Review

Eur Surg (2014) 46:113–117

DOI 10.1007/s10353-014-0258-8

A systematic review of hernia surgery in SIL

(single-incision laparoscopy) technique
A. H. Petter-Puchner · W. Brunner · S. Gruber-Blum · K. S. Glaser · R. H. Fortelny

Received: 29 December 2013 / Accepted: 27 March 2014 / Published online: 17 April 2014
© Springer-Verlag Wien 2014

Summary ing the incidence of incisional hernias at the trocar site

Background  Hernia repair in single-incision laparo- and safety in large cohorts are missing.
scopic surgery (SIL) technique has become increasingly
common at specialized centers. Still, safety issues and Keywords  Review  · Single incision (SIL)  · Hernia re-
potential benefits of SIL hernia repair have to be eluci- pair · Evidence
dated. This review summarizes available literature and
provides an overview of current developments.
Materials and methods  A literature search was per- Introduction
formed in PubMed, the Cochrane Database, and Google
for peer-reviewed publications on SIL hernia repair. Main Looking back at the recent past, single-incision lapa-
outcome parameters were defined, and it was attempted roscopic surgery (SIL) has been one of the hot topics in
to define clinical recommendations. general surgery. Impressive demonstrations of colonic,
Results  SIL technique can be applied for inguinal, hernia, bariatric, and endocrine procedures in SIL
ventral, and hiatal hernia repair. Operation times and technique have inspired the surgical community. His-
early results seem to be comparable with standard mul- torically, the rise of SIL can be seen as part of the devel-
tiport laparoscopy. opment triggered by the “white paper” on natural orifice
Conclusion  Distinct advantages of SIL hernia surgery endoscopic surgery (NOTES) already published in 2006
have yet to be demonstrated, as the level of evidence in by Rattner and Kalloo et al. [1]. This consensus article set
this field is low. Randomized controlled trials investigat- the mark for the quest of ever less invasive procedures to
preserve the integrity of the abdominal wall and to push
the envelope for the technical refinement of endoscopic
and laparoscopic instruments and devices. Although dis-
Dr. A. H. Petter-Puchner () · S. Gruber-Blum · R. H. Fortelny
Ludwig Boltzmann Institute for Experimental and Clincal tinctively different concepts (NOTES as endoscopic pro-
Traumatology, cedure per se with a more multidisciplinary approach),
Donaueschingenstrasse 13, SIL cannot be thought without NOTES, having opened
1200 Vienna, Austria the minds and outlined a perspective, unthinkable only
e-mail: [email protected] a decade ago [2]. Today, there are many centers world-
Dr. A. H. Petter-Puchner · S. Gruber-Blum · K. S. Glaser · wide that perform SIL hernia repair routinely, and this
R. H. Fortelny only seems logical, considering the transformation this
Department of Visceral, Oncological and General Surgery, field has gone through since the turning of the millen-
Wilhelminenspital, nium. A modern understanding of anatomy (nerve spar-
Vienna, Austria ing, subtle, and tension-free preparation) as well as new,
W. Brunner atraumatic fixation devices (e.g., fibrin sealant) com-
Center for Minimal Invasive Surgery, Hospital Rorschach, bined with new mesh technologies (macroporous, light
Sankt Gallen, Switzerland weight) was a milestone on the way to achieve excellent
R. H. Fortelny outcomes in terms of quality of life, reduction of chronic
Paracelsus Medizinische Privatuniversität, pain, and overall patients’ satisfaction [3–6]. SIL, in the-
Strubergasse 21, 5020 Salzburg, Austria ory, offers the methodological extension of this constant

13 A systematic review of hernia surgery in SIL (single-incision laparoscopy) technique   113

 Review

refinement. Today, all kinds of hernia repair have been SIL ventral hernia repair [27, 28], and 1 reported on a case
conducted in SIL technique, although parastomal hernia of SIL hiatal hernia repair [8]. The search in Google and at
repair procedures had not been published at the time of clinicaltrials.gov did not add relevant information.
the search [7–19]. No RCT was published until spring 2013; therefore, all
Therefore, one major question remains: “Is there a but one study did not exceed evidence level 2b according
measurable benefit for the patient performing SIL hernia to the Oxford classification (www.cebm.net). One study
surgery at a safety level at least comparable with standard comparing TAPP, TEP, and SIL-TAPP (n = 35 patients) dis-
laparoscopy?” played evident shortcomings in methodology [18]. The
The number of studies on SIL procedures, in general, observation period in this trial ranged from 2007 to 2011,
is still limited, and their quality is very heterogenic. A so that only a retrospective and indirect comparison of
review on colonic SIL procedures recently published had methods was possible, rendering it an evidence level 3a
to draw its conclusions on the results of only four ran- at best. This fact was not adequately stated by the authors.
domized, controlled trials (RCTs) [20]. There can be no The first entry in PubMed on SIL hernia repair dates
doubt that in the long run, esthetic advantages alone will back to 2008 and presents one case of SIL-TEP repair
not justify potential drawbacks of SIL (visibility of instru- in Croatia (which actually was presented in two publi-
ments during introduction through port, triangulation, cations), whereas the first case series of SIL-TAPP was
etc.). The issue whether SIL trocar site closure could be published by one author in a peer-reviewed journal
associated with a higher incidence of incisional hernia is (not PubMed listed at the time of publication) [25, 29].
controversially discussed [21, 22]. In this article, authors The search results and methodological shortcomings
have tried to systematically review available, clinical lit- are depicted in a PRISMA flowchart and a separate table
erature on SIL hernia repair and to summarize relevant (Fig. 1 and Table 1).
findings at this still early phase. Concerning prospective activities in the field, it is
most interesting that in the largest database on ongo-
ing RCTs (www.clinicaltrials.gov), only one RCT on the
Methods and materials subject was registered at the date of search. It describes a
comparison of classical TEP with SIL (assigned registra-
In March 2013, a search for the following keywords tion number: NCT01660048).
were conducted in the two major databases, PubMed
and Cochrane Database: “single incison laparoscopy
(SIL)” alone/and/or “surgery” and/or “hernia” and/or Main outcome parameters
“abdominal.”
Additionally, separate searches were performed on a. Feasibilty was the major outcome parameter. All eligi-
the website www.clinialtrials.gov to get an overview of ble studies confirmed the feasibility of inguinal, inci-
the status of ongoing SIL hernia trials, and on Google™ sional, and hiatal hernia repair in SIL technique.
using the same keywords. The Google search was subse- b. Operation time, recurrences, and patient satisfaction
quently filtered for publications in the form of abstracts were the secondary outcome parameters.
and articles to gain access to abstracts in supplementary Operation time: All authors concluded that SIL hernia
 
materials to congresses and consensus meetings. repair could be performed in a manner comparable
Expectedly, statistical analysis was waived because of with classical laparoscopy. Interestingly enough, only
the varying quality of studies, incomparable methods, one SIL hernia study addressed the impact of the
and low numbers of patients included. The difficulty to learning curve in depth, although the issue has been
design statistical sound and powerful studies is common
in hernia surgery as elucidated by Kapischke et al. [23].
ϮϬƐƚƵĚŝĞƐ͞^/>н,ĞƌŶŝĂ͞
Results
džĐůƵĚĞĚ ϮƐƚƵĚŝĞƐ ŽŶ ϭ ƐƚƵĚLJ ƐŚŽǁŝŶŐ ƐĞƌŝŽƵƐ ŇĂǁƐ
ĞƌŐŽŶŽŵŝĐƐ >ŽƉĞnjͲĂŶŽ ĞƚĂů͕͘ ŝŶŵĞƚŚŽĚŽůŽŐLJ͗^ĂƚŽĞƚĂů͕͘

Database search results ZŽLJĞƚĂů͘ ŶŽƚĞdžĐůƵĚĞĚ ďƵƚůŽǁ ĞǀŝĚĞŶĐĞ

A total of 20 studies on SIL hernia repair have been found

in the PubMed database, whereas no entry was retrieved
from the Cochrane library. Of these 20 studies, 2 focused ϴƐƚƵĚŝĞƐ ŽŶ^/>dW ϰ ƐƚƵĚŝĞƐ ŽŶ^/>dWW ϱ ƐƚƵĚŝĞƐ ŽŶ^/>s,Z ϴƐƚƵĚŝĞƐ ŽŶ^/>ŚŝĂƚĂů
EKZd EŽ Zd EŽ Zd ŚĞƌŶŝĂ ƌĞƉĂŝƌ͕EŽ Zd
on ergonomics and were not included for analysis of
clinical results [24]. Its results are discussed nevertheless
because they provide a valuable contribution to the cur- WZ/^DŇŽǁ ĐŚĂƌƚ͗͞ƐŝŶŐůĞнŝŶĐŝƐŝŽŶнůĂƉĂƌŽƐĐŽƉLJнŚĞƌŶŝĂ͞
ƐĞĂƌĐŚ ŝŶWƵďŵĞĚ͕ŽĐŚƌĂŶĞ ĚĂƚĂďĂƐĞ
rent evidence. Of the remaining 18 studies, 8 presented
SIL–total extra-abdominal preperitoneal mesh-plasty
(SIL-TEP) [11–13, 17, 25, 26], 4 SIL-transabdominal pre- Fig. 1  Illustration of algorithm of inclusion of eligible studies
peritoneal onlay mesh-plasty (SIL-TAPP) [6, 12, 26, 27], 5 into this review

114   A systematic review of hernia surgery in SIL (single-incision laparoscopy) technique 13

 Review

Table 1  Overview of the design and the procedures investi- hernia surgery already half a decade after its first descrip-
gated in the studies included tion. The results of this quest are somewhat surprising,
First RCT Type of Number of Follow- Journal as, although more studies are certainly in press, available
author surgery SIL patients up literature hardly answers any of the most eminent ques-
tions, which have been asked since the beginning. At a
Barbaros No Hiatal 1 < 1 year ISRN Gastroen-
terol. 2011 time when complex surgical SIL procedures, e.g., pan-
createctomies, are described, the repeated documen-
Barbaros No VHR 3 < 1 year Diagn Ther
Endosc. 2011 tation of feasibility of SIL hernia repair alone is neither
original nor novel any more [31].
Bower No VHR 7 < 1 year JSLS. 2011
In short, this review defines three problematic aspects
Cugura No
of the current situation.
Filipovic- No
Cugura
1. So far, SIL hernia research cannot claim a distinct
Fuentes No TEP 47 < 1 year Hernia. 2012 advantage of SIL over classic laparoscopy. In contrary,
He No TEP 3 < 1 year Hernia. 2011 the concern that larger SIL ports may lead to a higher
Klaus No TAPP N/S N/S Asian J Endosc incidence of incisional hernias in the umbilicus
Surg. 2011 remains the subject for future investigations, as well
Kucuk No TAPP 15 < 1 year Surg Endosc. as no recommendation on how to close the port site
2011 initially is made. These are basic questions, and the
Lopez No Ergo- Eur Surg Res. answers will decide whether SIL will gain a more wide-
nomics 2010 spread popularity in hernia surgery. Theoretically, this
Rahman No progress would only be logical because TAPP and TEP
Sanchez No VHR 1 < 1 year Cir Esp. 2010 have been pioneering fields for the acceptance of clas-
Sato No TAPP 35 < 1 year J Med Invest. sical laparoscopy and the constant playground for the
2012 implementation of the toolbox of innovative instru-
Surgit No TEP 23 < 1 year Surg Laparosc ments and devices.
Endosc Percutan 2. It seems remarkable how little attention has been paid
Tech. 2010 in the past 5 years to the topic of QoL. Great efforts
RCT randomized controlled trial, SIL single-incision laparoscopy, VHR have been made in classical TAPP, TEP, and IPOM
ventral hernia repair, TEP total extra-abdominal preperitoneal mesh-plasty, repair to elucidate the potential of atraumatic mesh
TAPP transabdominal preperitoneal onlay mesh plasty, N/S non specified fixation, e.g., by fibrin sealants. While consequently
more than a dozen RCTs and reviews were published,
systematically reviewed previously [30]. It must be offering balanced and robust evidence, this topic is
noted that the numbers on operation times and recur- amazingly underrepresented in the SIL trials. Stan-
rences are of limited relevance because most studies dardized methodologies for the assessment of the
were based on a consecutive, prospective recruitment QoL must be implied in SIL hernia research to create
of patients without (in)direct controls. The lack of ran- data comparable with classic procedures. It is the cru-
domization supports the assumption of bias toward cial interest of opinion leaders and proponents of the
inclusion of “better” patients in the SIL groups. No SIL technique to substantially engage in the clarifica-
recurrences were observed in relatively short obser- tion of these uncertainties, as it may well be that it will
vation periods (maximum observation period was 20 finally be the QoL determining a possible future in the
months in one study). routine clinical setting.
Recurrences: Two recurrences were reported by Sato
  3. Maybe the most intriguing aspect of this research is
et al., probably also due to relatively short periods of the fact that there is only a very limited number of
follow-up. In this context, it must be emphasized that SIL RCTs in the pipeline. It is clear that there are pos-
the issue of possible umbilical port-site hernias was sibly more trials planned than reported by the one
not discussed in detail. entry found in clinicaltrials.gov. Anyhow, surgeons
Patient satisfaction: Generally, the issue was under-
  interested in SIL are obliged to substantially add to
represented in SIL patients, and standardized mea- the body of evidence in the near future. Otherwise,
surement of the quality of life (QoL) as known from SIL will righteously lose ground without ever having
classical hernia research has not been performed. The come close to the full possibilities of the approach.
well-established Short Form 36 questionnaire was not Currently, SIL hernia repair seems to be doomed to
implemented routinely. remain the marginalized neighborhood of so many
other once promising techniques that have failed to
yield a distinct breakthrough.
Discussion
This is especially sad, as SIL has made great progress in
This review was performed to provide an overview of terms of feasibility and practicability. Any laparoscopic
current developments and the body of evidence in SIL procedure can possibly be performed in SIL technique.

13 A systematic review of hernia surgery in SIL (single-incision laparoscopy) technique   115

 Review

Contradicting the general perception, this progress has   6. Brunner W, Schirnhofer N, Waldstein-Wartenberg N, Frass
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The authors declare that there are no actual or potential comparative study of standard versus laparoendoscopic
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13 A systematic review of hernia surgery in SIL (single-incision laparoscopy) technique   117