Single-port cholecystectomy versus multi-port cholecystectomy: a prospective cohort study with 222 patients

Laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy for superior mesenteric artery syndrome with dysphagia: a case report

Background

Superior mesenteric artery (SMA) syndrome denotes a mechanical duodenal obstruction between the SMA and aorta. Total parenteral or enteral nutrition is the treatment of choice. However, surgical intervention is indicated if the patient’s condition does not improve with conservative treatment. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy.

Case presentation

A 64-year-old man was admitted to another hospital because of appetite loss and vomiting. There, he was diagnosed as having superior mesenteric artery (SMA) syndrome after appropriate investigation. He had had a cerebral infarction at age 57 years, since which he had lived in social housing because of complications of that infarction. A nasogastric tube was inserted into the third portion of the duodenum beyond the constricted section. He was discharged 2 months after admission his condition having improved. He was subsequently referred to our hospital for gastrostomy because the nasogastric tube had been in place for a long time and his condition had not improved. Additionally, gastrostomy was needed as a route for enteral nutrition because he had dysphagia, which had persisted despite attempts at rehabilitation, restricting his food intake to small amounts. Computed tomography (CT) revealed compression of the third portion of the duodenum between the SMA and aorta. After obtaining informed consent, we planned an operative procedure. We performed laparoscopic gastrojejunostomy under general anesthesia, followed by laparoscopic-assisted percutaneous endoscopic gastrostomy. The operation time was 156 min and there was little blood loss. Contrast radiography on postoperative day 3 revealed no evidence of leakage or stenosis. Enteral nutrition via the gastrostomy was started. He was discharged from our hospital on the 27th postoperative day. The gastrostomy was well tolerated and there has been no evidence of recurrence of SMA syndrome during follow-up.

Conclusion

Gastrostomy is often performed to provide a route for administering enteral nutrition in patients with dysphagia. Development of SMA syndrome in patients with dysphagia necessitates operative management of the obstruction. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy.

Health-related quality of life among patients with gallstone disease: a systematic review and meta-analysis of EQ-5D utility scores

PURPOSE

Gallstone disease or cholelithiasis is a chronic illness that usually presents with pain in the abdomen, vomiting and indigestion leading to impaired quality of life. EQ-5D utility score is a validated measure of health-related quality of life (HRQoL). We systematically reviewed the literature and synthesised EQ-5D utility scores among patients with gallstone disease and its improvement on treatment.

METHODS

We have systematically searched observational studies reporting EQ-5D utility scores of gallstone disease in PubMed, Scopus, and Embase databases, from inception until February 2021. We selected the studies adhering to the PRISMA guidelines. The selected studies were reviewed, and the EQ-5D utility values of pre and post cholecystectomy were pooled using the random-effects model.

RESULT

From identified 4,817 records of database search, eleven studies predominantly from western countries with 2,189 participants were included for systematic review and meta-analysis. The pooled EQ-5D and visual analogue scores were 0.87 (0.82 to 0.91, I² = 93.73%) and 83.30 (60.59 to 106.12, I² = 99.30%) respectively with high heterogeneity. The pooled EQ-5D and EQ-5D visual analogue scores post cholecystectomy treatment were 0.93 (0.91 to 0.95, I² = 90.17%) and 91.7 (85.99 to 96.35, I² = 97.93%) respectively. The mean difference between the baseline and post intervention were 0.05 (0.01 to 0.10, I² = 93.50%) and 10.58 (-8.63 to 29.79, I² = 98.32%) for EQ-5D and visual analogue scores respectively with high heterogeneity between the studies.

CONCLUSION

The pooled mean difference indicates improvement in HRQoL after cholecystectomy but with high heterogeneity. Further high-quality studies from Asian countries are required for globally representative quantification and precise estimates of HRQoL among gallstone diseases.

PROSPERO REGISTRATION ID

CRD42021234467.

Low long-term incidence of incisional hernia after cholecystectomy: A systematic review with meta-analysis

BACKGROUND

Various surgical approaches are available for cholecystectomy, but their long-term outcomes, such as incidence of incisional hernia, are largely unknown. Our aim was to investigate the long-term incidence of incisional hernia after cholecystectomy for different surgical approaches.

METHODS

This systematic review and meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42020178906). Three databases were searched for original studies on long-term complications of cholecystectomy with n > 40 and follow-up ≥6 months for incisional hernia. Risk of bias within the studies was assessed using the Newcastle-Ottawa Scale and the Cochrane "risk of bias" tool. Meta-analysis of the incidence of incisional hernia after 6 and 12 months was conducted when possible.

RESULTS

We included 89 studies. Of these, 77 reported on multiport or single-incision laparoscopic cholecystectomy. Twelve studies reported on open cholecystectomy and 4 studies on robotic cholecystectomy. Weighted mean incidence proportion of incisional hernia after multi-port laparoscopic cholecystectomy was 0.3% (95% confidence interval 0-0.6) after 6 months and 0.2% after 12 months (95% confidence interval 0.1-0.3). Weighted mean incidence of incisional hernia 12 months postoperatively was 1.5% (95% confidence interval 0.4-2.6) after open cholecystectomy and 4.5% (95% confidence interval 0.4-8.6) after single-incision laparoscopic cholecystectomy. No meta-analysis could be conducted for robotic cholecystectomy, but incidences ranged from 0% to 16.7%.

CONCLUSION

We found low 1-year incidences of incisional hernia after multiport laparoscopic and open cholecystectomy, whereas risks of incisional hernia were considerably higher after single-incision laparoscopic and robotic cholecystectomy.

Randomized controlled trial of single incision versus conventional multiport laparoscopic cholecystectomy with long-term follow-up

Background

Within the last years, single-incision laparoscopic cholecystectomy (SLC) emerged as an alternative to multiport laparoscopic cholecystectomy (MLC). SLC has advantages in cosmetic results, and postoperative pain seems lower. Overall complications are comparable between SLC and MLC. However, long-term results of randomized trials are lacking, notably to answer questions about incisional hernia rates, long-term cosmetic impact and chronic pain.

Methods

A randomized trial of SLC versus MLC with a total of 193 patients between December 2009 and June 2011 was performed. The primary endpoint was postoperative pain on the first day after surgery. Secondary endpoints were conversion rate, operative time, intraoperative and postoperative morbidity, technical feasibility and hospital stay. A long-term follow-up after surgery was added.

Results

Ninety-eight patients (50.8%) underwent SLC, and 95 patients (49.2%) had MLC. Pain on the first postoperative day showed no difference between the operative procedures (SLC vs. MLC, 3.4 ± 1.8 vs. 3.7 ± 1.9, respectively; p = 0.317). No significant differences were observed in operating time or the overall rate of postoperative complications (4.1% vs. 3.2%; p = 0.731). SLC exhibited better cosmetic results in the short term. In the long term, after a mean of 70.4 months, there were no differences in incisional hernia rate, cosmetic results or pain at the incision between the two groups.

Conclusions

Taking into account a follow-up rate of 68%, the early postoperative advantages of SLC in relation to cosmetic appearance and pain did not persist in the long term. In the present trial, there was no difference in incisional hernia rates between SLC and MLC, but the sample size is too small for a final conclusion regarding hernia rates.

Trial registration

German Registry of Clinical Trials DRKS00012447

A Comparative Study of Needlescopic Grasper Assisted Single Incision versus Three-Port versus Pure Single Incision Laparoscopic Cholecystectomy

Purpose

Single incision laparoscopic cholecystectomy (SILC) is a surgical method to treat gallbladder disease designed to reduce postoperative pain and improve cosmetic results. However, pure SILC (pSILC) has several inherent limitations. In this study, we report the surgical outcomes of SILC with needlescopic grasper (nSILC) compared with those of pSILC and conventional three-port laparoscopic cholecystectomy (TPLC).

Methods

This retrospective study enrolled 103 patients who underwent laparoscopic cholecystectomy for benign gallbladder disease in our hospital between January 2013 and January 2015. Among them, 33 patients underwent pSILC, 35 underwent nSILC, and 35 underwent TPLC. We collected demographic characteristics and operative data to analyze outcomes between groups.

Results

All procedures were done by laparoscopy and the gallbladder of each patient was completely removed. Women and younger patients were more to undergo SILC than TPLC. Analysis showed that the operation time of the nSILC group was longer than that of the TPLC group, but shorter than that of the pSILC group (skin to skin operation time [pSILC: 65.2±19.1 min, nSILC: 49.7±12.9 min, and TPLC: 43.4±14.7 min, p<0.001], and major procedure time [pSILC: 42.2±18.7 min, nSILC: 25.9±8.9 min, and TPLC: 23.4±12.7 min, p<0.001]). There were no significant differences between the groups for patient visual analogue scale score, length of hospital stay, or intraoperative blood loss.

Conclusion

nSILC is feasible surgical method in patients with benign gallbladder disease compared to TPLC, and that is an effective procedure to overcome the disadvantage of pSILC.

True single-port cholecystectomy with ICG cholangiography through a single 15-mm trocar using the new surgical platform "symphonX": first human case study with a commercially available device

BACKGROUND

Minimally invasive single-port surgery is often associated with large incisions up to 2-3 cm, complicated handling due to the lack of triangulation, and instrument crossing. Aim of this prospective study was to perform true single-port surgery (cholecystectomy) without the use of assisting trocars using a new surgical platform that allows for triangulation incorporating robotic features, and to measure the perioperative outcome and cosmetic results.

METHODS

As the first European site after FDA and CE-mark approval, the new device has been introduced to our academic center. In patients with cholecystitis and cholecystolithiasis, the operation was performed through only one 15-mm trocar. For patients safety, intraoperative cholangiography using intravenous ICG and a standard Stryker 1588 system was routinely performed.

RESULTS

Symphonx was used in n = 12 patients for abdominal surgery (6 females, mean age 42.5 [30-77], mean BMI 26.2 [19.3-38.9]. A total of 8 patients underwent surgery using no additional ports besides the 15-mm trocar; in the remaining patients, one assisting instrument (3-5 mm) was used. Mean OR time was 107 [72-221] minutes. The postoperative course was uneventful in 11 patients; in one patient, a seroma at the surgical site required interventional drainage 1 month postoperatively. No intraoperative complications occurred.

CONCLUSION

This is the first human case series using the commercially available symphonX platform for abdominal laparoscopic surgery and the first series using the system without assisting instruments. Laparoscopic cholecystectomy in patients with cholecystitis and cholecystolithiasis using the symphonX platform through only one 15-mm trocar is feasible, safe, and more cost-efficient compared to robotic platforms.

A systematic review of patient reported outcome measures (PROMs) and quality of life reporting in patients undergoing laparoscopic cholecystectomy

Patient reported outcome measures (PROMs) provide a valuable means of measuring outcomes subjectively from a patient's perspective, facilitating the assessment of service quality across healthcare providers, and assisting patients and clinicians in shared decision making. The primary aim of this systematic review was to critically appraise all historic studies evaluating patient reported quality of life, in adult patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. The secondary aim was to perform a quality assessment of cholecystectomy-specific PROM-validation studies. A literature review was performed in PubMed, Google ScholarTM, the Cochrane Library, Medline, CINAHL, EMBASE and PsychINFO databases up to September 2017. Study characteristics, PROM-specific details and a bias assessment were summarised for non-validation studies. A COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) analysis was performed to assess the methodological quality of identified PROM-validation studies. Fifty one studies were found to evaluate health-related quality of life (HRQoL) after laparoscopic cholecystectomy. Although 94.1% of these studies included PROMs as a primary outcome measure, <20% provided level 1 evidence through randomised controlled trials (RCTs). There was significant variation in the selection and reporting of PROMs, with no studies declaring patient involvement in PROM selection, and 88.2% of studies failing to document the management of missing data points, or non-returned surveys (33.3%). In the 6 PROM-validation studies identified, only 5 psychometric properties were evaluated, the findings of which were limited due to the small number of studies. This systematic review identifies a lack in consistency of study design and PRO reporting in clinical trials. Whilst an increasing number of studies are being performed to evaluate PROs, a lack of adherence to existing PRO administration and reporting guidelines is continuing to negatively affect study quality. We recommend that future clinical trials utilizing PROs should adhere to established comprehensive guidelines as described.

A promising technique for easier single incision laparoscopic cholecystectomy: needle grasper traction of gallbladder

Introduction

Laparoscopic cholecystectomy (LC) is the primary treatment method for benign gallbladder diseases. Single incision laparoscopic cholecystectomy (SILC) was reported to be superior in terms of work return, cosmetic results, and post-operative pain, but limited maneuver capacity and overlapping of hand tools are technical difficulties associated with SILC that endanger patient safety.

Aim

To perform SILC using a needle grasper for gallbladder traction, thus simplifying the dissection of Calot's triangle.

Material and methods

The files of patients who underwent elective LC for gallbladder stone and polyps in general surgery clinics between December 2013 and December 2014 were analyzed retrospectively. The patients were divided into two groups: needle-grasper-assisted SILC (nSILC) and conventional laparoscopic cholecystectomy (CLC). Age, gender, height, weight, body mass index, visual analog scale (VAS) scores, ASA score, duration of operation, duration of post-operative hospital stay, complications, drain use, conversion to open and conventional technique, and oral feeding beginning time were analyzed.

Results

There were no per-operative or post-operative complications in either of the groups, and no significant differences were found between the groups in terms of complications. The mean duration of the operation was significantly longer in the nSILC group. There was no difference between the groups in terms of hospital stay. The mean visual analogue scale (VAS) scores in conventional nSILC were significantly lower for all hours. The patient satisfaction in terms of cosmetic results was better in the nSILC group.

Conclusions

Needle-grasper-assisted SILC reduces the number of tools that need to be held by surgeons; it also provides safe dissection, better cosmetic results, and less post-operative pain in elective cases.

Hybrid transgastric appendectomy is feasible but does not offer advantages compared with laparoscopic appendectomy: Results from the transgastric appendectomy study

BACKGROUND

Very few transgastric procedures, the original objective of natural orifice translumenal surgery, have been reported in the international Natural Orifice Translumenal Surgery registers. In addition, most cases were controlled mainly by laparoscopy. To show the feasibility of hybrid transgastric appendectomy and to compare results with laparoscopic a prospective, nonrandomized study was conducted.

METHODS

From October 2010 to May 2013, patients with acute appendicitis were screened. If the patients met the inclusion criteria, transgastric appendectomy was offered. If the patient decided on laparoscopy, the consenting patients took part in the observational part of the study. The transgastric appendectomy procedure was controlled completely by the gastroscope, although a 3 mm grasper was used to tauten the appendix. Demographic and clinical parameters were collected. Quality of life and pain were measured with a Short Form-8 questionnaire and the Visual Analogue Scale.

RESULTS

Of the 273 patients who underwent an appendectomy, 65 agreed to take part in this study. Out of these, 30 (46.15%) underwent transgastric appendectomy and 35 (53.85%) underwent laparoscopy. No intraoperative complications were recorded. The operation duration rate was greater in the transgastric appendectomy group (94.5 minutes vs 69 minutes; P < .001). Conversions to open appendectomy and complications were the same. There were no differences in pain preoperatively or postoperatively. In both the transgastric appendectomy and laparoscopic groups, the quality of life of all the subscales increased markedly after successful resection of the pathology.

CONCLUSION

These preliminary results demonstrate the feasibility of transgastric appendectomy. The postoperative course and quality of life are comparable with laparoscopic appendectomy, but no improvement due to transgastric appendectomy could be demonstrated.

COMPARATIVE ANALYSIS OF IMMUNOLOGICAL PROFILES IN WOMEN UNDERGOING CONVENTIONAL AND SINGLE-PORT LAPAROSCOPIC CHOLECYSTECTOMY

Background

Surgical trauma triggers an important postoperative stress response characterized by significantly elevated levels of cytokines, an event that can favor the emergence of immune disorders which lead to disturbances in the patient's body defense. The magnitude of postoperative stress is related to the degree of surgical trauma.

Aim

To evaluate the expression of pro-inflammatory (TNF-α, IFN-γ, IL-1β, and IL-17) and anti-inflammatory (IL-4) cytokines in patients submitted to conventional and single-port laparoscopic cholecystectomy before and 24 h after surgery.

Methods

Forty women with symptomatic cholelithiasis, ranging in age from 18 to 70 years, participated in the study. The patients were divided into two groups: 21 submitted to conventional laparoscopic cholecystectomy and 19 to single-port laparoscopic cholecystectomy.

Results

Evaluation of the immune response showed no significant difference in IFN-γ and IL-1β levels between the groups or time points analyzed. With respect to TNF-α and IL-4, serum levels below the detection limit (10 pg/ml) were observed in the two groups and at the time points analyzed. Significantly higher postoperative expression of IL-17A was detected in patients submitted to single-port laparoscopic cholecystectomy when compared to preoperative levels (p=0.0094).

Conclusions

Significant postoperative expression of IL-17 was observed in the group submitted to single-port laparoscopic cholecystectomy when compared to preoperative levels, indicating that surgical stress in this group was higher compared to the conventional laparoscopic cholecystectomy.

Single center experiences of needle-scopic grasper assisted single incision laparoscopic cholecystectomy for gallbladder benign disease: comparison with conventional 3-port laparoscopic cholecystectomy

Purpose

Single incision laparoscopic cholecystectomy (SILC) has some technical problems. Our group has performed needlescopic grasper assisted SILC (nSILC) to overcome these problems. In this study, we introduce our technique and evaluate the safety and feasibility of this technique compared with the conventional laparoscopic cholecystectomy (CLC).

Methods

The medical records of 485 patients who received nSILC and CLC were reviewed retrospectively. Surgical outcomes including operative time, hospital stay, postoperative pain and perioperative complication were compared between the 2 techniques.

Results

Although wound complications were developed more frequently in nSILC group, there was no significant difference between groups in other surgical outcomes. In subgroup analysis, surgical outcomes of nSILC were similar with those of CLC not only in easy group but also in difficult group.

Conclusion

It seems that nSILC is safe and feasible not only in selected patients but also in difficult cases such as acute cholecystitis.

Single-incision laparoscopic surgery for biliary tract disease

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy (SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials (RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration (CBDE) methods have been used for more than one hundred years, laparoscopic CBDE (LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and single-incision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.

Single-port laparoscopic cholecystectomy vs standard laparoscopic cholecystectomy: A non-randomized, age-matched single center trial

AIM: To compare the safety of single-port laparoscopic cholecystectomies with standard four-port cholecystectomies.

METHODS: Between January 2011 and December 2012 datas were gathered from 100 consecutive patients who received a single-port cholecystectomy. Patient baseline characteristics of all 100 single-port cholecystectomies were collected (body mass index, age, etc.) in a database. This group was compared with 100 age-matched patients who underwent a conventional laparoscopic cholecystectomy in the same period. Retrospectively, per- and postoperative data were added. The two groups were compared to each other using independent t-tests and χ²-tests, P values below 0.05 were considered significantly different.

RESULTS: No differences were found between both groups regarding baseline characteristics. Operating time was significantly shorter in the total single-port group (42 min vs 62 min, P < 0.05); in procedures performed by surgeons the same trend was seen (45 min vs 59 min, P < 0.05). Peroperative complications between both groups were equal (3 in the single-port group vs 5 in the multiport group; P = 0.42). Although not significant less postoperative complications were seen in the single-port group compared with the multiport group (3 vs 9; P = 0.07). No statistically significant differences were found between both groups with regard to length of hospital stay, readmissions and mortality.

CONCLUSION: Single-port laparoscopic cholecystectomy has the potential to be a safe technique with a low complication rate, short in-hospital stay and comparable operating time. Single-port cholecystectomy provides the patient an almost non-visible scar while preserving optimal quality of surgery. Further prospective studies are needed to prove the safety of the single-port technique.

Phase II clinical experience and long-term follow-up using the next-generation single-incision platform FMX314

BACKGROUND

Single-incision minimally invasive surgery has previously been associated with incisions 2.0-3.0 cm in length. We present a novel single-incision surgical platform compatible for insertion through a standard 15-mm trocar we previously described in six patients with short-term follow-up data. The objective of this phase II study was to evaluate the safety and feasibility of the platform in a larger collective and to evaluate 1-year follow-up data of the phase I trial.

METHODS

The technology features a multiple-use introducer, accommodating the articulating instruments, and is inserted through a 15-mm laparoscopic trocar. Cholecystectomy is performed through an umbilical incision. A prospective feasibility study was performed at a single center. Inclusion criteria were age of 18-75 years and biliary colic, exclusion criteria were acute cholecystitis, dilation of the biliary tree, severe coagulopathy, BMI > 40 kg/m(2), or choledocholithiasis. Endpoints included complications, length of stay, pain medication, cosmetic results, and the presence of hernia.

RESULTS

Twenty-seven patients (23 females; phase I: 6 patients, phase II: 21 patients) with an average age of 41.7 years and BMI 26.6 kg/m(2) were recruited for the study. Umbilical incision length did not exceed 15 mm. There were no intraoperative complications. Average OR time decreased from 91 min for the first six cases to 56 min for the last six cases. Average length of stay was 7.8 h. Pain control was achieved with diclofenac for no more than 7 days. All patients had no adverse events at 5-month follow-up, and all phase I patients had no adverse events nor evidence of umbilical hernia at 1 year.

CONCLUSION

This study demonstrates that single-incision cholecystectomy with the platform is feasible, safe, and reproducible in a larger patient population. Long-term follow-up showed no hernias or other adverse events. Further studies will be needed to evaluate longer-term hernia rates.

Transumbilical single-incision laparoscopic distal pancreatectomy: primary experience and review of the English literature

BACKGROUND

Single-incision laparoscopic surgery (SILS) may represent an improvement over conventional laparoscopic surgery, and has been applied in many surgical procedures. However, for pancreatic surgery, experience is rather limited.

METHODS

The clinical records of 11 cases in which transumbilical single-incision laparoscopic distal pancreatectomy (TUSI-LDP) was performed at our institution since June 2009 were retrospectively analyzed, and all the literatures concerning TUSI-LDP were retrospectively reviewed.

RESULTS

All the 11 patients were female. The ages ranged from 20 to 73 years, with an average age of 38.0 years. The average body mass index (BMI) was 22.67 (18.6-26.2). Most TUSI-LDPs were successfully performed, with only one conversion to multi-incision surgery. Splenic preservation was performed in six cases. The mean operation time was 163.18 ± 63.18 minutes (range 95-300), and the mean intraoperative blood loss was 159.09 ± 181.02 ml (range 10-500 ml). The surgical wounds healed well, with good cosmetic wound healing, and the patients were discharged from hospital in a mean of 7.45 ± 1.44 days (range 5-10). Only one patient developed pancreatic leakage, which ceased spontaneously with only a drain for 61 days. The parameters were comparable with those found in the English literature.

CONCLUSIONS

These recent experiences suggest that SILS in pancreatic surgery is feasible for a select group of patients with relatively small lesions and low BMI, and that, with the gradual accumulation of surgeons' experience with SILS and improvement of laparoscopic instruments, it might become a safe option for some patients.

[Quality of life and visceral surgery]

Quality of life (QOL) is becoming more and more relevant in clinical research. An increasing number of publications each year confirmed this. The aim of this review is to summarize current data of QOL after surgical procedures. The results are represented by two examples each of malignant and benign diseases. The evaluation of QOL for patients with cancer is only possible with respect to the prognosis. Prospective randomized trials comparing laparoscopic and open surgery for early gastric cancer are only available from Asia. Data from the USA show that the QOL after gastrectomy was worse regardless of the surgical procedure. During the next 6 months the QOL improved but about one third of the patients had severe impairment during longer follow-up periods. Patients with R1 resection of pancreatic cancer showed only a slightly better prognosis but significantly better QOL compared to patients without resection. The results for the various procedures of cholecystectomy or hernia repair are not always consistent.

Transumbilical single-incision laparoscopic combined cholecystectomy and appendectomy: a retrospective comparative study

BACKGROUND

Single-incision laparoscopic surgery (SILS) developed rapidly in recent years. This report describes our initial experience on SILS combined cholecystectomy and appendectomy (SILSC&A) with a unique method of umbilical reconstruction. In addition, a retrospective comparison with conventional combined laparoscopic cholecystectomy and appendectomy (LC&A) was analyzed.

MATERIALS AND METHODS

Between April 2009 and December 2013, 62 patients with benign gallbladder and appendix disease underwent laparoscopic combined cholecystectomy and appendectomy at our institution. Of these, 34 (54.8%) underwent SILSC&A (Group 1), and 28 (45.2%) underwent LC&A (Group 2). Demographic, intraoperative, and postoperative data were analyzed retrospectively and compared between the two groups.

RESULTS

No significant differences were identified in the preoperative patient characteristics between the two groups. SILSC&A was associated with a shorter operative time (62.2 ± 19.7 versus 77.5 ± 21.4 minutes, respectively; P = .005) and better cosmetic results (4.6 ± 0.7 versus 4.1 ± 0.6, respectively; P = .004). There were no significant differences between the two groups with respect to other postoperative variables.

CONCLUSIONS

The present study suggests that SILSC&A is as safe and efficacious as conventional LC&A in experienced hands. A uniform method of umbilical reconstruction is helpful in improving cosmesis and decreasing hernia rate. Long-term follow-up and further prospective randomized trials are anticipated.

SMA Syndrome Treated by Single Incision Laparoscopic Duodenojejunostomy

Superior mesenteric artery (SMA) syndrome is a mechanical duodenal obstruction by the SMA. The traditional approach to SMA syndrome was open bypass surgery. Nowadays, a conventional approach has been replaced by laparoscopic surgery. But single incision laparoscopic approach for SMA syndrome is rare. Herein, we report the first case of SMA syndrome patient who was treated by single incision laparoscopic duodenojejunostomy.

Laparoscopic cholecystectomy using a novel single-incision surgical platform through a standard 15 mm trocar: initial experience and technical details

OBJECTIVE

Single-incision minimally invasive surgery has previously been associated with incisions 2.0-3.0 cm in length. We present a novel single-incision surgical platform compatible for insertion through a standard 15-mm trocar. The objective of this study is to evaluate the safety and feasibility of the platform.

METHODS

The technology is currently a Phase I investigational device. It features articulating surgical instruments and is inserted through a multiple-use introducer. The platform's introducer requires a standard 15-mm laparoscopic trocar. Cholecystectomy is performed through a 15-mm umbilical incision utilizing an additional epigastric 2-mm needle-port grasper for gallbladder retraction. A prospective feasibility study was performed at a single-center. Inclusion criteria were age 18-75 years and biliary colic. Patients were excluded if they had acute cholecystitis, dilation of the biliary tree, severe coagulopathy, BMI > 40 kg/m(2), or choledocholithiasis. Endpoints included the success rate of the platform, hospital length of stay, post-operative pain medication usage, cosmetic results, and presence of hernia.

RESULTS

Six patients (5 female) with an average age of 41 years and BMI 28 kg/m(2) underwent cholecystectomy with the platform. Average OR time was 91 min and umbilical incision length did not exceed 15 mm. One case was converted to standard laparoscopy due to mechanical failure of the clip applier instrument. There were no intraoperative complications. Post-operatively, two patients developed self-resolving umbilical ecchymoses. Average length of stay was 13 h. Pain control was achieved with diclofenac for less than 7 days. At 1 month follow-up there were no complications and no umbilical hernias.

CONCLUSIONS

This phase I study demonstrates that single-incision cholecystectomy through a 15-mm trocar with the Fortimedix Surgical B.V. single-incision surgical platform is feasible, safe, and reproducible. Additional benefits include excellent triangulation and range of motion as well as exceptional cosmetic results. Further studies will be needed to evaluate long-term hernia rates.

Intrahepatic glissonian approach for single-port laparoscopic liver resection

BACKGROUND

Minimal access surgery is moving toward reduced size and fewer ports. The aim of this article is to describe our experience with the intrahepatic Glissonian approach for single-port laparoscopic left lateral sectionectomy.

SUBJECTS AND METHODS

We have performed this procedure on 8 consecutive patients. A transumbilical incision is performed, and a single-incision platform is introduced. The operation begins with ultrasound examination of the liver. Intrahepatic Glissonian access of the portal pedicle from segments 2 and 3 is performed, and the pedicle is divided with a stapler. The liver is transected, and the left hepatic vein is divided with a stapler. A surgical specimen is retrieved through the single umbilical incision. No drains are left in place.

RESULTS

The median operative time was 68 minutes, and there was minimal bleeding. The median hospital stay was 1 day. Six patients were operated on for liver adenoma. There was no morbidity or mortality. During follow-up (median, 12 months), no patient developed incisional hernia. The cosmetic appearance of the incision was excellent in all cases.

CONCLUSIONS

Single-port laparoscopic left lateral sectionectomy is feasible and can be safely performed in specialized centers.

Laparoscopy in the era of enhanced recovery

Laparoscopy is one of the cornerstones in the surgical revolution and transformed outcome and recovery for various surgical procedures. Even if these changes were widely accepted for basic interventions, like appendectomies and cholecystectomies, laparoscopy still remains challenged for more advanced operations in many aspects. Despite these discussion, there is an overwhelming acceptance in the surgical community that laparoscopy did transform the recovery for several abdominal procedures. The importance of improved peri-operative patient management and its influence on outcome started to become a focus of attention 20 years ago and is now increasingly spreading, as shown by the incoming volume of data on this topic. The enhanced recovery after surgery (ERAS) concept incorporates simple measures of general management, and requires multidisciplinary collaboration from hospital staff as well as the patient and the relatives. Several studies have demonstrated a significant decrease in postoperative complication rate, length of hospital stay and reduced overall cost. The key elements of success are fluid restriction, a functioning epidural and preoperative carbohydrate intake. With the expansion of laparoscopic techniques, ERAS increasingly incorporates laparoscopic patients, especially in colorectal surgery. However, the precise impact of laparoscopy on ERAS is still not clearly defined. Increasing evidence suggests that laparoscopy itself is an additional ERAS item that should be considered as routine where feasible in order to obtain the best surgical outcomes.

Patient and parental scar assessment after single incision versus standard 3-port laparoscopic appendectomy: long-term follow-up from a prospective randomized trial

BACKGROUND

Single site laparoscopy for appendectomy is a technique with several case series suggesting a cosmetic advantage, but without prospective comparative data. We conducted a prospective, randomized trial comparing single site laparoscopic appendectomy to the standard 3-port approach, including scar assessment at early and long-term follow-up.

METHODS

Enrolled patients over 12years old and parents of patients less than 12years old were asked to complete the validated Patient Scar Assessment Questionnaire (PSAQ) at early follow-up around 6weeks and by phone after 18months. The PSAQ consists of 4 scored subscales: Appearance, Consciousness, Appearance Satisfaction, and Symptom Satisfaction. Each subscale has a set of questions with a 4-point categorical response (1=most favorable, 4=least favorable). The sum of the scores quantifies each subscale.

RESULTS

Early questionnaires were obtained from 98 3-port and 100 single-site patients with the single-site approach producing superior overall scar assessment (P=0.003). By telephone follow-up, questionnaires were completed by 49 3-port and 56 single-site patients at a median of 25 (18-32) months. In this longer-term follow-up, overall scar assessment was not significantly different between groups (P=0.06).

CONCLUSION

Patients or parents express superior scar assessment with the single site approach at early follow-up, but this difference disappears in the long-term.

Prospective, randomized clinical trial comparing the use of a single-port device with that of a flexible endoscope with no other device for transumbilical cholecystectomy: LLATZER-FSIS pilot study

BACKGROUND

Natural orifice transumbilical endoscopic surgery (NOTES) is a technique still in experimental development that requires clinical trials to assess its safety and efficacy. We present a pilot prospective, randomized, three-arm clinical trial of 1-year duration that was conducted as a noninferiority trial comparing single-incision laparoscopic surgery (SILS) and flexible single-incision surgery (FSIS) with conventional laparoscopy for elective cholecystectomy (NCT01558414).

METHODS

Sixty patients between aged 18 and 65 years who were eligible for elective cholecystectomy were randomly assigned in a 1:1:1 ratio (n = 20 per group): group A (SILS), single-incision endoscopic surgery using a transumbilical SILS™ device; group B (FSIS), single-incision transumbilical surgery using a flexible endoscope; and group C (CL), conventional laparoscopy. The main outcome variable of the study was "parietal complications" (wound infection, bleeding, and ventral hernia). The analysis was by intention to treat and attritions were not replaced.

RESULTS

Cholecystectomy was performed in 100 % of the cases; perioperative complications occurred in only 1.6 % of the cases, and umbilical surgical wound infection in 3.33 %, with no differences between groups. After a minimum follow-up of 1 year, no differences were noted in the frequency of parietal complications and no ventral hernias occurred. Postoperative pain, hospital length of stay, and downtime from work were similar in all three groups. Surgical time was longer in cases in which a single-incision transumbilical approach was used (58.95 min for SILS and 54.15 for FSIS vs. 49.21 for laparoscopy).

CONCLUSIONS

Single-incision transumbilical approaches are not inferior for safety or effectiveness compared with conventional laparoscopy. The transumbilical approach using a flexible endoscope is just as effective and safe as the other two procedures and is a promising single-incision approach.