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

Single-incision laparoscopic cholecystectomy at community hospitals in Honolulu, Hawai'i: a case series

This study aims to demonstrate the feasibility of implementing single-incision laparoscopic cholecystectomy in a community hospital setting. Minimally invasive surgical approaches for cholecystectomy achieve equivalent outcomes to the open surgical approach with less post-operative pain, improved cosmesis, shorter hospital stays, and decreased complications. Surgeons are attempting to reduce incisional trauma further by decreasing the number of incisions. A retrospective chart review was conducted for demographics, operating time, blood loss, conversion rate, length of stay, and presence of operative complications on patients undergoing single-incision laparoscopic cholecystectomy at two community hospitals between 2008 and 2011. One hundred and three patients (79 females and 24 males) underwent single-incision laparoscopic cholecystectomy. The mean age was 49.8 years (range 18-88). Ninety-six patients (93.2%) underwent elective procedures while 7 patients (6.8%) underwent urgent procedures. The mean operating time was 89.7 (± 28.3) minutes and the average blood loss was 33.7 (± 27.4) milliliters. Ninety-five (92.2%) of the procedures were successfully completed with a single-incision approach and 8 (7.8%) were converted to a multi-incisional approach, while none were converted to an open approach. The median length of stay was 4.75 hours. The post-operative complication rate was 7.4% (7/95) and included four superficial wound infections, one bile leak, one acute renal failure, and one urinary tract infection. These outcomes for single-incision laparoscopic cholecystectomy are comparable to other case series reported in the literature, and this retrospective review illustrates that single-incision laparoscopic cholecystectomy is feasible in a community setting.

Robotic single port cholecystectomy (R-LESS-C): experience in 36 patients

BACKGROUND

Laparoendoscopic single-site surgery (LESS) has emerged as a result of a search for "pain-less" and "scar-less" surgery. Laparoendoscopic single-site cholecystectomy (LESS-C) is probably the most common application in general surgery, although it harbors certain limitations. It was proposed that the da Vinci Single-Site (Si) robotic system may overcome some of the difficulties experienced during LESS, providing three dimensional views and the ability to work in a right-handed fashion. Thirty-six robotic single port cholecystectomies (R-LESS-C) performed with the da Vinci Si robotic system are evaluated in this paper

MATERIALS AND METHODS

R-LESS-C performed in 36 patients were reviewed. The data related to the perioperative period (i.e., anesthesia time, operation time, docking time, and console time) was recorded prospectively, whereas the hospitalization period, postoperative visual analogue scale (VAS) pain scores were collected retrospectively.

RESULTS

A total number of 36 patients, with a mean age of 40.1 years (21-64 years), underwent R-LESS-C. There were five men and 31 women. The mean anesthesia and operation times were 79.3 minutes (45-130 minutes) and 61.8 minutes (34-110 minutes), respectively. The mean docking time was 9.8 minutes (4-30 minutes) and the mean console time was 24.9 minutes (7-60 minutes). The mean hospital stay was 1.05 days (1-2 days) and the mean pain score (VAS) was 3.6 (2-8) in the first 24 hours. Incisional hernia was recorded in one patient.

CONCLUSION

R-LESS-C can be performed reliably with acceptable operative times and safety. The da Vinci Si robotic system may ease LESS-C. Two issues should be considered for routine use: expensive resources are needed and the incidence of incisional hernia may increase.

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

BACKGROUND

The aim of this study was to compare single-port access cholecystectomy (SPA) with the standard laparoscopic technique (LC) regarding the duration of the operation, complications, learning curve, late postoperative quality of life (QoL) and the incidence of incisional hernias.

METHODS

Between June 2009 and December 2011, a total of 122 SPA cholecystectomies were performed in our hospital. Simultaneously, 310 patients were operated on with the LC technique. In the LC group, 100 patients met the same criteria defined for SPA surgery. The two groups (SPA and LC) were compared by multivariable regression analysis. Endpoints of this study were quality of life (QoL) after 6 months by the EQ-5D questionnaire 5L and the incidence of incisional hernia 1 year after surgery. Operating time, hospital stay, and perioperative complications were also measured and compared. The median follow-up was 9.2 months (3-25 months).

RESULTS

The patients in the SPA group were younger and more often female. The mean operating time for group SPA was 73 min (35-136 min)-significantly longer than that for group LC with 60 min (33-190 min) (p < 0.001). Additional trocars were used in 8 of 122 (6.5 %) SPA patients. A conversion to open cholecystectomy was not necessary in SPA patients. The conversion rate in the LC group to open cholecystectomy was 2 % (2/100). The perioperative and postoperative complications and incisional hernia (5.5 %) were the same in both groups. QoL was significantly better in the SPA group in terms of mobility (p = 0,002), usual activity (p = 0.036), and overall anxiety (p = 0.026).

CONCLUSIONS

SPA cholecystectomy is safe, although the operation is significantly longer. No differences in terms of major complications or the incidence of incisional hernia were seen after 1 year. QoL was significantly better in patients operated on with the SPA technique.

Inflammation in laparoendoscopic single-site surgery versus laparoscopic cholecystectomy

INTRODUCTION

Laparoendoscopic single-site surgery (LESS) uses a multiple-entry portal in a single 3.0- to 4.0-cm incision in a natural scar, the umbilicus. The present study aimed to compare the inflammatory impact of classic video laparoscopic cholecystectomy (LC) versus LESS cholecystectomy.

METHODS

A prospective randomized controlled study was conducted from January to June 2011 at 2 university hospitals in Rio de Janeiro, Brazil. Fifty-seven patients (53 women, 4 men; mean age = 48.7 years) were randomly assigned to receive LC (n = 29) or LESS (n = 28) cholecystectomy. C-reactive protein (CRP) and interleukin 6 (IL-6) were measured from blood samples collected during induction of anesthesia and at 3 and 24 hours postoperatively.

RESULTS

Median IL-6 levels in the LESS and LC groups, respectively, were 2.96 and 4.5 pg/mL preoperatively, 11.6 and 28.05 pg/mL at 3 hours postoperatively (P = .029), and 13.18 and 15.1 pg/mL at 24 hours postoperatively (P = .52). Median CRP levels in the LESS and LC groups, respectively, were 0.33 and 0.44 mg/mL preoperatively, 0.40 and 0.45 mg/mL (P = .73) at 3 hours postoperatively, and 1.7 and 1.82 mg/mL (P = .84) at 24 hours postoperatively. We did not find a significant association between IL-6 (and CRP) and body mass index in the LESS group.

CONCLUSIONS

LESS cholecystectomy requires a larger size incision than LC. We found a tendency of less postoperative pain following LESS cholecystectomy than LC. There was also a tendency toward lower early inflammatory impact following LESS cholecystectomy versus LC.

Safety and feasibility for single-incision laparoscopic cholecystectomy in local community hospital: a retrospective comparison with conventional 4-port laparoscopic cholecystectomy

BACKGROUND

The aim of this study was to evaluate the safety and feasibility for single-incision laparoscopic cholecystectomy (SILC) by retrospective comparison with conventional laparoscopic cholecystectomy (CLC) in a local community hospital.

METHODS

SILC was introduced and performed in 57 patients for benign gallbladder diseases. Their clinical data were compared with those of 62 patients treated with CLC. They included patient demographic data and operative outcomes.

RESULTS

SILC was attempted in 57 patients and 52 cases (91.2%) were successfully completed. There were no statistical differences between the 2 groups in terms of operative time, blood loss, and postoperative complications. The length of hospital stay in the SILC group was significantly shorter compared with CLC (P < 0.0001).

CONCLUSIONS

SILC has been successfully introduced in a local community hospital. The safety and feasibility was also confirmed. The SILC procedure may become 1 standard option for the treatment of benign gallbladder diseases.

Development of a novel controllable, multidirectional, reusable metallic port with a wide working space

BACKGROUND

Endoscopic surgery is currently a standard procedure in many countries. Furthermore, conventional four-port laparoscopic cholecystectomy is developing into a single-port procedure. However, in many developing countries, disposable medical products are expensive and adequate medical waste disposable facilities are absent. Advanced medical treatments such as laparoscopic or single-port surgeries are not readily available in many areas of developing countries, and there are often no other sterilization methods besides autoclaving. Moreover, existing reusable metallic ports are impractical and are thus not widely used.

MATERIAL AND METHODS

We developed a novel controllable, multidirectional single-port device that can be autoclaved, and with a wide working space, which was employed in five patients.

RESULTS

In all patients, laparoscopic cholecystectomy was accomplished without complications.

CONCLUSION

Our device facilitates single-port surgery in areas of the world with limited sterilization methods and offers a novel alternative to conventional tools for creating a smaller incision, decrease postoperative pain, and improve cosmesis. This novel device can also lower the cost of medical treatment and offers a promising tool for major surgeries requiring a wide working space.

Comparative usability testing of conventional and single incision laparoscopic surgery devices

OBJECTIVE

The objective was to perform competitive usability testing to assess the user experience of conventional laparoscopic and laparoendoscopic single-site surgery (LESS) devices.

BACKGROUND

Recent advancements in single-incision instrumentation have created more interest in and usage of LESS. However, neither LESS nor its novel multichannel access devices have been thoroughly studied.

METHOD

Using a simulation test bed and standardized laparoscopic surgery task, the user experience of three commercially available LESS devices was compared to conventional laparoscopic ports based on time on task, errors, task success, and perceived ease of use.

RESULTS

There were no significant differences between devices for time on task, errors, or task success (p > .05). For all devices, there were significantly more recoverable than unrecoverable errors, and errors occurred more frequently during the second phase of the task when the dominant hand was more active (p < .0001). Conventional laparoscopy was rated as easier to use than were the LESS devices (p < .01).

CONCLUSION

Device performance of a basic laparoscopic task was similar in both conventional laparoscopy and LESS. Each of the LESS devices facilitated efficient and accurate aiming and grasping movements compared to conventional laparoscopy. Further investigation of human factors and ergonomics of LESS is needed to further develop, evaluate, and refine single-site surgery technologies to create a user experience equivalent to conventional laparoscopy.

APPLICATION

Competitive usability testing of medical devices yields objective performance data that can be used to inform purchase decisions and future device design improvements.

Single-incision versus conventional three-incision laparoscopic appendicectomy for appendicitis: a systematic review and meta-analysis

BACKGROUND

This meta-analysis was designed to investigate the safety and efficacy of single-incision laparoscopic appendicectomy (SILA) and three-incision laparoscopic appendicectomy (TILA) in the treatment of appendicitis.

MATERIALS AND METHODS

Studies published since 1992 that compared SILA versus TILA in laparoscopic appendicectomy were collected. Data on operative parameters, postoperative recovery, postoperative pain and complications, and hospitalization costs for SILA and TILA were meta-analyzed using fixed-effect and random-effect models.

RESULTS

Seventeen studies (1 randomized controlled trial and 16 retrospective studies) that included 1809 patients were studied. Of these patients, 793 and 1016 had undergone SILA and TILA, respectively. There was significantly shorter length of hospital stay; however, there were evidently higher conversion rate, and perhaps higher surgical difficulty and hospitalization costs for SILA compared with TILA. Other outcome variables such as operative time, blood loss, time to first oral intake, postoperative pain and complications were not found to be statistically significant for either group.

CONCLUSIONS

Compared with TILA, SILA has the advantage of shorter hospital stay, and it can achieve comparable operative time, blood loss, postoperative recovery, postoperative pain and complications with TILA. The drawback is that SILA is associated with higher conversion rate, and perhaps higher surgical difficulty and hospitalization costs. Whether it can achieve improvement in cosmesis remains to be confirmed.

Present and future advanced laparoscopic surgery

Modern laparoscopy, starting with Kurt Semm's insufflators and the first successful appendectomies, has only been around for approximately 30 years. Since those early successes, the technology has grown from the inception of basic laparoscopy to endoscopic surgery through natural orifices, and it continues to evolve by leaps and bounds with computer-assisted surgery and improved robotics in surgery. Without question, laparoscopy has revolutionized the way we perform standard surgery, especially relative to the techniques that had been used for hundreds of years. Despite the development of multiple novel technologies since the 1980s, very little has changed with regard to basic conceptualizations and practice of laparoscopy. In this review article, we will describe the highlights of recent advanced laparoscopic surgery procedures, their potential applications within the field of surgery, and how these advances may impact and improve future quality and patient outcomes.

Single-Incision Laparoscopic Cholecystectomy Using Conventional Laparoscopic Instruments and Comparison with Three-Port Cholecystectomy

Single-incision laparoscopic surgery also known as laparo-endoscopic single-site surgery for cholecystectomy is performed using a single umbilical skin incision through which a laparoscope and two instruments are introduced. It is virtually a "scarless" surgery. The present study was undertaken to evaluate the efficacy of single-incision laparoscopic cholecystectomy using conventional instruments and compare it with three-port laparoscopic cholecystectomy. Thirty patients who underwent single-incision cholecystectomy were compared to an equal number of patients who underwent three-port cholecystectomy. Both groups were assessed on the basis of operative time, intraoperative complications, postoperative pain, ambulation, hospital stay, and body image at first and third week. Single-incision cholecystectomy had the advantage of less postoperative pain, early ambulation, and better body image as compared to three-port cholecystectomy; the results being statistically significant. There was no statistically significant difference in operative time and hospital stay between the two groups. Single-incision laparoscopic cholecystectomy using conventional instruments is a safe and effective surgery. It gives better cosmetic results, almost scarless surgery, without increasing the cost of surgery.

Single-port versus multiport laparoscopic cholecystectomy: a prospective randomized clinical trial

PURPOSE

We report the outcomes of a randomized clinical trial of single-port laparoscopic cholecystectomy (SPLC) and multiport laparoscopic cholecystectomy (MPLC).

METHODS

Fifty-four patients (27 in each group) were randomized. A visual analog scale was used with a 10-point scale for an objective assessment of incisional pain and incisional cosmesis on postoperative days 1, 3, and 14.

RESULTS

The mean operating time was significantly longer in the SPLC. The mean cosmesis scores on postoperative days 3 (9.7 vs. 8.9, P = 0.01) and 14 (9.9 vs. 9.2, P<0.01) were significantly greater in the SPLC group than in the MPLC group. The group's mean visual analog scale scores for incisional pain, and their requirements for analgesics, did not differ significantly.

CONCLUSIONS

Although SPLC takes longer than MPLC, experienced laparoscopic surgeons can perform SPLC safely with results comparable with those for MPLC. SPLC is superior to MPLC in terms of short-term cosmetic outcomes.

Coagulation and fibrinolysis activation after single-incision versus standard laparoscopic cholecystectomy: a single-center prospective case-controlled pilot study

Laparoscopic cholecystectomy is associated with attenuated acute-phase response and hypercoagulable state compared with the open procedure. Single-incision laparoscopic cholecystectomy is a new technique aiming to minimize the invasiveness of the procedure. By comparing the degree of coagulation and fibrinolysis activation after conventional multiport (CLC) and single-incision (SILC) laparoscopic cholecystectomy, we aimed to determine whether the reduced incision size induces a lower thrombophilic tendency. Thirty-two adult patients with noncomplicated symptomatic cholelithiasis were nonrandomly assigned to CLC or SILC. Prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin complexes (TAT), D-dimers, fibrinogen, and von Willebrand factor levels were measured at baseline, at 1st, and 24th hour, postoperatively. Twenty-six patients were finally included in the study. Fifteen patients underwent CLC (male/female: 5/10) and 11 underwent SILC (male/female: 1/10). There were no perioperative complications. An almost similar postoperative pattern and degree of activation of coagulation and fibrinolysis pathways was noted in both groups. No statistically significant differences were found between SILC and CLC for F1 + 2, TAT, D-dimers, fibrinogen, and von Willebrand factor levels, duration of surgery, length of hospital stay, and postoperative morbidity. A similar pattern and extent of coagulation and fibrinolysis activation is present in SILC and CLC, and therefore there is no difference in tendency for thrombosis. Thromboembolic prophylaxis should be considered in SILC as recommended for CLC, pharmacologic or mechanical, considering the hemorrhagic risk and the presence of additional thromboembolism risk factors. SILC appears to be a safe, feasible technique that can be recommended for its potential advantages in cosmesis and reduced incisional pain.

Incisional hernia rate may increase after single-port cholecystectomy

BACKGROUND

The major concerns of single-port cholecystectomy are port-site hernia and cost. Essentially, a larger transumbilical incision is more likely to increase the incidence of incisional hernia. The effect of single-port cholecystectomy on hospital cost is controversial. This study evaluated single-port cholecystectomy and traditional four-port cholecystectomy with respect to perioperative outcomes, hospital cost, and postoperative complications.

PATIENTS AND METHODS

Between January 2010 and March 2011, 52 patients underwent single-port cholecystectomy, and 111 patients underwent traditional laparoscopic cholecystectomy. We used equal instruments in patients undergoing operation with the same surgical technique. Demographics, diagnosis, operative data, complications, length of hospital stay, and cost were compared between the two groups.

RESULTS

The patients undergoing laparoscopic cholecystectomy were significantly older than patients undergoing single-port cholecystectomy (55.8±13.8 years versus 48.7±12.7 years, P=.002). The trocar site hernia rate was 1.8% in laparoscopic cholecystectomy, and the port-site hernia rate was 5.8% in single-port cholecystectomy. This is the highest rate reported in the literature for port-site hernia following single-port cholecystectomy. Surgical techniques were not different in terms of conversion to open surgery, postoperative hospital stay, and operative time. The relative cost of single-port cholecystectomy versus laparoscopic cholecystectomy was 1.54.

CONCLUSIONS

Although single-port cholecystectomy seems to be a feasible surgical technique, it is not superior over the traditional laparoscopic cholecystectomy. Single-port cholecystectomy is equal to laparoscopic cholecystectomy with respect to conversion to open surgery, postoperative hospital stay, and operative time, but it is associated with high hospital cost and high port-site hernia rate.

Endoloop retraction technique in single-port laparoscopic cholecystectomy: experience in 27 patients

BACKGROUND

Single-port laparoscopic cholecystectomy (SPLC) has been one of the hottest topics in minimally invasive surgery. Various techniques have been described, but the search for better techniques and equipment still continues. The aim of this study is to share a new retraction technique and the results in 27 patients.

PATIENTS AND METHODS

Between May 2010 and May 2011, 27 patients underwent SPLC with the presented technique. The data related to the operative and postoperative measures were collected prospectively. Operation time, pain score (visual analog scale) in the first 24 hours after the operation, and length of hospital stay were recorded by an independent nurse.

RESULTS

Twenty-seven SPLCs were performed. Indications were symptomatic gallstone disease or gallbladder polyps without active inflammation. Mean operation time was 45.7 minutes (range, 30-80 minutes). In none of the patients was introduction of an additional port or conversion to conventional laparoscopic cholecystectomy needed.

CONCLUSIONS

The endoloop technique can be used to overcome retraction problem while preventing spillage of bile and reducing crowding of instruments with a practically invisible scar in selected patients.

Patient-reported outcomes after single-incision versus traditional laparoscopic cholecystectomy: a randomized prospective trial

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) is a newer approach that may be a safe alternative to traditional laparoscopic cholecystectomy (TLC) based on retrospective and small prospective studies. As the demand for single-incision surgery may be driven by patient perceptions of benefits, we designed a prospective randomized study using patient-reported outcomes as our end points.

METHODS

Patients deemed candidates for either SILC or TLC were offered enrollment in the study. After induction of anesthesia, patients were randomized to SILC or TLC. Preoperative characteristics and operative data were recorded, including length of stay (LOS). Pain scores in recovery and for 48 h and satisfaction with wound appearance at 2 and 4 weeks were reported by patients. We used the gastrointestinal quality of life index (GIQLI) survey preoperatively and at 2 and 4 weeks postoperatively to assess recovery. Procedural and total hospital costs per case were abstracted from hospital billing systems.

RESULTS

Mean age of the study group was 44.1 years (±14.8), 87% were Caucasian, and 77% were female, with no difference between groups. Operative times were longer for SILC (median = 57 vs. 47 min, p = 0.008), but mean LOS was similar (6.8 ± 4.2 h SILC vs. 6.2 ± 4.8 h TLC, p = 0.59). Operating room cost and encounter cost were similar. GIQLI scores were not significantly different preoperatively or at 2 or 4 weeks postoperatively. Patients reported higher satisfaction with wound appearance at 2 weeks with SILC. There were no differences in pain scores in recovery or in the first 48 h, although SILC patients required significantly more narcotic in recovery (19 mg morphine equivalent vs. 11.5, p = 0.03).

CONCLUSIONS

SILC is a longer operation but can be done at the same cost as TLC. Recovery and pain scores are not significantly different. There may be an improvement in patient satisfaction with wound appearance. Both procedures are valid approaches to cholecystectomy.

Cost assessment of instruments for single-incision laparoscopic cholecystectomy

This study concludes that a modified single-incision procedure for cholecystectomy using 2 regular ports inserted through the umbilicus can be performed at lower cost than a conventional 4-port procedure.

Background and Objectives:

Specially designed surgical instruments have been developed for single-incision laparoscopic surgery, but high instrument costs may impede the implementation of these procedures. The aim of this study was to compare the cost of operative implements used for elective cholecystectomy performed as conventional laparoscopic 4-port cholecystectomy or as single-incision laparoscopic cholecystectomy.

Methods:

Two consecutive series of patients undergoing single-incision laparoscopic cholecystectomy were assessed: (1) single-incision cholecystectomy using a commercially available multichannel port (n=80) and (2) a modified single-incision cholecystectomy using 2 regular trocars inserted through the umbilicus (n=20) with transabdominal sutures for gallbladder mobilization (puppeteering technique). Patients who underwent conventional 4-port cholecystectomy during the same time period (n=100) were selected as controls.

Results:

The instrumental cost of the single-incision cholecystectomy using a commercial port was significantly higher (median, $1123) than the cost for conventional 4-port (median $441, P < .0005) and modified single-incision cholecystectomy (median $342, P < .0005). The cost of the modified single-incision procedure was significantly lower than that for the 4-port cholecystectomy (P < .0005).

Conclusion:

The modified single-incision procedure using 2 regular ports inserted through the umbilicus can be performed at lower cost than conventional 4-port cholecystectomy.

Interim report: a randomized controlled trial comparing postoperative pain in single-incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) is increasingly practiced, but there have been no well-powered randomized trials investigating the technique. This non-inferiority trial aims to compare SILC with conventional four-port laparoscopic cholecystectomy (LC) with postoperative pain as the primary endpoint.

METHODS

We aim to randomize 100 patients into equal arms of SILC or LC. Exclusion criteria were: (i) acute cholecystitis; (ii) an ASA score of 3 or above; (iii) bleeding disorders; or (iv) previous upper abdominal surgery. Patients and postoperative assessors were blinded to the procedure received. The site and severity of pain was compared based on the visual analogue scale at 4 hours, 24 hours and 14 days postoperatively; non-inferiority was assumed when the lower boundary of the 95% confidence interval of the difference was above -1, and superiority when P ≤ 0.05.

RESULTS

We recruited 24 SILC and 26 LC patients. There were no conversions to open cholecystectomy or from SILC to LC. SILC was non-inferior for pain at umbilical sites at rest and at extra-umbilical sites at all times. At 24 hours postoperatively, SILC was associated with significantly less pain at extra-umbilical sites (rest: P = 0.002; movement: P = 0.004). There were no incidents of biliary injury or retained gallstones. Of the 24 SILC patients, 12.5% had postoperative complications (vomiting, mild fluid overload, wound infection) compared with 0% of LC patients (P = 0.110); all complications resolved with conservative management. Operating time, analgesic use, return to function, and overall satisfaction did not differ significantly between the two groups.

CONCLUSION

SILC is associated with reduced pain and is feasible in routine surgical practice.

Comparison of short-term surgical outcomes after single-incision laparoscopic versus multiport laparoscopic right colectomy: a two-center, prospective case-controlled study of 100 patients

BACKGROUND

Recent case studies have demonstrated the feasibility of single-incision laparoscopic colectomy (SILC). Few comparative studies for SILC and multiport laparoscopic colectomy (MLC) have been conducted. The aim of this case-controlled study was to compare the short-term surgical outcomes between SILC and MLC for right-sided colectomies.

METHODS

Between January 2010 and February 2012, data from the first 50 consecutive patients that underwent right SILS at one of the two institutions were compared with a group of 50 consecutive patients that underwent right MLC in the same period.

RESULTS

Median operative time was significantly shorter in SILC (97 vs. 112 min; p < 0.001). Between both groups, no statistically significant differences were found regarding number and nature of short-term complications, number of reoperations [4 (8%) vs. 6 (12%)], and mortality rate [1 (2%) vs. 2 (4%)]. Median postoperative hospital stay was 6 days for both groups.

CONCLUSION

SILC is a safe and feasible procedure when performed by experienced laparoscopic surgeons. Length of hospital stay and overall complication rates are comparable with MLC. Until today, no clear advantages of SILC over MLC have been demonstrated. However, due to its smaller incisional trauma, SILC could be a major step in improving cosmetic outcomes.

Single-incision vs three-port laparoscopic cholecystectomy: Prospective randomized study

AIM: To compare the clinical outcome of single-incision laparoscopic cholecystectomy (SILC) with three-port laparoscopic cholecystectomy (TPLC).

METHODS: Between 2009 and 2011, one hundred and two patients with symptomatic benign gallbladder diseases were randomized to SILC (n = 49) or TPLC (n = 53). The primary end point was post operative pain score (at 6 h and 7 d). Secondary end points were blood loss, operation duration, overall complications, postoperative analgesic requirements, length of hospital stay, cosmetic result and total cost. Surgical techniques were standardized and all operations were performed by one experienced surgeon, who had performed more than 500 laparoscopic cholecystectomies.

RESULTS: One patient in the SILC group required conversion to two-port LC. There were no open conversions or major complications in either treatment groups. There were no differences in terms of estimated blood loss (mean ± SD, 14 ± 6.0 mL vs 15 ± 4.0 mL), operation duration (mean ± SD, 41.8 ± 17.0 min vs 38.5 ± 22.0 min), port-site complications (contusion at incision: 5 cases vs 4 cases and hematoma at incision: 2 cases vs 1 case), total cost (mean ± SD, 12 075 ± 1047 RMB vs 11 982 ± 1153 RMB) and hospital stay (mean ± SD, 1.0 ± 0.5 d vs 1.0 ± 0.2 d) , respectively. TPLC had a significantly worse visual analogue pain score at 8 h after surgery (mean ± SD, 3.5 ± 1.6 vs 2.0 ± 1.5), however, the scores were similar on day 7 (mean ± SD, 2.5 ± 1.4 vs 2.0 ± 1.3). Cosmetic satisfaction, as determined by a survey at 2 mo follow-up favored SILC (mean ± SD, 8 ± 0.4 vs 6 ± 0.2).

CONCLUSION: SILC is a safe and feasible approach in selected patients. The main advantages are a better cosmetic result and less pain.

From multi-incision to single-incision laparoscopic cholecystectomy step-by-step: one surgeon's self-taught experience and retrospective analysis

BACKGROUND/OBJECTIVE

Single-incision laparoscopic cholecystectomy (SILC) is emerging as an alternative to standard four-incision laparoscopic cholecystectomy (4ILC). This study presents one surgeon's experience of SILC and a retrospective analysis of the data.

METHODS

Sixty-seven consecutive patients treated by a single surgeon and undergoing laparoscopic cholecystectomy (LC) for benign gallbladder diseases were enrolled. LCs were attempted with conventional instruments as follows: 24 three-incision laparoscopic cholecystectomies (3ILC); 10 two-incision laparoscopic cholecystectomies (2ILC); and 33 SILC.

RESULTS

The procedure conversion rate into the SILC, 2ILC, and 3ILC groups was 9.1%, 0%, and 8.3% respectively. Operative time was significantly longer with SILC (111.1±30.34 minutes) compared to 2ILC (79.1±15.74 minutes) and 3ILC (80.2±29.41 minutes) (p<0.01). Post-operative pethidine dosage was significantly lower in the 2ILC group (0.29±0.358 mg/kg) compared to the 3ILC group (1.02±0.802 mg/kg) (p<0.05). Length of hospital stay (LOS) was significantly shorter in the SILC group (2.52±0.566 days) compared to the 3ILC group (3.1±1.02 days) (p<0.05). There were no complications.

CONCLUSIONS

SILC is a safe and feasible procedure that is comparable to multi-incision laparoscopic cholecystectomy (MILC). We have introduced a recommended step-by-step training program. SILC needed longer operative time than MILC but has potential benefits in terms of LOS and post-operative pain.

Single-incision versus conventional laparoscopic cholecystectomy: a systematic review of available data

To evaluate the feasibility and limitation of single-incision laparoscopic cholecystectomy (SILC), we performed a systematic literature search and 11 studies were included. SILC was successfully performed in 91.9% participants and conventional instruments were used mostly. Although longer operative time was required for this novel procedure than the conventional laparoscopic cholecystectomy, mean difference was 18.54 minutes (P=0.0001) and a learning curve was noted. There was no significant discrepancy in overall complications and severe complications (P=0.51 and 0.82, respectively). No difference in the length of hospital stay between the 2 groups was detected (P=0.09). No consensus has reached on the postoperative pain score between the 2 techniques. SILC with conventional instruments was a feasible and safe approach. It may be offered as an alternative for cholecystectomy in carefully selected patients.

Clinical results between single incision laparoscopic cholecystectomy and conventional 3-port laparoscopic cholecystectomy: prospective case-matched analysis in single institution

Purpose

The aim of our study was to compare single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC) with respect to clinical outcomes.

Methods

Patients with less than a 28 body mass index (BMI) and a benign gall bladder disease were enrolled in this study. From January 2011 to February 2012, 30 consecutive patients who underwent SILC were compared with 30 patients who underwent CLC during the same period. In this study, all operations were performed by one surgeon. In each group, patient characteristics and perioperative data were collected.

Results

There was no significant difference in the preoperative characteristics. There was no significant difference in the postoperative laboratory result (alanine aminotransferase, aspartate aminotransferase, and alanine aminotransferase), number of conversion and complication cases, and length of hospital stay. The operation time was significantly longer in the SILC group (78.5 ± 17.8 minutes in SILC group vs. 34.9 ± 5.75 minutes in CLC group, P < 0.0001). The total nonsteroidal antiinflammatory drug usage during perioperative period showed significantly higher in SILC groups (162 ± 51 mg in the SILC group vs. 138 ± 30 mg in the CLC group), but there was no statistically significant difference in opioid usage between two groups. The postoperative pain score was significantly higher in the SILC group at second, third, and tenth postoperative day. Satisfaction of postoperative wound showed superiority in SILC group.

Conclusion

SILC seems to be an acceptable alternative to CLC with acceptable results. However, it is not enough to propose any real benefits of SILC when compared with CLC in terms of operation time and postoperative pain.

Randomized clinical trial of single-port, minilaparoscopic and conventional laparoscopic cholecystectomy

Background

This three-armed randomized clinical trial, with blinding of patients and outcome assessors, tested the hypothesis that single-port (SP) and/or minilaparoscopic (ML) cholecystectomy are superior to conventional laparoscopic (CL) cholecystectomy.

Methods

Patients eligible for elective laparoscopic cholecystectomy were randomized to SP, ML or CL procedures. The primary outcome was pain measured on a visual analogue scale twice daily during the blinded period. Secondary outcomes included duration of operation, technical performance score, complications, quality of life, cosmesis and patient satisfaction. Postoperative follow-up lasted 1 year.

Results

A total of 105 patients were randomized, 35 in each group. One conversion from a SP to a CL technique was necessary in a patient with chronic cholecystitis. Pain intensity was similar in the three groups, both during the blinded period (day 0 to 3; P = 0·865) and over the whole 7-day evaluation period (P = 0·911). The presence of clinically relevant between-group differences was ruled out (95 per cent confidence interval + 1·0 to − 0·5 for difference in pain scores between SP and CL groups, and − 0·8 to + 0·6 between ML and CL groups). Operating time was significantly longer for SP and ML than for CL cholecystectomy (P = 0·001). Postoperative complications included injury to the diaphragm (1), choledocholithiasis (1), wound infection (5) and hernia (1), all after SP cholecystectomy (P = 0·001). Twelve-month follow-up was complete in 99 patients (94·3 per cent). Cosmesis as rated by patients was significantly better at 6 months after SP and ML procedures (P = 0·043), but no difference was observed at 12 months (P = 0·229).

Conclusion

SP and ML cholecystectomy had no advantage over the CL approach in terms of postoperative outcome. Registration number: DRKS00000302 (German Registry of Clinical Trials).

Randomized clinical study for assessment of incision characteristics and pain associated with LESS versus laparoscopic cholecystectomy

BACKGROUND

Laparoendoscopic single-site surgery (LESS) has emerged as a technique that uses a natural scar, the umbilicus, within which a multiple-entry portal is placed into a 3.0-4.0-cm single incision to perform operations. The objective of this study was to compare incision size, wound complications, and postoperative pain of LESS compared with those of laparoscopic cholecystectomy (LC).

METHODS

A prospective randomized controlled study was conducted between January and June 2011 at two university hospitals in Rio de Janeiro, Brazil. Fifty-seven patients were randomly assigned to undergo laparoscopic or LESS cholecystectomy. Skin and aponeurosis wound sizes were recorded. A 10-point visual analog scale (VAS) was used to assess pain at postoperative hours 3 and 24. Healing and wound complications were assessed at follow-up.

RESULTS

A total of 57 patients, 53 women and 4 men with a mean age of 48.7 years, were randomly assigned to undergo LESS (n = 28) or LC (n = 29). The mean length of the umbilical skin incision was 4.0 cm (range = 2.1-5.8) in LESS and 2.7 cm (1.5-5.1) in LC (p < .0001). The mean internal aponeurosis diameter was 3.5 cm (2.0-5.5) in LESS and 2.3 cm (1.2-3.5) in LC (p < .0001). The mean operative time was 60.3 min (32-128) for LESS and 51.3 min (25-120) for LC (p = 0.11). Gallbladder perforation at detachment occurred in 15.69 % of the LESS cases and in 5.88 % of the LC cases (p = 0.028). The mean VAS score for pain at hour 3 was 2.0 points (0-7) for the LESS group and 4.0 (0-10) for the LC group (p = 0.07), and at postoperative hour 24 it was 0.3 points (0-6) for LESS and 2.3 (0-10) for LC (p = 0.03). There were no significant differences in wound complications. Incisional hernias were not found in either group.

CONCLUSIONS

The LESS single-port (SP) operations demand a bigger incision than LC surgery. However, there were no differences in healing, wound infections, and hernia development. We found a tendency of less postoperative pain associated with LESS/SP than with LC.

Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution

OBJECTIVE

To compare the incidence of bile duct injuries during single incision laparoscopic cholecystectomy (SILC) in relation to the accepted historic rate of 0.4% to 0.5% for standard laparoscopic cholecystectomy (SLC).

BACKGROUND

Technically, SILC is more challenging than SLC. The role and benefit of SILC in patient care has yet to be defined. Bile duct injuries have been reported in several series of SILC.

METHOD

A comprehensive database search of MEDLINE, EMBASE, CINAHL, and PubMed Central was performed to generate all reported cases of SILC to present. The search was limited to reports of 20 or more patients based on current literature of existing SILC learning curves. Data were analyzed using the Student t test and χ analyses where appropriate.

RESULTS

A total of 76 candidate studies were identified; 45 studies met inclusion criteria for an aggregate total of 2626 patients. Most SILCs were performed in the absence of acute cholecystitis (90.6%). The aggregate complication rate was 4.2%, and complications were graded according to the Dindo-Clavien Classification System. Nineteen bile duct injuries were identified for a SILC-associated bile duct injury rate of 0.72%.

CONCLUSIONS

There seems to be an increase in the rate of bile duct injuries during SILC when compared with historic rates during SLC. Because most SILCs are performed in optimal conditions, such as lack of acute inflammation, we urge caution in applying this technique to inflamed gallbladder pathology. Controlled trials are needed before conclusions are made regarding safety of SILC.

Magnetically anchored cautery dissector improves triangulation, depth perception, and workload during single-site laparoscopic cholecystectomy

INTRODUCTION

This study evaluated operative outcomes and workload during single-site laparoscopy (SSL) using a magnetically anchored cautery dissector (MAGS) compared with a conventional laparoscopic hook cautery (LAP).

METHODS

Each cautery was used to perform six SSL porcine cholecystectomies. For MAGS, the cautery device was inserted through the umbilical incision, magnetically coupled, and deployed; two graspers and a laparoscope were used. For LAP, two percutaneous retraction sutures, one grasper, a hook cautery dissector, and a laparoscope were used. Operative outcomes, surgeon ratings (scale, 1-5; 1 = superior), and workload (scale, 1-10; 1 = superior) were evaluated.

RESULTS

No significant differences were detected for operative outcomes and surgeon ratings, however, trends were detected favoring MAGS. Surgeon workload ratings were significantly better for MAGS (2.6 ± 0.2) vs. LAP (5.6 ± 1.1; p < 0.05). For MAGS, depth perception and triangulation were excellent and the safe handling protocol was followed with no complications. For LAP, the parallelism of instruments and lack of triangulation hindered depth perception, caused instrument conflicts, and resulted in two minor complications (one superficial liver laceration and one inadvertent burn to the diaphragm).

CONCLUSION

These data suggest that using the MAGS device for SSL cholecystectomy results in equivalent (or better) operative outcomes and less workload compared with LAP.

Meta-analysis of prospective randomized studies comparing single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC)

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) has gained acceptance among surgeons as there is a trend to minimize the invasiveness of laparoscopy. The aim of this meta-analysis has been to assess the feasibility and safety of SILC when compared to conventional multiport laparoscopic cholecystectomy (CMLC).

METHODS

A literature search for trials comparing SILC and CMLC was performed. Studies were reviewed for the outcomes of interest: patient characteristics; operative time and conversion rate; postoperative pain; length of hospital stay; postoperative complications; and patient satisfactory score (0-10). Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for qualitative variables.

RESULTS

Twelve prospective randomized trials comparing SILC and CMLC were analyzed. Overall, 892 patients were randomized to either SILC (465) or CMLC (427). Operative time was significantly longer in SILC (63.0 vs. 45.8 min, SMD = 1.004, 95% CI = 0.434-1.573). Patient satisfactory score significantly favored SILC (8.2 vs. 7.2, SMD = -0.759, 95% CI = -1.064 to -0.455). No other difference was found.

CONCLUSIONS

SILC is a safe and effective procedure for the treatment of uncomplicated benign gallbladder disease with a significant patient satisfaction. New multicenter randomized trials are expected to evaluate SILC in more complex circumstances such as acute cholecystitis, previous abdominal surgery, and severe obesity.

Single incision laparoscopic cholecystectomy: A review on the complications

BACKGROUND:

The aim of this study was to establish the incidence of postoperative complications after single incision laparoscopic cholecystectomy.

MATERIALS AND METHODS:

A literature search was performed using the PubMed database. Search terms included single incision laparoscopic cholecystectomy, single port cholecystectomy, minimal invasive laparoscopic cholecystectomy, nearly scarless cholecystectomy and complications.

RESULTS:

A total of 38 articles meeting the selection criteria were reviewed. A total of 1180 patients were selected to undergo single incision laparoscopic cholecystectomy. Introduction of extra ports was necessary in 4% of the patients. Conversion to open cholecystectomy was required in 0.4% of the patients. Laparoscopic cholangiography was attempted in 4% of the patients. The incidence of major complications requiring surgical intervention or ERCP with stenting was 1.7%. The mortality rate was zero.

CONCLUSION:

Although the number of complications after single incision laparoscopic cholecystectomy seems favourable, it is too early to conclude that single incision laparoscopic cholecystectomy is a safe procedure. Large randomised controlled trials will be necessary to further establish its safety.

Cholecystomucoclasis: revaluation of safety and validity in aged populations

Background

We evaluated the safety and validity of cholecystomucoclasis (CM) and compared its intraoperative characteristics with those of standard cholecystectomy (SC).

Methods

We enrolled 174 patients who underwent cholecystectomy and retrospectively evaluated the outcomes of patients in the SC and CM groups.

Results

Significant differences in age (71.1 vs. 61.9 years), American Society of Anesthesiologists physical status (ASA-PS), and serum C-reactive protein levels (CRP) (18.1 vs. 4.7 mg/dL) were observed between the CM and SC groups. Conversely, no significant differences were observed in the operation time (129 vs. 108 min), amount of blood loss (147 vs. 80 mL), intraoperative complications (0% vs. 5.7%), or duration of hospital stay (13.2 vs. 8.9 days) between the 2 groups. A high conversion rate (35.3%), postoperative complications (33%), and frequent drain insertions (94%) were observed in the CM group.

Conclusions

CM is a safe and valid surgical procedure and surgeons should not hesitate to transition to CM for patients who are of advanced age, in poor general condition (high ASA classification), or have high levels of serum CRP.

Renaissance of Minilaparoscopy in the NOTES and single port era

The authors suggest that minilaparoscopy should be considered as the most sophisticated evolution of laparoscopic surgery at the present time.

Single-fulcrum laparoscopic cholecystectomy: a single-incision and multi-port technique

BACKGROUND

  Single-incision laparoscopic cholecystectomy (LC) is still technically demanding and usually requires specially designed instruments. This article describes our own technique, a single-fulcrum LC using only standard ports and instruments.

METHODS

  Between March 2009 and December 2010, 130 consecutive patients, all scheduled to undergo elective LC, underwent this single-fulcrum LC for benign gallbladder disease. Perioperative surgical outcomes were retrospectively evaluated.

RESULTS

  One hundred and ten patients (84.6%) underwent successful single-fulcrum LC, and 20 patients (15.4%) were converted to conventional surgery (n= 18) or required additional trocars (n= 2) during the procedure because of umbilical hernia (n= 3), severe inflammation or adhesion (n= 9), impacted cystic duct stone (n= 3), anatomical anomaly (n= 3) and iatrogenic injury (n= 2). Two intraoperative complications (iatrogenic injury) were securely managed using additional trocars and there was no post-operative morbidity or mortality. This single-fulcrum LC could be performed with comparable cost to conventional LC, and the sequential operative time showed reasonable learning curve.

CONCLUSION

  Single-fulcrum LC is feasible, safe and quite reproducible. The surgical wound can be dramatically reduced at a similar cost to conventional LC. It may be an alternative procedure for most uncomplicated benign gallbladder disease.

Can residents safely and efficiently be taught single incision laparoscopic cholecystectomy?

OBJECTIVE

Single incision laparoscopic cholecystectomy (SILC) has recently emerged as an option for selected patients undergoing gallbladder removal. While SILC appears safe when performed by experienced surgeons under controlled conditions, there are no studies evaluating the SILC learning curve for incorporation into resident education and the effect on OR efficiency.

DESIGN, SETTING, AND PARTICIPANTS

Chief residents were taught and evaluated by a single attending surgeon facile with SILC techniques. Residents were transitioned from assistants to primary surgeon during their clinical rotation. Outcomes data were prospectively tabulated compared with data from standard laparoscopic SLC and attending surgeon SILC outcomes. The setting was an academic, tertiary care teaching hospital. Participants were chief residents rotating on hepatobiliary surgery service. Residents previously had demonstrated mastery of basic laparoscopic surgical techniques.

RESULTS

Seven chief residents were evaluated with a total of 49 SILCs with a mean of 7 (range 5-12) SILCS/resident. Five conversions to SLC occurred, all within the first 3 SILCs performed by the resident as operative surgeon. Mean blood loss was 30 mL. Median length of stay was <1 day. Average length of operation increased after the first 2 cases, reflecting the transition of the attending surgeon from primary surgeon to assistant role. By the fifth case, operative times returned to the attending surgeon SILC baseline and historical operative times for SLC at our institution. Factors associated with longer-length of surgery were increasing BMI and presence of acute or chronic cholecystitis, choledocholithiasis, and use of intraoperative cholangiogram. Five postoperative complications occurred and were not associated with position along the resident's learning curve. One death occurred due to metastatic laryngeal cancer within 30 days of SILC.

CONCLUSIONS

Residents can safely be taught the techniques of SILC with minimal disruption to operating room efficiency. Residents already proficient in the use of standard laparoscopic techniques transition to SILC quickly with a short learning curve and proper instruction.

Single-incision laparoscopic cholecystectomy: the first Malaysian experience

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) is an evolving concept in minimally invasive surgery. It utilizes the concept of inline viewing and a single incision that accommodates all of the working instruments. Here, we describe a single surgeon's initial experiences of using this technique in a tertiary hospital.

METHODS

Between January and September 2010, 21 patients underwent SILC for symptomatic cholelithiasis. The umbilicus was the point of access into abdomen for all patients using a 2.0-2.5-cm incision. The surgeries were performed using the Covidien SILS port with a 30° angled scope and two 5-mm conventional laparoscopic instruments.

RESULTS

Nineteen patients successfully underwent surgery (8 males and 11 females; mean age: 43 years). The mean body mass index was 25.9 kg/m(2) (range: 19.0-38.2 kg/m(2)). The mean operative time was 89 minutes (range: 55-135 minutes). Minimal blood loss was noted in each patient. The mean length of the postoperative stay was 1.1 days (range: 1-3 days). No complications or mortalities were associated with the technique. The visual analogue score for pain at the 1-day and 6-week follow-up examinations was 2 (range: 1-7) and 0.6 (range: 0-3), respectively. At 6 weeks, the mean satisfaction score for the resultant scar was 8.8 (range: 4-10) and the mean overall satisfaction score was 9.2 (range: 7-10). The mean time until returning to work or normal activities was 8.8 days (range: 1-21 days).

CONCLUSION

SILC is feasible and demonstrates a good clinical outcome.

Single-incision laparoscopic surgery used to perform transanal endoscopic microsurgery (SILSTEM) for T1 rectal cancer under spinal anesthesia: report of a case

Transanal endoscopic surgery has slowly gained widespread acceptance among colorectal surgeons, despite the need for specific training and the high costs of specialized instrumentation. At the other extreme, some laparoscopic surgeons recommend single port access surgery using a single-incision laparoscopic surgery port. Single-incision laparoscopic surgery was applied to perform transanal endoscopic microsurgery in a patient with T1 rectal cancer under spinal anesthesia. The patient was a 74-year-old man who presented with a 2-cm elevated lesion in the right anterior portion of the rectum. Ordinary laparoscopic instruments were used to perform submucosal resection. The tumor was completely excised from the rectal wall with the use of an ultrasonic surgical scissors. The patient recovered uneventfully and was discharged 4 days after the operation. There was no fecal incontinence or soiling during the postoperative follow-up. Colonoscopy at 4 months after the operation showed no recurrence of either adenocarcinoma or adenoma.

A prospective controlled trial comparing single-incision and conventional laparoscopic cholecystectomy: caution before damage control

PURPOSE

To evaluate the safety and feasibility of single-incision laparoscopic cholecystectomy (SILS-C) compared with conventional laparoscopic cholecystectomy (CLC).

METHODS

Sixty-five patients (SILS-C: 35, CLC: 30) were prospectively enrolled and operated with conventional straight instruments. The postoperative pain scores at 6, 24 hours, and 1 week, nausea, vomiting, commencement of oral intake, hospital stay, resumption of normal activities and work and satisfaction levels were noted.

RESULTS

Twenty-eight percent (10/35) SILS-C patients required introduction of additional trocars to complete the procedure. No patient required conversion to open. All the morbidity parameters were similar in both the groups, except that the seroma formation in the wound was significantly higher in the SILS-C group [SILS-C: 17% (6/35)/CLC: 0%, P=0.038]. One patient in SILS-C had a major bile duct injury.

CONCLUSIONS

SILS-C is safe and feasible with conventional instruments. However, caution needs to be exercised in view of a major bile duct injury and a higher rate of seroma formation in the wound.

Magnetically anchored camera and percutaneous instruments maintain triangulation and improve cosmesis compared with single-site and conventional laparoscopic cholecystectomy

BACKGROUND

This study evaluated operative outcomes and ergonomics for a magnetic camera (MAGS) used in conjunction with percutaneous instruments [percutaneous surgical set (PSS)] compared with single-site laparoscopic (SSL) and conventional laparoscopic (LAP) cholecystectomy techniques.

METHODS

Four surgical trainees each performed three porcine cholecystectomies using three randomized techniques including MAGS/PSS, SSL, and LAP. The operative outcomes, procedure-specific ratings (1-5 scale; 1 = superior), workload (1-10 scale; 1 = superior), and global impressions (1-10 scale; 10 = superior) were recorded. Comparisons used analysis of variance (ANOVA) on ranks (Kruskal-Wallis), and p values lower than 0.05 were considered significant.

RESULTS

The operative outcomes were similar except for significantly higher blood loss with SSL (16.3 ± 10.3) versus LAP (2.8 ± 1.5; p < 0.05) but not with MAGS/PSS (4.8 ± 3.8). Several inadvertent tissue-damaging events occurred with SSL but not with MAGS/PSS or LAP. The incision was significantly shorter with MAGS/PSS (29.3 ± 2.8 mm) and SSL (29.3 ± 2.5 mm) than with LAP (48.0 ± 3.6 mm; p < 0.05). Compared with SSL (3.6 ± 0.5), the procedure-specific ratings significantly favored MAGS/PSS (2.8 ± 0.4) and LAP (1.7 ± 0.2; p < 0.05). Ergonomics and technical challenges both were rated significantly inferior with SSL (4.3 ± 1.0 and 3.8 ± 0.5, respectively) versus LAP (1.5 ± 0.6 and 2.0 ± 0.8, respectively; p < 0.05) but not with MAGS/PSS (2.5 ± 1.0 and 3.0 ± 0.8, respectively). Both MAGS/PSS (4.5 ± 0.5) and SSL (4.8 ± 1.0) were associated with a significantly greater workload than LAP (2.5 ± 0.6; p < 0.05). Global impression ratings were significantly higher for LAP (8.7 ± 1.3) versus SSL (5.8 ± 2.0; p < 0.05) but not for MAGS/PSS (7.1 ± 1.8). Cosmesis was significantly better with MAGS/PSS (9.5 ± 0.6) versus LAP (6.5 ± 2.4; p < 0.05) but not with SSL (8.8 ± 1.3).

CONCLUSION

The MAGS/PSS technique allows better triangulation and fewer technical difficulties than SSL and better cosmesis than LAP. Further development of these devices is warranted.

Benefits and drawbacks of SILS cholecystectomy: a report of 60 SILS cholecystectomies with conventional instrumentation from an academic center

BACKGROUND

Single-incision laparoscopic surgery is a rapidly emerging approach to gallbladder disease.

METHODS

From February 2009 to September 2010, 60 patients were subjected to single-incision laparoscopic cholecystectomy. In all the patients, a 12-mm incision was made in the umbilicus and a 2-trocar technique was applied. Gallbladder was suspended with 2 sutures and the procedure was accomplished with standard partly reusable laparoscopic instruments.

RESULTS

In all, 41 women (68.3%) and 19 men (31.7%) were enrolled in this study. Mean age was 50.7 years (range = 17-72 years), mean body mass index was 26.2 kg/m(2) (range = 18.3-37.7 kg/m(2)) and mean operative time was 52.6 minutes (range = 30-120 minutes). No mortality or morbidity was recorded and hospital stay was less than 24 hours. At follow-up visits, no complications were recorded and cosmesis was excellent.

CONCLUSION

Single-incision laparoscopic cholecystectomy can be safely performed with conventional instrumentation with minimal cost.

Evaluation of Instrument Dexterity and Static Resistance of Laparoendoscopic Single-Site (LESS) Surgical Ports

There is a lack of data on instrument dexterity and interface resistance with respect to the emerging surgical technology of LESS ports. A comparative analysis was conducted to characterize the force to maneuver laparoscopic instruments at various working angles within three commercially available LESS ports. A novel test fixture was created where working angles of the instruments were systematically varied in both the horizontal and sagittal plane within synthetic skin and rigid inserts. Two standard 5-mm laparoscopic graspers and a 10-mm simulated laparoscope were inserted into the trocars of the SILS™, TriPort™ and GelPOINT™ LESS ports. The positions of the laparoscope and grasper (G1) were fixed, while the working instrument’s position (G2) was systematically varied to create a range-of-motion. The static force required to maintain a specific position for G2 was measured using a digital force gauge for that range-of-motion. The resistance created by each LESS port was most noticeable at greater separation angles. The GelPOINT™ provided the least resistance to instrument movement; while the TriPort™ required the greatest amount of force at all angular positions. The 15-mm skin interface yielded lower overall resistance for all ports compared to the 30-mm skin interface. Resistance created by each LESS port increased with greater angular separation. Increased thickness and rigidity of the abdominal wall resulted in greater static forces and reduced instrument range-of-motion for all surgical ports. LESS port design and geometry heavily influenced overall instrument range-of-motion, as well as the resistance found at extreme separation angles. Surgeons should consider the degree of instrument motion required specific to the procedure being performed when selecting a LESS port.

Single-incision laparoscopic hepatectomy for benign and malignant hepatopathy: initial experience in 8 Chinese patients

BACKGROUND

The single-incision laparoscopic surgery (SILS) technique has been used in many surgical procedures, but there are few reports regarding liver surgeries. The purpose of this study was to perform single-incision laparoscopic hepatectomy (SILH) using standard laparoscopic instrumentation in 8 Chinese patients. The advantages and prospective future applications of SILH are also described.

METHODS

Selected patients were hospitalized between December 2009 and November 2011. The procedure was accomplished through a 2.5-cm transabdominal wall incision using a laparoscope and 2 other instruments without the assistance of any articulating instruments or single multiport trocar.

RESULTS

All procedures were successfully performed without the need for supplemental trocars. Postoperative pathological examinations were supportive of the preoperative diagnoses. No complications such as perioperative hemorrhage or infections occurred.

CONCLUSION

SILH appears to be a safe approach and the results are cosmetically favorable. The accumulation of SILH experience and the development of instrumentation are needed for extensive use of this technique in hepatectomies.

Single-incision laparoscopic hepatectomy: a case report

AIMS

Single-incision laparoscopic procedures are reported to be accessible comprehensively for abdominal surgeries. Herein, we report 1 case of partial hepatectomy in which the single-incision laparoscopic surgery (SILS) technique or the laparoendoscopic single-site surgery was conducted.

CASE

One 53-year-old woman diagnosed with hepatic multicystis (the largest one had a diameter of 5 cm) underwent single-incision laparoscopic partial hepatectomy on January 1, 2010.

RESULTS

The entire procedure was completed in 105 minutes without any complications. The patient went out of bed for mobilization 8 hours after surgery and was discharged on the fifth postoperative day.

CONCLUSION

Single-incision laparoscopic procedures are available for many abdominal surgeries, whereas trials reported to perform partial hepatectomy using SILS are fewer. Therefore, our success in the case of partial hepatectomy by SILS provides another optional approach to liver surgeries.

From 3-port to new laparoendoscopic single-site (LESS) cholecystectomy: a critical analysis of available evidence

In recent years, laparoendoscopic single-site surgery (LESS) has gained greater interest and diffusion for the treatment of gallstones. This critical review aims to evaluate the feasibility and safety of LESS cholecystectomy versus the 3-port technique (TPT) through a comparative analysis of 5 parameters: mean operative time, intraoperative and postoperative complications, conversion to open, conversion to the 4-trocar technique and postoperative hospital stay. The authors performed a systematic search of the medical literature through a search of PubMed and Ovid EMBASE. Inclusion criteria were as follows: publication date between January 1, 2005, and December 31, 2010; English or Italian language; human participants and series of 20 operations or more. There were 5 manuscripts meeting the inclusion criteria for TPT and 23 for LESS. Only one prospective randomized controlled trial comparing TPT and LESS was identified. Operative time is significantly longer in the single-incision group. Complications and conversion rates to the 4-port technique are higher in LESS. Postoperative hospital stay is similar in the 2 groups. Rate of conversion to open is higher in TPT. Despite the number of publications on LESS cholecystectomy, the vast majority of data available in the literature are from small case series without any comparative data. Although LESS cholecystectomy is a fashionable technique there are few data available for an evidence-based determination as to the real benefits of this technique. Well-designed comparative studies are suggested to validate the clinical benefits and ensure that there are no new complications or added costs associated with the new technique.

Transumbilical single-port laparoscopic cholecystectomy using traditional laparoscopic instruments: a report of thirty-six cases

OBJECTIVE

To evaluate the feasibility and safety of the operation of transumbilical single-port laparoscopic cholecystectomy (TSPLC) by traditional laparoscopic instruments and summarize the initial experience.

METHODS

Sixty subjects with cholelithiasis were divided into two groups. One group (36 cases) underwent TSPLC and the control group (24 cases) underwent traditional three-port laparoscopic cholecystectomy (LC). Postoperative complications were observed and operation time, hospital days, visual analogue scale (VAS) after 6 and 24 h of operation, and subject satisfaction score were measured.

RESULTS

TSPLC and traditional LC were performed successfully in the two groups. The operation time in the TSPLC group was significantly longer than that in the control group. There was no statistically significant difference in hospital stay and VAS between the TSPLC and control groups. The subject satisfaction score in the TSPLC group was 91.2, significantly higher than that in the control group (P<0.01). All subjects recovered from the operation and no postoperative complication occurred during the period of two weeks after operation.

CONCLUSIONS

TSPLC is a feasible and safe method for cholecystectomy, although it may be more time-consuming. However, it is welcomed by patients who are more concerned with cosmetic outcomes. Future studies are needed to confirm its disadvantages and contraindications.

Public perception of LESS surgery and NOTES

INTRODUCTION

This study was undertaken to determine public attitudes toward laparoendoscopic single-site (LESS) surgery and natural orifice transluminal endoscopic surgery (NOTES) and to determine how they are impacted by age, gender, and obesity.

METHODS

One hundred fifty-two citizens completed a validated questionnaire. Pearson correlations were computed to determine relationships among items queried. Scores ranged from 1 (lowest) to 5 (highest) and are presented as median, mean ± SD.

RESULTS

The citizens generally liked their physique (4, 4 ± 1.0) and felt attractive (4, 4 ± 1.0). LESS surgery was appealing if it involved no more risk or recovery and none to minimally more pain, operative time, and cost. Older and heavier citizens were more interested in reduced risk, pain, and operative/recovery time and less interested in scarring/appearance. Thirty-nine percent would consider NOTES, though only with no more risk, pain, operative time, and cost (<$200). Older people regarded NOTES more favorably. Lack of scarring with NOTES was most important by only 32% of those participants that would consider undergoing a NOTES procedure.

CONCLUSION

Acceptance of LESS surgery and NOTES depends upon no additional risk and no or minimally increased pain, recovery time, and cost. Improved cosmesis is not generally a priority, particularly in older or heavier people. Safety, pain, and recovery time remain major issues in deciding operative choices.