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      Single-incision laparoscopic cholecystectomy: lessons learned for success

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          Abstract

          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through three and then two ports or with reduced-diameter trocars (needlescopic surgery) [5–9] have since been superseded by even less invasive and more innovative techniques, namely, single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery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.

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          Single-incision laparoscopic cholecystectomy: surgery without a visible scar.

          Laparoscopic cholecystectomy has been recognized since 1992 as the gold standard procedure for gallbladder surgery. The authors propose a single-incision laparoscopic (SILS) cholecystectomy as a step toward less invasive surgical procedures. A single intraumbilical 12-mm incision is made, and the umbilicus is pulled out, exposing the fascia. Pneumoperitoneum is induced with the Versastep Veress access needle. A 5-mm trocar then is introduced, and the abdominal cavity is explored with a 5-mm 30 degrees optic. Second and third trocars are introduced respectively at the left and right sides, near the first trocar. Two sutures are used to suspend the gallbladder and to ensure optimal exposure of the Triangle of Calot. Dissection is performed as a normal retrograde cholecystectomy using an Endoshear roticulator in the left trocar and an Endograsp roticulator in the right hand. The cystic artery and cystic duct are clipped separately with a standard 5-mm clip applier and then excised. The gallbladder is removed through the umbilical incision. Of the 12 patients who underwent SILS cholecystectomy without major complications, 8 had previously undergone other laparoscopic surgeries. The body mass index (BMI) exceeded 35 in three cases. Operative time decreased and stabilized from the first 3-h SILS cholecystectomy to approximately 50 min after the first five cases. At this writing, the authors find SILS cholecystectomy to be feasible, safe, and effective.
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            Laparoscopic cholecystectomy.

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              Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients

              Background Findings have shown that single-incision laparoscopic cholecystectomy (SILC) is feasible and reproducible. The authors have pioneered a two-trocar SILC technique at the University of Texas Southwestern. Their results for 100 patients are presented. Methods From January 2008 to March 2009, 100 patients with symptomatic gallbladder disease underwent SILC through a 1.5- to 2-cm umbilical incision using a two-port (5-mm) technique. For nearly all the patients, a 30° angled scope was used. The gallbladder was retracted, with two or three sutures placed along the gallbladder. These sutures were either fixated internally or placed through the abdominal wall to obtain a critical view of Calot’s triangle. The SILC procedure was performed using standard technique with 5-mm reticulating or conventional laparoscopic instruments. The cystic duct and artery were well visualized, clipped, and divided. Cholecystectomy was completed with electrocautery, and the specimen was retrieved through the umbilical incision. Results In this series, 80 women (85%) and 15 men (15%) with an average age of 33.8 years (range, 17–66 years) underwent SILC. Their mean BMI was 29.8 kg/m2 (range, 17–42.5 kg/m2), and 39% of these patients had undergone previous abdominal surgery. The mean operative time was 50.8 min (range, 23–120 min). The mean estimated blood loss was 22.3 ml (range, 5–125 ml), and 5% of the patients had an intraoperative cholangiogram. There were no conversions of the SILC technique. A two-trocar technique was feasible for 87% of the patients. For the remaining patients, either a three-channel port or three individual trocars were required. A SILC technique was used for 5% of the patients to manage acute cholecystitis or gallstone pancreatitis. Conclusion The SILC technique with a two-trocar technique is safe, feasible, and reproducible. The operating times are reasonable and can be lessened with experience. Even complex cases can be managed with this technique. Excellent exposure of the critical view was obtained in all cases. The SILC procedure is becoming the standard of care for most of the authors’ elective patients with gallbladder disease. Clinical trials are warranted before the SILC technique is adopted universally.
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                Author and article information

                Contributors
                noams@hadassah.org.il
                Journal
                Surg Endosc
                Surgical Endoscopy
                Springer-Verlag (New York )
                0930-2794
                1432-2218
                7 July 2010
                7 July 2010
                February 2011
                : 25
                : 2
                : 404-407
                Affiliations
                [1 ]Department of General Surgery and Trauma Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
                [2 ]New York University, New York, NY USA
                [3 ]University of California San Diego, San Diego, CA USA
                Article
                1179
                10.1007/s00464-010-1179-7
                3032176
                20607565
                561eb5d9-79db-444d-a9d1-ca07cf6cbfb7
                © The Author(s) 2010
                History
                : 5 July 2009
                : 4 March 2010
                Categories
                Article
                Custom metadata
                © Springer Science+Business Media, LLC 2011

                Surgery
                Surgery

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