**8. Problems and solutions seen in SIPES**

Rivas [16] has given a good list of problems and solutions in SILS. The encountered problems were clashing of instruments, lack of ideal operative ports, interference and deflection of laparoscope's light source by operating instruments, interference of wires or tubing that connect perpendicularly to instruments, difficulty with retraction of organs or structures, lack of time and patience to learn, loss of proprioception due to crossed instrument, and change of surgeon's mindset. The solutions suggested by him were the use of curved, reticulating, or flexible instruments, use of novel multichannel ports, use of an extra-long 5-mm angled laparoscope (50 cm), use of retracting sutures, continuous medical education, implementation of magnetically anchored instruments deployed though a single incision, and use of a 90° adaptor for the light source (for sharp change in its direction parallel to the laparoscope).

Collision of instruments is considered the main limiting factor for popularizing this technique. Other surgeons conquer this problem by using articulating instruments and angled tip fiber-optic camera. The use of articulating instruments was

**143**

*Single-Incision Pediatric Endosurgery (SIPES) DOI: http://dx.doi.org/10.5772/intechopen.85305*

help in obese children and bariatric surgery.

attend SILS workshops.

**Summary**

rant for sleeve gastrectomy.

**9. SIPES tips and tricks**

ports).

**9.1 Tips & Tricks in SIPES appendectomy**

and Olympus is more suitable for bariatric surgery.

ports to aid completion of the surgical procedure is still there.

difficult and almost impossible in small age group due to narrow and small working space, so the author has replaced it by standard straight instruments. The cameraman can stand away from the operating surgeon by using a 50 cm long laparoscope. The articulating and bent instrumentation requires training and experience, and we as other SIPES surgeons are confident that they are not needed in neonates and children. Bent graspers and the 45° rigid endoscope or the deflectable tip laparoscope to minimize instrument collision, both internally and externally, might be of

Retraction difficulties is again one of the most important challenges in SIPES; to overcome this problem, there are many tricks being used by surgeons like placing a thin grasper (2-mm Minilap Alligator-Stryker Endoscopy, San Jose, CA), transabdominal sutures, insertion of additional trocarless instrument, and using special laparoscopic magnetic graspers which coupled with external magnets [16, 17]. Transabdominal suturing is useful in small children due to their thin abdominal wall. These sutures are used to encircle the round ligament for liver retraction and seromuscular bites through hollow organs like intestine and gallbladder [16, 19]. Coordination between the surgeon and the camera driver is essential as much or more than it's needed in CLS. In case of intraoperative complication or failure of progression, the introduction of other transabdominal conventional laparoscopic

Engagement of OR staffs is essential to develop SIPES skills. In the beginning "converting an easy procedure into a harder one" is the sentence which you will hear as a SILS surgeon. Surgeons performing SIPES should have MIS skills and should

In our institute we are providing surgical trainees with advanced laparoscopic and SILS animal workshops. The trainees are doing many SIPES procedures during their rotation, like appendectomies, cholecystectomies, and splenectomies. Although our rotating trainees did not have previous experience in SILS, as we are the only SILS center in the region, by the end of their rotation, they will be able to perform SIPES safely.

• The position of SIPES port is mainly trans-umbilical, but it might be introduced in the left upper quad-

• Many types of ports are available, but Covidien© (Medtronic) is more suitable for pediatric patients,

• Insertion of extra port is always an option and is considered as conversion to mini laparoscopy (two

• Many challenges exist with SIPES, but there are always solutions as in conventional laparoscopy.

• Surgeons performing SIPES should have MIS skills and should attend SILS workshops.

SIPES appendectomy is increasing for its well-known cosmetic benefit. SIPES appendectomy is the most common procedure done in pediatric surgical units. The incision is strategically placed in the umbilicus with a perceived scarless abdomen. The technique is almost the same as in conventional procedure; it is performed

#### *Single-Incision Pediatric Endosurgery (SIPES) DOI: http://dx.doi.org/10.5772/intechopen.85305*

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

Uni-X by Pnavel, Tri or quadric port by Olympus, and AnchorPort R by SurgiQuest. (**Figure 1**) Each port has its own unique feature, so the selection of the port depends on the surgeon, availability, and cost factor. The author has found that Covidien© (Medtronic) port is the most suitable one as it is small in size and it can adopt

*Types of ports. A) Sils covidien, B) Gel point, C) Triport, D) Uni-X, E) Quadric port. F) Anchorport R by* 

Rivas [16] has given a good list of problems and solutions in SILS. The encountered problems were clashing of instruments, lack of ideal operative ports, interference and deflection of laparoscope's light source by operating instruments, interference of wires or tubing that connect perpendicularly to instruments, difficulty with retraction of organs or structures, lack of time and patience to learn, loss of proprioception due to crossed instrument, and change of surgeon's mindset. The solutions suggested by him were the use of curved, reticulating, or flexible instruments, use of novel multichannel ports, use of an extra-long 5-mm angled laparoscope (50 cm), use of retracting sutures, continuous medical education, implementation of magnetically anchored instruments deployed though a single incision, and use of a 90° adaptor for the light source (for sharp change in its direc-

Collision of instruments is considered the main limiting factor for popularizing this technique. Other surgeons conquer this problem by using articulating instruments and angled tip fiber-optic camera. The use of articulating instruments was

15 mm port for introducing GIA stapler and endobag.

**8. Problems and solutions seen in SIPES**

tion parallel to the laparoscope).

**142**

**Figure 1.**

*Surgiquest.*

difficult and almost impossible in small age group due to narrow and small working space, so the author has replaced it by standard straight instruments. The cameraman can stand away from the operating surgeon by using a 50 cm long laparoscope. The articulating and bent instrumentation requires training and experience, and we as other SIPES surgeons are confident that they are not needed in neonates and children. Bent graspers and the 45° rigid endoscope or the deflectable tip laparoscope to minimize instrument collision, both internally and externally, might be of help in obese children and bariatric surgery.

Retraction difficulties is again one of the most important challenges in SIPES; to overcome this problem, there are many tricks being used by surgeons like placing a thin grasper (2-mm Minilap Alligator-Stryker Endoscopy, San Jose, CA), transabdominal sutures, insertion of additional trocarless instrument, and using special laparoscopic magnetic graspers which coupled with external magnets [16, 17]. Transabdominal suturing is useful in small children due to their thin abdominal wall. These sutures are used to encircle the round ligament for liver retraction and seromuscular bites through hollow organs like intestine and gallbladder [16, 19].

Coordination between the surgeon and the camera driver is essential as much or more than it's needed in CLS. In case of intraoperative complication or failure of progression, the introduction of other transabdominal conventional laparoscopic ports to aid completion of the surgical procedure is still there.

Engagement of OR staffs is essential to develop SIPES skills. In the beginning "converting an easy procedure into a harder one" is the sentence which you will hear as a SILS surgeon. Surgeons performing SIPES should have MIS skills and should attend SILS workshops.

In our institute we are providing surgical trainees with advanced laparoscopic and SILS animal workshops. The trainees are doing many SIPES procedures during their rotation, like appendectomies, cholecystectomies, and splenectomies. Although our rotating trainees did not have previous experience in SILS, as we are the only SILS center in the region, by the end of their rotation, they will be able to perform SIPES safely.

#### **Summary**

