Single Incision Surgery: Is LESS More?

Is single incision surgery a worthwhile procedure? Does it make sense to perform or are the risks and difficulties associated with the procedure not worth the potential gain? How difficult might it be?

A query along these lines was recently posted on the OBGYN.net forum, as a clinician was interested in learning more about single incision surgeries from colleagues. There was no shortage of opinions and comments discussing the procedure and its worth.

One clinician, who had watched a procedure beamed lived to a conference he was attending, did not appear to be impressed with the procedure. In his opinion, one 2 cm incision did not seem better than a 1 cm plus a 5 mm incision for all the struggle and troubles associated with the procedure.

Another clinician who has performed a few single incision surgeries for oophorectomy noted that the most challenging part of the procedure was trying to avoid overlap of the instruments. That clinician postulated that a right angle or flexible scope might make the procedure easier and more successful. Overall, however, he was pleased with the procedure, noting that it was convenient to have a simple way to remove the ovary from the abdomen.

A colleague of his concurred, noting it is important to find options that are minimally invasive for his patients. To which, a clinician excitedly shared that a single incision robotic system is being tested in Europe and submitted to the US Food and Drug Administration.

Indeed, it would appear the most important pressing issue is to find a minimally invasive mechanism for gynecological surgical procedures. In a recent study looking the current status and controversies associated with single-incision laparoscopic procedures, the authors noted, “Scarless surgery is the Holy Grail of surgery.”¹ While they acknowledged that single-port surgery appears to be feasible, reasonably safe, and cosmetically advantageous to standard laparoscopy procedures, they also pointed to issues such as increased costs, which are due to instrumentation, increased learning curve and operative times. These researchers concluded their review by explaining, “With minimal access surgery changing at a rapid pace, only longer follow-up and controlled randomised studies will tell if single-incision laparoscopy is a meaningful and lasting technique or a stepping stone towards a truly scarless intervention.”

Another recent study points to the problem presented by one of the posters-working with bent instruments. In the study,² researchers compared patients who had adnexal surgery with laparoendoscopic single-site surgery (LESS) with a control group of patients who underwent similar procedures with conventional multiport laparoscopy and were operated consecutively in the same period. While they found that the LESS technique was technically feasible and safe, they found differences between the operation time and mean hospital stay. In commenting on this result, the researchers noted, “The surgeon must master the use of novel bent instruments in close proximity to each another.”

Overall, however, LESS in gynecology appears to be safe and effective. In a recent review of contemporary literature on LESS advances in gynecology, the authors further discussed its goals and possibilities.³ “Ongoing efforts to improve upon the morbidity and cosmetic sequelae of laparoscopic surgery have led to minimization of size and number of ports required for these procedures,” they explained. “LESS surgery is a recently coined surgical term used to describe various techniques that aim at performing laparoscopic surgery through a single, small skin incision concealed within the umbilicus.” In reviewing recently published studies, they note that the outcomes data demonstrate feasibility, safety and reproducibility for LESS in gynecology.

Ultimately, the goal of any surgery is to obtain the best outcomes possible for each patient. With the addition of this option to a clinician’s arsenal and its use under the right circumstances, there should be additional chances for successes.

What is your opinion on single incision surgery? Do you find the advantages out-weight the risks and what about the increased cost and learning curve?  Post your comment below.

References:

References
1. Rao PP, Rao PP, Bhagwat S. Single-incision laparoscopic surgery – current status and controversies. J Minim Access Surg. 2011;7(1):6-16.
2. Kavallaris A, Chalvatzas N, Hornemann A, et al. Laparoendoscopic single-site surgery (LESS) - is it feasible in gynecological surgery? Acta Obstet Gynecol Scand. 2011;90(2):195-7.
3. Fader AN, Cohen S, Escobar PF, Gunderson C. Laparoendoscopic single-site surgery in gynecology. Curr Opin Obstet Gynecol. 2010;22(4):331-8