Since its introduction approximately 20 years ago, laparoscopic cholecystectomy has
rapidly become the treatment of choice for symptomatic cholelithiasis [1–3]. Conventional
laparoscopic cholecystectomy generally is performed through four small incisions in
the abdominal wall [4]. In recent years, a less invasive method has been sought in
an effort to reduce postoperative pain and morbidities such as wound infection and
trocar-site hernias while further enhancing the cosmetic results. Initial attempts
to perform the procedure through three and then two ports or with reduced-diameter
trocars (needlescopic surgery) [5–9] have since been superseded by even less invasive
and more innovative techniques, namely, single-incision laparoscopic surgery (SILS)
and natural orifice transluminal endoscopic surgery (NOTES) [10–13].
Single-incision laparoscopic surgery is an attractive technique for cholecystectomy
due to its superior cosmetic results and potential to reduce the rate of wound complications
such as infection, hematoma, and hernia. This technique, however, is not straightforward.
The technical complexity of SILS naturally results in a steep learning curve and increased
operating room time and requires specialized equipment.
The primary technical obstacles of SILS currently include
Collision of instruments both within and outside the abdomen as a result of their
common entry point (“sword fighting”)
Inadequate triangulation
Compromised field of view due to obstruction by instruments entering the common port
Inadequate exposure and retraction.
Several techniques have since evolved to overcome these potential pitfalls [14–16].
By incorporating a number of these techniques, we have created a simplified technique
that has proved successful with both animal and human subjects. We describe both our
experience and what we have learned, which have allowed simplification of a technical
complex procedure.
Methods
The single-incision approach was used for 31 patients (28 women and 3 men). The indications
for surgery included recurrent biliary colic in 24 patients, acute cholecystitis in
5 patients, gallstone pancreatitis in 1 patient, and postcholedocholithiasis treated
with endoscopic retrograde cholangiopancreatography (ERCP) in 1 patient. The mean
patient age was 39.2 years (range, 19–65 years), and the mean body mass index (BMI)
was 26 kg/m2 (range, 19.2–36.1 kg/m2). Nine of the patients (29%) had undergone previous
lower abdominal surgery, appendectomy, or cesarean section.
In an effort to overcome the problem of “sword fighting,” instruments were introduced
into the peritoneal cavity through either a single 15-mm dual-seal trocar or three
5-mm low-profile trocars (Storz endoscopy, Tuttlingen, Germany) (Fig. 1). A flexible
endoscope, used in four of the operations, was introduced to the abdominal cavity
through the 10-mm seal in the 15-mm dual-seal trocar. In the remaining 27 cases, we
used a 5-mm 30º laparoscope and switched its insertion point during the procedure
as needed.
Fig. 1
5 mm low profile trocars (Storz endoscopy) inserted through a single 18 mm skin incision.
The use of these trocars enables minimal instruments’ collision and better maneuverability
Local triangulation was achieved using articulating instruments (Novare Surgical,
Cupertino, CA, USA) (Fig. 2). Retraction was accomplished using one of two techniques.
The first technique, applied in nine operations, used an endoloop to grasp the gallbladder
dome and then used a suture passer to retract the endoloop through the abdominal wall.
The second technique, applied in 20 operations, used endo-retractors (Virtual Ports
Ltd., Misgav, Israel) (Fig. 3).
Fig. 2
RealHand (TM) hook (Novare surgical) dissecting off the gallbladder from the liver
bed. The use of articulating instruments enables local triangulation, enhances dissection
capability and improves the view
Fig. 3
A Virtual Ports Endograb (TM). The use of endo-retractors optimizes retraction and
exposure capability including changing retraction angles during the operation. B Virtual
Ports Endograb (TM). The retraction of the gallbladder achieved with the device is
shown
The endo-retractor contains two grasping forceps. The first is attached to the gallbladder,
and the second is anchored anywhere on the peritoneal surface. Hence, retraction is
versatile, and retracting direction can be changed during the procedure as needed.
In two operations, no retraction device was used. The steps of the procedure were
exactly the same as in standard laparoscopic cholecystectomy.
The operative time, postoperative hospital length of stay, and complications were
recorded. Postoperative pain levels were established using the visual analog scale
(VAS) on postoperative day 1, and on the first outpatient follow-up visits occurred
on postoperative days 7 to 10. At that time, the patients also were questioned regarding
their return to usual daily activities and their general satisfaction.
Results
The surgery for all 31 patients was performed by the same surgical team. Single-incision
laparoscopic cholecystectomy was successfully performed for 30 of the 31 patients
(96.7%). One early conversion to standard laparoscopy was performed due to an intrahepatic
gallbladder and an overlying left hepatic lobe that prevented achievement of optimal
retraction of the Hartman’s pouch. The mean operative time (skin to skin) was 115
min (range, 54–230 min), and the times shortened along the learning curve (Fig. 4).
Fig. 4
The advancement in operative time along the learning curve. The first procedure has
taken 230 min while the latest ones took only 54–80 min
The earlier-mentioned solutions used to overcome the technical challenges provided
the following advantages:
The reduced external diameter of the low-profile trocars and the fact that only one
of these trocars had a valve for carbon dioxide (CO2) insufflation minimized collision
of instruments.
The versatility of the flexible endoscope achieved a superior operative view and enabled
adjustment of visual angles as the procedure required.
Alternating the insertion port of the 30° laparoscope with the other instruments resulted
in improved visualization and dissection capability.
The use of articulating instruments and endo-retractors improved the surgeon’s ability
to perform both a safe and efficient procedure.
Familiarity with these techniques resulted in a decreased operative time over the
course of our experience.
The mean hospital stay was 1.7 days (range, 1–7 days). No complications occurred for
the 30 patients who underwent surgery via the single-incision approach.
At the first outpatient follow-up visit on postoperative days 7 to 10, all the patients
expressed satisfaction with the procedure and its cosmetic result. All the patients
reported an uneventful return to their usual daily activities at that time.
Discussion
Single-incision laparoscopic surgery is an attractive approach for cholecystectomy.
However, several significant obstacles must be overcome before widespread application
of this technique can be expected. Recent studies have used different technical solutions
for these obstacles with varying success and complication rates [14–21].
Based on our experience, low-profile trocars, articulating laparoscopic tools, and
the use of endo-retractors transform single-incision laparoscopic cholecystectomy,
making it both feasible and safe. Larger series of single-incision laparoscopic cholecystectomy
have been presented [22, 23], but in the aspect of technical novelty, we believe this
series to be of special interest.
At our institution, we do not perform routine intraoperative cholangiography (IOC)
during cholecystectomy, and the current series did not include patients who needed
this procedure. If IOC is needed, we believe it could be performed using the single-incision
approach without major technical problems.
Our follow-up evaluation found that immediate postoperative pain levels were not lower
than those recorded for the population of patients who underwent standard laparoscopic
cholecystectomy. Despite this finding, it is worth mentioning that all 30 patients
successfully treated with single-incision laparoscopic cholecystectomy returned to
work within 7 to 10 days, which may indicate faster recovery after this procedure.
The cosmetic results of SILS are clearly superior to those of standard laparoscopy.
With proper placement of the incision within or at the superior border of the umbilicus,
none of our patients had a visible scar after full recovery.
Conclusion
Single-incision laparoscopic surgery is a technically challenging surgical approach.
Increased operative times are expected at the beginning of each surgeon’s learning
curve, but our initial experience indicates that such a curve is expected to be steep
for experienced surgeons. To overcome the technical obstacles and to perform single-incision
laparoscopic cholecystectomy with safety similar to that for standard laparoscopic
cholecystectomy, dedicated tools for this surgical approach are needed, as discussed
earlier. With such tools, SILS is a safe and feasible approach for cholecystectomy.