The kindest cut: single-port surgery at Yale

About 8 percent of the population has an appendectomy at some point in their lives, usually prompted by an attack of acute appendicitis. Until about 2000, appendectomies were performed using traditional “open” surgery techniques, in which surgeons gained access to the abdomen through a single, fairly large incision. For the past decade or so, appendectomies have more commonly been performed laparoscopically, with surgical instruments and a fiber-optic video camera inserted through three small incisions in the abdomen.

In the latest advance for this relatively common procedure, Kurt E. Roberts, M.D., assistant professor of surgery, has pioneered a new laparoscopic technique that requires only a single 11-millimeter incision, or “port.” In July 2007, Roberts performed the world’s first true single-incision, or single-port, laparoscopic appendectomy at Yale-New Haven Hospital, when he removed the appendix of a 22-year-old woman using only one small incision in the navel. He has since performed 12 more single-port appendectomies, and he has also broadened the technique to complete 4 single-port umbilical hernia repairs and, recently, 10 gall bladder removals.

“This is exciting news because a single-port appendectomy performed with only one small incision is even less invasive than the widely performed three-port laparoscopic appendectomy, which uses three incisions,” explains Roberts. “One incision equates to even less pain and shorter recovery time for the patient than the usual three.” Similarly, Roberts is now able to remove the gall bladder through only one incision in the navel, an operation traditionally performed with four incisions.

In recent years, the trend in abdominal surgery has been to reduce the number of incisions whenever possible. Roberts’ procedure, nicknamed the “puppeteer technique,” involves entering the abdomen, grasping the appendix, dissecting and removing it, all through one tiny incision. Because the surgical port is hidden in the navel, Roberts says, an already small incision becomes nearly invisible once the wound has healed, resulting in “tremendous medical and cosmetic benefits for the patients.”

Roberts is keenly interested in applying his single-port methods in natural orifice transluminal endoscopic surgery, or NOTES, a growing trend in which operations are performed through bodily orifices such as the mouth, or, in women, the vagina. Using NOTES, surgeons can avoid visible scarring, significantly reduce post-operative pain and gain unprecedented access to internal organs. Roberts believes that surgery is at the beginning of a revolution in which many procedures, including hernia repair and gastric banding for the treatment of obesity, may soon be performed using these new techniques of single-port surgery and NOTES.