Minimally invasive single-site incision offers new surgical options

Ariel Sikkila had surgery to remove her gall bladder, but it would be hard to tell by looking at her.

While some gall bladder surgeries are open, or performed through one large incision, most are done laparoscopically, that is, typically through four small incisions in the abdomen.

But Sikkila, a 25-year-old administrative assistant, had the procedure done through a single incision with the help of a robot, a technique that experts say is growing in popularity.

"My recovery was a lot easier than I thought it would be," the Greer woman said. "I don't think I was out a week. I had surgery on a Wednesday and worked half-days the next Monday and Tuesday."

Like laparoscopic surgery, single-site surgery uses a camera to see inside the abdomen and instruments that are operated by a surgeon sitting at a console some feet away from the operating table, said Dr. David Anderson, a general surgeon with Carolina Surgical Associates of Bon Secours Medical Group.

But the instruments, which are placed in the incision at the navel, are smaller and more flexible, he said. That allows more dexterity and range of movement, he said.

"We're making just one 1-inch incision rather than one half-inch incision and three or four quarter- to third-inch incisions," he said. "So the overall length is shorter and there are less incisions."

At Bon Secours St. Francis Health System, surgeons use the da Vinci robot in single-site surgery. It offers six to 10 times magnification and 3-D imaging, compared to 2-D images with standard laparoscopy, Anderson said. It also can use fluorescence to light up the anatomy so it is easier to see, he said.

Cosmetically, the results are better, too, he said.

"We do it right through the belly button, so it's partially hidden to begin with," he said.

Dr. David Godwin, who has performed almost 400 hysterectomies with the da Vinci robot, using anywhere from three to five incisions, is now doing them via single-site surgery as well.

"Instead of having the multiport surgery, you have one incision that you put all the instruments and camera through and you're able to do the same surgery," said Godwin, a gynecologist with Commonwealth Women's Health of Bon Secours Medical Group, adding the robot affords better visibility and precision.

"The thought is to be able to get away with the least number of incisions," he said.

As with the single-site gall bladder surgery, patients typically go home in less than a day, and the result is better cosmetically as well, he said.

"It's better to have one incision instead of a few," he said. "Most people would be happier."

The cost of the surgery is the same and is covered by insurance, Godwin said.

Patients are typically back to work in one to three weeks, depending on their jobs, he said. Even with laparoscopic surgery, they usually go back to work in two or three weeks as opposed to six to eight weeks with traditional open surgery, he said.

There is a learning curve to single-site surgery, the doctors said. But with proper training and experience, the risks are similar to laparoscopic surgery and include injury to the liver, the bile ducts and other surrounding structures, Anderson said. But the risk of infection should be reduced because there is just one incision, he said.

Dr. Donald W. Wiper III and Dr. Patrick Springhart, co-chairs of the robotics program at GHS, said single-site surgery may be more prone to hernia formation and is likely going to be more painful.

"The technology is also more expensive, which is a major concern as we all strive to deliver value to our patients and to the health care system. There is no evidence currently that patients will do better using single-site surgery as opposed to current minimally invasive platforms — either robotic or traditional laparoscopy," they said in a statement.

"Our position is to either wait to see a well designed research study published that proves (single-site surgery) is better — and worth the cost — or we will design and conduct that study ourselves," said Wiper.

Dr. Thomas Mann, chief of surgery at St. Francis, who has performed more than 30 single-site gall bladder surgeries, said it's all about the patient.

"The patient has less pain due to fewer incisions; it is cosmetically superior as the incision is hidden in the umbilicus (navel)," he said. "The surgeon has better visualization due to the use of fluorescent dye to identify anatomy. This reduces the chance of complications for the patient, which also reduces cost.

"This is the next generation of minimally invasive surgery."

Anderson said that when he did his surgical fellowship 20 years ago, laparoscopic surgery was the wave of the future. Now, he said, robotics are the next wave of minimally invasive surgery.

"We are always looking to do things in a less invasive way, with smaller incisions, less pain, quicker recovery," he said. "In the next five to 10 years, it will be the standard of care."

Sikkila suffered with gall bladder problems for years before deciding to have the surgery.

"It got to the point where I couldn't eat hardly anything," she said. "Everything made me feel sick to my stomach."

When she'd finally had enough, she chose the single-site surgery because she thought there would be a faster recovery and less pain. And though she was sore afterward, she managed to control the pain with ibuprofen after the first two nights, she said.

In two weeks, she was using a stationary bike and elliptical machine, and she was back to running in three weeks, she said.

The scar is minimal, "like someone drew a little smiley face" under her navel, and she expects that will fade with time.

"I didn't really know what to expect," she said. "Having my wisdom teeth out was worse."