OBES SURG DOI 10.1007/s11695-015-1709-4
Single Incision Laparoscopic Sleeve Gastrectomy: a Review Anastasios Stefanopoulos 1 & Konstantinos P. Economopoulos 1,2 & Vasileios Kalles 1,3
# Springer Science+Business Media New York 2015
Abstract We aim to summarize the existing evidence on the use of single incision sleeve gastrectomy (SILSG) for morbid obesity. A thorough literature search for studies reporting outcomes of SILSG was performed. Data on patient demographics, operative details, and surgical outcomes were analyzed. Sixteen studies incorporating 945 patients (90.6 % women) with a mean age of 37 years were included in the analysis. A commercially available single-port device was used in 89.7 % of the cases. The mean operative time was 64.7 min, with two cases (0.2 %) of intraoperative and 27 cases (2.8 %) of postoperative complications. There were no perioperative deaths reported, while the mean postoperative hospital stay was 2.5 days. SILSG is a feasible and safe approach, with low complication and mortality rates in carefully selected patients.
Keywords Single incision . SILS . Sleeve gastrectomy . Single port . Bariatric surgery
* Anastasios Stefanopoulos [email protected]
Introduction Since its introduction as a standalone operation, laparoscopic sleeve gastrectomy (LSG) has gained popularity among surgeons, and a great number of obese patients have been offered this modern technique [1, 2]. Still, the need for better cosmetic outcome, as expressed by both patients and surgeons, has led to the introduction of novel minimally invasive techniques in bariatric surgery. Single incision laparoscopic sleeve gastrectomy (SILSG) has been proposed as an alternative approach to the conventional multiport laparoscopic procedure. In SILSG, the procedure is performed through a single skin incision, potentially optimizing the aesthetic outcome. Adjustable gastric banding, Roux-en-Y gastric bypass, and sleeve gastrectomy have all been performed using the single incision technique, and this approach has been validated by several initial studies, which have demonstrated its feasibility and safety [3–9]. As the number of reports on the outcomes of SILSG has been growing, our study aims to summarize the existing evidence on the surgical outcomes of the use of SILSG in the treatment of morbid obesity.
Konstantinos P. Economopoulos [email protected]
Search Strategy and Article Selection
Vasileios Kalles [email protected]
The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines. A thorough search of the English literature (last search: December 20, 2014) in PubMed and Google Scholar bibliographic databases was performed. The investigators, working separately, executed the search using the following keywords in all possible
Society of Junior Doctors, Athens, Greece
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
2nd Department of Surgery, Naval and Veterans Hospital of Athens, Athens, Greece
combinations: Bsingle incision,^ Bsingle site,^ Bsingle port,^ Blaparoscopic,^ Bsleeve gastrectomy.^ The existing literature was searched to identify eligible articles that fulfill the following criteria: (i) the reported operation was single incision laparoscopic sleeve gastrectomy in human adults, (ii) patient demographics as well as intraoperative and postoperative complications were clearly stated, and (iii) a minimum of 10 patients were included in the study. Any discrepancies between the investigators about the inclusion or exclusion of studies were discussed in order to find articles that best matched the criteria. Moreover, the reference lists of all included articles were assessed for additional potentially eligible studies.
through a single skin incision were used in 8.1 % of the cases. Further details on the port device used for access to the peritoneal cavity are summarized in Table 3. In order to perform the sleeve gastrectomy, most surgeons (82.7 %) used a 36 F bougie as a guide at the lesser curvature. For completion of the procedure, an additional port was used in 33 % of the cases. For the total of 945 cases included in the present analysis, the mean operative time was 64.7 min (range 30–205 min), including 18 patients who underwent a simultaneous cholecystectomy and one patient who underwent simultaneous hiatal hernia repair.
Conversion to standard laparoscopy was needed in nine cases (0.9 %) (Table 4). There was no reported case of conversion to open surgery. Intraoperative complications were encountered in 0.2 % of the patients who underwent SILSG (2 cases), namely one case of staple line failure and one case of liver laceration.
For each eligible study, data were extracted relative to demographics (number of patients, mean age, sex, comorbidities, preoperative BMI), operative technical details (incision site, incision length, device/ports used, bougie size, operative time), intraoperative and postoperative complications, and length of hospital stay.
Conversions and Intraoperative Complications
Early and Late Postoperative Complications and Length of Hospital Stay
Statistical Analysis All data extracted from eligible studies were tabulated, and the outcomes were analyzed cumulatively. A descriptive approach was attempted in all parameters. No further statistical analysis was performed.
Results Article Selection and Patient Demographics From the retrieved studies, 70 were assessed for eligibility, and 16 were finally included in the present analysis (Fig. 1). The selected articles contained data on 945 patients (88 men, 857 women) with a mean age of 37.01 years (range 18– 66 years) and a mean preoperative BMI of 38.7 kg/m2 (Table 1). Hyperlipidemia was the most prevalent comorbidity among the patients included in the present study (30.9 %). Other significant comorbidities were diabetes mellitus (30.5 %), joint pain/osteoarthritis (21.2 %), fatty liver disease (19.7 %), hypertension (18.7 %), and gastroesophageal reflux disease (8.8 %) (Table 2).
Early complications were encountered in 2.8 % of the patients, with the most common complication being intra-abdominal hemorrhage (8 cases, 0.8 %). Other significant complications included five cases of wound seroma (0.5 %) and five cases of postoperative leakage from the staple line (0.5 %). Less common complications were wound infection in three cases, portal vein thrombosis in two cases, and intestinal perforation, pulmonary embolus, nausea, and hand paresthesia in one case each. Seven patients (0.7 %) required reoperation for the management of the above complications (Table 5). Conservative treatment was selected in four cases of hemoperitoneum, while a case with postoperative staple line leakage was managed by placement of a covered stent. No perioperative death was recorded among all patients included in the present study. The mean length of hospital stay was 2.5 days (range 1– 12 days) (including the cases reported by Mittermair et al., who reports that the prolonged length of stay was due to the Austrian insurance and clearing system). Late postoperative complications were reported in 12 patients (1.2 %) and included five cases of trocar hernia, two cases of gastroesophageal reflux disease, and five cases of cholecystitis or cholelithiasis. Weight Loss Outcomes
Operative Technical Details An incision in the navel was performed in the majority of the cases (98.5 %) reported, measuring 2.5–4 cm in length. A commercially available single-port device was used in 89.7 % of the patients, whereas conventional rigid ports
Mean excess weight loss (EWL) ratio data at 6 months postoperatively were available for 665/945 patients. For these patients, the mean EWL ratio was 71.6 %. Moreover, the mean EWL ratio at 12 months postoperatively was 78.9 % and was available for 52.5 % of the patients.
Fig. 1 Study flow chart
Discussion Numerous studies have demonstrated that bariatric surgery is more efficient in the management of morbid obesity than conservative medical treatment [10–14]. Bariatric surgery has evolved over the last years from open surgery to tiny incisions, and, currently, one of the most popular operations in bariatric surgery is laparoscopic sleeve gastrectomy (LSG). Although LSG has been reported to have very satisfying outcomes, the quest for operations with superior cosmesis and improved pain results has led to the introduction of novel, less invasive techniques in the field of bariatric surgery [6, 15]. Minimally invasive surgery techniques such as single incision laparoscopy and surgery through natural orifices (NOTES) have generated considerable interest. These techniques have decreased the number of ports and incisions
needed to perform an operation, resulting in a better cosmetic outcome. As the technological advances have allowed the development of new surgical instruments and devices, much of the recent research has focused on single incision laparoscopic surgery, while, on the other hand, as far as NOTES is concerned, the available evidence is more scarce [16, 17]. The first reported single incision laparoscopic procedure was a hysterectomy performed in 1991 by Pelosi et al. . Since then, the single incision laparoscopic approach has been used in many other procedures such as splenectomy , cholecystectomy , colectomy , appendectomy , and nephrectomy . Some of these procedures (i.e., cholecystectomy, appendectomy) have been increasingly popular over the last few years, while other, more complicated procedures are still offered in selected centers of high expertise in advanced laparoscopic surgery. The first SILSG was reported
OBES SURG Table 1
General characteristics of the studies included in the analysis
Patients’ no Mean age Min age Max age Male Female Pre Op BMI kg/m2
Saber et al.  Taller et al.  Delgado et al.  Farias et al. 
2010 2010 2012 2012
Surg Obes Relat Dis. Surg Obes Relat Dis. Surg Endosc Obes Surg
14 10 20 237
Alevizos et al.  Mittermair et al.  Nguyen et al.  Park et al.  Pourcher et al.  Ghinagow et al. Maluenda et al.  Fernandez et al.  Lakdawala et al. Gomberawalla et al. Galvani et al. Noel et al.
2012 2012 2012 2012 2012 2013 2014 2014 2014 2014 2014 2014
Minim Invasive Ther Allied Technol. 12 Am Surg. 40 J Laparoendosc Adv Surg Tech A. 26 Surg Obes Relat Dis. 25 Surg Obes Relat Dis. 60 Transl GI Cancer 51 Eur Surg 20 Obes Surg 74 Obes Surg 300 Obes Surg 36 Surg Laparosc Endosc Percutan Tech. 10 J Visc Surg 10
44.2 37.6 46 36
NR 26 20 NR
NR 52 66 NR
7 0 5 16
7 10 15 221
53.8 41.2 40.1 33.5
44.5 37 44 49 40.1 31 34.5* 34.2 35.5 43.3 37 41.5
28 19 NR 22 21 18 21 NR NR NR 24 27
60 62 NR 63 63 50 57 NR NR NR 50 52
3 0 9 2 6 13 0 2 23 2 0 0
9 40 17 23 54 38 20 72 277 34 10 10
41.8 40.8 42 47.1 46.5 36.3 35.1 34 39.9 43.06 50 40.11
NR not reported *Median age
by Saber et al. in 2008 , and, since then, the amount of reports on SILSG in the international medical literature has been growing fast. Many investigators have documented their experience with SILSG until now, and, as our study outlined, more than 900 cases have been reported so far. LSG is routinely offered to patients 18–65 years old, mainly due to the irreversible character of the operation, as well as the operative risk for older people with various comorbidities. Indeed, in our cohort of patients treated with SILSG, the age range was 18–66 years. Furthermore, as per our results, SILSG is mainly offered to female patients. The most likely explanation for this is that, as women are usually of shorter height, smaller BMI, have a smaller liver size, and usually have less abdominal and visceral fat, they might represent better candidates for the single incision technique , and bias the surgeon’s choice toward to this more technically challenging approach. Table 2 Most frequently reported comorbidities of the patients included in the present study
Percent Hyperlipidemia Diabetes mellitus Joint pain/osteoarthritis Fatty liver Hypertension Gastroesophageal reflux Hyperuricemia Sleep apnea
30.9 30.5 21.2 19.7 18.7 8.8 8 7.3
Significant exclusion criteria for patients have been reported by nearly all authors [3, 4, 6, 15, 16, 25–30] (Table 6). The most common were as follows: (a) BMI greater than 50 kg/ m2, (b) height greater than 180 cm, (c) previous operations in the abdomen, and (d) substance or drug abuse. Ghinagow et al.  also excluded patients with severe GERD and Barrett’s disease. It is evident that the selection criteria for patients are very important for the safety of the procedure [3, 4, 6, 15, 16, 25, 30]. Also, the exclusion of patients with body height greater than 180 cm has been reported to facilitate easier access to the fundus, and thus minimize the risk of leaving any part of the fundus in the gastric sleeve . Adhesions from previous operations and extensive adipose Table 3
Devices used for access to the peritoneal cavity
Patients, n (%)
Gelport/Gelpoint (Applied Medical, Rancho Santa Margarita, CA, USA) Covidien SILS™ Port (Covidien Surgical, Mansfield, MA, USA) LESS Triport/Quadport (Olympus Medical, Nagano, Japan) Multiple conventional ports OCTO™ Port (DalimSurgnet, Seoul, Korea) SSL™ (Ethicon Endo-Surgery, Cincinnati, OH, USA) SPIDER® (Transenterix Surgical, Inc, Durham, NC, USA) Not reported
366 (38.7 %) 321 (34 %) 111 (11.7 %) 77 (8.1 %) 30 (3.2 %) 20 (2.1 %) 10 (1.1 %) 10 (1.1 %)
OBES SURG Table 4 Reasons for conversion from SILS to multiport laparoscopy during SILSG
Reasons for conversion
Number of cases
Delgado et al.  Farias et al.  Alevizos et al.  Alevizos et al.  Nguyen et al. 
Technical difficulty due to insufficient endostapler length Insufficient working space (previous abdominoplasty) Intraoperative bleeding Technical difficulty Lowvisualization
1 1 1 1 1
Park et al.  Maluenda et al.  Fernandez et al.  Fernandez et al. 
Transection of the nasogastric tube Poor vision of the esophagogastric junction Intraoperative bleeding from short gastric vessels Difficulty in liver retraction
1 1 1 1
tissue are possible contraindications for SILSG, due to the fact that the safety of the procedure has not been sufficiently established in this patient group [3, 6, 15]. During the first years of use of the single incision approach in LSG, the procedure suffered from significant technical and anatomic difficulties [5, 36]. For example, in super obese or very tall patients (height greater than 180 cm), the angle of His and the left crus are very distant from the entry point. Although longer instruments have been used for these patients, it nevertheless remains technically very demanding for bariatric surgeons to complete a SILSG in this patient group [3, 6, 26–29]. The loss of triangulation in the confined space of the abdominal cavity is another important factor for the increased difficulty of performing SILSG. The insertion of multiple instruments in such a close proximity through a common point of entry produces significant movement limitation and conflict between the instruments. In order to surpass these limitations, the surgeon has to implement different arrangements for the instrument positioning (e.g., coaxial or crossing arrangement ). The flexible and curved instruments, as well as multichannel single ports with interchangeable 5-, 10-, and 12-mm instrument access that have been introduced lately, offer increased maneuverability and have significantly reduced the challenge posed in the adoption of SILSG, by restoring the lost triangulation and offering a better vision to the working space [6, 29]. The navel, which has traditionally been a point of entry in laparoscopic surgery, was also the most frequently used point
Table 5 Early postoperative complications of SILSG that required operative management
of SILSG port placement. The majority of authors suggested that the umbilicus was the best entry point, providing a better cosmetic outcome, with lower risk of damaging the internal viscera [3, 4, 6, 15, 16, 25–30]. A wide range of devices have been used in SILSG, and there still are reports of using conventional rigid laparoscopy ports inserted one next to another, in order to minimize the incision scar, and thus perform single incision (but not single-port) laparoscopic sleeve gastrectomy. Notably, in approximately one third of the cases, the surgeon used an extra trocar in order to complete the operation, and this essentially means that, in order to simulate the standard laparoscopic surgery, and/or retract the liver, and/or dissect the short gastric vessels up to the right crus, some triangulation is often needed. Nevertheless, although the single incision is modified with the insertion of an extra 3–5-mm assistance trocar, an overall cosmetic advantage is still achieved , and it is generally considered acceptable as long as it is essential for the safety of the patient . Liver retraction is one of the most challenging parts of this operation. An adequate retraction of the liver is very important since it minimizes the risk of complications [3, 4, 6, 12, 15, 16, 25, 30]. During the procedure, the liver can be retracted with many ways such as sutures, devices inserted through an assistant trocar, percutaneous liver retractors, or by the traction of the stomach itself [4, 6, 16, 26, 29, 37]. Saber et al.  suggested that, if patients follow a low-calorie diet 2 to 4 weeks prior to surgery, the retraction of the liver is easier. Robotassisted single-site surgery, which is being developed as part
Farias et al.  Farias et al.  Farias et al.  Delgado et al.  Delgado et al.  Mittermair et al.  Mittermair et al. 
Leakage Hemoperitoneum Intestinalperforation Hemoperitoneum Hemoperitoneum Leakage Hemoperitoneum
Multiport laparoscopic exploration, antral leak Multiport laparoscopic exploration, no findings Multiport laparoscopic exploration Reoperation Reoperation Exploratory laparotomy, oversew SILS exploration, clip placement
OBES SURG Table 6
Reported inclusion and exclusion criteria for SILSG
Saber et al. 
Taller et al.  Delgado et al.  Farias et al. 
Mittermair et al. 
National Institute of Health criteria for obesity surgery BMI=35–55 kg/m2 ● BMI=30–46 kg/m2 ● Xiphoumbilical distance 40 or >35 kg/m2associated with severe comorbidities ● Age=18–65years; ● BMI≥32 kg/m2 with obesity-related comorbidities or ≥37 kg/m2 irrespective of comorbidities.
Alevizos et al. 
Ghinagow et al. 
Lakdawala et al. 
● Obese conditions ● Medically indicated LSG ● BMI ≤40 kg/m2 ● Xiphoumbilical distance 60 kg/m2 ● Previous major abdominal surgery with excessive scarring ● Patients with large ventral hernias ● Patients with large hiatal hernia/GERD ● Patients with history of substance abuse ● Weight>300 lbs and BMI>50 kg/m2 ● History of open upper GI surgery NR NR
of robotic surgery platforms, might be able to overcome the ergonomic drawbacks of SILS techniques, including liver retraction and loss of triangulation; however, the current experience with this platforms is limited [38, 39], and the costeffectiveness of such systems will need to be analyzed. As per our results, the mean time for completion of a SILSG procedure should typically be around 70 min, in the hands of experienced laparoscopic surgeons. The operative time of SILSG is comparable to that of standard LSG, as the latter is shown in several existing studies [11, 40, 41]. However, in studies comparing SILSG with standard laparoscopy, the operative time was observed to be greater for the SILS approach (summarized by Moreno-Sanz et al. ). Furthermore, the surgeon’s learning curve is prolonged in SILSG and is mainly established with the skill of triangulation, as it is technically very difficult and demanding to handle laparoscopic instruments in such a confined and restricted space [15, 16, 26]. SILSG, as shown by the results of our study, is a safe procedure, with the intraoperative and postoperative complication rate being below 1 and 3 %, respectively. Hemoperitoneum was the most common cause of postoperative morbidity; however, none of the patients required laparotomy, and it was successfully treated in all cases. Furthermore, no mortality has been recorded yet following a SILS sleeve gastrectomy. The complication rate after SILSG, as depicted in our study, is comparable to that reported in standard LSG in high-volume centers (Table 7). Excess weight loss (EWL) is, unquestionably, one of the principal outcomes of bariatric surgery. Although the primary purpose of the present study was to assess the feasibility and safety of SILSG, we also sought to cumulatively report the outcomes as far as weight loss is concerned. In our study, the mean EWL at 12 months was 78.9 %, which is comparable to the expected EWL results after LSG, which range between 50 and 70 % in most published series . This is reasonable, as there are no alterations in the technique itself, nor reasons that would rationalize a better weight loss outcome for SILSG over standard LSG, and this has also been reported in previous studies comparing SILSG and standard LSG patients . Still, as the SILSG technique is relatively new, its efficacy has to be studied in the long term as far as EWL is concerned. Furthermore, specific patient characteristics, such as younger age or female sex, they may play a role in the final EWL after Table 7
LSG or SILSG, but this remains to be elucidated in future studies . A few studies went on to compare SILSG with conventional LSG in terms of feasibility and outcome [4, 6, 15, 32]. Even though the results of the postoperative pain are not well documented in both procedures, it is generally accepted that SILSG is superior to a standard LSG . On the other hand, in terms of cost, the disposable equipment used in SILSG can lead to significant increase of the operative cost, and therefore, it has been noted that SILSG overall can be more costly than standard LSG [4, 16]. Finally, regarding the postoperative cosmetic outcome, which is considered as the main advantage of the single incision technique, according to the existing evidence from studies comparing SILSG with standard LSG, patients undergoing SILSG were reported to be significantly more satisfied from the aesthetic outcome of their surgical scar [24, 32], especially when it was buried in the umbilicus. The cosmetic advantage has been considered even more pertinent in case of patients with a tendency for a hypertrophic scar or a keloid formation . Still, the advantage of superior cosmesis is very difficult to quantify, and the dependence on subjective criteria does not allow for objective conclusions. The present study sought to summarize all the existing data on SILS sleeve gastrectomy, and cumulatively report its safety and surgical outcomes. However, certain limitations apply regarding the results depicted herein: First of all, about half of the presented results come from the two bigger series published so far by Farias et al.  and Lakdawala et al. , and thus, our report might bear significant weight bias from the results of these studies. Second, as already mentioned earlier, the majority of authors have selected patients for SILSG very carefully. Thus, the results of SILSG cannot be extrapolated to all morbidly obese patients, but only to patients with similar characteristics to the patient samples included in the present analysis. In addition, most of the studies included in our analysis report outcomes of SILSG in the hands of experienced laparoscopic surgeons, in high volume centers. As someone would probably expect, complication rates and other parameters such as operative time or hospital stay may vary among less experienced surgeons who plan to or have already implemented SILSG in their practice. Finally, the results regarding the postoperative follow-up of the patients are very heterogeneous and sometimes poorly reported, obviating the need for better record of the follow-up of these patients.
Reported outcomes of standard laparoscopic sleeve gastrectomy from selected studies
Number of patients
Operative time (range) (min)
Postoperative complications rate
Fuks et al.  Lee et al.  Han et al.  Cottam et al. 
2008 2007 2005 2006
Surgery Surg Endosc Obes Surg Surg Endosc
135 216 130 126
103 (30–550) 66 (45–180) 70 (45–100) 143 (90–210)
5.1 % 7.4 % 3.5 % 13 %
Conclusions In summary, SILSG is a feasible and safe alternative approach for performing sleeve gastrectomy, with low complication rates and no reported mortality. However, clinical criteria that qualify patients for SILSG should be precisely defined. The future of this procedure will be determined from the outcome of its use in randomized controlled studies or prospective cohort studies with longer follow-up periods. Continuous improvement on minimally invasive techniques along with careful patient selection may be the key to decrease the complication rate and the associated morbidity of SILSG. Acknowledgments None. Conflict of Interest The authors declare that they have no conflict of interest. Informed Consent Does not apply.
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This article does not contain any studies with human participants or animals performed by any of the authors.