Page 44 - World Journal of Laparoscopic Surgery

Michael M Lawenko et al

peritoneal flap was closed over the mesh with tackers. The DISCUSSION
GIST tumor was lifted using sutures and wedge resection Single port endolaparoscopy (SPES) further minimized the
was performed with linear staplers (Echelon™, Johnson invasiveness of the surgical procedure by limiting the trauma
and Johnson, New Jersey, USA) using 4 blue cartridges. from several incisions to a single incision. Different endo-
Intraoperative endoscopy was performed to assess laparoscopic procedures using this approach were seen to
completion of the resection and to verify the staple line. be feasible and safe, 9-12 there still is no proven advantage of
The specimen was extracted and the umbilical incision was this technique over conventional endolaparoscopy. We
closed with absorbable sutures. believe that decreasing the number of incisions and
increasing the number of procedures done will be the great
Case 2: 55 years old male with traumatic left diaphragmatic
advantage of single port surgery.
hernia and symptomatic gallstone disease. The single port
We made use of two devices locally available: the
device (Triport™, Olympus, Tokyo, Japan) was inserted
SILS™ device (Covidien, Norwalk, USA) and the
via a 2 cm supraumbilical, incision. Articulated instruments
Triport™ (Olympus, Tokyo, Japan). In 2 cases, the SILS™
and hook diathermy were used. The gallbladder fundus was
6
retracted using sutures (puppet technique) and the cystic device was used. This is an hour glass shaped port made
of an elastic polymer that is squeezed to fit a 2 cm incision
duct and artery were clipped with hemostatic clips (Hem-
into the abdominal cavity. It comes with low profile 5 mm
o-Lok™, Weck, N Carolina, USA). The left diaphragmatic
and a 12 mm trocars which are inserted into the port. The
hernia was identified and incarcerated omentum was
Triport™ was used in one case. This access device has 3
reduced. Repair was done with 2-0 nonabsorbable sutures.
gelatin coated working ports, namely one 12 mm and two
An additional 5 mm port in the left subcostal was necessary
5 mm ports and an insufflation and gas release port. The
to achieve the triangulation needed to assist in endosuturing.
adjustable double layer transparent plastic sheath is adjusted
A 15 × 10 cm polyester composite mesh (Parietex™
to the thickenss of the abdominal wall (up to 10 cm). 13-15
Covidien, Norwalk, USA).
Comparing the ports, we found that the Triport™ was
Case 3: 77 years old female with a left ovarian cyst and a easier to insert in a 2 cm incision and is versatile on different
right incisional hernia from a previous appendectomy. The abdominal wall thickness. The drawback is its more
single port device (SILS™, Covidien, Norwalk, USA), port propensity for gas leak around the incision site, the difficulty
was inserted in a 2 cm incision in the left lower abdominal in inserting instruments through the gelport cap and the
quadrant. The uterus was lifted using an intrauterine retractor friction encountered with instrument movement in and out
and left oophorectomy was completed using bipolar scissors. of the port. This was remedied with a small incision over
Subsequent adhesiolysis was done and the omentum was the gelport caps and lubrication of instrument with lubricating
freed and reduced into the abdominal cavity. The hernial jelly. The SILS™ port on the other hand has a more airtight
defect was closed with nonabsorbable transfascial sutures seal and greater ease of instrument insertion and movement.
and covered with a 10 × 15 cm antiadhesive mesh (C-Qur™, Its drawback is that is requires a certain effort to insert in a
Atrium Medical, Hudson, USA). Mesh fixation with 2 cm incision and it was not suited for abdominal wall
transfascial sutures and titanium tackers (Protack™, thickness greater than 5 cm. Introduction of the 12 mm
Covidien, Norwalk, USA) was done. trocar was very difficult and it made the port expand,
affecting the inflow of gas. This was remedied but removing
RESULTS two 5 mm trocars while using the 12 mm trocar.

Procedure Operating Intraoperative Port used Additional Size of Size of
time (minutes) complications 5 mm port incision (cm) scar (cm)
TAPP + Gastric 250 None SILS™ Nil 2 2.5
wedge resection
Cholecystectomy + 210 small laceration Triport™ 1 2 2.5
Diaphragmatic hernia repair of the liver
Oophorectomy + Incisional 105 None SILS™ Nil 2 2.5
hernia repair

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