The SILS procedure has been successfully applied to conditions such as appendectomy, cholecystectomy, splenectomy, antireflux operations, and adrenalectomy in the pediatric population.4,6–8
Most of the reported series are small, single-surgeon experiences, and long-term results are yet to be validated. One very obvious benefit of this procedure is the superior cosmesis with no visible scarring. In the current era where a high premium is placed on cosmesis, it is likely that this technology will see an increased demand. Its sustainability as a craft, however, will depend on its long-term safety record and mastery of the technique by a large body of surgeons. The initial results with laparoscopic cholecystectomy were inferior to the open technique due to poor understanding of the technology and its applications.9
It is imperative that similar mistakes are not repeated when newer stealth surgical techniques like SILS and NOTES (Natural Orifice Transluminal Endoscopic Surgery) are offered to the general population. Surgical training programs should take the lead in ensuring that new technology is safely and effectively taught to the new generation of trainees. In our series, residents proficient in conventional laparoscopic appendectomy had a substantial learning curve to perform a relatively simple procedure, appendectomy, using the SILS technique. The 30° cameras, energy source (electrocautery), meso-appendix dissection technique, and endoloop ligation of the appendix stump were exactly the same as the technique used in our conventional laparoscopic appendectomy procedures.
The SILS technique, while having a steep learning curve, can be performed with adequate mentoring and preparation on the part of the trainee. In our early experience, only 1 patient out of the 20 (5%) was converted to conventional multiport appendectomy. In previously published studies,3,10
this conversion rate has been shown to be between 4% and 20%.The resident mean operative time of 73 min was longer than the 35 to 55 min of attending operative time. The latter times were similar to those described in other recent studies that were performed by attending surgeons.3,11
The electrocautery dissection of the meso-appendix and endoloop ligation of the stump increases the duration of the SILS appendectomy as compared to studies that use endoscopic staplers. Manipulation of the endoloop to the appendico-cecal junction takes time to learn with the SILS technique. Our case mix was also more varied with a higher incidence of perforated appendicitis and fewer elective interval procedures. Some studies have noted a higher incidence of umbilical wound infections with this procedure.11,12
This is presumed to be secondary to the radial pressure on the surrounding tissues from manipulation of the instruments through a narrow working channel. With the development of trocars with built-in wound protecting specimen retrieval systems, the incidence of such infection may decrease. SILS instruments may be unwieldy for small infants, and we limited its applicability in our institution to children > 4 y of age. Angled laparoscope navigation and ergonometric movement of colocated camera and instruments are factors that will likely evolve with time and will make the procedure easy. Development of the flexible tip laparoscope is a step in this direction. In our early experience with this device (used in 2 of 20 cases), there appeared to be minimal conflict between the scope and the instruments as compared to the regular laparoscope.
The inability to successfully impart skill training in general surgical programs, as technology has evolved and work hour restrictions developed, has led to a mushrooming of fellowship programs in various surgical subspecialties. The Halstedian apprenticeship model of surgical training depended on development of skill-, rule-, and knowledge-based behavior under the supervision of an expert surgeon.13
Novel teaching methods need to be developed to facilitate resident learning in this era where great importance is accorded to work-hour restriction, ethics, patient safety concerns, and surgical department economics. Imparting SILS skills may require designated simulator time, development of simulation technology to reinforce such skills, and devotion of slightly longer operating room times to resident education in surgical training programs. SILS skills should include an ability to work with crossed instruments, ambidextrous dissection, left-handed endoloop application, and angled-scope navigation.
In our experience, SILS technology appears to be promising for the treatment of acute appendicitis. The technique can be imparted satisfactorily to general surgery residents without advanced laparoscopic skills, with the caveat that the conclusion is not based on objective criteria that evaluate the resident performance of the key steps of the operation.