Single Incision Laparoscopic Surgery, SILS, is another way to do laparoscopic surgery but may not add value.

Today I spent the day at Ohio State University at a conference about performing Single Incision Laparoscopic Surgery, also referred to as SILS.

Over the last three years I have been involved in the development of SILS technology as well as technology to perform surgery using natural orifices such as the mouth, vagina or rectum without making incisions in the skin at all. So using new devices to perform laparoscopic surgery through a single fairly small incision is not new to me. But it did start me thinking about how much value there is to this technique.

The transition from open operations using a single large incision was the only way operations were able to be done until the late 1980’s. Then surgeons began to do operations through several very small incisions by using a scope with an attached camera called a laparoscope with the image projected on a TV screen. Today most bariatric operations are performed using the laparoscopic approach. In fact in my practice I do nearly all the bariatric operations using a laparoscopic approach and do an open operation for bariatric surgery only a couple of times a year.
This revolution from large incisions to laparoscopic surgery brought with it a tremendous amount of added value to our patients. In bariatric surgery this technique results in less pain, less infections at the incisions, less risk of hernia in the incisions, better cosmetic results and earlier return to work to mention a few of the benefits. There is no argument today that laparoscopic bariatric surgery has resulted in better outcomes.

The question is whether a Single Incision Laparoscopic Surgery adds additional value beyond the present standard laparoscopic approach.

In the SILS approach a single incision, usually about one and a half inch in length, is made in the skin and in the muscle layer of the abdomen. One of several devices is inserted into this incision that allows all of the instruments needed in the operation to be passed through the device. After the operation is completed, the incision through the muscle layer of the abdomen is closed with stitches as is the skin layer.

Surgeons are constantly looking for ways to perform surgery that adds value for our patients. However, although this technique is a very legitimate way to do an operation we must ask ourselves whether this adds value to our patients or not. It does not result in less pain, less risk of infection, and may increase the risk on a hernia forming in the incision since a larger incision is made in the muscle layer of the abdomen.

About the only possible added benefit to the patient is a better cosmetic result and this may only occur if the operation is done through the belly button, (which surgeons call the umbilicus).

Let’s call “a spade a spade”. The biggest benefit may be for the surgeon to “market” his practice. There does not appear to be a significant value to the patient at this time. I think it is very legitimate to offer this option to patients in select situation and I will offer this option to my patients that I think might be interested. However, this should only be offered as long as it is not touted as adding a lot of value to the patient and any additional risks are explained.

It is a wonderful privilege to have our patients trust us to do the best on their behalf. Surgeons must make sure we are honest and transparent in how we present these options to our patients. Our Hippocratic Oath binds us to “first do no harm”. Marketing should not drive these decisions.

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