JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 2, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2013.0250
Single-Incision Laparoscopic Sleeve Gastrectomy Versus Multiport Laparoscopic Sleeve Gastrectomy: Analysis of 80 Cases in a Single Center Robert Sucher, MD,* Thomas Resch, MD,* Elisabeth Mohr, MD, Alexander Perathoner, MD, Matthias Biebl, MD, Johann Pratschke, MD, and Reinhard Mittermair, MD
Background: Through efficacy and improved safety, multiport laparoscopic sleeve gastrectomy (LAPS-G) has emerged as an important and broadly available treatment option for people with severe and complex obesity. Because a single-incision laparoscopic sleeve gastrectomy (SILS-G) would be less invasive, we applied this novel surgical technique for a selected number of patients enrolled into our minimally invasive bariatric program. Subjects and Methods: A retrospective review of prospectively collected data from 80 morbidly obese patients who qualified for SILS-G or LAPS-G was performed from January 2011 to May 2012. Results: SILS-G and LAPS-G were performed in 40 patients, respectively. All patients were female. Mean age was 41 (range, 19–73) years (SILS-G, 37 [19–62] years; LAPS-G, 43 [24–73] years; P = not significant). Preoperative body mass index was 40.8 (35.1–45.0) kg/m2 in the SILS-G group and 43.8 (35.0–47.8) kg/m2 in the LAPS-G group (P = not significant). Total operative time was significantly lower in the SILS-G group (85 – 21 minutes) compared with the LAPS-G group (97 – 26 minutes) (P < .05). Median percentage excess weight loss was comparable in both groups (SILS-G, 57.2%; LAPS-G, 53.7%) at 6.6 months after surgery. Mean hospital stay was 5 days (SILS-G, 5 [4–24] days; LAPS-G, 6 [4–14] days; P = not significant). Complication rates were low in both groups: leakage, 2.5% in SILS-G and 0% in LAPS-G; bleeding, 2.5% in SILSG and 2.5% in LAPS-G; and trocar-site hernia, 0% in both groups. Patients operated on with single-incision laparoscopy had a significantly better cosmetic outcome as assessed by a scar satisfaction assessment questionnaire (P < .01). Conclusions: SILS-G is a feasible and safe operative procedure that leads to a significant reduction of total operative time compared with a multiport access procedure. Further potential benefits associated with singleincision laparoscopic surgery remain to be investigated objectively.
emerged. The basic motto behind this evolution was deliver more through less.2 Accordingly, bariatric surgery has evolved from the era of large incisions used in open surgery and multiple small incisions in laparoscopy to minimally invasive single-incision techniques. To date there is no perfect bariatric procedure. Patient selections are based on local availability, the individual balance of risks and benefits, and ultimately patient choice. Established procedures include the Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding operation, which account for more than 95% of all bariatric surgical procedures worldwide.3 Purely
n the last decades, bariatric surgery has emerged as an important and broadly available treatment option for severely obese patients in whom conservative treatment strategies have proven ineffective. Although prevalently renowned as an additional tool to life-style changes and potential drug therapies, bariatric surgery has inevitably provided us with the most efficient weight loss solution for obese individuals.1 As a result of this popularity in gastrointestinal surgical interventions, a great interest in the development of novel surgical devices and less invasive procedures has
Department of Visceral, Transplant, and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria. *The first two authors contributed equally to this work.
malabsorbtive procedures, such as biliopancreatic diversion and its variant the duodenal switch, play minor roles as primary procedures but still remain an alternative option for patients who may not respond adequately to less radical procedures. Although laparoscopic sleeve gastrectomy is relatively new in the field of bariatric surgery, it has become the popular preferred method among bariatric surgeons because of its technical simplicity compared with the Roux-en-Y gastric bypass operation and other malabsorbtive procedures.4 Likewise, it is well accepted among patients because gastrointestinal continuity is maintained and no foreign device needs to be implanted into the human body, which bears the risk of infection and migration.5 Usually laparoscopic sleeve gastrectomy requires four or five skin incisions positioned across the upper abdomen to place laparoscopic trocars for surgery.6–8 Since its first inception into gynecology,9 single-incision laparoscopic surgery (SILS) has been a dynamic field experiencing giant leaps in technique and instrumental design. This has recently facilitated its expansion from general surgical procedures like appendectomy, cholecystectomy, and splenectomy to more complex bariatric operations like sleeve gastrectomies and implantation of adjustable gastric bandings.10–14 More recently Saber et al.15 and Huang et al.16 strikingly reported the first single-access Roux-en-Y gastric bypass. Single-incision laparoscopy literally consists of one single umbilical incision as the only entry for all surgical instruments to obtain an excellent cosmetic outcome with the wound finally completely hidden in the umbilicus.17 Further key benefits of this novel surgical technique may comprise a significant reduction of postoperative pain and a shorter hospital stays while having complications rates comparable to those of conventionally accepted procedures. At Innsbruck Medical University (Innsbruck, Austria) we have been performing both the conventional multiport and the single-incision sleeve gastrectomy from 2008. This study was designed to evaluate the feasibility and identify possible limitations of single-incision laparoscopic sleeve gastrectomy (SILS-G) compared with the conventional multiport variant. Subjects and Methods Study design
Prospectively collected data from 80 female patients who underwent sleeve gastrectomy from January 2011 to May 2012 were analyzed. Multiport laparoscopic sleeve gastrectomy (LAPS-G) and SILS-G were performed in 40 patients each. The study was approved by the institutional review board, and informed consent pertaining to both procedures was obtained from all patients. The same surgical team consisting of one senior surgeon and one surgical resident performed all operations. Prior surgery anthropometric parameters were evaluated, and all patients were subjected to a routine gastroduodenoscopy, esophageal manometry, and 24-hour pH monitoring. No liquid diet was supplied to our patients preoperatively. Exclusion criteria from this study were as follows: (1) previous bariatric surgery or abdominal surgery with excessive scarring; (2) age less than 18 years or more than 75 years; and (3) patients with a body mass index (BMI) of less than 35 kg/m2 or more than 50 kg/m2.
SUCHER ET AL.
Prior to surgery patients received 2.2 g of amoxicillin for infectious prophylaxis. Intra- and postoperative pain therapy consisted of piritramid (0.1 mg/kg i.v.) given immediately after surgery and paracetamol (1 g i.v.) as well as metamizol (1000 mg i.v.) administered every 8 hours after surgery. During the entire hospitalization period, prophylaxis for deep vein thrombosis comprised daily injections of low-molecularweight heparin (starting 12 hours prior to surgery) and administration of deep vein thrombosis stockings. Postoperative outcomes in terms of percentage excess weight loss (%EWL), resolution of comorbidities, and complication rates were compared at a follow-up of 6.6 months. The %EWL was defined as ([operative weight – follow-up weight]/operative excess weight) · 100.18 At 3 months postsurgery patients were interviewed and assessed using our patient scar satisfaction assessment questionnaire. Regarding scar satisfaction, patients could give five possible responses: excellent = 1, good = 2, fair = 3, acceptable = 4, and poor = 5. A lower score indicated a favorable outcome. Statistical analysis
Results are expressed as mean (range) values. Statistical analysis was performed using the Mann–Whitney U test to compare the median value of two groups (Prism version 5.0 software; GraphPad Software, La Jolla, CA). A P value of < .05 was considered to be statistically significant. Surgical technique of SILS-G
Patients were placed on the operation table in the medium lithotomy position, allowing the surgeon to stand between the split legs. The assistant was positioned at the left side of the patient. With the patient under general anesthesia, a 4-cm vertical transumbilical incision was made, and the abdomen was entered via an open technique. Either a GelPOINT (Applied Medical, Rancho Santa Margarita, CA) advanced access platform (n = 10) with one 12-mm and three 5-mm GelPOINT trocars or the OCTO-Port (AFS Medical, Austria) (n = 30) was used. Pneumoperitoneum was achieved with carbon dioxide insufflation, maintaining a continuous intraabdominal pressure of 14 mm Hg. For SILS we used a 5-mm, 30 optic (Stryker Endoscopy, Montreux, Switzerland) and 5-mm Ligasure (Valleylab; Covidien, Mansfield, MA) as well as 5-mm flexible graspers (Karl Storz, Tuttlingen, Germany). In the steep reverse Trendelenburg position the sleeve gastrectomy was started 6 cm proximal to the pylorus by dissection of the gastrocolic as well as the gastrosplenic ligament from the greater curvature of the stomach. By lifting the stomach the left lobe of the liver was automatically pulled up, and posterior adhesions to the pancreas were carefully separated, while care was taken to avoid injury to the spleen. Finally, the left crus of the diaphragm and the angle of His were completely dissected free to avoid leaving a posterior pouch when generating the sleeve in this region. No extra retraction of the left lobe of the liver was necessary in our patients, and no preoperative liquid diet to reduce liver volume was applied. In a next step a 36 French bougie was inserted orally into the stomach and placed against the lesser curvature. The gastric sleeve was subsequently prepared using a long Echelon Flex, 60-mm, linear stapler (Ethicon Endo-
SINGLE-INCISION LAPAROSCOPIC SLEEVE GASTRECTOMY
Surgery, a Johnson and Johnson Company, Cincinnati, OH) following the edge of the calibrating bougie. A golden cartridge (open staple height, 3.8 mm; closed staple height, 1.8 mm) was used two times starting 6 cm proximal to the pylorus followed by a blue cartridge (open staple height, 3.5 mm; closed staple height, 1.5 mm). Between the closure of the stapler and its firing a 30–45-second interval was observed in every case. Sequential firing of the stapler completed the transection at the gastroesophageal junction. After the resection was completed, the staple line was inspected carefully for any malformation of the staples. Reinforcement of the staple line, and in particular of junctions of each staple firing, was performed regularly by application of endosurgical titanium clips (Ligamax; Ethicon). Finally, the transected stomach was removed directly through the port without using any specimen collection bag, and the abdomen was closed with 0/0 polyglactin 910 (Vicryl; Ethicon) interrupted sutures. All patients left the operation room without a nasogastric tube. An upper gastrointestinal series with diatrizoate meglumine and diatrizoate sodium (Gastrografin; Bracco Diagnostics Inc., Princeton, NJ) was performed on postoperative Day 1, and if it was negative the patient was put on liquid diet consumption for 1 day. Because of the Austrian insurance and clearing system patients were discharged as early as postoperative Day 4 once they were able to maintain hydration and manage pain with oral analgetics. A routine follow-up with attention to electrolyte and vitamin levels was recommended at 3, 6, and 12 months after surgery, and patients were invited to fill out a scar satisfaction assessment questionnaire at 3 months after surgery. Surgical technique for LAPS-G
The multiport sleeve gatrectomy was performed as described by Moy et al.6 with the patient in the supine position on a split-leg operating table. In brief, a 12-mm trocar (Autosuture; Covidien) was placed approximately 5 cm proximal to the umbilicus with an open entry, and pneumoperitoneum was achieved with carbon dioxide. Three additional 12-mm trocars were placed under direct vision into the right and left middle epigastrium and one in the right upper quadrant for liver retraction, which was carried out using a straight liver retractor. All further surgical steps were essentially the same as described for the single-incision technique. Once the stomach was transected, the remnant was put into a specimen collection bag and removed. Again, reinforcement of the stapler line was achieved with endosurgical titanium clips (Ligamax). Finally, all incisions were closed with 0/0 Vicryl sutures. In our first 36 cases of multiport sleeve gastrectomy, a 15-Robinson drain was inserted and placed into the left upper abdomen without brushing the staple line.
Table 1. Demographics of the Two Groups of Laparoscopic Sleeve Gastrectomy Patients SILS-G (n = 40)
Age (years) 37 (19–62) 43 (24–73) [mean (range)] 2 BMI (kg/m ) 40.8 (35.1–45.0) 43.8 (35.0–47.8) [mean (range)] a 0 (0%) 36 (90%) Drainage [n (%)] Operation time 84.8 – 21.3 97.4 – 26.0 (minutes) (mean – SD)a Length of hospital stay 5 (4–24) 6 (4–14) (days) [mean (range)] Comorbidities [n (%)] Hyperlipidemia 3 (7.5%) 4 (10%) Hypertension 4 (10%) 2 (5%) Diabetes mellitus 1 (2.5%) 2 (5%) Cosmetic outcome 1.1 (1–2) 2.0 (1–3) [mean (range)]b,c a
P < .05. P < .01. On a scale of 1–5. BMI, body mass index; LAPS-G, multiport laparoscopic sleeve gastrectomy; SD, standard deviation; SILS-G, single-incision laparoscopic sleeve gastrectomy. b c
significant). The mean operative time was significantly shorter in the SILS-G group compared with the LAPS-G group (SILS-G, 84.8 – 21.3 minutes; LAPS-G, 97.4 – 26.0 minutes; P < .05). No conversion to standard laparoscopic surgery or open surgery was needed. No intraoperative and postoperative deaths occurred. Overall, we had three postoperative surgical complications (3.75%) (Table 2). One patient in the SILS-G group developed a stapler line leakage near the esophagogastric junction, which was diagnosed at postoperative Day 4. It is interesting that the postoperative upper gastrointestinal x-ray series performed with Gastrografin was negative on postoperative Days 1 and 4 for this patient, and the leak was solely diagnosed by clinical symptoms (fever, 38.5C; tachycardia, 100/ minute; pain visual analog scale, 5). The patient underwent relaparotomy and abdominal lavage, the leak was oversewn with (polydioxanone) monofilament synthetic absorbable suture (PDS; Ethicon) 5.0 running sutures, two drains were positioned close to the leak, and an endoscopic stent was placed. The further course was uneventful, and the patient
Table 2. Postoperative Complications n (%)
Following evaluation of anthropometric parameters, demographics, and comorbidities, no statistical differences were observed between the two groups (Table 1). In total, 80 female patients (SILS-G, n = 40; LAPS-G, n = 40) underwent sleeve gastrectomy at our institution. The mean age was 41 (range, 19–73) years, and mean preoperative BMI was 42.5 (range, 35.0–47.8) kg/m2 (SILS-G, 40.8 [35.1–45.0] kg/m2; LAPS-G, 43.8 [35.0–47.8] kg/m2; P = not
LAPS-G (n = 40)
Complication Leakage Bleeding Reflux Trocar-site hernia
SILS-G (n = 40) 1 1 2 0
(2.5%) (2.5%) (5%) (0%)
LAPS-G (n = 40) 0 1 3 0
(0%) (2.5%) (7.5%) (0%)
LAPS-G, multiport laparoscopic sleeve gastrectomy; SILS-G, single-incision laparoscopic sleeve gastrectomy.
could be discharged on postoperative Day 24 without further complications. Two postoperative bleedings (2.5%), one within the SILS-G group (2.5%) and another one within the LAPS-G group (2.5%), which were also solely detected by clinical symptoms (tachycardia, 100/minute; low blood pressure