Commentary Regarding Dimitrokallis et al.: Single-Incision Laparoscopic Sleeve Gastrectomy: Yes or No?

Obesity is an increasingly important healthcare issue, and recent advances in bariatric surgery have improved the safety and efficacy of weight loss operations, leading to an increase in the number of bariatric surgeries performed each year. An 18-year report from the International Bariatric Surgery Registry, published in The American Journal of Surgery in 2006, concluded that bariatric surgery patients are now older and heavier, length of stay is shorter, and the laparoscopic approach is most commonly used. ¹

Initially performed as the first stage of a two-step biliopancreatic diversion with duodenal switch or Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy is now a stand-alone procedure. Currently, more surgeons are becoming acquainted with the single-port technique, which advertises improved cosmetic and postoperative outcomes.

In their article, the authors of “Single Incision Laparoscopic Sleeve Gastrectomy: Review and a Critical Appraisal” ² reviewed 19 existing studies, which included 1679 patients, to summarize the available data on single-incision laparoscopic sleeve gastrectomy in regard to the procedure's feasibility, technicality, safety profile, and outcomes. The mean patient age was 39 years, and the mean preoperative body mass index was about 42 kg/m². In 60.5% of cases, a left upper quadrant incision was used, with the addition of what is described as a “multiport system” in 97.6% of the cases. The mean operative time was 94.6 minutes. The conclusion the authors reach in their review is that the single-incision approach is safe and feasible, with a reported tendency for less postoperative analgesia and better wound satisfaction.

Proponents of the traditional laparoscopic sleeve gastrectomy might argue that additional studies, including randomized controlled trials with longer follow-up, would assist in determining if there are true benefits of single-incision laparoscopic sleeve gastrectomy. While operative time, hospital length of stay, and postoperative analgesia outcomes are comparable between multiport and single-incision approaches, the question regarding cosmetic outcome remains: how significantly does cosmetic appearance impact patients, and at what risk does this place them for development of incisional hernias? Current data do not characterize long-term outcomes; therefore, the ultimate impact of the larger incision needed for single-incision approach may not yet be apparent. Additionally, how do single-site operations fare against conventional laparoscopy in terms of cost-effectiveness if highly customized instruments are required to avoid “clashing” in the single-port site? Studies from the domain of laparoscopic cholecystectomy may suggest analogous results.

In 2013, Marks et al. published a prospective, randomized, multicenter single-blinded trial of traditional multiport laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy. ³ Two hundred patients were randomized to single-incision versus multiport laparoscopic cholecystectomy. At 1-year follow-up, total hernia rates were 1.2% in multiport laparoscopic cholecystectomy and 8.4% in single-incision laparoscopic cholecystectomy. Nevertheless, cosmesis scoring and patient preference favored single-incision laparoscopic cholecystectomy at 12 months.

Also in 2013, Arezzo et al. performed a systematic review and meta-analysis from randomized controlled trials through December 2011 comparing single-incision laparoscopic cholecystectomy versus multi-incision laparoscopic cholecystectomy. A total of 996 patients were included. There was no mortality. The mean operating time was 47.2 minutes for multi-incision laparoscopic cholecystectomy and 58.1 minutes for single-incision laparoscopic cholecystectomy. Cosmetic outcomes were better in the single-incision group, and postoperative pain was mildly reduced in the single-incision group versus the multi-incision group.

Both reviews support cosmetic benefits, but the review by Marks et al. shows a sevenfold increase in the incidence of incisional hernia for single-incision laparoscopic cholecystectomy versus multiport. Over time, the incidence will likely be even higher in a solely bariatric population. The question still remains, at what increased incidence of incisional hernia rate is the purported cosmetic and analgesic benefit negated by the need to perform additional operative intervention for incisional hernias? At this time, further long-term outcomes need to be accrued before a definitive conclusion to the risks and benefits can be reached. This article does support the feasibility of single-incision sleeve gastrectomy, but it does not provide any evidence for superiority over the multiport approach.