Learning Curve in Single Port Endoscopic Surgery

Sujith I Wijerathne, MBBS, MRCS, Dino A Liem, MD, Shaik A Buhari, FRCS, Narendra Agarwal, MBBS, MS, Chiara Montana, MD, Davide Lomanto, MD, PhD, FAMS. Minimally Invasive Surgery Centre, Department of Surgery, National University Health System, Singapore.

The MIS development towards a lesser invasive approach is evolving and in the last year the newly advocated Single or Reduced Port Endoscopic Surgery is gaining popularity. Single Port Endo-laparoscopic Surgery (SPES) has shown to have a favorable outcome in many surgical procedures and its utilization is increasing worldwide.

Early report showed a feasibility of the SPES technique in the most common procedures as appendectomy, cystectomy and cholecystectomy but seems to be technically more challenging. We started performing SPES since 2008 and we have reported its application in many different procedures from appendectomy to cholecystectomy, from adrenalectomy to TEP and TAPP. As for any procedure and especially for endolaparoscopic procedures a time for learning is required until the outcome can be comparable to the standard procedure. Aim of our study is to evaluate the clinical data from patients who underwent single port surgery for appendectomy N=42), inguinal hernia (n=73) and cholecystectomy (n=65) and define the learning curve for each procedure. All parameters of patients operated using SPES were collected and analyzed. Data including patient demographics, operating time, conversions, intraoperative and early postoperative complications was analyzed and compared using SPSS software.

73 hernias were repaired using TEP (35) and TAPP (n=28) (mean age was 49.39 years (range, 20-81)). The mean operating time for unilateral hernias was 75.67 minutes (range, 49-144) whereas for bilateral hernias it was 101.37 minutes (range, 62-150), No difference between TEP and TAPP procedure. 42 appendectomy performed (31F;11M), mean operative time was 40.4 min (range 29-76) while 65 cholecystectomy mean operative time was 36 min (range:23-86) No intra–operative or early post–operative complications were reported except 2 conversion to standard lap in appendectomy group; 1 in TEP group. No conversion in the cholecystectomy group. None of the patients required a stay of more than 23 hours and none had a pain score > 2 at the time of discharge. No incisional hernia or recurrence detected during the mean follow-up of 13 months (9-34mths). OT time and intra-operative complications were evaluated and plotted on a graphical scale.

Results showed that the operating time stabilized at around 12 cases (46 min) for inguinal hernias, around 9 cases (38 min) for appendectomy and 11 cases for cholecystectomy (41min). No intra-operative complications were observed.

Our study showed that SPES is a safe and feasible method for common surgical procedures and in experienced hands it can be mastered in about 10 cases and even during the learning curve it carries a low morbidity and conversion rate.

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