Obesity Surgery

, 18:1628

Single Laparoscopic Incision Transabdominal (SLIT) Surgery—Adjustable Gastric Banding: A Novel Minimally Invasive Surgical Approach

Authors

    • Department of SurgeryUniversity of California Irvine Medical Center
  • Marcelo W. Hinojosa
    • Department of SurgeryUniversity of California Irvine Medical Center
  • Brian R. Smith
    • Department of SurgeryUniversity of California Irvine Medical Center
  • Kevin M. Reavis
    • Department of SurgeryUniversity of California Irvine Medical Center
Case Report

DOI: 10.1007/s11695-008-9705-6

Cite this article as:
Nguyen, N.T., Hinojosa, M.W., Smith, B.R. et al. OBES SURG (2008) 18: 1628. doi:10.1007/s11695-008-9705-6

Abstract

Natural orifice transluminal endoscopic surgery (NOTES) has become an exciting area of surgical development. However, there are significant limitations to this surgical concept due to the lack of surgical expertise and appropriate flexible instrumentation. An alternative and competing technology to NOTES is single-access surgery. We present a novel surgical technique for placement of an adjustable gastric band utilizing a single laparoscopic incision which was ultimately used for implanting the subcutaneous access port. This new technique is called single laparoscopic incision transabdominal (SLIT) surgery which describes an advanced laparoscopic bariatric operation that can be performed through a tiny slit. The operative time was 55 min. There were no intraoperative complications. The patient did well postoperatively and was discharged on postoperative day 1. There were no postoperative complications at 1-month follow-up. Adjustable gastric banding performed through a single laparoscopic incision is technically feasible. The procedure was performed with mostly existing ports, laparoscopic instrumentations, and visualization platform. Advantages of SLIT surgery compared to conventional laparoscopic surgery will ultimately require further randomized clinical trials.

Keywords

LaparoscopySingle-site surgeryBariatric surgeryGastric bandingSingle laparoscopic incision transabdominal surgery

Introduction

Natural orifice transluminal endoscopic surgery (NOTES) is the newest and most exciting area of surgical development in recent times. Potential benefits of NOTES include lack of an abdominal scar, reduction of postoperative pain, the ability to be performed under conscious sedation, and faster recovery. However, until now, the majority of human clinical experiences with NOTES are hybrid procedures requiring access through a natural orifice (transorally or transvaginally) in combination with an umbilical port for safe peritoneal entry and maintenance of pneumoperitoneum. [13] A true NOTES procedure without the use of any abdominal port(s) is still under investigation with many potential obstacles such as a safe closure of the gastrotomy.

A competing surgical technology to NOTES is single-port or single-access transabdominal surgery. The idea behind single-access or single-port surgery is to advance minimally invasive surgical techniques to the next frontier with the use of only a single laparoscopic incision in comparison to the current laparoscopic procedure which requires at least four incisions and often up to seven incisions in certain complex cases. For example, rather than performing a laparoscopic cholecystectomy through the conventional four laparoscopic trocars, the procedure would be performed through a single port which ultimately will be used for extraction of the surgical specimen. The single port is normally placed periumbilical so essentially there will be no visible abdominal scar. The potential benefits of single-access incision are less postoperative pain, although no clinical data are currently available, and no visible scar(s). Single-access surgery has been described primarily for basic laparoscopic operations that do not require laparoscopic suturing. [4] We present a laparoscopic bariatric operation, placement of an adjustable gastric band, which was performed entirely through a single laparoscopic incision. The procedure was termed SLIT surgery which stands for single laparoscopic incision transabdominal (SLIT) surgery.

Case Study and Surgical Technique

A 38-year-old woman with a body mass index of 39 kg/m2 and a history of hypertension, obstructive sleep apnea, gastroesophageal reflux disease, and coronary artery disease underwent laparoscopic placement of an adjustable gastric band utilizing a single abdominal incision. Our conventional laparoscopic band operation requires placement of five abdominal trocars. In this case, a single 4-cm incision was made to accommodate implantation of the subcutaneous access port. The location of the incision was at the midline between the xyphoid process and the umbilicus. Through this incision, pneumoperitoneum was established with a Veress needle. A 15-mm trocar was placed and the adjustable gastric band was inserted into the peritoneal cavity. The 15-mm port was removed and replaced with four 5-mm trocars through this single incision (Fig. 1). The left lobe of the liver was retracted using a flexible 5-mm liver retractor instrument and was fixed with a self-retaining retractor. A 5-mm flexible-tip camera was used for visualization. The remaining two ports were utilized as the main operative ports by the surgeon. The hepatogastric ligament was divided and the right crus of the diaphragm was mobilized. The retroesophageal space was developed and a flexible right-angle instrument was passed through the space to exit adjacent to the angle of His. The suture attached to the adjustable gastric band was attached to the right-angle instrument and then passed through the retroesophageal space, wrapping the band around the proximal stomach. The adjustable gastric band was then closed. Three anterior gastrogastric sutures were placed to prevent anterior slippage. The catheter from the band was exteriorized through the surgical incision and attached to the subcutaneous access port (Fig. 2). All trocars were removed and the fascia defect was closed with sutures. The subcutaneous access port was secured to the rectus fascia using an automated fascia-securing device (Fig. 3a,b). Dressing was applied to the incision (Fig. 4).
https://static-content.springer.com/image/art%3A10.1007%2Fs11695-008-9705-6/MediaObjects/11695_2008_9705_Fig1_HTML.jpg
Fig. 1

Single laparoscopic incision transabdominal surgery—adjustable gastric banding showing two rigid operative instruments, a self-retaining liver retractor and an additional port for the flexible-tip camera

https://static-content.springer.com/image/art%3A10.1007%2Fs11695-008-9705-6/MediaObjects/11695_2008_9705_Fig2_HTML.jpg
Fig. 2

Upon completion of placement of the laparoscopic adjustable gastric band, the catheter from the gastric band was exteriorized through the single surgical incision and attached to the access port. The length of the surgical incision was only slightly larger than the length of the subcutaneous access port

https://static-content.springer.com/image/art%3A10.1007%2Fs11695-008-9705-6/MediaObjects/11695_2008_9705_Fig3_HTML.gif
Fig. 3

a All laparoscopic ports were removed and the band access port was secured to the rectus fascia using an automated fascia-securing device. b The subcutaneous port was securely implanted within the single-access incision

https://static-content.springer.com/image/art%3A10.1007%2Fs11695-008-9705-6/MediaObjects/11695_2008_9705_Fig4_HTML.jpg
Fig. 4

Dressing is placed over the single incision after SLIT-adjustable gastric banding

The operative time was 55 min. There were no operative complications. The patient did well postoperatively and was discharged on postoperative day 1. There were no postoperative complications.

Discussion

Laparoscopy has revolutionized the way surgeons perform general surgical operations, and this innovation has slowly adapted to bariatric surgery. At the current time, there are more bariatric operations being performed utilizing the laparoscopic technique than the open technique. Innovations in new instrumentation and technology have recently pushed minimally invasive surgery into a new frontier of even less invasive approaches. NOTES has been an exciting area of interest for surgeons and gastroenterologists with many institutions performing research in this field. However, NOTES procedures are limited by difficulty in access, lack of appropriate flexible instrumentation, and reluctance to break the sterility barrier. Single-access surgical technology is an alternative to NOTES, which is a less invasive platform compared to conventional laparoscopy but may utilize existing instrumentation and visualization systems. This paper described our technique for placement of an adjustable gastric band utilizing a single surgical incision which was ultimately used for implantation of the subcutaneous access port.

Placement of an adjustable gastric band system requires a sterile environment which eliminates NOTES as a surgical access option. Since this procedure requires implantation of a subcutaneous access port, the largest incision was utilized to perform the entire laparoscopic portion of the procedure. By performing the procedure through a single incision, we essentially cut down the number of surgical incisions from five to one. This paper is intended to document the feasibility of single-access surgery for placement of a laparoscopic adjustable gastric band. Clinical advantages of this approach will eventually require a randomized controlled trial comparing laparoscopic adjustable gastric band vs. SLIT—gastric banding. However, the obvious and undeniable advantage of this technique is improved cosmesis. Intuitively, reduction in the number of surgical incisions from five to one should also reduce postoperative pain. Disadvantages of SLIT surgery include the small degree of instrument triangulation, difficulty in performing intracorporeal suturing, and the lack of tissue retraction by the assistant surgeon. However, some of these disadvantages may be overcome with the development of flexible-tipped instruments, ports with smaller profiles, and the use of extracorporeal suturing techniques. Despite the limitations of SLIT surgery, we were able to perform our operation with a reasonable operative time of 55 min which is not substantially longer compared to our mean operative time of 50 min with conventional laparoscopy.

Similar to NOTES, advantages for SLIT surgery may include less postoperative pain and improved cosmesis. However, unlike the limitations of NOTES, SLIT surgery utilizes existing laparoscopic instrumentation and visualization platforms, maintains a sterile operating environment, and can possibly be performed with a shorter learning curve. Even if it is true that NOTES procedures can be performed in the future, the learning curve for NOTES will be lengthy, and from studies of laparoscopic gastric bypass we know that the learning curve can be associated with a significantly higher morbidity and even mortality. With this knowledge in mind, research in the field of SLIT surgery should be examined as a less invasive alterative to laparoscopic surgery or as a bridge for surgeons to gain expertise in operating within the confines of a single surgical incision. After all, NOTES is ultimately a single-port procedure that is placed strategically through the natural orifice.

In conclusion, we documented the feasibility of SLIT—adjustable gastric banding. The procedure was performed with mostly existing ports and laparoscopic instrumentation and visualization platforms. Development of newer instrumentation may facilitate this new operative approach which will not require as long of a learning curve in comparison to NOTES. Further advantages of SLIT surgery compared to conventional laparoscopic surgery will ultimately require further randomized clinical trials.

Copyright information

© Springer Science + Business Media, LLC 2008