Single-Incision Laparoscopic Surgery (SILS) or Zero Scar Bariatric Surgery

Overview:

Single-incision laparoscopic Surgery (SILS) (Zero Scar Bariatric Surgery) is a surgery done through the umbilicus or belly button by a single cut. It is a surgery done without leaving any major scars as the cut is hidden beneath the umbilicus or belly button. The scars are virtually invisible as they are hidden beneath the belly button. Individuals who undergo this procedure do not complain of pain and have a faster recovery. It also has better cosmetic results are the scars are not visible. 

The technique of SILS:

SILS is a surgical procedure done by using a single cut. It is a laparoscopic procedure. It does not use multiple cuts used in other procedures or larger cuts. The cut made in this surgery is 5-12 mm in size,1/2 inch, and just at or above the umbilicus. All the special instruments to be used in this procedure are inserted through this cut or opening. The cut is closed by using stitches and bandages. 

Indications:

SILS is indicated for a variety of procedures. These are:

• Laparoscopic gall bladder removal (cholecystectomy) 
• Laparoscopic sleeve gastrectomy and gastric banding procedures for weight loss 
• Appendix removal procedure 
• Heller myotomies in esophagus disorders
• Adrenalectomy for adrenal tumors 
• Surgical resection of the large intestine is called Hemicolectomy. 
• Sigmoidectomy to remove a part of the sigmoid colon.
• Splenectomy for surgical removal of spleen

SILS for bariatric surgery is indicated in the following individuals. It is done when an individual has excess weight, is obese, and is unable to lose weight by other means. The body mass index (BMI) parameter is to measure obesity. Any BMI > 40 indicates extreme obesity. Extreme obesity along with comorbid conditions like cardiovascular diseases, hypertension, high lipid levels, Diabetes mellitus, cancers, stroke, a condition called obstructive sleep apnea, and infertility are indicative of bariatric surgeries. 

Contraindications:

SILS or zero scar bariatric surgery is not indicated in pregnancy. 

Advantages:

SILS has many advantages over routine procedures. These include

• Reduced number of incisions 
• Reduced scar formation after the procedure 
• Reduced morbidity 
• Decreased wound infections, bleeding sites, and herniations. 
• Improved cosmetic look due to less number of scars 
• Faster recovery due to fewer healing areas 
• It is the most advanced technology that has replaced many traditional surgeries. 

Before the procedure: 

Before SILS, an individual should discuss the necessity and importance of the procedure with the healthcare provider (HCP). Complete details of the medical history, medications, or any history of previous surgeries should be given to the HCP. Few blood tests, urine tests, and imaging studies may be needed to understand the present physical condition of the individual. An Obesity Surgery-Mortality Risk score (OS-MRS) is used for risk stratification to narrow down which treatment suits a particular individual. 

Diet will be restricted and a list of medications to be stopped and another list to be used before the procedure will be given. A two-week milk diet is prescribed to reduce liver size. This also reduces any resistance during the laparoscopic intervention. The surgery will be done on an empty stomach. Hence it is necessary to refrain from eating anything 8-12 hours before surgery. 

During the procedure: 

The procedure is done under general anesthesia and the individual will be asleep during the procedure. Using an antiseptic solution, the surgical area is cleaned. A small cut is placed below the belly button or umbilicus. A triport is attached to the area where the cut is given. This allows the passage of various instruments. A small camera attached to a special instrument is sent through the opening of the triport. This helps in the visualization of the inner surgical area. This port also allows the removal of the smoke generated during the procedure. The surgical procedure is carried out based on the intended bariatric procedure for weight loss like sleeve gastrectomy or Lap band surgery. Then the incision is closed and bandaged or taped. 

After the procedure:

Individuals are brought to the recovery room and watched carefully till the vitals stabilize. Later the individual may be prescribed certain antibiotics and painkillers to reduce infection. The individual is advised to be on sugar-free, non-carbonated liquids for a week. This is followed by pureed foods for the next 3 weeks. One can have normal solids about four weeks after surgery. 

An individual is advised to avoid strenuous activities for about six weeks. Patients are advised to have at least 1-2 liters of fluids, protein for strength, vitamin and mineral supplements to avoid any deficiencies, and to avoid foods with concentrated doses of sugars and starches. 

Success:

SILS is considered successful if it is done without any additional incisions or ports. 

Challenges:

There are certain challenges with this procedure like a restricted number of working instruments causing restricted freedom of movement of the instruments. This can be overcome by using a large device with multiple ports to enter various instruments. However, using a single large instrument with multiple ports can lead to subcutaneous hematoma or seroma formations. The main challenge is the loss of triangulation which is generally done in laparoscopic procedures. This can be overcome by using angulated instruments and training. Using semirigid instruments can also help to overcome this challenge. 

Conclusion: 

Single-incision laparoscopic surgery is a surgical procedure done with a single cut. As there are no multiple incisions, and no large scars formed after this procedure, this has the advantage of faster recovery, less pain, and a small scar that is virtually invisible. 

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