Single-incision Laparoscopic Surgery (SILS) Versus Standard Laparoscopic Surgery: a Comparison of Performance Using a Surgical Simulator

Introduction: SILS has emerged as a promising minimally invasive surgical approach. However, SILS may not allow the same level of manual dexterity and technical performance compared to standard laparoscopic surgery (LAP). We compare the performance of standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS) using either SILS or LAP techniques.

Methods: Medical students, surgical residents, and attending physicians were recruited for the study in accordance with an IRB-approved protocol. The subjects were grouped according to previous LAP and SILS experience. The inexperienced group (IE) had no previous FLS, LAP, or SILS experience. The laparoscopic-experience group (LE) had performed >25 LAP operations but no SILS procedures. The SILS-experience group (SE) consisted of attending LAP surgeons who had also performed at least 5 SILS operations. Each subject performed standardized tasks from FLS including peg transfer (PEG), pattern cutting (CIRCLE), placement of ligating loop (LOOP), and intracorporeal suturing (SUTURE) using a standard, three-port, FLS box-trainer with standard laparoscopic instruments. For SILS, the subjects used an FLS box modified to accept a Covidien SILS Port ™ with two working ports for instruments and one port for a 30-degree 5mm laparoscope. SILS tasks were performed with Covidien Roticulator™ instruments capable of unilateral articulation. SILS suturing was performed using a Covidien SILS Stitch™ (articulating Endostitch™ device). Performance of FLS tasks was graded using standard time and accuracy metrics. Individual task scores as well as overall laparoscopic FLS score (LS) and overall SILS FLS score (SS) were calculated for each participant, and normalized to previously published FLS scoring criteria used to distinguish competent (>54%) and non-competent surgeons (<54%).

Results: A total of 27 subjects participated in the study. SS was lower than LS in all groups. LS increased with experience level, but was similar between LE and SE groups. SS increased with experience level and was different among all groups.

Mean Score (%) ± Standard Deviation, According to Study Group
IE(n=13) LE(n=9) SE(n=5)
LAP SILS LAP SILS LAP SILS
PEG
61 ± 29 * 8 ± 16 93 ± 11 * 27 ± 24 98 ± 7 * 65 ± 21
CIRCLE 22 ± 17 * 17 ± 4 63 ± 25 * 31 ± 21 80 ± 4 64 ± 12
LOOP 31 ± 23 18 ± 19 72 ± 14 42 ± 39 84 ± 11 80 ± 16
SUTURE
24 ± 32 * 43 ± 18 85 ± 16 67 ± 13 100 ± 2 * 89 ± 10
OVERALL SCORE
34 ± 14 * 19 ± 11 79 ± 13 * 42 ± 16 91 ± 5 * 75 ± 12
* p < 0.05

Conclusion: SILS is more technically challenging than standard laparoscopic surgery. Using currently available SILS platforms and instruments, even surgeons with SILS experience are unable to match their LAP performance. Surgical simulation can provide a way to objectively benchmark new platforms and instruments for SILS. Specialized training curriculums should be developed for inexperienced surgeons who wish to perform SILS.


Session: Podium Presentation

Program Number: S094

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