A Conversation With SAGES President, C. Daniel Smith, MD

Article preview reprinted from Medtech Insight - July/August 2009

C. Daniel Smith, MD, recently sat down with Medtech Insight to discuss trends in minimally invasive surgery and the single-incision laparoscopic approach. Smith is the current president of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), and professor of surgery and chair of the surgery department at the Mayo Clinic, Jacksonville, FL. Read more...

A Conversation With SAGES President, C. Daniel Smith, MD

Article preview reprinted from Medtech Insight -  July/August 2009

C. Daniel Smith, MD, recently sat down with Medtech Insight to discuss trends in minimally invasive surgery and the single-incision laparoscopic approach. Smith is the current president of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), and professor of surgery and chair of the surgery department at the Mayo Clinic, Jacksonville, FL.

Q: Do you have any estimates of how many single-incision laparoscopies have been performed to date?

C. Daniel Smith: I really don't, but my discussions with surgeons lead me to think it's much more than we probably realize.

Q: What are the challenges of performing this type of surgery?

The big challenge is the change from the angle of manipulation or the angle of approach to the organ or the area of interest, going from 45 degrees to virtually zero degrees, or more of an inline approach. In other words, right now when we place our trocars, the right hand and left hand, as they approach the target, are coming in at an angle. With single incision, everything is axial and along that single axis of the one port. And that's a challenge. Many of our instruments are not made to perform in that in-line orientation.

Q: Is this disorienting for surgeons?

It can be very disorienting, because the angle of view and the angle of approach of the instruments are all along the same axis. In a 2-D laparoscopic environment, the angles that you get with multiple trocars in different locations can help compensate for the loss of 3-D.

Q: It seems to me that some device developers are expecting physicians to adapt and change their technique to perform single-incision procedures while others are actually trying to recreate triangulation with new technologies. Would you agree with that?

I couldn't have said it better. The big challenge is the loss of triangulation. There are a couple issues or aspects to this. One is access through a single site, and how to best maintain pneumoperitoneum and maintain the seal around the instruments through a single trocar or a single platform. And then, the triangulation issue, and the question of whether or not we can really achieve triangulation with existing instruments, or whether we need a new family of instruments to allow triangulation through the single port.

But remember, manufacturers are looking for their fastest route to market. For example, a company that has already developed a port for single incision procedures may not necessarily want to wait for the development of articulating instruments. Instead, they're probably going to come forward and say, 'You can do this right now with your in-line instruments; there's a different learning curve, we'll put out a course and we'll teach you how to overcome some of the triangulation issues.' So, I'm not sure that the companies' marketing approach necessarily appropriately directs where we need to be heading and where we ultimately want to be.

Q: The lectures at SAGES on single-incision laparoscopy were standing room only, but there seemed to be little consensus at the meeting on the value of the single-incision approach. What issues need to be resolved before we see widespread adoption of single-incision laparoscopy?

I think the true value still has to be defined: is the benefit going to be in reduced pain, is it going to be in cosmesis, or is it going to be in length of stay for some procedures? Is it going to be in lower cost because of shorter operative times, or less equipment or supply expense? One trocar instead of three or four trocars, for example, may lead to a cost benefit. At the same time, it must not compromise the quality of the outcome or introduce a higher risk of complications. So, there's a lot of enthusiasm, a lot of interest, but we haven't absolutely defined those two areas: What is its benefit? And are we sure we're not going to increase our complications?

Right now, if you're talking about single incision for some of the more basic laparoscopic procedures like appendectomy or cholecystectomy, it may be easier for physicians to accept a future role for those procedures. When you get into more complex procedures like sleeve gastrectomy or gastric band placements, you're talking about a patient population that's a little more challenging because of body habitus or intra-abdominal fat, and physicians may not be as readily convinced that single incision is going to have a future. But I think the current discussion and lack of consensus probably just reflects the enthusiasm, but also the uncertainty that exists because of where we're at in the evolution of this technique. We are waiting to find out what the true value is going to be with modern single-incision surgery.

by Anne Staylor

Find out what's in store for the next generation in minimally invasive surgery in the NEW 48-Page SPECIAL REPORT from Medtech Insight: "Fulfilling the Promise of the Scarless Surgery Revolution -- When will breakthrough endoscopic technologies hit prime time?"  Find out more...

About Medtech Insight

Medtech Insight newsletter provides insights into the technology and market developments (devices, instrumentation, biomaterials, gene therapy, tissue engineering, etc.) impacting a wide range of surgical and non-surgical clinical practices (cardiothoracic & vascular surgery, general surgery, orthopedics & spine surgery, interventional radiology/cardiology, etc.). Learn more at www.medtechinsight.com.