'Scarless' Gallbladder Surgery: SILS and NOTES

Surgery performed through a “scope” is now very common. Orthopedic surgeons can look at the inside your knee with a small scope. Gastrointestinal specialists use flexible scopes to exam the colon and stomach without the need for major surgery. General surgeons have been using scopes for the past 10 to 15 years for a variety of procedures. The most common procedure performed with the aid of a laparoscope is a laparoscopic cholecystectomy or gallbladder removal.

The laparoscope was developed and pioneered in the late 1980s and early 1990s. It is not a laser or a telescope, although these are common misconceptions. The laparoscope is a rigid one-foot long fiber-optic camera. When plugged into a video screen, it allows us to see the inside of a patient’s abdomen.

The laparoscope is inserted through the abdominal wall via a five- to10-millimeter incision and a device called a “port.” Other ports are then placed via five-millimeter incisions and surgical instruments are passed through them for dissecting and removing the gallbladder. This approach to gallbladder removal is called the minimally invasive surgical or “MIS” approach and is the current standard of care in the United States. The MIS approach has also been adapted for colorectal surgery, appendectomy, and hernia repair, among many others.

More than four million laparoscopic operations are performed yearly worldwide. It has been clearly documented over the years that the benefits of MIS techniques include less post-operative discomfort, faster return to work or daily activities, and more acceptable cosmetic outcomes. There is also a decreased immune or stress response, lower chance of forming adhesions (bands of scar tissue), and a decreased incidence of incisional hernia as a result of the smaller incisions.

In an effort to push MIS techniques further along the spectrum toward truly noninvasive surgery, a group of surgeons and gastroenterologists have begun to research surgery via a natural orifice (i.e. mouth, rectum, or vagina). The idea of natural orifice translumenal endoscopic surgery or “NOTES” is currently experimental. Surgeons have successfully removed the gallbladder with a flexible scope placed through the mouth. The scope is placed through the mouth and a hole is made in the stomach to then enter the abdominal cavity. With specialized instruments placed through the scope, the gallbladder is dissected and pulled out through the mouth while the patient is under anesthesia. The hole in the stomach is closed and the scope withdrawn. The patient is left with no scar. It is believed that this approach will lead to virtually zero recovery time.

The NOTES gallbladder surgery has been successfully accomplished transvaginally and through the rectum as well. The NOTES approach is currently considered experimental and is in the very early developmental stages. Safety regarding closure of the stomach or other entry point is still not standardized, nor is the instrumentation.

In addition to the problem of having to enter the abdomen through the stomach, the NOTES technique requires the surgeon to operate a camera and at least two instruments through a single hole rather than the three or four holes (ports) that are used in the MIS technique. Thankfully, the technology industry has partnered with surgeons to provide new instrumentation that makes single point of entry a feasible option for gallbladder removal.

The single incision laparoscopic surgical or “SILS” technique serves as a bridge from MIS laparoscopy to NOTES. With the SILS technique, the gallbladder is removed by making a single one-inch incision in the belly button. Three small ports are placed together within the same incision for a camera and two instruments. This approach enables the patient to have a single small, barely visible scar within the belly button. This is the so-called “scarless” gallbladder surgery. It is not an experimental procedure. No natural orifice is compromised and if any difficulties arise during surgery, extra ports can be added immediately, converting it to a standard MIS approach. Innovation for the SILS approach is the safest way to eventually progress to NOTES.

To date, hundreds of SILS gallbladder removals have been performed around the country in a select few surgical centers, including Memorial University Medical Center in Savannah. More advanced MIS operations such as appendectomy, colon resection, and kidney removal have also been performed using the SILS technique. The technique offers a better cosmetic result, may lead to faster recovery, and results in fewer long-term hernia complications because there are fewer incisions.

It is exciting to see laparoscopic techniques advance. They continue to make surgeries safer and less invasive for the people who need them.

Written by Christopher Senkowski, M.D., of ACI -- Surgical Associates and Oliver Whipple, M.D., of Memorial Health Bariatrics.