A new technique for two-trocar laparoscopic cholecystectomy

Feasibility and Safety of Three-Port Laparoscopic Cholecystectomy Compared to Four-Port Laparoscopic Cholecystectomy

Background

The standard four-port laparoscopic cholecystectomy (LC) is the gold standard procedure. The various clinical trials and reports in the literature have suggested that the three-port technique LC can be done safely with acceptable results.

Still, that the three-port LC offers any added benefits to the patient is a controversial issue especially in view of safety and feasibility. In this study, we report the experience of three-port LC compared to four-port LC technique, its safety, feasibility and outcomes.

Materials and methods

A prospective randomized study was conducted between two groups which included 165 cases - 93 patients were included in three-port LC (Group A) and 72 patients in four-port LC (Group B). Operative time, intraoperative complications, postoperative pain, length of hospital stay, analgesics requirement, conversion to open and return to normal activities were parameters of evaluation.

Results

Demographic data was comparable in both the groups. Three-port LC Group A had lesser post-operative pain and analgesics requirements. The mean postoperative pain visual analogue scale (VAS) score on day 1 was (4.16 and 6.24), on day 7 was (1.26 and 1.81) in three-port group and in four-port LC group, respectively. The mean days of analgesics requirement were 2.56 days and 4.21 days among three-port group and four-port group, respectively

Length of hospital stay was less and returning to work was early in three-port group. There was no statistical difference in operative time. The mean operative time among three-port LC group A and four-port LC group B was 36+/-8.6 minutes (30-68) and 39+/-7 minutes (30-90), respectively. The overall outcomes were comparable to four-port LC.

Conclusion

Three-port LC is a feasible and safe procedure for LC with satisfactory outcomes like lesser postoperative pain, postoperative stay and less scars, when performed by experienced hands, especially in acute cholecystitis. The use of fourth port should be done when required in a difficult situation.

Two-incision laparoscopic cholecystectomy performed via the “marionette” technique versus conventional laparoscopic cholecystectomy in pediatrics

Background

Laparoscopic cholecystectomy (LC) has considered the gold standard for the treatment of symptomatic gallstones. The “marionette” technique is a surgical technique for performing a safe, two-incision laparoscopic cholecystectomy without the use of an additional port or any new access devices. This study aimed to compare between the cost and outcome of two incisions LC performed via the marionette technique and the standard LC in pediatrics.

Results

All 32 children with symptomatic cholecystolithiasis were discharged from the hospital in the first postoperative day with no statistically significant difference within days to return to normal work (p = 0.607). The operative time in the group (A) which included 16 children who underwent 2 incisions marionette style LC technique was non-significantly longer time (p = 0.184) than the group (B) which included 16 children who underwent conventional 4 incisions LC technique. Visual analog scores for pain showed a significant difference between both groups at 6 h and 12 h postoperative (p = 0.000 and 0.003, respectively). Overall patient in marionette group was very satisfied by fewer incision and better cosmesis.

Conclusion

Marionette technique performed by an experienced surgeon among pediatric shows a statistically significant cost benefit while maintaining good operative time, less postoperative pain, and more patient’s satisfaction and provides excellent aesthetic results.

Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis

BACKGROUND

The purpose of this study was to evaluate improvements in cosmetic results and postoperative morbidity for single-incision laparoscopic cholecystectomy (SILC) in comparison with multiport laparoscopic cholecystectomy (MLC).

METHODS

A literature search was undertaken for RCTs comparing SILC with MLC in adult patients with benign gallbladder disease. Primary outcomes were body image and cosmesis scores at different time points. Secondary outcomes included intraoperative and postoperative complications, postoperative pain and frequency of port-site hernia.

RESULTS

Thirty-seven RCTs were included, with a total of 3051 patients. The body image score favoured SILC at all time points (short term: mean difference (MD) -2·09, P < 0·001; mid term: MD -1·33, P < 0·001), as did the cosmesis score (short term: MD 3·20, P < 0·001; mid term: MD 4·03, P < 0·001; long-term: MD 4·87, P = 0·05) and the wound satisfaction score (short term: MD 1·19, P = 0·03; mid term: MD 1·38, P < 0·001; long-term: MD 1·19, P = 0·02). Duration of operation was longer for SILC (MD 13·56 min; P < 0·001) and SILC required more additional ports (odds ratio (OR) 6·78; P < 0·001). Postoperative pain assessed by a visual analogue scale (VAS) was lower for SILC at 12 h after operation (MD in VAS score -0·80; P = 0·007). The incisional hernia rate was higher after SILC (OR 2·50, P = 0·03). All other outcomes were similar for both groups.

CONCLUSION

SILC is associated with better outcomes in terms of cosmesis, body image and postoperative pain. The risk of incisional hernia is four times higher after SILC than after MLC.

[Mini-laparoscopic cholecystectomy as an innovative method in minimally invasive abdominal surgery]

INTRODUCTION

In our study, we applied a mini-laparosopic approach during laparoscopic cholecystectomy (LC) (using the minimum size of trocars with the simultaneous intention to reduce their number). The advantages and disadvantages of the mini-LC approach were compared with those of traditional LC.

PATIENTS AND METHODS

During mini-LC procedures, we used 3 ports (11 mm, 5 mm, 3.5 mm). Mini-LC was performed in 10 patients, and the results were compared with those of 10 cases of traditional LCs. The two groups were homogenous in terms of gender, age, BMI and ASA classification. Comparison criteria included operative time, the need to use an extra port, conversion rate, oral analgesic requirement, early/late complications and cosmetic results.

RESULTS

There were no significant differences in terms of operative time, blood loss, hospital stay and complications. Cumulative size of incisions was 19.5 mm with mini-LC- and 41 mm in the LC group, respectively, and the tissue injury was 124.2 mm(2) and 448.2 mm(2). Cosmetic results of mini-LC were highly improved by these values. Increased oral analgetic requirements were detected in LC group.

CONCLUSION

Mini-LC is a safe procedure with outstanding cosmetic results accompanied by less oral analgetic requirements. In selected patients, it can be recommended as an alternative method of traditional LC.

Two-port mini laparoscopic cholecystectomy compared to standard four-port laparoscopic cholecystectomy

INTRODUCTION:

Two-port mini laparoscopic cholecystectomy (LC) has been proposed as a safe and feasible technique. However, there are limited studies to evaluate the effectiveness of the procedure. This study is a prospective randomised trial to compare the standard four-port LC with two-port mini LC.

MATERIALS AND METHODS:

A total of 116 consecutive patients undergoing LC were randomised to four-port/two-port mini LC. In two-port mini LC, a 10-mm umbilical and a 5-mm epigastric port were used. Outcomes measured were duration and difficulty of operation, post-operative pain, analgesia requirements, post-operative stay, complications and cosmetic score at 30 days.

RESULTS:

Out of 116 patients, the ratio of M:F was 11:92, with mean age 40.79 ± 12.6 years. Twelve patients (nine in four-port group and three in two-port group) were lost to follow-up. The mean operative time were similar (P = 0.727). Post-operative pain was significantly low in the two-port group at up to 24 hrs (P = 0.023). The overall analgesia requirements (P = 0.003) and return to daily activity (P = 0.00) were significantly lower in two-port group. The cosmesis score of the two-port group was better than four-port group (P = 0.00). However, the length of hospital stay (P = 0.760) and complications (P = 0.247) were similar between the two groups.

CONCLUSION:

Two-port mini LC resulted in reduced pain, need for analgesia, and improved cosmesis without increasing the operative time and complication rates compared to that in four-port LC. Thus, it can be recommended in selected patients.

Single-access laparoscopic colectomy utilizing gravity in the lateral decubitus position

BACKGROUND

Only a limited number of instruments can be used in single-access laparoscopic colectomy, and triangulation must be forfeited to avoid instrument collision. We investigated whether this problem could be overcome by performing laparoscopic colectomy by the use of the lateral decubitus position, making full use of gravity.

OBJECTIVE

The aim of this study was to determine whether single-access laparoscopic colectomy could be achieved while maintaining patients in the lateral decubitus position.

DESIGN

This was a prospective study.

SETTING

This single-center study was conducted in a hospital.

PATIENTS

Ten consecutive patients (4 men and 6 women) with stage II or III colon cancer were included.

INTERVENTIONS

Each patient was placed in the lateral decubitus position. Single-port access to the abdomen was provided by a 3.0-cm incision at the umbilicus. The roots of the supplying or draining vessels were isolated and divided for lymphadenectomy. Next, the colon was dissected from a lateral approach, without the help of the assistant. The specimen was extracted from the single-access incision. Extracorporeal or intracorporeal anastomosis was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was the feasibility of single-access laparoscopic colectomy in the lateral decubitus position.

RESULTS

There were no intraoperative complications and no need for conversions to conventional laparoscopic surgery, open surgery, or the supine position. The median total surgical time was 154 minutes (interquartile range, 135-220 minutes). Surgical blood loss was slight (<20 mL) in all patients. No postoperative complications occurred. The median postoperative hospital stay was 7 days (interquartile range, 5-7 days).

LIMITATIONS

The sample size was small.

CONCLUSIONS

Our results show that single-access laparoscopic colectomy in the lateral decubitus position is safe and feasible.

Single-scar laparoscopic colectomy with intracorporeal attachable and detachable instruments

BACKGROUND

In single-access laparoscopic colectomy, the number of instruments that can be inserted through the single-access site is limited by instrument collision. To compensate, triangulation is necessary, but the operative field becomes inadequate. To overcome this problem, intracorporeal attachable and detachable instruments can broaden the field of visceral tissue by retracting from at least 2 points.

OBJECTIVE

We tested this new procedure for colon cancer surgery.

DESIGN

This is a prospective study.

SETTING

This study was conducted at a single-center hospital.

PATIENTS

Ten consecutive patients (3 male and 7 female) with stage II or III colon cancer underwent the procedure.

INTERVENTIONS

All patients received a 3.0-cm incision at the umbilicus or right iliac fossa. At least 2 clips and a suspending bar were inserted through a 12-mm port in a multiport access device. The clips grasped the mesocolon at different points and were retracted with either an extracorporeal magnet or fine-loop retractors; this broadened the operative field in the mesocolon by at least 2 points. The mesocolon was dissected with a medial to lateral approach. The suspended bar was tied to 2 fine-loop retractors and manipulated to enlarge the operative field in the mesocolon. The roots of the vascular pedicles were isolated and divided during lymph node dissection. After extracting the specimen, an anastomosis was performed.

MAIN OUTCOME MEASURES

Intra- and postoperative complications due to inadequate access were the primary outcomes measured.

RESULTS

There were no intraoperative complications and no need for conversions to open surgery or second access ports. The median total surgical time was 182 minutes (range, 122-245). Surgical blood loss was slight (range, 1-20 mL) in all patients. No postoperative complications occurred. The postoperative hospital stay was 5 to 7 days.

LIMITATIONS

The sample size was small.

CONCLUSIONS

This study showed that intracorporeal attachable and detachable instruments were safe and feasible for this procedure.

Single-port laparascopic cholecystectomy: scarless cholecystectomy

Objective. Single-incision laparoscopic surgery is a new advanced technology to further minimize the invasiveness of laparoscopy through a single small incision hidden in the umbilicus. The objective is to describe short and long-term outcomes of SILS cholecystectomy. Methodology. Patients with gallbladder pathologies were unselectively enrolled and were prospectively studied between April 2009 and April 2010 and completed a post-operative follow-up for 12 months. Results. There were 22 women and 8 men. Mean age was 46 years. Twenty-one patients had biliary colic, seven had acute cholecystitis, one had gallbladder polyp, and another had resolving acute pancreatitis. Mean operative time was 104.3 ± 44 minutes. Mean BMI was 30.42 and the average pain score was 3.2 ± 1.1. One more port was inserted to help in finishing the procedure in one patient. There was no conversion to a standard laparoscopic or open technique. There was one post-operative bile collection from a missed cyctic duct of Luschka. Mean hospital stay was 1.2 days. Conclusion. Single-port laparoscopic cholecystectomy is feasible. Early conversion to a standard laparoscopic technique is advised to avoid serious complications. The procedure has an obvious cosmetic benefit. Additional prospective trials are necessary to define the benefits of single-port laparoscopic cholecystectomy.

Is there still any role for minilaparoscopic-cholecystectomy? A general surgeons' last five years experience over 932 cases

Laparoscopy has rapidly emerged as the preferred surgical approach in a number of different diseases because it ensures correct diagnoses and appropriate treatment. The use of mini-instruments (5 mm or less in diameter) and, when possible, the reduction of the number of trocars used might be its natural evolution. Laparoscopic cholecystectomy is a gold standard technique. The aim of the present work is to illustrate the results of the prospective experience of minilaparoscopic cholecystectomy (5 mm MLC) performed at our institution. Between August 2005 and July 2010 a total of 932 patients (mean age 45 years) underwent a laparoscopic cholecystectomy. Amongst them, 887 (95.1%) were operated on with a 5 mm-three trocar approach and in the remaining 45 cases (4.8%) a 3 mm trocar was used. The primary endpoint was the feasibility rate of the techniques. Secondary endpoints were safety and the impact of the techniques on duration of laparoscopy. In two cases conversion to laparotomy was necessary. We needed to add a fourth-5 mm trocar in the 10.7% of the cases (95 patients) in the 5 mm MLC. There were two cases of redo-laparoscopy in this group due to bile leakage from the cystic duct in one case, and to bleeding from the gallbladder bed in the other. Minor occurrence ranged as high as 2.1% in the 5 mm-MLC group, while it was nil in the 3 mm-MLC patients. The present experience shows that the 5 mm-three trocars MLC is a safe, easy, effective and reproducible approach to gallbladder diseases. Such features make the technique a challenging alternative to conventional laparoscopy both in the acute and the scheduled setting. We consider the 3 mm-MLC approach suitable only in selected cases, young and thin patients, due to the fragility of the smaller instruments.

Single-site umbilical laparoscopic cholecystectomy

Until the mid-1980s, cholecystectomy was performed through a generous right upper abdominal incision. After the early reports from Europe and the United States on the safety and feasibility of laparoscopic cholecystectomy, the minimally invasive revolution began. This revolution has continued to the current time, where surgeons are attempting to perform minimally invasive procedures with less or no visible scarring. Cholecystectomy is ideally suited for the single-site umbilical laparoscopic approach to obviate the need for epigastric and supraumbilical incisions. This article will describe the single-site umbilical laparoscopic cholecystectomy, which has been performed at Children's Mercy Hospital since 2009. Also, the literature concerning this approach in adults and in children will be discussed. Finally, a prospective randomized trial comparing the single-site cholecystectomy with the traditional 4-port laparoscopic cholecystectomy will also be described.

The road to reduced port surgery: from single big incisions to single small incisions, and beyond

Single-port surgery has seen almost as rapid an application as multiport laparoscopy during the early 1990s. Hopefully, we will learn from our predecessors to apply the dictums of safety and science as we move forward with this new technique to ensure adequate adoption and successful outcomes with limited errors and concerns along the way.

[Single port transumbilical cholecystectomy [SILS] -- 30 non-selected cases]

Single port laparoscopic surgery became popular all over the world, and cholecystectomy represents the most frequent intervention with this technique. We compared transumbilical single port laparoscopic cholecystectomies (SILS) to conventional three-port laparoscopic cholecystectomies (LC), which were performed by the same surgeon between 2008-2010. As regards SILS cases, they represent a non-selected series. Transabdominal sutures were not applied in any of those, but one additional 5 mm port was inserted in two SILS cases. Only straight instruments were used in all but two SILS cholecystectomies. Mean age of patients was lower in the SILS group, however male:female ratio and BMI were similar. While none of the procedures were converted in the SILS group, one needed to be done so in the LC patients. One of the SILS patients underwent a transumbilical laparoscopic wash-out for an intrabdominal haematoma, which developed due to non-surgical reasons. Mean operative time and postoperative hospitalisation was 75.9 ± 25 minutes and two days in the SILS group, while 55.7 ± 17 minutes and 2.8 days in the LC group, respectively. We concluded that transumbilical single port cholecystectomy can be performed safely by using conventional straight instruments. We could not identify any publication about non-selected SILS cholecystectomy series in the English language literature.

Single-working-instrument, double-trocar, clipless cholecystectomy using harmonic scalpel: a feasible, safe, and less invasive technique

AIM

The aim of this study was to evaluate the safety and efficacy of the Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH) in the closure/division of the cystic duct and artery, and bladder dissection in laparoscopic cholecystectomy as a single working instrument, with the use of a two-working-trocar technique, compared with the regular laparoscopic clip/cautery, three-trocar technique.

METHODS

This prospective study included 160 patients with symptomatic gallstone disease who were randomly assigned for laparoscopic cholecystectomy by either Harmonic shear as a single working instrument, with the two-trocar technique (group 1 = 80 patients) or group 2 (regular clip/cautery, three-trocar technique) comprising 80 patients.

RESULTS

No significant complications were encountered in either group; however, 1 case in the regular laparoscopy group suffered mild leakage that was treated conservatively. Intraoperative bile spillage was insignificantly comparable in both groups (10 versus 13%; P = 0.46). The median operative time was statistically significantly shorter in the Harmonic group (20 versus 45 minutes; P = 0.0001). Also, hospital stay was significantly shorter in the Harmonic group (1 versus 1.5 days, respectively; P = 0.001), but no statistically significant difference was found in the incidence of postoperative complications. The overall cosmetic results and patient satisfaction was better in the Harmonic group.

CONCLUSIONS

The Harmonic shear is as safe and effective as the clip/cautery technique in laparoscopic cholecystectomy in achieving hemobiliary stasis, with shorter operative time, especially if used solely as a working instrument. The two-trocar technique is safe, feasible, and provides better cosmetic results and patient satisfaction.

Initial surgeon training for single port access surgery: our first year experience

This study suggests that single port access techniques can be easily learned in an animate laboratory setting.

Background:

We have developed a single port access (SPA) surgical technique that allows for procedures to be done through a single umbilical port incision <20 mm in length. For a new approach to be universally beneficial, it needs to be easily learned and applied.

Methods:

Single port access abdominal procedures are performed through one umbilical incision where skin and soft tissue flaps are raised from the underlying fascia to allow insertion of up to 4 instruments. Fifty surgeons with varying degrees of laparoscopic training participated in SPA training programs at Drexel University to learn and apply the SPA technique through participation in an animate (porcine) laboratory.

Results:

All surgeons successfully performed the SPA access technique without difficulty and completed the cholecystectomy in <55 minutes (average, 42). Eight surgeons successfully performed placement of a cholangiogram catheter. All recognized the value of a formal training symposium to learn SPA techniques before performing SPA procedures in their practice.

Conclusions:

The SPA technique has been successfully shown to be an approach that is easily learned and accomplished. We believe this is a necessary and important bridge towards proficiency in performing SPA procedures in clinical patients.

Single-port-access (SPA) cholecystectomy: a multi-institutional report of the first 297 cases

BACKGROUND

An important aspect of a new surgical technique is whether it can be performed by other surgeons in other institutions. The authors report the first 297 cases in a multi-institutional and multinational review of laparoscopic cholecystectomy performed via a single portal of entry.

METHODS

Data were collected retrospectively for the initial patients undergoing single-port cholecystectomy by 13 surgeons who performed these procedures in their institutions after training by the authors. The review included operative time, blood loss, incision length, length of hospital stay (LOS), necessary additional trocars, and other parameters important to cholecystectomy. A database of all the single-port-access (SPA) surgeries performed by the surgeons included demographic and procedural details, LOS, complications, and initial follow-up data.

RESULTS

To date, 297 single-port cholecystectomies have been performed for a variety of diagnoses, primarily cholelithiasis. The average operative time was 71 min, and the average LOS was 1-2 days. The average blood loss was minimal. The use of additional port sites outside the umbilicus occurred in 34 of the cases. Of the 35 intraoperative cholangiograms performed, 34 were successful. No significant complications occurred except for seromas and minor postoperative wound infections. These results are comparable with those for standard multiport cholecystectomy. In addition, no access site hernias (ASH) occurred.

CONCLUSIONS

The findings demonstrate that SPA surgery is an alternative to multiport laparoscopy with fewer scars and better cosmesis. One factor affecting the rate for adoption of SPA surgery among other surgeons is the reproducibility of this new procedure. Although this study had insufficient data to determine fully the benefits of SPA surgery, the feasibility of this procedure with safe, acceptable results was demonstrated in this initial large series across multinational institutions.

Single Port Access (SPA) laparoscopic ventral hernia repair: initial report of 30 cases

BACKGROUND

Laparoscopic ventral hernia repair has been demonstrated to be an acceptable and successful technique. Aside from similar, albeit fewer, complications compared to open hernia repair, the laparoscopic technique has the additional complication of port site hernia to its follow-up criteria. Our initial experience with reduced port surgery in hernias was described as a two-port one-stitch repair technique in 2002. We initially applied our Single Port Access (SPA) technique to ventral hernia repairs and reported it at the American Hernia Society meeting in 2008. Now we present the first 30 cases, some with 6-24-month follow-up.

METHODS

The charts of 30 patients undergoing surgery for primary and recurrent ventral hernias employing the SPA technique were reviewed. The SPA technique was applied through a 1.0-1.6-cm incision remote from and lateral to the hernia location in the abdominal wall. Polypropylene-based coated mesh and non-fascial fixation were used in all cases.

RESULTS

All procedures were completed via the SPA technique. Operative time, length of stay, and estimated blood loss were acceptable. The size of mesh placed ranged from 81 to 500 cm(2). Postoperative seromas were observed and all resolved spontaneously. There have been no wound infections or port site hernias during the 6-24-month follow-up period. There have been no recurrent hernias at the primary site.

CONCLUSION

We have successfully demonstrated the applicability of Single Port Access surgery for ventral hernia repair. In our initial series we performed this procedure on smaller hernias but have now begun applying it to larger repairs.

New classification of the anatomic variations of cystic artery during laparoscopic cholecystectomy

AIM: To investigate the anatomic variations in the cystic artery by laparoscopy, and to provide a new classification system for the guidance of laparoscopic surgeons.

METHODS: Six hundred patients treated with laparoscopic cholecystectomy from June 2005 to May 2006 were studied retrospectively. The laparoscope of 30˚ (Stryker, American) was applied. Anatomic structures of cystic artery and conditions of Calot's triangle under laparoscope were recorded respectively.

RESULTS: Laparoscopy has revealed there are many anatomic variations of the cystic artery that occur frequently. Based on our experience with 600 laparoscopic cholecystectomies, we present a new classification of anatomic variations of the cystic artery, which can be divided into three groups: (1) Calot's triangle type, found in 513 patients (85.5%); (2) outside Calot's triangle, found in 78 patients (13%); (3) compound type, observed in 9 patients (1.5%).

CONCLUSION: Our classification of the anatomic variations of the cystic artery will be useful for decreasing uncontrollable cystic artery hemorrhage, and avoiding extrahepatic bile duct injury.

Ergonomic evaluation of three new principles for mono-incision in laparoscopic surgery

Several instruments exist for performing a simple laparoscopic procedure through one trocar-incision. However, all of these instruments have well-known image-related disadvantages. In order to solve these problems three principles have been developed for which a new device was designed. The functionality of this device was evaluated with regard to four parameters: duration of task completion, number of errors, image-stability and preference by users. Although the differences between the three principles were small, the tests clearly showed that the problems surgeons experienced before have been significantly diminished by the new device. Time measurements showed a preference for principles 1 and 2 (1: manual zoom camera in combination with a standard grasping device; 2: laparoscope with an angle of 45 degrees in combination with a standard grasping device), the surgeons expressing preference for principle 2. Furthermore, the new trocar system is the first device for mono-incision in which two standard instruments (currently available on the market) are used simultaneously without enlarging the incision. Finally, each surgeon can work with the new device using the principle he/she is preferring.