Surgeons have made great advances in developing single port surgery. Still, questions remain with regard to the impact the technique has in improving surgical care, leaving some surgeons to speculate that there is an even better technique on the horizon.

March 15, 2010

When Italian surgeon Giuseppe Navarra, MD wrote the first reports of a gall bladder surgery performed through a single port in 1997, he discussed why he thought the technique would not go any further.

When Italian surgeon Giuseppe Navarra, MD wrote the first reports of a gall bladder surgery performed through a single port in 1997, he discussed why he thought the technique would not go any further.

With issues of safety, longer operative times and limitations in terms of the types of patients single port surgery could be performed on, the surgical technique overall did not seem to offer any major improvements in patient care.

According to Paul G. Curcillo II, MD, FACS, Vice Chairman of the Department of Surgery and Director of Robotic and Minimal Access Surgery at Drexel University College of Medicine in Philadelphia, PA, gynecologists had been practicing the concept of single port surgery for years using very specific instrumentation to do tubal ligations and explorations. The problem, though, was that the technique could not be spread out to other procedures.

So, Dr. Curcillo began looking for a way to move single port surgery forward into other procedures. Together with Stephanie A. King, MD, FACOG, Chief of Gynecologic Oncology at Drexel University College Of Medicine, the surgeons performed the first Single Port Access (SPA) surgical procedures.

“In September of 2004, we published a technique to repair laparoscopic ventral hernias through two holes instead of four or five,” Dr. Curcillo says.

Through 2006, Dr. Curcillo and Dr. King continued to reduce the number of holes in a number of procedures while using standard laparoscopic instruments. In April 2007, the team performed their first few cases using one hole to do procedures that routinely used three or four holes. In May 2007, the first SPA cholecystectomy was performed and in June 2007, Dr. King performed the first oopherectomy using the technique.

“Since then, we have now done about 350 cases combined,” Dr. Curcillo says. “We’ve done just about every case imaginable, everything GYN and general surgery combined.”

Despite Dr. Curcillo and Dr. King’s success, questions of the true value of SPA remain.
The Advantages—Potential And Proven
For Homero Rivas, MD, MBA, FACS, Assistant Professor of Surgery in the Gastrointestinal Endocrine Division at UT Southwestern Medical Center in Dallas, TX, he and his surgical team turned to single port surgery in 2007 to achieve some of the principles of Natural Orifice Transluminal Endoscopic Surgery (NOTES).

“We had been exploring the concept of NOTES, but it proved to be very challenging, very controversial and expensive with a lot of time involved with very little return of investment,” he says.

Making one incision hidden ideally in the umbilicus, Dr. Rivas found he could offer some of the same values that NOTES may have as far as no visual scars, very little pain and a faster recovery.

 Performing the bulk of his single port procedures on cholecystectomy and appendectomy cases, Dr. Rivas says he has seen undeniable cosmetic benefits for patients. In addition, there are other potential advantages that still need to be proven, including:

  • Less pain.
  • Faster recovery.
  • Lesser need for medications.
  • Less psychological repercussion or reminder to the patient that they actually had surgery.

Just like there are potential advantages for patients in single port surgery, there are some for surgeons as well. “It’s a dramatically valued proposition for a surgeon to tell a patient that we can offer them major abdominal surgery with no resulting scar,” Dr. Rivas says.

He also says some of the initial challenges associated with single port surgery are evolving as it becomes more common. Once the basic concepts, challenges and solutions of the technique are understood, most surgeons can overcome otherwise long learning curves that would increase their operative times.

He also says some of the initial challenges associated with single port surgery are evolving as it becomes more common. Once the basic concepts, challenges and solutions of the technique are understood, most surgeons can overcome otherwise long learning curves that would increase their operative times.

Additionally, while at first only certain patients were considered candidates for single port surgery—those who were thin,  those who did not have complex diseases or co-morbidities, and those who hadn’t had multiple abdominal operations—with gained experience, the technique is opening up to more complex patients. 

Further, Dr. Rivas explains, instrumentation to get access and to keep access through a single port has helped enable the technique’s development. Today, surgeons are more efficient using articulating flexible instruments that provide more angles of freedom.

Weighing Benefits and Costs
“Anytime you do something new, there are going to be elements that may change the safety factor or make it more complicated,” Dr. Curcillo says.
Still, the more complicated procedures may only be worthwhile if the benefits outweigh the costs. In developing their SPA technique, Dr. Curcillo and Dr. King identified a few key areas in which single port surgery needed to demonstrate improvements over multi-port surgery in order to move forward:

Safety. “It has to be as safe as what we call multi-port procedures, meaning you can’t do something new through one hole that’s not as safe as through four holes,” Dr. Curcillo says.

Take for example the laparoscopic cholecystectomy in the early 1990s, when laparoscopy was first introduced. As Dr. Curcillo says, there was an increased incidence of injuring the common bile duct in these procedures. While the increase in complication was never accepted by surgeons, it was realized that the benefits offered to patients through laparoscopy was such a dramatic improvement over an open procedure in terms of recovery that it was worth it to work through the complications.

“What [surgeons] said was, ‘ok, we changed the patients outcomes to be so much better that let’s work with this. Because we have an increased risk of common bile duct injury, we have to come up with a way to make sure that doesn’t go higher.’ The complications were not accepted, but the benefits were so dramatic that we pushed through it,” Dr. Curcillo says.

The problem with single port surgery is that the safety benefits of surgery through one hole are not as great when compared to four holes as the benefits of laparoscopy when compared to open surgery.

“If I am going to send a patient home six hours after surgery, is it a benefit to send them home five hours after surgery?” Dr. Curcillo explains. “If a patient is going to take four narcotic pills after a four-hole gall bladder surgery and with SPA surgery, they take two, is that really a benefit? From a patient recovery standpoint, from a pain standpoint, from an outcomes standpoint, the benefits are not as large as they were in the early ‘90s. Now, any problems, any new complications, any increased complications aren’t going to be nearly as worthwhile.”

Economic and ecologic costs. Over the last 20 years of laparoscopy, surgery has moved into a disposable environment, Dr. Curcillo says, which has increased both the economic and ecologic costs associated with single port surgery. By using all reusable, standard laparoscopic instrumentation and less trocars in their SPA technique, Dr. Curcillo and Dr. King have found they can save on costs while reducing medical waste.
“If a hospital makes $1,000 on a gallbladder surgery, and somebody introduces a new device that is $400 and the hospital doesn’t get reimbursed for that new device, that means the hospital now has to spend $400 more and now only make $600 on that procedure,” he explains. “If that new device makes things so much better, then it may be worth it from some other standpoint, but what we’ve now shown is that additional cost in devices may not offer any benefits.”

Surgeon training. With the origination of NOTES, it was accepted that the technique would be reserved for high-end, highly-trained surgeons.

“That’s ok if you’re talking about a procedure that there’s only 40,000 or 50,000 per year being done,” Dr. Curcillo says. “You can train enough people to do that. But gall bladders and hysterectomies are not only the most common procedures we do, but they’re also done by almost every general surgeon and every gynecologist out there. So, we couldn’t come up with a technique that patients would have to travel 200 miles to find a specialist to do it. We want something that every general surgeon, every gynecologist could be offered an opportunity to do.”

Dr. Curcillo and Dr. King developed a step-wise training platform with their SPA technique. Additionally, companies that offer single port devices are running training sessions on the technique using the new tools.

A Bridge To The Next Step
In developing their SPA technique, Dr. Curcillo and Dr. King have now proven single port surgery is as good as multi-port surgery, allowing them to move forward.

“We spent the last three years taking an idea that a lot of people said was not going to happen, showing them it is possible and getting to the point where now every major meeting has courses on it,” Dr. Curcillo says.
However, for surgeons looking to first embark on single port surgery, Dr. Curcillo offers some sound pieces of advice:

  • Take a non-biased course offered by physicians dedicated to doing this technique.
  • Don’t do it alone and follow a step-wise progression. After taking a course and performing an SPA procedure in a lab, go back and do the first surgery on the patient through three holes. Get comfortable through three holes then do a couple of cases with two holes, then do a single port, Dr. Curcillo says. Throughout this progression, have someone to bounce ideas off of and learn from.
  • Be safe. “Don’t ever sacrifice safety just to be able to say you did the next best thing,” he advises. “If you’re doing a case with one hole, and safety is at risk, put in another port and when the patient wakes up, let them know you had to use two holes instead of one, but it was done safely.”

In addition, Dr. Rivas offers these words of wisdom:

  • Have an open mind. “As laparoscopic surgeons, we take pride in being very forward thinking, very proactive,” he says. “Yet, we are among the most conservative surgeons out there. Whenever there is an innovative procedure, we are skeptical and criticize it as much as we can, so being open minded is the first and biggest step.”
  • Become familiar with the instruments. Any new instruments used in single port surgery can be used in conventional laparoscopic surgery first as practice.
  • Be transparent with your patients. Let them know that this is something you are implementing to your practice and that it is something new, even though in concept, it is similar to what you have done for many years.

As for the future? Dr. Curcillo says it may lie in the question—what if we just move that hole? Move the hole to mouth or the rectum or the vagina and now surgeons can do NOTES. In the end, perhaps single port surgery is simply a stepping stone to an even greater innovation in surgery that is yet to be seen.

“Now, you begin to see a bridge,” Dr. Curcillo says. “Maybe here is a way for us to get there by marrying NOTES to single port. It may not be the future, but it may lead us to something even better.”