Dr. Shawn M. Garber, MD, FACS, is the Director of the Long Island Institute for Minimally Invasive Surgery and New York Bariatric Group in New Hyde Park, NY. He also works as Chief of Bariatric Surgery and Chief of Mid-Level Practitioners at Mercy Medical Center in Rockville Centre, NY.
In an exclusive interview, he talks with Surgical Products about his experience practicing single port surgery, the instrumentation and technology he has been using, and what he sees for the future as single-incision surgery continues to advance.
How long have you been practicing single port surgery?
Dr. Garber: For approximately a year I’ve been practicing single port surgery, mainly for Lap-Band surgery, as well as for cholecystectomies.
What advantages has single port surgery offered for your bariatric patients?
Dr. Garber: There are multiple advantages to the patient. One of the big advantages is improved cosmetic results. For patients who would have five incisions for a Lap-Band, we do it through one incision inside the belly button.
In fact, we just had an abstract accepted by the American Society of Metabolic and Bariatric Surgeons (ASMBS) where we compared our Single Incision Laparoscopic Surgery (SILS) Lap-Band to an age- and BMI-matched group that had traditional Lap-Band and it showed that SILS Lap-Band patients used less pain medication. This is a big advantage all around. Patients have a lot less pain after surgery. From an economic aspect, hopefully patients will stay in the hospital for a shorter period of time and will have a quicker recovery.
Are there certain patients who are better candidates for single port surgery, or is this technique advantageous for all patients?
Dr. Garber: Earlier on, we limited the single-incision procedures to the patients with a lower body mass index (BMI)—the smaller patients who had less fat around their organs and inside the abdomen.
Now, as we get more experienced and the instrumentation has improved, we are able to treat more patients through single-incision. We started out operating on people with a BMI of 40. Now we can treat people with a BMI up to 50 through single incision.
Some of the previous instruments that we had were too short and we couldn’t reach the area that we had to work on. However, new instruments have incorporated added length and extra articulation. This helps us operate on taller patients and bigger patients. It improves the procedure and makes it quicker to suture.
Are there certain obstacles you face as a surgeon doing single port surgery in the OR?
Dr. Garber: There is definitely a learning curve to single incision surgery versus traditional laparoscopic surgery. When you do traditional laparoscopic surgery, you have multiple ports, so the instruments are spaced apart. When you use a single incision, all your instruments go into one hole and one of the obstacles you need to overcome is when instruments bang into each other.
Now, we are using new instruments with an extra degree of articulation so you put them in and the ends extends out. By doing that, you’re actually crossing your instruments, so instead of a straight arm that you’re used to [in laparoscopic surgery], you have to get used to crossing your instruments while you’re working.
It adds another degree of difficulty to laparoscopic surgery. However, once you get used to it, you learn which instruments to put into which holes and how to place your instruments to work with that extra degree of articulation that you’re not used to using.
In terms of instrumentation, what advances in single port surgery products have helped make these procedures easier for you as a surgeon?
Dr. Garber: The biggest advancement thus far for single incision surgery has been the port, such as the SILS™ Port from Covidien. Prior to having that port available, we would put three or four tiny trocars through one incision.
That caused problems because when you do laparoscopic surgery, you blow the abdomen up with carbon dioxide so you can see inside and see what you’re doing. By putting 4 different holes in the abdominal wall through a single incision, the biggest problem we had was that the air would leak out, so you couldn’t maintain that pressure inside the abdomen you needed to work. By having the single incision port, it works amazingly in maintaining the pneumoperitoneum (the air inside the abdomen).
Next, the instruments with the extra degree of articulation are also an important advancement. In order to do single-incision surgery, you can’t just use straight, normal instruments because they end up banging into each other and it’s very difficult. So by having these instruments where they actually articulate, that allows us to do the surgery better, as well.
Finally, instrumentation like Covidien’s SILS™ Stitch, provides an extra degree of articulation as well as the extra length we need to suture. I like to do all the surgeries through the belly button, so for a taller patient you need more reach to get up to the top part of the stomach to operate. Before, it was very difficult to suture in single-incision surgery because the instruments were crossing. This new technology saves a lot of time in the OR and it makes it much easier to do the suturing as well.
What advice would you offer fellow surgeons who may be looking to embark on single incision surgery who haven’t yet?
Dr. Garber: It’s added a lot to my practice. It’s the newest wave in laparoscopic surgery. From a marketing perspective, the biggest thing we are marketing right now is single incision because it is very appealing to patients to say ‘we can do your surgery through one incision hidden inside your belly instead of having little cuts all over your abdomen.’ So from a marketing perspective, it is something surgeons and hospitals should look into starting to do because people are going to be asking for it.
Also, surgeons need to be careful. There is a learning curve to it. You should definitely take courses and learn from people who have already done these procedures. You are taking a simple surgery like a laparoscopic removal of the gallbladder and making it more difficult by doing it through a single incision. You don’t want to have any complications during that learning curve, so it’s very important to get that proper training to be able to do these surgeries properly right from the beginning.
What do you see for the future as single port surgery becomes more common?
Dr. Garber: I think the way surgery has evolved, it has gone from open surgery and big incisions to laparoscopic surgery and now to single-incision. The next thing that people are talking about is NOTES, or surgery with no incisions.
I think a big part of technology in surgery is to make incisions smaller and smaller, and then eventually have no incisions. I think that is the way medicine is moving, and SILS surgery is one step on the way to the next step, which may be NOTES surgery down the road.