know whether single-port surgery is a game changer, noting that needlescopic surgery with two-millimeter instruments works pretty well.
Single-port surgery is being used today for almost every procedure imaginable.
The speaker's head of colorectal surgery now prefers single-port surgery for colectomies in adults because they make a single incision to remove the colon anyway.
An operative laparoscope can be used to remove the appendix, grasp it, and pull it out through the umbilicus very easily.
Robotics for single-port surgery may be very good in the future, but the speaker considers it another way to waste money currently.
NOTES initially led to single-port surgery, and single-port surgery may eventually enable NOTES procedures after techniques improve.
Danny Scott's magnetic instruments may be dropped through a single port and controlled from outside to perform sophisticated operations including camera insertion.
Single-port surgery provides a great cosmetic result and does add that benefit without question.