Upload
junior-mckenzie
View
231
Download
0
Embed Size (px)
Citation preview
SILS Complications
Dan Geisler, MD, FACS, FASCRS
2
Disclosures
Covidien Consultant
3
4
5
6
7
V A R I A B L E S
8
V A R I A B L E S
TROCARS
SURGEONS STEPS
SEQUENCE
INSTRUMENTS
POSITIONING
9
Challenges of Laparoscopic Colorectal Surgery
Multiple QuadrantsMultiple VesselsSmall Bowel PositioningBowel TransectionBowel Anastomosis
10
Challenges of Laparoscopic Colorectal Surgery
Time ConsumingTechnically ChallengingTechnical AbilityAdvanced TechnologyCapable Assistants
11
Strategy to Combat Time Constraints of Laparoscopic Colorectal Surgery
break operation into directly productive vs. nonproductive actions
standardizestandardize approach to improve efficiency retraction performed by gravitygravitykeep repositioning to a minimum
3 Trocar Technique
12
SILS Colectomy
Advantages• simplified method• need only a camera operator• safe and efficient• reproducible
13
“Problems” with M.I.S.
14
“Problems” with M.I.S.
Problems with SILS
15
Laparoscopic CRSImproved cosmesis
Decreased pain
Decreased recovery
16
“Problems” with M.I.S.
Decreased ability to complain of pain
• Improvement in maximum pain score
on POD1 & POD2 (p<0.05)
• Shorter LOS
Papaconstantinou & Thomas
SILS
17
“Problems” with M.I.S.Decreased ability to complain of pain
Inability to “show off” a big scar
SILS
18
“Problems” with M.I.S.Decreased ability to complain of pain
Inability to “show off” a big scar
SILS
19
“Problems” with M.I.S.Decreased ability to complain of pain
Inability to “show off” a big scar
Having to return to work earlier
20
21
Laparoscopic Colectomy Less blood loss Quicker recovery to normal function Better margins of resection Better visualization
• Mesorectal excision• Decrease incidence of autonomic nerve injury• More precise surgical procedure
Less wound related problems• Infection • Dehiscence • Incisional hernia
Minimally invasive procedure
Advantages
22
SILS Colorectal
Surgery
23
SILS Colectomy N = 99 Age = 9 – 93 30 with previous abdominal operations BMI = 26 (15 – 39)
24
SILS Colectomy N = 99
Diagnosis UC: 46 Neoplasia: 17 Crohn’s: 10 Diverticulitis: 10 FAP: 2 Other: 14
25
SILS ColectomyN = 99 OR Time: 105 minutes (13 – 245) Incision Length: 3.7 cm (1.2 – 7.8)
LN Harvest*: 44
26
SILS ColectomyN = 99
Ports 87 SILS 12 Additional Ports
• 1: 9
• 2: 1
• 3: 2
27
Complications?
Wound Complications Infections
• Similar
• Easy to deal with
Hernias? • Too early to tell
• Access technique?
28
HerniaVariable rates of occurrenceDependent on locationAvoidable?Tissue necrosis?
29
HerniaVariable rates of occurrenceDependent on locationAvoidable?Tissue necrosis?
WE DON’T KNOW!!!!!
30
Difficulties?
5 mm endoeye SKILLED camera operator Camera, then instruments
• Not both at the same time
Splenic flexure
31
Difficulties?
Port SILS (Covidien)
• Atraumatic
• Simplistic
• Easy to use
Triport, Ethicon, Gelpoint
32
SILS Colorectal Benefits over conventional laparoscopy
Drawbacks over conventional laparoscopy
Incidence of hernia formation?
33
SummarySingle port laparoscopy in colorectal surgery Minimize abdominal trauma May utilize a natural body orifice or scar such as the
Umbilicus Potential decrease in morbidity Certainly superior cosmesis
“NOTES” Natural Orifice Transluminal Endoscopic Surgery”……..experimental
SPL seems to be a practical clinical step towards NOTES
34
SummarySingle port laparoscopy in colorectal surgery Minimize abdominal trauma May utilize a natural orifice or scar such as the Umbilicus Potential decrease in morbidity Certainly superior cosmesis
“NOTES” Natural Orifice Transluminal Endoscopic Surgery”……..experimental
SPL seems to be a practical clinical step towards NOTES
A BRIDGE TO THE FUTURE!!!