Journal of Minimal Access Surgery

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Year : 2011  |  Volume : 7  |  Issue : 4  |  Page : 253--254

SMILS: Single-site, multi-Incision, laparoscopic surgery, the way forward?

Saurabh Misra 
 Department of General Surgery, Apollo Hospital, Bangalore, India

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Saurabh Misra
C1/901, L and T South City, Arekery Mico Layout, Bannerghatta Road, Bangalore - 560 076

How to cite this article:
Misra S. SMILS: Single-site, multi-Incision, laparoscopic surgery, the way forward?.J Min Access Surg 2011;7:253-254

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Misra S. SMILS: Single-site, multi-Incision, laparoscopic surgery, the way forward?. J Min Access Surg [serial online] 2011 [cited 2021 Dec 6 ];7:253-254
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Dear Sir,

I have read with great interest, the special edition on Laparo-Endoscopic Single Incision Surgery (LESS). The single-incision laparoscopic surgery (SILS) indeed is an advancement over the multi-port laparoscopic surgery. However, there are certain concerns about the procedure, which are valid and need to be addressed before it can be taken as a procedure of choice. Firstly, the post-operative pain is indeed more in the LESS group in the first 24 hours compared with the conventional laparoscopic surgery, which has been highlighted in a few studies. [1] We share this observation. Secondly, there is a concern regarding incisional hernias in these patients. [2],[3] Lastly, the cost burden, which the patient has to withstand when opting for this form of surgery makes it a lesser attractive choice.

To address these issues, in our institution, we have developed a rather simple form of laparoscopic surgery, which we call as SMILS or 'Single-site, Multi-incision Laparoscopic Surgery'. This concept arose from the fact that triangulation of the instruments can be achieved within the umbilicus, without getting preoccupied with the idea of 'single incision', that is, the SILS port can be achieved on the umbilicus without the port itself. The ports used in the technique were routine reusable ports (low-profile ports are useful) and the instruments were either routine laparoscopic surgery instruments or articulating ones.

In this technique, all the three ports are placed directly on the umbilicus in a strategic way using three separate incisions. The orientation of the three ports differs with the kind of surgery. As this surgery is not a single-port surgery, no flaps are raised as described in SIMPLE [4] and no special ports were used, thus avoiding the problems faced with it like the seroma formation or huge cost burden faced with SILS port. We made three ports of 5 mm each on the umbilicus [Figure 1] and [Figure 2] and surprisingly had little difficulty in operating as we were already doing LESS surgery on a regular basis. However, this technique closely resembles to that described by Piskun and Rajpal, who used only two ports on the umbilicus. [5] {Figure 1}{Figure 2}

We have done more than 29 surgical procedures, including laparoscopic cholecystectomy, laparoscopic appendectomy, laparoscopic tubal ligations, laparoscopic ectopic surgery, laparoscopic ovarian cyst surgery and compared our results with those of the LESS group, which we had done earlier; the result of which is due for publication. The organs are retrieved either by making one of the ports as 10 mm or connecting two adjacent ports.

The advantages, we observed, were that the post-operative pain, seemed less compared with the LESS group. Moreover, the postoperative scar was very much better than the single-incision group, and as there were no incisions larger than 5-10 mm, there were less chances of incisional hernia. Above all, the cost of the surgery was almost same as that of conventional laparoscopic surgery. A large scale study is under way to document these observations with respect to pain scores, cosmoses, and cost effectiveness, comparing the two techniques.


1Woldrich JM, Holmes N, Palazzi-Churas K, Alagiri M, DeCambre M, Kaplan G, et al. Comparison of laparoendoscopic single-site, conventional laparoscopic, and open nephrectomy in a pediatric population. Urology 2011;78:74-7.
2Rao PP, Rao PP, Bhagwat S. Single incision laparoscopic surgery: Current status and controversies. J Minim Access Surg 2011;7:6-16.
3Singh R, Omiccioli A, Hegge S, McKinley C. Does the extraction-Site location in laparoscopic surgery have an impact on incisional hernia rates? Surg Endosc 2008;22:2596-600.
4Podolsky ER, Rottman SJ, Poblete H, King SA, Curcillo PG. Single port access (SPA) cholecystectomy: A completely transumbilical approach. J Laparoendosc Adv Surg Tech A 2009;19:219-22.
5Piskin G, Rajpal S. Transumbilical Laparoscopic Cholecystectomy utilizes no incision outside the umbilicus. J Laparoendosc Adv Surg Tech A 1999;9:361-4.