Abstract
Background
Single incision laparoscopic bariatric surgery has developed over the last few years, with single incision laparoscopic adjustable gastric banding (SILS-AGB) being performed most commonly. However, there are no randomised controlled trials and few matched studies comparing SILS-AGB to conventional laparoscopic multi-port multiport adjustable gastric banding (LAGB). Our aim was to study any differences in outcome and analgesic requirements between two matched groups of gastric band patients (SILS-AGB and LAGB).
Methods
Between June 2009 and September 2010, 111 patients underwent SILS-AGB and 99 patients underwent LAGB performed by a single surgeon (AGP). Patients were matched for age, sex, weight, BMI and co-morbidities. Forty six SILS-AGB and LAGB patients were included for analysis. Their outcomes were compared for operating times, conversions, analgesia requirements, morbidity and mortality.
Results
Patients characteristics between the SILS-AGB and LAGB groups were similar with no differences in their median age (44 vs 47 years), sex (m:f; 7:39 vs 4:42), body mass index (43.1 vs 44.4 kg/m2) or co morbidities respectively. In the SILS-AGB group the median operating time (70 min) was not significantly longer than in LAGB group (61.5 min, p = 0.07). However, SILS-AGB patients used less opiates (p < 0.01) than the LAGB patients. There was no difference in morbidity, mortality or readmission rates.
Conclusion
SILS-AGB is a safe and feasible option and is comparable with LAGB. Post operative demand for analgesia was significantly less in the SILS-AGB group. Further comparisons of post operative pain and long term outcomes are required; however preliminary results are promising.
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Background
Single incision laparoscopic surgery (SILS) has developed over recent years and is gaining popularity across multiple surgical specialities, including bariatric surgery [1]. The theoretical advantages of single incision laparoscopic bariatric surgery include less abdominal wall trauma, less pain, earlier discharge and a better cosmetic scar. However, technical challenges in SILS include lack of triangulation and limited space in which to manipulate instruments. Additional hurdles arise in the morbidly obese patient from excessive intra-abdominal fat and hepatomegaly. Overcoming these challenges, a small number of enthusiasts have shown case series which demonstrate the safety and technical feasibility of SILS in gastric banding (SILS-AGB), gastric bypass, and sleeve gastrectomy [2–4].
To date there are no randomised controlled trials and only a limited number of studies comparing SILS-AGB to conventional laparoscopic adjustable gastric banding (LAGB). The objective of our study was to compare the outcomes of two matched groups of gastric band patients undergoing SILS-AGB and LAGB and thereby assess the safety, feasibility and benefits of SILS-AGB.
Methods
Between June 2009 and September 2010, 111 patients underwent SILS-AGB and 99 patients underwent LAGB performed by a single surgeon (AGP). Patients who fulfilled day surgery criteria which include a weight of less than 150 kg, minimal co morbidities, living within 5 mile radius and social support at home, underwent day-case gastric band insertion. All other patients were treated as in-patient.
Patients from the SILS-AGB and LAGB groups were matched for age, sex, weight, body mass index (BMI), American Society of Anaesthesia (ASA) grade and co morbidities. After matching, 46 SILS-AGB and 46 LAGB patients were found to be comparable. Outcomes from these two groups were then compared in terms of operating times, conversions, morbidity, mortality, opiate requirements, length of stay and readmission rates. Operating time was defined as the time from skin preparation to the point at which the wound dressing was applied.
All patients received intravenous antibiotics and deep vein thrombosis prophylaxis. Total intravenous (IV) anesthesia using propofol (125 mg/kg/min) with remifentanyl (0.5 mg/kg/min) was administered for induction and maintenance. IV hydration was maintained with 2–3 L of Hartmann’s solution. Peri-operative analgesia regimen consisted of 1 g of intravenous paracetamol, 10 mg of intravenous morphine or diamorphine, and 75 mg of intravenous diclofenac at the end of surgery.
Operative Procedures
The LAGB technique is similar to that described by Ren and Fielding in 2003 [5], whilst our SILS-AGB has more recently been described [6]. In brief, all patients were placed in a supine position with the surgeon standing to the right of the patient. In LAGB, four ports are inserted across the upper abdomen and an additional incision to accommodate a liver (Nathanson) retractor. For those undergoing SILS-AGB, intraperitoneal access was achieved through a small transverse incision made half-way between the xiphisternum and umbilicus to the right of the midline. All SILS-AGB operations were performed using four instrument channels within a single incision, accommodating the liver retractor, camera and two working channels. In all procedures the Angle of His was dissected using electrical hook diathermy and with the pars flaccida approach the gastric band was locked in position. The band was secured in place with the help of gastrogastric plication. The port was fashioned on the right anterior rectus sheath.
Post operative analgesia was dispensed as required which included morphine, tramadol or codeine. Any additional requirement for opioid analgesia was recorded and calculated to a morphine equivalent dose based on an equianalgesic table [7]. All complications were recorded. Discharge medications included 1 g of paracetamol six hourly and 50 mg of diclofenac eight hourly for 7 days.
All patients were regularly followed up at 6 weeks and then every 3 months for the first year, during which their bands were adjusted according to their needs. The weights and body mass indices of the patients were documented during follow up.
Statistical Analysis
SPSS version 17 was used for statistical analysis. In both groups the distribution of parameters were expressed as median values and ranges. All comparisons were performed using non parametric Mann Whitney tests. A two sided p value of less than 0.05 was considered statistically significant.
Results
Patients characteristics between the SILS-AGB (n = 46) and LAGB (n = 46) groups were similar in terms of age, sex, BMI, weight, height, ASA grading and co-morbidities (Table 1). The individual obesity related co-morbidities were also similar in both groups (Table 2).
In the SILS-AGB group, median operating time of 70 min was longer than LAGB (61.5 min) although it was not statistically significant (p = 0.07). There were no conversions to open surgery in either group. However, in the SILS-AGB group a single additional port was required in 4 patients (4/46, 9 %), due to simultaneous hiatus hernia repair, omental retraction and anatomical variation. There were no complications recorded except for one patient who presented with a wound infection in the SILS-AGB group. Additional opiate use in the post-operative period was significantly less in the SILS-AGB group (median 10 mg) than the LAGB group (median 17 mg) (p < 0.01). In both groups, length of stay, readmission and excess weight loss were similar (Table 3).
Discussion
The development of SILS, Mini-laparoscopy and NOTES has been driven through technical innovation and surgical advances. With greater awareness of these new surgical techniques the demand for these procedures is increasing and is in part patient driven. In a questionnaire based study by Bucher [8], patients appeared to favour scarless surgery, with single incision surgery being preferred over NOTES. If SILS can be performed safely with similar efficacy of a conventional multi-incision procedure then it may be the preferred option by patients.
The first SILS gastric band [9] was reported in 2008 almost 11 years after the first SILS cholecystectomy [10]. Bariatric patients have their own surgical challenges often presenting with considerable intra-abdominal fat and hepatomegaly. Early SILS-bariatric experiences are commonly reported in patients with a median BMI of 40 kg/m2, with BMI >50 kg/m2 being excluded [2, 11–19]. In our series, patients undergoing SILS-AGB were initially performed in those with a 40 kg/m2. However once the surgical technique was established this limit was relaxed with the heaviest patient having a BMI of 67 kg/m2 and successfully undergoing a SILS-AGB. Therefore, with experience SILS-AGB can be an option for super obese patients.
Surgical complexity also translates into longer operating times and this can be seen in early series of SILS-AGB, with a median operating time of 80 min (range 65–105 min) [2, 11–14]. Surgical times have improved with greater experience, now commonly 55–65 min [6, 15]. Whilst some report that the learning curve in SILS is swift, the surgical challenges of the bariatric patient can take longer to overcome [17]. To date operative times in the SILS-AGB remain longer than traditional LAGB. In our experience operative times for SILS-AGB and LAGB are similar with no significant difference (p = 0.07). Operating times were also similar in the comparative study by Nguyen et al. (65 vs 66 min, p > 0.05) [16]. However in two other comparative studies, SILS-AGB took a significantly longer time to perform [17, 18] (Table 4).
Retraction of the fatty/enlarged liver is a challenge with all SILS upper gastrointestinal procedures which may also contribute to longer operating times. Hepatomegaly can cause difficulty while undertaking traditional LAGB. However the use of a liver retractor such as the Nathanson retractor through an epigastric incision below the xiphisternum results in good retraction and exposure. Whilst some surgeons may make an additional incision to accommodate a liver retractor during ‘SILS’ others have used tapes or ties to suspend the liver [2, 4, 12, 13, 15, 18]. In our series, we adopt a true single incision approach with no additional abdominal incision for slings or retraction. Instead the use of the ‘snake’ retractor through the single incision, allows adequate vision and exposure for the majority of cases. On occasions an additional port may be required to retract the liver to improve exposure of the operating field.
Many aspects of SILS-AGB differ from a conventional laparoscopic approach and this includes the camera view, clashing of instruments, crossing of hands during dissection and suturing and lack of external triangulation. The difficulty of a procedure may also be gauged by conversion to multiport technique, or laparotomy, as well as operating time. Considering all series to date an additional port has been required in 0–7 % cases [2, 6, 11–15]. An additional port is often sufficient in repairing an incidental hiatus hernia or for omental retraction as we discovered in our study. In the literature, conversion to a traditional multi incision procedure ranges between 0 and 13 % in the three matched comparative studies [2, 6, 11–15] (Table 4). There were no conversions to a 5-port technique in our SILS-AGB group. Additional ports or conversion to a multiport technique may at times be necessary to safely complete the band insertion.
There is a theoretical belief that a SILS technique results in less post-operative pain than a multiport approach [9]. There have been two randomised controlled trials comparing SILS with multiport laparoscopic cholecystectomy both which showed better pain profiles in the SILS group [19, 20]. Saber et al., in their comparative study of gastric bands showed that the SILS-AGB patients had significantly lower post operative VAS scores (2.5 vs 3.5) [p < 0.5] [17]. In our study pain was measured objectively by the amount of additional opiate required in the post operative period. The SILS-AGB patients were found to request less opiates compared to the multi incision LAGB group (median 10 mg vs 17 mg, p < 0.01). These findings are similar to Raman et al., who have shown that SILS-AGB patients required significantly less postoperative patient controlled analgesia (33 vs 49 mg, p < 0.01) and required outpatient analgesics for a significantly shorter period (2 vs 5.7 days, p < 0.05) compared to their LAGB counterparts [18]. These studies support our finding that there may be decreased post operative pain and analgesic requirement following SILS-AGB. However the decrease in pain does not appear to translate into a decreased length of stay both in our study or the other matched comparison studies [16–18].
Following surgery, median follow-up for SILS-AGB was 12.5 months and LAGB was 14 months. Within the two groups there was no difference in post-operative immediate or short term complications rates, readmission rates or excess weight loss.
In conclusion, the evidence suggests that SILS-AGB can be performed safely with similar surgical outcomes as LAGB in the short term. There may be an advantage of less post-operative analgesia and possibly decreased post-operative pain.
References
Pfluke JM, Parker M, Stauffer JA, et al. Laparoscopic surgery performed through a single incision: a systematic review of the current literature. J Am Coll Surg. 2011;212(1):113–8.
Saber AA, El-Ghazaly TH. Early experience with single incision transumbilical laparoscopic adjustable gastric banding. Obes Surg. 2009;19:1442–6.
Saber AA, El-Ghazaly TH, Dewoolkar AV, et al. Single-incision laparoscopic sleeve gastrectomy versus conventional multiport laparoscopic sleeve gastrectomy: technical considerations and strategic modifications. Surg Obes Relat Dis. 2010;6:658–64.
Huang CK, Yao SF, Lo CH, et al. A Novel Surgical Technique: Single-Incision Transumbilical Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg. 2010;20:1429–35.
Ren CJ, Fielding GA. Laparoscopic adjustable gastric banding: a surgical technique. J Laparoendosc Adv Surg Tech A. 2003;13(4):257–63.
Patel AG, Murgatroyd B, Ashton WD. Single Incision Laparoscopic Adjustable Gastric Banding: 111 Cases. Surg Obes Relat Dis. 2011. doi:10.1016/j.soard.2011.06.013.
Lawlor P, Pereira J, Bruera E. Dose Ratios Among Different Opioids: Underlying Issues and an Update on the Use of the Equianalgesic Table. In: Bruera E, Portenoy RK, Bruera E, Portenoy RK, editors. Topics in Palliative Care Volume 5. New York: Oxford University Press; 2001. p. 247–76.
Bucher P, Pugin F, Ostermann S, et al. Population perception of surgical safety and body image trauma: a plea for scarless surgery? Surg Endosc. 2011;25:408–15.
Nguyen NT, Hinojosa MW, Smith BR, et al. Single laparoscopic incision transabdominal (SLIT) surgery-adjustable gastric banding: a novel minimally invasive surgical approach. Obes Surg. 2008;18(12):1628–31.
Navarra G, Pozza E, Occhionorelli S, et al. One-wound laparoscopic cholecystectomy. Br J Surg. 1997;84:695.
Teixeira J, McGill K, Koshy N, et al. Laparoscopic single-site surgery for placement of adjustable gastric band—a series of 22 cases. Surg Obes Relat Dis. 2010;6:31–45.
Tacchino RM, Greco F, Matera D. Laparoscopic gastric banding without visible scar: a short series with intraumbilical SILS. Obes Surg. 2010;20:236–9.
Keidar A, Shussman N, Elazary R, et al. Right-Sided Upper Abdomen Single-Incision Laparoscopic Gastric Banding. Obes Surg. 2010;20:757–60.
Galvani CA, Gallo AS, Gorodner MV. Single-incision and dual-incision laparoscopic adjustable gastric band: evaluation of initial experience. Surg Obes Relat Dis. 2010. doi:10.1016/j.soard.2010.09.017.
Koh CE, Martin DJ, Cavallucci DJ, et al. On the road to single-site laparoscopic adjustable gastric banding: lessons learned from 60 cases. Surg Endosc. 2011;25(3):947–53.
Nguyen N, Slone J, Reavis K. Comparison study of conventional laparoscopic gastric banding versus laparoendoscopic single site gastric banding. Surg Obes Relat Dis. 2010;6:503–7.
Saber AA, El-Ghazaly TH, Elain A, et al. Single-incision laparoscopic placement of an adjustable gastric band versus conventional multiport laparoscopic gastric banding: a comparative study. Am Surg. 2010;76(12):1328–32.
Raman SR, Franco D, Holover S, et al. Does transumbilical single incision laparoscopic adjustable gastric banding result in decreased pain medicine use? A case-matched study. Surg Obes Relat Dis. 2011;7(2):129–33.
Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, et al. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc. 2010;24:1842–8.
Bucher P, Pugin F, Buchs NC, et al. Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy. Br J Surg. 2011;98(12):1695–702.
Conflict of Interests
Saurav Chakravartty: no conflict of interest
Beth Murgatroyd: no conflict of interest
David Ashton: no conflict of interest
Ameet Patel: no conflict of interest
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Chakravartty, S., Murgatroyd, B., Ashton, D. et al. Single and Multiple Incision Laparoscopic Adjustable Gastric Banding: a matched comparison. OBES SURG 22, 1695–1700 (2012). https://doi.org/10.1007/s11695-012-0704-2
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DOI: https://doi.org/10.1007/s11695-012-0704-2