Single Incision Laparoscopic Surgery (SILS) Training Using a Modified Skills Curriculum

Single Incision Laparoscopic Surgery (SILS) is an innovative approach to minimally invasive surgery and as such carries a learning curve for both new techniques and new technology. In this video we present a training paradigm for SILS skill training using a modified Fundamentals of Laparoscopic Surgery (FLS) curriculum.

In SILS the laparoscope and instruments are placed through a single access incision. While this may minimize scarring and pain, there are a number of technical challenges to SILS. Most notably the instruments and laparoscope are oriented in a coaxial orientation, rather than the triangulated orientation used in standard laparoscopy. This leads to conflicts between instruments and between the instruments and the laparoscope. The angle of approach to tissues of interest is also head-on rather than from the side, thereby reducing the ability of the surgeon to dissect behind structures such as the cystic duct.

In order to mitigate these disadvantages, instruments capable of articulation may be used. This however, increases the learning curve, as the instruments must be manipulated in novel ways. Articulating instruments are frequently used with the hands reversed and the instruments crossing at the fulcrum of the single incision site. Thus, the surgeon must manipulate the right instrument with the left hand and vice versa.

Fundamentals of Laparoscopic Surgery is a well-established training curriculum for laparoscopy developed by SAGES. It consists of a didactic training module followed by skills training in a box trainer with five discrete tasks: Peg Transfer, Circle Cutting, Endoloop, Suturing and Extracorporeal Knot-Tying, and Suturing and Intracorporeal Knot-Tying. The standard FLS trainer box is not suited to SILS training, as it has a built-in camera rather than a laparoscope. Additionally, port placement in the FLS trainer box is in the standard triangulated position, and not in the SILS coaxial orientation.

In this video we demonstrate a modified box trainer with both conventional and SILS capabilities. We perform the standard FLS tasks using conventional straight instruments in the coaxial orientation, and then compare two different types of articulating instruments in the SILS environment. In our experience a mixture of conventional and articulating instruments is best, with the choice of instrument tailored to the task at hand.

Session: Video Channel

Program Number: V051

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