Single-incision laparoscopic surgery (SILS™) versus standard laparoscopic surgery: a comparison of performance using a surgical simulator

Single-incision laparoscopic surgery (SILS (TM)) is a potentially less invasive approach than standard laparoscopy (LAP). However, SILS (TM) may not allow the same level of manual dexterity and technical performance compared to LAP. We compared the performance of standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS) program using either the LAP or the SILS (TM) technique. Medical students, surgical residents, and attending physicians were recruited and divided into inexperienced (IE), laparoscopy-experienced (LE), and SILS (TM)-experienced (SE) groups. Each subject performed standardized tasks from FLS, including peg transfer, pattern cutting, placement of ligating loop, and intracorporeal suturing using a standard three-port FLS box-trainer with standard laparoscopic instruments. For SILS (TM), the subjects used an FLS box-trainer modified to accept a SILS Port (TM) with two working ports for instruments and one port for a 30A degrees 5-mm laparoscope. SILS (TM) tasks were performed with instruments capable of unilateral articulation. SILS (TM) suturing was performed both with and without an articulating EndoStitch (TM) device. Task scores, including cumulative laparoscopic FLS score (LS) and cumulative SILS (TM) FLS score (SS), were calculated using standard time and accuracy metrics. There were 27 participants in the study. SS was inferior to LS in all groups. LS increased with experience level, but was similar between LE and SE groups. SS increased with experience level and was different among all groups. SILS (TM) suturing using the articulating suturing device was superior to the use of a modified needle driver technique. SILS (TM) is more technically challenging than standard laparoscopic surgery. Using currently available SILS (TM) platforms and instruments, even surgeons with SILS (TM) experience are unable to match their overall LAP performance. Specialized training curricula should be developed for inexperienced surgeons who wish to perform SILS (TM).