Sunday, February 3, 2013

Single Port Appy?

First off, I am rather dubious of this whole "single port" business as a new tool in the laparoscopic armamentarium.  Several reasons. 

One, given the two dimensional aspect to today's instrumentation, there is a high premium on the concept of "triangulation" of your ports.  In other words, being able to approach a target from angled positions on the abdominal wall augments the efficiency and usefulness of right and left handed instrument control.  Approaching a target with instruments originating from a zero degree position is awkward at best, and hemorrhagic stroke inducing at worst.  Ultimately, in perhaps the most stinging rebuke, it lacks elegance.  Any surgeon worth a darn, from a technical perspective, will always seek the Way of Elegance when performing an operation.  (As an aside, relative absence of elegance is directly correlated with overall OR mood and surgeon/ancillary staff relationships.)   Until the instrumentation improves (i.e. articulating capabilities, curved shafts, ect) then any and all attempts at zero degree single port laparoscopy will be efforts in frustration. 

Two, in order to insert a port that allows three instruments, one has to necessarily make a larger fascial incision.  Larger fascial incisions ineluctably lead to higher hernia rates.  Ergo, single port surgery will lead to higher long term incisional hernia rates.  It's very simple and intuitive.  No degrees in quantum mechanics required for general surgery. 

A recent RCT from Annals demonstrates entirely expected findings.  Outcomes (short term) were noted to be similar whether one used single port surgery or conventional three port techniques.  Interestingly, the outcome most cited by single port enthusiasts as a reason for their strategy (better cosmesis) was no better in conventional vs single port in the study. 

So a surgeon is faced with a pseudo dilemma.  Should he learn a new technique that offers no improvement on post operative pain, no better wound infection rate, lacks the element of elegance and comfort, is more expensive and likely leads to significantly higher rates of incisional hernia in the long run? 

Answer seems obvious to me.  

Objective: To compare surgical outcomes and quality of life between single-port laparoscopic appendectomy (SPLA) and conventional laparoscopic appendectomy (CLA) in patients with acute appendicitis.

Background: A prospective randomized single center study was performed to compare the outcome of SPLA and CLA in patients with acute appendicitis.

Methods: A total of 248 patients were randomized, but because of 18 withdrawals, the outcome of 224 is analyzed, 116 in CLA and 114 in SPLA.

Results: There was no significant difference in the overall complication rate (P = 0.470). There were no significant differences in infectious complications between the SPLA group and the CLA group (10.2% and 12.4%, respectively). The wound complication rate between the 2 groups was not significant (5.1% and 10.6%, respectively; P = 0.207). Cosmetic satisfaction score, 36-item short-form health survey, and postoperative pain scores were not significantly different between 2 groups.

Conclusions: SPLA failed to show any advantages over CLA relative to pain and cosmesis. However, SPLA is as safe as CLA


JenL said...

Fully agree.
In fact, in my training (years ago) I learned a single-port, hand assist technique...very effective, low technology, very rare incisional hernia. It involved the placement of an incision in the RLQ.
The three port lap appy works very well, and the standard open appy still has its uses. Single port lap appy is a solution searching for a problem.

Paracelsus said...

Sure, I do single port appendectomies with great elegance and success: a single RIF "port" about 3cm wide, through which I triangulate my open surgery instruments...

There actually exist curved instruments for single-port techniques, but I think that's rather irrelevant, and your points remain valid. Why would you invest more in terms of R&D and training, when the approach itself is flawed? Say you perfect the single port technique in appendectomy and cholecystectomy (and nothing can prevent anyone from doing just that, actually), it will still be an awkward way of doing things, sort of very much out of line with other laparoscopic operations (stomach, colon, etc.) where single port would be utterly unfeasible, which would throw surgeons out of balance every time switching back and forth between two ways of achieving laparoscopic approach.

A single port would become a valid approach if you'd use it to somehow deploy (and anchor on the wall using it) some sort of cyber-hand, a complex device comprising telescopic, flexible or angled elements, able to move in three dimensions, moved by pulleys and such connected to an external motor, and controlled remotely, indirectly (no need to triangulate any more) - perhaps I'm describing the next generation of surgical robots, which would actually be more than glorified bulks of metal that one or two residents still have to hold on to during long, painful hours of "robotic surgery".