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Single-Incision Laparoscopic Surgery in ASCs: 5 Thoughts From Dr. Huy Nguyen

Historically, invasive, large incisions were necessary to perform "open" abdominal surgical procedures. While effective, this method increased the possibility of multiple complications, including post-operative pain, wound infection, incisional hernia and prolonged hospitalization. Concerns over the rate of complications and morbidities led surgeons to develop laparoscopic surgical techniques, in which operations in the abdomen are performed through small incisions — usually 0.5-1.5 cm — as opposed to larger, open incisions across the surgical site.

Laparoscopic surgery employs miniature surgical instruments and video monitoring equipment so that surgeons may enter the abdomen with far less disturbance of the surrounding structures. In 2008, surgeons developed single-incision laparoscopic surgery, an advancement that requires only one small keyhole incision in the abdomen rather than three to four small incisions (as required through traditional laparoscopic surgery).

Huy T. T. Nguyen, DO, performed the first SILS laparoscopic cholecystectomy (the surgical removal of the gallbladder) in Sept. 2008. Since then, he has worked with medical device companies such as Covidien, Johnson & Johnson and Stryker to develop smaller instruments for the SILS procedure. Over the last three years, his group of three surgeons has performed over 800 cases and has advanced past gallbladder procedures to colon procedures with SILS from their practice in San Jose, Calif.

While data suggests that less than 1 percent of surgeons currently perform SILS, Dr. Nguyen believes that number can change with the right education and training. Here he discusses five important points on SILS in ambulatory surgery centers.

1. SILS results in less pain and shorter recovery time for patients. According to Dr. Nguyen, SILS benefits the patient by providing a shorter recovery time and less pain. "There's obviously less pain because you don't make a big cut — you make a small incision," he says. "Typically for gallbladder surgery, you make four incisions, and with SILS, you only make one."

He says the recovery time is also shorter, meaning patients can go home on the same day. This makes the surgery ideal for ambulatory surgery centers, where any residual pain can be treated in the PACU and the patient can be sent home within an hour of the procedure.

2. Surgery center leaders can convince payors with cost-saving opportunities. SILS is performed by only a few physicians across the country, so convincing payors to set up reimbursement contracts for the procedure may be tricky at first. In order to convince them, Dr. Nguyen recommends presenting an experienced, knowledgeable physician who can explain the merits of the procedure. The physician may be able to assuage payor fears better than a CEO, who has less knowledge of the clinical safety of the procedure.

He says surgery centers can also emphasize the cost-saving opportunity for the payor if the patient is treated at the ASC. For example, gallbladder patients will be much more expensive to treat in a hospital — especially if they delay surgery to the extent that they have to go to the emergency room. From the payor's perspective, it is much more cost-effective to encourage patients to seek treatment at an ASC immediately than to wait for ER care.

3. Advanced laparoscopic skills are needed to perform the surgery.
SILS is only appropriate for ASC patients when performed by an experienced, trained surgeon, Dr. Nguyen says. "SILS is an advanced type of surgery, and you need advanced laparoscopic skills," he says. "Not every surgeon can do this. Even with your standard laparoscopic surgery, not many surgeons can do the standard one."

He says the surgery requires a "learning curve" of about 30 cases to master. If surgeons at your ASC want to adopt the procedure, they need to dedicate themselves to learning the single-incision technique. He recommends that surgeons start out with the lap chole procedure if possible, as other procedures (such as colon surgery) are more advanced.

4. Staff should be trained alongside the surgeon. Luckily for busy surgery centers, staff training for the SILS technique is minimal. The most important part of the procedure is ensuring the lead surgeon is comfortable and well-trained in SILS. Once the surgeon is comfortable, the staff should train alongside him or her. He adds that the surgery will likely produce a better result if the surgeon works with the same staff on a consistent basis.

5. SILS could be expanded to other procedures in the future. While SILS is currently limited to gallbladder surgery and colon surgery in Dr. Nguyen's practice, he says the procedure could easily be expanded to other areas in the future. He suggests that lap-band procedures, appendectomies and OB/GYN surgeries such as ovarian cystectomies and hysterectomies could be appropriate for SILS. If one of your surgeons is comfortable using the SILS technique, ask him or her whether the technique could be expanded to other surgeries in your center.

Related Articles on ASC Specialties:
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