Closing The Gap
It’s clear among the surgical community that an increasing number of surgeons are embarking on the single port surgery approach. From the cosmetic benefit of virtually hiding the incision scar in the umbilicus to the potential for reduced pain and a quicker recovery, benefits of this new technique are becoming more apparent.
In order for patients and surgeons to reap the possible benefits of single port surgery, though, the technique must be performed efficiently. Operating through a single port presents its own set of unique challenges that surgeons must overcome to remain efficient in the OR. One particular area of difficulty: suturing.
The industry has begun to provide new-and-improved instrumentation to enable more efficient suturing through a single port. As the instrumentation advances, surgeons get closer to closing the gap on mastering single port surgery, and understanding its overall role in surgery’s future.
Time Is Money
According to Shawn M. Garber, MD, FACS, Director of the Long Island Institute for Minimally Invasive Surgery and New York Bariatric Group in New Hyde Park, NY, and Chief of Bariatric Surgery and Chief of Mid-Level Practitioners at Mercy Medical Center in Rockville Centre, NY, there are many ways surgeons can choose to suture.
“Some surgeons tie the knots intracorporeally, meaning inside the abdomen,” he says. “Some surgeons tie the knots extracorporeally outside the abdomen. The key thing is to do what the surgeon is most comfortable with, and then, obviously, you want to do what is most efficient. Time is money in the operating room.”
As Dr. Garber explains, before a surgeon should even begin to consider tackling single port surgery, they need to master suturing in traditional laparoscopy. Surgeons who cannot suture well in laparoscopy will face difficulty moving to a single port.
“It’s important to be confident in regular laparoscopic suturing before even venturing into doing single incision lap surgery,” he says.
According to Scott Sanders, group vice president of product and procedure development for the Surgical Energy Division of Gyrus ACMI, once a surgeon is able to perform both extracorporeal and intracorporeal suturing in laparoscopic surgery, the learning curve for suturing in the single port may lessen.
“It’s nothing different than what you’re doing now, you’re just working in a tighter space,” he says.
The main difference between suturing in single port surgery compared to a traditional laparoscopic case is the added challenge of triangulation, Sanders says. In traditional laparoscopic surgery, a surgeon will triangulate the instruments to space them apart in order to achieve the angle needed to tie the knot. With single incision surgery, instruments cannot be separated as easily because they’re all inserted through the same port.
“The instruments kind of clash one against the other, or what we call ‘sword fighting’,” explains Jorge Lense, MD, FACOG of Cherokee Women’s Health Specialists in Georgia, a surgeon who has been practicing single port surgery since 2008. “You have to stop and think, ‘how can I approach my objective?’ or ‘triangulate on the tissue without clashing swords? ’ You just have to stop and think about what you’re doing and how to angle the instruments.”
This lack of triangulation can often present a real challenge to surgeons when it comes time to suture. According to Dr. Garber, it’s “close to impossible” to tie intracoporeal knots in single port surgery. He says it can be done using standard laparoscopic instruments, but it is often difficult and time-consuming. Most surgeons find themselves limited to extracorporeal knot-tying.
“Some surgeons will tie extracoporeal knots and push the knots down inside the abdomen because you can take bites of the stomach with standard laparoscopic needle holders,” he says. “It’s very difficult to tie the knots without being able to triangulate your instruments.”
According to Dr. Lense, traditional sutures also have presented a problem in single port surgery. Until recently, he used a regular needle and a needle driver to suture in single port surgery, and often had difficulty getting the needle in and out of the trocar. He also notes that many sutures are not specifically manufactured for laparoscopic surgery.
“If you have a 27" suture and you’re tying sutures in the umbilicus, you only have about two inches of suture hanging out of the trocar,” Dr. Lense explains. “It’s very difficult to tie the knot.”
Recently, several instruments have been brought to market to address the unique challenges associated with suturing in a single port environment.
For Dr. Garber and Dr. Lense, they’ve found a solution in devices such as the EndoStitch™ device from Covidien. The device shuttles the needle back-and-forth “like a sewing machine,” Dr. Lense says, so triangulation of the instruments is not needed in order to place intracoporeal sutures. The newer version of the device, the SILS™ Stitch also articulates so surgeons can achieve the angle they need to suture.
To address the need for more efficient suturing in advanced laparoscopic procedures, Richard Fleenor, president and CEO of PARE Surgical, Inc. introduced the 5 mm Quik-Stitch device for minimally invasive surgeries.
Eliminating the need for triangulation, the device is suited for single port applications. It incorporates a pre-tied locking Roeder knot in various suture spool configurations, a 19 mm straight needle and self-righting needle driver.
Meanwhile, companies such as EndoEvolution, LLC are working to develop an articulating suturing device to deploy curved needles for suturing through a 5 mm port.
According to Sanders, instruments such as curved graspers have helped surgeons suture more efficiently in single port surgery by making it easier to grab the needle and put it through tissue. He also notes that many surgeons have turned to barbed sutures for knotless suturing.
“Surgeons are able to go in and have the suture catch,” he says. “They’re able to throw the next stitch and do a nice running suture and have each one lock almost like an interrupted suture.”
Less Is More
Despite recent instrument advancements, this technique and the associated technology is still in the development stage. “Suturing is one area where I think they’re starting to get innovation from various companies, but many surgeons are still using existing laparoscopic-intended instrumentation to make it work through a single port,” Sanders says.
In the future, he predicts improvements to instrumentation will involve aspects such as better handle design, lengths of instruments and articulation.
Dr. Lense says he would like to see improved ergonomics on single port surgery suturing devices, saying rotating the instrument, angulating it and deploying sutures with one hand can be a bit of a challenge. He also notes the curvature of the needles is sometimes an issue and, in the future, would like to have more options for different needle sizes. The key, though, he says, lies in the ability for articulating equipment to continue to improve.
“As the instrumentation gets better, I think it’s going to get quicker and easier to suture through a single port,” Dr. Lense says. “I always say, ‘Why did I ever put those other ports there in the first place?’”
As it grows, many surgeons and industry experts feel single port surgery is simply the next step toward Natural Orifice Transluminal Endoscopic Surgery (NOTES).
As Sanders explains, single port surgery has allowed the industry to give more thought about how to simplify a procedure, what instrumentation can be used and what needs to be modified in order to facilitate NOTES in the future. For example, PARE Surgical has recently introduced a flexible suturing system that can go out of a flexible scope.
“Single port at least gives the beginning of: 'What ways can we approach suturing or closure in single port that could lend itself to NOTES,?'” he says.
For now, Dr. Garber urges fellow surgeons to start learning and getting involved in single port surgery, or they may risk “missing the boat.”
“Single incision surgery is a great thing to add to a surgeon's practice,” Dr. Garber says. “It’s a great marketing opportunity. It’s the next wave of the future.”
Dr. Lense concurs, and says it’s in the best interest of surgeons and their patients to continue to develop less invasive ways of performing surgery.
“The Hippocratic Oath of medicine is ‘First, Do No Harm’ and when you are doing surgery, of course, you’re doing harm,” he says. “You’re weighing the risks of doing some harm for a greater benefit. By doing a single incision surgery, you’re optimizing the Hippocratic Oath by doing less harm during surgery to achieve your objective. ‘Less is more’ definitely applies very well to single incision surgery.”