Routine Utilization of Single-Incision Pediatric Endosurgery (SIPES): A 5-Year Institutional Experience

Introduction

Single-incision pediatric endosurgery (SIPES) is an acronym used to describe operations during which multiple instruments are used through a single access site. This technology has not been universally adopted. In a recent publication by Rich et al., ¹ experience and attitudes of 115 International Pediatric Endosurgery Group members toward SIPES was assessed via survey. Of these respondents, practicing in 32 countries, 71% had performed SIPES and 83% of those performing SIPES were operating at academic/university centers. In addition to this recent publication, Saldana and Targarona ² have prepared a comprehensive SIPES literature review. In their article, they identified documentation of operations on 4212 children and concluded that, although prospective analysis is only present for SIPES appendectomy, good outcomes have generally been described.

When preparing this study, we hypothesized that SIPES is comparable to traditional multiport operations with regard to operative times, complication rates, and conversion rates. We tested our hypothesis through retrospective review and present the largest single-institutional SIPES experience to date. In total, 1322 operations were performed over a 5-year period. We describe the technique used, outline median operative times with comparison with those recently published for multiport operations, and report our complication rates.

Patients and Methods

Since 2009, we have prospectively maintained a SIPES database. Data collected include demographics, procedure type, operative time, estimated blood loss, instance of added ports or open conversion, complications, and time to follow-up. With Institutional Review Board approval (protocol number FWA00005960), a retrospective review of these prospectively collected data was conducted. Statistical analysis was performed using JMP Pro version 10.0.2 software (SAS Institute Inc., Cary, NC).

Initially, access to the abdominal cavity was obtained via multiple fascial stabs through a single skin incision at the umbilicus. Efforts to distance the instruments and avoid clash often required elevation of generous flaps, increasing risk for hematoma, seroma, abscess, and pain. Over time, usage of prefabricated access devices gained favor in our practice. At present time, we use Olympus TriPort™ and QuadPort™ (Advanced Surgical Concepts, Bray, Ireland) devices (Olympus America, Center Valley, PA). These devices eliminate the need for lateral flaps, reducing the instance of previously stated complications. In addition, they possess built-in wound protectors that eliminate the need for specimen retrieval bags.

Access device insertion was consistent with all procedures. A midline incision was created within the confines of the umbilicus. Under direct visualization, the fascia was incised vertically up to a length of 2 cm, and the access port was deployed. Appendectomy was performed using an Olympus TriPort. The appendiceal artery was divided with hook electrocautery, and the appendix was stapled intracorporeally. During cholecystectomy, the abdomen was accessed as previously described. Although we have used a transabdominal suture to suspend the gallbladder in the past, more recently a miniaturized grasping device has been placed directly through the abdominal wall in the right upper quadrant to provide cephalad traction on the gallbladder. The operation was then performed in the standard fashion, with hook electrocautery used in place of clips when dividing the cystic artery.

Once appendectomy and cholecystectomy have been mastered, more complex operations may be performed with minor modifications. Splenectomy, in our opinion, is best performed using a QuadPort. The reduced number of instrument channels and the smaller maximum channel size of the TriPort, in our experience, mandate placement of additional ports. Gel ports that allow placement of trocars with larger channel diameters, permitting passage of larger specimen retrieval bags that are often needed, have also been used with success. During other operations, such as Nissen fundoplication with gastrostomy and colectomy with diverting or end ostomy, one may use future stoma sites for placement of additional instruments. When these stomas are large, one can place a second prefabricated multichannel device to allow passage of multiple instruments. We have included these in our SIPES database because the only scar not related to a stoma is the one positioned at the umbilicus.

Results

Over a 5-year period, 1322 SIPES operations were performed. Appendectomy was the most common procedure (n=875), followed by cholecystectomy (n=210). These procedures accounted for 82.1% of all operations. Other SIPES operations performed are listed in Table 1.

Median operative times for more commonly performed SIPES procedures compare favorably with those of multiport cases, as indicated in Table 1.^3–6 Additional ports were infrequently needed. At least one extra port was required during 2.2% and 4.3% of appendectomies and cholecystectomies, respectively. Instance of conversion to open was less than 0.5% for these procedures. During other operations, additional ports were positioned at planned stoma sites. This is evident in Table 1, where intestinal and miscellaneous cases (e.g., Nissen fundoplication with gastrostomy) required additional ports. Splenectomy required placement of additional ports during 44.2% of cases, a rate higher than previously published.^2,7 We have demonstrated that the number of channels in a SIPES port is a major contributing factor to this increased need for added ports. ⁸ Our open conversion rate of 4.7% is greater than the 1.3% conversion rate reported by Walsh et al. ⁹ for multiport laparoscopic splenectomy. The significance of this is uncertain, given that we performed only two open conversions in a relatively small population. One conversion was a result of bleeding, and one was to facilitate dissection at the superior pole of a large specimen.

Sixty-six percent of patients were seen postoperatively in the clinic, with a median follow-up duration of 26 days. Fifty-three complications occurred in these 871 patients, giving an overall postoperative complication rate of approximately 6%. Surgical-site infections occurred in 4.8% of patients, with 4 of 42 requiring drainage after failed antibiotic therapy. Umbilical hernias were identified in 3 patients, and postoperative bleeding occurred once. Of the 34 patients undergoing inguinal hernia repair, 4 (11.8%) experienced recurrence.

Discussion

Some have questioned the benefits of SIPES, focusing on increased cost secondary to a perceived need for specialized equipment. Multiple investigators have reported similar cost after comparing multiport and single-site operations,^10–12 and it has been demonstrated that standard laparoscopic equipment can be used.^13–15 In addition to increased cost, some believe that postoperative pain is greater following SIPES operations. Although this might have been true in the past, when generous lateral flaps were needed to allow for spacing of individual ports within a single skin incision, the development of prefabricated multichannel devices permits limitation of the fascial incision to ≤2 cm in length. Postoperative pain has been noted to be similar to that experienced following multiport operations.^12,16 Physical attributes have also been offered as a caution, ¹⁷ but body habitus was not found to increase risk in operations such as SIPES appendectomy. ¹⁸ Proponents of SIPES offer shortened length of stay ¹⁹ and superior scar assessment at early follow-up ²⁰ as benefits of the technology when compared with traditional multiport procedures.

To our knowledge, this series represents the largest institutional SIPES experience published to date. Through incorporation into routine practice and maintenance of a prospective database, we are able to compare operative duration for single-site laparoscopic procedures with published multiport times. We have demonstrated, as outlined in Table 1, that procedure times for common SIPES operations compare favorably with those for multiport cases. We also report low rates of both conversion and postoperative complication. Our morbidity rate of 6.1% is on par with rates reported in the literature for multiport operations. In a meta-analysis performed by Aziz et al., ²¹ a 1.5% surgical-site infection rate for appendectomy was reported. This is lower than our reported cumulative rate of 4.8%. In our series, most of these infections were treated with antibiotics alone. When a similar analysis was performed by Scott et al. ²² for multiport cholecystectomy, an overall morbidity rate of 4% was identified. A higher morbidity rate of 11% was reported by Rescorla et al. ²³ when reviewing their multiport spleen experience in 231 children.

This study has weaknesses that warrant acknowledgement. Although data were prospectively collected, this analysis was retrospective and is subject to biases inherent to the design type. In addition to retrospective design, cost analysis and objective measurement of patient/family satisfaction with cosmesis were not performed. Lastly, our follow-up rate was only 66%. Because we are the primary referral center for children and the only institution in our region routinely performing single-access laparoscopic operations, however, it is our belief that most of the postoperative complications were captured.

Single-site laparoscopy has been more thoroughly evaluated in the adult literature, but increasing numbers of studies support its implementation in the pediatric population. We have embraced the technology and incorporated it into routine practice. The SIPES technique offers potential for improved cosmesis without increased risk. Although finances were not evaluated in this study, use of standard laparoscopic instruments and elimination of specimen retrieval bags have lowered procedural costs. As more surgeons use single-site laparoscopy and commercial competition increases, we anticipate continued cost reduction.

In conclusion, SIPES can be safely incorporated into routine surgical practice. Application of the technology is varied, and cosmetic outcome is subjectively excellent. Operative times, rates of conversion, and incidence of complications are similar to those of more traditional multiport operations. Through continued investigation and refinement, we anticipate increased accessibility of the technique as operative costs continue to decline.