Single-incision laparoscopic sleeve gastrectomy: Is it worth it?

Use of single-incision laparoscopic surgery (SILS) has now been reported in almost every abdominal operation, including all types of colectomies [1], subtotal and total gastrectomies [2,3], bariatric surgery [4–6], cholecystectomy [7], and appendectomy [8,9], among others. In this issue of SOARD, Pourcher et al. [10] report perioperative and weight loss outcomes for 62 consecutive patients, with a median preoperative body mass index of 52.2 kg/m 2 (range: 50–87), who underwent SILS sleeve gastrectomy. No comparison group is available. Perioperative results are commendable, with a median duration of surgery of 89 minutes (range: 42–212 min), with 12 patients (19.3%) needing conversion to multi-incision laparoscopic technique, no conversion to open surgery, and only 2 complications (6.3%, both postoperative bleeding). At a median follow-up of 21 months, weight loss outcomes were similar to what is expected after standard multi-incision laparoscopic sleeve gastrectomy. The authors conclude that SILS sleeve gastrectomy for super-obese patients is “technically feasible, reproducible and safe in this series.” Although others have also reported feasibility with the SILS approach [4,6,10], it is important to underscore that the study by Pourcher et al. [10] was not designed or powered to define safety standards. In addition, and based on statements from the paper’s discussion section, the authors do seem to believe that SILS “minimize[s] surgical trauma, ”“ is less invasive,” and is “the natural evolution of multiport laparoscopic sleeve gastrectomy.” All these authors’ beliefs, however, are not supported by their manuscript’s data or the available literature. Although SILS has been used for multiple abdominal operations, it has not gained widespread acceptance by the surgical community. Reasons are that SILS is more challenging because of loss of instrument triangulation and also that it has not been found to provide any benefit to the patient, other than potentially improved cosmetic results [1,6–9]. Results of recent meta-analyses of randomized controlled trials for patients who underwent SILS versus multi-incision laparoscopic cholecystectomy have found that rate of conversion to open surgery, length of hospital stay, postoperative pain, adverse events, and superficial site wound infections were similar, at the expense of longer operative times, greater cost, and higher single port-site incisional hernia rate when the single-port incision is placed at the umbilicus [11–13]. Similar outcomes were observed in meta-analyses of randomized controlled trials for almost all other abdominal operations [1,3,9,14], with a higher superficial site wound infection rate after SILS appendectomy compared with conventional laparoscopic appendectomy in a large study from South Korea [9]. So, why should one choose to offer SILS if all patient-related outcomes, other than possibly cosmetic results, are similar or worse? We commend and encourage continuing clinical research into technological and technique developments that can result in improved patient outcomes, but we are not convinced, at this point, that the deletion of a few 3- or 5-mm ports and the added struggle to perform SILS is justified in the patient with class III obesity.