Abstract
I was influenced by the early adult surgeons who had test-driven the process, and, at the time, the idea of natural orifice translumenal endoscopic surgery (NOTES® [American Society for Gastrointestinal Endoscopy (Oak Brook, IL) and Society of American Gastrointestinal and Endoscopic Surgeons (Los Angeles, CA)]) was still fairly radical. The idea of having no scar was great, but the idea of making a hole in the stomach to take out the gallbladder or the appendix, or a hole in the rectum or vagina, seemed extreme, especially in kids. So I was attracted to the idea of no scar, but without the extra risk of the NOTES approach.
That was what originally intrigued me. Dr. Todd Ponsky was quick to notice the single-site approach, and a group of people went to Cleveland to discuss it. He showed a few of the first cases he had done.
I was intrigued at that being a small step forward for minimal access surgery, not the difference between open and laparoscopic, but a small move in a direction with less trauma, perhaps, and certainly better cosmesis.
When I first started, appendectomy and cholecystectomy were the procedures we focused on. I found that the single-site appendectomy was a straightforward operation with a manageable learning curve. And, in Birmingham, we were able to quickly train the fellows in the single-site appendectomy because there was such a high volume. Actually, it became common to also start helping our [postgraduate year] PGY-2s and 3s do single-site appendectomies.
For cholecystectomies, I have had a tendency to use a 2.4-mm disposable grasper through a stab incision in the right upper quadrant to help lift the gallbladder up. Although, we now accomplish everything through a single site without that little stab. So, I think early in the experience the idea of not being too rigid about it and adding trocars if you need to, or extra help if you need to, was an important thing to do to get people very comfortable with it, especially the operating room nurses, as well as the residents and fellows.
So it is key to have exposure to the high-volume procedures early on, which then can spur thinking about doing other things such as adnexal pathology, and eventually splenectomies. I think a very good application for single-site is ileocecectomies or limited bowel resections, and then moving to the harder things like fundoplications and total colectomies.
Yes, but I think that is a very important point, Dan. I think that the reason that many of the pediatric surgeons who tried it early on and then abandoned single-site was because there is a real steep learning curve to learning how to open the umbilicus and close the umbilicus so that you do not have an unsightly belly button and do not get outside of the umbilical ring.
So even in the setting of, say, a splenectomy, the incision is still entirely within the umbilical folds, but that incision is bigger than what you would normally perhaps have in the umbilicus for a multiport splenectomy, and you can get the spleen out more easily through single-site incision.
I do think there is a learning curve, and I modified the approach at the umbilicus many, many times before settling in on something that I thought really was reproducible with a very low unsightly umbilicus or erythema or swollen incision that gave ample space to get your instruments in and work.
I feel very strongly it should be very vertical. I personally, at every case, take a marking pen, and I make the dots just within the umbilical range that is the extent of the incision. So, I never let the fellows or residents make that decision.
I then make the vertical skin incision and carry it down and through the linea alba. As you know, you can take the linea alba incision further than the skin incision if you need to.
Well, first of all, closing the fascia is important. I know some surgeons who have a tendency to want to run a suture from below and above and tie it in the middle, but that leaves a big knot right under the thin umbilical skin that you close. I believe that leads to suture irritation, suture abscesses, and potentially a suture poking up through the skin closure.
So I very intentionally close the linea alba vertically starting at one end with a knot that is well underneath the fat, not right underneath the umbilical skin, and run it down and close it ending, again, underneath the subcutaneous fat, so that the suture knot is not directly beneath the closed umbilical skin.
Regarding the umbilical skin closure, I have had good results with using a three-stitch buried dermal stitch. I place a dermal stitch at the bottom, the top, and one in the middle. With the middle stitch, I usually catch dermis, a little bit of fascia, and then dermis again to sort of tuck the skin down right there.
Yes, usually three little stitches.
Other than the technical aspects we just discussed, I would say the variation and progression of different approaches for the trocar. Early on, say around the time of my first single-site cholecystectomy, I remember I was using a product that really forces you to make the incision a certain length, like 2.5 cm, for that trocar to fit.
So one of the “aha” moments was when I discovered the trocars that have the plastic lining where you can make any size skin and fascial incision, and it still fits.
Another thing is to use a smaller instrument; if 3-mm instruments or 4-mm instruments will work instead of 5-mm, that gives you a lot more space to work with.
Certainly, the long 30° or 45° telescope is very helpful, so that the hand is out of the way, as well as adding the 90° adapter angle on the light cord—so you are not bumping your hands. These are just technical things that were important as we progressed through the sequence of learning about this.
One final thing I would say is the idea that you get comfortable working cross-handed, so if you are doing a cholecystectomy and you want to retract the fundus of the gallbladder to the patient's right, you are doing that with your right hand, and your left hand is coming to the medial aspect of the critical window and doing the dissection.
That is right. So you actually have to get better with your left hand as a dissector, I think.
No. But one of the reasons I have really stuck with the single-site approach is I do believe that that is a real possibility of a breakthrough in the future as we can use the robotic platforms that are being developed for single-site.
I certainly can envision one day almost a flexible-type scope going through the umbilicus that has the light, the insufflation, and the multiple working channels, and it is robotically driven around to do what you need to do. And it will fit very nicely through the umbilicus.
Doing single-site fundoplications is difficult. The techniques of sewing and tying, even if you are able to sew left-handed, are different and cumbersome and not like doing it in a normal laparoscopic approach. For the more challenging operations, to be able to do that robotically, single-site, would be very beneficial.
The other thing that is exciting is to realize that this can be applied even in neonates. I remember the first single-site pyloromyotomy that I did with one of our fellows in Birmingham. It was really neat to see that that was doable. And the first operation took just 20 minutes—just like a regular laparoscopic pyloromyotomy would take. Those little stab wounds are so small, I am not sure there is a major cosmetic benefit to single-site pyloromyotomy. However, it is pushing the envelope to see what you can do simply and effectively and develop new technology.
Another point I wanted to make is that once you start doing the single-site approach, you suddenly realize you do not need as many trocars, even if you need to add a few. So you find that your gallbladder cholecystectomy can be done very easily with two or three instead of four trocar sites. Your splenectomy, if you are having a hard time doing it single-site, you can very easily do it by adding one or maybe two other trocars, instead of four or five. So you really do cut down on your number of access trocars and sites.
I think at some level it is probably the appendectomy to get started because that is an operation that most of our fellows and residents come in feeling like they know how to do. There is a new learning curve when you suddenly start doing it single-site, and so doing a high volume of appendectomies allows you to then be confident in moving on to other approaches, other cases.
Yes. It is really great for adnexal pathology as well because even if it is something that you feel like you need to mobilize up and out, oftentimes that will reach and come out through the umbilicus if you need to do something external.
Exactly. So the notion of starting with putting in an umbilical multiuse port of some sort at the start of your operation and taking a look and deciding how many other trocars you may or may not need, I think is a benefit.
Also, there have been some articles published recently that I am pleased to see showing that cost can be less with a single-site approach. In our experience at Birmingham, when we did a cost analysis by substituting one umbilical trocar and taking away a number of other trocars, as well as things like an Endocatch bag for appendicitis or a cholecystectomy because the appendix or gallbladder can be pulled up through the enlarged umbilical incision, it showed a cost savings as well.
No, I have used both stab incisions through the umbilical fascial plate, but I have also used the plastic port for that as well.
Well, I did not know how it would work in a 6-week-old, but it does. I have done a handful with the regular single-site port that we use.
That would be a good idea. I think there are enough differences in terms of how your hands work and understanding this idea of cross-handedness. I think it would be great to have a model that would help trainees do this. And, in fact, I am putting on courses now here in Buffalo, and we have a single-site trainer that has been used that is not very sophisticated, but it allows fellows to learn in the lab about the angles, the crossing of the hands, how the telescope works, and how you can raise one of the handles up and one of the handles down to keep them out of the way.
We also have our third-year residents doing training in an inanimate trainer before coming to the operating room.
To be honest, if we can move to the single-site transumbilical robotic model that may provide us what we need at a comfort level and lower-risk-factor level than the traditional NOTES approach.
That is my impression from other people that are doing a lot of this. Our Chinese and Vietnamese colleagues are doing very advanced single-site surgery at present—choledochal cysts, biliary atresia, and such.
Right. I think in the long run, if we can do something simple like pyloric stenosis and progress to choledochal cysts and duodenal atresias, that will be key in this field. We have to make sure it is safe, and we have to make sure that we can do the operation in a time frame that is very reasonable. At the end of the day to have no scar is a big deal.
You know, when we first started doing laparoscopic surgery, you would have the parents who would pull up their shirt to show you their open cholecystectomy scar. I now have parents pulling up their shirt to show me their laparoscopic cholecystectomy scar, which most of the time is not a big deal. Yet sometimes those scars get a little hypertrophic and turn dark and be fairly worrisome to the patient and family.
I know your group has done a prospective trial looking at this, and at least for certain procedures you found that the single-site approach resulted in superior cosmesis.
In summary, the idea is the operation is probably a little harder to do single-site, but in my mind it does provide no-scar surgery, which has value that we just do not have a great way of measuring.
I think if you are a surgeon out there in practice and you wanted to start with something like appendectomies and you understand the technical aspects that we have discussed, it is probably an operation that experienced laparoscopic surgeons could tackle. And again, there is nothing wrong with starting off by putting the umbilical trocar in and, say, one other trocar until you get better at that. Then switch to all transumbilical.
For the less experienced surgeons, or residents/fellows in a teaching environment, some mentorship is helpful. When I moved to Buffalo, the faculty were not doing single-site. I think it was important that I took the time to scrub with them on a number of appendectomies and gallbladders to get their comfort level up, so they felt comfortable themselves, and ultimately teaching residents and fellows.
I agree.
In a freestanding children's hospital, you do not have an adult surgeon down the hall to go watch, so I did not have the adult surgeon who was doing single-site to be a mentor and inspiration. It really came from an American College of Surgeons meeting and then Dr. Todd Ponsky putting together the group in Cleveland to brainstorm and discuss it.
I left Cleveland very committed to trying it, and within a day or two of getting back to Birmingham, I started. I thought it would also help us develop some new instrumentation that might be helpful with laparoscopy. I have enjoyed working with the companies on trocars and instruments and that sort of thing as well. Then, the fellows in Alabama all got very excited about it and really enjoyed it, and ultimately pushed it.
It is also important to recognize Dr. Keith Georgeson. He was a convert as well. Another individual who deserves mention is Dr. Oliver Muensterer, who has had tremendous vigor and eagerness to continue doing something new—the two of us, in some ways, competed with each other and helped push it along as well.