Single Incision Surgery (SILS) v1

Normal keyhole surgery involves making multiple small incisions in the tummy and inserting instruments though those incisions. With SILS, I make only 1 incision and normally this will be in the belly button. The incision is about 2 cm in length. Through that incision, the telescope and operating instruments are inserted into the tummy to perform the procedure.

Through this I can undertake a varity of gynaecology procedures ranging from simple to complex ones including:

• removal of fallopian tubes and ovaries
• removal of ovarian cysts
• treatment of ectopic pregnancy
• freeing of ahesions
• hysterectomy
• sacro colpopexy for management of prolapse
• removal of fibroids

SILS can be used with either conventional laparoscopy or robotic surgery. The latter is preferred for complex surgery as robot technology enhances the simplicity and safety of the procedure.

With SILS, the recovery can be better than conventional keyhole surgery with multiple cuts in the tummy. There appears to be less pain due to there being only one incision. It results in less bruising and muscle trauma. The cosmetic outcome is better. I thus offer it to patients where I believe it will be a suitable technique for their problems.

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Info on advanced hysteroscopy

Hysteroscopy is inserting a telescope into the cavity of the womb to allow visualisation of the contents. In doing so, the presence and site of abnormalities can be detected. Usually combined with a curette, it provides more accurate information than a curette alone.
It is used to treat many conditions. Fibroids and polyps can be resected. Abnormal shaped cavities due to the presence of a septum can be refashioned to a more normal cavity. Excessive scar tissue causing Asherman’s syndrome can be divided and endometrial ablation for treatment of heavy periods are also examples where advanced hysteroscopic techniques have been used to achieve good outcomes with minimal stress. In many instances it has replaced the need for more major surgery.

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Robotic surgery

Using a robot to assist in surgery is becoming widespread and popular in all fields of surgery. Initially used in prostatic surgery, its use has advanced to other fields including gynaecology, bowel and weight loss surgery, ear nose and throat disease and heart surgery to name a few. The popularity stems from the significant advantages over conventional laparoscopy derived from improved optics and flexibility of the equipment used. Currently the device used is the Da Vinci robotic system.

My training in robotic surgery commenced in New York where I learnt to use the Da Vinci system. I then went to South Korea and learnt the Single Incision Surgery (SILS) Technique from Professor Kim at Yongsei University.

Like conventional laparoscopy, multiple small cuts are made in the tummy. Through these cuts, gas is instilled to inflate the tummy up. Then a telescope and robotic arms with instruments are inserted. The surgeon sits on a separate console and manipulates the telescope and the robotic arms whilst performing the operation.

 The advantages of the robotic system over conventional laparoscopy are:

• Enhanced vision – 3D high definition vision allows amazing detailed definition of anatomy. It enables more precise surgery to be performed.
• Wristed instruments – the ends of the instruments used for the operation are wristed. This means the ends are flexible and can move about like you can bend your wrists. This allows increased manoeuvrability especially in small confined areas being operated on. This is in contrast to conventional laparoscopy where the instruments are fixed.
• Better hand eye co ordination Improved co ordination of all instruments which are under the direct control of the surgeon. This is in contrast to conventional laparoscopy where the surgeon only holds 2 out of possibly 4 instruments, the other two being held by an assistant surgeon. In that instance the surgeon has to not only concentrate on operating but also coordinating the assistant surgeon’s movements. With the robot he controls it all him/herself.
• Better ergonomic positioning. Sitting on a separate console to control the instruments, the positioning for the surgeon especially in long operating cases is more relaxing. This reduces the possibility of tiredness and discomfort which comes from standing and moving about using different instruments when using conventional laparoscopy.

In my experience of over 100 cases of robotic surgery, I have found that the patients appear to have:

• Shorter hospital stay
• Less blood loss
• Less pain
• Fewer complications
• Faster return to normal activities

I now routinely offer robotic surgery for

• hysterectomy,
• removal of severe endometriosis,
• removal of fibroids
• sacro colpopexy for prolapse
• reversal of tubal sterilisation
• freeing up of severe adhesions

Where appropriate I also use the SILS technique in robotic surgery to enhance the recovery and cosmetic outcomes for the patient.

In many patients, despite major surgery, their recovery is so good that they can be disharged home the following day. Where suitable, same day discharge can also be achieved, even for hysterectomy.

Info on conventional laparoscopy

This well-established technique revolutionised surgery when it was first introduced. Widely used in all fields of surgery, it has resulted in a significant reduction in risks and enhanced recovery in patients in all forms of surgery, some of which are indeed very major ones.

In Gynaecology, it involves making small cuts in the tummy and inflating it with gas. A telescope is then inserted and the internal organs are visualised. Multiple other instruments are inserted through other small incisions and major surgery can then be performed. They range from hysterectomy, removal of ovarian cysts, fibroids, removal of endometriosis and surgery for prolapse and incontinence, removal of ectopic pregnancy and tubal re anastomosis are some examples of this.

Prior to laparoscopy, to undertake such surgery would have involved making a big cut in the tummy. This had greater risks with infection in the wound, blood loss and resultant internal scarring. In laparoscopy, due to the small cuts and smaller instruments used, the procedure became less invasive. Hence the term minimally invasive Surgery. This resulted in lower risk surgery and quicker recovery for the patient.

In my practice, most of my laparoscopy procedures are discharged home the same day. With more complex surgery the stay is usually longer although I have had women having hysterectomy going home the same day. Needless to say, this is dependent on a number of factors including the wishes of the patient and the support available at home. For most women, they experience a recovery phase of only 1-2 weeks before returning to normal activities and work.

I have also introduced the SILS technique in my practice of laparoscopy. Using a single incision, only through the belly button, I can perform all the surgery through that. With this I am finding an improved outcome with less pain and better cosmetic result. Whilst a good technique, it can only be used in appropriately selected cases.