Single Laparoscopic Incision Transabdominal (SLIT) Surgery—Adjustable Gastric Banding: A Novel Minimally Invasive Surgical Approach
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- Nguyen, N.T., Hinojosa, M.W., Smith, B.R. et al. OBES SURG (2008) 18: 1628. doi:10.1007/s11695-008-9705-6
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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.
KeywordsLaparoscopySingle-site surgeryBariatric surgeryGastric bandingSingle laparoscopic incision transabdominal surgery
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. [1–3] 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.  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
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.
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.