A modified technique of single-incision laparoscopic hepaticojejunostomy for children with choledochal cysts

Background

To present a modified laparoscopic surgical technique that works to optimize the surgical view in laparoscopic total excision of choledochal cyst in pediatric patients.

Methods

From June 2015 to June 2017, a total of 48 pediatric cases of choledochal cyst were admitted. Their age ranged from 15 month to 8 years (average 3.5 years). The Todani types were: type I (n = 32) and type IVa (n = 16), according to the diagnostic criteria of ultrasound, abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP).

Results

Total cystic excision with hepaticoenterostomy was accomplished laparoscopically in 48 cases with our transumbilical single -incision method without conversion to open surgery. Average duration of operation was 200 min (range 170–240 min), average intraoperative blood loss was 9 ml (range 6–14 ml) without the need for blood transfusion. The 72-h postoperative ultrasound reported no abdominal effusion, when the intraperitoneal drainage tube was removed. There was no postoperative complication during the 6 months of follow-up.

Conclusions

We accomplished the same postoperative outcome in laparoscopic total cyst excision with our modified method as that with conventional laparoscopic surgery. This technique allows the operator to have a stabilized surgical view without needing to rely on an assistant to hold up the liver lobe for larger operative space.

Single incision versus standard multiport laparoscopic cholecystectomy: up-dated systematic review and meta-analysis of randomized trials

BACKGROUND AND PURPOSE

We aimed to compare single incision laparoscopic cholecystectomy (SILC) to the standard multiport technique (MLC) for clinically relevant outcomes in adults.

METHODS

Systematic review and random-effects meta-analysis of randomized trials.

RESULTS

We identified 30 trials (SILC N = 1209, MLC N = 1202) mostly of moderate to low quality. Operating time (30 trials): longer with SILC (WMD = 12.4 min, 95% CI 9.3, 15.5; p < 0.001), but difference reduced with experience - in 10 large trials (1321 patients) WMD = 5.9 (-1.3, 13.1; p = 0.105). Intra-operative blood loss (12 trials, 1201 patients): greater with SILC, but difference practically irrelevant (WMD = 1.29 mL, 0.24-2.35; p = 0.017). Procedure failure (27 trials, 2277 patients): more common with SILC (OR = 13.9, 4.34-44.7; p < 0.001), but overall infrequent (SILC pooled incidence 4.39%) and almost exclusively addition of a trocar. Post-operative pain (29 trials) and hospital stay (22 trials): no difference. Complications (30 trials): infrequent (SILC pooled incidence 5.35%) with no overall SILC vs. MLC difference. Incisional hernia (19 trials, 1676 patients): very rare (15 vs. 4 cases), but odds significantly higher with SILC (OR = 4.94, 1.26-19.4; p = 0.025). Cosmetic satisfaction (16 trials, 11 with data at 1-3 months): in 5 trials with non-blinded patients (N = 513) in favour of SILC (SMD = 1.83, 0.13, 3.52; p = 0.037), but in 6 trials with blinded patients (N = 719) difference small and insignificant (SMD = 0.42, -1.12, 1.96; p = 0.548).

DISCUSSION

SILC outcomes largely depend on surgeon's skill, but regardless of it, when compared to MLC, SILC requires somewhat longer operating time, risk of incisional hernia is higher (but overall very low) and early cosmetic benefit is modest.

CONCLUSION

From the (in)convenience and safety standpoint, SILC is an acceptable alternative to MLC with a modest cosmetic benefit.