Single-incision laparoscopic sleeve gastrectomy: Initial experience in 20 patients and 2-year follow-up

Abstract

The transumbilical route began being clinically feasible with or without unique access devices.
The setting for this study was a private practice at Clínica Las Condes, Santiago, Chile.
The objective was to describe our experience performing a laparoscopic sleeve gastrectomy (LSG) via transumbilical route using a single-port access device in addition to standard laparoscopic instruments.
A prospective nonrandomized protocol was applied to patients fulfilling the following inclusion criteria: to have been medically indicated for an LSG, to have a body mass index (BMI) of less than or equal to 40 kg/m(2), and the distance between the xiphoid appendix and umbilicus should be less than 22 cm. All patients were female with a median (p50) age of 34.5 (ranging from 21 to 57) years, a median weight of 92 (ranging from 82.5 to 113) kg, and a median BMI of 35.1 (ranging from 30.5 to 40) kg/m(2). The device insertion technique, the gastrectomy, and postoperative management are described.
LSG via transumbilical route was successfully carried out in 19 of the 20 patients in whom the procedure was performed; one patient had to be converted to a conventional laparoscopic procedure. Mean operating time was 127 (ranging from 90 to 170) min. On the second postoperative day, all patients were assessed through an upper gastrointestinal barium-contrasted radiological series. There was neither morbidity nor mortality in this group. Excess weight loss at 25 months after surgery was 114 %.
Single-port LSG can be successfully performed in selected obese patients with a BMI of less than 40 kg/m(2) using traditional laparoscopic instruments. The technique allows performing a safe and effective vertical gastrectomy.

Full text

Original Article
32 Single-incision laparoscopic sleeve gastrectomy: initial experience in 20 patients and 2-year follow-up
1 3
Summary
Background e transumbilical route began being clini-
cally feasible with or without unique access devices.
Setting e setting for this study was a private prac-
tice at Clínica Las Condes, Santiago, Chile.
Objective e objective was to describe our expe-
rience performing a laparoscopic sleeve gastrectomy
(LSG) via transumbilical route using a single-port access
device in addition to standard laparoscopic instruments.
Method A prospective nonrandomized protocol was
applied to patients fullling the following inclusion crite-
ria: to have been medically indicated for an LSG, to have
a body mass index (BMI) of less than or equal to 40kg/
m
2
, and the distance between the xiphoid appendix and
umbilicus should be less than 22cm. All patients were
female with a median (p50) age of 34.5 (ranging from 21
to 57) years, a median weight of 92 (ranging from 82.5 to
113) kg, and a median BMI of 35.1 (ranging from 30.5 to
40) kg/m
2
. e device insertion technique, the gastrec-
tomy, and postoperative management are described.
Results LSG via transumbilical route was successfully
carried out in 19 of the 20 patients in whom the proce-
dure was performed; one patient had to be converted to
a conventional laparoscopic procedure. Mean operating
time was 127 (ranging from 90 to 170) min. On the second
postoperative day, all patients were assessed through an
upper gastrointestinal barium-contrasted radiological
series. ere was neither morbidity nor mortality in this
group. Excess weight loss at 25 months after surgery was
114 %.
Conclusions Single-port LSG can be successfully per-
formed in selected obese patients with a BMI of less than
40kg/m
2
using traditional laparoscopic instruments. e
technique allows performing a safe and eective vertical
gastrectomy.
Keywords Laparoscopic sleeve gastrectomy · Single-
incision laparoscopic surgery· Single-site surgery
Introduction
Since the introduction of laparoscopic cholecystectomy,
abdominal surgery has been looking to achieve most of
its surgical interventions to be performed on solid and
hollow viscera through minimally invasive procedures.
Because of this reason, laparoscopic surgery has become
the standard technique for several abdominal surgical
procedures, such as cholecystectomy, appendectomy,
antireux surgery and achalasia, splenectomy, colec-
tomy, and bariatric surgery.
Furthermore and in a parallel manner, over the past
20 years, minimally invasive surgery has progressed from
surgery with minimal incisions, which includes laparo-
scopic surgery, to transorice surgery, with no skin inci-
sions, using natural orices such as the mouth, vagina,
and rectum as ports of entry. However, this technique is
highly demanding from a technical point of view. Besides,
the proper technology has to be available in the operating
room, and the learning curve is slow. Moreover, this tech-
nique has the signicant disadvantage of going through
healthy organs such as the stomach, vagina, and rectum
to access the peritoneal cavity. Because of this disadvan-
tage, transorice surgery is still in its initial stages, and
F.Maluenda,MD, FACS() · P.Burdiles,MD, FACS ·
J.Giordano,MD, FACS · M.Molina,RN
Department of Surgery, Clínica Las Condes,
Lo Fontecilla 441, 7591046 Las Condes, Santiago, Chile
e-mail: fmaluenda@clc.cl
F.Maluenda,MD, FACS · A.Csendes,MD, FACS (Hon)
Department of Surgery, University Hospital,
University of Chile, Santiago, Chile
J.León,MD
Clínica Alemana, Santiago, Chile
Received: 9 September 2013 / Accepted: 17 December 2013 / Published online: 5 February 2014
© The Author(s) 2013. This article is published with open access at Springerlink.com
Eur Surg (2014) 46:32–37
DOI 10.1007/s10353-013-0246-4
Single-incision laparoscopic sleeve gastrectomy:
initial experience in 20 patients and 2-year follow-up
F. Maluenda · J. León · A. Csendes · P. Burdiles · J. Giordano · M. Molina

Original Article
Single-incision laparoscopic sleeve gastrectomy: initial experience in 20 patients and 2-year follow-up 33
1 3
it probably will require a long time before it can become
more accepted [1].
Transumbilical surgery has emerged as an interme-
diate procedure in the evolution of surgery, as it allows
abdominal surgery to be performed with only one port at
the umbilicus, which is almost invisible, most likely with
fewer traumas to the abdominal wall, a faster recovery,
and a decrease in the use of analgesics [2–4].
e use of the umbilicus as the port of entry provides
an excellent laparoscopic access to the abdominal cav-
ity in general, and it presents a natural scar in which any
new incision will not be noticed. is can be achieved
by using several trocars or a single transumbilical port.
is technique is already available for clinical use [5]
using traditional laparoscopic instruments, and there
are many single-port devices available in the market.
rough a single incision, usually less than 3 cm wide
in the skin and umbilical aponeurosis, there is the pos-
sibility of installing a device that consists of three or four
access channels, using the same amount of laparoscopic
instruments.
In recent years, the development of bariatric surgery
has allowed continuous and progressive training in lapa-
roscopic techniques, which are applied to severely over-
weight patients. One of these techniques, laparoscopic
sleeve gastrectomy (LSG), is the one that has increased
the most as a single procedure per year. is procedure
poses a particular challenge in minimally invasive sur-
gery, as given its proved eectiveness for weight loss in
the short term and the safety of this method, its medical
prescription has recently been extended to moderately
obese patients [6]. Because of this group extension, our
team has applied this method to patients with a body
mass index (BMI) that ranges between 30 and 40kg/m
2
,
and who have problems associated to metabolic, cardio-
vascular, and osteoarticular comorbidities, which would
benet from weight loss or be corrected once it has
occurred. is determines that patients with obesity class
I and II are potential candidates for a gastrectomy using
this new abdominal minimal access approach.
Objectives
e objectives of this study were as follows: to evaluate
the feasibility of performing laparoscopic vertical gas-
trectomy via transumbilical route, using a single-port
abdominal access device in addition to straight tradi-
tional laparoscopic instruments; and to replicate the LSG
technique and achieve the same magnitude and quality
standards of the gastrectomy as those achieved via con-
ventional laparoscopy with four or ve access trocars.
Material and methods
e authors started performing transumbilical surgery
at the beginning of 2009 [7], initially performing this
procedure on selected cases of elective cholecystecto-
mies and emergency appendectomies. After becoming
familiar with the use of this device and this new surgical
approach, a prospective nonrandomized protocol was
designed, which included the criteria that dened which
type of obese patients were LSG candidates (Table1).
A total of 20 patients underwent an LSG using the
transumbilical route. All these patients were female with
a median (p50) age of 34.5 (ranging from 21 to 57) years,
a median weight of 92 (ranging from 82.5 to 113) kg, and
a median BMI of 35.1 (ranging from 30.5 to 40) kg/m
2
.
All patients were evaluated from a digestive, nutritional,
metabolic, cardiovascular, and mental perspective. ey
were presented to the Multidisciplinary Committee of
Obesity, where the prescription of this surgical treatment
was approved due to their level of obesity and associated
morbidity.
Surgical technique
e patient is positioned with both legs apart in reversed
Trendelenburg position with a 15° tilt. e surgeon’s
position is between the legs of the patient. e proce-
dure begins with a vertical transumbilical incision of
approximately 3 cm on the cutaneous and fascia sur-
face. Once the fascia has been opened, the multilumen
port (SSL

, Ethicon Endo-Surgery) is installed with three
work channels, two 5mm and one 12mm in diameter,
and the pneumoperitoneum is created reaching an intra-
abdominal pressure of 15 mmHg. e rigid 30°, 5-mm
and 50-cm length optic is introduced at a 30° angle. e
gastric intervention itself begins with the skeletization
of the greater curvature starting at 3cm from the pylo-
rus. A small opening toward the retrogastric space is
created. In some cases, separating the liver required the
use of an additional trocar or the installation of a Veres
needle in the epigastrium to be used as a hepatic separa-
tor. At this time, the anesthesiologist takes out the gastric
tube and introduces transorally a 36F calibrating gastric
tube, which advances transpyloric until the duodenum,
attaching it to the lesser curvature to act as a calibrator
and to avoid narrowness of the remnant gastric tube.
After installing the calibrating gastric tube and after
the surgeon ensures that there is no other probe in the
stomach, the gastric section starts from distal to proxi-
mal portions using the linear staplers (Echelon Flex 60

,
Table 1 Inclusion criteria which defined the type of patients
candidates to LSG
1. Obese conditions
2. Medically indicated LSG
3. BMI equal or less to 40 kg/m
2
4. Distance less than 22 cm between the xiphoid appendix and the umbilicus
5. Interest in having surgery with less incision
6. Female gender
7. Written informed consent
LSG laparoscopic sleeve gastrectomy, BMI body mass index

Original Article
34 Single-incision laparoscopic sleeve gastrectomy: initial experience in 20 patients and 2-year follow-up
1 3
day, which was continued for 10 days. On day 11, a hypo-
caloric soft diet was begun, fractioned until day 30.
Follow-up
Ambulatory clinical control was carried out in postoper-
ative days 10 and 30, and later at 3, 6, and 12 months after
surgery. e mean follow-up was 25 (10–38) months.
e percentage of excess weight loss was calculated by
knowing the real weight and the theoretical weight of the
patient according to the weight and height acceptable for
adult Chilean population, adapted from the data of the
Metropolitan Life Insurance Company, USA.
Results
In the rst two patients of this series, the gastrectomy
began with the gastric skeletization of the entire greater
curvature from distal to proximal portions in the same
way as the authors performed LSG with conventional
laparoscopy [7]. After this, gastric section was carried out
using mechanical sutures. Both of these patients required
the use of an additional 5-mm trocar in the middle line to
use retractor forceps or a 5-mm camera. From the third
patient onward, the technique was modied to the previ-
ously described one, and the need of an additional trocar
was avoided.
Mean operating time was 127min, ranging from 90 to
170min. e most time-consuming procedures were in
patient 1 and 5. e rst patient of this series was oper-
ated on for 170 min and required the use of an addi-
tional trocar in the middle line. e other patient with an
extended operation time was the fth patient. However,
this patient did not require the installation of an addi-
tional trocar.
In 19 of the 20 patients in whom the transumbilical
procedure was attempted, the procedure was success-
ful and exclusively achieved by this route. In one patient
(the last one), additional trocars had to be installed due
to the impossibility of obtaining proper visualization of
the esophagogastric junction as a result of a voluminous
fatty liver. is yields a conversion percentage of 5 %
(1/20 patients).
Also, two patients suered from a large umbilical her-
nia, and the device was installed through their hernial
defect; once the gastrectomy was nished, a standard
umbilical herniorrhaphy was performed.
In these 20 patients, no relationship between their
height and the distance between the xiphoid appendix
and navel was found as a factor that facilitated the proce-
dure and that could have resulted in a decrease in operat-
ing time.
All radiological examinations with diluted barium sul-
fate were satisfactory, indicating good ow to distal por-
tions and absence of leaks, narrowness, and/or residual
gastric fundus.
Ethicon Endo Surgery), starting with two sets of 2.0-mm
staple cartridge (green), followed by the application of
ve to six sets of 1.5-mm staple cartridge (blue). Once
the stomach has been almost entirely sectioned, the gas-
tric skeletization of the greater curvature starts from the
antrum to the His angle by using the ultrasonic energy
device (Harmonic Ace

, Ethicon Endo-Surgery). e
objective while approaching the gastroesophageal junc-
tion is the visualization of the left crus and the left border
of the abdominal esophagus, sectioning the short vessels
and phrenoesophagic membrane in its left half. e last
line of mechanical sutures is located 10mm away from
the His angle, with the purpose of completely dissecting
the gastric fundus.
Hemostasis of the gastric edge is carried out by elec-
trocoagulation of the section’s edge, applying clips to
any bleeding point or installing absorbable hemostats
directly on the bloody edge. Once the gastric section is
completed, the anesthesiologist introduces 60 to 80ml of
methylene blue to assess the presence of any leakage.
e extraction of the gastrectomy piece is carried out
through the umbilical incision. e fascia is sutured
using interrupted stitches of 2–0 absorbable mate-
rial, and intradermic sutures of 4–0 absorbable mono-
laments are applied to the skin. None of the patients
required intra-abdominal drains.
In addition to analgesics, local inltration with 10ml
of bupivacaine at 0.5 % was used in the umbilical incision
once the procedure was nished.
Antibiotic prophylaxis was used as one dose of rst-
generation cephalosporin, during the induction of anes-
thesia, followed by two postoperative doses. To prevent
thromboembolic disease, antiembolic stockings were
used in addition to an intermittent pneumatic com-
pressor for lower extremities during the intraoperative
periods, followed by the use of low-molecular-weight
heparin 6h after surgery, which is continued once a day
until the patient is discharged. All patients got up and out
of bed, assisted by a physical therapist, to walk around
within 12–18h of completing surgical procedure. ey all
had two sessions of respiratory and general therapy per
day during their stay in the hospital.
Postoperative management
Postoperative analgesia was based on the use of a con-
tinuous intravenous solution consisting of metamizol
(3g per day) and a nonsteroidal anti-inammatory drug
(ketoprofen, 300mg daily) for 48h. Proton pump inhibi-
tors were used at the induction of the anesthesia and
were continued for 30 days.
On next day after surgery, all patients were submitted
to a barium swallow study to assess the shape of the gas-
tric tube, absence of leakage or strictures, and satisfac-
tory gastric emptying. We prefer barium sulfate instead of
water-soluble contrast, as in our experience, the quality
and details of images are better with barium [8, 9].
After this radiological examination, patients were
given a fractioned hypocaloric liquid diet of 300–400cal/

Original Article
Single-incision laparoscopic sleeve gastrectomy: initial experience in 20 patients and 2-year follow-up 35
1 3
we introduced rigid optics of 50-cm length and a curved
grip forceps, which have optimized close-up vision, and
it avoided instruments bumping into each other outside
the abdomen.
is new form of surgery poses a special technical
challenge, which is triangulation. When three work chan-
nels are used, after the optic is placed, there are only two
channels available, which usually are for the section,
coagulation, and dissection instruments and for the trac-
tion forceps. Counter traction must then be done in a
“natural” way, anatomically, taking advantage of the sup-
port and immobilization structures that the organs natu-
rally have. In obesity surgery, greater diculty is added
because of the enormous size the patients have, which
results in greater distance between the instrument-enter-
ing point and the operating site, which is mobile. In this
case, one has to be capable of covering the entire stomach
to its full extension, considering that the typical length of
the instruments is insucient and that the upper gastric
third cannot be reached in a precise and fast way.
To keep both of these aspects that are technically rel-
evant in this technique, and due to the diculties pre-
sented at the beginning of this series, we decided to
modify the order of the gastrectomy: starting with the
gastric section at the beginning of the operation, when
the support elements anatomically hold the stomach
allowing for much better presentation and vision of the
remaining gastric tube. In a prospective randomized
study, Dapri et al. [17] compares two LSG techniques,
depending on whether the greater curve is rst devascu-
larized followed by the gastric section or vice versa. He
concludes that it seems to be easier and takes less time to
rst section the stomach and then devascularize it.
Lakdawala et al. [18] compared in a randomized pro-
spective study conventional LSG versus transumbili-
cal LSG, with 50 patients per group. ey found that the
operative time and intraoperative bleeding were similar
in both groups, although the transumbilical group had
considerably less pain from the eighth hour after surgery,
resulting in a decrease in the use of analgesics. ere-
fore, it has been concluded that the technique benets
are an invisible scar as well as a decrease in postopera-
tive pain. Other descriptive reports of patients who have
undergone a transumbilical LSG [19–21] using dierent
devices mention a reported operating time of 2h without
the need of converting to open or conventional surgery,
and with little need of resorting to additional trocars in
selected populations. e technique is recommended as
safe, technically feasible, and reproducible.
e surgeries in our series have also lasted, on aver-
age, a little more than 2h, although they were our rst
patients. When a new technique is introduced, more
time is used in the intraoperative phase, just like when
the standard laparoscopic LSG technique started being
used some years ago. Two patients also had an umbili-
cal hernia through which a single incision was made in
the navel, performing two procedures at the same time: a
gastrectomy and an umbilical herniorrhaphy. is situa-
tion was not initially expected by us, but we believe that
After the radiological studies, oral ingestion of frac-
tioned liquids was started, and these were well toler-
ated. Eleven patients were discharged after 48h and the
remaining nine 72h after surgery.
ere was no morbidity at all up to 30 postoperative
days in this group of patients. Four patients developed
gallstones 1 year after surgery, of whom three were oper-
ated by transumbilical approach and the fourth was
operated in another institution by classic laparoscopic
approach. Of the 20 patients, 19 were checked up and
only 1 (5 %) was lost for later follow-up (Table 2). e
mean excess weight loss at 6, 12, and 24 months after sur-
gery was 99 %, 118 %, and 114 %, respectively.
Discussion
Ever since laparoscopic surgery has been regarded the
new “standard” in abdominal surgery, a permanent
quest has existed concerning the further reduction in
the number of ports for abdominal access routes. e
search has been mainly oriented in two directions: sur-
gery through natural orices and exclusive access using
the transumbilical route [4].
While surgery through natural orices has progressed
very slowly, transumbilical surgery has evolved rap-
idly, and over the past couple of years, there are several
reports of cholecystectomies [10, 11], appendectomies
[12], colectomies [13], and nephrectomies [14, 15] per-
formed using this route. e introduction of this form
of intervention is closely linked to the development of
unique access devices by industry. ere are already sev-
eral of these devices with three or more work channels in
clinical use [2, 3], all with a reduced diameter of 3–4cm.
In bariatric surgery, Saber et al. [16] published the rst
report of an LSG performed using this route in 2008, stat-
ing that seven obese patients with a BMI > 50kg/m
2
had
undergone surgery with a transumbilical device. ere
was no need to convert to conventional laparoscopic
surgery or open surgery, and the mean operating time
was 125min. After this initial experience, it was recom-
mended as a safe procedure that is technically feasible
and reproducible.
We started using unique access devices in 2009, when
performing cholecystectomies and appendectomies.
However, the rest of the optics and instruments that were
used were the same as the ones used for laparoscopic
surgery in any medical center; that is, 5- and 10-mm-
diameter optics and 30° angle in addition to straight
forceps of 5-mm diameter and 43-cm length. Afterward,
Table 2 Mean percentage excess weight loss after sleeve
gastrectomy in different periods
1 month 46.7
3 months 74.4
6 months 99.5
12 months 111
25 months 114

Original Article
36 Single-incision laparoscopic sleeve gastrectomy: initial experience in 20 patients and 2-year follow-up
1 3
c. e addition of another trocar may seem to eliminate
the transumbilical concept. Although this is true, the
most important point to consider in this surgery is
patient’s safety much more than surgical interest in
nishing surgery by a single-port device. We believe
that it adds nothing important to use a small 5-mm
trocar if it is needed (in 10 % of the patients).
e authors believe that this technical innovation should
be available to patients even though this requires further
training for surgeons as well as the acquisition of new
skills. is technique potentially has signicant benets,
mainly a decrease in postoperative pain and an improved
cosmetic appearance for patients because there is no vis-
ible scar. ese aspects and other potential benets must
still be proved in time and through randomized future
studies.
In contrast, the application of the transumbilical
technique in bariatric surgery presents the challenge of
identifying within the obese population the appropriate
candidate for this procedure, applying the ideal selection
criteria to oer this technique safely and eectively.
Conclusions
e results of the present study suggest that LSG can be
successfully performed in selected obese patients with a
BMI of less than 40kg/m
2
using a unique access device
with traditional laparoscopic instruments. e tech-
nique allows performing a safe and eective vertical gas-
trectomy. However, a greater number of patients should
be evaluated to prove the ecacy of this procedure, and
a longer follow-up is still needed to establish it as a stan-
dard technique.
Conict of interest
Dres. Fernando Maluenda, Juan León, Attila Csendes,
Patricio Burdiles, José Giordano, and Macarena Molina
have no conicts of interest or nancial ties to disclose.
Open Access
is article is distributed under the terms of the Creative
Commons Attribution Noncommercial License which
permits any noncommercial use, distribution, and repro-
duction in any medium, provided the original author(s)
and the source are credited.
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Original Article
Single-incision laparoscopic sleeve gastrectomy: initial experience in 20 patients and 2-year follow-up 37
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