One-wound laparoscopic cholecystectomy

Single incision laparoscopic fundoplication: A systematic review of the literature

BACKGROUND

Fundoplication, was first introduced as a surgical treatment method of gastroesophageal reflux disease. Consequently, several modifications of this method have been described, whereas laparoscopic fundoplication was recently introduced. Although single incision (SI) fundoplication was considered as an alternative to the conventional laparoscopic approach, several studies reported an increased operation duration, and high rates of multiport conversion and incisional hernia.

AIM

To provide a current overview of the technical variations and the postoperative outcomes of patients submitted to SI fundoplication.

METHODS

The present systematic review of the literature was designed and conducted on the basis of the PRISMA guidelines. A systematic screening of the electronic scholar databases (Medline, Scopus and Web of Science) was performed.

RESULTS

Literature search resulted in the identification of 19 studies. Overall, 266, 137 and 110 SI Nissen, Dor and Toupet fundoplications were reported, respectively. In the majority of the trials, standard laparoscopic instruments were used. The left liver lobe was displayed through the use of forceps, graspers, retractors, drains or even glue. Both intra-corporeal and extracorporeal suturing was described. Mean operative time was 136.3 min. Overall complication rate was 5.2% and the rate of incisional hernia was 0.9%. No mortality was reported.

CONCLUSION

Due to the methodological heterogeneity and the lack of high quality studies comparing multi to single access techniques and the several variations, we conclude that further well designed studies are necessary, in order to evaluate the role of SI fundoplication.

Technical feasibility of totally natural orifice cholecystectomy in a swine model

The goal of this study was to evaluate the feasibility of totally NOTES performing a cholecystectomy without laparoscopic assistance. A gastroscope was used through a transvaginal access in five acute female pigs. An incision of 2 cm was created in the vagina and pneumoperitoneum was obtained with a Veress needle. The gallbladder was located in the abdominal cavity using endoscopic transillumination for spatial orientation. After the abdominal suspension of the gallbladder the cholecystectomy was completed with the NOTES technique in four animals without complications. In one animal we had technical problems and the procedure was stopped. The mean operative time was 110 minutes. The transvaginal approach provides complete abdominal exploration and both the cystic duct and artery were identified, clipped, and transected. After dissection the gallbladder was removed through the vagina. Our results showed that completely transvaginal NOTES cholecystectomy is a feasible technique performed only with a flexible endoscope.

Laparoendoscopic single site (LESS) cholecystectomy

INTRODUCTION

The journey from conventional "open" operations to truly "minimally invasive" operations naturally includes progression from operations involving multiple trocars and multiple incisions to operations involving access through the umbilicus alone. Laparoscopic operations through the umbilicus alone, laparoendoscopic single site surgery (LESS), offer improved cosmesis and hopes for less pain and improved recovery. This study was undertaken to evaluate our initial experience with LESS cholecystectomy and to compare our initial experience to concurrent outcomes with more conventional multiport, multi-incision laparoscopic cholecystectomy.

METHODS

All patients referred for cholecystectomy over a 6-month period were offered LESS. Outcomes, including blood loss, operative time, complications, and length of stay were recorded. Outcomes with our first LESS cholecystectomies were compared to an uncontrolled group of concurrent patients undergoing multiport, multi-incision laparoscopic cholecystectomy at the same hospital by the same surgeon.

RESULTS

Twenty-nine patients of median age 50 years undergoing LESS cholecystectomy from November 2007 until May 2008 were compared to 29* patients, median age 48 years, undergoing standard multiport, multiple-incision laparoscopic cholecystectomy over the same time period. Median operative time for patients undergoing LESS cholecystectomy was 72 min and was not different from that of patients undergoing multiport, multi-incision laparoscopic cholecystectomy (p = 0.81). Median length of hospital stay was 1.0 day for patients undergoing LESS cholecystectomy and was not different from patients undergoing standard laparoscopic cholecystectomy (p = 0.46). Operative estimated blood loss was less than 100 cc for all patients. No patients undergoing attempted LESS cholecystectomy had conversions to "open" operations; two patients had an additional trocar(s) placed distant from the umbilicus to aid in exposure. Three patients undergoing LESS cholecystectomy had complications: two were troubled by pain control and another had urinary retention.

CONCLUSIONS

LESS cholecystectomy is a safe and effective alternative to standard laparoscopic cholecystectomy. It can be undertaken without the expense of added operative time and provides patients with minimal, if any, apparent scarring. We believe LESS cholecystectomy will be driven by consumer demand, and therefore, laparoscopic surgeons will need to become proficient with LESS procedures.

Three-port laparoscopic cholecystectomy by harmonic dissection without cystic duct and artery clipping

BACKGROUND

The technique of laparoscopic cholecystectomy (LC) still has areas of refinements. To decrease the number of ports, a cannula may be replaced by a percutaneous suture suspension of the gallbladder. The risk of tissue injury caused by repeat blind extraction and insertion of various instruments in and out of the abdomen may be decreased by the use of the multipurpose harmonic dissector.

METHODS

One hundred consecutive patients with symptomatic cholelithiasis underwent 3-port LC entirely performed by harmonic dissector without cystic duct and artery clipping.

RESULTS

In 8 cases, a fourth trocar was necessary. In 2 cases, the cystic duct was clipped after an unsafe ultrasound sealing. In 1 case, continuous bleeding from the liver required the use of diathermy. No common bile duct injury was registered.

CONCLUSIONS

The 3-port harmonic LC is a feasible, effective, and safe technique.

Mini-laparoscopic cholecystectomy in children under 10 years of age with sickle cell disease

BACKGROUND

Cholelithiasis is very common in patients with sickle cell disease (SCD) and is responsible for recurrent attacks of abdominal pain. The ideal management, especially for children, remains controversial. The purpose of the present study was to evaluate the safety and outcome of mini-laparoscopic cholecystectomy (MLC) in young children under age of 10 years with SCD.

METHODS

A prospective study was carried out of 75 children with SCD under 10 years of age with recurrent abdominal pains seen between August 2001 and March 2004 at Armed Forces Hospital, Khamis Mushayt, Saudi Arabia, who were screened for cholelithiasis. Twelve (16%) of the 75 children were found to have gallstones. The mean age was 7.8 years (range 4-9 years). All 12 children underwent MLC. Anaemia was corrected preoperatively in all the patients. Operative time, intraoperative complications, hospital stay, and postoperative recurrent abdominal pain were recorded.

RESULTS

The mean operating time was 46.5 min (range: 35-65 min). Intraoperative cholangiogram failed in two children due to narrow cystic ducts. The mean hospital stay was 2.1 days (range: 2-4 days). No patient required intra-abdominal drain. The mean follow-up period was 13.4 months (range: 4-24 months). The only postoperative complication was deep jaundice 1 month postoperatively due to cholestasis, and this responded to medical treatment. None of the children had recurrent abdominal pain after MLC.

CONCLUSION

Mini-laparoscopic cholecystectomy is a safe surgical procedure for the management of cholelithiasis in children with SCD and leads to improvement in the quality of life by decreasing the frequency of recurrent abdominal pain.

A new method of laparoscopic cholecystectomy using three trocars combined with suture retraction of gallbladder

BACKGROUND AND PURPOSE

Since the establishment of laparoscopic cholecystectomy (LC) for benign gallbladder lesions, the four-trocar method has been the standard procedure. However, the fourth trocar generally is used just for fundic retraction of the gallbladder. We have developed a three-trocar method for LC and performed it in 132 patients.

PATIENTS AND METHODS

After the creation of the pneumoperitoneum, the first 10-mm trocar sheath was inserted in the subumbilicus for the endoscope, the second 5-mm trocar in the epigastric paramedian point for the working port, and the third 5-mm trocar in the subcostal area for grasping forceps. Monofilament nylon with a straight needle was inserted through the right 7th intercostal space in the anterior axillary line, and the seromuscular layer of the gallbladder fundus was punctured and retracted toward the anterior abdominal wall. After that, usual cholecystectomy was performed.

RESULTS

Among the 132 patients who underwent the three-trocar method, 10 cases (8%) needed a fourth trocar. No patient was converted to open cholecystectomy. There were no significant differences in the operating time, the length of hospital stay after the operation, or the use of analgesics between the three-trocar and the four-trocar methods. No major complication was recognized.

CONCLUSION

This method also has cosmetic advantages. Therefore, we believe this method might be recommended for LC.