An "all 5-mm ports" selective approach to laparoscopic cholecystectomy, appendectomy, and anti-reflux surgery

Suprapubic Cholecystectomy Improves Cosmetic Outcome Compared to Classic Cholecystectomy

Currently, cholecystectomy is performed laparoscopically. While the conventional approach (CA) with four access ports persists, other methods seek to reduce trauma or to optimize cosmetic results. In this study, the safety and cosmetic outcome of a suprapubic approach (SA) were evaluated. Between 2015 and 2016, patients undergoing elective cholecystectomy either by CA or by a suprapubic approach (SA) at our institution were included. The cosmetic outcome, postoperative morbidity, operative time and length of stay were evaluated. Pictures of the site of intervention were taken 6−12 months postoperatively and rated on a scale from 1 (unsatisfying aesthetic result) to 5 (excellent aesthetic result). Five “non-medical” and five “medical” raters as well as one board-certified plastic surgeon performed the ratings. A total of 70 patients were included (n = 28 SA, n = 42 CA). The two groups did not differ in baseline characteristics (age, gender, BMI). The SA group showed a significantly better aesthetic outcome compared to the CA group 4.8 (4.8−4.9) vs. 4.2 (3.8−4.4), (p > 0.001). Medical raters: 4.0 (3.8−4.2) vs. 4.8 (4.6−5.0), (p < 0.001); non-medical raters: 4.2 (3.8−4.6) vs. 5.0 (4.8−5.0), (p < 0.001); plastic surgeon: 4.0 (4.0−4.0) vs. 5.0 (5.0−5.0), (p < 0.001). Fair interrater consistency was demonstrated with an ICC of 0.47 (95% CI = 0.38−0.57). No significant difference in the complication rate (1 (3.5%) in SA vs. 6 (14%) in CA, (p = 0.3)), or the operating time 66 (50−86) vs. 70 (65−82) min, (p = 0.3), were observed. Patients stayed for a median of three (3−3) days in the SA group and 3 (3−4) days in the CA group (p = 0.08). This study demonstrated that the suprapubic approach is an appropriate alternative to conventional laparoscopic cholecystectomy, presenting a better cosmetic outcome with a similar complication rate.

Comparison of Needlescopic and Conventional Laparoscopic Fundoplication for Gastroesophageal Reflux Disease-Related Diseases: A Propensity Score-Matched Analysis

Background: Recently, in pursuit of minimal invasion, needlescopic surgery (NS) using forceps thinner than the previous standard has garnered attention as a surgical approach to various diseases. Objective: We compared the outcomes of NS for gastroesophageal reflux disease (GERD)-related diseases with the conventional method using propensity score-matched analysis. Subjects and Methods: Among 205 of 328 cases who underwent laparoscopic fundoplication for the first time from June 2008 to December 2019, excluding 115 cases using mesh and 8 cases undergoing reduced port surgery, 25 subjects in the NS group and 25 subjects in the conventional group were extracted upon propensity score matching for six factors: age, gender, body mass index, degree of esophageal hiatal hernia, duration of intraesophageal acid reflux, and severity of reflux esophagitis. Results: The NS group used the Toupet method, whereas the conventional group used the Nissen method for 2 cases and the Toupet method for 23 cases. There were no significant differences between them (P = .490). Although the operative time (143 versus 112 minutes, P = .038) was longer in the NS group, there were no differences in the bleeding volume (nearly equal at 0 mL in both groups), laparotomy conversion rate, intraoperative complications, and postoperative complications (P = .588, P = 1.000, P = 1.000, P = 1.000, respectively). There was also no significant difference in recurrence: 2 cases in the conventional group (8%) and 1 case in the NS group (4%) (P = 1.000). Moreover, the degree of esophageal hiatal hernia, the severity of reflux esophagitis, and the duration of intraesophageal acid reflux all improved after the surgery in both groups (NS group: P = .001, P < .001, P = .002; conventional group: P = .007, P < .001, P = .003). Conclusions: The short-term outcomes of NS for GERD-related diseases were good, with a longer operative time but no difference in terms of safety or outcomes compared with the conventional method. This study was approved by the Institutional Review Board of the Jikei University School of Medicine [30-238 (9259)].

Total 5-mm port approach: a feasible technique for both elective and emergency laparoscopic cholecystectomy

BACKGROUND

The laparoscopic approach is considered the standard of care for cholecystectomy. Attempts to minimize incisions with single site and natural orifice approaches have shown promise but also have limitations. Technological advances have facilitated decreased port size, which may have a variety of benefits. The aim of this study was to determine the feasibility of an all 5-mm port approach for patients undergoing both elective and emergency laparoscopic cholecystectomy.

METHODS

A consecutive series of laparoscopic cholecystectomies at three different hospitals using all 5-mm ports was prospectively evaluated. Recorded outcomes included operative findings, procedural difficulties, the need to extend the umbilical incision during extraction, operative time, length of stay and post-operative complications.

RESULTS

A total of 101 patients were included and all had a successful cholecystectomy without the need for additional ports. The umbilical incision was extended for gallbladder extraction in 29 (29%) patients. Eight (8%) patients experienced minor post-operative complications and there were no major complications. Cholangiography was performed in 98% of cases and three patients underwent successful common bile duct exploration without requiring additional ports. In a small number of cases, there was difficulty with the quality of the view through the 5-mm laparoscope but this was rectified by removing old or damaged laparoscopes from the circulating stock.

CONCLUSION

This study demonstrates that laparoscopic cholecystectomy using all 5-mm ports is both feasible and safe, and is comparable to published outcomes after conventional laparoscopic cholecystectomy. Further work is needed to determine whether this approach can also improve short- and long-term outcomes.

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.

Minithoracoscopy: a complementary technique for medical thoracoscopy

Minithoracoscopy, currently defined as thoracoscopy with instruments of a diameter between 2 and 5 mm, is part of the general evolution of endoscopy towards mini-invasiveness. Its most relevant indications in the field of medical thoracoscopy are small effusions, pleural effusions in patients with narrow intercostal spaces and suspected tuberculous pleurisy in areas of low incidence of tuberculosis. In general, it increases the versatility of medical thoracoscopy.

Laparoscopic cholecystectomy combined using miniaturised instruments in transgastric gall bladder removal: performed on 63 patients

Background. The laparoscopic cholecystectomy is a perfectly codified surgical procedure. The development of recent innovative and experimental surgical techniques Natural Orifice transluminal endoscopic surger (N.O.T.E.S.) which reduces the abdominal wall trauma leads us to develop a combined procedure of a standard dissection using miniaturised instruments already existing on the market (3 and 5 mm wide) and a gall bladder removal through a short gastrotomy Natural Orifice Specimen Extraction (N.O.S.E.). Methods. Our objective was to evaluate the safety, the feasibility, and the reproducibility of our new approach. After reviewing existing products on the market and a feasibility study, we put in place a protocol in our structure for patients on whom the procedure was performed. We carried out a gall bladder removal by a short gastrotomy, located on the anterior gastric wall, which then reduced the abdominal wall trauma and allowed them to resume normal physical activity quickly without risk of trocar site hernia. Results. We performed the procedure described in this paper on 63 patients, between April 2008 and July 2009. There were 14 men and 49 women with an average age of 46.8 years (ranging from 28 to 77) and an average BMI of 27.2. 30 patients had at least one gallstone larger than 10 mm. There was no postoperative gastric or abdominal wall complication and a fast recovery for all the patients in our study. Conclusions. This procedure is feasible, reproducible, with good results and minimal abdominal wall trauma. It is also safer than N.O.T.E.S. and endoscopic clipping and recovery, allowing normal physical activity, fast and, without risk of incisional hernia.

Fixity of ports to the abdominal wall during laparoscopic surgery: a randomized comparison of cutting versus blunt trocars

BACKGROUND

Dislodgement of ports from the abdominal wall is a common problem during laparoscopic surgery. The aim of this study was to evaluate port stability using either cutting or blunt-tipped trocars.

METHODS

Patients undergoing laparoscopic surgery were randomized to have the secondary ports inserted using either cutting or blunt-tipped trocars. The fixity of ports to the abdominal wall was evaluated at the start and completion of surgery by measuring the total traction force required to displace the ports. Similarly, the friction forces required to displace instruments within the ports were measured.

RESULTS

Thirty patients were randomized into two groups (15 patients in each group), and a total of 114 ports (cutting, n = 51; blunt, n = 63) were evaluated. The groups were comparable in age, gender, body mass index, and operating time. The total traction forces needed to displace the 5-mm and 10-mm ports were significantly lower when cutting trocars were used at both the beginning (2.6 vs. 11.8 N, p < 0.001, and 6.3 vs. 15.5 N, p = 0.014, respectively) and completion of surgery (1.3 vs. 6.7 N, p < 0.001, and 1.1 vs. 12.0 N, p = 0.001, respectively). The declines in the total traction forces from the start to the completion of surgery were significant for the 5-mm and 10-mm cutting-trocar ports (p = 0.031 and p = 0.043, respectively) but not for the blunt-trocar ports (p = 0.088 and p = 0.152, respectively). While no significant differences between the instruments' friction forces and the traction forces of the cutting-trocar ports were observed, the former were significantly lower than the traction force needed to displace the blunt-trocar ports. This explains the significantly greater frequency of spontaneous port dislodgements when cutting ports were employed (25.5% vs. 1.6%, p < 0.001). Port-site bleeding was encountered only in patients (n = 2, 13%) where cutting trocars were used.

CONCLUSIONS

Port fixity to the abdominal wall during laparoscopic surgery declines with time. The insertion of ports using a blunt-tipped trocar is associated with significantly greater stability and fixity of the port to the abdominal wall. The use of blunt-tipped trocars is recommended for routine practice in laparoscopic surgery.

Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy

This review article is a tribute to the genius of Professor Erich Muhe, a man ahead of his times. We trace the development of laparoscopic cholecystectomy and detail the tribulations faced by Muhe. On the occasion of the twentieth anniversary of the first laparoscopic cholecystectomy, we take another look at some of the controversies surrounding this gold standard in the management of gallbladder disease.