Single incision laparoscopic surgery (SILS): Challenges at population level based on an initial experience

Six patients (1 male; 5 female; age range 28 to 42 years) underwent SILS over a twelve month period from 2010 to 2011. The main end points were time taken to complete the SILS cholecystectomy and conversion to 4-port laparoscopic cholecystectomy. In 5 (83%), surgery was completed using SILS and the time taken ranged from 100mins to 180mins (median 120mins). Subjective assessment revealed that SILS was a more difficult procedure compared with laparoscopic cholecystectomy, chiefly due to lack of familiarity of the team and limitation in mobility due to the lack of triangulation that is otherwise available with 4-port laparoscopic cholecystectomy.


Results
Six patients (1 male; 5 female; age range 28 to 42 years) underwent SILS over a twelve month period from 2010 to 2011. The main end points were time taken to complete the SILS cholecystectomy and conversion to 4-port laparoscopic cholecystectomy. In 5 (83%), surgery was completed using SILS and the time taken ranged from 100mins to 180mins (median 120mins).
Subjective assessment revealed that SILS was a more difficult procedure compared with laparoscopic cholecystectomy, chiefly due to lack of familiarity of the team and limitation in mobility due to the lack of triangulation that is otherwise available with 4-port laparoscopic cholecystectomy.

Introduction
Single incision laparoscopic surgery is the current topic of debate in the world of minimal access surgery.
Although it offers better cosmesis, the practical benefit of the procedure to the masses cannot be evaluated until it can be reproduced with safety and success in basic centres where a routine four port cholecystectomy can be performed. The operating surgeon must also be skilled to overcome the difference in approach to the surgery in SILS. The aim of our study was to evaluate the feasibility of performing SILS in a Government Hospital with facilities that are available for basic laparoscopy.

Materials and method
The study was conducted in Wenlock Hospital which is open cholecystectomy. In three cases, an additional port was used toward the end of the procedure, to facilitate dissection of gall bladder from the liver bed, due to need for retraction of a floppy gall bladder. In four cases, a silicon port with multiple openings (one 10mm, two 5mm port) was used, while in two patients a 5mm port was introduced through a separate fascial defect just next to the 10mm optical port, a modification which comprised a single skin incision which incorporated multiple fascial defects. Additionally, we used a fundal traction suture in one patient, while in the remainder, Hartman's pouch alone was retracted with forceps. The cystic duct was divided between double ligatures knotted extracorporeal, as a 5mm clip applicator is not available in the hospital. In the first three cases we used conventional straight instruments where as in subsequent cases we used rigid bent instruments. The gall bladder was elevated from its bed using a monopolar hook and additional ports were placed in three cases for better traction on the gall bladder, to facilitate quicker dissection. The side port also allowed for placement of a 14 Fr Ryles tube as a drain if required.
The gall bladder was delivered via the umbilical incision in all cases. All patients recovered without complication and continue to remain on regular follow up.

Results
The demography of the patients is shown in table 1. to undertake only precise required dissection that was required to perform the procedure. Blood loss was negligible in all cases. Following surgery, all patients were ambulant the same evening and were discharged within twenty four hours of surgery. Sutures were removed on the eighth post-operative day, during which, we observed that there were no wound infections. The surgeon found using single incision multiple port technique easier to perform than using single access port, especially since conventional instruments were used.

SILS is the newest entrant in minimal access surgery.
Although gynecologists have performed procedures like tubal ligation using a single incision laparoscopic technique for long, the new found enthusiasm among general surgeons is recent [1,2]. Like every change in surgery it too is bound to be met with criticism. Navarre In our experience, we determined that single incision   [7]. There are several reviews to show that SILS can be performed safely and in a manner that is equivalent to conventional laparoscopic cholecystectomy but the reviews fail to sufficiently discuss the cost of the procedure to patients and the health system [8][9][10][11]. The acid test is if a technique can be cost effective to the general public with the same safety profile as the current available modality.
Cosmesis may not be a criterion in people at large when SILS is compared to traditional laparoscopic surgery. In comparative procedures, when the pain factor, recovery time and time to work are similar, it will be cost, which we have not addressed in our study, and availability, that ultimately determines the choice of procedure.
However, in practical terms, single incision surgery is yet to be made available at similar cost as conventional laparoscopy. It is the author's perception that even though SILS is an attractive option in selected cases, it cannot be used at community level where a four port cholecystectomy is gold standard.