When Mouret performed the first laparoscopic cholecystectomy in Lyons in 1988, a true revolution followed. The contrast between a big muscle-splitting Kocher, or a long upper midline, incision, and four small holes was profound in its impact.

It led, as we all know, to less pain for the patient, which reduced postoperative complications, wonderful improvements for both the patient and the surgeon. Finally, we could extirpate diseased organs without causing real suffering, and often prolonged stay in hospital with complications, due simply to the cut we had made. Patients caught on rather quickly, and the second revolution unfolded—patient-driven choice of surgical technique. We’d never seen anything like it. Patients demanded laparoscopic surgery, the media supported them, and surgeons had to adapt very quickly to maintain their practice, and their livelihood. Thus, the explosion of laparoscopic surgery in the 1990s.

All intra-abdominal procedures, from a simple appendectomy through to a living-related liver transplant donor operation, are now performed laparoscopically.

Recently, general surgeons have been performing many of the basic surgical procedures, such as appendectomy, cholecystectomy, lap band, sleeve gastrectomy, gastric bypass, fundoplication, and segmental colon resections through a single incision, or, in the case of gastric procedures, a single working incision, and another for the liver retractor. The obvious benefit is cosmesis, especially if the incision is placed inside the umbilicus. It may well be the only benefit.

This is certainly no revolution. The difference between four or five small incisions and one bigger one at the umbilicus, in terms of pain and mobility, is minimal. It bears no resemblance to what happened in 1988. Is it a step forward for the patient? Definitely, if the patient is worried about their scars. Otherwise, not really. Can it be
done? Certainly. Should it be done? Only if the surgeon finds the technique interesting, and feels that the cosmetic benefit is worth the extra trouble and difficulty. Will patients demand it? I doubt it. I have been doing single incision laparoscopic surgery (SILS) in New York for 2 years, and have done over 1,000 cases, but have only had one patient request it. Some patients comment favorably on the incision at follow-up, but to be honest, it’s rare.

That being said, I enjoy doing surgery this way. I’ve been doing laparoscopic surgery since 1990, and love being able to help people without hurting them too much. Now I love doing it without leaving patients with easily visible incisions. This is especially so for women, who don’t have the luxury of body hair to hide incisions. It is also valuable for African Americans who are prone to keloid scarring. This is important with bariatrics, when women often start dating after they lose weight. It removes the need to explain what all the incisions are for, until they are comfortable discussing their surgery.

I have done SILS lap bands, lap band revisions and replacement, Roux Y gastric bypass and Nissen fundoplication. I will use the lap band operation to discuss the techniques and tricks that I have found to expedite the surgery.

Everyone who does laparoscopic surgery knows that triangulation of the instruments is the key to an easy day in the operating room (OR). It becomes second nature, and governs all port positions. SILS does away with triangulation. That’s why it’s harder than standard laparoscopic surgery. The jump from five-port lap band placement to one- or two-port lap band placement is challenging, to say the least.

I would recommend that surgeons do it in a stepped fashion, over 20 cases. It worked for me. These transition cases, and certainly the next 20 true SILS cases, should all be women with a BMI in the 40s, who typically have less intra-abdominal fat than men.

First, I would remove the 5-mm left upper quadrant port used to retract stomach and omentum, and place it in the 15-mm incision used for the port, and just get used to the ports being close. I would then do the same with the left-handed grasper, but maintain the camera in the left upper quadrant port, to keep good visualization of the angle of His. Once comfortable with this, I would move the camera to the port incision, and work with two hands. I leave the Nathanson liver retractor where it is, at the xiphisternum.

The major skill is to be able to retract the stomach and the omentum, to place the angle of His under traction, with the left hand, and then dissect with the hook in the right hand. One’s hands are crossed for the whole operation.

The second skill needed is to be able to suture with hands almost parallel. It is easier to do this closer to the target than further away. I throw the knot as normal, but close each throw using a pulley–push pull technique to overcome the difficulty in getting lateral movement of the graspers. All the movement is toward the head. This feels very odd at the start, but becomes second nature.

Only when the surgeon is comfortable with this should they move the incision to the umbilicus. Lets face it—to be of any cosmetic value, the incision has to be buried in the umbilicus. This greatly affects one’s view of the hiatus and left crus, and the surgeon really needs those retraction skills to get good visualization. Knot tying is also more difficult, as you are even further away, and the range of movement less. Don’t move to the umbilicus until you can tie knots in a higher port placement.

I would avoid doing any men until you’ve done 20 women, no matter what the BMI. I would also avoid doing anyone with a very long torso early in your experience, as it can be quite difficult to comfortably reach the hiatus.